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Ultrasound-Guided Airway Management in the Austere Setting

Rapp J, Hampton K 17(1). 130 (Journal Article)

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Foreign Language Short Course: Special Operations Clinical Research Fundamentals

Kemplin KR, Bowling F 17(2). 12 - 17 (Journal Article)

When we do not know a language, we are at the mercy of an interpreter. The same is true for research: Special Operations Forces (SOF) clinicians not actively involved in research initiatives may rely on scientific interpreters, so it is important to speak some of the language personally. For any clinician, using evidence in practice requires a working knowledge of how that evidence was generated from research, which requires an understanding of research science language. Here we review common basics of research science to reinforce concepts and elements of experimental and nonexperimental research.

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Assessment of Trainer Skill to Control Groin-Wound Bleeding: Use of Junctional Tourniquet Models on a Manikin

Kragh JF, Aden JK, Shackelford S, Moore VK, Dubick MA 17(2). 39 - 48 (Journal Article)

Background: The purpose of this study was to assess the skills of trainers using different junctional tourniquet models to control groin bleeding in a manikin. Materials and Methods: In 204 assessments, 17 trainers used four junctional tourniquet models three times each to control simulated hemorrhage. The models included the Combat Ready Clamp (CRoC), Junctional Emergency Treatment Tool (JETT), Abdominal Aortic and Junctional Tourniquet (AAJT), and SAM Junctional Tourniquet (SJT). The criteria of assessment included effectiveness (i.e., control [yes-no]), time to stop bleeding, total blood loss, and bleeding rate. Results: All uses were effective. By model, the results of mean blood loss and time to stop bleeding were different with varying levels of statistical significance: control was worst with the JETT and AAJT, moderate with the AAJT and SJT, and best with the SJT and CRoC. The means sharing a level were not significantly different, but a mean in more than one level was not different from itself. The composite outcome results were 90% good for CRoC and 67% good for JETT, whereas results for the SJT and AAJT were in between, and only the result of the CROC and JETT comparison was significant. The ease of use varied significantly; JETT was more difficult to use and all others were easier. The analysis attributed to the users 19% of the variance of results for time, 44% for blood loss volume, and 67% for bleeding rate. Most users preferred the SJT (53% before and 70% after assessment). Conclusion: Effectiveness was attained by all users with each of the four models of junctional tourniquet. The analysis demonstrated that up to 67% of the variance of performance results could be attributed to the users.

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A Prospective Randomized Controlled Two-Arm Clinical Study Evaluating the Efficacy of a Bioelectric Dressing System for Blister Management in US Army Ranger Recruits

Housler GJ, Cross S, Marcel V, Kennedy DO, Husband M, Register A, Roberts T, Grubbs S, Dudewicz D, Setka n, Bay C, Wendelken ME, Izadjoo MJ 17(2). 49 - 58 (Journal Article)

This study focused on a clinically relevant healthcare problem in the military: acute soft tissue wounds, or blisters. The trial was a prospective, controlled, randomized two-arm study evaluating the efficacy of a bioelectric dressing, Procellera®, applied topically two to three times per week for 2 weeks to blisters developed in Ranger trainees during training at Fort Benning, Georgia. A total of 80 US Army Ranger recruits with blister wounds below the knee were randomly assigned to one of two treatment groups (n = 40/group). The primary goal was to assess the clinical efficacy (rate of healing) of administered Procellera in conjunction with the standard-of-care (SOC) treatment, moleskin and Tegaderm ®, on the healing rate of blisters compared with the SOC treatment alone. The secondary end points for efficacy were the quantities of wound fluid biomarkers and bacterial bioburden. The tertiary end point was assessment of pain in the treatment group compared with that of the control group during the 2-week study. The results showed no statistical difference between the SOC and SOC+Procellera groups in wound healing and pain. Wound fluid was reported for 24 participants (64.9%) in the SOC group and 21 participants (56.8%) in SOC+Procellera group at the baseline measurement (ρ = .475); however, the wounds were devoid of fluid on follow-up visits. The mild nature of the wounds in this study was apparent by the low pain scores at the beginning of the study, which disappeared by the follow-up visits. The average wound sizes were 2.2cm2 and 1.5cm2 for the SOC and SOC+Procellera groups, respectively. This trial protocol should be conducted on open softtissue wounds in severe heat. To our knowledge, this is the first clinical study conducted within the US Army Rangers training doctrine.

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Meningococcal Disease

Burnett MW 17(1). 90 - 92 (Journal Article)

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Load Carriage-Related Paresthesias (Part 2): Meralgia Paresthetica

Knapik JJ, Reynolds K, Orr R, Pope R 17(1). 94 - 100 (Journal Article)

This is the second of a two-part series addressing symptoms, evaluation, and treatment of load carriage- related paresthesias. Part 1 addressed rucksack palsy and digitalgia paresthetica; here, meralgia paresthetica (MP) is discussed. MP is a mononeuropathy involving the lateral femoral cutaneous nerve (LFCN). MP has been reported in load carriage situations where the LFCN was compressed by rucksack hipbelts, pistol belts, parachute harnesses, and body armor. In the US military, the rate of MP is 6.2 cases/10,000 personyears. Military Servicewomen have higher rates than Servicemen, and rates increase with age, longer loadcarriage distance or duration, and higher body mass index. Patients typically present with pain, itching, and paresthesia on the anterolateral aspect of the thigh. There are no motor impairments or muscle weakness, because the LFCN is entirely sensory. Symptoms may be present on standing and/or walking, and may be relieved by adopting other postures. Clinical tests to evaluate MP include the pelvic compression test, the femoral nerve neurodynamic test, and nerve blocks using lidocaine or procaine. In cases where these clinical tests do not confirm the diagnosis, specialized tests might be considered, including somatosensory evoked potentials, sensory nerve conduction studies, high-resolution ultrasound, and magnetic resonance imaging. Treatment should initially be conservative. Options include identifying and removing the compression if it is external, nonsteroidal inflammatory medication, manual therapy, and/or topical treatment with capsaicin cream. Treatments for intractable cases include injection of corticosteroids or local anesthetics, pulsed radiofrequency, electroacupuncture, and surgery. Military medical care providers may see cases of MP, especially if they are involved with units that perform regular operations involving load carriage.

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Graduate Medical Education in Tactical Medicine and the Impact of ACGME Accreditation of EMS Fellowships

Tang N, Levy MJ, Margolis AM, Woltman N 17(1). 101 - 104 (Journal Article)

Physician interest in tactical medicine as an area of professional practice has grown significantly over the past decade. The prevalence of physician involvement in terms of medical oversight and operational support of civilian tactical medicine has experienced tremendous growth during this timeframe. Factors contributing to this trend are multifactorial and include enhanced law enforcement agency understanding of the role of the tactical physician, support for the engagement of qualified medical oversight, increasing numbers of physicians formally trained in tactical medicine, and the ongoing escalation of intentional mass-casualty incidents worldwide. Continued vigilance for the sustenance of adequate and appropriate graduate medical education resources for physicians seeking training in the comprehensive aspects of tactical medicine is essential to ensure continued advancement of the quality of casualty care in the civilian high-threat environment.

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Analgesia and Sedation Management During Prolonged Field Care

Pamplin JC, Fisher AD, Penny A, Olufs R, Rapp J, Hampton K, Riesberg J, Powell D, Keenan S, Shackelford S 17(1). 106 - 120 (Journal Article)

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Clinical Image: Visual Estimation of Blood Loss

Donham B, Frondozo R, Petro M, Reynolds A, Swisher J, Knight RM 17(1). 68 - 71 (Journal Article)

Military prehospital providers frequently have to make important clinical decisions with only limited objective information and vital signs. Because of this, accurate estimation of blood loss, at the point of injury, can augment any available objective information. Prior studies have shown that individuals significantly overestimate the amount of blood loss when the amount of hemorrhage is small, and they tend to underestimate the amount of blood loss with larger amounts of hemorrhage. Furthermore, the type of surface on which the blood is deposited can impact the visual estimation of the amount of hemorrhage. To aid providers with the ability to accurately estimate blood loss, we took several units of expired packed red blood cells and deposited them in different ways on varying surfaces to mimic the visual impression of combat casualties.

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A Perspective on the Potential for Battlefield Resuscitative Endovascular Balloon Occlusion of the Aorta

Knight RM 17(1). 72 - 75 (Journal Article)

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has a place in civilian trauma centers in the United States, and British physicians performed the first prehospital REBOA, proving the concept viable for civilian emergency medical service. Can this translate into battlefield REBOA to stop junctional hemorrhage and extend "golden hour" rings in combat? If yes, at what level is this procedure best suited and what does it entail? This author's perspective, after treating patients on the battlefield and during rotary wing evacuation, is that REBOA may have a place in prehospital resuscitation but patient and provider selection are paramount. The procedure, although simple in description, is quite complicated and can cause major physiologic changes best dealt with by experienced providers. REBOA is incapable of extending the golden hour limiting the procedure's utility.

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Basic Biostatistics and Clinical Medicine

Banting J, Meriano T 17(1). 76 (Journal Article)

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Human Performance Optimization and Precision Performance: The Future of Special Operations Human Performance Efforts

Russell A, Deuster PA 17(1). 80 - 89 (Journal Article)

The Precision Medicine Initiative (PMI) was launched by the White House to promote individualized medicine. Although the focus of the PMI is on curing disease, we introduce the concept of Precision Performance (P2)- advances that might "enable a new era of human performance optimization through research, technology, and policies that empower warfighters and those who support them to work together toward development of individually optimized performance" (The White House, 2015). We provide a limited review of the current state of the science in human performance optimization (HPO) and show that averages among individuals can be both misleading and potentially counterproductive. Several examples where individual differences have historically presented challenges to HPO research and application are provided, as are ideas on how such differences might be leveraged to enable new opportunities to approach the goal of individually optimized human performance. We end with a few questions likely to be of increasing importance if the notion of P2 continues to evolve and mature; we also provide limited recommendations, given this is a nascent concept. The Special Operations Forces human performance programs can move the science forward by considering and then implementing the infrastructures, processes, and approaches to best identify and exploit emerging tools for ever greater and faster P2 data collection, analyses, sharing, and applications.

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Effectiveness of Pulse Oximetry Versus Doppler for Tourniquet Monitoring

Wall PL, Buising CM, Grulke L, Troester A, Bianchina N, White S, Freymark R, Hassan A, Hopkins JW, Renner CH, Sahr SM 17(1). 36 - 44 (Journal Article)

Background: Pulse oximeters are common and include arterial pulse detection as part of their methodology. The authors investigated the possible usefulness of pulse oximeters for monitoring extremity tourniquet arterial occlusion. Methods: Tactical Ratcheting Medical Tourniquets were tightened to the least Doppler-determined occluding pressure at mid-thigh or mid-arm locations on one limb at a time on all four limbs of 15 volunteers. A randomized block design was used to determine the placement locations of three pulse oximeter sensors on the relevant digits. The times and pressures of pulsatile signal absences and returns were recorded for 200 seconds, with the tourniquet being tightened only when the Doppler ultrasound and all three pulse oximeters had pulsatile signals present (pulsatile waveform traces for the pulse oximeters). Results: From the first Doppler signal absence to tourniquet release, toe-located pulse oximeters missed Doppler signal presence 41% to 50% of the times (discrete 1-second intervals) and missed 39% to 49% of the pressure points (discrete 1mmHg intervals); fingerlocated pulse oximeters had miss rates of 11% to 15% of the times and 13% to 19% of the pressure points. On toes, the pulse oximeter ranges of sensitivity and specificity for Doppler pulse detection were 71% to 90% and 44% to 51%, and on fingers, the respective ranges were 65% to 77% and 78% to 83%. Conclusion: Use of a pulse oximeter to monitor limb tourniquet effectiveness will result in some instances of an undetected weak arterial pulse being present. If a pulse oximeter waveform is obtained from a location distal to a tourniquet, the tourniquet should be tightened. If a pulsatile waveform is not detected, vigilance should be maintained.

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Pediatric Trauma: Management From an Austere Prospective

Gray J, Linklater DR, Johnston J, Donham B 17(1). 46 - 53 (Journal Article)

Pediatric trauma represents a notable proportion of casualties encountered by Combat medics, physician assistants, and physicians while in the deployed setting. Most of these resuscitation teams receive limited pediatric- specific training and suffer subsequent emotional stress due the perceived high-stakes nature of caring for gravely wounded children. Even when children survive long enough to arrive at combat support hospitals, there remain high risks for morbidity and mortality for many of them. There are numerous reports of the epidemiological characteristics of these pediatric patients, the common mechanisms of injury, the hospital lengths of stay, and calls for pediatric-specific equipment and specialist presence in-theatre. There is scant literature, however, on child-specific battlefield resuscitation and training for initial providers, and we believe that, with appropriately tailored pediatric resuscitation education and training strategies, there is some potential for a reduction in the morbidity and mortality associated with childhood combat injury.

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Cat on a Hot Tin Roof: Mechanical Testing of Models of Tourniquet After Environmental Exposure

O'Conor DK, Kragh JF, Aden JK, Dubick MA 17(1). 27 - 35 (Journal Article)

Background: The purpose of the present study was to mechanically assess models of emergency tourniquet after 18 months of environmental exposure to weather to better understand risk of component damage. Materials and Methods: An experiment was designed to test tourniquet performance on a manikin thigh. Three tourniquet models were assessed: Special Operations Forces Tactical Tourniquet Wide, Ratcheting Medical Tourniquet, and Combat Application Tourniquet. Unexposed tourniquets formed a control group stored in a laboratory; exposed tourniquets were placed outdoors on a metal roof for 18 months in San Antonio, Texas. Two users, a military cadet and a scientist, made 300 assessments in total. Assessment included major damage (yes-no), effectiveness (hemorrhage control, yes-no), casualty survival (alive-dead), time to stop bleeding, pressure, and blood loss. Time, pressure, and blood loss were reported in tests with effectiveness. Results: Exposed devices had worse results than unexposed devices for major damage (3% [4/150] versus 0% [0/150]; ρ = .018), effectiveness (89% versus 99%; ρ = .002), and survival of casualties (89% versus 100%; ρ < .001). In tests for effectiveness, exposed devices had worse results than unexposed devices for time to stop bleeding (29 seconds versus 26 seconds; ρ = .01) and pressure (200mmHg versus 204mmHg; ρ = .03, respectively), but blood loss volume did not differ significantly. Conclusion: Compared with unexposed control devices, environmentally exposed tourniquets had worse results in tests of component damage, effectiveness, and casualty survival.

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The Highest-Impact Combat Orthopedic and Extremity Injury Articles in the Past 70 Years: A Citation Analysis

Nam J, Do WS, Stinner DJ, Wenke JC, Orman JA, Kragh JF 17(1). 55 - 66 (Journal Article)

The objective of this study was to identify the most-cited peer-reviewed combat orthopedic and extremity injury articles published during the past 70 years. Orthopedic trauma presents ongoing challenges to both US civilian and military healthcare personnel. Improvements in combat trauma and extremity injury survival and quality of life are the result of advances in orthopedic trauma research. The Web of Science (including Science Citation Index) was searched for the most cited articles related to combat orthopedic trauma, published from 1940 to 2013. The most-cited article was by Owens et al. (Journal of Orthopaedic Trauma, 2007; 137 citations). Between the 1990s and 2000s, there was a 256% increase in the number of highly cited publications. A total of 69% of the articles were on the topics of comorbid vascular trauma (25%), epidemiology (23%), or orthopedic trauma (21%). This study identifies some of the most important contributions to combat orthopedic trauma and research and the areas of greatest scientific interest to the specialty during the past seven decades and highlights key research that has contributed to the evolution of modern combat orthopedic traumatology.

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Invasive Reduction of Paraphimosis in an Adolescent Male While in a Deployed Austere Environment

Pham C, Zehring J, Berry-Caban CS 17(1). 9 - 13 (Case Reports)

Paraphimosis is a urologic emergency resulting in tissue necrosis and partial amputation, if not reduced. Paraphimosis occurs when the foreskin of the uncircumcised or partially circumcised male is retracted behind the glans penis, develops venous and lymphatic congestion, and cannot be returned to its normal position. Invasive reduction of paraphimosis requires minimal instruments and can be accomplished by experienced providers. This case describes a 10-year-old local national with paraphimosis over 10 days that required invasive reduction in a deployed austere environment in Africa.

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A Soldier With an Exertional Heat Injury, Ischemic-Appearing Electrocardiogram, and Elevated Troponins: A Clinical Case Report

Schauer SG, Pfaff JA 17(1). 14 - 16 (Case Reports)

Heat injuries are a common occurrence in the military training setting due to both the physically demanding nature of the training and the environments in which we train. Testing is often done after the diagnosis of a heat injury to screen for abnormalities. We present the case of a 20-year-old male Soldier with an abnormal electrocardiogram (ECG) with a possible injury pattern and an elevated troponin level. He underwent a diagnostic cardiac angiogram, which demonstrated no abnormal findings. He was returned to duty upon recovery from the catheterization. Ischemic-appearing ECG and troponin findings may be noted after heat injury. In this case, it was not associated with any cardiac lesions.

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Resuscitative Endovascular Balloon Occlusion of the Aorta: Pushing Care Forward

Teeter W, Romagnoli A, Glaser J, Fisher AD, Pasley J, Scheele B, Hoehn M, Brenner M 17(1). 17 - 21 (Case Reports)

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA), used to temporize noncompressible and junctional hemorrhage, may be deployable to the forward environment. Our hypothesis was that nonsurgeon physicians and high-level military medical technicians would be able to learn the theory and insertion of REBOA. Methods: US Army Special Operations Command medical personnel without prior endovascular experience were included. All participants received didactic instruction of the Basic Endovascular Skills for Trauma Course™ together, with individual evaluation of technical skills. A pretest and a posttest were administered to assess comprehension. Results: Four members of US Army Special Operations Command-two nonsurgeon physicians, one physician assistant, and one Special Operations Combat Medic-were included. REBOA procedural times moving from trial 1 to trial 6 decreased significantly from 186 ± 18.7 seconds to 83 ± 10.3 seconds (ρ < .0001). All participants demonstrated safe REBOA insertion and verbalized the indications for REBOA insertion and removal through all trials. All five procedural tasks were performed correctly by each participant. Comprehension and knowledge between the pretest and posttest improved significantly from 67.6 ± 7.3% to 81.3 ± 8.1% (ρ = .039). Conclusion: This study demonstrates that nonsurgeon and nonphysician providers can learn the steps required for REBOA after arterial access is established. Although insertion is relatively straightforward, the inability to gain arterial access percutaneously is prohibitive in providers without a surgical skillset and should be the focus of further training.

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A Novel Ultrasound Transmission Gel for Resource-Constrained Environments

Monti JD 17(1). 22 - 25 (Journal Article)

Ultrasound represents an ideal diagnostic adjunct for medical personnel operating in austere environments, because of its increasing portability and expanding number of point-of-care applications. However, these machines cannot be used without a transmission medium that allows for propagation of ultrasound waves from transducer to patient. This article describes a novel ultrasound gel alternative that may be better suited for resource-constrained environments than standard ultrasound gel, without compromising image quality.

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