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Targeted Intervention Improves Symptoms and Impairments in Patients With Mild Traumatic Brain Injury With Chronic Symptom: A Prospective, Multiple Interventional Research Trial

Eagle SR, Kontos AP, Collins MW, Mucha A, Holland CL, Edelman K, Benso S, Schneider W, Soose R, Okonkwo DO 21(2). 61 - 66 (Journal Article)

Background: Mild traumatic brain injury (mTBI) and its potential long-term consequences is a primary concern for the US military. The purpose of the study is to evaluate if participants improved in anxiety/mood symptoms, sleep quality, and vestibular/ocular symptoms following a 6-month active intervention, and to explore the effect of targeted treatment for those with specific symptoms/impairments (e.g., psychological, sleep, ocular, vestibular). Materials and Methods: A multidisciplinary clinical team adjudicated participants (n=72, 35.8±8.6 years old, 19% female) to have one of the following primary clinical trajectories: psychological (PSYCH; n=34), sleep (SLEEP; n=25) and vestibular/ocular (VESTIB/OCULAR; n=18). Participants returned for follow-up assessment 6 months later. Assessments included the Post-Concussion Symptom Scale [PCSS], Generalized Anxiety Disorder-7 [GAD-7], Pittsburgh Sleep Quality Index [PSQI], and Dizziness Handicap Inventory [DHI]. Change in concussion symptoms and primary outcome for the given trajectory (i.e., PSYCH=GAD-7, SLEEP=PSQI, VESTIB/OCULAR=DHI) was assessed. Results: Following the 6-month intervention, participants reduced PCSS Score (-14.5±2.4; p<.001; η2=0.34), GAD-7 (-3.1±0.5; p<.001; η2=0.34), PSQI (-2.7±0.5; p<.001; η2=0.34) and DHI (-9.2±2.0; p<.001; η2=0.23). PSYCH (n=34) reduced PCSS score (-17.9±3.6; p<.001; η2=0.45) and GAD-7 (-3.1±0.7; p<.001; η2=0.38). SLEEP (n=25) reduced PCSS score (-8.8±4.4; p=.06; η2=0.15) and PSQI (-3.6±0.9; p<.001; η2=0.45) scores. VESTIB/OCULAR (n=18) reduced PCSS score (-16.7±4.8; p=.03; η2=0.45), and DHI (-15.7±5.5; p=.012; η2=0.35). Conclusions: Large effects were observed for concussion, anxiety, sleep, and dizziness symptom reduction over 6-month treatment. Each primary outcome demonstrated a larger treatment effect for the given trajectory than the overall sample, indicating that targeted treatment can reduce symptom burden in patients with mTBI with chronic symptoms.

Prevalence of Low Back and Cervical Back Pain in Military Helicopter Crews: An Underestimated Italian Problem

Marchesini M, Ippolito C, Ambrosini L, Bignami EG, Fasani M, Abbenante D 21(2). 67 - 71 (Journal Article)

Background: Studies have highlighted the incidence and prevalence of chronic pain, which is an epidemic problem in all career sectors, as well as estimated the economic loss that follows its pathology. Several studies have indicated a high incidence of chronic osteoarticular pain in military service members, particularly in flight personnel. To date, no studies have estimated the incidence of pain pathology in the Italian military population, despite the implications related to flight qualification. Methods: A survey was conducted on helicopter flight personnel undergoing periodic annual evaluation. Results: A statistically significantly higher incidence of pain pathology than that reported in the global civilian population was demonstrated. More than 80% of the interviewed population reported moderate-to-severe back pain (45% in the lumbar tract and 38% in the cervical tract). Further, it was found that most staff with chronic pain do not use drugs or other treatments for severe pain because of concerns that such treatment approaches may compromise flight qualifications. Discussion: The present study observed a high incidence of pain in Italian military flight personnel and examined the degree to which this problem is undertreated in these individuals. To address this problem, further in-depth and larger investigations that include therapeutic protocols to resolve such pain pathologies should be conducted. Such investigations could help to reduce pain experienced by flight personnel and enhance the productivity of the Italian military forces while considering the pharmacologic limitations related to the task. Conclusion: Chronic lumbar and neck pain is more common in military helicopter crews than in the civilian population. The true figure is frequently underestimated because of staff concerns regarding the potential influence of therapies on work activity.

A Survey of Tranexamic Acid Use by US Tactical Emergency Medical Support Providers

McGuire SS, Klassen AB, Mullan AF, Sztajnkrycer MD 21(2). 72 - 76 (Journal Article)

Background: Tactical Emergency Medical Support (TEMS) providers may encounter severe traumatic injuries, with associated hemorrhagic shock, coagulopathy, and hyperfibrinolysis. Tranexamic acid (TXA) administration represents a potential intervention in this operational environment. This study evaluated TXA availability and use among US tactical medical personnel supporting law enforcement tactical teams. Methods: An anonymous on-line survey of the American College of Emergency Physicians (ACEP) Tactical Emergency Medicine (TEM) section was administered. Results: Fifty respondents were included in the final study. Fifty-four percent reported TXA availability, with 14% reporting its use at least once in the past year. Additional available resuscitative products included crystalloids (88%) and packed red blood cells (6%). Twenty-five respondents reported managing ≥ 1 patient(s) with hemorrhagic shock in the past year. Resuscitative measures included crystalloids (96%), TXA (68%), and blood products (16%). Overall, 88% of respondents were supportive of TXA use. Full-time teams, those with ≥ 3 monthly callouts, and teams that carried blood products were more likely to have TXA. Conclusions: Half of respondents reported managing a patient with hemorrhagic shock in the past year. Although 88% were supportive of TXA use, only 54% reported availability. Tactical teams with higher call volume and more resources were more likely to carry TXA. Further studies evaluating TEMS patient wounding patterns and barriers to TXA utilization are required.

A Case Study of Long-Range Rotary Wing Critical Care Transport in the Battlefield Environment

Eastman J, Dumont J, Green K 21(2). 77 - 79 (Journal Article)

Military medical evacuation continues to grow both in distance and transport times. With the need for long-range transport of greater than 2 hours, crews are having to manage critical care patients for longer trips. This case study evaluates one specific event in which long-range transport of a sick noncombat patient required an enroute critical care team. Medical electronics and other equipment require special attention. Oxygen bottles and batteries for medical devices become the limiting factor in transport from point to point. Having to juggle multiple data streams requires prioritization and reassessment of interventions. Using the mnemonic "bottles, bags, batteries, battlefield environment" keeps the transport paramedic and enroute care nurse on track to effectively deliver the patient to the next level of care. Consideration should be given to such mnemonics for long critical care transports.

Case Report of Infectious Myositis in the Austere Setting

Sarkisian S, Sletten ZJ, Roberts P, Powell T 21(2). 80 - 84 (Journal Article)

Although skin and soft tissue infections are common in the deployed setting, infectious myositis is relatively uncommon. Bacterial infection of the muscle is the most common infectious etiology and can result in a spectrum of disease, to include abscess formation to necrotizing myositis, toxic shock syndrome, and death. Diagnosis can be elusive, particularly in the early stages. Recognition and proper management are crucial to prevent complications. The authors present a case report of infectious myositis diagnosed and managed in an austere deployed environment, as well as a discussion regarding current recommendations on diagnosis and treatment.

Detection of Potential Pathogenic Bacteria on the Surfaces of Female Urinary Diversion Devices Following a Short Duration Military Training Exercise

Peters AM, Yu I, Menguito M, Morrow S, Barnhill JC, Washington MA 21(2). 85 - 88 (Journal Article)

Background: Female Servicemembers are increasingly being incorporated into the combat arms and Special Operations communities. Female urinary diversion devices (FUDDs) have been used to facilitate urination in the austere environments that are encountered by Servicemembers. Importantly, the potential for the bacterial contamination of these devices has not been evaluated. The goals of this study were to determine whether microorganisms adhere to the surfaces of FUDDs in the field environment and to demonstrate the presence of potential pathogens on the used devices. Materials and Methods: A total of 15 devices that were used in a comprehensive 18-24-hour military field exercise were tested for the presence of microorganisms. Briefly, each device was swabbed, and the swabs were used to inoculate blood agar plates to encourage bacterial growth. The resulting bacterial colonies were identified, and the surface topography of the devices was investigated with electron microscopy. Results: Although microscopy revealed few surface features capable of facilitating bacterial attachment, several species were recovered. Significantly, a biofilm-forming strain of Proteus mirabilis (P. mirabilis) was detected on two of the devices. P. mirabilis is a mobile urinary pathogen that can potentially migrate from the surface of the device into the urinary tract of the user. Conclusion: Commercial FUDDs can support bacterial growth and harbor potential pathogens. Care should be taken to ensure that Servicemembers are aware of the importance of the proper care and cleaning of these devices in the field environment. To this end, standard operating procedures should be developed and distributed.

Far-Forward Blood Donation and Donor Performance

Guilllotte CA, Schilling BK 21(2). 89 - 91 (Journal Article)

Fresh whole blood transfusion is advantageous when operating far-forward for both its availability and its physiological advantages over component therapy. However, the far-forward environment may place high physical performance demands on the donor immediately after donation. The aim of this paper was to briefly review the current literature on the effects of whole blood donation on a male donor's immediate physical performance after a standard donation volume of one unit (~450mL). Studies demonstrate reductions in peak volume of oxygen (VO2peak) of ~4% to 15% and time to exhaustion (TTE) of ~10% to 19% in the first 24 to 48 hours after donation. Anaerobic or cognitive performance has not been shown to decrease, but data on these parameters are limited. Donor physical performance decrements after a standard 450mL donation are minimal and may be mitigated through proper exercise training because training status may positively affect many variables that blood donation temporarily attenuates.

Intermittent Fasting: Can It Help Optimize Human Performance?

Deuster PA, Scott JM 21(2). 92 - 97 (Journal Article)

Nutritional fitness is a key goal of every Special Operations Forces (SOF) Operator, and nutrition is one way of potentially gaining a necessary edge. Although fad diets are popular among SOF Operators, many have no evidence with regard to military-specific tasks. One fad diet-intermittent fasting (IF)-is clearly the rage across the United States (US) and popular as a dietary pattern. Most fad diets are studied in the context of various chronic diseases, in particular, cardiovascular disease, diabetes, and obesity, and there are no data on the benefits among SOF or any military population. Thus, evidence demonstrating improvements in performance is typically lacking. Despite no clear evidence, many still devote their lives to popular fad diets. We address whether IF confers performance improvements in SOF by first discussing the concepts of metabolic flexibility and metabolic shifting, then describing IF and its subtypes, after which we summarize the literature with regard to cardiovascular disease and obesity. We close with how IF impacts performance and discuss who should use consider using IF as a dietary pattern.


Crecelius EM, Burnett MW 21(2). 98 - 99 (Journal Article)

Human brucellosis can be caused by different Brucella spp. When conducting operations in a country with high rates of brucellosis, extra precautions should be taken. Appropriate personal protective measures should be used in situations when close contact with animal carcasses cannot be avoided. Clinical diagnosis, treatment, and prevention are discussed.

Vitamin A and Bone Fractures: Systematic Review and Meta-Analysis

Knapik JJ, Hoedebecke BL 21(2). 100 - 107 (Journal Article)

Vitamin A is a generic term for compounds that have biological activity similar to that of retinol and includes carotenoids like ß-carotene and α-carotene. Some studies suggest high dietary intake of vitamin A can increase bone fracture risk. This investigation involved a systematic review and meta-analysis examining the association between vitamin A and fracture risk. Published literature was searched to find studies that (1) involved human participants, (2) had prospective cohort or case-control study designs, (3) contained original quantitative data on associations between dietary intake of vitamin A and fractures, and (4) provided either risk ratios (RRs), odds ratios (ORs), or hazard ratios (HRs) with 95% confidence intervals (95% CIs) comparing various levels of vitamin A consumption to fracture risk. Thirteen studies met the review criteria. Meta-analyses indicated that risk of hip fracture was increased by high dietary intake of total vitamin A (RR = 1.29; 95% CI = 1.07-1.57) or retinol (RR = 1.23; 95% CI = 1.02-1.48). Hip fracture risk was reduced by high dietary intake of total carotene (RR = 0.62; 95% CI = 0.42-0.93), ß-carotene (RR = 0.72; 95% CI = 0.58-0.89), or α-carotene (RR = 0.81; 95% CI = 0.67-0.97). Total fracture risk was not associated with any vitamin A compound. High intake of total vitamin A or retinol increased hip fracture risk, while high intake of some carotenoids reduced hip fracture risk.

Fresh Whole Blood Transfusion: Perspectives From a Federal Law Enforcement Agency Tactical Program

Kemp SJ, Levy MJ, Knapp JG, Steiner LA, Tang N 21(2). 108 - 111 (Journal Article)

A Brief Introduction to Phases of Clinical Medical Research for the SOF Medic

Merkle A, Randles J 21(2). 112 - 114 (Journal Article)

This is the first of an ongoing series to provide a background into reading medical research literature for the SOF medic.

Special Forces Medical Sergeant/Special Operations Independent Duty Corpsman Candidates: Large Animal Module

Yost JK, Yates J, Smith B, Workman DJ, Matlick D, Wilson ME, Wilson A 21(2). 115 - 118 (Journal Article)

Background: Medical care provided by Special Operations Forces (SOF) combat medics is vital for establishing communication with local populations. In many of these communities, livestock hold a valuable position within the social, political, and cultural structure. The West Virginia University (WVU) Special Forces Medical Sergeant/Special Operations Independent Duty Corpsman (SFMS/SOIDC) Large Animal Module is designed to provide a foundational experience in livestock husbandry and veterinary procedures to SOF combat medic candidates. This study was conducted to determine the participants' base knowledge of food animal production and to evaluate if the program content was sufficient for increasing their knowledge of the subject matter. Methods: A quasi-experimental design utilizing pre-test and post-test instruments was used. The validity of the testing instruments was established by a panel of subject matter experts and the instruments' reliability was determined by a split-half analysis using SPSS® statistical software. The difference between the pre-test and post-test examinations were compared for 66 candidates who were assigned to WVU Health Sciences Center for the applied medical experience program and 46 counterparts assigned to other institutions by a match pair analysis. Results: Seventy-five percent of the subjects had no previous livestock exposure, and only 7% had previously participated in the 4-H program or Future Farmers of America (FFA). The average improvement in scores, pre-test versus post-test, was significantly greater for those that attended the module (18.5 versus 0.9). Conclusion: Few SFMS/SOIDC candidates have prior knowledge of livestock husbandry practices. The large animal module successfully provides education on livestock husbandry practice to participants. Knowledge of livestock production can assist SOF medics in establishing rapport with indigenous populations while on mission.

Military Use of Point of Care Ultrasound (POCUS)

Savell SC, Baldwin DS, Blessing A, Medelllin KL, Savell CB, Maddry JK 21(2). 35 - 42 (Journal Article)

Background: Point of care ultrasound (POCUS) offers multiple capabilities in a relatively small, lightweight device to military clinicians of all types and levels in multiple environments. Its application in diagnostics, procedural guidance, and patient monitoring has not been fully explored by the Military Health System (MHS). The purpose of this narrative review of the literature was to examine the overall use of POCUS in military settings, as well as the level of ultrasound training provided. Methods: Studies related to use of POCUS by military clinicians with reported sensitivity/specificity, accuracy of exam, and/or clinical decision impact met inclusion criteria. After initial topical review and removal of duplicates, two authors selected 17 papers for consideration for inclusion. Four of the authors reviewed the 17 papers and determined the final inclusion of 14 studies. Results: We identified seven prospective studies, of which three randomized subjects to groups. Five reports described use of POCUS in patients, two used healthy volunteers, two were in simulation training environments, four used animal models to simulate specific conditions, and one used a cadaver model. Clinician subjects ranged from one to 34. Conventional medics were subjects in six studies. Four studies included special operations medics. One study included nonmedical food service inspectors. The use of ultrasound in theater by deployed consultant radiologists is described in three reports. Conclusions: Military clinicians demonstrated the ability to perform focused exams, including FAST exams and fracture detection with acceptable sensitivity and specificity. POCUS in the hands of trained military clinicians has the potential to improve diagnostic accuracy and ultimately care of the war fighter.

Pressure Responses of Tourniquet Practice Models to Calibrated Force Applications

Wall PL, Hingtgen E, Buising CM 21(2). 11 - 17 (Journal Article)

Background: Tourniquet training sometimes involves models, and a certification process is expected to use something other than human limbs; therefore, investigating model- and limb-pressure responses to force application is important. Methods: Pressure response to force was collected for a 3.8cm-wide nonelastic strap and a 10.1cm-wide elastic strap placed over 14 objects. Each object was suspended; an inflated neonatal blood pressure cuff was placed atop the object with the strap over the bladder; and strap ends were connected below with 4.54kg weights attached at 20-second intervals to 27.24kg. Results: Pressure-response curves differed by strap, thigh aspect (medial, lateral, ventral, dorsal; n = 2 subjects; p < .0001); subject (medial thigh; n = 3 subjects; p < .0001); and object (thighs; small and large pool noodles ± central metal rod, foam yoga roller, coffee can, 20% ballistic gel cylinder [Gel; Clear Ballistics;] with central metal tubing, rolled pair of 5mm yoga mats ± central metal rod, hemorrhage-control training thigh [Z-Medica], sand-filled training manikin limb [Drumm Emergency Solutions]; p < .0001). Compliance, circumference, support techniques, and surface interactions, especially with the 10.1cm-wide elastic strap, affected pressure responses: smaller circumference, lower compliance, and lower surface coefficient of friction were associated with higher pressure/force applied. Conclusions: Different objects have different pressure-response curves. This may be important to acquisition and retention of limb tourniquet skills and is important for systems for certifying tourniquets.

Winter 2020 Journal (Vol 20 Ed 4)

Vol 20 Ed 4
Winter 2020 Journal of Special Operations Medicine
ISSN: 1553-9768

View the Table of Contents

Available for preorder. Estimated ship date is December 31st 2020

Prehospital Needle Decompression Improves Clinical Outcomes in Helicopter Evacuation Patients With Multisystem Trauma: A Multicenter Study

Henry R, Ghafil C, Golden A, Matsushima K, Eckstein M, Foran CP, Theeuwen H, Bentley DE, Inaba K, Strumwasser A 21(1). 49 - 54 (Journal Article)

Background: The utility of prehospital thoracic needle decompression (ND) for tension physiology in the civilian setting continues to be debated. We attempted to provide objective evidence for clinical improvement when ND is performed and determine whether technical success is associated with provider factors. We also attempted to determine whether certain clinical scenarios are more predictive than others of successful improvement in symptoms when ND is performed. Methods: Prehospital ND data acquired from one air ambulance service serving 79 trauma centers consisted of 143 patients (n = 143; ND attempts = 172). Demographic and clinical outcome data were retrospectively reviewed. Patients were stratified by prehospital characteristics and indications. Objective outcomes were measured as improvement in vital signs, subjective patient assessment, and physical examination findings. Univariate analysis was performed using chi-square for variable proportions and unpaired Student's t-test for variable means; p < .05 was considered statistically significant. Results: The success rate of ND performed for hypoxia (70.5%) was notably higher than ND performed for hemodynamic instability (20.3%; p < .01) or cardiac arrest (0%; p < .01). Compared to vital sign parameters, clinical examination findings as part of the indication for ND did not reliably predict technical success (p > .52 for all indications). No difference was observed comparing registered nurse versus paramedic (p = .23), diameter of catheter (p > .13 for all), or length of catheter (p = .12). Conclusion: Prehospital ND should be considered in the appropriate clinical setting. Outcomes are less reliable in cases of cardiopulmonary arrest or hypotension with respiratory symptoms; however, this should not deter prehospital providers from attempting ND when clinically indicated. Additionally, the success rate of prehospital ND does not appear to be related to catheter type or the role of the performing provider.

Performance Characteristics of Fluid Warming Technology in Austere Environments

Blakeman T, Fowler J, Branson R, Petro M, Rodriquez D 21(1). 18 - 24 (Journal Article)

Resuscitation of the critically ill or injured is a significant and complex task in any setting, often complicated by environmental influences. Hypothermia is one of the components of the "Triad of Death" in trauma patients. Devices for warming IV fluids in the austere environment must be small and portable, able to operate on battery power, warm fluids to normal body temperature (37°C), and perform under various conditions, including at altitude. The authors evaluated four portable fluid warmers that are currently fielded or have potential for use in military environments.

Rationale and Implementation of a Novel Special Operations Medical Officer Course

Fedor PJ, Dorsch J, Kharod C, Paladino L, Rush SC 21(1). 25 - 29 (Journal Article)

Background: The Air Force Special Warfare Medical Officer Course was created to address the lack of operationally focused, job-specific clinical training for medical officers (MOs). This course addresses the gap in knowledge, skill, and application of operational medicine, as well as the behavioral health, human performance, education, and medical oversight of Operators. Methods: The course was designed around the senior author's decade of experience piecing together training for his own role as a pararescue flight surgeon and informed by 5 years of flight surgeon courses, lessons learned from case studies of ill-prepared deployed physicians, and input from prehospital medicine subject matter experts. Results: Air Force pararescue and special tactics flight surgeons, physician assistants, and an independent duty medical technician (IDMT) attended. The course consisted of 10 full weekdays of didactics and skills sessions covering theory and application of operational medicine, human performance optimization, behavioral health for Operators, adult education theory, principles of prehospital clinical oversight, and other expeditionary concepts. The course culminated with combat casualty care scenario-based exercises, in which the providers performed operational medicine in full kit with weapons and simulation rounds. Discussion: For many logistical and practical reasons, civilian medical experience, traditional military medical training, existing special operations medical courses, and "merit badge" card classes are not adequate preparation for this specialized role. Focused, job-specific training should be provided to Special Operations Forces Medical Officers (SOFMO) and, ultimately, to any MO deploying in support of medics or combatants. The goal is to maximize the success of military medical operations while reducing the morbidity and mortality of combat and training casualties. Conclusion: This operationally focused MO course can serve as a model for the future training of SOFMO and has stimulated discussion for consideration of a joint approach to prehospital medical training.

Conversion of the Abdominal Aortic and Junctional Tourniquet (AAJT) to Infrarenal Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Is Practical in a Swine Hemorrhage Model

Stigall K, Blough PE, Rall JM, Kauvar DS 21(1). 30 - 36 (Journal Article)

Background: Two methods of controlling pelvic and inguinal hemorrhage are the Abdominal Aortic and Junctional Tourniquet (AAJT; Compression Works) and resuscitative endovascular balloon occlusion of the aorta (REBOA). The AAJT can be applied quickly, but prolonged use may damage the bowel, inhibit ventilation, and obstruct surgical access. REBOA requires technical proficiency but avoids many of the complications associated with the AAJT. Conversion of the AAJT to REBOA would allow for field hemorrhage control with mitigation of the morbidity associated with prolonged AAJT use. Methods: Yorkshire male swine (n = 17; 70-90kg) underwent controlled 40% hemorrhage. Subsequently, AAJT was placed on the abdomen, midline, 2cm superior to the ilium, and inflated. After 1 hour, the animals were allocated to an additional 30 minutes of AAJT inflation (continuous AAJT occlusion [CAO]), REBOA placement with the AAJT inflated (overlapping aortic occlusion [OAO]), or REBOA placement following AAJT removal (sequential aortic occlusion [SAO]). Following removal, animals were observed for 3.5 hours. Results: No statistically significant differences in survival, blood pressure, or laboratory values were found following intervention. Conversion to REBOA was successful in all animals but one in the OAO group. REBOA placement time was 4.3 ± 2.9 minutes for OAO and 4.1 ± 1.8 minutes for SAO (p = .909). No animal had observable intestinal injury. Conclusions: Conversion of the AAJT to infrarenal REBOA is practical and effective, but access may be difficult while the AAJT is applied.

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