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Advise and Assist: A Basic Medical Skills Course for Partner Forces

April MD, Lopes T, Schauer SG, Meneses M, Roszenweig H, Byram D, Timms-Williams Z, Shields TP, Cross AN, Hoffmann LJ 17(4). 63 - 67 (Journal Article)

Background: Training partner forces in battlefield first-responder medical skills is an important component of US military advise-and-assist operations. We designed and executed a training curriculum focused on high-yield-based medical skills to prevent death on the battlefield for non-English speaking members of the Turkish, Azerbaijani, and Albanian militaries deployed to Afghanistan. Methods: We designed a 2-hour training curriculum focusing on four basic medical skills: (1) assessment of scene safety; (2) limb tourniquet application; (3) wound bandaging; and (4) patient transportation via litter. Our combat medics delivered standardized training using both didactic and practicum components. Instructors made beforeand- after assessments of the proficiency of each participant for each skill in accordance with the Dreyfus model of skill acquisition. We also administered before-and-after, Likertscale- based surveys for training participants to report their self-assessed comfort level with each of the four skills. Results: We delivered training to 187 participants over five classes. All 28 participants in the final teaching class completed the study. Instructors categorized each participant's skill level as novice before training for all four skills. After the training curriculum, all participants achieved a skill level consistent with advanced beginner for all four skills. Participants reported significant improvements in self-reported comfort levels for all taught procedures (ρ < .001 by Wilcoxon signed-rank test for all four skills). The largest reported increase in median comfort level was for tourniquet application: median pretraining comfort level, 4 (interquartile range [IQR], 0-6.25) versus 9.5 (IQR, 9-10) posttraining. Conclusion: Our curriculum resulted in significant improvements in instructor-assessed proficiency and self-reported comfort level for all four basic medical skills. Although our outcome measures have important limitations, this curriculum may be useful framework for future medics and physicians designing battlefield first-responder training curricula for members of foreign militaries.

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Experience With Prehospital Damage Control Capability in Modern Conflict: Results From Surgical Resuscitation Team Use

DuBose JJ, Martens D, Frament C, Haque I, Telian S, Benson PJ 17(4). 68 - 71 (Journal Article)

Background: Early resuscitation and damage control surgery (DCS) are critical components of modern combat casualty care. Early and effective DCS capabilities can be delivered in a variety of settings through the use of a mobile surgical resuscitation team (SRT). Methods: Twelve years of after-action reports from SRTs were reviewed. Demographics, interventions, and outcomes were analyzed. Results: Data from 190 casualties (185 human, five canine) were reviewed. Among human casualties, 12 had no signs of life at intercept and did not survive. Of the remaining 173 human casualties, 96.0% were male and 90.8% sustained penetrating injuries. Interventions by the SRT included intravascular access (50.9%) and advanced airway establishment (29.5%). Resuscitation included whole blood (3.5%), packed red blood cells (20.8%), and thawed plasma (11.0%). Surgery was provided for 63 of the 173 human casualties (36.4%), including damage control laparotomy (23.8%) and arterial injury shunting or repair (19.0%). SRTs were effectively used to augment an existing medical treatment facility (70.5%), to facilitate casualty transport (13.3%), as an independent surgical entity at a forward ground structure (9.2%), and in mobile response directly to the point of injury (6.9%). Overall survival was 97.1%. Conclusion: An SRT provides a unique DCS capability that can be successfully used in a variety of flexible roles.

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Diagnostic Accuracy of Emergency Bedside Ultrasonography to Detect Cutaneous Wooden Foreign Bodies: Does Size Matter?

Fleming ME, Heiner JD, Summers S, April MD, Chin EJ 17(4). 72 - 75 (Journal Article)

Background: Soft-tissue occult foreign bodies are a concerning cause of morbidity in the emergency department. The identification of wooden foreign bodies is a unique challenge because they are often not detectable by plain radiography. The purpose of this study was to determine the diagnostic accuracy of emergency physician-performed ultrasonography to detect wooden foreign bodies of varying sizes. We hypothesized that sonographic sensitivity would improve with increasing foreign body size. Methods: We conducted a blinded, prospective evaluation using a previously validated, chicken, soft-tissue model to simulate human tissue. We inserted wooden toothpicks of varying lengths (1mm, 2.5mm, 5mm, 7.5mm, 10mm) to a depth of 1cm in five tissue models. Five additional models were left without a foreign body to serve as controls. Fifty emergency physicians with prior ultrasonography training performed sonographic examinations of all 10 models and reported on the presence or absence of wooden foreign bodies. Results: Subjects performed 10 ultrasonography examinations each for a total of 500 examinations. For the detection of wooden foreign bodies, overall test characteristics for sonography included sensitivity 48.4% (95% confidence interval [CI], 42.1%-54.8%) and specificity 67.6% (95% CI, 61.3%- 73.2%). Sensitivity did not change as object size increased (ρ = s.709). Conclusion: Emergency physician bedside ultrasonography demonstrated poor diagnostic accuracy for the detection of wooden foreign bodies. Accuracy did not improve with increasing object size up to 10mm. Providers should consider alternative diagnostic modalities if there is persistent clinical concern for a retained, radiolucent, soft-tissue foreign body.

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Expeditionary Resuscitation Surgical Team: The US Army's Initiative to Provide Damage Control Resuscitation and Surgery to Forces in Austere Settings

D'Angelo M, Losch J, Smith B, Geslak M, Compton S, Wofford K, Seery JM, Morrison M, Wedmore I, Paimore J, Gross K, Cuenca PJ, Welder MD 17(4). 76 - 79 (Journal Article)

Improvements in surgical care on the battlefield have contributed to reduced morbidity and mortality in wounded Servicemembers. 1 Point-of-injury care and early surgical intervention, along with improved personal protective equipment, have produced the lowest casualty statistics in modern warfare, resulting in improved force strength, morale, and social acceptance of conflict. It is undeniable that point-of-care injury, followed by early resuscitation and damage control surgery, saves lives on the battlefield. The US Army's Expeditionary Resuscitation Surgical Team (ERST) is a highly mobile, interprofessional medical team that can perform damage control resuscitation and surgery in austere locations. Its configuration and capabilities vary; however, in general, a typical surgical element can perform one major surgery and one minor surgery without resupply. The critical care element can provide prolonged holding in garrison, but this diminishes in the austere setting with complex and acutely injured patients.

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Efficacy of the Mnemonic Device "MARCH PAWS" as a Checklist for Pararescuemen During Tactical Field Care and Tactical Evacuation

Kosequat J, Rush SC, Simonsen I, Gallo I, Scott A, Swats K, Gray CC, Mason B 17(4). 80 - 84 (Journal Article)

Background: The application of Tactical Combat Casualty Care (TCCC) represents evidence-based medicine to improve survival in combat. Over the past several years, US Air Force Pararescuemen (PJs) have expanded the mnemonic device "MARCH" to "MARCH PAWS" for use during tactical field care and tactical evacuation (TACEVAC). The mnemonic stands for massive bleeding, airway, respiration, circulation, head and hypothermia, pain, antibiotics, wounds, and splinting. We undertook this performance improvement project to determine the efficacy of this device as a treatment checklist. Methods: The mission reports of a 16-PJ combat rescue deployment to Operation Enduring Freedom (OEF) from January through June 2012 were reviewed. The triage category, mechanism of injury, injury, and treatments were noted. The treatments were then categorized to determine if they were included in MARCH PAWS. Results: The recorded data for missions involving 465 patients show that 45%, 48%, and 7%, were in category A, B, and C, respectively (urgent, priority, routine); 55% were battle injuries (BIs) and 45% were nonbattle injuries (NBIs). All treatments for BI were accounted for in MARCH PAWS. Only 9 patients' treatments with NBI were not in MARCH PAWS. Conclusion: This simple mnemonic device is a reliable checklist for PJs, corpsmen, and medics to perform TACEVAC during combat Operations, as well as care for noncombat trauma patients.

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Clinical Update: The Risk of Opioid Toxicity and Naloxone Use in Operational K9s

Palmer LE, Gautier A 17(4). 86 - 92 (Journal Article)

The increasing use of opioids (e.g., fentanyl, carfentanil) for illicit drug manufacturing poses a potential life-threatening hazard to law enforcement officers and first responders (e.g., EMS, fire and rescue) who may unknowingly come into contact with these drugs during the course of their daily activities. Similarly, Operational canines (OpK9s) of all disciplines-detection (drug, explosive, accelerant), patrol, tracking, search and rescue, and others-are at risk for accidental illicit opioid exposure. The most serious adverse effect of opioid exposure is respiratory depression leading to slow, shallow breathing or complete cessation of voluntary breathing (respiratory arrest). Naloxone, an opioid antagonist, is the antidote for reversing the effects of an opioid overdose in both humans and OpK9s. This clinical update describes the potential risks associated with opioid exposure as well as the use of naloxone as it pertains to the OpK9.

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Military Prehospital Use of Low Titer Group O Whole Blood

Warner N, Zheng J, Nix G, Fisher AD, Johnson JC, Williams JE, Northern DM, Hellums JS 18(1). 15 - 18 (Case Reports)

The military's use of whole-blood transfusions is not new but has recently received new emphasis by the Tactical Combat Casualty Care Committee. US Army units are implementing a systematic approach to obtain and use whole blood on the battlefield. This case report reviews the care of the first patient to receive low titer group O whole blood (LTOWB) transfusion, using a new protocol.

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Benefit of Critical Care Flight Paramedic-Trained Search and Rescue Corpsmen in Treatment of Severely Injured Aviators

Snow RW, Papalski W, Siedler J, Drew B, Walrath B 18(1). 19 - 22 (Case Reports)

During routine aircraft start-up procedures at a US Naval Air Station, an aviation mishap occurred, resulting in the pilot suffering a traumatic brain injury and the copilot acquiring bilateral hemopneumothoraces, a ruptured diaphragm, and hepatic and splenic contusions. The care of both patients, including at point of injury and en route to the closest trauma center, is presented. This case demonstrates a benefit from advanced life-saving interventions and critical care skills beyond the required scope of practice of search and rescue medical technicians as dictated by relevant instructions.

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Challenges of Transport and Resuscitation of a Patient With Severe Acidosis and Hypothermia in Afghanistan

Brazeau MJ, Bolduc CA, Delmonaco BL, Syed AS 18(1). 23 - 28 (Case Reports)

We present the case of a patient with new-onset diabetes, severe acidosis, hypothermia, and shock who presented to a Role 1 Battalion Aid Station (BAS) in Afghanistan. The case is unique because the patient made a rapid and full recovery without needing hemodialysis. We review the literature to explain how such a rapid recovery is possible and propose that hypothermia in the setting of his severe acidosis was protective.

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The Shrail: A Comparison of a Novel Attachable Rail System With the Current Deployment Operating Table

Dilday J, Sirkin MR, Wertin T, Bradley F, Hiles J 18(1). 29 - 31 (Case Reports)

The current forward surgical team (FST) operating table is heavy and burdensome and hinders essential movement flexibility. A novel attachable rail system, the Shrail, has been developed to overcome these obstacles. The Shrail turns a North Atlantic Treaty Organization litter into a functional operating table. A local FST compared the assembly of the FST operating table with assembling the Shrail. Device weight, storage space, and assembly space were directly measured and compared. The mean assembly time required for the Shrail was significantly less compared with the operating table (23.36 versus 151.6 seconds; p ≤ .01). The Shrail weighs less (6.80kg versus 73.03kg) and requires less storage space (0.019m3 versus 0.323m3) compared with the current FST operating table. The Shrail provides an FST with a faster, lighter surgical table assembly. For these reasons, it is better suited for the demands of an FST and the implementation of prolonged field care.

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Bringing Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Closer to the Point of Injury

Pasley JD, Teeter WA, Gamble WB, Wasick P, Romagnoli AN, Pasley AM, Scalea TM, Brenner ML 18(1). 33 - 36 (Case Reports)

Background: The management of noncompressible torso hemorrhage remains a significant issue at the point of injury. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used in the hospital to control bleeding and bridge patients to definitive surgery. Smaller delivery systems and wirefree devices may be used more easily at the point of injury by nonphysician providers. We investigated whether independent duty military medical technicians (IDMTs) could learn and perform REBOA correctly and rapidly as assessed by simulation. Methods: US Air Force IDMTs without prior endovascular experience were included. All participants received didactic instruction and evaluation of technical skills. Procedural times and pretest/posttest examinations were administered after completion of all trials. The Likert scale was used to subjectively assess confidence before and after instruction. Results: Eleven IDMTs were enrolled. There was a significant decrease in procedural times from trials 1 to 6. Overall procedural time (± standard deviation) decreased from 147.7 ± 27.4 seconds to 64 ± 8.9 seconds (ρ < .001). There was a mean improvement of 83.7 ± 24.6 seconds from the first to sixth trial (ρ < .001). All participants demonstrated correct placement of the sheath, measurement and placement of the catheter, and inflation of the balloon throughout all trials (100%). There was significant improvement in comprehension and knowledge between the pretest and posttest; average performance improved significantly from 36.4.6% ± 12.3% to 71.1% ± 8.5% (ρ < .001). Subjectively, all 11 participants noted significant improvement in confidence from 1.2 to 4.1 out of 5 on the Likert scale (ρ < .001). Conclusion: Technology for aortic occlusion has advanced to provide smaller, wirefree devices, making field deployment more feasible. IDMTs can learn the steps required for REBOA and perform the procedure accurately and rapidly, as assessed by simulation. Arterial access is a challenge in the ability to perform REBOA and should be a focus of further training to promote this procedure closer to the point of injury. Keywords: hemorrhage control; independent duty medical technician; resuscitative endovascular balloon occlusion of the aorta; REBOA

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Intelligent Exam for Crucial Intelligence. . .

Dare C, Hampton K 18(2). 141 (Journal Article)

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What's in a Rash? Viral Exanthem Versus CBRNE Exposure: Teleconsultation Support for Two Special Forces Soldiers With Diffuse Rash in an Austere Environment

Lee HD, Butterfield S, Maddry J, Powell D, Vasios WN, Yun H, Ferraro D, Pamplin JC 18(2). 133 - 135 (Journal Article)

Objective: Review clinical thought process and key principles for diagnosing weaponized chemical and biologic injuries. Clinical Context: Special Operation Forces (SOF) team deployed in an undisclosed, austere environment. Organic Expertise: Two SOF Soldiers with civilian EMT-Basic certification. Closest Medical Support: Mobile Forward Surgical Team (2 hours away); medical consults available by e-mail, phone, or video-teleconsultation. Earliest Evacuation: Earliest military evacuation from country 12-24 hours. With teleconsultation, patients departed to Germany as originally scheduled without need for Medical Evacuation.

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Epidemiologic Evidence and Possible Mechanisms for the Association Between Cigarette Smoking and Injuries. Part 2: Is the Relationship Between Smoking and Injuries Causal?

Knapik JJ, Bedno SA 18(2). 117 - 122 (Journal Article)

Part 1 of this series reviewed the epidemiologic evidence for the association between cigarette smoking and injuries and possible biological and psychosocial mechanisms to account for this relationship. In the present article, nine criteria are explored to determine if smoking is a direct cause of injuries (i.e., a causal relationship). There is substantial evidence that individuals who smoked in the past have a higher subsequent risk of injury. A recent meta-analysis found that smokers in the military were 1.31 times more likely to be injured than nonsmokers and Servicemembers with low, medium, and high levels of smoking had 1.27, 1.37, and 1.71 times, respectively, the risk of injury compared with nonsmokers. The association between smoking and injuries has been reported in at least 18 US military studies and in 14 civilian studies in seven countries. The biological plausibility of the association was discussed extensively in part 1 of this series. A possible alternative explanation with sufficient data was that smokers may be risk takers and it is the risk-taking behavior that increases injury risk (not smoking per se). Once an individual no longer smokes, a decrease in injury risk has been reported for at least bone health and wound healing. The effects of smoking do not appear to be specific to one type of injury, possibly because of the numerous compounds in tobacco smoke that could affect tissues and physiological processes, with evidence provided for bones, tendons, and healing processes. The association was consistent with other knowledge, with some evidence provided from other types of medical problems and trends in smoking and injury-related mortality. In summary, the association between smoking and injuries appears to meet many of the criteria for a causal relationship.

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Dietary Supplements for Musculoskeletal Pain: Science Versus Claims

Crawford C, Saldanha L, Costello R, Deuster PA 18(2). 110 - 114 (Journal Article)

Special Operations Forces (SOF) face unique challenges that manifest themselves both mentally and physically. The extremes of training and combat can affect the readiness to perform at peak levels, especially when confronted with musculoskeletal pain. Many SOF Operators turn to dietary supplements in hopes of gaining an edge. Although some supplements are now being marketed for pain, decisions to use these products need to be driven by information that is evidence based. We describe SOF-specific evidence-based recommendations for the use of dietary ingredients for pain that emerged from a rigorous scientific evaluation. These recommendations are compared with the label claims made in the commercial market by companies selling products to combat musculoskeletal pain. This information can be used by the SOF medical community to assist Operators in making informed decisions when considering or selecting dietary supplements for maintaining and optimizing performance.

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Survey of Casualty Evacuation Missions Conducted by the 160th Special Operations Aviation Regiment During the Afghanistan Conflict

Redman TT, Mayberry KE, Mora AG, Benedict BA, Ross EM, Mapp JG, Kotwal RS 18(2). 79 - 85 (Journal Article)

Background: Historically, documentation of prehospital combat casualty care has been relatively nonexistent. Without documentation, performance improvement of prehospital care and evacuation through data collection, consolidation, and scientific analyses cannot be adequately accomplished. During recent conflicts, prehospital documentation has received increased attention for point-of-injury care as well as for care provided en route on medical evacuation platforms. However, documentation on casualty evacuation (CASEVAC) platforms is still lacking. Thus, a CASEVAC dataset was developed and maintained by the 160th Special Operations Aviation Regiment (SOAR), a nonmedical, rotary-wing aviation unit, to evaluate and review CASEVAC missions conducted by their organization. Methods: A retrospective review and descriptive analysis were performed on data from all documented CASEVAC missions conducted in Afghanistan by the 160th SOAR from January 2008 to May 2015. Documentation of care was originally performed in a narrative after-action review (AAR) format. Unclassified, nonpersonally identifiable data were extracted and transferred from these AARs into a database for detailed analysis. Data points included demographics, flight time, provider number and type, injury and outcome details, and medical interventions provided by ground forces and CASEVAC personnel. Results: There were 227 patients transported during 129 CASEVAC missions conducted by the 160th SOAR. Three patients had unavailable data, four had unknown injuries or illnesses, and eight were military working dogs. Remaining were 207 trauma casualties (96%) and five medical patients (2%). The mean and median times of flight from the injury scene to hospital arrival were less than 20 minutes. Of trauma casualties, most were male US and coalition forces (n = 178; 86%). From this population, injuries to the extremities (n = 139; 67%) were seen most commonly. The primary mechanisms of injury were gunshot wound (n = 89; 43%) and blast injury (n = 82; 40%). The survival rate was 85% (n = 176) for those who incurred trauma. Of those who did not survive, most died before reaching surgical care (26 of 31; 84%). Conclusion: Performance improvement efforts directed toward prehospital combat casualty care can ameliorate survival on the battlefield. Because documentation of care is essential for conducting performance improvement, medical and nonmedical units must dedicate time and efforts accordingly. Capturing and analyzing data from combat missions can help refine tactics, techniques, and procedures and more accurately define wartime personnel, training, and equipment requirements. This study is an example of how performance improvement can be initiated by a nonmedical unit conducting CASEVAC missions.

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Surgery at Sea: The Effect of Simulated High Sea States on Surgical Performance

Pierce E, Rapada R, Herder PA, LaPorta AJ, Hoang TN, Pena M, Blankenship J, Kiser J, Catlin SA 18(2). 64 - 70 (Journal Article)

Background: The US Navy initiated design concepts for a Medical Mission Module Support Container (M3SC), a mobile operating room capable of rapid installation aboard maneuverable ships within proximity of active combat units. The M3SC provides an alternative echelon of care in the current trauma system by decreasing the time between point of injury, arrival, and surgical intervention. The mobile ships used as M3SC platforms, however, are more susceptible to oceanic conditions that can induce detrimental physiologic motion sickness in medical personnel and patients aboard the vessels. This study investigated the effects of different sea-state motion conditions on the performance of surgical teams. Methods: Six four-person surgical teams performed 144 procedures in an M3SC aboard a Stewart motion table that simulated motion profiles of sea states 0, 3, and 4. A modified human-worn partial- task surgical simulator was used as a surgical surrogate to simulate the four most common, wartime, improvised explosive device injuries in the past 10 years. Electroencephalographs and heart rate variability (HRV) data were collected from surgeons and surgical technologists during each procedure to assess real-time physiologic responses to motion. Two postprocedure surveys, a Surgical Task Load Index and a Motion Sickness Assessment Questionnaire, were given to assess subjective responses of workload stress and motion-induced kinetosis. Surgical subject matter experts quantified surgical performance after each procedure by measuring blood loss and orthopedic pin placement to evaluate each intervention. Results: Motion did not significantly influence overall performance (ρ = .002). Surgical procedure was the strongest predictor of performance. HRV was used to measure stress and was increased in surgical technologists; however, HRV was decreased for surgeons and technologists in motion. There was a significant interaction between role and motion (ρ = .002): Surgeons had higher workloads than did surgical technologists and neither demonstrated differences between motion and no motion. Surgeons demonstrated significantly decreased workloads under motion conditions (ρ = 0.002); however, surgeons perceived their workload to be higher. We attribute this to their increased critical thinking and physical execution of procedures. Surgeons and surgical technologists showed a trend toward HRV suppression within the motion conditions. This may indicate a coping response to the increased stress of the motion setting. Procedure and team dynamic were the strongest predictors of overall performance, suggesting a learning curve exists and that added focus on training should be enforced. Conclusion: Based on data collected in this study, similar surgical procedures should be implemented aboard these classes of ships. By doing so, injured military personnel would have more timely access to care. Surgical team members were aware of craft motion, used compensatory measures, and exhibited some physiological response.

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Old Tricks for New Dogs? John Caddy and the Victorian Origins of TCCC

Reynolds PS 18(2). 58 - 62 (Journal Article)

The success of Tactical Combat Casualty Care (TCCC) in reducing potentially preventable combat deaths may rely on both specific interventions (such as tourniquets) and the systematized application of immediate care. Essential elements of a combat care system include clear specification of immediate care priorities, standardized methodology, and inclusion and training of all nonmedical personnel in early response. Although TCCC is fairly recent, the construct is similar to that first suggested during the mid-nineteenth century by John Turner Caddy (1822-1902), a British Royal Navy staff surgeon. Although naval warfare engagements at the time were relatively infrequent, casualties could be numerous and severe and often overwhelmed the small medical staff on board. Caddy recognized that nonmedical personnel properly trained in the fundamentals of combat injury management would result in lives saved and greatly improved morale. The novelty was in his attempt to make procedures simple enough to be performed by nonmedical personnel under stress. However, Caddy's guidelines were completely overlooked for nearly two centuries. The principles of best practice for managing combat trauma injuries learned in previous wars have often been lost between conflicts. Understanding the historical roots of combat first responder care may enable us to better understand and overcome barriers to recognition and retention of essential knowledge.

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