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Telemedicine Supervision of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Catheter Placement

Qasim Z, Graham C 22(1). 108 - 110 (Case Reports)

The rapid control of traumatic or nontraumatic exsanguinating hemorrhage in critically injured patients is key to limiting morbidity and mortality in civilian and military practice. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been developed to address potentially preventable death from torso or lower extremity junctional hemorrhage. This time-critical, high-acuity, low-occurrence procedure sometimes precludes the appropriate supervision of clinicians familiar with it. We describe the case of a patient who had recently undergone liver transplantation presenting to the intensive care unit (ICU) and found to be in severe nontraumatic hemorrhagic shock, necessitating REBOA placement as part of the resuscitation. The bedside proceduralist was trained but inexperienced in the procedure and was supervised by a telemedicine intensivist, resulting in rapid and safe insertion. We describe what to our knowledge is the first use of telemedicine to supervise the successful placement of a REBOA catheter in a critically ill patient and discuss how this can potentially benefit military clinicians working in low-resource, far-forward environments.

Pulseless Arrest After Rapid Sequence Intubation of the Massively Hemorrhaged Warfighter: A Case Series

Schwarzkoph BW, Iteen D, Auten B 22(1). 104 - 107 (Case Reports)

Management of hemorrhagic shock and airway stabilization are two pillars of trauma resuscitation which have a dependent, yet incompletely understood relationship. Patients presenting with traumatic hemorrhage may manifest shock physiology prior to intubation, conferring a higher risk of postintubation hypotension, pulseless arrest, and mortality. This case series describes of a group of seven US military members with combat-related trauma who experienced pulseless arrest after rapid sequence intubation in a role 2 or role 3 setting. All except one of the patients had hemodynamics suggesting hemorrhagic shock prior to intubation. This case series highlights the need for further research to define which trauma patients are at risk of postintubation pulseless arrest. It also focuses on the knowledge gap related to the role that delayed airway management and judicious blood product resuscitation may play in preventable death after injury.

Contrived Breathing Circuit Connection for Emergency Percutaneous Transtracheal Ventilation by Needle Cricothyrotomy in the Field

Naftalovich R, Iskander AJ 22(1). 102 - 103 (Journal Article)

Surgical airway approaches are, at times, last resort options in difficult airway management. In Special Operations these interventions confront distorted anatomy from combat trauma, extreme conditions, and may be performed by non-medically trained personnel. Under these circumstances, needle cricothyroidotomy using a large bore intravenous catheter can be considered. A small syringe connected to the needle can confirm transtracheal placement through air aspiration before passing the angiocatheter over the needle. Button activated retracting needles should be avoided for this when possible. We recommend a 3-mL Luer-lock syringe because a small syringe is better suited for generating pressure and once the catheter is in the trachea, this same syringe can be connected to bag valve ventilation by replacing its plunger with a connector from a 6.5-, 7-, or 7.5-mm endotracheal tube. Adding these small and light high-yield items to the Tactical Combat Casualty Care medic inventory should be considered in future revisions.

Injuries and Interventions on Transported Military Working Dogs Within the US Central Command

Johnson SA, Carr C, Reeves LK, Bean K, Schauer SG 22(1). 97 - 101 (Journal Article)

Background: Limited veterinary care is available in the far forward environment, leading to human medical personnel being responsible, in part, for treatment of military working dogs (MWD). Though guidelines for MWD care exist, there is little research on the care and treatment of MWDs by human medical personnel. There is a lot of research on the care and treatment of MWDs. Methods: This is a secondary analysis of a dataset from the Transportation Command (TRANSCOM) Regulating Command & Control and Evacuation System (TRAC2ES) database within the US Central Command (CENTCOM) from 2008 to 2018. Within this dataset specific to regulated transport from locations within CENTCOM, we abstracted all entries involving MWDs and analyzed causes of injury, type of injury, and interventions performed on traumatically and non-traumatically injured MWDs. Results: Within our dataset, there were 84 MWD cases for analysis. Of those, 36 (43%) were transported for traumatic injuries, and the remaining 48 (57%) were transported for other medical ailments. The most common cause of trauma was gunshot wound (31%), followed by explosion (22%). The majority of trauma MWDs had injuries to the extremities (67%), and hemorrhage requiring intervention occurred in 25%. The most common interventions performed on traumas were analgesia (67%), antibiotics (31%), IV fluids (28%), and surgery (31%). The most common indications that occurred in MWDs treated for nontraumatic medical indications were gastrointestinal diseases (33%), followed by nontraumatic orthopedic injuries (21%). Conclusions: Of the MWDs in our dataset, most were transported for nontraumatic medical events. The most frequent intervention performed was medication administration for both traumatic and medical ailments. Our dataset adds to the limited body of MWD data from theater.

Linear Regression as a Method to Prioritize Humanitarian Efforts in Stability Operations

Nicholson J, Perry MJ 22(1). 92 - 96 (Journal Article)

With a mandate to work by, with, and through host nation partners, Special Operations Forces (SOF) often face the challenge of pursuing humanitarian endeavors in the hopes of securing access to a specific population and mapping the human terrain. Likewise, should limitations in the rules of engagement (ROE) shift incentives from lethal to non-lethal effects, commanders must find unique ways to exert influence on the operational environment. However, with inevitable resource constraints such as money and time, it can be exceedingly difficult to determine which humanitarian project to undertake, especially in a population whose needs are multifaceted. Linear regression, a statistical tool available within the standard Microsoft Excel package on government computers, permits the modeling of predictive outcomes between a number of independent variables against a dependent variable. This allows the determination of significance and effect for each independent variable, which can facilitate a thoughtful recommendation to commanders for project selection. Using Iraq as an example, publicly available information (PAI) provides a wealth of records to make data-driven assessments for mutually beneficial shaping efforts in a stability operations framework. Additionally, this paper will highlight how data can be analyzed without a reliance on statistical software that is unlikely to be present in the tactical environment.

Battlefield Management of Facial Fractures Using Minnie Ties: An Innovative Technique for Maxillomandibular Fixation

Ivory JW, Jenzer AC 22(1). 87 - 91 (Journal Article)

Application of maxillomandibular fixation (MMF) for the treatment of jaw fractures has a long history stretching back thousands of years. Modern methods of MMF require extensive training for correct application and are often not practical to perform in a forward operating environment. Most MMF methods carry inherent risks of sharps injuries and exposure to bloodborne pathogens. The authors present a method of MMF with Minnie Ties, which are simple, effective, and much safer than traditional methods of MMF.

Austere Fasciotomy: Alternative Equipment for Performance in the Field

DeSoucy ES, Hewitt CW, Bolleter S 22(1). 81 - 86 (Journal Article)

Background: Acute compartment syndrome (ACS) following extremity trauma requires rapid fasciotomy to avoid significant morbidity and limb loss. Four-compartment fasciotomy of the leg is a surgical procedure typically performed in the operating room; however, casualties who cannot be rapidly transported may need fasciotomies in the prehospital setting. In the absence of traditional operating instruments (e.g., scalpel, long Metzenbaum scissors, electrocautery), alternative means of fasciotomy may be needed. We undertook a proof-of-concept study using cadaver models to determine whether leg fasciotomies could be performed with alternative devices compared with the surgical standard. Methods: Two-incision, four-compartment fasciotomies were performed on fresh, never-frozen, non-embalmed cadaver legs using a scalpel for the initial skin incision, followed by release of the fascia using one of the following instruments: 5.5-in curved Mayo scissors; Benchmade rescue hook (model BM-5BLKW); rescue hook on the Leatherman Raptor multitool (model 831741-FFP); Leatherman Z-Rex multitool rescue hook (model LM93408); or No. 10 PenBlade (model PB-M-10- CAS). The procedures were performed by a surgeon. Skin and fascia incisional lengths were recorded along with a subjective impression of the performance for each device. Post-procedural dissection was performed to identify associated injuries to the muscle, superficial peroneal nerve, and the greater saphenous vein (GSV). Results: All devices were able to adequately release the fascia in all four compartments. All rescue hooks (Benchmade, Raptor, and Z-Rex) required a "pull technique" and a skin incision of equal length to the fascia incision. The PenBlade was used in a "push technique," similar to the standard scissor fasciotomy through a smaller skin incision. There was one superficial peroneal nerve transection with the rescue hooks, but there were no GSV injuries or significant muscle damage with any instrument. Conclusion: Four-compartment fasciotomy can be performed with readily available alternative equipment such as rescue hooks and the PenBlade. Hook-type devices require longer skin incisions compared with scissors and the PenBlade. In contested environments, patients with ACS may require fasciotomy prior to evacuation to surgical teams; training combat medics in the use of these alternative instruments in the field may preserve life and limb.

Efficacy of Vancomycin Powder in Mitigating Infection of Open Penetrating Trauma Wounds on the Battlefield: An Evidence-Based Review

TerBeek BR, Loos PE, Pekari TB, Tennent DJ 22(1). 76 - 80 (Journal Article)

Background: Open penetrating trauma wounds to the extremities remain the most common injuries encountered in combat and are frequently complicated by bacterial infections. These infections place a heavy burden on the Servicemember and the healthcare system as they often require multiple additional procedures and can frequently cause substantial debility. Previous studies have shown that vancomycin powder has demonstrated efficacy in decreasing infection risks in clean and contaminated orthopedic surgical wounds. Methods: This review evaluates the most prevalent organisms cultured post-trauma, the current Tactical Combat Casualty Care (TCCC) guidelines for antibiotic prophylaxis, and relevant research of vancomycin's prophylactic use. Results: Results from previous studies have shown a time-dependent reduction in bacterial load when vancomycin powder is introduced early post injury in traumatic orthopedic wounds. Furthermore, perioperative application affords a cost-effective method to prevent infection with minimal adverse effects. Discussion: The current TCCC guidelines advocate for the use of antibiotics at the point of injury. When vancomycin powder is used in synergy with these guidelines, it can contribute a timely and powerful antibiotic to prevent infection. Conclusion: The prophylactic use of vancomycin powder is a promising adjunctive agent to current Clinical Practice Guidelines (CPG), but it cannot be conclusively determined to be effective without further research into its application in traumatic combat wounds.

Use of Knives and Multitools to Perform a Cadaveric Limb Amputation

Baker RA, Worth K, Pourrajabi N, Martin J, Mitchell S, Baker S 22(1). 71 - 75 (Journal Article)

Background: An austere field amputation can be a life-saving procedure for an entrapped patient when standard equipment is not available or operable. The objective of this study was to use hand tools to perform cadaveric amputations in < 2 minutes. Methods: Timed guillotine amputation of the extremities on three cadavers was attempted using four available hand tools: a multitool, a rescue tool, a hunting knife, and a fixedblade knife. The primary outcome was successful amputation of the extremity in < 2 minutes. Results: Amputation success was different among the tools. The multitool amputated 78% of attempts; the hunting knife, 67%; the rescue knife, 56%; and the fixed-blade knife, 44%. The distal tibia/fibula and radius/ ulna were amputated successfully in 100% of attempts, whereas none of the tools could amputate the femur. The multitool received the best subjective ranking - 1.4 (p = .001) - by amputators, with the fixed-blade knife receiving the worst score. Conclusions: In the rare circumstance that an emergent field amputation requires a hand tool, the multitool is a capable instrument for a distal extremity amputation.

Expeditionary Mechanical Ventilation in Conjunction With Extracorporeal Life Support During Ground Transport

Beely BM, Harea GT, Wendorff DS, Choi JH, Sieck K, Karaliou V, Cannon JW, Lantry JH, Cancio LC, Sams VG, Batchinsky AI 22(1). 64 - 69 (Journal Article)

Background: We assessed the use of an FDA-cleared transport ventilator with limited functions and settings during ground transport in a swine model of ground evacuation. We hypothesized that when used as an adjunct to extracorporeal life support (ECLS), the device would enable safe mobile ventilatory support during ground evacuation. Methods: Female Yorkshire swine (n = 11; mean, 52.4 ± 1.3 kg) were sedated and anesthetized and received mechanical ventilation (MV) with a standard intensive care unit (ICU) ventilator and were transitioned to the Simplified Automated Ventilator II (SAVe II; AutoMedx) during ground transport. MV served as an adjunct to ECLS in all animals. Ventilator performance was assessed in the uninjured state on day 1 and after bilateral pulmonary contusion on day 2. Data were collected pre- and post-transport on both days. Results: During 33 transports, the SAVe II provided similar ventilation support as the ICU ventilator. Mean total transport time was 38.8 ± 2.1 minutes. The peak inspiratory pressure (PIP) limit was the only variable to show consistent differences pre- and post-transport and between ventilators. No adverse events occurred. Conclusion: As an adjunctive supportive device during ground transport, the SAVe II performed adequately without failure or degradation in subject status. Further testing is warranted to elucidate the clinical limits of this device during standalone use.

Feasibility of Obtaining Intraosseous and Intravenous Access Using Night Vision Goggle Focusing Adaptors

Iteen A, Koch EJ, Wojhan A, Gutierrez R, Hildreth A, Rudinsky S, Deaton TG, Zarow GJ 22(1). 56 - 63 (Journal Article)

Background: The optimal tactical lighting for performing medical procedures under low-light conditions is unclear. Methods: United States Navy medical personnel (N = 23) performed intravenous (IV) and intraosseous (IO) procedures on mannequins using a tactical headlamp, night vision goggles (NVGs), and night vision goggles with focusing adaptors (NVG+A) utilizing a randomized within-subjects design. Procedure success, time to completion, and user preferences were analyzed using analysis of variance (ANOVA) and nonparametric statistics at p < .05. Results: IV success rates were significantly greater for the headlamp (74%) than for NVG (35%; p < .03) and somewhat greater than for NVG+A (52%; p = .18). IO success rates were high under each lighting condition (96% to 100%). Time to completion was significantly faster using headlamp (IV, 106 ± 28 s; IO, 47 ± 11 s) than NVG (IV, 168 ± 80 s; IO, 56 ± 17 s) or NVG-A (IV, 157 ± 52 s; IO, 59 ± 27 s; each p < .01). Posttesting confidence on a 1-to-5 scale was somewhat higher for NVG+A (IV, 2.9 ± 0.2; IO, 4.2 ± 0.2) than for NVG (IV, 2.6 ± 0.2; IO, 4.0 ± 0.2). Participants cited concerns with NVG+A depth perception and with adjusting the adaptors, and that the adaptors were not integrated into the NVG. Conclusion: While this mannequin study was limited by laboratory conditions and by the lack of practice opportunities, we found some small advantages of focusing adaptors over NVG alone but not over headlamp for IV and IO access in low-light conditions.

The Myths of Uncontrolled Emergence Reactions and Consideration to Stop Mandatory, Protocolled Midazolam Coadministration With Ketamine

Hiller HM, Drew B, Fisher AD, Cuthrell M, Spradling JC 22(1). 49 - 54 (Journal Article)

Ketamine continues to demonstrate its utility and safety in the austere and prehospital environment, but myths persist regarding the frequency of behavioral disturbances and unpleasant reactions. These myths have led to protocolled midazolam co-administration. Properties of midazolam and other benzodiazepines have the potential to cause significant morbidity and potential mortality. Because of this risk, benzodiazepines should only be administered when the treating provider determines that the patient's symptoms warrant it. We also present evidence that agitation and altered mental status (AMS) encountered with ketamine occurs during titration of lower pain control regimens and is much less likely to occur with higher doses. As such, in most prehospital situations, the treatment for this "incomplete dissociation" is more ketamine, not the addition of a potentially dangerous benzodiazepine.

Fall 2018 Journal (Vol 18 Ed 3)

Vol 18 Ed 3
Fall 2018 Journal of Special Operations Medicine
ISSN: 1553-9768

View the Table of Contents

Available for preorder. Estimated ship date is September 30th 2022

Prolonged Field Care in Support of Operation Inherent Resolve, 2016

Blaine C, Abbott M, Jacobson E 18(3). 120 - 123 (Journal Article)

The authors present their experience in emergency and longterm medical care by Special Operations Forces (SOF) medical providers in an austere environment. In this case, a Special Forces Operational Detachment-Alpha (SFOD-A) was deployed in support of Operation Inherent Resolve, partnered with indigenous combat forces.

Draw-over Anesthesia Bringing the "Dark Art" Back Into the Light

Graves MW, Billings S 18(3). 125 - 133 (Journal Article)

Knowledge Versus Suspicion

Turconi M, Dare C, Hampton K 18(3). 124 (Journal Article)

Damage Control Resuscitation in Prolonged Field CareDamage Control Resuscitation in Prolonged Field Care

Fisher AD, Washbum G, Powell D, Callaway DW, Miles EA, Brown J, Dituro P, Baker JB, Christensen JB, Cunningham CW, Gurney JM, Lopata J, Loos PE, Maitha J, Riesberg JC, Stockinger Z, Strandenes G, Spinella PC, Cap AP, Keenan S, Shackelford SA 18(3). 109 - 119 (Journal Article)

How the International Special Training Centre Is Training World-Class Medics: An Outline of the NATO Special Operations Combat Medic Course

Christensen JB 18(3). 103 - 108 (Journal Article)

The North Atlantic Treaty Organization (NATO) Special Operations Combat Medic (NSOCM) course is specifically designed to train 24 highly selected Special Operations Forces (SOF) members to treat trauma and nontrauma patients who have life-threatening diseases and/or injuries. The NSOCM course is held at the International Special Training Centre (ISTC) in Pfullendorf, Germany, and exemplifies ISTC's mission to build interoperability and strengthening alliances between multinational partners. The 24-week NSOCM course is taught by subject matter experts and SOF members from around the globe. Building interoperability and capacity with common NATO standards is crucial to medical support of all future SOF missions where military units and other small elements will be vitally dependent on each other for combined missions at the regional, national, or NATO level. A better understanding and knowledge of the current SOF medic role and the capabilities they need to bring to the battlefield will help advance their scope from the "classic" trauma scenarios to the more advanced clinical medicine and prolonged field care situations. The NSOCM must become a critical-thinker and be able to recognize and treat these health risks and conditions in remote, austere environments, finding the right solution with a limited arsenal at their disposal. The ISTC-NSOCM course is designed to help bridge this gap and raise situational awareness for the NATO on-the-ground medical professionals to ensure "the more they know the more apt they are to save a life." In essence, it is ISTC's goal to meet these challenges by training NSOCMs to meet these multidimensional demands. This article outlines ISTC's development and design of the NSOCM course and new adaptations as we move forward into our third year of training world-class medics.

Osteoarthritis: Pathophysiology, Prevalence, Risk Factors, and Exercise for Reducing Pain and Disability

Knapik JJ, Pope R, Orr R, Schram B 18(3). 94 - 102 (Journal Article)

Osteoarthritis (OA) is a disorder involving deterioration of articular cartilage and underlying bone and is associated with symptoms of pain and disability. The incidence of OA in the military increased over the period 2000 to 2012 and was the first or second leading cause of medical separations in this period. Risk factors for OA include older age, black race, genetics, higher body mass index, prior knee injury, and excessive joint loading. Animal studies indicate that moderate exercise can assist in maintaining normal cartilage, and individuals performing moderate levels of exercise show little evidence of OA. There is considerable evidence that among individuals who develop OA, moderate and regular exercise can reduce pain and disability. There is no firm evidence that any particular mode of exercise (e.g., aerobic training, resistance exercise) is more effective than another for reducing OA-related pain and disability, but limited research suggests that exercise should be lifelong and conducted at least three times per week for optimal effects.


Burnett MW 18(3). 92 - 93 (Journal Article)

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