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Yugoslav Guerrilla Hospital Design Features and Operation in World War II

Colesar MT, Baker JB 23(3). 18 (Journal Article)

In the most austere combat conditions, Yugoslav guerillas of World War II (WWII) demonstrated an innovative and effective hospitalization system that saved countless lives. Yugoslav Partisans faced extreme medical and logistical challenges that spurred innovation while waging a guerrilla war against the Nazis. Partisans used concealed hospitals ranging between 25 to 215 beds throughout the country with wards that were often subterranean. Concealment and secrecy prevented discovery of many wards, which prototypically contained two bunk levels and held 30 patients in a 3.5 × 10.5-meter space that included storage and ventilation. Backup storage and treatment facilities provided critical redundancy. Intra-theater evacuation relied on pack animals and litter bearers while partisans relied on Allied fixed wing aircraft for inter-theater evacuation.

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What a Special Operations Cognitive Assessment Should Look Like

Biggs A, Heller T, Colvin K, Wood D, Jewell JA, Littlejohn LF 23(3). 18 (Journal Article)

Special Operations organizations have recently demonstrated their commitment to enhanced cognitive functioning and improving brain health through the development of a Cognitive Domain. However, as this new enterprise becomes supported by more resources and personnel, a critical question involves what cognitive assessments should be conducted to evaluate cognitive functions. The assessment itself forms a crux in the Cognitive Domain that could mislead cognitive practitioners if not properly applied. Here, the discussion addresses the most important criteria to satisfy in the development of a Special Operations cognitive assessment, including operational relevance, optimization, and speed. Cognitive assessments in this domain must incorporate the following: (1) a task with clear operational relevance to ensure meaningful results, (2) no ceiling effects so that performance can support cognitive enhancement initiatives, and (3) the task itself should impose a minimal time requirement to avoid creating a substantial logistical burden. A dynamic threat assessment task supported by drift diffusion modeling can meet all requisite criteria, while also providing more insight into decision parameters of Special Operations personnel than any currently used test. The discussion concludes with a detailed description of this recommended cognitive assessment task, as well as the research and development steps needed to support its application.

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Phosphorus Burn Management with Multimodal Analgesia

Saint-jean L, Corcostegui S, Galant J, Derkenne C 23(3). 82 (Case Reports)

We report the case of a patient suffering from a chemical burn caused by white phosphorus, for whom initial management required decontamination using multimodal analgesia. This case report should be familiar to other military emergency physicians and Tactical Emergency Medical Support for two reasons: 1) A phosphorus burn occurs from a chemical agent rarely encountered, with minimal research available in the medical literature, despite the use of this weapon in the recent Ukrainian conflict, and 2) We discuss the use of multimodal analgesia, combining loco-regional anesthesia (LRA) and an intranasal pathway, which can be used in a remote and austere environment.

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Artificial Blood Development Implications for Military Medicine

Melanson V, Hershfield J, Deegan MK, Cho H, Perinon D, Bateman SL, Barnhill JC 23(3). 63 (Journal Article)

Massive hemorrhaging remains the most common cause of preventable battlefield deaths. Blood used for trauma care requires a robust donation network, capacity for long-term storage, and extensive and accurate testing. Bioengineering technologies could offer a remedy to these constraints in the form of blood substitutes-fluids that could be transfused into patients to provide oxygen, carry away waste, and aid in coagulation-that would be used in prolonged casualty care and in far-forward settings, overcoming the obstacles of distance and time. The different molecular properties of red blood cells (RBCs), blood substitutes, and platelet replacements contribute to their respective utilities, and each type is currently represented in ongoing clinical trials. Hemoglobin oxygen carriers (HBOCs) are the most advanced RBC replacements, many of which are currently being evaluated in clinical trials in the United States and other countries. Despite recent advancements, challenges remaining in the development of blood alternatives include stability, oxygen capacity, and compatibility. The continued research and investment in new technologies has the potential to significantly benefit the treatment of life-threatening emergency injuries, both on the battlefield and in the civilian sector. In this review, we discuss military blood-management practices and military-specific uses of individual blood components, as well as describe and analyze several artificial blood products that could be options for future battlefield use.

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Pain Control and Point-of-Care Ultrasound: An Approach to Rib Fractures for the Austere Provider

Snyder R, Brillhart DB 23(3). 70 (Journal Article)

Rib fractures are common injuries that cause significant discomfort and can lead to severe pulmonary complications. Rib injury most often results from high-velocity traumatic mechanisms, while rarely representing underlying metastatic disease or secondary injury due to pulmonary illness. Because most rib fractures are caused by obvious trauma, algorithms are focused on treatment rather than investigating the exact mechanism of rib fractures. Chest radiographs are often the initial imaging performed but have proven to be unreliable in identification of rib fracture. Computed tomography (CT) is a diagnostic option as it is more sensitive and specific than simple radiographs. However, both modalities are generally unavailable to Special Operations Forces (SOF) medical personnel working in austere locations. These medical providers could potentially diagnose and treat rib fractures in any environment using a standardized approach that includes clarity of mechanism, pain relief, and point-of-care ultrasound (POCUS). This case demonstrates an approach to the diagnosis and treatment of a rib fracture in a 47-year-old male who presented to a military treatment facility with unlocalized flank and back pain, but the methods employed have applicability to the austere provider working far from the resources of a medical center.

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Combat Vascular Access: A Scoping Review

Smith S, White J, McGuire T, Meunier B, Ball I, Hilsden R 23(3). 32 (Journal Article)

Medical leadership must decide how to obtain vascular access in a combat environment. Adequate combat trauma resuscitation requires efficient vascular access. A search of the Medline and EMBASE databases was conducted to find articles on combat vascular access. The primary dataset of interest was the type of vascular access obtained. Other data reviewed included who performed the intervention and the success rate of the intervention. The search strategy produced 1,339 results, of which 24 were included in the final analysis. Intravenous (IV), intraosseous (IO), and central venous access have all been used in the prehospital combat environment. This review summarizes the available combat literature to help commanders make an evidence-based decision about their prehospital vascular access strategy.

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Social Fitness and the Social Domain: A Holistic Approach Based on Total Force Fitness

McCarthy R, Park GH, Barczak-Scarboro NE, Barrientos S, Chamberlin R, Hansom A, Messina LA 23(3). 85 (Journal Article)

The Total Force Fitness (TFF) framework was envisioned as a holistic framework of interrelated domains, whereby impact in one domain could have cascading implications for the others. For this reason, definitional clarity surrounding how to achieve fitness in the various domains is crucial. Social fitness definitions tend to focus on individual efforts and overlook the powerful impact of the social group and the social environment on the individual. In this article, various definitions of social fitness are analyzed in an effort to broaden the current understanding of the social domain. Some of the knowledge gaps in understanding social fitness and the resulting challenges are addressed before reviewing a few existing social fitness interventions. Finally, this study offers recommendations for improvement, along with future directions for the increased integration of the social domain into the TFF framework.

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Mobility Solutions After a Lower Extremity Fracture and Applicability to Battlefield and Wilderness Medicine

Childers W, Alderete JF, Eliason TD, Goldman SM, Nicolella DP, Pierrie SN, Stark GE, Studer NM, Wenke JC, Wilson JB, Dearth CL 23(3). 91 (Journal Article)

The potential for delayed evacuation of injured Service members from austere environments highlights the need to develop solutions that can stabilize a wound and enable mobility during these prolonged casualty care (PCC) scenarios. Lower extremity fractures have traditionally been treated by immobilization (splinting) followed by air evacuation - a paradigm not practical in PCC scenarios. In the civilian sector, treatment of extremity injuries sustained during remote recreational activities have similar challenges, particularly when adverse weather or terrain precludes early ground or air rescue. This review examines currently available fracture treatment solutions to include splinting, orthotic devices, and biological interventions and evaluates their feasibility: 1) for prolonged use in austere environments and 2) to enable patient mobilization. This review returned three common types of splints to include: a simple box splint, pneumatic splints, and traction splints. None of these splinting techniques allowed for ambulation. However, fixed facility-based orthotic interventions that include weight-bearing features may be combined with common splinting techniques to improve mobility. Biologically-focused technologies to stabilize a long bone fracture are still in their infancy. Integrating design features across these technologies could generate advanced treatments which would enable mobility, thus maximizing survivability until patient evacuation is feasible.

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Comparison of DripAssist to Traditional Method for Achieving Rate Infusions by U.S. Army Medics

Golden DJ, Castaneda P, Carius BM, Simmons CJ 23(3). 9 (Journal Article)

Literature finds improper intravenous (IV) infusion rates as the most common cause of medication administration errors (MAE). Calculating drip rates and manipulating roller clamps while counting drops within the drip chamber to manage IV infusions - known as the traditional method (TM) - increases the likelihood of IV MAEs compared to electronic infusion pumps. The DripAssist, a novel in-line device, allows users to monitor and adjust infusion rates without calculating rates or counting drops. We conducted a prospective, randomized, crossover study with a convenience sample of U.S. Army medics initiating infusion rates using the DripAssist and the TM. Investigators randomized participants to start with the TM or DripAssist and achieve three specific infusions using an in vitro model. The primary outcome was the time to achieve the desired infusion rate measured in seconds. Secondary outcomes included drip rate accuracy and volume infused over one hour. End user feedback included method confidence on a 100-point Bandura scale and appraisal using a five-point Likert item. Twenty-two medics demonstrated faster time to achieve infusion rates with the DripAssist over TM (median 146.5 seconds vs. 207.5 seconds, p = .003). A sequence effect noted faster time to achieve desired infusion rates with the TM after completing infusions with DripAssist (p = .033). The DripAssist demonstrated significantly improved accuracy for drip rate and volume administered over one hour compared to TM (median rate error: 5% versus 46%, p <.001; median volume percentage error: 26.5% versus 65%, p <.001). The DripAssist had significantly higher user confidence (median 80 vs. 47.5, p <.001) and was perceived as easier to use (median 4 vs. 2, p = <.001) and more likely to be learned, remembered, and performed by a medic (median 5 vs. 3, p <.001). Most participants (90%) preferred the DripAssist for establishing a rate-specific infusion. The DripAssist demonstrated significantly faster time to achieve infusion rates, improved accuracy, and increased user confidence. Sequence effects may confound time data. We recommend further studies of the DripAssist by prehospital medical personnel in more austere environments.

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Altered Sympathoadrenal Activity Following Cold-Water Diving

Kelly K, Pautz CM, Palombo LJ, Jensen AE, Melau J, Turcotte LP, Solberg PA 23(3). 74 (Journal Article)

Introduction: Little data exist on the effect of extremely cold-water diving on thermo-metabolic hormone secretion. Moreover, the impact of repetitive dives on the stress response is unknown. The purpose of this study was to determine the effects of two daily bouts of cold-water diving on the hormonal and metabolic profile of elite military personnel and to measure the stress response. Methods: Healthy, male, Norwegian Special Forces operators (n = 5) volunteered for this study. Physiological and hormone data were analyzed prior to and following twice-daily Arctic dives (3.3°C). Results: Core temperature was maintained (p > .05), whereas skin temperature was significantly reduced over the course of each dive (p < .01). Pairwise comparisons revealed adrenocorticotropic hormone (ACTH) and cortisol concentration significantly decreased across both dives and days (p < .001). Adrenaline and noradrenaline significantly increased across both time and day (p < .001). Leptin, testosterone, and IGF-1 significantly decreased over time but recovered between days. Conclusion: The main findings of this effort are that there is a rapid sympathetic-adreno-medullary (SAM/SNS) response to cold-water diving and a suppression of the hypothalamic-pituitary-adrenal (HPA) axis and hormones related to repair and recovery. While the sample size was too small to determine the role of SAM/SNS, HPA, and thyroid hormone effect on thermoregulation, it addresses a gap in our understanding of physiological adaptions that occurs in extreme environments.

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20th Anniversary Collector's Edition

The 20th Anniversary Collector's Edition features all 4 editions of the 2020 Journal of Special Operations Medicine. Each edition features a retrospective look at the evolution of SOF Medicine and TCCC protocols.

The Spring edition focuses on the use of whole blood, Summer deals with Hemorrhage Control, Fall looks at Prolonged Field Care, and Winter dives into the changes to TCCC.

Regular price for all 4 journals is $160 - buy the set for $128 - a 20% savings!

$128.00
Summer 2023 Journal (Vol 23 Ed 2)

Vol 23 Ed 2
Summer 2023 Journal of Special Operations Medicine
ISSN: 1553-9768

View the Table of Contents
Preorder only - Estimated ship date 15 July 2023

$47.00
TCCC Critical Decision Case Studies

Butler FK 23(2). 126 (Case Reports)

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Sepsis-Induced Coagulopathy and Disseminated Intravascular Coagulation: What We Need to Know and How to Manage for Prolonged Casualty Care

Nam JJ, Wong AI, Cantong D, Cook JA, Andrews Z, Levy JH 23(2). 118 (Journal Article)

Coagulopathy can occur in trauma, and it can affect septic patients as a host tries to respond to infection. Sometimes, it can lead to disseminated intravascular coagulopathy (DIC) with a high potential for mortality. New research has delineated risk factors that include neutrophil extracellular traps and endothelial glycocalyx shedding. Managing DIC in septic patients focuses on first treating the underlying cause of sepsis. Further, the International Society on Thrombolysis and Haemostasis (ISTH) has DIC diagnostic criteria. "Sepsis-induced coagulopathy" (SIC) is a new category. Therapy of SIC focuses on treating the underlying infection and the ensuing coagulopathy. Most therapeutic approaches to SIC have focused on anticoagulant therapy. This review will discuss SIC and DIC and how they are relevant to prolonged casualty care (PCC).

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Bilateral Above the Knee Amputation in Afghanistan

Schoenberger T, Foret B, Evans J, Shishido AA 23(2). 114 (Journal Article)

Prolonged Casualty Care (PCC) has become an essential component to Special Operations Forces (SOF) pre-mission training. However, it has not regularly been required in recent combat operations with the availability of medical evacuation (MEDEVAC) support. Poor weather conditions at an austere SOF outpost created an emergency unreachable by aeromedical evacuation. Herein, we report a case of an emergency bilateral above-the-knee amputation procedure performed by three Special Forces Medical Sergeants (18D(a), 18D(b), and 18D(c)) and supporting Army medics with minimal telemedicine consult and guidance.

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Tick-Borne Encephalitis: An Update for the Special Operations Forces Provider

Kaur H, Shishido AA 23(2). 110 (Journal Article)

Tick-borne encephalitis (TBE) is a severe disease caused by the tick-borne encephalitis virus (TBEV). TBEV is endemic throughout Eurasia and can cause persistent neurologic deficits and death. Special Operations Forces (SOF) participating in field exercises or operations in TBE-endemic countries are at significantly increased risk of infection. Unlike Lyme disease and other tick-borne illnesses, transmission of TBEV can be immediate, and early tick removal does not reduce the risk of infection. While there are no virus-specific treatments available, the US Food and Drug Administration (FDA) recently approved a TBE vaccine that has yet to be incorporated into formal Department of Defense (DoD) recommendations. SOF medical providers should be aware of this disease entity and consider the TBE vaccine when planning exercises and operations in areas of responsibility (AORs) with TBE-endemic countries. This review serves as a refresher and update on the epidemiology, transmission, and management of TBE for the SOF provider.

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Critical Hypophosphatemia in a Special Operations Combat Dive Candidate: A Case Report

Davis G, Czarnik J, Evans J, McGrane OL 23(2). 107 (Case Reports)

In contrast to shallow water (hypoxic) blackout and swimming-induced pulmonary edema (SIPE), acute electrolyte disturbance secondary to acute respiratory alkalosis is not considered a common Combat Swimmer injury but has the potential to be life-threatening. We present the case of a 28-year-old Special Operations Dive Candidate who presented to the Emergency Department after a near-drowning incident with altered mental status, generalized weakness, respiratory distress, and tetany. He was found to have severe symptomatic hypophosphatemia (1.00mg/dL) and mild hypocalcemia secondary to intentional hyperventilation between subsurface "cross-overs," causing subsequent acute respiratory alkalosis. This is a unique presentation of a common electrolyte abnormality in a highly specialized population that is self-limiting when caused by acute respiratory alkalosis but poses a significant danger to Combat Swimmers if rescue personnel are not able to respond quickly.

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Conventional Resilience and the Impact of Catastrophic Injury Exposure on Special Operations Surgical Teams

Jeschke EA, Baker JB, Wyma-Bradley J, Dorsch J, Huffman SL 23(2). 102 (Journal Article)

This article presents a justification for using an ethnographic approach to research resilience. Our hypothesis is that the conventional resilience construct is ineffective in achieving its stated goal of mitigating diagnosable stress pathologies because it is grounded in a set of assumptions that overlook human experience when examining human performance in combat. To achieve this goal, we (1) describe the evolution of the strategic framework within which the conventional resilience construct is defined; (2) highlight certain limiting assumptions entailed in this framework; (3) explain how bottom-up ethnographic research relates the medic's practical performance to military requirements and mission capabilities; and (4) articulate the unique elements of our study that widen the aperture of the conventional resilience construct. We conclude by gesturing to initial research findings.

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Management of Type 3c Diabetes in an Elite Tactical Athlete

Avilla J, Rerucha C, Hu C 23(2). 99 (Journal Article)

The presentation of Type 3c diabetes is atypical, accounting for 0.5-1% of all types of diabetes. Combining this with the healthy Special Operations community is even more profound. A 38-year-old active-duty male in Special Operations developed acute abdominal pain and vomiting while deployed. He was diagnosed with severe acute necrotizing pancreatitis secondary to Type 3c diabetes, and the management of his condition became increasingly difficult. This case highlights Type 3c diabetes and the complexity of formulating a comprehensive treatment plan for a tactical athlete.

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How the Five Principles of High Reliability Organizations Align with the Five Truths of Special Operations

Biggs A, Jewell J, Littlejohn LF 23(2). 94 (Journal Article)

Special Operations medicine must provide highly reliable healthcare under intense and sometimes dangerous circumstances. In turn, it is important to understand the principles inherent to building a High Reliability Organization (HRO). These principles include (1) sensitivity to operations; (2) preoccupation with failure; (3) reluctance to simplify; (4) resilience; and (5) deference to expertise. Understanding them is crucial to turning good ideas into sound practical benefit in operational medicine. A prime teaching opportunity involves an interesting coincidence that occurred during the emergence of HROs. Specifically, United States Special Operations Command (USSOCOM) adopted five Special Operations Forces (SOF) Truths that contribute to success in Special Operations, including (1) humans are more important than hardware; (2) quality is better than quantity; (3) SOF cannot be mass produced; (4) competent SOF cannot be created after emergencies occur; and (5) most Special Operations require non-SOF support. These five Truths have more in common with the five HRO principles than merely quantity. They describe the same underlying ideas with a key focus on human performance in high-risk activities. As such, when presented alongside the five HRO principles, there is an opportunity to improve the overall health and performance of SOF personnel by integrating these principles across the range of Special Operations medicine from point of injury care to garrison human performance initiatives. The following discussion describes in greater detail the five HRO principles, the five SOF Truths, and how these similar ideas emerged as more than just a useful coincidence in illustrating the key concepts to produce high performance.

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