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Priorities for a 21st-Century Defense: Aligning U.S. Army Environmental Science and Engineering Officer Resources with the Department of Defense Strategic Guidance

Licina D, Rufolo D, Story M 13(2). 38 - 43 (Journal Article)

The recently published Department of Defense (DoD) strategic guidance highlights the need to "shape a joint force for the future." Supporting requirements to shape the joint force while the overall DoD force structure is reduced will be challenging. Fortunately, based on its unique training and experience, the Army Environmental Science and Engineering Officer (ESEO) profession is positioned today to fill anticipated joint public health requirements. Obtaining the U.S. Army Medical Department (AMEDD) approval to meet these requirements will have near-term consequences for the ESEO profession as some existing (albeit antiquated) authorizations may go unfilled. However, long-term dividends for the Medical Service Corps (MSC), AMEDD, Army, and DoD will be achieved by realigning critical resources to future joint and interagency requirements. Assigning ESEOs now to organizations such as the Theater Special Operations Commands (TSOCs), U.S. Agency for International Development (USAID), and the North Atlantic Treaty Organization (NATO) with perceived and real joint force health protection/public health requirements through unique means will ensure our profession remains relevant today and supports the joint force of tomorrow.

CBRNE TC3: A Hybrid Approach to Casualty Care in the CBRNE Environment

Strain JE 13(2). 44 - 53 (Journal Article)

The implementation of Tactical Combat Casualty Care (TCCC) guidelines for the Operation Enduring Freedom and Operation Iraqi Freedom contingency operations has dramatically reduced preventable combat deaths. A study of these principles and their application to medical treatment in the chemical, biological, radiological, nuclear, and high-yield explosives (CBRNE), weapons of mass destruction (WMD) environment is presented as a potential readiness and force multiplier for units engaged in this area of operations. Preparing medical operators for support of WMD sampling and mitigation missions requires extensive preventive medicine and post-exposure and downrange trauma threat preparedness. Training and equipping CBRN operators with treatment skills and appropriate interventional material requires pre-implementation planning specific to WMD threats (e.g., anthrax, radiation, organophosphates, and contaminated trauma). A scenario-based study reveals the tactics, techniques, and procedures for training, resourcing, and fielding the CBRN operator of the future.

Recent Considerations in Tactical Medicine

Rush SC 13(2). 54 - 58 (Journal Article)

A philosophical approach to tactical and remote medicine should be reflected in the gear (e.g., equipment and technology) chosen as well as the protocols used. The gear needs to be lightweight and small volume. As much as possible, it should have multiple uses, and there should be no redundancy with other items. When modern technology (e.g., hemostatic gauze, pulse oximeters, etc.) allows it to have unique applications, it should be used. Otherwise, if simple basic gear works, it should remain a staple (e.g., cravats). Protocols should reflect the goal to provide thorough care in an efficient manner. They should be straightforward and scaleable and be capable of being trained in a fashion that will allow them to become automatic under duress. These guiding principles establish a basis from which the Special Operations Forces/Tactical Medic or PJ can operate to maximal effectiveness. This article will describe current thinking in Pararescue as it relates to gear and protocols.

An Introduction to Survival, Evasion, Resistance, and Escape (SERE) Medicine

Smith MB 13(2). 25 - 32 (Journal Article)

When an individual finds himself/herself in a survival, evasion, resistance, or escape (SERE) scenario, the ability to treat injuries/illnesses can be the difference between life and death. SERE schools are responsible for preparing military members for these situations, but the concept of SERE medicine is not particularly well defined. To provide a comprehensive working description of SERE medicine, operational and training components were examined. Evidence suggests that SERE medicine is diverse, injury/illness patterns are situationally dependent, and treatment options often differ from conventional clinical medicine. Ideally, medical lessons taught in SERE training are based on actual documented events. Unfortunately, the existing body of literature is dated and does not appear to be expanding. In this article, four distinct facets of SERE medicine are presented to establish a basis for future discussion and research. Recommendations to improve SERE medical curricula and data-gathering processes are also provided.

Endovascular Resuscitation Techniques for Severe Hemorrhagic Shock and Traumatic Arrest in the Presurgical Setting

True NA, Siler S, Manning JE 13(2). 33 - 37 (Journal Article)

Novel aortic catheter-based resuscitation interventions aimed at control of noncompressible torso hemorrhage and resuscitative perfusion are undergoing active research and development. These methods have been reported as resuscitative endovascular balloon occlusion of the aorta, selective aortic arch perfusion, and profound hypothermia (emergency preservation and resuscitation). These interventions are advanced options to treat noncompressible torso hemorrhage and hemorrhage-induced traumatic cardiac arrest in the presurgical environment. However, to achieve maximum potential benefit, such interventions need to be initiated as soon as possible. This means that these advanced interventions should be adapted for use in austere military treatment facilities and, when feasible, initiated at the point of injury. This report argues for the feasibility of advanced endovascular resuscitation interventions in the austere military theater.

No Slackers in Tourniquet Use to Stop Bleeding

Polston RW, Clumpner BR, Kragh JF, Jones JA, Dubick MA, Baer DG 13(2). 12 - 19 (Journal Article)

Background: Tourniquets on casualties in war have been loose in 4%-9% of uses, and such slack risks death from uncontrolled bleeding. A tourniquet evidence gap persists if there is a mechanical slack-performance association. Objective: The purpose of the present study was to determine the results of tourniquet use with slack in the strap versus no slack before windlass turning, in order to develop best practices. Methods: The authors used a tourniquet manikin 254 times to measure tourniquet effectiveness, windlass turns, time to stop bleeding, and blood volume lost at 5 degrees of strap slack (0mm, 25mm, 50mm, 100mm, and 200mm maximum). Results: When comparing no slack (0mm) to slack (any positive amount), there were increases with slack in windlass turns (ρ < .0001, 3-fold), time to stop bleeding (ρ < .0001, 2-fold), and blood volume lost (ρ < .0001, 2-fold). When comparing no slack to 200mm slack, the median results showed an increase in slack for windlass turns (ρ < .0001), time to stop bleeding (ρ < .0001), and blood volume lost (ρ < .0001). Conclusions: Any slack presence in the strap impaired tourniquet performance. More slack had worse results. Trainers can now instruct tourniquet users with concrete guidance.

Quality of Care Assessment in Forward Detection of Extremity Compartment Syndrome in War

King DR, Kragh JF, Blackbourne LH 13(2). 20 - 24 (Journal Article)

Background: Recent efforts to improve the quality of care in the Afghanistan theater have focused on extremity compartment syndrome, a common, disabling, and costly problem. To identify opportunities to improve care, the present survey was undertaken to observe the use of two standard methods-the traditional, improvised method and the common, off-the-shelf method-for determining intracompartmental pressures in the lower extremities of combat casualties. Methods: As part of a quality of care improvement effort during Operation Enduring Freedom, all combat casualties presenting to a forward surgical team at Forward Operating Base Shank from August to November 2011 with lower-extremity major trauma were evaluated for signs and symptoms of compartment syndrome. Results: Ten casualties had pressure measurement surveyed simultaneously using both methods. A two one-sided test analysis demonstrated a mean difference of -0.13 (90% confidence interval, -0.36 to 0.096), which indicated that the methods were similar. A repeated-measures analysis yielded a p value of .72, indicating no statistical difference between the methods. The receiver operating characteristic curve demonstrated excellent agreement within the prespecified limits (±2mm Hg, area under the curve 1.0), which indicated that the methods were similar. Conclusion: The main finding of the quality of care effort was that clinicians received similar information from use of two standard methods for far forward measurement of pressures to detect extremity compartment syndrome. This finding may help clinicians improve the quality of care in the theater in detecting, diagnosing, and monitoring compartment syndrome.

Delayed Diagnosis of Pelvic hematoma without Fracture Due to Military Parachuting

Cunningham CW, Kotwal RS, Kragh JF 13(2). 4 - 7 (Case Reports)

The U.S. military has been conducting static-line parachute jumps for nearly a century. Beginning with World War II, military forces have also employed full-scale airborne operations as a method for insertion into combat. Through the years, injuries from blunt trauma as a result of static-line parachute jumps have evolved little with the refinement of equipment, training, and tactics. Parachute jumps continue to invoke primarily musculoskeletal injuries, especially to the lower extremities, back, neck, and head. These injuries are usually straightforward in their presentation and diagnosis. We describe the delayed diagnosis of a pelvic hematoma due to an uncommon blunt trauma jump injury. The purpose of this case report is to increase awareness of injury patterns during paratrooper operations, as well as to review the diagnosis and management of occult hemorrhage. Specific objectives for the readers are to (1) know the common injury types and patterns for airborne operations, (2) know the descent rate of T-10C/D parachutes and factors influencing the rate, (3) recognize signs and symptoms associated with a pelvic hematoma, and (4) recognize common complications resulting from a pelvic hematoma.

Intraorbital Training Munition

Davies BW, Hink EM, Enzenauer RW 13(2). 8 - 11 (Case Reports)

Objectives: To present a case report of an intraorbital training munition during combat simulation. Methods: A 36-year-old National Guardsman presented to our hospital after being struck in the right orbit with a training munition during combat exercises at Fort Carson, Colorado. The clinical findings, treatment course, and outcome of the case are discussed with review of the literature. Results: An anterior orbitotomy and retinal detachment repair was performed on the patient. The training munition was recovered through the entrance wound in the upper eyelid. At 1 month postoperative, the patient's vision was 20/20 with correction. No complications were noted. Conclusions: This case report is serves as an example of the ocular morbidity associated with training munitions as well as a reminder of the importance of compliance with protective eyewear during training exercises. While surgical excision is this case was straightforward, intraorbital foreign bodies can pose a significant surgical challenge.

Abdominal Aortic Tourniquet™ Use in Afghanistan

Anonymous A 13(2). 1 - 2 (Journal Article)

The Abdominal Aortic Tourniquet™ was used recently used in Afghanistan to control severe hemorrhage in a casualty who had traumatic bilateral amputations of the lower extremities. Excerpts from the medical provider's account of the tactical evacuation phase of care are provided.

Traumatic Visual Loss and a Limitation of Point-of-Care Ocular ultrasound: A Case Report

Nydam T, Tanksley S 13(1). 55 - 57 (Journal Article)

Incorporation of point-of-care ultrasound into the skill set of Special Operations medical providers should come with an appreciation of the potential limitations of the technology. We present a case of a U.S. Army Special Forces Soldier who suffered traumatic monocular vision loss after being struck in the eye during a combatives tournament. Evaluation in the emergency department (ED) included an unremarkable ocular ultrasound, despite a high clinical suspicion of intraocular pathology. Ophthalmologic consultation was obtained emergently. Optical coherence topography and a dilated fundoscopic examination were performed, which revealed a small subretinal hemorrhage. We will review the history of ocular ultrasound and its sensitivity to detect intraocular pathology. We will also emphasize the need to obtain specialty consultation when the clinical suspicion for intraocular pathology is high despite a negative ocular ultrasound.

Gunshot Wound to the Distal Phalanx: A Case Review

Hoy RD, Paul J 13(1). 58 - 60 (Journal Article)

Background: This report describes the case of a Soldier who sustained a gunshot wound from a 9mm to the distal phalanx and presented to the authors while they were deployed on a recent joint training mission to Southwest Asia.

Difficult Diagnoses in an Austere Environment: A Clinical Vignette-The Presentation, Diagnosis, and Management of Ichthyosis

Pickard-Gabriel CJ, Rudinsky S 13(1). 61 - 65 (Journal Article)

Lamellar ichthyosis (LI) is a rare inherited skin disorder of cornification, with an incidence of approximately 1 in 200,000 births. It is one of three types of autosomal recessive congenital ichthyosis (ARCI), a collective term for the spectrum of nonsyndromic ichthyoses caused by a number of well-described genetic mutations. We describe the case of LI diagnosed in a 10-day-old child of a Somali refugee at a free clinic in downtown Djibouti. Initial concern was for staphylococcal infection versus congenital disease. With the use of digital photographs, consultation with experts accessed through the Army Teledermatology Consultation Service supported a diagnosis of ARCI. Providing care to patients in austere environments can present numerous medical challenges. A provider cannot be expected to be able to diagnose and treat every disease and disorder alone, especially if there is a language barrier. Telemedicine can help close the gap in knowledge, particularly when presented with a challenging case. With a novel presentation, simply taking a photograph and e-mailing a consultant can quickly augment one's medical acumen, ensuring appropriate diagnosis and treatment.

Functional Screening for Vestibular and Balance Problems Soon After head Injury: Options in Development for the Field or Aid Station

Lawson BD, Rupert AH, Cho TH 13(1). 42 - 48 (Journal Article)

Vestibular balance dysfunction has been documented as a military problem after duty-related barotrauma and/ or traumatic head acceleration. We are fostering the development of rapid, portable, fieldable tests of balance function after such vestibular insults. We consulted on military-relevant tests with more than 50 vestibular researchers, scientific advisors, clinicians, and biomedical engineers working for government agencies, universities, clinics, hospitals, or businesses. Screening tests and devices appropriate for early (post-injury) military functional assessment were considered. Based on these consultations, we recommend that military field tests emphasize dynamic, functional, and duty-relevant aspects of standing balance, gait, visual acuity, perception of visual vertical, and vertigo. While many current tests are useful for the clinic, they often require modification before they are suitable for military field and aid station settings. This report summarizes likely future military testing needs, giving priority to testing approaches in development that promise to be rapid, portable, field-ready, semiautomated, usable by a nonspecialist, and suitable during testing and rehabilitation.

Evaluation of a Removable Intraoral Soft Stabilization Splint for the Reduction of headaches and Nightmares in Military PTSD Patients: A Large Case Series

Moeller DR 13(1). 49 - 54 (Journal Article)

This large case series reports the results of using a removable soft intraoral stabilization splint in the treatment of chronic headaches and chronic nightmares in 60 military post-traumatic stress disorder (PTSD) patients of the Vietnam, Desert Storm, Operation Iraqi Freedom, and Operation Enduring Freedom conflicts. Patient treatment criteria included meeting all of the following requirements: minimum of three headaches per week; minimum of three nightmares per week; minimum of three sleep interruptions per week; minimum of three intraoral or extraoral (craniofacial) trigger points; and previous PTSD diagnosis by the U.S. Army or Veterans Administration with duration of this disorder for a minimum of three years. Significant reduction (60%-90%) in headache and nightmare severity, intensity, and duration was obtained in 75% of the 44 patients who completed the three-month follow-up.

Development of a Rugged handheld Device for Real-Time Analysis of heart Rate: Entropy in Critically Ill Patients

Mejaddam AY, van der Wilden GM, Chang Y, Cropano CM, Sideris AC, Hwbejire JO, Velmahos GC, Alam HB, de Moya MA, King DR 13(1). 29 - 33 (Journal Article)

Introduction: The usefulness of heart rate variability (HRV) and heart rate complexity (HRC) analysis as a potential triage tool has been limited by the inability to perform real-time analysis on a portable, handheld monitoring platform. Through a multidisciplinary effort of academia and industry, we report on the development of a rugged, handheld and noninvasive device that provides HRV and HRC analysis in real-time in critically ill patients. Methods: After extensive re-engineering, real-time HRV and HRC analyses were incorporated into an existing, rugged, handheld monitoring platform. Following IRB approval, the prototype device was used to monitor 20 critically ill patients and 20 healthy controls to demonstrate real-world discriminatory potential. Patients were compared to healthy controls using a Student's t test as well as repeated measures analysis. Receiver operator characteristic (ROC) curves were generated for HRV and HRC. Results: Critically ill patients had a mean APACHE-2 score of 15, and over 50% were mechanically ventilated and requiring vasopressor support. HRV and HRC were both lower in the critically ill patients compared to healthy controls (ρ < 0.0001) and remained so after repeated measures analysis. The area under the ROC for HRV and HRC was 0.95 and 0.93, respectively. Conclusions: This is the first demonstration of real-time, handheld HRV and HRC analysis. This prototype device successfully discriminates critically ill patients from healthy controls. This may open up possibilities for real-world use as a trauma triage tool, particularly on the battlefield.

Single versus Double Routing of the Band in the Combat Application Tourniquet

Clumpner BR, Polston RW, Kragh JF, Westmoreland T, Harcke HT, Jones JA, Dubick MA, Baer DG, Blackbourne LH 13(1). 34 - 41 (Journal Article)

Background: Common first aid tourniquets, like the Combat Application Tourniquet (CAT) of a windlass and band design, can have the band routed through the buckle in three different ways, and recent evidence indicates users may be confused with complex doctrine. Objective: The purpose of the present study is to measure the differential performance of the three possible routings in order to better understand good tourniquet practice. Methods: A training manikin was used by two investigators to measure tourniquet effectiveness, time to stop bleeding, and blood loss. Results: The effectiveness rate was 99.6% (239/240) overall. Results were similar for both single-slit routings (inside vs. outside, p > 0.05). Effectiveness rates (yes-no results for hemorrhage control expressed as a proportion of iterations) were not statistically different between single and double routing. However, the time to stop bleeding and blood loss were statistically different (ρ < 0.05). Conclusions: CAT band routing, through the buckle either singly or doubly, affects two key performance criteria: time to stop bleeding and volume of blood lost. Single routing proved to be faster, thereby saving more blood. Learning curves required to optimize user performance varied over 30-fold depending on which variable was selected (e.g., effectiveness vs. blood loss).

The use of Dietary Supplement Among Soldiers From the Macedonian Special Operations Regiment

Kjertakov M, Hristovski R, Racaj M 13(1). 19 - 24 (Journal Article)

Objectives: To determine the prevalence and type of dietary supplement used, reasons for use, and sources of supplement information among Macedonian elite Soldiers. Methods: Anonymous self-reported questionnaires containing questions about demographic characteristics and dietary supplementation practices were distributed to 134 Soldiers, of whom 80 were recruited from the Ranger Battalion (R) and 54 from the Special Force Battalion (SF). Results: The Soldiers completed and returned 132 questionnaires. Overall, 66.6% of the Soldiers, including 70.3% of SF and 64.1% of R, reported using supplements within the 3 months before the survey. On average, each of these Soldiers used 3.7 ± 2.9 supplements. The most commonly used supplements were multivitamins (50.0%) and vitamin C (47.7%). The most frequently cited reason for using supplements was to improve general health (51.6%). Primary sources of supplement information were friends (42.0%) and books/magazines (40.9%). Conclusions: Dietary supplement use was found to be common and widespread among this military subpopulation. Given this, and the fact that the majority of the Soldiers do not receive accurate information about supplements, educational intervention regarding the safety and efficacy of these products is needed if unnecessary or harmful supplementation practices are to be prevented.

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