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Critical Competencies of Military Embedded Health and Performance Professionals: The "Culture General" Approach

Chamberlin R, McCarthy R, Lunasco TK, Park GH, Deuster PA 22(3). 118 - 123 (Journal Article)

Human performance teams (HPT) delivering a wide range of services within military unit communities serve as a model for advancing business practices in support of the 2018 National Defense Strategy. Relatively new, the demand for these embedded professionals continues to grow in response to its favorable proximity, community-based design, operationalized delivery system, and adaptive business practices. However, many civilian professionals come from diverse disciplines of specialties and experiences. As they integrate into unit communities, it becomes known that many do not possess formal training or experience working with the US military or its Servicemembers, delivering community-based services, operating in the capacity of a force multiplier, or culturally adapting their professional skills. Given the steep learning curve in transitioning from a conventional delivery model to the military embedded model, even newly minted military health and performance professionals may be underprepared when they arrive at their assigned military unit communities. In this article, we examine the military's embedded health and performance service delivery model. We add specific focus on those critical "embedded" professional competencies and skills foundational to establishing and sustaining thriving service delivery. We then offer strategies and tools collected from embedded health and performance professionals currently serving in military unit communities across the Department of Defense (DoD). Finally, we provide a rationale for the need for embedded competency training to improve the preparedness of professionals who are currently serving, will be serving, or have a general interest in serving as an embedded professional within DoD military unit communities.

Implications of Neurological Directed-Energy Weapons for Military Medicine

Lyon RF, Gramm J, Branagan B, Houck SC 22(3). 104 - 107 (Journal Article)

Since 2016, there has been an increase in reported cases of intelligence officers and diplomats hearing pulsing sounds and experiencing neurophysiologic and cognitive symptoms. These varied and often intense symptoms manifest in ways similar to a traumatic brain injury (TBI) but without inciting trauma. Known formerly as "unconventionally acquired brain injury" (UBI), these events are now labeled "anomalous health incidents" (AHIs). Investigations of these incidents suggest reasons to be concerned that a specific type of neuroweapon may be the cause-a directed energy weapon (DEW). Neuroweapons that target the brain to influence cognition and behavior are leading to a new domain of warfare-neurowarfare. The implications and resultant stakes, especially for the Special Operations community, are significant. This article focuses specifically on the implications of DEWs as a neuroweapon causing UBIs/AHIs for military medical practitioners and suggests using a comprehensive strategy, analogous to that of chemical warfare or other weapons of mass destruction (WMD), to improve our preparedness for the medical repercussions of neurowarfare.

Hypertonic Saline for Severe Traumatic Brain Injury With Herniation: A Military Prehospital Case Report

Antonino N, Payne R, Gaddy M, DeSoucy ES, Rush SC, Michael R 22(3). 98 - 100 (Journal Article)

Severe traumatic brain injury (sTBI) is a devastating injury with limited prehospital therapies available. The Joint Trauma System (JTS) Clinical Practice Guidelines recommend hypertonic saline (HTS) for casualties with sTBI and signs of impending or ongoing herniation (IOH), but its use by combat medics has never been reported in the literature. This report details the management of a pregnant patient with sTBI and signs of IOH, including the use of HTS, by US Air Force pararescumen in an austere prehospital setting. Treatment with HTS was followed by improvement in the patient's neurologic exam and successful evacuation to definitive care where her child was delivered alive. Additionally, we review the pathophysiology and signs of herniation, the mechanism of action of hyperosmotic therapies, and the rationale behind the use of HTS in the combat setting.

Bilateral Pneumothoraces in a Tandem Parachuting Passenger Without Traumatic Impact: A Case Report

Fedor PJ, Riley B, Fowl DA, Donahue A 22(3). 94 - 97 (Case Reports)

In parachuting, orthopedic and head injuries are well-documented risks associated with the parachute deployment and landing phases. Thoracic injuries have only been seen on rare occasion in conjunction with direct impact trauma. In this report, we detail a case of a young, healthy, tandem skydiving passenger who suffered bilateral pneumothoraces with delayed symptom onset, with no identifiable injury during the jump or landing. Exploring the forces of the parachute "opening shock," we suggest a plausible compressive mechanism for this novel presentation, as well as briefly discuss the options for diagnosis and conservative management of pneumothorax in the operational context. While this is an exceedingly rare event, pneumothorax should be considered in patients complaining of thoracic symptoms following a skydive.

Operational Consideration for Definitive Airway Management in the Austere Setting: A Case Report

Morvan J, Cotte J, des Deserts MD, Worlton T, Menini W, Cathelinaud O, Pasquier P 22(3). 90 - 93 (Journal Article)

In modern and asymmetric conflicts, traumatic airway obstruction caused by penetrating injury to the face and neck anatomy is the second leading cause of preventable mortality. Definitive airway management in the emergency setting is most commonly accomplished by endotracheal intubation. When this fails or is not possible, a surgical airway, usually cricothyrotomy, is indicated. The clinical choice for establishing a definitive airway in the austere setting is impacted by operational factors such as a mass casualty incident or availability and type of casualty evacuation. This is a case report of a patient with severe cervicofacial injuries with imminent airway compromise in the setting of a mass casualty incident, without possibility of sedation and mechanical ventilation during his evacuation. The authors seek to highlight the considerations and lessons learned for emergency cricothyrotomy.

Walking Quadriplegic: Cervical Myelopathy in an Ambulating Combat Support Soldier

Treyster DA, Riordan R, Rotello EN, Falcon J, Charny G 22(3). 86 - 89 (Journal Article)

We discuss a case of a 27-year-old male Soldier who presented with acute to subacute vague radicular complaints, which were atypical for and out of proportion to the imaging findings. Imaging demonstrated compressive cervical myelopathy at the levels of C3/C4 and C4/C5. Paradoxically, the patient's history revealed a remote nerve root compression, not cord compression, at the same levels. Identification and prompt surgical management led to the reversal of significant neurologic deficits that were present preoperatively. This case highlights the difficulty of identifying this rare condition among a plethora of otherwise benign and common cervical spondyloses seen in the Special Operations population. This study aims to bring to light the subtle history and physical characteristics that can assist Special Operations healthcare providers in making an otherwise elusive diagnosis. Last, it highlights a utility to documenting baseline spinal exam findings for the force to better identify subtle injuries.

Women in US Military History

Garceau-Kragh G 22(3). 75 - 83 (Editorial)

A Review of Acute Kidney Injury

Weidner DA, Yoo MJ 22(3). 70 - 74 (Case Reports)

Acute kidney injury (AKI) is a serious, often silent, medical condition with diverse etiologies and complex pathophysiology. We discuss the case of a patient injured in a single vehicle rollover. Included is a discussion of prevention and supportive care, with a focus on electrolyte repletion, fluid correction, minimization of nephrotoxic exposures, and identification and treatment of the root cause.

Ultrasonography Performed by Military Nurses in Combat Operations: A Perspective for the Future?

Balasoupramanien K, Comat G, Renard A, Meusnier J, Montigon C, Pitel A, Bascou M, Dubourg R, Cazes N 22(3). 65 - 69 (Journal Article)

Introduction: In current French military operations, it is not uncommon for military nurses (MNs) alone to be required to support soldiers in isolated areas. At a time when advanced practice nurses in the civilian sector develop extended skills, we asked MNs about their willingness to be trained in pointof- care ultrasound (POCUS). Methods: We conducted a webbased survey from 1 November 2018 to 1 December 2018, including all MNs deployed in Operation Barkhane. The questionnaire, sent by e-mail, aimed to describe the willingness of MNs to be trained in POCUS. Their opinion on the usefulness of this training, the situations, and ultrasound (US) targets that seemed most useful to them were also studied. Results: Thirty of 34 questionnaires were completed. On average, MNs had 7.4 years of practice and had been deployed three times for military operations. Five MNs reported having had informal training in clinical US by the military physicians (MPs) they work with and had performed POCUS in real-life situations; 24 (96%) of the untrained MNs wanted to be trained. Twenty- nine (96%) of the MNs felt that there was added value in knowing how to perform POCUS, especially in operations and in isolated posts without an MP. Focused assessment with sonography for trauma and pleural and renal US were the targets considered most useful to them, in that order. Conclusion: MNs are interested in learning POCUS and say it would be beneficial for the patient. Available scientific data tend to validate their ability after a brief training course to perform reliable, targeted US examinations in the field.

Edith Nourse Rogers: A Pioneer for Women, Military Veterans, and US Medical Education

Bellaire CP, Ditzel RM, Meade ZS, Love ZD, Appel JM 22(3). 62 - 64 (Journal Article)

This year is the 80th anniversary of the Women's Army Auxiliary Corps. The passage of this seminal legislation - sponsored by Edith Nourse Rogers - formalized the role of women in the US military and compensated them for their service and in the event of injury or illness. Rogers was a pioneer in her own right. A trailblazer for women and a staunch advocate for military veterans' healthcare, Rogers was forged by her wartime experiences. The authors describe Rogers' contributions as a congresswoman during World War II and during her 35 years of public service in the House of Representatives. Congresswoman Rogers was foundational to the modern US healthcare system.

Helicopter Crashes in the Deployed Combat Setting: The Department of Defense Trauma Registry Experience

Jude JW, Spanier AM, Hiller HM, Weymouth WL, Cunningham CW, Hill GJ, Schauer SG 22(3). 57 - 61 (Journal Article)

Background: Military helicopter mishaps frequently lead to multiple casualty events with complex injury patterns. Data specific to this mechanism of injury in the deployed setting are limited. We describe injury patterns associated with helicopter crashes. Materials and Methods: This is a secondary analysis of a Department of Defense Trauma Registry (DODTR) dataset from 2007 to 2020 seeking to describe prehospital care within all theaters in the registry. We searched within the dataset for casualties injured by helicopter crash. A serious injury was defined by an abbreviated injury scale of ≥3 by body region. Results: We identified 120 casualties injured by helicopter crash within the dataset. Most were Army (64%), the median age was 30 (interquartile range [IQR] 26-35), and most were male (98%), enlisted service members made up the largest cohort (47%), with most injuries occurring during Operation Enduring Freedom (69%). Only 2 were classified as battle injuries. The median injury severity score was 9 (IQR 4-22). Serious injuries by body region are the following: thorax (27%), head/neck (17%), extremities (17%), abdomen (11%), facial (3%), and skin/superficial (1%). The most common prehospital interventions focused on hypothermia prevention/management (62%) and cervical spine stabilization (32%). Most patients survived to hospital discharge (98%). Conclusions: Serious injuries to the thorax were most common. Survival was high, although better data capture systems are needed to study deaths that occur prehospital that do not reach military treatment facilities with surgical care to optimize planning and outcomes. The high proportion of nonbattle injuries highlights the risks associated with helicopters in general.

Performance Evaluation of the Solo-T and the Combat Application Tourniquet in a Perfused Cadaver Model

Holinga GJ, Foor JS, Van Horn SL, McGuire JE 22(3). 49 - 55 (Journal Article)

Purpose: We evaluated a 10.2-cm-wide, minimally elastic, adhesive wrap-based tourniquet (Solo-T or ST) alongside a 3.8-cm-wide windlass-based tourniquet (Combat Application Tourniquet Generation 7, or CAT) to determine if the tension wrap-tightened ST could deliver hemorrhage control equivalent to the windlass-tightened CAT. Methods: A cadaver model was used to simulate lower-thigh femoral arterial hemorrhage at "normal" (146 ± 5mmHg) and "elevated" (471 ± 3mmHg) perfusion pressures (mean ± standard error). Three study participants used the ST and CAT to control hemorrhage during 48 timed trials. Arterial occlusion was established by Doppler ultrasound and tourniquet performance was quantified by under-tourniquet pressure cuffs. Results: Participants achieved 100% (24/24) occlusion success rates and reported similar ease of use for both tourniquets. Occlusion and application times (mean ± standard error) were similar (p > .05) for the ST and CAT under "normal" (occlusion, ST: 25 ± 2 seconds, CAT: 22 ± 2 seconds; application, ST: 27 ± 2 seconds, CAT: 26 ± 2 seconds) and "elevated" (occlusion, ST: 24 ± 7 seconds, CAT: 24 ± 7 seconds; application, ST: 25 ± 7 seconds, CAT: 25 ± 7 seconds) perfusion alike. The ST mean completion pressures (mean ± standard error) were > 40% lower than the CAT under both "normal" perfusion (ST: 110 ± 20mmHg; CAT: 210 ± 30mmHg; p = 0.009) and "elevated" perfusion (ST: 190 ± 50mmHg; CAT: 340 ± 30mmHg; p = 0.03). Conclusion: The adhesive wrap-based ST tourniquet delivered equivalent hemorrhage control performance at significantly lower completion pressures than the CAT.

Workload of Swedish Special Forces Operators Experienced During Stressful Simulation Training: A Pilot Study

Hindorf M, Berggren P, Jonson C, Lundberg L, Jonsson A 22(3). 42 - 48 (Journal Article)

Introduction: Stress week was included during training of Special Forces (SF) Operators in Sweden to test their ability and limits for handling stress in different unknown situations and environments at a military training facility in Sweden. The aim of the study was to examine the effects of stress and workload experienced in various tasks during firefighting and military medicine simulation training. Methods: This pilot study was performed during the second day of stress week. The National Aeronautics and Space Administration Task Load Index (NASA-TLX) is a validated, subjective, and multidimensional assessment tool for rating perceived workload with six subscales: mental demand, physical demand, temporal demand, performance, effort, and frustration. These subscales were used as an indicator of stress experienced. The different tasks were assessed by the SF Operators by rating the NASA-TLX subscales for each task, which were then analyzed and compared using ANOVA. Results: There was a significant difference between the two simulation exercises assessed by the participants and instructors, and both groups considered firefighting to be more demanding than medical. The participants perceived the mental and physical demands as more demanding in the firefighting exercises, as well as for the level of frustration and effort. However, no differences regarding performance or temporal demands between the simulation exercises were found. Conclusion: The principle "train as you fight" implies difficult and demanding situations. When exposing Swedish SF Operators to challenging situations, assessment of perceived stress and performance are possible.

Generating Competent Special Operations Clinicians From Military Graduate Medical Education

Hiller HM, Hill GJ, Shea S, Fernandes J, Earl K, Knight J, Schaffrinna A, Donham B, Allen PB 22(3). 37 - 41 (Journal Article)

Units within the Special Operations Forces (SOF) community require medically competent and operationally proficient medical providers (physicians, physician assistants, and nurse practitioners, among others) to support complex mission sets. The expectations placed on providers who successfully assess for and are selected into these units are high. These providers are not only expected to be experts in their respective subspecialities, but also to serve as staff officers, provide medical direction for SOF medics, serve as medical advisors to the command team, and provide direct medical support for kinetic operations. They are expected to perform these functions with little oversight and guidance and when geographically separated from higher units. Graduates from military Graduate Medical Education (GME) programs are extremely well-educated and can provide high quality medical care. However, they often find themselves ill-prepared for the extra demands placed upon them by the Special Operations community due to a lack of operational exposure. The authors of this paper recognized this gap and propose that the Joint Emergency Medicine Exercise (JEMX) model can help augment the body of knowledge required to perform well as a provider in a Special Operations unit.

A Lost Opportunity: The Use of Unorthodox Training Methods for Prehospital Trauma Care

McCarthy J, Lauria MJ, Fisher AD 22(3). 29 - 35 (Journal Article)

Prehospital trauma care guidelines and instruction have advanced significantly over the past 20 years. Although there have been efforts to create a standardized approach to instruction, the use of unorthodox techniques that lack supporting evidence persists. Many instructors use unrealistic scenarios, "no-win" scenarios, and unavoidable failing situations to train students. Doing so, however, creates student confusion and frustration and can result in poor skill acquisition. These training techniques should be reconsidered, with focus placed instead on the development of technical skills and far skill transfer. Knowing when to apply the appropriate type and level of stress within a training scenario can maximize student learning and knowledge retention. Furthermore, modalities such as deliberate practice, cognitive load theory (CLT), and stress exposure training (SET) should be incorporated into training. To improve delivery of prehospital trauma education, instructors should adopt evidence-based educational strategies, grounded in educational and cognitive science, that are targeted at developing long-term information retention as well as consistent, accurate, and timely life-saving interventions.

Active Warfighter Resilience: A Descriptive Analysis

Barczak-Scarboro NE, Cole WR, DeFreese JD, Fredrickson BL, Kiefer AW, Bailar-Heath M, Burke RJ, DeLellis SM, Kane SF, Lynch JH, Means GE, Depenbrock PJ, Mihalik JP 22(3). 22 - 28 (Journal Article)

Purpose: Our aim in this study was to psychometrically test resilience assessments (Ego Resiliency Scale [ER89], Connor-Davidson Resilience Scale [CD-RISC 25], Responses to Stressful Experiences Scale [RSES short-form]) and describe resilience levels in a Special Operations Forces (SOF) combat sample. Methods: Fifty-eight SOF combat Servicemembers either entering SOF (career start; n = 38) or having served multiple years with their SOF organization (mid-career; n = 20) self-reported resilience, mild traumatic brain injury (mTBI) history, and total military service. Results: All resilience metrics demonstrated acceptable internal consistency, but ceiling effects were found for CD-RISC and RSES scores. ER89 scores were moderate on average. ER89 scores were higher in SOF career start than mid-career Servicemembers (ηρ2 = 0.07) when accounting for the interaction between SOF career stage and total military service (ηρ2 = 0.07). Discussion: SOF mid-career Servicemembers had similar ER89 resilience scores with more total military service. The SOF career start combat Servicemembers had higher ER89 measured resilience with less total military service only, potentially showing a protective effect of greater service before entering SOF. Conclusion: The ER89 may be a more optimal military resilience metric than the other metrics studied; longitudinal research on SOF combat Servicemember resilience is warranted.

Whole Blood Storage Temperature Investigation in Austere Environments

Avila CO, Sayson SC, Bennett B 22(3). 19 - 21 (Journal Article)

Introduction: Military medical research has affirmed that early administration of blood products and timely treatment save lives. The US Navy's Expeditionary Resuscitative Surgical System (ERSS) is a Role 2 Light Maneuver team that functions close to the point of injury, administering blood products and providing damage-control resuscitation and surgery. However, information is lacking on the logistical constraints regarding provisions for and the stability of blood products in austere environments. Methods: ERSS conducted a study on the United States Central Command (USCENTCOM) area of responsibility. Expired but properly stored units of stored whole blood (SWB) were subjected to five different storage conditions, including combinations of passive and active refrigeration. The SWB was monitored continuously, including for external ambient temperatures. The time for the SWB to rise above the threshold temperature was recorded. Results: The main outcome of the study was the time for the SWB to rise above the recommended storage temperature. Average ambient temperature during the experiment involving conditions 1 through 4 was 25.6°C (78.08°F). Average ambient temperature during the experiment involving condition 5 was 34.8°C (94.64°F). Blood temperature reached the 6°C (42.8°F) threshold within 90 minutes in conditions 1 and 2, which included control and chemically activated ice packs in the thermal insulated chamber (TIC). Condition 2 included prechilling the TIC in a standard refrigerator to 4°C (39.2°F), which kept the units of SWB below the threshold temperature for 490 minutes (approximately 8 hours). Condition 4 entailed prechilling the TIC in a standard freezer to 0.4°C (32.72°F), thus keeping the units of SWB below threshold for 2,160 minutes (i.e., 36 hours). Condition 5 consisted of prechilling the TIC to 3.9°C (39.02°F) in the combat blood refrigerator, which kept the SWB units below the threshold for 780 minutes (i.e., 13 hours), despite a higher average ambient temperature of almost +10°C (50°F). Conclusion: Combining active and passive refrigeration methods will increase the time before SWB rises above the threshold temperature. We demonstrate an adaptable approach of preserving blood product temperature despite refrigeration power failure in austere settings, thereby maintaining mission readiness to increase the survival of potential casualties.

Development and Evolution of a Comprehensive Mild Traumatic Brain Injury Inpatient Rehabilitation Program: A Nursing Perspective

Modi SS, Goff D, Guess D, Meigs K, Hoskin A, Doncevic S, Perla L, Pejoro S, Sallah C 22(3). 15 - 18 (Journal Article)

The James A. Haley Veterans' Hospital in Tampa, Florida has developed an innovative approach to the unique rehabilitation needs of active duty Special Operations Forces (SOF) and veterans with chronic conditions related to their military service. Tampa's program, the Post-Deployment Rehabilitation and Evaluation Program (PREP), was established in 2008. The interdisciplinary team includes one nurse practitioner and eight staff registered nurses. The Veterans Health Administration (VHA) is using Tampa's established and successful PREP as a model to actively expand the program to other Veterans Administration (VA) Polytrauma Rehabilitation Centers over the next several years. There are several important nursing and rehabilitation team considerations for the successful development of these mild traumatic brain injury (mTBI) inpatient rehabilitation programs.

Operation Blood Rain Phase 2: Evaluating the Effect of Airdrop on Fresh and Stored Whole Blood

Fuentes RW, Shawler EK, Smith WD, Tong RL, Barnes WJ, Moncada M, Bohlke CW, Mitchell AL 22(3). 9 - 14 (Journal Article)

Background: Transfusion of whole blood (WB) is a lifesaving treatment that prolongs life until definitive surgical intervention can be performed; however, collecting WB is a time-consuming and resource-intensive process. Furthermore, it may be difficult to collect sufficient WB at the point of injury to treat critically wounded patients or multiple hemorrhaging casualties. This study is a follow-up to the proof-of-concept study on the effect of airdrop on WB. In addition, this study confirms the statistical significance for the plausibility of using airdrop to deliver WB to combat medics treating casualties in the pre-hospital setting when Food and Drug Administration (FDA)-approved cold-stored blood products are not available. Methods: Forty-eight units of WB were collected and loaded into a blood cooler that was dropped from a fixed-wing aircraft under a Standard Airdrop Training Bundle (SATB) parachute or 68-in pilot chute. Twenty-four of these units were dropped from a C-145 aircraft, and 24 were dropped from a C-130 aircraft. A control group of 15 units of WB was storedin a blood cooler that was not dropped. Baseline and post-intervention laboratory tests were measured in both airdroppedand control units, including complete blood count; prothrombin time/partial thromboplastin time (PT/PTT); pH, lactate, potassium, bilirubin, glucose, fibrinogen, and lactate dehydrogenase (LDH) levels; and peripheral blood smears. Results: The blood cooler, cooling packs, and all 48 WB units did not sustain any major damage from the airdrop. There was no evidence of hemolysis. Except for the one slightly damaged bag that was not sampled, all airdropped blood met parameters for transfusion per the Joint Trauma System Whole Blood Transfusion Clinical Practice Guideline and the Association for the Advancement of Blood and Biotherapies (AABB) Circular of Information for the Use of Human Blood and Blood Components. Conclusions: Airdrop of fresh or stored WB in a blood cooler with a chute is a viable way of delivering blood products to combat medics treating hemorrhaging patients in the pre-hospital setting. This study also demonstrated the portability of this technique for multiple aircraft. The techniques evaluated in this study have the potential for utilizationin other austere settings such as wilderness medicine or humanitarian disasters where an acute need for WB delivery by airdrop is the only option.

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