George T, Jordan M, Bianchi W, Boboc M, Zarow GJ, Natarajan R, Walchak AC, Roszko PJ 19(1). 89 - 94 (Journal Article)

Background: Military forces render emergency care in marine environments, where care for exsanguination is challenging. However, the effect of saltwater on the functionality of hemostatic agents is unknown. In this study, we used thromboelastography (TEG) to quantify the effect of saltwater on the efficacy of five gauze products. Methods: Blood from 24 healthy adult men was diluted by 30% with hetastarch to mimic hemodilution. Dry and saltwater-soaked Kerlix™, ChitoGauze®, Combat Gauze®, NuStat™, and WoundClot™ were contrasted in terms of the TEG parameters of speed of clot initiation (R), clot amplification (K), α angle (i.e., clot formation rate), and maximum amplitude of clot (MA), using repeated-measures analysis of variance at the p < .05 statistical significance threshold. Results: Compared with untreated dilute blood, R was significantly faster when any dry or wet gauze was added, with the fastest R values recorded for Combat Gauze. K and α angle findings were mixed. MA was greater than diluted blood for dry hemostatic gauze, but in the wet condition, only the MA for Combat Gauze was significantly greater than that of diluted blood. Conclusion: Gauze products, wet or dry, improved clotting compared to diluted blood without gauze. Saltwater exposure did not significantly detract from this benefit. Our findings suggest that Combat Gauze may be the choice hemostatic gauze for maritime environments.

Conkright W, Deuster PA 19(1). 107 - 112 (Journal Article)

Modern-day warfare and operational tempo require Special Operations Forces (SOF) personnel to be ready and able to perform optimally on the battlefield at all times. To do this, US Special Operations Command has invested in high-performance training centers and human performance staff, including performance dietitians. Performance dietitians are critical, because it is widely recognized that nutrition affects all aspects of health and performance, particularly for the SOF Operator. These aspects include everything from physical and sensory to psychosocial and cognitive factors, as well as environmental exposures and genetic predispositions. The impact of nutrition on performance has been well established, with specific recommendations and position stands on fueling for athletics from multiple international organizations. However, sports nutrition guidelines are based on outcomes from sample means rather than individual changes in performance. Precision performance nutrition solutions must include a systems-based approach and consider the individuality of the Operator along with their interactions with their environment. The purpose of this article is to summarize what is known about performance nutrition and outline what can be done to move toward personalized precision nutrition. We discuss pitfalls and challenges with regard to mission-specific goals, optimization versus adaptation, and longitudinal tracking; and present our view of the future.

Palmer LE 19(1). 99 - 106 (Journal Article)

Similar to people, airway obstruction is a potentially preventable cause of combat and line of duty death for civilian law enforcement Operational K9s (OpK9) and military working dogs (MWD). Basic (i.e., body positioning, manual maneuvers, bag-valve-mask ventilation) and advanced (i.e., endotracheal intubation, surgical airways) airway techniques are designed to establish a patent airway, oxygenate and ventilate, and protect from aspiration. A surgical airway (cricothyrotomy [CTT] or tracheostomy [TT]) is warranted for difficult airway scenarios in which less invasive means fail to open an airway (aka "Cannot intubate, cannot oxygenate"). In people, the surgical CTT is the preferred surgical airway procedure; most human prehospital providers are not even trained on the TT. Currently, only the TT is described in the veterinary literature as an emergent surgical airway for MWDs. This article describes the novel approach of instituting the surgical CTT for managing the canine difficult airway. The information provided is applicable to personnel operating within the US Special Operations Command as well as civilian tactical emergency medical services that may have the responsibility of providing medical care to an OpK9 or MWD.

Conlon EG, Wright KT 19(1). 125 - 127 (Journal Article)

Atopic dermatitis (eczema) and psoriasis are two common chronic skin diseases that affect many people, including active- duty military Servicemembers and their families. Both conditions have significant psychosocial impacts and can lead to substantial morbidity if undiagnosed and left untreated. We compare and contrast atopic dermatitis and psoriasis in terms of epidemiology, etiology, presentation, diagnosis, and treatment. The goal is to help military medical providers distinguish between the two diseases and provide practical steps for treatment and long-term management.

Knapik JJ, Pope R, Hoedebecke SS, Schram B, Orr R 19(1). 113 - 124 (Journal Article)

Osteoarthritis (OA) is a disorder involving the deterioration of articular cartilage and underlying bone and is associated with symptoms of pain and disability. In military personnel, the incidence of OA has increased between 2000 and 2012 and was the first or second leading cause of medical separations in this period. It has been suggested that consumption of chondroitin sulfate (CS) may reduce the pain and joint deterioration associated with OA. This article reports on a systematic review and meta-analysis of the effectiveness of CS on reducing OA-related pain and joint deterioration. PubMed and Ovid Embase databases and other sources were searched to find randomized, double-blind, placebo-controlled trials on the effects of orally consumed CS on pain and/or joint structure. The outcome measure was the standardized mean difference (SMD) which was the improvement in the placebo groups minus the improvement in the CS groups divided by the pooled standard deviation. There were 18 trials meeting the review criteria for pain with SMD -0.41, 95% confidence interval (95% CI) -0.57 to -0.25 (negative SMD favors CS). Six studies met the review criteria for joint space narrowing with SMD -0.30, 95% CI -0.61 to +0.00. Two studies meet the review criteria for cartilage volume with SMD -0.11, 95% CI -0.48 to +0.26. Larger dosages (1200mg/d) had greater pain reduction efficacy than lower dosages (≤ 1000mg/d). These data suggest that CS has small to moderate effectiveness in reducing OA-related pain but minimal effects on joint space narrowing and no effect on cartilage volume. It is important that clinicians recommend pharmaceutical-grade CS to their patients due to the variability in the amount of CS in dietary supplements purporting to contain CS.

Dare C, Hampton K 19(1). 130 (Journal Article)

Schmidgal EC, Wright KT 19(1). 128 - 129 (Journal Article)

Lesions of the scalp can present a challenging differential diagnosis to the primary care provider, especially in remote military settings where specialist care is not immediately available. Scalp lesions can be painful and disfiguring, and cause duty limitations if they interfere with the donning of personal protective equipment such as helmets, hardhats, or firefighting gear. We present a case of dissecting scalp cellulitis on an active- duty Navy Sailor who was leaving on an extended underway period on his ship the next day.

Benjamin JM, Chippaux J, Jackson K, Ashe S, Tamou-Sambo B, Massougbodji A, Akpakpa OC, Abo BN 19(2). 18 - 22 (Case Reports)

A 20-year-old man presented to a rural hospital in Bembéréké, northern Benin, after a witnessed bite from a small, dark snake to his left foot that occurred 3 hours earlier. The description of the snake was consistent with several neurotoxic elapids known to inhabit the area in addition to various species from at least 10 different genera of non-front-fanged colubroid (NFFC) venomous snakes. The presentation was consistent with the early signs of a neurotoxic snakebite as well as a sympathetic nervous system stress response. Diagnosis was further complicated by the presence of a makeshift tourniquet, which either could have been the cause of local signs and symptoms or a mechanical barrier delaying venom distribution and systemic effects until removal. Systemic envenomation did not develop after the removal of the constricting band, but significant local paresthesias persisted for longer than 24 hours and resolved after the administration of a placebo injection of normal saline in place of antivenom therapy. This was an unusual case of snakebite with persistent neuropathy despite an apparent lack of envenomation and a number of snakebite- specific variables that complicated the initial assessment, diagnosis, and treatment of the patient. This case presentation provides clinicians with an opportunity to familiarize themselves with the differential diagnosis and approach to a patient bitten by an unidentified snake, and it illustrates the importance of symptom progression as a pathognomonic sign during the early stages of a truly serious snake envenomation. Treatment should be based on clinical presentation and evolution of symptoms rather than on snake identification alone.

Lau AM, Johnston MJ, Rivard SS 19(2). 14 - 17 (Case Reports)

The initial livedo skin changes of cutis marmorata, also known as cutaneous decompression sickness (DCS), are transient in nature. Accordingly, early images of violaceous skin changes with variegated, marbled, or mottled appearance are rare, whereas later images of deep, erythematous, or violaceous skin changes are readily available. This case presents the opportunity to view the early skin changes characteristic of cutaneous DCS, which would likely manifest at Level I care in the setting of a diving injury during Special Operations missions in austere environments. The unique diving context also allows an overview of DCS in addition to a review of skin eruptions associated with various marine life. As diving is frequently used by Naval Special Warfare, topics presented in this case have significant relevance to Special Operations.

Godbee DC 19(2). 34 - 39 (Journal Article)

Sarkar D, Martinez J 19(2). 23 - 28 (Case Reports)

There is a growing body of literature on the safe, effective use of tranexamic acid (TXA) for hemostasis in a variety of clinical settings. We present a case series of three patients with difficult-to-treat epistaxis where standard treatment methods were not effective. Using atomized intranasal TXA (ATXA) as part of a stepwise treatment approach, we were able to achieve hemostasis and manage all three cases independently, and we did so without major complications in our emergency department (ED). Given recent literature showing the underuse of TXA in combat casualties, ATXA, if formulated and delivered properly, may be of benefit for epistaxis and other significant hemorrhage cases. Further work must be done to elucidate the mechanism of action, specific dose, delivery method, use indications, and safety profile of ATXA.

Wall PL, Buising CM, Donovan S, McCarthy C, Smith K, Renner CH 19(2). 48 - 56 (Journal Article)

Background: Appropriate strap pressure before tightening-system use is an important aspect of nonelastic, limb tourniquet application. Methods: Using different two-handed techniques, the strap of the Generation 7 Combat Application Tourniquet (C-A-T7), Tactical Ratcheting Medical Tourniquet (Tac RMT), Tactical Mechanical Tourniquet (TMT), Parabelt, and Generation 3 SOF® Tactical Tourniquet-Wide (SOFTTW) was secured mid-thigh by 20 appliers blinded to pressure data and around a thigh-sized ballistic gel cylinder by gravity and 23.06kg. Results: Pulling only outward (90° to strap entering buckle) achieved the lowest secured pressures on thighs and gel. For appliers, the best holding location was above the buckle, and the best strap-pulling direction was tangential to the thigh or gel (0° to strap entering buckle). Preceding tangential pulling with outward pulling resulted in higher secured pressures on the gel but did not aid appliers. Appliers generally did not reach secured pressures achievable for their strength. Of 80 thigh applications per tourniquet, 77 C-A-T7, 41 Tac RMT, 35 TMT, 16 Parabelt, and 10 SOFTTW applications had secured pressures greater than 100mmHg. Conclusions: The default for best tourniquet strap-application technique is to hold above the buckle and pull the strap tangential to the limb at the buckle. Additionally, neither strength nor experience guarantees desirable strap pressures in the absence of pressure knowledge.

Kragh JF, Wright-Aldossari B, Aden JK, Dubick MA 19(2). 41 - 47 (Journal Article)

Background: To investigate questions about application of emergency tourniquets in very young children, we investigated practices of Combat Application Tourniquet (C-A-T) use on a simulated infant-sized limb to develop ways to improve readiness for caregiving. Methods: This study was conducted as investigations of C-A-Ts used by two individuals in deliberate practice. The practice setup simulating a limb of infants aged 3−5 months included a handrail (circumference, 5.25 in.). This setup needed a specific modification to the instructions for use to adhere the band between the clips. Each user performed 100 practices. Results: With accrual of experience, application time was shorter for each user, on average in a power law of practice, and more ease was associated when less time was taken to apply the tourniquet. The ease of use was associated with accrued experience through deliberate practice of a tourniquet user while under coached learning. A check of tourniquet fit on a 4.25-in. limb also entailed the modification used in the 5.25-in. limb. However, an additional modification of wrapping the band in a figure-8 pattern around the rod was needed because the rod and clip could not meet. The fit on a 3.25-in. limb was impracticable for a workaround. Tourniquet use was harder for smaller limbs (i.e., 4.25 in. and 3.25 in.). A map of tourniquet fit was sketched of which sized limbs were too big, too small, within the fit zone, or at its borders. Conclusion: C-A-Ts mechanically fit the simulated limbs of infants aged 3−5 months, and C-A-T use was practicably easy enough to allow experienced users to fit tourniquets to limbs well using a specific modification of the routine technique. The findings and knowledge generated in this study are available to inform researches and developments in best preparation practices for instructing first aid.

Schwartz RB, Shiver SA, Reynolds BZ, Lowry J, Holsten SB, Akers TW, Lyon M 19(2). 69 - 72 (Journal Article)

Background: Junctional hemorrhage is a potentially preventable cause of death. The Abdominal Aortic and Junctional Tourniquet (AAJT) compresses major vascular structures and arrests blood flow in exsanguinating hemorrhage. In a human model, the AAJT was effective in stopping blood flow in the femoral arteries via compression of the distal aorta. This study compares the ability of AAJT and Combat Gauze (CG) to stop hemorrhagic bleeding from a hemicorporectomy in a swine model. Method: Six anesthetized swine were used. Carotid arterial catheters were placed for continuous mean arterial pressure (MAP) readings. A hemicorporectomy was accomplished with a blade lever device by cutting the animal through both femoral heads transecting the proximal iliac arteries and veins. Hemorrhage control was attempted with the AAJT and regular Kerlix gauze or CG packing and direct pressure followed by Kerlix gauze placed over the CG. The primary outcome measure was survival at 60 minutes. Results: The 60-minute survival was 100% for the AAJT and 0% for the CG group. During the 60-minute monitoring period, only one CG animal achieved hemostasis. For the AAJT group, the mean time to hemostasis was 30 seconds. Initial MAP was higher in the AAJT group (mean, 87mmHg) than the CG group (mean, 70mmHg). The mean 60-minute MAP was 73mmHg for the AAJT group. Mean blood loss at 5 minutes and mean total blood loss were greater in the CG group than in the AAJT group. Conclusion: AAJT is superior to CG in controlling hemorrhage in a junctional wound in a swine model.

Rocklein Kemplin K, Paun O, Godbee DC, Brandon JW 19(2). 57 - 66 (Journal Article)

Background: Due to alarming rates of suicide in Special Operations Forces (SOF) and associated effects of traumatic stress in military populations writ large, resilience initiatives thought to influence Servicemembers' mitigation of traumatic stress and thus lower suicide risks have been implemented throughout the services. Since combat operations commenced in multiple theaters of war nearly two decades ago, resilience in conventional military populations became a topic of keen interest throughout departments of defense worldwide as well. Despite researchers' consistent assertions that SOF are highly resilient and at low risk for suicide, granular analysis of pertinent research and escalating suicide in SOF reveals no empirical basis for those beliefs. Methods: We report findings from an integrative review of resilience research in SOF and larger military populations to contextualize and augment understanding of the phenomenon. Results: Throughout the literature, conceptual and operational definitions of resilience varied based on country, context, investigators, and military populations studied. We identified critical gaps in resilience knowledge in the military, specifically: Resilience has not been studied in SOF; resilience is not concretely established to reduce suicide risk or proven to improve mental health outcomes; resilience differs when applied as a psychological construct; resilience research is based on specific assumptions of what composes resilience, depending on methods of measurement; resilience studies in this population lack rigor; research methodologies and conflicting interests invite potential bias. Conclusion: This integrative review highlights emergent issues and repetitive themes throughout military resilience research: resilience program inefficacy, potential investigator bias, perpetuated assumptions, and failure to capture and appropriately analyze germane data. Because of overall inconsistency in military resilience research, studies have limited external validity, and cannot be applied beyond sampled populations. Resilience cannot be responsibly offered as a solution to mitigating posttraumatic stress disorder nor suicide without detailed study of both in SOF.

Wolfe GA, Petteys SM, Phelps JF, Wasmund JB, Plackett TP 19(2). 81 - 86 (Journal Article)

Sulfur mustard has been used in conflicts for more than a century. Despite international recognized bans on the use of chemical weapons, there continue to be reports of their use. The authors provide a contemporary overview of sulfur mustard injury and its management in the acute, subacute, and chronic periods.

Schauer SG, April MD, Aden JK, Rowan M, Chung KK 19(2). 77 - 80 (Journal Article)

Background: The military is rapidly moving into a battlespace in which prolonged holding times in the field are probable. Ketamine provides hemodynamic support and has analgesic properties, but the safety of prolonged infusions is unclear. We compare in-hospital mortality between intubated burn intensive care unit (ICU) patients receiving prolonged ketamine infusion lasting ≥7 days or until death versus controls. Methods: We conducted a before/after cohort study of patients undergoing admission to a burn ICU with intubation within the first 24 hours as part of treatment for thermal burns. In January 2012, this ICU implemented a novel continuous ketamine infusions protocol. We performed a preintervention and postintervention cohort analysis. Results: We identified 2394 patients meeting our inclusion criteria-475 in the ketamine group and 1919 in the control group. Regarding burn total body surface area (TBSA) involvement, there were 1533 in the <10% group, 586 in the 11-30% group, and 281 in the >31% group. The median number of ventilator-free days within the first 30 days did not vary significantly between the ketamine group and the control group: 8.5 days (interquartile range [IQR] 1-16 days) versus 8 days (IQR 3-13 days, p = .442). Subjects receiving ketamine had higher mortality rates: 59.4% (n = 117) versus 40.6% (n = 80, p < .001), with an odds ratio for in-hospital mortality of 7.51 (95% CI 5.53-10.20, p < .001). When controlling for TBSA category, ventilator days and vasopressor administration, there was no association between ketamine and in-hospital mortality (0.66, 0.41-1.05, p = .08). Conclusions: When controlling for confounders, we found no difference in in-hospital mortality between the prolonged ketamine infusion recipients versus non-recipients.

Martin CJ, Plackett TP, Rush RM 19(2). 73 - 76 (Journal Article)

The past few years have noted significant declines in combat casualty exposure over the course of a deployment. As a result, overall confidence and comfort in performing potentially life-saving therapies may wane during a deployment. Development of training simulators provides a method for bridging this gap. Herein, a field-expedient vascular trauma trainer for noncompressible torso hemorrhage is described. A low-fidelity simulator was created using a Penrose drain, intravenous tubing, suture, and a cardboard box. A higher-fidelity simulator was created using an aortobifemoral bypass graft, double-lumen endotracheal tube, suture, and an upper torso mannequin. The two trainers were successfully used to train for peripheral shunt placement and definitive vascular repair. The trainer makes use of supplies readily found at most Role 2 and 3 facilities and that are obtainable for Role 1 facilities providing damage control surgery. It provides a just-in-time way to develop and sustain confidence in the damage control principles applicable to vascular injuries.

Schauer SG, Naylor JF, Chow AL, Maddry JK, Cunningham CW, Blackburn MB, Nawn CD, April MD 19(2). 91 - 94 (Journal Article)

Background: Airway compromise is the second leading cause of preventable death on the battlefield. Unlike a cricothyrotomy, supraglottic airway (SGA) placement does not require an incision and is less technically challenging. We compare the survival of causalities undergoing cricothyrotomy versus SGA placement. Methods: We used a series of emergency department (ED) procedure codes to search within the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. This is a subanalysis of that data set. Results: During the study period, 194 casualties had a documented cricothyrotomy and 22 had a documented SGA as the sole airway intervention. The two groups had similar proportions of explosive injuries (57.7% versus 63.6%, p = .328), similar composite injury severity scores (25 versus 27.5, p = .168), and similar AIS for the head, face, extremities, and external body regions. The cricothyrotomy group had lower AIS for the thorax (0 versus 3, p = .019), a trend toward lower AIS for the abdomen (0 versus 0, p = .077), more serious injuries to the head (67.5% versus 45.5%, p = .039), and similar rates of serious injuries to the face (4.6% versus 4.6%, p = .984). Glasgow Coma Scale (GCS) scores were similar on arrival to the ED (3 versus 3, p = .467) as were the proportion of patients surviving to discharge (45.4% versus 40.9%, p = .691). On repeated multivariable analyses, the odds ratios for survival were not significantly different between the two groups. Conclusions: We found no difference in short-term outcomes between combat casualties who received an SGA vs those who received a cricothyrotomy. Military prehospital personnel rarely used either advanced airway intervention during the recent conflicts in Afghanistan and Iraq.

Schauer SG, April MD, Tannenbaum LI, Maddry JK, Cunningham CW, Blackburn MB, Arana AA, Shackelford S 19(2). 87 - 90 (Journal Article)

Background: Airway obstruction is the second most common cause of potentially preventable death on the battlefield. We compared survival in the combat setting among patients undergoing prehospital versus emergency department (ED) intubation. Methods: Patients were identified from the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. We defined the prehospital cohort as subjects undergoing intubation prior to arrival to a forward surgical team (FST) or combat support hospital (CSH), and the ED cohort as subjects undergoing intubation at an FST or CSH. We compared study variables between these cohorts; survival was our primary outcome. Results: There were 4341 intubations documented in the DODTR during the study period: 1117 (25.7%) patients were intubated prehospital and 3224 (74.3%) were intubated in the ED. Patients intubated prehospital had a lower median age (24 versus 25 years, p < .001), composed a higher proportion of host nation forces (36.1% versus 29.1%, p < .001), had a lower proportion of injuries from explosives (57.6% versus 61.0%, p = .030), and had higher median injury severity scores (20 versus 18, p = .045). A lower proportion of the prehospital cohort survived to hospital discharge (76.4% versus 84.3%, p < .001). The prehospital cohort had lower odds of survival to hospital discharge in both univariable (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.51-0.71) and multivariable analyses controlling for confounders (OR 0.70, 95% CI 0.58-0.85). In a subgroup analysis of patients with a head injury, the lower odds of survival persisted in the multivariable analysis (OR 0.49, 95% CI 0.49-0.82). Conclusions: Patients intubated in the prehospital setting had a lower survival than those intubated in the ED. This finding persisted after controlling for measurable confounders.