Sims K, Montgomery HR, Dituro P, Kheirabadi BS, Butler FK 16(1). 19 - 28 (Journal Article)

Exsanguination from wounds in the so-called junctional regions of the body (i.e., the neck, the axilla, and the groin) was responsible for 19% of the combat fatalities who died from potentially survivable wounds sustained in Afghanistan or Iraq during 2001 to 2011. The development of improved techniques and technology to manage junctional hemorrhage has been identified in the past as a high-priority item by the Committee on Tactical Combat Casualty Care (CoTCCC) and the Army Surgeon General's Dismounted Complex Blast Injury (DCBI) Task Force. Additionally, prehospital care providers have had limited options with which to manage hemorrhage resulting from deep, narrow-track, penetrating trauma. XStat™ is a new product recently approved by the US Food and Drug Administration as a hemostatic adjunct to aid in the control of bleeding from junctional wounds in the groin or axilla. XStat has now been recommended by the CoTCCC as another tool for the combat medical provider to use in the management of junctional hemorrhage. The evidence that supports adding XStat to the TCCC Guidelines for the treatment of external hemorrhage is summarized in this paper.

Gibson R, Housler GJ, Rush SC, Aden JK, Kragh JF, Dubick MA 16(1). 29 - 35 (Journal Article)

Background: Emergency tourniquet use has been associated with hemorrhage control and improved survival during the wars since 2001. The purpose of the present study is to compare the differential performance of two new tactical tourniquets with the standard-issue tourniquet to provide preliminary evidence to guide decisions on device development. Methods: A laboratory experiment was designed to test the effectiveness of tourniquets on a manikin thigh. Three models of tourniquets were assessed. The Rapid Application Tourniquet System (RATS) and the Tactical Mechanical Tourniquet (TMT) were compared with the standard-issue Combat Application Tourniquet® (C-A-T). Two users conducted 30 tests each. Results: Percentages for effectiveness (hemorrhage control, yes/no) and distal pulse cessation did not differ significantly by model. When compared with the RATS, the C-A-T performed better (ρ < .001) for time to hemorrhage control and fluid loss. The C-A-T and TMT had comparable responses for most measures, but the C-A-T applied more pressure (ρ = .04) than did the TMT for hemorrhage control. Conclusion: All three tactical tourniquets showed substantial capacity for hemorrhage control. However, the two new tourniquet models (RATS and TMT) did not offer any improvement over the C-A-T, which is currently issued to military services. Indeed, one of the new models, the RATS, was inferior to the C-A-T in terms of speed of application and simulated loss of blood. Opportunities were detected for refinements in design of the two new tourniquets that may offer future improvements in their performance.

Stewart CL, Nawn CD, Mulligan J, Grudic G, Moulton SL, Convertino VA 16(1). 6 - 13 (Journal Article)

Background: Humans are able to compensate for significant loss of their circulating blood volume, allowing vital signs to remain relatively stable until compensatory mechanisms are overwhelmed. The authors present several clinical and performance case studies in an effort to demonstrate real-time measurements of an individual's reserve to compensate for acute changes in circulating blood volume. This measurement is referred to as the Compensatory Reserve Index (CRI). Methods: We identified seven clinical and two physical performance conditions relevant to military casualty and operational medicine as models of intravascular volume compromise. Retrospective analysis of photoplethysmogram (PPG) waveform features was used to calculate CRI, where 1 represents supine normovolemia and 0 represents hemodynamic decompensation. Results: All cases had CRI values suggestive of volume compromise (<0.6) not otherwise evident by heart rate and systolic blood pressure. CRI decreased with reduced central blood volume and increased with restored volume (e.g., fluid resuscitation). Conclusion: The results from these case studies demonstrate that machine-learning techniques can be used to (1) identify a clinical or physiologic status of individuals through real-time measures of changes in PPG waveform features that result from compromise to circulating blood volume and (2) signal progression toward hemodynamic instability, with opportunity for early and effective intervention, well in advance of changes in traditional vital signs.

Kragh JF, Moore VK, Aden JK, Parsons DL, Dubick MA 16(1). 14 - 17 (Journal Article)

Background: The Combat Application Tourniquet® (C-A-T) is the standard-issue military tourniquet used in first aid in 2015, and the current model is called Generation 6. Soldiers in the field, however, have been asking for design changes in a possible Generation 7 to improve ease of use. This study compared the differential performance in use of the C-A-T in two designs: Generation 6 (C-A-T 6) versus a prototype Generation 7 (C-A-T 7). Methods: A laboratory experiment was designed to test the performance of two tourniquet designs in hemorrhage control, ease of use, and user preference. Ten users of the two C-A-T models placed them on a manikin thigh to stop simulated bleeding. Users included trauma researchers and instructors of US Army student medics. Ten users conducted 20 tests (10 each of both designs). Results: Most results were not statistically significant in their difference by C-A-T design. The mean difference in blood loss was statistically significant (ρ = .03) in that the C-A-T 7 performed better than the C-A-T 6, but only in the mixed statistical model analysis of variance, which accounted for user effects. The difference in ease-of-use score was statistically significant (ρ = .002); the C-A-T 7 was easier. All users preferred the C-A-T 7. Conclusion: In each measure, the C-A-T Generation 7 prototype performed similar or better than Generation 6, was easier to use, and was preferred.

Levy MJ 15(4). 157 - 159 (Journal Article)

McSwain NE 15(4). 160 - 162 (Journal Article)

Guthrie RM, Chorba R 16(1). 1 - 5 (Case Reports)

Purpose: Chronic mechanical neck pain can have a complex clinical presentation and is often difficult to treat. This case study illustrates a successful physical therapy treatment approach using dry needling and auricular acupuncture techniques. Case Report: A 51-year-old active-duty, male US Marine was treated by a physical therapist in a direct-access military clinic for chronic neck pain poorly responsive to previous physical therapy, pharmacologic, and surgical interventions. Needling techniques were combined with standard physical therapy interventions to address the comprehensive needs of the patient. Within five treatments, the patient reported reduced pain levels from 8-9/10 to 0-2/10, improved sleep quality, and increased function with daily activities. Over several months, the patient reduced multiple medication use by greater than 85%. The effects of treatment were lasting, and the patient accomplished a successful transition to an independent maintenance program. Conclusion: Needling techniques have the potential to expedite favorable physical therapy outcomes for active-duty service members suffering from chronic mechanical and degenerative neck pain. The dramatic improvements observed in this case warrant additional exploration of treatment efficacy and delineation of best practices in the delivery of these techniques.

Butler FK 15(4). 149 - 152 (Journal Article)

Holcomb JB, Butler FK, Rhee P 15(4). 153 - 156 (Journal Article)

Keenan S 15(4). 125 (Journal Article)

Fabbri WP 15(4). 142 - 145 (Journal Article)

Washington MA, Barnhill JC, Duff MA, Griffin J 15(4). 113 - 116 (Journal Article)

Acute and chronic wound infections can both be encountered in the deployed setting. These wounds are often contaminated by bacteria and fungi derived from the external environment. In this article, we present the case of a wound infection simultaneously colonized by Enterobacter cloacae (a bacterial pathogen) and Trichosporon asahii (an unusual fungal pathogen). We describe the examination and treatment of the patient and review the distinguishing characteristics of each organism

Caci JB 15(4). 117 - 124 (Journal Article)

Medical intelligence is an underused or sometimes misapplied tool in the protection of our Soldiers and the execution of nonkinetic operations. The somewhat improved infrastructure of the operational environment in Iraq and Afghanistan led to an inevitable sense of complacency in regard to the threat of disease nonbattle injury (DNBI). The picture changed somewhat in 2010 with the advent of the village stability program and the establishment of SOF camps in austere locations with degraded living situations rife with exposure risks. In addition, the increasing deployments to unstable locations around the globe, reminiscent of typical Special Operations Forces (SOF) missions before the Global War on Terrorism, indicate a need for better preparation for deployment from the standpoint of disease risk and force health protection. A knowledge gap has developed because we simply did not need to apply as stringent an evaluation of DNBI risk in environments where improved life support mitigated the risk for us. The tools necessary to decrease or even eliminate the impact of DNBI exist but they must be shared and implemented. This article will present four vignettes from current and former SOF Force Health Protection personnel starting with a simple method of executing Medical Intelligence Prep of the Environment (MIPOE) and highlighting situations in which it either was or could have been implemented to mitigate risk and decrease the impact on mission accomplishment and individual operators. A follow-on article will present vignettes of the successful application of MIPOE to nonkinetic operations.

Knapik JJ, Pope R, Orr R, Grier T 15(4). 102 - 108 (Journal Article)

This article traces the history of the athletic shoe, examines whether selecting running shoes based on foot arch height influences injuries, and examines historical data on injury rates when physical training (PT) is performed in boots versus running shoes. In the 1980s and into the 2000s, running shoe companies were advertising specialized shoes with "motion control," "stability," and "cushioning," designed for individuals with low, normal, and high arches, respectively. Despite marketing claims that these shoes would reduce injury rates, coordinated studies in Army, Air Force, and Marine Corps basic training showed that assigning or selecting shoes on this basis had no effect on injury rates. Consistent with this finding, biomechanical studies have shown that the relationships between arch height, foot joint mobility, and rear-foot motion are complex, variable, and frequently not as strong as often assumed. In 1982, the US Army switched from PT in boots to PT in running shoes because of the belief that boots were causing injuries and that running shoes would reduce injury rates. However, a historical comparison of injury rates before and after the switch to running shoes showed virtually no difference in injury risk between the two periods. It is not clear at this point if the type of footwear effects injury incidence.

Peffer J, Ley N, Wuelher J, d'Andrea P, Rittberg C, Losch J, Lynch JH 15(4). 109 - 112 (Journal Article)

Austere environments such as Africa pose clinical challenges, which are multiplied for Special Operations Forces (SOF) providers who must face these challenges with limited resources against the tyranny of distance. These limited resources apply not only to treatment tools but to diagnostic tools as well. Laboratory diagnostics may provide critical information in diagnosis, initial triage, and/or evacuation decisions, all of which may enhance a patient's survival. However, unlike in climatecontrolled, fixed-facility hospitals, the deployed SOF provider must have access to a simple, reliable device for point-of-care testing (POCT) to obtain clinically meaningful data in a practical manner given the surroundings.

Pasiakos SM, Sepowitz JJ, Deuster PA 15(4). 89 - 95 (Journal Article)

Military recommendations for dietary protein are based on the recommended dietary allowance (RDA) of 0.8g of protein per kilogram of body mass (BM) established by the Food and Nutrition Board, Institute of Medicine (IOM) of the National Academies. The RDA is likely adequate for most military personnel, particularly when activity levels are low and energy intake is sufficient to maintain a healthy body weight. However, military recommendations account for periods of increased metabolic demand during training and real-world operations, especially those that produce an energy deficit. Under those conditions, protein requirements are higher (1.5-2.0g/kg BM) in an attempt to attenuate the unavoidable loss of muscle mass that occurs during prolonged or repeated exposure to energy deficits. Whole foods are recommended as the primary method to consume more protein, although there are likely operational scenarios where whole foods are not available and consuming supplemental protein at effective, not excessive, doses (20-25g or 0.25-0.3g/kg BM per meal) is recommended. Despite these evidence-based, condition-specific recommendations, the necessity of protein supplements and the requirements and rationale for consuming higher-protein diets are often misunderstood, resulting in an overconsumption of dietary protein and unsubstantiated health-related concerns. This review will provide the basis of the US military dietary protein requirements and highlight common misconceptions associated with the amount and safety of protein in military diets.

Burnett MW 15(4). 96 - 98 (Journal Article)

In mid-September 2009, a 22-year-old critically ill Soldier was medically evacuated from a treatment facility in southern Afghanistan to Landstuhl Regional Medical Center in Germany. Despite the efforts of the team at Landstuhl, this patient died and became the US military's first known victim of Crimean-Congo hemorrhagic fever (CCHF). CCHF is caused by a virus, which bears the same name. Because a vaccine is lacking, as well as an effective antiviral treatment, prevention is key.

Shishido AA, Letizia A 15(4). 99 - 101 (Journal Article)

Middle East respiratory syndrome (MERS) emerged in the Arabian Peninsula in 2012, and subsequently spread to other countries in Europe and Asia, and to the United States. As of August 2015, the disease has infected 1,400 patients, of whom 500 have died, yielding a 36% mortality rate. The exact mode of transmission is unknown and there are no proven treatments. While the overall case rate for MERS has been low, its presence in countries that house US troops, unknown mode of transmission, and high mortality rate make it a significant health concern among US military personnel.

Downs JW, Biggane PJ 15(4). 75 - 78 (Journal Article)

A case of fever and thrombocytopenia in a 33-year-old Special Forces Soldier with recent deployment to the Philippines is discussed, as are differential diagnosis and initial medical management at an overseas, fixed US military medical treatment facility. The authors discuss lessons learned that are applicable for Special Operations Forces (SOF) medical providers and recommend a renewed and continued emphasis on tropical medicine and infectious disease training for SOF medical providers.

LeClair TG, Meriano T 15(4). 83 - 88 (Journal Article)