Articles

Crecelius EM, Burnett MW 21(2). 98 - 99 (Journal Article)

Human brucellosis can be caused by different Brucella spp. When conducting operations in a country with high rates of brucellosis, extra precautions should be taken. Appropriate personal protective measures should be used in situations when close contact with animal carcasses cannot be avoided. Clinical diagnosis, treatment, and prevention are discussed.

Knapik JJ, Hoedebecke BL 21(2). 100 - 107 (Journal Article)

Vitamin A is a generic term for compounds that have biological activity similar to that of retinol and includes carotenoids like ß-carotene and α-carotene. Some studies suggest high dietary intake of vitamin A can increase bone fracture risk. This investigation involved a systematic review and meta-analysis examining the association between vitamin A and fracture risk. Published literature was searched to find studies that (1) involved human participants, (2) had prospective cohort or case-control study designs, (3) contained original quantitative data on associations between dietary intake of vitamin A and fractures, and (4) provided either risk ratios (RRs), odds ratios (ORs), or hazard ratios (HRs) with 95% confidence intervals (95% CIs) comparing various levels of vitamin A consumption to fracture risk. Thirteen studies met the review criteria. Meta-analyses indicated that risk of hip fracture was increased by high dietary intake of total vitamin A (RR = 1.29; 95% CI = 1.07-1.57) or retinol (RR = 1.23; 95% CI = 1.02-1.48). Hip fracture risk was reduced by high dietary intake of total carotene (RR = 0.62; 95% CI = 0.42-0.93), ß-carotene (RR = 0.72; 95% CI = 0.58-0.89), or α-carotene (RR = 0.81; 95% CI = 0.67-0.97). Total fracture risk was not associated with any vitamin A compound. High intake of total vitamin A or retinol increased hip fracture risk, while high intake of some carotenoids reduced hip fracture risk.

Kemp SJ, Levy MJ, Knapp JG, Steiner LA, Tang N 21(2). 108 - 111 (Journal Article)

Merkle A, Randles J 21(2). 112 - 114 (Journal Article)

This is the first of an ongoing series to provide a background into reading medical research literature for the SOF medic.

Yost JK, Yates J, Smith B, Workman DJ, Matlick D, Wilson ME, Wilson A 21(2). 115 - 118 (Journal Article)

Background: Medical care provided by Special Operations Forces (SOF) combat medics is vital for establishing communication with local populations. In many of these communities, livestock hold a valuable position within the social, political, and cultural structure. The West Virginia University (WVU) Special Forces Medical Sergeant/Special Operations Independent Duty Corpsman (SFMS/SOIDC) Large Animal Module is designed to provide a foundational experience in livestock husbandry and veterinary procedures to SOF combat medic candidates. This study was conducted to determine the participants' base knowledge of food animal production and to evaluate if the program content was sufficient for increasing their knowledge of the subject matter. Methods: A quasi-experimental design utilizing pre-test and post-test instruments was used. The validity of the testing instruments was established by a panel of subject matter experts and the instruments' reliability was determined by a split-half analysis using SPSS® statistical software. The difference between the pre-test and post-test examinations were compared for 66 candidates who were assigned to WVU Health Sciences Center for the applied medical experience program and 46 counterparts assigned to other institutions by a match pair analysis. Results: Seventy-five percent of the subjects had no previous livestock exposure, and only 7% had previously participated in the 4-H program or Future Farmers of America (FFA). The average improvement in scores, pre-test versus post-test, was significantly greater for those that attended the module (18.5 versus 0.9). Conclusion: Few SFMS/SOIDC candidates have prior knowledge of livestock husbandry practices. The large animal module successfully provides education on livestock husbandry practice to participants. Knowledge of livestock production can assist SOF medics in establishing rapport with indigenous populations while on mission.

Savell SC, Baldwin DS, Blessing A, Medelllin KL, Savell CB, Maddry JK 21(2). 35 - 42 (Journal Article)

Background: Point of care ultrasound (POCUS) offers multiple capabilities in a relatively small, lightweight device to military clinicians of all types and levels in multiple environments. Its application in diagnostics, procedural guidance, and patient monitoring has not been fully explored by the Military Health System (MHS). The purpose of this narrative review of the literature was to examine the overall use of POCUS in military settings, as well as the level of ultrasound training provided. Methods: Studies related to use of POCUS by military clinicians with reported sensitivity/specificity, accuracy of exam, and/or clinical decision impact met inclusion criteria. After initial topical review and removal of duplicates, two authors selected 17 papers for consideration for inclusion. Four of the authors reviewed the 17 papers and determined the final inclusion of 14 studies. Results: We identified seven prospective studies, of which three randomized subjects to groups. Five reports described use of POCUS in patients, two used healthy volunteers, two were in simulation training environments, four used animal models to simulate specific conditions, and one used a cadaver model. Clinician subjects ranged from one to 34. Conventional medics were subjects in six studies. Four studies included special operations medics. One study included nonmedical food service inspectors. The use of ultrasound in theater by deployed consultant radiologists is described in three reports. Conclusions: Military clinicians demonstrated the ability to perform focused exams, including FAST exams and fracture detection with acceptable sensitivity and specificity. POCUS in the hands of trained military clinicians has the potential to improve diagnostic accuracy and ultimately care of the war fighter.

Wall PL, Hingtgen E, Buising CM 21(2). 11 - 17 (Journal Article)

Background: Tourniquet training sometimes involves models, and a certification process is expected to use something other than human limbs; therefore, investigating model- and limb-pressure responses to force application is important. Methods: Pressure response to force was collected for a 3.8cm-wide nonelastic strap and a 10.1cm-wide elastic strap placed over 14 objects. Each object was suspended; an inflated neonatal blood pressure cuff was placed atop the object with the strap over the bladder; and strap ends were connected below with 4.54kg weights attached at 20-second intervals to 27.24kg. Results: Pressure-response curves differed by strap, thigh aspect (medial, lateral, ventral, dorsal; n = 2 subjects; p < .0001); subject (medial thigh; n = 3 subjects; p < .0001); and object (thighs; small and large pool noodles ± central metal rod, foam yoga roller, coffee can, 20% ballistic gel cylinder [Gel; Clear Ballistics; clearballistics.com] with central metal tubing, rolled pair of 5mm yoga mats ± central metal rod, hemorrhage-control training thigh [Z-Medica], sand-filled training manikin limb [Drumm Emergency Solutions]; p < .0001). Compliance, circumference, support techniques, and surface interactions, especially with the 10.1cm-wide elastic strap, affected pressure responses: smaller circumference, lower compliance, and lower surface coefficient of friction were associated with higher pressure/force applied. Conclusions: Different objects have different pressure-response curves. This may be important to acquisition and retention of limb tourniquet skills and is important for systems for certifying tourniquets.

Henry R, Ghafil C, Golden A, Matsushima K, Eckstein M, Foran CP, Theeuwen H, Bentley DE, Inaba K, Strumwasser A 21(1). 49 - 54 (Journal Article)

Background: The utility of prehospital thoracic needle decompression (ND) for tension physiology in the civilian setting continues to be debated. We attempted to provide objective evidence for clinical improvement when ND is performed and determine whether technical success is associated with provider factors. We also attempted to determine whether certain clinical scenarios are more predictive than others of successful improvement in symptoms when ND is performed. Methods: Prehospital ND data acquired from one air ambulance service serving 79 trauma centers consisted of 143 patients (n = 143; ND attempts = 172). Demographic and clinical outcome data were retrospectively reviewed. Patients were stratified by prehospital characteristics and indications. Objective outcomes were measured as improvement in vital signs, subjective patient assessment, and physical examination findings. Univariate analysis was performed using chi-square for variable proportions and unpaired Student's t-test for variable means; p < .05 was considered statistically significant. Results: The success rate of ND performed for hypoxia (70.5%) was notably higher than ND performed for hemodynamic instability (20.3%; p < .01) or cardiac arrest (0%; p < .01). Compared to vital sign parameters, clinical examination findings as part of the indication for ND did not reliably predict technical success (p > .52 for all indications). No difference was observed comparing registered nurse versus paramedic (p = .23), diameter of catheter (p > .13 for all), or length of catheter (p = .12). Conclusion: Prehospital ND should be considered in the appropriate clinical setting. Outcomes are less reliable in cases of cardiopulmonary arrest or hypotension with respiratory symptoms; however, this should not deter prehospital providers from attempting ND when clinically indicated. Additionally, the success rate of prehospital ND does not appear to be related to catheter type or the role of the performing provider.

Blakeman T, Fowler J, Branson R, Petro M, Rodriquez D 21(1). 18 - 24 (Journal Article)

Resuscitation of the critically ill or injured is a significant and complex task in any setting, often complicated by environmental influences. Hypothermia is one of the components of the "Triad of Death" in trauma patients. Devices for warming IV fluids in the austere environment must be small and portable, able to operate on battery power, warm fluids to normal body temperature (37°C), and perform under various conditions, including at altitude. The authors evaluated four portable fluid warmers that are currently fielded or have potential for use in military environments.

Fedor PJ, Dorsch J, Kharod C, Paladino L, Rush SC 21(1). 25 - 29 (Journal Article)

Background: The Air Force Special Warfare Medical Officer Course was created to address the lack of operationally focused, job-specific clinical training for medical officers (MOs). This course addresses the gap in knowledge, skill, and application of operational medicine, as well as the behavioral health, human performance, education, and medical oversight of Operators. Methods: The course was designed around the senior author's decade of experience piecing together training for his own role as a pararescue flight surgeon and informed by 5 years of flight surgeon courses, lessons learned from case studies of ill-prepared deployed physicians, and input from prehospital medicine subject matter experts. Results: Air Force pararescue and special tactics flight surgeons, physician assistants, and an independent duty medical technician (IDMT) attended. The course consisted of 10 full weekdays of didactics and skills sessions covering theory and application of operational medicine, human performance optimization, behavioral health for Operators, adult education theory, principles of prehospital clinical oversight, and other expeditionary concepts. The course culminated with combat casualty care scenario-based exercises, in which the providers performed operational medicine in full kit with weapons and simulation rounds. Discussion: For many logistical and practical reasons, civilian medical experience, traditional military medical training, existing special operations medical courses, and "merit badge" card classes are not adequate preparation for this specialized role. Focused, job-specific training should be provided to Special Operations Forces Medical Officers (SOFMO) and, ultimately, to any MO deploying in support of medics or combatants. The goal is to maximize the success of military medical operations while reducing the morbidity and mortality of combat and training casualties. Conclusion: This operationally focused MO course can serve as a model for the future training of SOFMO and has stimulated discussion for consideration of a joint approach to prehospital medical training.

Stigall K, Blough PE, Rall JM, Kauvar DS 21(1). 30 - 36 (Journal Article)

Background: Two methods of controlling pelvic and inguinal hemorrhage are the Abdominal Aortic and Junctional Tourniquet (AAJT; Compression Works) and resuscitative endovascular balloon occlusion of the aorta (REBOA). The AAJT can be applied quickly, but prolonged use may damage the bowel, inhibit ventilation, and obstruct surgical access. REBOA requires technical proficiency but avoids many of the complications associated with the AAJT. Conversion of the AAJT to REBOA would allow for field hemorrhage control with mitigation of the morbidity associated with prolonged AAJT use. Methods: Yorkshire male swine (n = 17; 70-90kg) underwent controlled 40% hemorrhage. Subsequently, AAJT was placed on the abdomen, midline, 2cm superior to the ilium, and inflated. After 1 hour, the animals were allocated to an additional 30 minutes of AAJT inflation (continuous AAJT occlusion [CAO]), REBOA placement with the AAJT inflated (overlapping aortic occlusion [OAO]), or REBOA placement following AAJT removal (sequential aortic occlusion [SAO]). Following removal, animals were observed for 3.5 hours. Results: No statistically significant differences in survival, blood pressure, or laboratory values were found following intervention. Conversion to REBOA was successful in all animals but one in the OAO group. REBOA placement time was 4.3 ± 2.9 minutes for OAO and 4.1 ± 1.8 minutes for SAO (p = .909). No animal had observable intestinal injury. Conclusions: Conversion of the AAJT to infrarenal REBOA is practical and effective, but access may be difficult while the AAJT is applied.

Cook RK, McDaniel J, Pelaez M, Beltran T, Webb O 21(1). 37 - 39 (Journal Article)

Background: Sterilization of healthcare instruments in an expeditionary environment presents a myriad of challenges including portability, cost, and sufficient electrical power. Using pressure cookers to sterilize instruments presents a low-cost option for sterilization in prehospital settings. This project's objective was to determine if sterility can be achieved using a commercially available pressure cooker. Methods: Presto® 4-quart stainless steel pressure cookers were heated using Cuisinart® CB-30 cast-iron single burners. One 3M™ Attest™ 1292 Rapid Readout Biological Indicator and one 3M™ Comply™ SteriGage™ integrator strip were sealed in a Henry Schein® Sterilization Pouch and placed in a pressure cooker and brought to a pressure of 103.4kPa. Sterility was verified after 20 minutes at pressure. The Attest vials were incubated in a 3M Attest 290 Auto-Reader for 3 hours with a control vial. Results: Sterility using the pressure cooker was achieved in all tested bags, integrator strips, and Attest vials (n = 128). The mean time to achieve the necessary 103.4kPa was 379 seconds (standard deviation (SD) = 77). Neither the ambient temperature nor humidity were found to affect the pressure cooker's time to achieve adequate pressure, nor the achieved depth on the integrator strip (all p > .05). Conclusion: This study provides evidence that sterilization is possible with offthe- shelf pressure cookers. Though lacking US Food and Drug Administration (FDA) approval, the use of this commercially available pressure cooker may provide a method of sterilization requiring minimal resources from providers working in expeditionary environments.

Cotte J, Montcriol A, Benner P, Belliard V, Roumanet P, Puidupin A, Puidupin M 21(1). 41 - 43 (Journal Article)

Introduction: In the French army, combat casualty care (CCC) training involves the use of simulation. The application of this pedagogic method in a cross-cultural environment has not previously been described. In this report, we explore the challenges highlighted by multiple training sessions for foreign medical providers in West Africa. Methods: We collected the data from six 2-week courses held in Libreville, Gabon. Our main objective was to describe the course; our secondary objective was to assess our trainees' progress in their knowledge of CCC. Results: The first week involved lectures, technical workshops, and single-patient simulations. The second part emphasized multiple-victim simulations and interactions with combatants and was held in the Gabonese rainforest. Sixty- two trainees undertook the six sessions. Their knowledge improved during the course, from a median score of 4 (of a maximum of 40) before to 9.5 after (p < .05). Discussion: Our study is the first to describe medical-level CCC training in a cross-cultural environment. Challenges are numerous, notably differences in the expected roles of instructors and trainees. Mitigating those difficulties is possible through cultural awareness and self-awareness. Our results are limited by the absence of evaluation of improvement in the actual management of patients. Conclusion: CCC training using medical simulation is feasible in a cross-cultural environment.

Bailey RA, Simon EM, Kreiner A, Powers D, Baker L, Giles C, Sweet R, Rush SC 21(1). 44 - 48 (Journal Article)

Uncontrolled hemorrhage secondary to unstable pelvic fractures is a preventable cause of prehospital death in the military and civilian sectors. Because the mortality rate associated with unstable pelvic ring injuries exceeds 50%, the use of external compression devices for associated hemorrhage control is paramount. During mass casualty incidents and in austere settings, the need for multiple external compression devices may arise. In assessing the efficacy of these devices, the magnitude of applied force has been offered as a surrogate measure of pubic symphysis diastasis reduction and subsequent hemostasis. This study offers a sensor-circuit assessment of applied force for a convenience sample of pelvic compression devices. The SAM® (structural aluminum malleable) Pelvic Sling II (SAM Medical) and improvised compression devices, including a SAM Splint tightened by a Combat Application Tourniquet® (C-A-T; North American Rescue) and a SAM® Splint tightened by a cravat, as well as two joined cravats and a standard-issue military belt, were assessed in male and female subjects. As hypothesized, compressive forces applied to the pelvis did not vary significantly based on device operator, subject sex, and subject body fat percentage. The use of the military belt as an improvised method to obtain pelvic stabilization is not advised.

Renkiewicz GK, Hubble MW 21(1). 55 - 64 (Journal Article)

Background: EMS personnel are often exposed to traumatic material during their duties. It is unknown how prior military experience affects the presence of stress in EMS personnel. Methods: This was a prospective cross-sectional study. Nine EMS agencies provided data on call mix, while individuals were recruited during training evolutions. The survey evaluated sociodemographic factors and the relationship between childhood trauma and previous military service using the Adverse Childhood Experiences questionnaire, Life Events Checklist DSM-5, and Military History Questionnaire. Descriptive statistics calculated personal trauma profiles, comparing civilian EMS personnel to those with prior service. Hierarchical linear regression assessed the predictive utility of military history to scores on the Impact of Events Scale-Revised. Results: A total of 765 EMS personnel participated in the study; 52.8% were male, 11.4% were minorities, and 11.6% had prior military service. A total of 64.4% of civilian EMS providers had any stress syndrome, while that number was 71.8% in those with prior military service. Hierarchical linear regression identified that years of service and the performance of combat patrols or other dangerous duty accounted for a unique criterion variance in the regression model. Conclusions: Prior military service or combat deployments alone do not contribute to the presence of stress syndromes. However, performance of combat patrols or other dangerous duties while deployed was a contributing factor. These results must be interpreted holistically, as other factors contribute to the presence of vicarious trauma (VT) in EMS personnel who are also veterans.

Noyes BP, Mclean JB, Walchak AC, Zarow GJ, Gaspary MJ, Knoop KJ, Roszko PJ 21(1). 65 - 69 (Journal Article)

Background: Delivering medical care in nighttime conditions is challenging, as 25% of Special Operations medical Operators have reported that problems with lighting contributed to poor casualty outcomes. Red light is often used in nighttime operations but makes blood detection difficult and diminishes depth perception and visual acuity. Red-green combination lighting may be superior for differentiating blood from tissue and other fluids but had not been tested versus red-only or green-only lighting for combat-related medical procedures, such as wound suturing. Methods: Dark-adapted medical resident physicians (N = 24) sutured 6cm long, 3cm deep, full-thickness lacerations in deceased swine under red-only, green-only, and red-green lighting provided by a tactical flashlight using a randomized within-subjects design. Time to suture completion, suture quality, user ratings, and user preference data were contrasted at p < .05. This study was approved by Naval Medical Center Portsmouth IRB. Results: Suture completion time and suture quality were similar across all lighting conditions. Participants rated red-green lighting as significantly easier for identifying blood, identifying instruments, and performing suturing (p < .01). Red-green lighting was preferred by 83% of participants compared to 8% each for red-only and green-only (p < .001). Conclusions: Pending further study under tactical conditions, red-green lighting is tentatively recommended for treating battlefield wounds in low-light environments.

Jerome JE, Pons PT, Haukoos JS, Manson J, Gravitz S 21(1). 71 - 76 (Journal Article)

Background: Uncontrolled external hemorrhage is a common cause of preventable death. The Hartford Consensus recommendations presented the concept of a continuum of care, in which police officers should be considered an integral component of the emergency medical response to active shooter incidents. Recent publications have reported individual cases of tourniquet application by police officers. This report analyzed all documented cases of hemorrhage control using tourniquets applied by police officers in a single large metropolitan police department. Methods: A retrospective computerized search of all public safety communications center reports and police officer documentation for cases of tourniquet application was conducted by searching for the word "tourniquet." Each case was evaluated for indication and appropriateness using Stop The Bleed criteria for tourniquet placement. In addition, police response time was compared to emergency medical services (EMS) response time in an effort to determine if there was a time difference in response to the bleeding patient that could potentially impact patient outcomes. Results: Forty- three cases were identified over the 6-year period ending in December 2019. The majority of cases involved gunshot wounds and most were civilian victims. Injured police officers accounted for two cases (gunshot wound and dog bite). Review of the officers' narratives indicated that most applications appeared justified using the Stop The Bleed criteria (two cases were questionable if a tourniquet was necessary and one may have been placed in an incorrect location). On average, police arrived 4 minutes sooner than EMS did. Conclusion: Several reports in the literature document the success of police officer application of tourniquets to control limb hemorrhage. Most of the reports involved a small number of case reports. This is the largest case series to date from a single urban police department.

Heileson JL, Funderburk LK, Cardaci TD 21(1). 78 - 85 (Journal Article)

Fish oil supplementation (FOS) is beneficial for human health and various disease states. FOS has recently received attention related to its anabolic and anti-catabolic effects on skeletal muscle and cognitive performance. Since Special Operations Forces (SOF) personnel endure rigorous combat and training environments that are mentally and physically demanding, FOS may have important applications for the SOF Warfighter. The purpose of this narrative review is to explore the evidence for FOS and its application to multiple physiological and psychological contexts experienced by SOF personnel. For physical performance, FOS may promote lean body mass (LBM) accretion; however, there seems to be minimal impact on strength, power, or endurance. During physiological stress, FOS may preserve strength, power, LBM (during muscle disuse, not weight loss) and enhance recovery. For cognition, FOS likely improves reaction time, mental fatigue, and may reduce the incidence and severity of mild traumatic brain injury; however, FOS has minimal impact on attentional control and mood states. No safety concerns were evident. In conclusion, there are multiple applications of FOS for SOF personnel. Due to the minimal safety concerns and potential anabolic, anti-catabolic and cognitive benefits, FOS is a viable method to promote and sustain SOF Warfighter physical and cognitive performance. Although promising, the FOS trials to date have not been conducted in the context of the multi-stressor environments experienced by SOF personnel, thus, future studies should be conducted in a SOF population.

Kamarainen A, Virtanen J, Lintunen J, Kolkkinen J, Nykopp I, Isotalo M, Valimaa J, Uotila T 21(1). 90 - 93 (Journal Article)

Purpose: An immediate paramedic tactical response unit was implemented into a civilian emergency medical services (EMS) system. This was compared with the preexisting traditional tactical EMS support (TEMS). The primary aim of the study was to evaluate the effect on tasking frequencies. The secondary aims of the study were to assess mission timings and the effect on patient encounters. Methods: Paramedics with tactical emergency medical training provided immediate response on a 24/7 basis. They responded to support police in high-risk TEMS scenarios and incidents in a Tactical Emergency Casualty Care (TECC) role. Tasking frequencies, timings, and clinical input were compared between the first year of immediate response and 3 preceding years of TEMS. Results: The number of TEMS dispatches increased from an average of 5 to 54 annually. The median time from dispatch to scene arrival decreased from a median of 54 minutes (interquartile range [IQR] 39-65) to 17 minutes (IQR 11-26) (p < .0001). The overall mission duration decreased from a median of 3 hr 13 min (IQR 2 h 29 min to 4 h 40 min) to 1 h 12 min (IQR 34 min-1 h 18 min) (p < .0001). The number of treated patients increased from one minor injury annually to 13 severe and six minor injuries annually. Conclusions: Implementing immediate tactical paramedic response significantly decreases response time and mission duration and increases the number of activations and resultant number of treated patients.

Kuhlwilm V 21(1). 94 - 101 (Journal Article)

Introduction: Sucking chest wounds occur when injuries penetrate the thorax and inhalation results in air entering the pleural cavity. Well documented in the prehospital environment, treatment should be chest seal application to attempt prevention of an expanding pneumothorax. However, a seal might occlude the pathway for the escape of air and lead to a worsening tension pneumothorax. Methods: The author conducted a literature search of studies reporting the efficacy of various chest seals for treating sucking chest wounds and the prevention of a tension pneumothorax. Study results were compared to current international guidelines. Results/Discussion: Included were four studies testing chest seals in a swine model of hemopneumothorax. Vented and unvented chest seals stabilized cardiorespiratory parameters after an open pneumothorax, but only vented chest seals showed more success at preventing a tension pneumothorax. Chest seals with flutter valves seemed to be inferior. An additional study showed that vertical movements and soiled skin were more stressful on the applied chest seals. Eight international guidelines were identified: four focused on the tactical environment, and four appeared to be more civilian-oriented. Only two of the civilian-oriented guidelines did not prefer vented chest seals. Conclusion: Vented chest seals seem to be superior to unvented chest seals, and most international guidelines have updated their recommendations for the use of vented chest seals. However, frequent physical examinations for early signs of a developing or worsening tension pneumothorax are the best medical care.