JSOM Winter 2012 by Kenneth Martin

Journal of Special Operations Medicine

™

Published Quarterly by Breakaway Media, LLC 1275 66th St. N #41494, St Petersburg, FL 33743-1494 • (727) 748-7141

Executive Editor Michelle DuGuay Landers, BSN, MBA, RN Lt Col, AFR NC (Ret) editor@JSOMonline.org

Medical Editor Dan C. Godbee, MD LTC, MC, FS, DMO, FL-ARNG Battalion Surgeon 3rd Battalion, 20th SFG (A) medicaleditor@JSOMonline.org

Academic Content Advisory Editor Kate Froede, MSN, RN, CCEMTP kate.froede@JSOMonline.org

PEER-REVIEW BOARD Kersch, Thomas J., MD Keenan, Kevin N., MD Kennebeck, Gregory A., MD, FACEP, FAAFP Kirby, Thomas R., OD Kragh, John F., Jr., MD Lephart, Scott M., PhD Lesperance, Rich, N., MD Llewellyn, Craig H., MD Logan, Bret W., MD Lutz, Robert H., MD Lyons, Dennis M., NREMT, ATP Mandry, Cris V., MD, FACEP Martinez, Manuel, EMT-P, CCEMTP, DMT McCown, Michael E., DACVPM Miller, Robert M., NREMT-P Montgomery,. Harold R., EMT, ATP Morgan, Andrew R. MD, FACEP Mosely, Dan, S., (Trey), MD Mouri, Michael P., MD, DDS Murray, Clinton K., MD, FACP Noback, Robert K., MD, SFS, MPH-TM Ong, Richardo C., MD Ostergaard, Cary A., MD Pallis, Mark, DO, FAAOS, DMO Palmore, Carroll A., DMD Parks, Philip D. II, MD, MPH-TM, MOccH Payne, James, HMCS, NREMT-P, ATP Pennardt, Andre M., MD Peterson, Robert D., MD Pfaff, James, A., MD, FACEP, FAAEM Ralston, Ernest K., PhD, PG, EMT-P, ATP Renz, Evan M., MD Risk, Gregory C., MD Rosenthal, Michael D., PT, DSc Rausch, Richard E.,Tactical Medic, Special Agent Steinberg, Barry, MD, DDS, PhD, FACS Talbot, Timothy S., MD Taylor, Wesley M., DVM Thompson, William D., MPAS, APA-C Vasios, William N. III APA-C Wedmore, Ian, S., MD, FACEP Wightman, John M., MD, MA Williams, Christopher S., MD, SFS Veliz, Cesar E., NREMT-P, ATP Viola, Steven P., (SEAL) 18D, NREMT-P

Ackerman, Bret T., DO Adams, Bruce D., MD, FACEP Antonacci, Mark A., MD Arne´, Bruce C., DDS, MS Barnes, Scott D., MD Behar, Jean-Marc, EMT-P, Tactical Medic, Special Agent Boccio, Paul E., Ph.D. Bograkos, Bill, MA, DO, FACOEP Brandon, Jonathan W., BS, 18D Butler, Frank, K., MD Calvano, Chris, MD, PhD, FACS Christian, John, PsyD Coldwell, Douglas M., PhD, MD, FSIR Cook, Gray, MSPT, OCS, CSCS Davis, William J., COL (Ret) Debboun, Mustapha, Ph.D., BCE Deveaux, Peter G. LTC, MD, FACS Diebold, Carroll J., MD Licina, Derek, MPH, DrPH(c) Doherty, Michael C., BA, MEPC, MSS Dominguez, John C., ATP, FP-C Farr,Warner, D., MD, MPH, MSS Flinn, Scott D., MD Forsten, Robert D., DO, FS, DMO Fudge, James M., DVM, MPVM Gephart, William, PA-S Giebner, Steven D., MD Giles, James T., DVM Greydanus, Dominique J., EMT-P Goldstein, Scott, DO, FACEP, FAAEM, EMT-T Gosch, Terry L., DMV, MPH Goss, Donald L., DPT, OCS, ATC, CSCS Hammesfahr, Rick, MD Hanel, Rita M., DVM, DACVIM, DACVECC Harris, Kevin D., DPT, OCS, CSCS Hesse, Robert W., RN, CFRN, FP-C Heath, Donald C., Jr., EMT/P, SWAT, Tactical Medic Hester, Alan, R., 18D, MA Holcomb, John B., MD Holt, Eric, MD Hoyt, Robert E., MD, FACP Johnson, Jeremy, DO, RDMS Kane, Shawn F., MD, FAAFP Kacprowicz, Robert, MD, FAAEM Kauvar, David S., MD

TEXT EDITORS Doherty, Michael C., BA, MEPC, MSS Forsten, Robert D., DO Gephart, William J., PA-S Hesse, Robert W., RN, CFRN, FP-C

Kleiner, Douglas M., PhD Peterson, Robert D., MD VanWagner, William, PA-C

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Bringing Together the Educational Interests of Special Operations and Tactical Medicine Winter 2012, Vol 12, Edition 4

JSOM

ISSN: 1553-9768

Journal of Special Operations Medicine™

Editorial Board i From the Publisher and Editor v Call for Papers vii Publication Guidelines viii Submission Criteria ix

Feature Articles

Atrial Fibrillation with Rapid Ventricular Response following use of Dietary Supplement Containing 1,3 Dimethylamylamine and Caffeine Michael Armstrong, MD

Case Series of Pectoralis Major Muscle Tears in Joint Special Operations Task Force-Philippines Soldiers Diagnosed by Bedside Ultrasound Vincent Ball, MD, FACEP; Kevin Maskell, MD; James Pink, 18D

Global Health Language and Culture Competency Charles Beadling, MD; John Maza, MD; Gregg Nakano, MALD; Maysaa Mahmood, PhD; Shakir Jawad, MD; Ali-Al-Ameri, MD; Scott Zuerlein, PhD;Warner Anderson, MD

War Time Medicine on a Peace Time Mission Steven Reynolds 18D; Ashley Mclemore; Austin Squires 18D

Combat Ready Clamp Medic Technique Robert V. Tovmassian, SFC, USA; John F. Kragh, Jr., MD; Michael Dubick, PhD; David G. Baer, PhD; Lorne H. Blackbourne, MD

USSOCOM TCCC CASEVAC Set Program: A Retrospective and Overview John “Brad” Gilpin

Redefining Technical Rescue and Casualty Care for SOF: Part 1 McKay S.D., EMT-P; Johnston J., EMT-P, 18D; Callaway D.W., MD, MPA

Perspective

Making the Jump …Transitioning from Military to Civilian Paramedicine Mike Smith, BS, MICP

Letter to the Editor

A Novel Cryotherapy Compression Wrap in the 17 Management of Acute Ankle Sprains: Potential Use for Special Operators on the Battlefield Mark Boland, PT, MPT; Ivan Mulligan, PT, DSc, SCS; Justin Payette, PT, DPT; Jennifer Serres, PhD; Reginald O’Hara, PhD; Genny Maupin, MPH

Abstracts from Current Literature

Biofeedback Self-Regulation Training to Treat Post-Concussion Headache in a Special Operations Support Soldier Craig M. Jenkins, PhD, ABPP

COL Warner “Rocky” Farr

Biometrics in Support of Special Forces Medical Operations Michael R. Kershner, COL, SF (Retired)

Forward Assessment of 79 Prehospital Battlefield Tourniquets Used in the Current War David R. King, MD; Gwendolyn van der Wilden, MSC; John F. Kragh, Jr., MD; and Lorne H. Blackbourne, MD

Addressing Maternal Healthcare Needs in the Counterinsurgency Environment Gregory Lang, MD, MPH; Christine E. Lang, MD, MPH

From the SEMA

MSG Harold R. Montgomery USSOCOM Senior Enlisted Medical Advisor

SOCCENT TSOC Surgeon NATO SOF Medical Advisor LTC Daniel Irizarry

109 110

TCCC Updates

Memos 111 Abstracts 124

TEMS Updates

Tactical Emergency Casualty Care (TECC) Update, Winter 2012

132

Current and Future Implications of the National TEMS Initiative and Council

133

Medical Technology Updates

136

Photo Gallery

140

Directory of Advertisers

143

Fast Combat and Fast Responder

Intensive Skills Week for Military Medical Students 45 Increases Technical Proficiency, Confidence, and Skills to Minimize Negative Stress Genevieve Mueller, MS3; Bonnie Hunt, MS4; Van Wall, MS3; Robert Rush Jr, MD; Alan Molof, DO; Ian Wedmore, MD; James Schmid, PA-C; Anthony LaPorta, MD Resourcing Interventions Enhance Psychology Support Capabilities in Special Operations Forces LTC Craig A. Myatt, PhD; J.W. Auzenne, MA

106

Upcoming Events

Please visit the JSOM website at: https://www.jsomonline.org/Professional_Development.php for a list of upcoming courses and conferences.

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Est. 2000

Winter 2012 Volume 12, Edition 4 ISSN: 1553-9768

™ A Peer Reviewed Journal that Brings Together the International Interests of First-Responders in the SOF Medical and TEMS Community

› › › › › › › › › › › › › ›

Supplement-Induced A-Fib with RVR in a Special Warfare Sailor Bedside Ultrasound Diagnosis of Pectoralis Major Muscle Tears in SOF Global Health Language and Cultural Competency Battlefield Management of Acute Ankle Sprains with Cryotherapy Biofeedback Self-Regulation Training to Treat Post-Concussion Headache Biometrics Support in Special Forces Medical Operations Prehospital Battlefield Tourniquet Use in Current Conflicts Maternal Health Needs in Counterinsurgency Contexts Performance and Stress Levels of Military Medical Students War Time Medicine in a Peace Time Mission Combat Ready Clamp: Techniques for Medics Resourcing Interventions Enhances Psychological Support Capabilities in SOF Retrospective Overview of the USSOCOM TCCC CASEVAC Set Program Redefining Technical Rescue and Casualty Care for SOF: Part 1

Dedicated to the Indomitable Spirit and Sacrifices of the SOF Medic

Plus… Medical Technology Updates, TCCC and TEMS Updates, and more

SOF high altitude medical and MEDEVAC training in Wyoming. Correction to Fall 2012 edition cover. SAR Corpsmen and crew members for the 1 MEF CASEVAC team with Task Force Tarawa off-load casualties from USMC CH-46E’s. This photo was taken at the captured airfield of Jalibad, Iraq during the initial push in 2003.

Breakaway Media is a professional Journal Publishing Company dedicated to advancing the body of knowledge for medical and paramedical professionals operating in tactical, military, wilderness, disaster, or other austere environments. We are continuing to evolve and significantly enhance the academic awareness of the JSOM in order to meet the increasingly complex clinical reference needs in the unconventional medicine community. Breakaway Media strives to insure the JSOM delivers the highest standard of medical information and resources to improve outcomes for patients and the provision of emergency healthcare in an austere environment worldwide. Our dedicated staff and peer- review editors emphasize high standards of quality in content and presentation in all of our article submissions. The JSOMs unwavering mission is to promote the professional development of the Special Operations Forces (SOF) and Tactical Emergency Medical Support (TEMS) medical personnel by providing a forum for the examination of the latest advancements in unconventional medicine. Because the quality of the articles published by this community of highly-trained professionals is . so cutting edge, the JSOM has been highly-searched and recognized through the National Library of Medicine’s Our readership has expanded into all areas of emergency medicine that can implement the lessons learned from these articles into their everyday practice. Copyright © 2012 by Breakaway Media, LLC

Breakaway Media, LLC PO Box 41494, St Petersburg, FL 33743-1494 (727) 748-7141 (office) (727) 409-8603 (cell) Please contact us at publisher@jsomonline.org for any reprint requests. Graphic Design by Pro Production Graphic Services

from the EDITOR Greetings JSOM readers!

years before switching services in 1990 to become an Air Force Over the past 10 years, trauma C-130 Flight Nurse. She decare on the battlefield has imployed to Desert Shield/Storm proved dramatically. As cutting and participated in many exeredge SOF medical providers you cises to include Bright Star. She have so many lessons learned served as the Officer in Charge to share with your peers. The of Training and Education for JSOM is the place to share what her reserve unit and through coMichelle DuGuay Landers you learned with the commuordination with MacDill AFB, nity of medical providers that USSOCOM, and the ATF, was successful in getting 90% will benefit the most. If you are considering submitting of the unit’s flight medics EMT-B certified. She became to the JSOM, please be sure to read our Submission Cri- an IMA reservist assigned to HQ AF Reserve Command/ teria, located on page ix of the journal as well as on our SG in 2000 and was attached to the SOCOM/SG ofwebsite under the Publications Tab. Please be sure to fice where she started the Journal of Special Operations carefully read all 13 points, but most importantly, note Medicine. She spent 11 years in charge of management, numbers 8, 9, and if you are a USSOCOM member, 12. production, publication, and distribution of the JSOM. The Spanish Advanced Tactical Paramedic Manual (Training Supplement) is now available on the JSOM Online Store! It includes a detailed index of Spanish to English commonly used medical words and phrases.

She acquired twelve years of United States Special Operations Command experience and has a strong working knowledge of SOF medical needs. She is skilled in analyzing for quantity and quality of peer-reviewed scientific/ medical content and planning, organizing, and directing an editorial board of health professionals through each peer-review process.

Returning to the JSOM in Spring 2013 is Picture This – a quarterly section dedicated to Dermatology in the austere environment!

Michelle holds a Bachelor’s in Nursing and a Master’s in Business Administration/Management. Her 26-year clinical nursing career includes being a flight nurse in both the military and private sector, emergency and critical care nursing, as well as being an EMT-B and a legal nurse consultant and expert witness. She served as the military liaison to the FL 3 Disaster Medical Assistance Team (DMAT).

NEW! We are now offering a digital only subscription. We are just a few short weeks from SOMA. Be sure to come by to visit the JSOM upstairs in the Exhibit Hall at Booth 624. On behalf of the JSOM staff, we look forward to seeing everyone there. A little about the our Publisher and Staff Editors who work to put out this unique journal that has become an integral part of SOF medicine:

Lt Col Landers retired in 2011 and began Breakaway Media, LLC to continue to publish the JSOM. —Michelle DuGuay Landers Publisher and Editor

Michelle DuGuay Landers was commissioned as a Lieutenant in the Army Reserve in 1987 and served as a clinical nurse in a Combat Support Hospital unit for three

LTC (Dr.) Dan Godbee, medical editor Kate Froede, MSN, RN, CCEMTP has for The Journal of Special Operations over a decade of clinical practice as a Medicine has been on the JSOM Editonurse specialist (trauma/emergency) and rial Board since 2001. Dan is the Bathas taught military and civilian courses talion Surgeon for the 3rd Battalion, in critical care, prehospital trauma, and 20th Special Forces Group (Airborne) critical care transport. Ms. Froede’s unin the Florida Army National Guard. dergraduate degree is from Canada’s He has over 35 consecutive years of top institution, Queen’s University. She LTC (Dr.) Dan Godbee military service. Dr. Godbee joined the holds a Master of Science in Nursing Medical Editor Army as a Private in 1976, and served from Loyola University New Orleans; six years on active duty with the 82nd her research focus was outcomes from Airborne Division and the 5th Special polytrauma specific to traumatic brain Forces Group. In the Army Reserve, injury. She completed post-graduate he was in the 11th SFG in Columwork at Vanderbilt University, and is bus, GA, the Joint Special Operations currently in the doctoral nursing proMedical Training Center, and the 75th gram at Loyola University New Orleans Combat Support Hospital in Gulfport, studying the practice-based evidence of MS. Dr. Godbee is an alumni of The Special Operations medics and the inGeorgia Institute of Technology, holdfluences on care delivery and curricular ing a Bachelor’s Degree in Mechaniadvancement. Ms. Froede has extensive cal Engineering, and graduate degrees knowledge in evaluating academic pubin both Mechanical and Industrial lications, clinical evidence, and the rigor Engineering. He graduated medical of scientific study. She has personally school from Mercer University School authored publications, and has evaluKate Froede of Medicine in Macon, GA, and did ated evidence to support military health MSN, RN, CCEMTP an Emergency Medicine Residency at initiatives presented to Senate Defense Academic Content Louisiana State University in Baton committee personnel. Ms. Froede has Advisory Editor Rouge, LA, where he served as Chief worked with Wounded Warrior medical Resident. Dr. Godbee currently works as a faculty physi- research consortia, and was also instrumental in highcian at the Emergency Medicine Residency Program at lighting DoD policies regarding polytraumatic injuries LSU in Baton Rouge. Prior to medical school, he had for which the Purple Heart is awarded. Kate has held a previous career as an engineer working in software nursing positions at Ft. Bragg, NC, Ft. Lewis, WA, and implementation and hardware upgrades for small comoverseas, for which she received awards for civilian and puter systems. LTC Godbee was an enlisted person for public service. Most recently, Ms. Froede was nominated over 24 years and his MOSs include 18C, 18D, 18F, and as a 2012 Jonas Foundation for Nursing Excellence 18Z. He held positions as Team Engineer, Team Medic, Scholar, for which she was selected and awarded a grant, Intelligence Sergeant, Team Sergeant, Company Medic, based on her proposed doctoral topic of study involving and Company Operations Sergeant. During his service the military. as a NCO, Dr. Godbee had deployments to Iran, Israel/ Egypt, Sudan, and did an exchange with the British SAS. LTC Godbee was commissioned as a medical officer in 1999. He has deployments to Iraq as a Brigade Surgeon and Arabic Linguist with the 2nd Infantry Division, and both Iraq and Afghanistan as a Battalion Surgeon with the 20th SFG. Dr. Godbee’s qualifications include, Special Forces, Flight Surgeon, Dive Medical Officer, Jumpmaster, Pathfinder, Air Assault, and Combat Diver. He holds the Combat Medic Badge and the Expert Infantryman’s Badge. His language qualifications are Arabic (Eqyptian) and Russian. In his career with LSU, Dr. Godbee has held positions as director of emergency ultrasound and director of advanced life support.

The Journal of Special Operations Medicine (JSOM) is a quarterly, peer-reviewed journal and is indexed in PubMed. The critical mission of the JSOM is to provide world-wide identification and debate of medical issues relevant to Special Operations Forces (SOF) and Tactical Emergency Medical Support (TEMS).

Papers should be submitted electronically via email in either Microsoft Word or Mac Pages and should include a cover sheet containing corresponding Author’s name, Paper Title, affiliation, mailing address, phone, fax number, email address, etc. All images must be sent separately as hi-resolution jpegs.

The JSOM is crucial to medical NCO and Officer professional development. Emerging and new trends in the field of Special Operations and TEMS medical care and equipment is found first and most prominently through publication in the JSOM.

Authors should indicate interest or send articles (even if not yet finished) to: editor@jsomonline.org. The submitted papers must be written in English and describe original work not yet published nor currently under review by other journals.

The JSOM is the only publication that brings together military, civilian and federal agencies with tactical emergency medical assets, and those with an interest in prehospital emergency medicine in the wilderness or austere environment in one unique forum to promote the sharing of knowledge and tradecraft proficiency. The JSOM provides real-time, lifesaving information for urban and rural battlefields.

Our goal is to inform authors about their paper(s) within two weeks of receipt. All submitted papers, if relevant to the theme and objectives of the journal, will go through an external peer-review process. Submissions should include an abstract, 5–10 keywords, and the e-mail address of the corresponding author. Upcoming deadlines are as follows:

Article submissions must relate actionable information for SOF medical personnel to implement in real-time to provide expert care and treatment to our forces. Submissions relevant to many host nation (HN) military that are trained by or accompany our SOF personnel are also welcome to submit. Many HN civilians benefit from the diffusion of knowledge imparted by publication in the JSOM.

Spring 2013 • editorial close – 1 December Summer 2013 • editorial close – 25 February Fall 2013 • editorial close – 24 May Winter 2013 • editorial close – 1 September

We have dedicated editorial and advisory staff to assist you with technical writing and article submissions. Your ideas are important to us, and we will get them published! We are accepting manuscripts in All Fields relating to SOF and TEMS medicine. Don’t miss this opportunity to publish in the JSOM and showcase worldwide your work and lessons learned.

Please visit our website at https://www.jsomonline.org/ Distribution.php for more information.

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JSOM Disclaimer Statement The Journal of Special Operations Medicine (JSOM) is a quarterly journal the presents professional medical information to expand the knowledge of military SOF, civilian and governmental law enforcement agencies with tactical emergency medical support (TEMS). It promotes collaborative partnerships among services, components, and various specialties. The JSOM conveys medical service support information and provides a peer-reviewed, quality print medium to encourage dialogue concerning Special Operations medical initiatives. The views contained herein are those of the authors and do not necessarily reflect the views of the Department of Defense. The JSOM does not hold itself responsible for statements or products discussed in the articles. Unless so stated, material in the JSOM does not reflect the endorsement, official attitude, or position of the JSOM or of its Editorial Board. Content All scientific articles are peer-reviewed prior to publication. The Journal of Special Operations Medicine reserves the right to edit all submitted material. Please submit articles in Word Doc format to editor@jsomonline.org. Please see Submission Criteria in journal for all requirements. Submissions All articles and images submitted by USSOCOM members must continue to be reviewed and pre-approved by the author’s S2 and PAO prior to submission to the JSOM. Authors must adhere to standard OPSEC practices and refrain from mentioning specific units, specific locations, troop strengths, names of actively serving SOCOM personnel, TTPs, vulnerabilities, and any other information that could be of use to an adversary. copyright Copyright © 2012 by Breakaway Media, LLC. Please contact publisher@jsomonline.org for any reprint requests. Breakaway Media, LLC, 1275 66th St. N #41494, St Petersburg, FL 33743-1494. Telephone: O-727-748-7141; C-727-409-8603. indexing The JSOM is serial indexed (ISSN) with the Library of Congress. Articles published in the peer-reviewed Journal of Special Operations Medicine are indexed in MEDLINE® the National Library of Medicine’s (NLM) bibliographic database of life sciences and biomedical information. Inclusion in the MEDLINE database ensures that citations to the JSOM will be identified to researchers during searches for relevant information using any of several bibliographic search tools, including the NLM’s. Online Please visit us at http://www.jsomonline.org. The PDFs from 2000–early 2011 are available online. Starting with the Spring 11 edition, the JSOMs are available through a digital subscription as a flip-book. Please visit our Professional Development calendar for upcoming medical training and conferences. We will be posting important topics that you “Need to Know Now” so keep checking out the website. New is our Journal of Special Operations Group on LinkedIn. Be sure to join our group at http://www.linkedin.com/groups/Journal-Special-Operations-Medicine4549541?trk=myg_ugrp_ovr. I will be posting important journal related topics, as well as it is m open forum to discuss SOF or TEMS relevant topics. You can also follow us on our Facebook page and on Twitter. Subscriptions The JSOM is available through a variety of paid subscription options at https://www.jsomonline.org/Subscriptions .php. The digital subscription gives you the benefit of having access to the current and all back issues at your fingertips, as well as all our PubMed indexed articles in full-text under one easy to search tab. Contact us at subscriptions@jsomonline.org for group or library subscription rates. Advertising For advertising rates, please go to https://www.jsomonline.org/Advertisers.php to download the JSOM Media Kit. Contact us at advertising@jsomonline.org.

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Journal of Special Operations Medicine Volume 12, Edition 2/Summer 2012

1. U se the active voice when possible. This is our most common editorial problem and often requires extensive re-writes. Use the sequence “subject – verb – object.” 2. Secure permission before including names of personnel mentioned in your piece. Do not violate copyright laws. If the work has been published before, include that information with your submission. 3. Format articles to be single-spaced, ten-point Times Roman font, aligned on the left, and justified on the right. Double space between sentences. Be sure the document allows for editing with no restrictions. 4. Important: Include an abstract, biography, and headshot photo of all authors as part of the article. 5. Use a minimum of acronyms; spell out all acronyms when first used. Remember that your audience is interservice, civilian, and international. 6. Put the point of the article in the introductory paragraph and restate it in the closing or summary. Subtlety is not usually a virtue in a medical publication. 7. We do not print reviews of particular brands of items or equipment unless that brand offers a distinct advantage not present in other products in the field. The author must specify in the article the unique features and advantages the product offers in order to justify an exception to this rule. The author must also specify whether the product was purchased by him or his unit, or supplied for free by the seller or manufacturer. Finally, the author must disclose any relationship with the manufacturer or seller, whether financial, R&D, or other. 8. References: DO NOT insert endnotes, footnotes, or use roman numerals. Cite all references in order of use; the reference number remains the same if used multiple times. We prefer APA style; however, we will accept any academic reference style (APA, MLA, or Chicago Manual of Style) as long as you remain consistent throughout your article. Complete formatting details can be found at http://owl.english.purdue.edu/owl/section/2/. If unsure, please contact the editor at editor@jsomonline.org. 9. Submit high-resolution (300 dpi) quality photographs with your article. Send photos separately from the document to facilitate high-resolution conversion into a publishing format. Images imbedded into word documents do not transfer to publishing programs and lose resolution when pulled out of the word document, resulting in a poor quality print image. We prefer that images be sent electronically in a jpeg format or original application files (Adobe Photoshop, Illustrator, MS Excel, Powerpoint). Please name all images as to what they are (i.e., Figure 1, Figure 2, etc.) and designate placement in the article using the filename. If you send original pictures, we will make every attempt to return your pictures, but will not account for lost or damaged items. 10. We reserve the right to edit all material for content and style. We will not change the author’s original point or contention, but may edit clichés, abbreviations, vernacular, etc. Whenever possible, we will give the author a chance to respond to and approve such changes. We may add editorial comments, particularly where controversy exists, or when a statement is contrary to established doctrine. However, the author must assume responsibility for his own statements, whether in accordance with doctrine or not. Both medical practice and the military doctrine are living bodies of knowledge, and JSOM’s intent is not to stifle responsible debate. 11. Special Operations requires sensitivity to natives of host countries, occupied regions, and so on. We feel that patronizing terms generally are inappropriate for our pages. Realistic language of Operators (including some “four-letter” words) may be tolerated in anecdotal and historical articles, especially when used as direct quotes or when such use is traditional among Operators. We will delete or change blatantly offensive use. 12. All articles written by USSOCOM members must be reviewed and pre-approved by your S2 and PAO prior to submission to the JSOM. Authors must adhere to standard OpSec practices and refrain from mentioning specific units, specific locations, troop strengths, names of actively serving SOCOM personnel, TTPS, vulnerabilities, and any other information that could be of use to an adversary. 13. Send submissions by email to editor@jsomonline.org. The JSOM is your journal and serves as a unique opportunity for you to pass your legacy to the SOF and TEMS community!

The Journal of Special Operations Medicine (JSOM) is a quarterly peer-reviewed journal that is an official forum for professional discourse on global Special Operations Medicine. The JSOM transcends military and civilian Special Operations medicine by bringing forth practical and sensible ideas and techniques to the civilian TEMS provider currently operating in a Law Enforcement environment.

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The annual pocket-sized JSOM Training Supplement is a quick reference in a lifesaving situation. It includes the Tactical Trauma Protocols, Tactical Medical Emergency Protocols, USSOCOM Recommended Drug List, Tactical Canine TCCC, Burn Charts, Nerve Chart, and the Military Acute Concussion Evaluation (MACE) Charts.

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Journal of Special Operations Medicine Volume 12, Edition 2/Summer 2012

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Atrial Fibrillation with Rapid Ventricular Response following use of Dietary Supplement Containing 1,3 Dimethylamylamine and Caffeine Michael Armstrong, MD

Abstract Our nationâ&#x20AC;&#x2122;s servicemembers commonly use dietary supplements to enhance their performance. Despite this prolific use, many of these products have detrimental side-effects that compromise servicemembersâ&#x20AC;&#x2122; health and could, by proxy, compromise a mission. This paper presents the case of a 32-year old Navy Special Operations Forces (SOF) Sailor who, prior to physical training, used a supplement containing 1,3 Dimethylamylamine (DMAA), and then developed atrial fibrillation with rapid ventricular response. He required intravenous calcium channel blocker administration, followed by beta blockers, for rate control. As military providers, we routinely ask our patients about their use of supplements and while the regulation of these products is beyond the scope of practice for most of us, it is our duty to become better educated about the risks and benefits of these supplements. We must educate our patients and our commands on the potential harm that these supplements may pose.

prolapse. An ECG performed four months prior to this incident, during his five-year physical exam, showed sinus bradycardia, a common finding in fit servicemembers and athletes. The patient reported using a DMAA-containing supplement, at the recommended dose, prior to his workout. He used the same product daily for approximately one week, took a week off, and this was his first use of the product since. The only other supplement he reported taking was whey protein, occasionally taken with or as a meal. His emergency department management included continuous monitoring and administration of 10mg IV diltiazem. A CBC, urinalysis, TSH, Fibrin D-Dimer, alcohol, and drug panel were collected. His heart rate slowed to the 100s. The patient was then transferred via ACLS capable ambulance to a military medical treatment facility (MTF) with available cardiology for definitive management. On arrival at the MTF, he had a heart rate of 103 bpm, with a blood pressure of 113/72mmHg. On exam, he was comfortable in bed and appeared to be in no acute distress. He had an irregular rhythm on the cardiac exam by auscultation and arterial palpation, confirmed by ECG (see Figure 1), revealing ongoing atrial fibrillation.

Keywords: Atrial fibrillation, supplements, DMAA, special operations, 1,3 Dimethylamylamine

Case Report A 32-year old active duty Navy SOF Sailor developed chest pressure and shortness of breath during his normal one to two hour afternoon physical training, which consisted of high-intensity aerobic intervals. He went home and after five hours of continued symptoms, presented to the local emergency department. Electrocardiogram (ECG) revealed atrial fibrillation with rapid ventricular response at a rate in the 140 beats per minute (bpm) and no ST segment changes. The patient denied any chest pain, diaphoresis, nausea, syncope, or cough. He did recall having some past chest pressure during strenuous workouts that resolved quickly after the workouts. His medical history was significant only for a craniotomy secondary to encephalitis in 1997. He was in excellent physical shape in order to meet his duty requirements. Family history was notable for maternal mitral valve

Figure 1 Members ECG on admission to military medical facility showing classic A-Fib: irregular rhythm with few discernible P-Waves

The remainder of his examination was normal. A complete metabolic panel was normal, with Na of 143 and K of 3.8. All of the labs returned as normal with the exception of the cardiac panel, which revealed a normal troponin and CK MB, but the creatine kinase was elevated at 263 U/L (55–170), suggestive of skeletal muscle injury, but not cardiac injury. He was started on esmolol in the emergency department, as there was no response to the diltiazem. The patient was admitted to the internal medicine service, placed on telemetry. Cardiology was consulted. He was transitioned from the intravenous short-acting esmolol to longer acting oral metoprolol because he converted to a sinus rhythm by the time he reached the floor. The effectiveness of the beta blocker seemed appropriate because unlike calcium channel blockers, beta blockers decrease the responsiveness of the heart to the sympathetic nervous system, but in general is contraindicated in stimulant overdose due to unopposed alpha stimulation, leading to hypertension.13 The patient underwent a transthoracic echocardiogram showing a structurally normal heart in sinus rhythm with an ejection fraction of 55–60% (normal). A cardiac panel was redrawn. The creatine kinase was reduced to 183U/L and repeat ECG showed sinus bradycardia with a rate of 52 bpm. The patient was discharged home on metoprolol after 24 hours of inpatient care. After discharge, he completed a sleep study and two holter monitor studies, all of which returned as normal. Three months after the event, he demonstrated full physical activity without further episodes of chest pain. With the endorsement of his cardiologist, he was granted a medical waiver and returned to naval SOFduty.

Dietary Supplements The market for dietary supplements (DS) has significantly increased in the past decade from $17.8 billion in 2001 to about $25 billion in 2008.1,2 Approximately half of adult Americans and a slightly larger proportion of active duty Soldiers in the United States (U.S.) Army reported using any type of DS in 2009. Of these Soldiers, those who engaged in greater amounts of exercise, had college degrees, or were members of SOF had an even higher incidence of DS use. In a 2010 study of 990 active duty Soldiers, 78% of Special Forces (SF) Soldiers reported use of DS.2 This is not surprising, given that SOF across all military branches train at levels similar to world class athletes. Coincidentally, supplement use is also common among world class athletes.3 In response to a review of 926 adverse event reports, the U.S. Food and Drug Administration (FDA) banned the sale of ephedra-containing supplements in March 2004.

These adverse event reports included cases of stroke, myocardial infarction, and sudden cardiac death related to ephedra use. Ephedra is a plant extract containing a mixture of ephedrine, pseudoephedrine, and phenylpropanolamine. Ephedrine accounts for the majority of alkaloid in ephedra extracts and is an alpha- and betaadrenergic receptor agonist. By stimulating the receptors at the end organ of the sympathetic nervous system, it activates the fight-or-flight responses leading to increased systolic and diastolic blood pressure, peripheral vasoconstriction, increased heart rate, increased cardiac contractility and central nervous system stimulation.4 Prior to the ban, servicemembers typically took ephedra in preparations combined with caffeine, which increases the side-effects of heart palpitations and anxiety. By July 2004, the ephedra market had largely been replaced by supplements combining caffeine and synephrine. There have been no conclusive links to adverse effects related to these supplements. Despite that, strong associations of serious side-effects were reported in the case of stroke in a 36-year old woman, syncope in a 22-year old woman, and myocardial infarction in a 55-year old woman. In rodent studies, high doses of synephrine were associated with an increased incidence of ventricular arrhythmias and death.5,6,7,8 Over the last few years, DMAA has made an initial impact on the supplement market as a new substitute for ephedra. DMAA was originally developed by Eli Lilly as a nasal decongestant in 1944, due to its powerful vaso constrictive action. According to DMAA’s patent report, its pharmacological profile demonstrates less central nervous system effects compared with amphetamine and ephedra. The pharmacology of DMAA has not been revisited since.9,10 This compound still may possess potentially dangerous side-effects. In 2010, a legal DMAA supplement taken at the package-recommended dose was associated with a significant (66mm × 21mm × 31mm) basal ganglion hemorrhage.11 After this incident, the Ministry of Health in New Zealand banned the sale of DMAA.12 In the United States, DMAA can be found in several weight loss and pre-workout supplements commonly sold in the community and on military bases (anecdotal observation).

Discussion Dietary supplements, regardless of their claims of being natural and/or safe, are not necessarily without risk. This case report describes a young man with an athletic lifestyle whose emergent medical condition correlated to use of a specific DS. He exercised at his regular intensity during a routine day and then sustained a medical emergency. The specific cause was not been determined, but the patient history was remarkable for consumption of

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

the DMAA supplement prior to the workout. His history of chest pressure with strenuous workouts in the past could be suggestive of angina, but he would be a very atypical patient and there were no findings pointed to this diagnosis during his workup up by either the emergency department or cardiologist that pointed to this diagnosis. Conduction system pathology was considered unlikely, given that the patient was found to have a structurally and physiologically normal heart by diagnostic echo and multiple normal holter studies, but an electrophysiology study was not ordered. He has not had a recurrence of symptoms since returning to full activity and cessation of DS use. More than half of active duty Soldiers, and an even larger percentage of our elite servicemembers, use DS products on a regular basis to enhance performance.2 While it is concerning that the adverse incident described in this paper happened in a relatively controlled environment, in which access to medical care was adequate. If a similar situation were to occur in a more austere environment, the result could be mission compromise, a costly medevac, or even preventable death. The Army recently started investigating DMAA and plans to conduct a case-control study to determine if there are adverse side-effects associated with these DS.14 This is a good first step toward understanding any potential harm posed by this supplement. Already many DMAA-containing supplements have been banned from sale on military bases, but they are still readily and legally available off-base.14 DMAA replaced the market for Ephedra (banned in 2004) and bitter orange, which also fell out of favor.4 Banning one substance will drastically cut down on its use, but will not eliminate the problem, nor will it prevent the next DS – with potentially unknown side effects – from entering the market. Two possible approaches may be effective: change the DS regulations at the federal level, or aim educational efforts at consumers. Currently, two different systems are in place for evaluating medicinal products. Through the FDA and required phase testing, pharmaceuticals are considered dangerous substances until proven safe and effective through extensive testing and randomized control trials.1 On the other hand, DS are minimally regulated by the federal government and are marketed as safe until proven otherwise. This initial evidence occurs via case reports, followed by research studies, and eventually is determined by liability litigation, and may finally result in regulation.15 Each of these systems is ultimately used to market products to improve health and well-being, which results in profit for the companies that produce them. However, no guarantee exists that the product will not be recalled due to unanticipated adverse effects, even in the extensively tested pharmaceuticals. This presents a Atrial Fibrillation with Rapid Ventricular Response

New onset arrhythmia when unstable is an emergency and ACLS algorithm should be followed. In the stable patient rate control is achieved first followed by anticoagulation in those at risk for thrombus prior to cardioversion. Atrial fibrillation is a indicator of multiple disease states, some of which are life threatening. Adapted from M Sabatine “Pocket Medicine 2nd Ed.” Lippincott Williams & Wilkins 2004

dilemma for discussing the risks and benefits of DS with patients who believe the marketing claims and are using the DSs to improve fitness and performance. Educational approaches may be the most judicious way to tackle DS use in the military. Medical providers can offer team members timely information about the risks related to DS, including the lack of federal regulation, potential for harm, and biases related to marketing. Cultivation of a skeptical attitude may promote improvements in health and well-being, and empower servicemembers to make better and more informed health choices. While education may not eliminate the use of DS, we can provide the best available health education to our SOF members about the advertised products that can put their health in significant peril. References 1. D Marcus, A Grollman. (2002). Botanical Medications. The need for new regulations. New England Journal of Medicine. 347:2073–2076. 2. H Lieberman, et al. (2010). Use of dietary suppliments among active-duty U.S. Army Soldiers. American Journal of Clinical Nutrition. 92:985–995.

3. J Hughes, B Shelton, T Hughes. (2010). Suspected dietary supplement injuries in Special Operations Soldiers. Journal of Special Operations Medicine. 3:14–24. 4. P Gregory. (2007). Evaluation of the stimulant content of dietary supplements marketed as Ephedra-Free. Journal of Herbal Pharmacology. 1:65–72. 5. C Haller, N Benowitz, P Jacob. (2005). Hemodynamic effects of ephedra-free weight-loss suppliments in humans. American Journal of Medicine. 118:998–1003. 6. D Marcus, A Grollman. (2003). Ephedra-free is not danger-free. Science. 301:1669–1670. 7. R Holmes, J Tavee. (2008). Vasospasm and stroke attributed to ephedra-free xenadrine: Case Report. Military Medicine. 173:708–710. 8. J Nasir, et al. (2004). Exercise-induced syncope associated with QT prolongation and ephedra-free xenadrine. Mayo Clinic Proceedings. 79:1059–1062. 9. S Vorce, et al. (2011). Dimethylamylamine: A drug causing positive immunoassay results for amphetamines. Journal of Analytical Toxicology. 35:183–187. 10. U.S. PATENT 2350318, Rohrmann, Ewald, “AMINOALKANES,” issued May 30, 1944; retrieved from http:// www.freepatentsonline.com/2350318.html. 11. P Gee, S Jackson, J Easton. (2010). Another bitter pill: A case of toxicity from DMAA party pills. Journal of the New Zealand Medical Association. 123:1327. 12. New Zealand Ministry of Health “DMAA Banned from 9 April 2012” [News Article] Retrieved from http://www .health.govt.nz/news-media/news-items/dmaa-banned-9april-2012. 13. N Handly “Amphetamine Toxicity” Published 02 April 2012; Accessed 17 July 2012; http://emedicine.medscape .com/article/812518-overview. 14. T Tritten “Soldiers to be subjects as Army studies whether DMAA is dangerous” Stars and Stripes; Published March

1, 2012; [Department of Defense authorized news outlet] Retrieved from http://www.stripes.com/news/Soldiers-tobe-subjects-as-army-studies-whether-dmaa-is-dangerous1.170432. 15. National Institute of Health “Background Information: Dietary Supplements” http://ods.od.nih.gov/factsheets/ dietarysupplements/ Accessed March 7, 2012.

LT Armstrong was commissioned into the Naval Medical Corp in 2004 through the Health Professions Scholarship Program. LT Armstrong earned a Bachelors in natural science, a Masters of Biomedical Engineering, and Medical Degree from the University of South Florida in Tampa, FL. He then completed an internship in general surgery at Naval Medical Center San Diego followed by completion of the Undersea Medical Officer’s Course at Naval Undersea Medical Institute, Groton, CT. After becoming an undersea medical officer, LT Armstrong was transferred to Naval Branch Health Clinic Kings Bay as the sole Undersea Medical Officer for the Naval Hospital Jacksonville Area of Responsibility. In addition to caring for two dive lockers, two EOD mobile units, the shore based submarine community and one of the largest radiation health programs in the Navy, LT Armstrong routinely consulted with Naval Information Operations Command, Ft Gordon, GA. Upon completion of this tour LT Armstrong transferred to Naval Submarine Support Center Kings Bay, GA where he currently supports the healthcare needs of Naval Submarine squadrons 16 and 20. Email: michael.armstrong@med.navy.mil.

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

Case Series of Pectoralis Major Muscle Tears in Joint Special Operations Task Force-Philippines Soldiers Diagnosed by Bedside Ultrasound Vincent Ball, MD, FACEP; Kevin Maskell, MD; James Pink, 18D

Abstract remainder of the examination including examination and function of his biceps and rotator cuff was unremarkable. We performed a bedside ultrasound over the area of tenderness, which revealed a large hematoma (Figure 1B). We placed the patient in a sling and provided analgesia and anti-inflammatory medications. We obtained magnetic resonance imaging (MRI) at a host-nation hospital, which was interpreted as a high-grade tear of the pectoral major muscle at the musculo-tendinous junction. We routinely evacuated the patient from the theater for surgical evaluation and rehabilitation.

Pectoralis major muscle tears are an uncommon injury although reported most prevalently among young male athletes (e.g. SOF personnel). We describe two cases occurring in Joint Special Operations Task Force-Philippines (JSOTF-P) Soldiers, review the physical examination and sonographic findings suggestive of a high-grade injury, and discuss treatment options.

Case 1 A 31-year-old Special Forces Soldier presented complaining of right chest pain that started while bench-pressing the day prior. The avid lifter was pressing 225 pound and felt a pop and “zipper-like” pain to his lateral chest. He denied previous illness, injury, and use of steroids. His previous medical history was unremarkable. On examination (Figure 1A) he had small areas of ecchymosis on the bilateral pectoral major muscles and focal tenderness to palpation, but no visible abnormality at the lateral pectoral region. He was able to forwardly flex the humerus against mild resistance with the shoulder in abduction and external rotation simulating a bench press, but was weaker (4/5) than the unaffected side (5/5). The

Case 2 A 27-year-old Special Forces Soldier presented complaining of right chest pain, which started while benchpressing the day prior. He was lifting a light-weight during the end of his workout when he felt a “pop.” He related having previous pain in the same area with an unremarkable MRI of the rotator cuff one year prior. He denied other medical history, trauma, and use of steroids. On examination he had an area of ecchymosis on his upper anterior biceps. He had focal tenderness Figure 1B Ultrasound of right lateral pectoral major at area of tenderness. H-hematoma.

Figure 1A Frontal view of Patient 1

Figure 1C Unaffected left pectoral showing normal muscle tissue.

to palpation at the lateral pectoralis major muscle and was unable to forwardly flex his humerus against gravity with his shoulder abducted in external rotation. A bedside ultrasound (Figure 2A, B) identified a large hematoma. We placed the patient in a sling and provided analgesia. A subsequent MRI identified a complete disruption of his pectoralis major at the musculo-tendinous insertion (Figure 2C). The patient was evacuated from the theater for surgical evaluation.

Figure 2B Ultrasound image of hematoma (H).

Figure 2C Corresponding MRI showing complete tear at musculo-tendinous junction (arrow). D-deltoid CBcoracobrachialis HM-humerus PM-pectoralis major.

Discussion The pectoralis major is a large sheet like muscle, which has its origins in two heads (the clavicular and sternal heads), which insert on the lateral aspect of the bicepital groove of the humerus. The fibers from the sternal head twist 180 degrees so that fibers that are superior at the origin insert inferiorly and vice-versa (Figure 3). It is supplied by the medial and lateral pectoral nerves and by the pectoral branch of the thoracoacromial artery. It Figure 2A Linear ultrasound probe scanning near insertion of pectoral major at area of tenderness.

is primarily responsible for movement of the shoulder joint, responsible for adduction, internal rotation, and forward flexion of the humerus. Complete pectoral muscle rupture is a relatively rare condition, with fewer than 200 cases reported in the literature to date, most occurring in the past 30 years.1 As can be expected, it is most commonly seen among athletes, though there are case reports from a variety of populations including elderly nursing home residents.2 Tears among athletes occur almost exclusively in men. While a variety of activities cause rupture of the pectoralis major, the most frequent is weight lifting, especially the bench press. Pectoral muscle injury is typically described by extent of the tear as a percentage of the total muscle size and location. A commonly recognized muscle tear classification system breaks tears down into Grades 1, 2, or 3. Grade 1 is defined as less than 5% of the muscle involved; Grade 2,

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

Figure 3 Normal pectoralis major muscle showing the clavicular, sternal, and abdominal heads forming the tendon, astericks, inserting into the humerus.

as a partial tear of the muscle with >â&#x20AC;&#x2030;5% involvement; and Grade 3 as a complete tear of the muscle head.3 Another classification system is the Tietjen system. In this system, sprains and contusions are type I injuries, partial tears are type II, and complete tears are type III. Type III injuries are then further divided according to location into muscle origin ruptures (IIIA), belly ruptures (IIIB), musculo-tendinous junction ruptures (IIIC), muscle/tendon avulsions (IIID), bony avulsion from the insertion (IIIE), and muscle/tendon substance ruptures (IIIF).5 Type III injuries are most common, representing 91% of reported injuries, with type IIID the most common subtype with 65% of all injuries.4 This apparent predominance of severe injuries may be confounded by publication bias given the small number of cases reported. The mechanism involved in pectoral muscle rupture is typically either direct trauma, such as breaking a fall, or indirect trauma, such as from extreme muscle tension while the arm is in abduction and external rotation.4 In the case of injuries during the bench press, the injury occurs while the weight is lowered to the chest. They are usually a result of uncoordinated motions due to muscle fatigue, which result in excessive muscle loading against an eccentric contraction (i.e. while the weight is being lowered). The mechanism is particularly important in evaluating these injuries because it is linked to location of the rupture within the muscle. Direct traumatic mechanisms typically lead to rupture within the pectoral muscle belly, while indirect trauma is associated with avulsion of the humeral insertion.6 Patients typically present with specific recollection of an event causing the injury. They may or may not report

hearing/feeling a popping or snapping sound or a tearing sensation in the axilla associated with immediate pain. On exam, patients will typically have significant weakness to flexion, adduction, and internal rotation of the arm. Acutely, swelling and ecchymosis overlying the injury will severely limit the ability to detect muscular defects. Once this resolves, the patient will demonstrate an asymmetric contour of the anterior axillary fold, often with a palpable defect. An abnormal bulge to the anterior chest wall may also be seen, indicating medial retraction of the pectoralis.1 Historically, the diagnosis of pectoral muscle rupture was entirely clinical. Clinical distinction between a partial and complete tear can be difficult as other muscles such as the deltoid and coracobrachialis function to flex and abduct the humerus. Additionally, an injury to the biceps or supraspinatus muscles or tendons must be considered in the differential diagnosis of a pectoralis major muscle tear. Tenderness to palpation of the biceps muscle or tendon or weakness with flexion of elbow suggests biceps abnormality while tenderness of the supraspinatus muscle or tendon near its insertion at the greater tubercle of the humerus is suggestive of supraspinatus (rotator cuff) abnormality. The authors recommend palpation of each muscle and tendinous insertion to exclude these differentials and recommend sonographic examination if abnormality is suspected. A palpable defect and lack of firing of the pectoralis major muscle on contraction are suggestive of injury and necessitate imaging. The provider can rule out a pectoralis major muscle tear by a normal physical examination and lack of hematoma on ultrasound.

Imaging Plain radiographs are of limited utility except in cases involving bony avulsion at the muscle or tendinous insertion. Computed tomography (CT) has been similarly limited in detecting these injuries. At present, the imaging study of choice, although not readily available in austere environments, is MRI.1,4-6 MRI reliably identifies the presence and location of injuries, as shown in a study of fifteen patients whose injuries were later confirmed surgically.7 Use of ultrasound to diagnose pectoral muscle rupture was first described among the elderly.2 As shown in the cases reported here, sonography of the area of suspected rupture will demonstrate a hematoma, which is depicted as a hypoechoic (darker than the surrounding tissues) area that disrupts the normal pattern of muscle fibers. A hematoma is suggestive of a torn muscle. A large hematoma, combined with a palpable deficit and significant muscular weakness is concerning for a complete disruption. Given the availability of ultrasound and its ability to both diagnose and localize the injury, it is considered a very useful adjunct in the early diagnosis of pectoral muscle rupture.5 It has not yet replaced MRI as the definitive imaging study in this injury. Optimal

Case Series of Pectoralis Major Muscle Tears in Joint Special Operations Task Force-Philippines Soldiers

sonographic images are obtained by utilizing a linear, high megahertz transducer. The authors recommend starting the scan along a normal portion of the muscle and scan toward the area of tenderness or palpable deficit. One may scan the unaffected side for comparison. As most pectoralis major tears occur at the lateral musculo-tendinous junction, careful attention is necessary to identify and distinguish the adjacent deltoid and coracobrachialis muscles and humerus (Figure 2B, C). An important item in the differential diagnosis of pectoral muscle rupture is biceps rupture. Both injuries can have similar causes and presentations but can be easily distinguished with physical examination and sonography. Also of note in the differential diagnosis is congenital absence of the pectoral muscle. The pectoralis major is the most commonly absent muscle and while this absence is frequently associated with other characteristic anatomic changes including webbing of the fingers on the same side of the absent pectoralis major (Poland’s syndrome), there is at least one reported case of a Soldier who was able to complete routine military tasks, albeit with some difficulty, despite absence of the pectoralis major.8

Treatment Two broad treatment approaches exist for pectoralis major muscle tears – conservative and surgical. Surgical management can then be further subdivided into early (within weeks) and late (months later). Given the relative rarity of the condition in the reported literature, studies comparing these options are generally small, leading to an overall poor quality of evidence and difficulty in determining the optimal approach to care. This is further exacerbated by the disparate nature of the groups where pectoral ruptures have been reported (young athletes and elderly nursing home residents). Current expert opinion favors early surgical management for highly active patients with physically demanding vocational and avocational needs such as Special Operations, with conservative management reserved for more sedentary and elderly patients. This is supported by several small studies and case series showing improved outcomes with surgical management, especially early surgery, but further research is needed.5, 9-11 The authors recommend orthopedic surgeon evaluation within two weeks of injury of any patient with suspected Grade 2 (partial tear of the muscle with > 5% involvement) and Grade 3 tears (complete tear of the muscle head) as it is difficult to distinguish between a large Grade 2 and Grade 3 disruptions.

Case Resolution Case 1 Upon return to home duty station the patient underwent a repeat MRI that identified a partial pectoralis major

muscle tear at the musculo-tendinous junction. Orthopedic surgery evaluated the patient and concluded he was not a surgical candidate. The patient was kept in a sling for two weeks and started rehabilitation immediately upon redeployment. Case 2 Upon return to home station the patient underwent surgical repair for his complete musculo-tendinous tear and at eight weeks postoperatively was improving steadily.

Conclusion Pectoralis major muscle tears are an uncommon injury in the general population, but can be expected among Special Operations Soldiers. Tears most often occur along the musculo-tendinous insertion near the insertion into the humerus. Point of care ultrasound can reliably identify a hematoma indicative of a muscle tear and distinguish the extent of the muscle disruption, although MRI is the definitive diagnostic modality. The limited literature supports early surgical repair of active young adults with complete or high grade musculo-tendinous disruptions. In a deployed environment, a thorough physical examination and point-of-care ultrasound can assist in determining who needs further imaging and consultation with orthopedic surgery.

References 1. Hasegawa, K, Schofer, J. (2010) Rupture of the pectoralis major: a case report and review. Journal of Emergency Medicine; 38(2) (Feb):196–200. 2. Beloosesky, Y, Grimblat, J, et al. (2003). Pectoralis major rupture in the elderly: clinical and sonographic findings. Clinical Imaging; 27(4) (Jul-Aug):261–4. 3. Rehman, A, Robinson, P. (2005). Sonographic Evaluation of Injuries to the Pectoralis Muscles. American Journal of Radiology; 184:1205–1210. 4. Provencher, M, Handfield, K, et al. (2010). Injuries to the pectoralis major muscle: diagnosis and management. The American Journal of Sports Medicine; 38:1693–1707. 5. Kakwani, R, Matthews, J, et al. (2007). Rupture of the pectoralis major muscle: surgical treatment in athletes. International Orthopaedics; 31:159–163. 6. Petilon, J, Carr, D, et al. (2005). Pectoralis major muscle injuries: evaluation and management. Journal of the American Academy of Orthopedic Surgery; 13(1) (Jan-Feb): 59–68. 7. Connell, D, Potter, H, et al. (1999) Injuries of the pectoralis major muscle: Evaluation with MR Imaging. Radiology; 210:785–791. 8. Hee Lee, Y, Chun, S. (1991). Congenital absence of pectoralis major: a case report and isokinetic analysis of shoulder motion. Yonsei Medical Journal; 32(1):87–90. 9. Hanna, C, Glenny, A, et al. (2001). Pectoralis major tears: comparison of surgical and conservative treatment. British Journal of Sports Medicine; 35:202–206.

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10. Quinlan, J, Molloy, M, et al. (2002). Pectoralis major tendon ruptures: when to operate. British Journal of Sports Medicine; 36:226–228. 11. Wang, Y, Jeng, C, et al. (2006). Pectoralis major muscle tear diagnosed with magnetic resonance imaging and ultrasound – a case report. Tzu Chi Medical Journal; 17(6): 441–444.

CPT Kevin Maskell is an emergency medicine resident at Madigan Army Medical Center. SFC James Pink is a senior medical sergeant from 1st Special Forces Group (Airborne) and was the previous NCOIC of the medical clinic at JSOTF-P.

LTC Vincent Ball is an emergency medicine physician at Madigan Army Medical Center, who formerly was the command surgeon of JSOT-P and a former 18A detachment commander. MAJ(P) Ball is the Corresponding author. Email: docball40@gmail.com. Phone: 253-6516470. Mailing Address: Department of Emergency Medicine, Madigan Army Medical Center, 9040 Jackson Avenue, Fort Lewis, Tacoma, WA 98431.

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Case Series of Pectoralis Major Muscle Tears in Joint Special Operations Task Force-Philippines Soldiers

Global Health Language and Culture Competency Charles Beadling, MD*; John Maza, DO**; Gregg Nakano, MALD*; Maysaa Mahmood, PhD*; Shakir Jawad, MD*; Ali-Al-Ameri, MD*; Scott Zuerlein, PhD*; Warner Anderson, MD***

ABSTRACT This article presents findings from a survey conducted to examine the availability of foreign language and culture training to Civil Affairs health personnel and the relevance of that training to the tasks they perform. Civil Affairs forces recognize the value of cross-cultural communication competence because their missions involve a significant level of interaction with foreign governments’ officials, military, and civilians. Members of the 95th Civil Affairs Brigade (Airborne) who had a health-related military occupational specialty code were invited to participate in the survey. More than 45% of those surveyed were foreign language qualified. Many also received predeployment language and culture training specific to the area of deployment. Significantly more respondents reported receiving cultural training and training on how to work effectively with interpreters than having received foreign language training. Respondents perceived interpreters as important assets and were generally satisfied with their performance. Findings from the survey highlight a need to identify standard requirements for predeployment language training that focuses on medical and health terminology and to determine the best delivery platform(s). Civil Affairs health personnel would benefit from additional cultural training that focuses on health and healthcare in the country or region of deployment. Investing in the development of distance learning capabilities as a platform for delivering health-specific language and culture training may help ease the time and resources constraints that limit the ability of Civil Affairs health personnel to access the training they need.

Introduction Civil Affairs personnel are uniquely positioned to respond to the challenges of today’s security environment.1,2 As

the lead for Department of Defense (DoD) efforts at preemptive engagement and post-conflict stabilization, Civil Affairs units have the ability to create direct, immediate, and tangible benefits in many countries and regions around the world.3,4 They build schools, roads, and clinics, dig wells, and provide basic healthcare services to indigenous populations in remote and underserved areas. Because of their unique capabilities, Civil Affairs activities play a critical role in preventing conflict, promoting regional stability, and strengthening perceptions of the United States in the eyes of the world.4 The primary goal of most Civil Affairs engagements is to develop and maintain influence in regions that are important to the national interests of the United States.3 Because the nature of their engagement involves a significant level of interaction with foreign governments’ officials, militaries, and civilians, Civil Affairs organizations recognize the importance of cross-cultural communication competence.5 Civil Affairs personnel are required and expected to have the knowledge and ability to communicate effectively with target audiences in foreign environments.6,7 Cross-cultural communication has not been a priority for the military health community, since traditionally the Military Health System has focused on force health protection and readiness. This is likely to change as emphasis continues to be placed on foreign language and culture training across DoD and more responsibilities are assigned to military health personnel overseas.8,9 The DoD is increasingly deploying health assets to provide assistance to many developing countries by implementing public health interventions that impact people’s lives.9-11 Identifying the competencies for health-specific language and culture preparedness is the first step to address the language and culture training needs within the military health system. This article reports findings from

*Center for Disaster and Humanitarian Assistance Medicine, Uniformed Services University of the Health Sciences, 11300 Rockville Pike, Suite 707, Rockville, MD 20852 **Special Operations Command EUROPE ***International Health Division, Office of the Assistant Secretary of Defense (Health Affairs), Force Health Protection and Readiness, 5113 Leesburg Pike, Suite 800A, Falls Church, VA 22041

a survey of members of the 95th Civil Affairs Brigade (Airborne) that looked at the availability of foreign language and culture training to Civil Affairs health personnel and the relevance of that training to the specific tasks they performed during their most recent deployment.

Methods Members of the 95th Civil Affairs Brigade (Airborne) who have a health-related military occupational specialty code were invited to respond to a web-based questionnaire consisting of 49 items. Eligible members received an invitation letter via e-mail, which provided a brief summary of the study, an estimate of the time it would take to complete the questionnaire, and the URL for the survey website. One week later, a thank you/reminder email message was sent, expressing appreciation to those who completed the questionnaire and reminding those who had not completed the survey that it was available for completion(the reminder e-mail also included the URL for the survey website). After an additional week, a second thank you/reminder e-mail containing the link to the web-based questionnaire was sent. The questionnaire website was closed following a 4-week data collection period. The questionnaire included sociodemographic information including service, rank, sex, military occupational specialty, position, and deployment experience, as well as foreign language qualification, whether or not they received language and culture training prior to their most recent deployment, tasks performed during the most recent deployment, and the perceived utility of the language and culture training. Descriptive statistical analyses for individual questionnaire items were performed. Response data were summarized as frequencies and percentages and we calculated the means and standard deviations where appropriate. Correlation analysis was used to investigate the relationship between pre-deployment language and culture training and task execution ability. The Spearman rank-order correlation was used to calculate the strength of the hypothesized relationship. P-values less than 0.05 were considered significant. This study was approved by the Human Research Protection Program at the Uniformed Services University of the Health Sciences.

Findings The overall response rate for the survey was 93.5% (100 out of 107 responded to the questionnaire). Most of the respondents were Civil Affairs medics and more than 45% were foreign language qualified (Table 1). The most frequently reported languages in which the respondents were trained were Spanish (35.6%), French (13.3%), Arabic (13.3%), and Russian (8.9%). Other reported languages included Bahasa, Pashto, Korean, Hindi, and Punjabi. Proficiency levels varied depending on the language, but were most commonly reported as 0 Global Health Language and Culture Competency

Table 1 Study Participants

Number

Percent

Rank Officer

8.2

Enlisted

91.8

Physician

Public Health

Preventive Medicine

Veterinarian

5.1

Dentist

86.7

Military Occupational Specialty

Civil Affairs Medic

3.1

Speaks Language other than English (Yes)

Other

50.5

Foreign Language Qualified (Yes)

45.9

Have Multicultural Background (Yes)

39.8

or 1. In spite of the emphasis on foreign language training, surveyed Civil Affairs personnel relied heavily on interpreters when performing tasks during their most recent deployment (Figure 1). Interpreters were perceived as important assets; 79% of respondents experienced situations where it was important for them to use an interpreter to communicate with non-English speaking individuals. Of those who used interpreters, 76.4% said they were satisfied with their interpreterâ&#x20AC;&#x2122;s proficiency in the host nation language and were able to work effectively with them; 58.8% said they were satisfied with their interpreterâ&#x20AC;&#x2122;s ability to translate medical terms. Civil Affairs personnel within the brigade can be deployed worldwide, but because of current operational needs, most recent deployments were to the U.S. Central Command area of responsibility (AOR), particularly Iraq and Afghanistan. Prior to their most recent deployment, 20.6% of respondents received foreign language training (specific to the area of deployment), 48.5% received cultural training (specific to the area of deployment), and 50.5% received training on how to work with interpreters. Civil Affairs health personnel deploy as part of a multi-member Civil Affairs Teams (CATs) and use a combination of skills and capabilities to build relationships and establish trust with the local population. Survey respondents experienced situations where they needed to have the skills and capabilities to form partnerships with the local population (82.1%), gain credibility (84.2%), and negotiate (75.8%). They applied their technical skills to build the capacity of the host nation professionals (by serving as mentors (74.7%) and providing training (70.5%) and to provide healthcare

Figure 1 Communication Tools Used During the Most Recent Deployment

services to host nation patients (63.9%). To perform all these tasks effectively, 73.7% of respondents said it was essential for them to understand the culture of the people with whom they worked. Pre-deployment language and culture training appeared to have a favorable effect. Survey respondents who received pre-deployment language training were less likely to experience language difficulties (Figure 2). Perception of training utility was noticeable in the following areas: applying social etiquette, interpreting information observed in a foreign environment, and delivering culturally appropriate patient care (Table 2). Pre-deployment language training correlated positively with the ability to communicate effectively with host nation population and counterparts (Table 3). Stronger correlation patterns were observed between pre-deployment cultural training and training on how to work with interpreters and with

the ability to perform most tasks. Survey respondents indicated that they would have liked additional training in the following areas: local language medical and health terminology (82.4%), how local people understand health problems in a specific country or region (76.5%), how healthcare is provided in a specific country or region (74.1%), and local names of diseases, symptoms, and perceived causes (72.9%).

Discussion Findings from this study clearly illustrate the emphasis the 95th Civil Affairs Brigade (Airborne) places on foreign language and culture training. More than 45% of the 足surveyed Civil Affairs health personnel were qualified (determined using the Defense Language Proficiency Testing (DLPT) in at least one foreign language. Because Civil Affairs personnel do not always deploy to an area where

Figure 2 Effectiveness of Pre-Deployment Training

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

Table 2 Perceived Utility of Pre-Deployment Foreign

Language and Culture Training Agree/ Strongly Agree

Disagree/ Strongly Disagree

P-value

Apply appropriate social etiquette

38.3%

15.9%

< 0.001

Establish credibility with people

38.0%

25.0%

0.048

Deliver culturally appropriate patient care

36.8%

17.9%

0.003

Interpret observation gained through observation

35.5%

20.4%

0.018

Negotiate

32.6%

23.9%

0.172

Gain trust of the people

31.6%

19.0%

0.04

Communicate with host nation population

15.8%

44.2%

< 0.0001

Communicate with host nation counterparts

13.7%

47.4%

< 0.0001

The Training Helped Me:

Table 3 Correlation between Receiving Pre-Deployment

Foreign Language and Culture Training and the Ability to Perform Tasks Received Pre-Deployment Training Foreign Language

Culture

How to Work with Interpreter

Communicate with HN Counterparts

0.354*

0.473*

0.526*

Communicate with HN Population

0.308*

0.382*

0.480*

Apply Appropriate Social Etiquette

0.205

0.427*

0.471*

Interpret Information Gained through Observation

0.306*

0.475*

0.480*

Negotiate

0.220

0.459*

0.520*

Establish Credibility

0.242*

0.445*

0.650*

Gain Trust

0.237*

0.421*

0.496*

Provide Culturally Appropriate Patient Care

0.197

0.294

0.474*

Note: *The measure of association was statistically significant at p < 0.05.

ing on how to work effectively with interpreters than foreign language training. Pre-deployment culture training and training on how to work with interpreters seemed to provide a better return on the investment, as indicated by respondents’ perceptions of the benefits of training they received as well as observed correlation patterns with the ability to perform tasks. Interpreters are an important asset in Civil Affairs missions. Survey respondents were generally satisfied with the performance of their interpreters. One area that could benefit from additional improvement is the interpreter ability to translate medical terminology. There are multiple ways this can be accomplished. Providing additional training in health terminology to interpreters and/or Civil Affairs health personnel is one option. Using mobile translation devices that can accurately and reliably translate key medical terms and phrases is another option. Developing training material for this purpose could benefit from the identification of standard requirements for pre-deployment language training that focuses on medical and health terminology and an assessment of the best delivery platform(s). Survey respondents expressed a need for additional cultural training focused on health and healthcare in the country or region of deployment. Although many receive general cultural training, the expressed need was for additional knowledge that would allow them to effectively navigate health settings in foreign environments. This type of training could be incorporated as an add-on module to the general culture training many already receive prior to deployment. Health-specific culture training could also be offered in conjunction with the ‘technical training’ Civil Affairs health personnel receive to prepare them to perform essential medical stability operations tasks. A few comments were made about the lack of time and resources to receive additional pre-deployment training, even if the training is critically needed. No survey questions addressed the sources of pre-deployment language and culture training, but findings from a separate survey show that online resources are the primary source of pre-deployment language and culture training, particularly for enlisted personnel.12 Leveraging existing patterns of utilization of pre-deployment language and culture training by investing in the development of distance learning capabilities may help ease some these constraints and broaden access to the required training.

Conclusion the language in which they are trained is spoken, pre- deployment training may be offered to prepare them for deployment. Based on the survey findings, members of the 95th Civil Affairs Brigade (Airborne) were more likely to receive pre-deployment cultural training and/or trainGlobal Health Language and Culture Competency

The 95th Civil Affairs Brigade (Airborne) philosophy is to train soldiers to a higher proficiency in fewer languages.13 Findings from this survey show less emphasis on pre-deployment foreign language training compared to investment in long-term training that focuses on a

core set of essential languages. Findings also show that Civil Affairs personnel use interpreters to bridge the communication gap and are generally satisfied with their performance. There is room for improvement when it comes to translating medical or health terminology. Civil Affairs health personnel and their interpreters would benefit from additional training focused on medical and health terminology. Although approximately half of the respondents received general cultural training prior to their most recent deployment, many said they would like additional training focused on health and healthcare in the country or region of deployment. Those providing such training should take into consideration the fact that pre-deployment training is constrained by limitations on available time and resources. Investing in the development of distance learning capabilities to deliver health-specific language and culture training may help transcend these constraints and broaden access to training platforms. References 1. Ridge, E. (2009). U.S. Civil Affairs Literature Review. Washington DC: Center for Startegic and International Studies (CSIS), 2009. Retrieved May 2, 2012 from the Center for strategic and International Studies website. Website: (http://csis.org/files/media/csis/pubs/090129_civil_affairs_ literature_review.pdf). 2. Holshek, C. (2006). The Scroll and the Sword: Synergizing Civil-Military Power. Carlisle Barracks, Pennsylvania: U.S. Army War College, 2006. Retrieved May 2, 2012 from the Defense Technical Information center (DTIC) website. Website: (http://www.dtic.mil/cgi-bin/GetTRDoc?AD =ada449439). 3. Grimes, G. (2009). Civil Affairs: Gathering the Reins. Small Wars Journal, 2009. Retrieved May 2, 2012 from the Small Wars Journal website. Website: (http://smallwars journal.com/jrnl/art/civil-affairs-gathering-the-reins). 4. Holmes, A. (1997). Civil Affairs Reflections of the Future. Issues of Democracy; 2 (3) (July): 6–10. 5. U.S. Department of Defense (2008). Civil-Military Operations. Joint Publication 3-57. Washington, DC: Joint Chiefs of Staff, 2008. Retrieved May 2, 2012 from the Defense Technical Information Center (DTIC) website. Website: (http://www.dtic.mil/doctrine/new_pubs/jp3_57.pdf). 6. U.S. Department of the Army (2007). Civil Affairs Tactics, Techniques, and Procedures. Field Manual 3-05.401. Washington, DC: U.S. Department of the Army, 2007. Retrieved May 2, 2012 from the Official Department of the Army Publications and Forms website. Website: (http:// armypubs.army.mil/doctrine/Active_FM.html). 7. McDonnell, G. (2009). Civil Affairs – Vanguard for the Emerging Army Reserve Profession. Carlisle Barracks, Pennsylvania: U.S. Army War College, 2009. Retrieved May 2, 2012 from the Defense Technical Information center (DTIC) website. Website: (http://www.dtic.mil/cgi-bin/ GetTRDoc?AD=ADA498761). 8. Department of Defense (2011). Language Skills, Regional Expertise, and Cultural Capabilities in the Department of

Defense (DoD). Washington, DC: Secretary of Defense Memorandum, 2011. 9. U.S. Department of Defense (2010). Department of Defense Instruction 6000.16: Military Health Support to Stability Operations, 2010. Retrieved May 2, 2012 from the Defense Technical Information center (DTIC) website. Website: (http://www.dtic.mil/whs/directives/corres/ pdf/600016p.pdf). 10. Bonventre, E., Hicks, K., Okutani, S (2009). U.S. National Security and Global Health. An Analysis of Global Health Engagement by the U.S. Department of Defense. Washington, DC: Center for Strategic and International Studies (CSIS), 2009. Retrieved May 2, 2012 from the Center for strategic and International Studies website. Website: (http://csis.org/files/publication/090421_Bonventre_US NationalSecurity_Rev.pdf). 11. National Intelligence Council (2008). Strategic Implications of Global Health. Washington, DC: Intelligence Community Assesment (ICA) 2008-10D, 2008. Retrieved May 2, 2012 from the Office of the Director of National Intelligence (ODNI) website: (http://www.dni.gov/nic/PDF _GIF_otherprod/ICA_Global_Health_2008.pdf). 12. Beadling C, Jawad S, Mahmood M, et al. (2012). Foreign Language and Cross-Cultural Competency Questionnaire-Provincial Reconstruction Teams. The Center for Disaster and Humanitarian Assistance Medicine, Bethesda, MD (Unpublished Technical Report). 13. Maza J. (March 2012). 95th Civil Affairs Brigade (Airborne) – Command Information Brief. Presented at the Language and Cross-Cultural Competency in Medical Stability Operations Stakeholder Conference, Arlington, VA (Personal Communication).

Charles W. Beadling, MD is currently the Director, Center for Disaster and Humanitarian Assistance Medicine (CDHAM), in the Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences. The CDHAM serves as a focal point of expertise for the Department of Defense in the evolving missions of Global Health Engagements. Primary mission areas include developing education and training programs for U.S. military medics and Partner Nation personnel, scholarly work in the areas of global health and support to and DoD agencies and the Combatant Commands. Dr. Beadling was commissioned in the Air Force in 1975 after completing his Bachelor of Science degree in Life Sciences at the USAF Academy. He attended Undergraduate Navigator Training at Mather Air Force Base, California, and served as squadron navigator until 1980. That year, he entered medical school at the Uniformed Services University of Health Sciences in Bethesda, MD. Upon graduating from medical school in 1984, Dr. Beadling began a residency in Family Practice at David Grant Medical Center, Travis AFB, CA. He had numerous operational, academic, leadership, and command assignments until his retirement from the AF, as a Colonel, effective 1 March 2009. Dr. Beadling has held an academic appointment as Assistant Professor of Military

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

and Emergency Medicine, Uniformed Services University of the Health Sciences, since 1993 and is a Fellow of the American Board of Family Medicine. He holds the International Diploma in Humanitarian Assistance from Fordham University, where he has served as faculty. Dr. Beadling also holds the Diploma in the Medical Care of Catastrophes from the Society of the Apothecaries of London, and serves as an Examiner for candidates seeking the Diploma. Warner Anderson, MD, FACP is currently the Director of the International Health Division in the Office of the Assistant Secretary of Defense for Health Affairs. Dr. Anderson is a Special Forces qualified physician and an anthropologist; he is an internal medicine and emergency medicine specialist. A founding editor of Journal of Special Operations Medicine, he has enjoyed a career in Indian Health Service, as well as in the National Guard and Army Reserve. He has two deployments to Iraq, first with Civil Affairs in Operation IRAQI FREEDOM-1 as chief of the national-level public health team, and again as company surgeon to the SF unit responsible for the Iraqi Counterterrorist Force and Iraqi Special Forces. He was associate dean at the Joint Special Operations Medical Training Center from 2002 through 2007, and DCO and plank owner of the Special Warfare Medical Group. He retired as a Colonel and is now a DoD supervisory physician. He has received a Legion of Merit, a Purple Heart Medal, a Bronze Star Medal with V device, and two more Bronze Star Medals, as well as other military and civilian awards. LTC John Maza, DO is currently the Command Surgeon, Special Operations Command-Europe. LTC Maza is a preventive medicine physician and a flight surgeon. He is a member of the American Society of Osteopathic Physicians; American College of Preventive Medicine; and Society of Army Flight Surgeons. LTC Maza was the Command Surgeon for the 95th Civil Affairs Brigade (Airborne) in Fort Bragg, North Carolina. Maysaa Mahmood, PhD is a Research and Evaluation Scientist at the Center for Disaster and Humanitarian Assistance Medicine (CDHAM), and an Assistant Professor of Military and Emergency Medicine at the Uniformed Services University of the Health Science (USUHS). She is currently working with the Defense Medical Language Initiative (DMLI) team to design, develop, and implement needs assessment and program evaluation for the Defense Medical Language and Culture Initiative. Dr. Mahmood studied pharmaceutical economics, outcomes, and policy research at the University of Arizona, College of Pharmacy focusing on evidence-based approaches to enhance health systems’ ability to ensure equitable access to quality and costeffective medicines. Global Health Language and Culture Competency

Gregg Nakano, MALD provided development and outreach coordination services for the Defense Medical Language Initiative (DMLI). Previously, he served with the International Health Division, which authored DoDI 6000.16 “Military Health Support for Stability Operations” as well as USAID Office of Foreign Disaster Assistance where he provided civil-military coordination support in Guatemala, Iran, Iraq, Indonesia, and Philippines. Mr. Nakano initiated the creation of U.S. Agency of International Development (USAID)’s Joint Humanitarian Operations Course (JHOC) and expanded the security portion of USAID’s Iraq pre-deployment training. A former Marine officer, Mr. Nakano participated in Operations Desert Shield, Desert Storm and Special Purpose Joint Task Force Los Angeles. He has studied Mandarin and Farsi at Fudan University and University of Tehran’s ICPS respectively. Scott Zuerlein, PhD, MHA, FACHE has been with CDHAM since April 2011 and provides program management and subject matter expertise to programs executed within the Center. Dr. Zuerlein served 22 years as a Medical Service Corps Officer within the U.S. Air Force Medical Service, his active service culminated with an assignment as the Medical Security Cooperation lead within the U.S. Central Command’s Command Surgeons Office. Dr. Zuerlein earned a Bachelor of Science degree in General Business Management from the University of Wyoming, a Masters in Health Services Administration from the Army-Baylor University, and a Doctorate in Health Policy and Management from the University of South Florida’s College of Public Health. Dr Zuerlein offers a range of expertise and experience in the areas of health services administration, health policy, public health, and global health systems engagement and development. Shakir Jawad, MD is a Senior Scientist on International Health and Medical Stability Operations at the Center for Disaster and Humanitarian Assistance Medicine (CDHAM), and Assistant Professor of Military and Emergency Medicine at the Uniformed Services University of the Health Science (USUHS). Prior to joining CDHAM, he served as a senior International health analyst at the International Health Division, Office of the Assistant Secretary of Defense for health affairs. In 2003, Dr. Jawad assumed a number of senior leadership positions at the Iraqi Ministry of Health including Director General (Assistant Secretary) for military medical affairs and Director General (Assistant Secretary) for Operations and Technical Affairs. Before 2003, Dr. Jawad held the rank of Brigadier General and was the Director and Chair of the Orthopedic Surgery Department at Hammad Shihab Teaching Military Hospital (the Iraqi Walter Reed Army Medical center equivalent). Dr. Jawad was born and raised in Baghdad, Iraq and received his medical degree in 1981 from Al-Mustansiryah

University. He earned is Board Certificate in Orthopedic Surgery in 1992. Ali Alameri, MD is a Health Systems Scientist (Middle East) at the Center for Disaster and Humanitarian Assistance Medicine (CDHAM). Dr. Alameri is also an Assistant Professor of Military and Emergency Medicine at the Uniformed Services University of the Health Science (USUHS). He is a regular speaker on Cultural Competency for the Center for Deployment Psychology. Prior to joining CDHAM, he served as a consultant for the International Health Division, Office of the Assistant Secretary

of Defense for Health Affairs working on health system reconstitution and evaluating the role of health in national reconciliation. Before arriving to the United States, Dr. Alameri held the rank of Brigadier General (Sel) and served as the Deputy Surgeon General of the Iraqi Armed Forces. Dr. Alameri is a physician (General Surgeon) and, prior to April 2003, he held the rank of Colonel. He was a Manager of General Surgery Department in an Iraqi army military hospital, and he had the experience of working 24 years in the Iraqi military, civilian, and private health sectors.

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

A Novel Cryotherapy Compression Wrap in the Management of Acute Ankle Sprains: Potential Use for Special Operators on the Battlefield Mark Boland, PT, MPT, OCS; Ivan Mulligan, PT, DSc, SCS; Justin Payette, PT, DPT, SCS; Jennifer Serres, PhD; Reginald O’Hara, PhD; Genny Maupin, MPH

ABSTRACT Objective: Musculoskeletal injuries related to training and operational missions frequently affect military personnel. A common treatment for these injuries is the PRICE (protection, rest, ice, compression, and elevation) method, which is time consuming and impractical in the field. Therefore, the primary objective of this study was to determine the effectiveness of the cryotherapy wrap compared to a traditional treatment in the management of acute ankle sprains. Methods: A randomized controlled clinical trial was conducted in a university research laboratory with 13 subjects (9 males and 4 females) with the following physical characteristics: age (yr) 20.6 ± 2.2, height (cm) 177.0 ± 14.3, weight (kg) 76.6 ± 20.6, and body mass index (kg/m2) 24.1 ± 3.7. Participants were instructed to perform PRICE with a traditional ice pack and compression wrap (control group) or with an Arctic Ease® cryotherapy wrap (test group) for 48 hours following enrollment in the study. The Numeric Pain Scale, Foot and Ankle Ability Measure, and ankle/foot volumetric measurement were performed at initial presentation and 24-hour, 48-hour, and 7-day follow-up intervals. Results: While the comparison of the Numeric Pain Scale scores, Foot and Ankle Ability Measure scores, and volumetric changes between groups revealed no statistically significant differences (p > 0.01), there was an 86% compliance rate for subjects in the cryotherapy wrap group compared to a 17% compliance rate of subjects in the control group. Conclusions: The cryotherapy wraps performed comparably to ice therapy and therefore may be especially applicable to military personnel required to operate in austere and hostile environments where traditional therapies are unrealistic. Although this pilot study did not demonstrate that the cryotherapy wraps produce statistically superior results, trends emerged in the data suggesting that subject compliance rate may be improved by using an alternative form of cryotherapy compression, which could lead to better management of pain, edema, and functional recovery. Future research should include a larger sample size to verify this claim. Keywords: cryotherapy, ankle sprain, ice, edema, compression

Introduction Musculoskeletal injuries resulting from training exercises and combat events are relatively common among military personnel. In fact, these injuries account for a large number of noncombat injuries and result in significant cost to the military through both lost duty time and medical costs. A 2010 study conducted by the Air Force Research Laboratory identified Battlefield Airmen (BA) as one of the primary groups at risk for this type of injury.1 BA are composed of Pararescue Jumpers (PJs), Special Operations Weather Team, Combat Controllers, and Tactical Air Control Party. These individuals are considered to be an elite group of airmen, both physically and mentally, and undergo intense training lasting up to two years. As a result of their intense and high volume physical training regimen, many do not complete the program. Approximately 15% of those who do not complete training are due to medical-related events, which were often diagnosed as musculoskeletal diseases. Of these diseases, a large percent were “sprains and strains of joints and adjacent muscles,” most of which were of the lower extremity.2 For example, additional physical dangers contributing to lower extremity injury rates in Combat Controllers are partially attributed to carrying gear weighing between 140 to 160 pounds to high altitudes (e.g. > 10,000 feet) on uneven and rugged terrain.3 PJs are another elite group of BA who conduct combat rescue missions all over the world. PJs suffer even higher rates of lower extremity injuries partially attributed to their overall mission requirements and additional physical dangers, such as parachuting into unknown drop zones. Additionally, an estimated 60% of PJs are unable to complete their initial training phase due to a lower extremity injury.3 The physically demanding operational missions of BA result in an increased risk of musculoskeletal injuries on the battlefield and during training.3 Following a musculoskeletal injury, cryotherapy is one of the first lines of treatment during the acute or postacute stage. In the acute phase, cryotherapy’s most immediate physiological effects are to decrease tissue

and interarticular temperature resulting in decreased pain, tissue metabolism, muscle spasm, circulation, inflammation, edema, and sensory nerve conduction velocity.4-9 These effects are important initially to decrease the extent of secondary injury caused by the byproducts of these physiological mechanisms that may cause further injury to the immediate surrounding area.9-11 The effects of cryotherapy have been shown to have an enhanced physiological effect when used in conjunction with compression, which further controls excessive fluid accumulation in the interstitium.11-13 The most effective treatment for acute musculoskeletal injury is a combination of treatments including protection, rest, ice, compression, and elevation (PRICE).14 The PRICE treatment has been documented and is generally accepted as the standard treatment for acute musculoskeletal injuries.9,14,15 It is important to begin this treatment as soon as possible and to maintain the treatment through the acute phase of injury to prevent secondary injury to the injured and surrounding tissue.9 During field training exercises and in combat situations, despite the need for continued treatment, compliance is often low due to the constraints associated with these environments (i.e., ice is not always readily available, and circumstances are not always such that the injured limb can be elevated). Despite the widespread use of cryotherapy treatment, there is much disagreement about the most effective treatment parameters including duration, frequency, and compression.16,17 There are several studies that report that intermittent ice and compression yield favorable results over “traditional” ice treatment.12,18,19 Other studies found that long duration low grade cooling may be clinically valuable in improving recovery after traumatic soft tissue injury.10,11 In recent years, new cryotherapy products introduced to the market have attempted to provide a more convenient and efficient product to treat musculoskeletal injuries. To date, little evidence has been provided to assess the effectiveness of these products for clinical use. When evaluating an acute ankle sprain, it is important to establish the severity of the injury. Grading of an ankle sprain ranges from a grade I to grade III, with grade I being the least severe and grade III being most severe. A grade I ankle sprain presents with no structural instability, mild to moderate discomfort, mild ecchymosis, and gradual onset of edema, with full or partial weight bearing on the affected limb. A grade II ankle sprain demonstrates slight to no instability, moderate to intense discomfort, significant ecchymosis, and a sudden onset of edema with difficult or impossible independent weight bearing. Grade III ankle sprains display gross instability, severe pain, severe and dispersed ecchymosis, and a sudden onset of edema that is difficult to control, while displaying the inability to bear weight on the ankle.20,21 If the patient is unable to bear weight, it is important to

rule out fracture. The Ottawa Ankle Rules are a screening tool that have been shown to be a highly sensitive test in ruling out ankle fracture.22 The product of interest in this study is a self-adhering cryotherapy compression wrap that provides a long duration low grade cooling to the site of injury. It is a Food and Drug Administration approved physical medicine therapeutic class 1 device approved for use as a reusable hot or cold pack (regulation number 890.5700), a disposable hot or cold pack (regulation number 890.5710), and an elastic bandage (regulation number 880.5075).23 This product was chosen for this study because it provides both cryotherapy and compression to the injury site. The product is worn by the patient for 2 to 4 hours at a time, at which point the used wrap is rehydrated and a new wrap is applied. The proposed benefit of the cryotherapy compression wrap is that it provides cooling and compression to the injury site while providing the opportunity for increased patient compliance. The primary objective of this study was to compare the effectiveness of the Arctic Ease® cryotherapy wrap (Arctic Ease, Phoenixville, PA) to traditional treatment in the management of acute ankle sprains. The hypothesis is that the cryotherapy compression wrap will demonstrate a significant decrease in edema and pain and an increase in functional mobility when compared to a traditional ice and compression regimen following an ankle sprain.

Methods Participants Fourteen subjects volunteered to participate in the study. One subject fit the criteria for the Ottawa Ankle Rules24 and was referred for radiographic testing and found to have a fracture. Therefore, 13 subjects [9 male and 4 female, age (yr) 20.6 ± 2.2, height (cm) 177.0 ± 14.3, weight (kg) 76.6 ± 20.6, and body mass index (BMI) kg/ m2 24.1 ± 3.7] were included in our study. These physical characteristics are similar to a Combat Controller trainee population, which has typical physical characteristics to include mean age (yr) 28.9 ± 5.7, height (cm) 179.2 ± 6.2, weight (kg) 84.6 ± 10.3, and BMI (kg/m2) 26.3 ± 2.8.25 Nonetheless, the psychological characteristics of the population subset used in this study may not be representative of a Combat Controller trainee, and this is a heterogeneous sample. The inclusion criteria included subjects between 18–26 years of age who had suffered an acute (grade II–III) ankle sprain within 48 hours of enrollment in the study. Subjects were excluded if any of the following criteria were met: history of a previous ankle sprain in the last 6 months, Raynaud’s disease or other form of cold sensitivity, age outside of the 18- to 26-year-old range, history of ankle or foot

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

surgery on the involved lower extremity, or a positive finding on clinical exam on the Ottawa Ankle Rules or with a confirmed fracture via radiograph. Prior to participation, the subjects were required to review and sign the informed consent form that was approved by the Saint Francis University Institutional Review Board. Next, subjects completed a demographic and injury history questionnaire and a self-reported activities questionnaire (Foot and Ankle Ability Measure, FAAM). The demographic questionnaire provided information about the subject’s past medical history, injury history, and current status. The FAAM is an evaluative instrument that assesses physical function of individuals with musculoskeletal disorders of the leg, foot, and ankle.26 Patients were also asked to report their pain on the numeric pain scale. This scale requires patients to rate their perceived pain on a scale of 0–10 with 10 being the most severe.27 For each test session, subjects underwent a standard clinical examination including volumetric assessment, which was performed to determine ankle volume. Volume was determined by measuring the amount of water displaced by the ankle using a volumetric measuring tank. Subjects were then randomly assigned to the wrap or control group. The control group was instructed to follow a traditional program to self-manage the ankle sprain for the next 48 hours according to the PRICE protocol. They were issued a 4-inch compression bandage to wear for 48 hours and instructed in appropriate application of the device using a figure eight wrapping technique. They were instructed to elevate the involved lower extremity above the heart as often as possible and to apply a traditional ice pack to the injured ankle for up to 20 minutes every 2 to 3 hours. The wrap group was instructed to follow the same instructions, with a cryotherapy compression wrap being substituted for the ice and compression bandage in the treatment protocol. Subjects in this group were instructed to utilize the cryotherapy compression wrap for 2 to 4 hours before removing the wrap to rehydrate the product. During this time, a second cryotherapy compression wrap was applied. Subjects were instructed to continue this treatment for 48 hours. The cryotherapy compression wrap used in this study is the Arctic Ease® Cryotherapy Wrap, which is a compression wrap type device 4 inches in width by 60 inches in length. The product is a polymer-treated wrap that absorbs heat energy, creating a thermodynamic cycle in which heat is removed from tissue, thus causing it to be cooled. It is reusable, odorless, and latex and adhesive free and also allows the user to maintain mobility during use. The product may be applied at either room temperature or precooled. In either application, the manufacturer states

the product provides a low grade cooling effect at approximately 20.1–22.8° C.28 Both groups were asked to complete a journal outlining their compliance to the prescribed treatment during the first 48 hours. Subjects in both groups were reevaluated at the 24-hour, 48-hour, and 7-day mark after the initial assessment. Data were then analyzed to compare the effectiveness of the cryotherapy compression wrap to the PRICE method. Response variables for this study include the Numeric Pain Scale, volumetric measurements, FAAM score, and compliance. Numeric Pain Scale Subjects completed the Numeric Pain Scale during the initial assessment and at each follow-up session described previously. Subjects were asked to choose a number on a scale from 0 (no pain) to 10 (severe pain) that corresponded to their current pain level.27 Volumetric Measurements At each testing interval, ankle volume was determined by measuring the amount of water displaced by the ankle in a volumetric measuring tank. The reliability of this method of volumetric measurement has been demonstrated in previous literature.29,30 The procedure for using this device was operationally defined and understood by all investigators prior to data collection. The subjects were instructed to slowly lower their ankle into the tank from a seated position (hips flexed to 90°, knees flexed to 90°, ankles at neutral) until the foot was resting flat on the bottom of the tank and the shaft of the tibia was in a vertical position. Water displaced was collected and measured using a graduated cylinder in milliliters. The water temperature was between 20.0° C and 22.2° C. Foot and Ankle Ability Measure The functional ability of subjects was assessed at each testing interval using the FAAM Activities of Daily Living (ADL) subscale. This outcome measure has demonstrated good reliability and validity and has been shown to be more responsive to changes in functional status than other instruments.26 The assessment requires subjects to rate their functional abilities in 21 different ADLs on a scale ranging from 4 to 0, with 4 being “no difficulty” and 0 being “unable to do.” Responses marked as not applicable are not counted in the total score. The number of items with a response was multiplied by 4 to obtain the maximum potential score. The total score is then divided by the maximum potential score and multiplied by 100 to determine the FAAM ADL subscale score. Statistical Analysis Statistical analyses were performed using Minitab® 16.1.1 software (Minitab Inc., State College, PA). Descriptive statistics include mean and standard deviation. Independent

A Novel Cryotherapy Compression Wrap in the Management of Acute Ankle Sprains

t-tests were used to compare mean scores between the wrap and control groups to determine if statistically significant differences existed.

demonstrated compliance to the prescribed treatment, while 17% (1/6) demonstrated compliance in the control group.

Results

Discussion

The control and wrap groups’ demographics are presented in Table 1. There were no significant differences noted in any of the demographics between groups.

This study examined the effectiveness of a novel cryotherapy treatment on pain, edema, and self-reported functional activities. Both the control group and the cryotherapy compression wrap group demonstrated a similar decrease in pain. The minimum detectable difference that indicates a meaningful difference in Numeric Pain Score has been identified as 1.39.27 Both groups demonstrated over a three-point change after 7 days, suggesting that either treatment was effective in decreasing subjective reports of pain.

The mean differences of the measurements taken at each testing interval are noted in Table 2. When comparing the control group to the cryotherapy wrap group, there were no statistically significant differences when examining FAAM scores, volume changes, or Numeric Pain Scores. Finally, the groups’ mean measurements for each response variable (Numeric Pain Score, FAAM, volume reduction) are presented in Figures 1–3, respectively.

This study also examined functional improvement using the FAAM outcome measure. This measure has been demonstrated as reliable and valid in physical therapy literature.26 The minimal detectable difference indicating a clinically significant improvement is eight points or greater. As shown in Table 2, both groups demonstrated a change in the FAAM score that exceeded the

Patient compliance to the prescribed treatment assessed by a compliance journal completed by the subjects varied greatly between groups. In the wrap group, 86% (6/7) Table 1 Subject Demographics

Control Group (n=6) Demographic

Mean

Age (yr)

21.17

Experimental Group (n=7)

Standard Deviation

Mean

1.60

20.14

2.67

p-value

95% Confidence Interval

0.417

(–1.70, 3.75)

Height (cm)

180.34

16.62

174.17

12.52

0.475

(–12.54, 24.88)

Weight (kg)

84.40

25.90

70.20

13.60

0.266

(–13.60, 42.0)

BMI (kg/m )

25.39

4.75

22.93

2.39

0.288

(–2.60, 7.52)

Table 2 Mean Difference in Outcome Measures Between Testing Interval and Baseline – Comparison of Control Group vs. Wrap Group

Control Group Outcome Measure

Mean Difference

Cryotherapy Compression Wrap Group

Standard Deviation

Mean Difference

Standard Deviation

p-value

95% Confidence Interval

Change of pain 24 hours

2.17

1.47

2.14

1.07

0.974

(–1.61,1.66)

Change of pain 48 hours

3.00

1.67

2.00

2.12

0.421

(–1.76, 3.76)

3.50

1.87

3.67

2.07

0.886

(–2.74, 2.41)

Change of FAAM score 24 hours (%)

Change of pain 7 days

10.33

6.53

10.00

8.52

0.938

(–8.99, 9.65)

Change of FAAM Score 48 hours (%)

20.30

15.80

13.60

9.10

0.403

(–10.87, 24.34)

Change of FAAM score 7 days (%)

29.30

14.30

23.33

9.99

0.423

(–10.38, 22.39)

Change of volume 24 hours (mL)

68.36

89.70

82.20

140.0

0.834

(–157.0, 129.4)

Change of Volume 48 hours (mL)

–79.64

241.0

16.71

53.60

0.407

(–353.0, 169.0)

Change of Volume 7 days (mL)

–61.85

256.0

58.30

52.80

0.311

(–395.0, 154.0)

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

Figure 1 The mean Numeric Pain Scores at each testing

interval

Figure 2 The mean FAAM scores at each testing interval

Figure 3 The mean volume measurements at each testing

interval

minimal detectable change, suggesting either treatment is effective. Although not statistically significant, the volumetric changes demonstrated a slight downward trend, indicating the cryotherapy compression wrap group had a greater decrease in edema as compared to the control group (Figure 3). The control group demonstrated an increase in edema 48 hours and 7 days after the injury. These results may suggest that the cryotherapy/compression wrap may be more effective for controlling edema. Alternatively, these results may be related to a decrease

in subject compliance among the subjects in this group. In this study, only 17% of the subjects in the control group were compliant with the prescribed treatment, while the cryotherapy wrap group demonstrated 86% compliance. These findings suggest that compliance may be improved by using an alternative cryotherapy/compression product, which may create potential for improved clinical outcomes. Given these findings, it may be suggested that the Arctic EaseÂŽ product would be an effective alternative to the standard PRICE protocol in the management of pain, edema, and functional recovery following ankle sprains. More importantly, the cryotherapy compression wrap could be used in the field because it does not require ice and the wrapâ&#x20AC;&#x2122;s cooling effect can be reactivated by rerolling it and then placing it inside a zip-lock bag with 2 teaspoons of water. Due to the wrapâ&#x20AC;&#x2122;s lightweight features and its advanced reactivation cooling technology, it could be considered as an alternative form of cryotherapy for Battlefield Airmen during training and in the battlefield. Nonetheless, this novel form of cryotherapy has not been tested in the field on this population but may be worth examining in the future. The limitations of this study included a small sample, which limits the generalization of the results to a similar population. Further research with a larger sample size and other populations would be needed to determine if the trends noted in this study are reproducible. It would also be beneficial to compare this method of treatment to other accepted methods including continuous cold water therapy and intermittent compression to fully examine its efficacy. Additionally, all subjects in this study did not complete the journal indicating how they used the interventions described in the wrap and control group. For this study, this group of investigators only examined collegiate-aged subjects. Therefore, it is unknown if these results would be reproduced in other subject populations. When treating these injuries, the clinician may surmise that as function improves swelling would decrease. This was not seen in our study. Although edema improved in the wrap group and increased in the control group, both groups demonstrated a notable change in function, as reported on the FAAM. This is consistent with other research examining the relationship between edema and functional activity level. Man et al. reported there was no relationship between ankle-foot swelling and selfassessed ankle function.31 Researchers have demonstrated that combining cryotherapy and compression provides better results than cryotherapy alone.12 Additionally, research conducted by Merrick et al. suggested that continuous cryotherapy

A Novel Cryotherapy Compression Wrap in the Management of Acute Ankle Sprains

may reduce the magnitude of secondary tissue injury.11 The product tested in this study provides both continuous cryotherapy and compression, which may explain why the wrap group demonstrated a greater decrease in swelling as compared to the PRICE protocol. Traditionally, when an individual sustains a soft tissue injury, specifically an ankle sprain, the initial management includes PRICE. Cryotherapy is usually recommended for 20 minutes every 2 to 3 hours.14 Although this is the most widely accepted method to treat this injury, it is not always practical, especially in an operational environment. Since the cryotherapy wraps do not require refrigeration and are light weight, they offer an ideal treatment option that is feasible for use in the field. Because this product is portable, easy to apply, and seems to provide an effective cryotherapy and compression intervention, it may be a convenient and appropriate product for use in the military domain. It could be easily utilized by injured military members without impacting mission requirements, which sometimes make compliance to prescribed treatment difficult in this population. In particular, military members in similar austere and rigorous conditions may also benefit where immediate medical care is not always possible. References 1. Webb, T.S., Master, E.R., Wells T.S. (2009). Injury and disability identification and reduction, AFRL-RH-WPTR-2010-0020. Wright-Patterson AFB, OH: Air Force Research Laboratory, Human Effectiveness Directorate. 2. Maupin, M. (2012). Analysis of medical events among battlefield airmen trainees, AFRL-SA-WP-SR-2012-0004. Wright-Patterson AFB, OH: U.S. School of Aerospace Medicine, Aeromedical Research Department. 3. Warha, D., Webb, T., Wells, T. (2009). Illness and injury risk and healthcare utilization, United States Air Force battlefield airmen and security forces, 2000–2005. Military Medicine; 174(9):892–898. 4. Kowal, M.A. (1983). Review of physiological effects of cryotherapy. Journal of Orthopaedic and Sports Physical Therapy; 5(2):66–73. 5. Agafly, A.A., George, K.P. (2007). The effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance. British Journal of Sports Medicine; 41:365–369. 6. Lee, H., Natsui, H., Akimoto, T., Yanagi, K., Ohshima, N., Kono, I. (2005). Effects of cryotherapy after contusion using real-time intravital microscopy. Medicine and Science in Sports and Exercise; 37(7):1093–1098. 7. Martin, S.S., Spindler, K.P., Tarter, J.W., Detwiler, K., Petersen, H.A. (2001). Cryotherapy: an effective modality for decreasing intraarticular temperature after knee arthroscopy. American Journal of Sports Medicine; 29(3):288–291. 8. Nadler, S.F., Wiengand, K., Kruse, R.J. (2004). The physiologic basis and clinical applications of cryotherapy and thermotherapy for the pain practitioner. Pain Physician; 7:395–399.

9. Knight, K.L. (1995). Cryotherapy in Sport Injury Management. Champaign, IL: Human Kinetics. 10. Schaser, K.D., Disch, A.C., Stover, J.F., Lauffer, A., Bail, H.J., Mittlmeier, T. (2007). Prolonged superficial local cryotherapy attenuates microcirculatory impairment, regional inflammation, and muscle necrosis after closed soft tissue injury in rats. American Journal of Sports Medicine; 2007;35(1):93–102. 11. Merrick, M.A., Rankin, J.M., Andres, F.A., Hinman, C.L. (1999). A preliminary examination of cryotherapy and secondary injury in skeletal muscle. Medicine and Science in Sports and Exercise; 31(11):1516–1521. 12. Knobloch, K., Grasemann, R., Spies, M., Vogt, P.M. (2008). Midportion Achilles tendon microcirculation after intermittent combined cryotherapy and compression compared with cryotherapy along: a randomized trial. American Journal of Sports Medicine; 36(11):2128–2138. 13. Schröder, D., Pässler, H.H. (1994). Combination of cold and compression after knee surgery: a prospective randomized study. Knee Surgery, Sports Traumatology, Arthroscopy; 2(3):158–165. 14. Wolfe, M.W.,Uhl, T.L., Mattacola, C.G., McCluskey, L.C. (2001). Management of ankle sprains. American Family Physician; 63(1):93–105. 15. Ivins, D. (2006). Acute ankle sprain: an update. American Family Physician; 74(10):1714–1720. 16. MacAuley, D. (2001). Do textbooks agree on their advice on ice? Clinical Journal of Sport Medicine; 11(2):67–72. 17. Bleakley, C., McDonough, S., MacAuley. D. (2004). The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. American Journal of Sports Medicine; 32(1):251–261. 18. Airaksinen, O., Kolari, P., Miettinen, H. (1990). Elastic bandages and intermittent pneumatic compression for treatment of acute ankle sprains. Archives of Physical Medicine and Rehabilitation; 71(6):380–183. 19. Bleakley, C., McDonough, S., MacAuley, D. (2006). Cry otherapy for acute ankle sprains: a randomised controlled study of two different icing protocols. British Journal of Sports Medicine; 40(8):700–705. 20. Wilkerson, G.B., Horn-Kingery, H.M. (1993). Treatment of the inversion ankle sprain: comparison of different modes of compression and cryotherapy. Journal of Orthopaedic and Sports Physical Therapy; 17(5):240–246. 21. Wexler, R.K. (1998). The injured ankle. American Family Physician; 57(3):474–480. 22. Stiell, I.G., McDowell, I., Nair, R.C., Aeta, H., Greenberg, G., McKnight, R.D., Ahuja, J. (1992). Use of radiography in acute ankle injuries: physicians’ attitudes and practice. Canadian Medical Association Journal; 147(11):1671–1678. 23. U.S. Food and Drug Administration. Establishment registration & device listing. www.accessdata.fda.gov. (2012); Retrieved July 23, 2012 from http://www.accessdata.fda .gov/scripts/cdrh/cfdocs/cfrl/rl.cfm. 24. Jenkin, M., Sitler, M.R., Kelly, J.D. (2010). Clinical usefulness of the Ottowa Ankle Rules for detecting fractures of the ankle and midfoot. Journal of Athletic Training; 45(5):480–482. 25. Walker, T.B., Lennemann, L.M., McGregor, J.N., Mauzy, C., Zupan, M.F. (2011). Physiological and pyschological

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

characteristics of sucessful combat controller trainees. Journal of Special Operations Medicine; 11(1):39–47. 26. Martin, R.L. Irrgang, J.J., Burdett, R.G., Conti, S.F., Van Swearingen, J.M. (2005). Evidence of validity for the Foot and Ankle Ability Measure (FAAM). Foot & Ankle International; 26(11):968–983. 27. Kendrick, D.B., Strout, T.D. (2005). The minimum clinically significanct difference in patient-assigned numeric scores for pain. American Journal of Emergency Medicine; 23(7):828–832. 28. Arctic Ease, LLC. (2011). Retrieved July 23, 2012, from http://www.arcticease.com/. Rucinkski, T.J., Hooker, D.N., Prentice, W.E., Shields, E.W., Cote-Murray, D.J. (1991). The effects of intermittent compression on edema in postacute ankle sprains. Journal of Orthopaedic and Sports Physical Therapy; 14(2):65–69. 29. Coté, D.J., Prentice, W.E. Jr., Hooker, D.N., Shields, E.W. (1998). Comparison of three treatment procedures for minimizing ankle sprain swelling. Physical Therapy; 68(7):1072–1076. 30. Man, I.O., Morrissey, M.C. (2005). Relationship between ankle-foot swelling and self-assessed function after ankle sprain. Medicine and Science in Sports and Exercise; 37(3):360–363.

Mark A. Boland, PT, MPT, OCS earned his bachelor’s degree in Health Science in 2001 and master’s degree in Physical Therapy in 2003 from Saint Francis University. He is a Board Certified Clinical Specialist in Orthopedic Physical Therapy. He serves as the Director of Rehabilitation at the DiSepio Center for Rehabilitation and is also the Director of the Orthopaedic Physical Therapy Residency Program at the DiSepio Institute for Rural Health and Wellness at Saint Francis University. He is an adjunct assistant professor in the Department of Physical Therapy at Saint Francis University. Ivan Mulligan, PT, DSc, SCS, ATC, CSCS earned his bachelor’s degree in education from California University of PA in 1993. He earned a master’s degree in physical

therapy at Gannon University in 1995 and completed a doctorate in sports physical therapy at Rocky Mountain University in 2003. He is a Board Certified Clinical Specialist in Sports Physical Therapy. He is the Director of the Sports Physical Therapy Residency Program at the DiSepio Institute for Rural Health and Wellness at Saint Francis University. He is currently serving as the President of the Pennsylvania Physical Therapy Association. Justin Payette PT, DPT, SCS, CSCS received his BS in Biology from Northwestern College, and DPT from Marquette University. He completed his sports residency at St. Francis University, and became board certified as a specialist in sports physical therapy May of 2012. Justin currently works as a Physical Therapist for Ahtletico Physical Therapy in Berwyn Illinois. Jennifer Serres, PhD is a Biomedical Engineer in the Department of Aeromedical Research at the USAF School of Aerospace Medicine in the 711 Human Performance Wing at Wright Patterson AFB, OH. She earned her PhD in Engineering from Wright State University in 2008. She conducts aeromedical research focusing on the optimization of Airmen performance in adverse environments. Genny Maupin, MPH is an Epidemiologist at the USAF School of Aerospace Medicine. Gen serves in a support role for researchers at the School, in both epidemiology and statistics. She has ten years of research experience in immunology, respiratory diseases, injury epidemiology, mental health, and aerospace medicine. Reginald B. O’Hara, PhD is an Research Physiologist in the Department of Aeromedical Research at the USAF School of Aerospace Medicine in the 711 Human Performance Wing at Wright Patterson AFB, OH. He earned his Ph.D. in Exercise Physiology in 2007. He conducts aeromedical research focusing on the optimization of Airmen performance in adverse environments.

A Novel Cryotherapy Compression Wrap in the Management of Acute Ankle Sprains

Biofeedback Self-Regulation Training to Treat Post-Concussion Headache in a Special Operations Support Soldier Craig M. Jenkins, PhD, ABPP

Abstract Biofeedback assisted self-regulation training can be an effective treatment for post-concussion headaches. The following is an example of using biofeedback assisted self-regulation training as an intervention to treat posttrauma headaches in a Special Operations Forces (SOF) support soldier. This Soldier was a 23-year-old male who had suffered a concussion while off duty four months earlier and continued to experience headache. Threemodality biofeedback (temperature, surface electromyogram and skin conduction) was used to help the patient learn to self-regulate and control his headaches. This was accomplished over four visits over two weeks. This was a compressed timeline to allow him to deploy with his unit. This form of treatment can be a viable nonmedication based option for addressing post concussion headaches for deploying Soldiers.

Introduction Post-concussion headache can have characteristics of either tension type headache, migraine type headache, or both.1 Head injuries, specifically minor traumatic brain injury (mTBI) and traumatic brain injury (TBI), have been a significant concern for our troops with the employment of improvised explosive devices on the battlefield. Hoge, McGurk, Thomas, Cox, Engel, and Castro2 reported that in one brigade of the 2,525 Soldiers sampled, nearly 15% reported a head injury during a combat deployment to Iraq. This is consistent with other studies that found the rates of post-concussive headache to be about 15%.3,4 Theeler and Erickson5 reported that 41% of returning Soldiers who presented with headache in specialty care reported they sustained a head injury while deployed. Clearly post-concussion headache is a concern for the U.S. Army. Biofeedback has been a demonstrated effective treatment for migraine as well as tension type headaches.6,7 Chronic tension type headache is effectively addressed through surface electromyogram (sEMG) biofeedback self-regulation.7 Blood-volumepulse and thermal focused biofeedback are more effective

for migraine type headache.6 Therefore sEMG, peripheral temperature, and also skin conduction would be the modalities for biofeedback assisted self-regulation training for this case.

History A 23-year-old single male enlisted (E-4) SOF support Soldier who suffered frequent (nearly daily) headaches after a concussion was referred by his physician to psychiatrically clear him for deployment and to address his headaches. He sustained a head injury during an altercation while off-duty four months earlier. During the event he experienced no loss of consciousness or any amnesia, but he did have mild confusion. He also sustained a fractured nose. He denied alcohol intoxication at the time of the incident. Shortly after the event, a computed tomography (CT) scan revealed blood in the ethmoid sinus and likely the maxillary sinus. He was treated with tramodol and acetaminophen with oxycodone for his head pain with some relief after the initial concussion. He had blurry vision for several days after the event. He demonstrated difficulties with memory and arithmetic calculations 45 days after the event. He reported that he had difficulties expressing himself and indicated that he had always had difficulties with maintaining attention. He had a prior concussion two years earlier during a â&#x20AC;&#x153;hard landingâ&#x20AC;? while conducting an airborne landing. He had headaches for a short time after the parachuting incident as well. He reported that the headaches resolved spontaneously from his earlier concussion but not the most recent one. He had a neuropsychological assessment at two months post-event that revealed residual language, memory, and attention deficits. He was placed on methylphenidate to improve his attention. He was not able to remain on tramadol and be able to deploy. At almost three months post-incident he had improved in all areas of functioning

with the exception of headache. He and his treatment team were largely pleased with the results. He was preparing and eager to deploy to a combat zone. However, he was not able to deploy due to recently being placed on the methylphenidate. The policy for deployment to CENTCOM is that a Soldier is to be stable on that particular medication at that dose for 90 days.8 He had not yet reached the 90-day mark while stable on the methylphenidate. His physician had cleared him for deployment and initiated the process to gain a waiver from requisite medical authorities. At the same time a referral was made to a clinical health psychologist for his attention difficulties and headache and to evaluate for other potential psychiatric problems. The patient’s medical record was reviewed and the patient examined. Most of the postconcussion symptoms were absent save the attention challenges and headaches. This was consistent across all evaluators (e.g., primary care physician, neuropsychologist and the treating clinical health psychologist). He complained of headaches for the four months after the incident. He described his headaches as “feeling like a balloon being overfilled” in the front of his head (frontal) on most days. He typically would rate this as 7 out of 10. He endorsed mild photophobia associated with the headache at times. He reported that over the counter medications did not help his headache. He was offered, and agreed to, biofeedback assisted self-regulation training as a non-pharmacological treatment option. Normally treatment sessions would be weekly. The treat ment was to be condensed in hope that he would receive a waiver to deploy with his unit.

consistent with less parasympathetic response and could have implications for his headache. Furthermore, greater reduction of muscle tension as seen in lower sEMG activation would also be desirable.

Treatment The plan was to use biofeedback-assisted self-regulation training to reduce and or eliminate his headache. The training was to start with a progressive muscle relaxation (PMR) protocol of three sessions. PMR is a relaxation technique where patients tense muscles to acquire awareness of that muscle group and then use that awareness to enhance a relaxation response. The patient tenses and relaxes each muscle group in the body. This would be followed by autogenic relaxation training protocol again for three sessions. Autogenic relaxation is when a patient uses autosuggestion as well as awareness of body sensation to gain a relaxation response. Direct feedback would complete the treatment for about nine sessions. Direct feedback is when the patient uses the biofeedback monitors to change their physical response. All of the modalities employed in the assessment would be continued in the treatment. Table 1 shows the mean and standard deviations for the final two minutes of each training session. The treatment course was condensed to several meetings a week rather than once per week to attempt to gain control of the soldier’s headache while allowing him to deploy with his unit. His first training session was conducted during the same visit as his baseline assessment. Unfortunately the temperature instrumentation failed to work during his initial Table 1 Biofeedback to Address Post Trauma Headache

sEMG mean (SD)*

SC mean (SD)

Temp. mean (SD)

Rest

3.23 (4.20)

6.45 (0.17)

63.1 (0.09)

Relax

2.45 (0.72)

6.52 (0.05)

63.1 (0.02)

Stress

4.67 (0.75)

7.13 (0.19)

63.1 (0.04)

Relax

2.93 (1.24)

6.12 (0.13)

63.1 (0.03)

PMR 1#

1.87 (0.74)

5.34 (0.19)

—

PMR 2

2.72 (0.50)

9.92 (0.57)

92.6 (0.49)

PMR 3

1.96 (0.57)

6.68 (0.08)

88.4 (2.48)

Autogenic Relaxation

2.21 (0.48)

2.17 (0.08)

94.3 (0.14)

Assessment A baseline self-regulation assessment was conducted using multimodal biofeedback instrumentation. This included resting, attempt at relaxation, mild stressor, and then another attempt at relaxation conditions. Measurements included sEMG on bi-frontalis, skin conduction from the first and third fingers on his non-dominate hand (left), and peripheral temperature from the second finger on his non-dominate hand. The values for the assessment can be seen in Table 1 for each modality providing the mean and standard deviation for each one minute condition. The Soldier exhibited a good response. He was able to relax himself during both relaxation periods to a degree as seen in decreases on sEMG, as well as skin conduction. He also exhibited a good response to the mild stressor as seen in increases in activity on both sEMG and skin conduction. However, his peripheral temperature was low (approximately 62° F) with low variability for all conditions. This condition is

Assessment (full 1 min condition)

Treatment (final 2 min of training)

Notes: *Surface electromyogram (sEMG); Skin conduction (SC); and peripheral temperature in Fahrenheit (Temp) # Progressive muscle relaxation (PMR)

Biofeedback Self-Regulation Training to Treat Post-Concussion Headache in a Special Operations Support Soldier

training. This was unfortunate particularly due to the poor response he had had during the assessment in this modality. However, he was able to make improvements on both sEMG, from an average of 4.32 millivolts (mv) to an ending mean of 1.87mv. During the session he had improvement on skin conduction as well, with a reduction from an average of 7.24 micro Siemens (μs) to a mean of 5.34 μs. He was to practice the PMR daily. He reported one headache between his first and second training session three days later. During the second training session he made improvements on peripheral temperature (ending value of 92.6° F). His response on skin conduction was poor with an ending value of 9.92 μs when compared to his first training session. His ending value of 2.72mv for sEMG can be considered a fair response. During his third training session, he had a very good response across all modalities ending with a sEMG of 1.95mv, skin conduction of 6.68μs, and a peripheral temperature of 88.4° F. Interestingly he reported a mild headache during this session which corresponded with a drop in his peripheral temperature to 64.4° F. He was able to resolve his headache and increase his peripheral temperature. In the interval leading to his next visit, he reported experiencing one headache that he was able to resolve using self-regulation techniques (PMR). He was very pleased with the results and confident in his abilities to control his body’s responses. His fourth training session was autogenic relaxation. He performed fairly well on two of three modalities. He achieved ending values of skin conduction of 2.17μs and a peripheral temperature of 94.3° F. However his sEMG (2.21mv) was not as low as optimal or as low as he obtained in the past. He was to return in a few days to continue treatment; however, the waiver was granted allowing him to deploy to Iraq. He continued to be headache free after the four biofeedback training sessions over two weeks. While in Iraq he was monitored by his physician. He denied having problems with headache while deployed or after his return.

Discussion This Soldier was very motivated to be rid of his headaches and so he was likely adherent to his at-home practice. This is probably the most important contribution to the treatment. He exhibited fairly good selfregulation skills as seen in his baseline assessment, which likely contributed to his positive response to the treatment. He developed the skills to better self-regulate more quickly than most people. Typically treatment takes about six weeks to allow enough practice time.

The support that his unit provided him and their eagerness to have him remain a part of the team were also likely important factors providing a reinforcing effect. Similarly, coordination with the Soldier’s physician was another important factor for effective assessment and referral as well as subsequent monitoring. All of these factors combined were important for this Soldier to obtain control over his headaches. He had intense headaches nearly daily prior to treatment and was able to become headache free.

Conclusions While there is a good deal of literature on the treatment of tension as well as migraine headache with biofeedback there has been only very sparse published material on post-traumatic headache and biofeedback and no controlled trials that I could find. Further trials and studies should be conducted on the use of biofeedback for post-traumatic headache. Addressing blast- related post-traumatic headache should be specifically investigated due to the prevalence of this means of injury during combat. Concussion-induced headache can be a vexing problem. This is particularly true for a military population during war. This case study demonstrates the potential of using biofeedback to address post trauma headaches. Although the present case is not blast-related, and this Soldier’s response to training can be seen as quicker than most, the application holds promise for other service members with trauma-induced headache. This is particularly true for SOF Soldiers who are generally highly motivated and may prefer and benefit from non-medication based treatments for headaches so as to be available for world-wide deployment.

References 1. Evans R. Post-traumatic headaches. Neurologic Clinics [serial online]. February 2004; 22(1):237–249. Available from: PsychINFO, Ipswich, M.A. Accessed June 10, 2012. 2. Hoge C., McGurk D., Thomas J., Cox A., Engel C., Castro C. (2008). Mild traumatic brain injury in U.S. Soldiers returning from Iraq. New England Journal of Medicine [serial online]. January 31; 358(5):453–463. Available from: Academic Search Premier, Ipswich, MA. Accessed June 10, 2012. 3. Solomon S. (2005). Chronic post-traumatic neck and head pain. Headache: The Journal of Head And Face Pain [serial online]. January; 45(1):53–67. Available from: PsycINFO, Ipswich, MA. Accessed June 10, 2012. 4. Faux S., Sheedy J. (2008). A prospective study in the prevalence of posttraumatic headache following mild traumatic brain injury. Pain Medicine [serial online]. November; 9(8):1001–1011. Available from: PsycINFO, Ipswich, MA. Accessed June 10, 2012. 5. Theeler B., Erickson J. (2009). Mild head trauma and chronic headaches in returning U.S. Soldiers. Headache:

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

The Journal of Head and Face Pain [serial online]. April; 49(4):529–534. Available from: PsycINFO, Ipswich, MA. Accessed June 10, 2012. 6. Nestoriuc Y., Martin A. (2007). Efficacy of biofeedback for migraine: A meta-analysis. Pain [serial online]. March; 128(1-2):111–127. Available from: PsycINFO, Ipswich, MA. Accessed June 10, 2012. 7. Nestoriuc Y., Rief W., Martin A. (2008). Meta-analysis of biofeedback for tension-type headache: Efficacy, specificity, and treatment moderators. Journal of Consulting and Clinical Psychology [serial online]. June; 76(3):379–396. Available from: PsycINFO, Ipswich, MA. Accessed June 10, 2012. 8. United States Central Command. (2011). Ppg-tab a: Amplification of the minimal standards of fitness for deployment to the CENTCOM AOR; to accompany mod 10 to USCENTCOM individual protection and individual/unit deployment policy Retrieve from http://www.pdhealth.mil/ dcs/pre_deploy.asp.

Lieutenant Colonel Craig M. Jenkins, PhD is a board certified Clinical Health Psychologist assigned to the 10th Special Forces Group (Airborne) as the Group Psychologist. He has more than a decade of experience within Special Operations Forces, most of that providing operational psychology support. He has conducted multiple combat tours in Afghanistan and Iraq. LTC Jenkins is focused on improving the health and performance of Special Operations Forces as well as providing operational support to commands.

Biofeedback Self-Regulation Training to Treat Post-Concussion Headache in a Special Operations Support Soldier

Biometrics in Support of Special Forces Medical Operations Michael R. Kershner, COL, SF (Retired)

Abstract Recommendations on ways in which the ODA can leverage biometrics in medical operations to improve their security, improve relations with indigenous personnel, and contribute to the larger theater biometrics program.

Special Forces (SF) have served as the “go to” solution for numerous challenges throughout the spectrum of conflict, even when they were not the optimal choice. However, as much press as they garner for their “public” operations, SF Soldiers often prove to be of far more value for those operations that do not make the press – not because they are classified, but because they are under the radar and do not catch the notice of the media. SF troops generally prefer it that way. They are engaged around the world, in as many as seventy countries every day. They are there because they first won the hearts and minds of the country team, then they proceeded to prove their value on the ground – from engagement and shaping to training and operations, from Phase 0 back to Phase 0. It was the long-term commitment of SF that brought peace to El Salvador. It was the enduring engagement of SF that professionalized the Colombian Army, making it one of the most effective forces in the world and stabilizing that democracy in the process. This premier shaping capability is made possible by two primary characteristics: the small footprint of the Special Forces Operational Detachment Alpha (ODA) or “A Team” and the extraordinarily effective mix of skills present on those teams. Regardless of talk at the club, no one skill set is more important than others in the large scale, nor is any skill set disposable. However, the Special Forces Medical Sergeant (18D) can quickly become the most important man on the team. When he is needed, he is needed and no one else can substitute. 18Ds are considered by many to be the finest first-response and trauma medical technicians in the world. This esteem is not simply due to his training, but is also due to his psychological makeup, which combines readiness to accept a challenge with a calm strength in the most stressful situations. The

medic also plays a critical part in engagement strategies for the team. He serves as the focal point for Health Service Support (HSS) at the “pointy end of the spear.” Though primarily trained with an emphasis on trauma medicine, the 18D also has a working knowledge of dentistry, veterinary care, public sanitation, water quality and optometry. When deployed on a mission, the SF Medic provides initial medical screening and evaluation of allied and indigenous personnel. He is expected to provide examination and care to detachment members, maintaining the individual and group health needed to accomplish the mission. He supervises medical care and treatment and is capable of operating a combat laboratory, treating emergency and trauma patients, and developing and providing medical intelligence as required. Biometrics can support these critical functions in many ways. Biometrics provides a valuable tool to the SF Medic as he supervises medical care and treatment of indigenous or allied personnel over extended periods of time. Biometrics is a general term used alternatively to describe a characteristic or a process. As a characteristic, biometrics is a measurable biological (anatomical and physiological) and behavioral characteristic that can be used for automated recognition. The biological characteristics, commonly referred to as modalities, most useful to identify individuals in an operational area are fingerprints, iris images, facial photos, and DNA. Behavioral traits, such as a signature, the keystroke pattern on a keyboard, or gait, are generally less useful. As a process, biometrics is an automated method of recognizing an individual based on measurable biological (anatomical and physiological) and behavioral characteristics. For operational biometrics, we use the terms interchangeably. Biometrics is used in two ways: verification and identification. Verification compares one biometric to an identified biometric (1:1) to verify that an individual is who they say they are: e.g., only one “Joe Smith” has that particular fingerprint or iris pattern. Identification compares one biometric to a database of biometrics (1:n) to find out who an individual is: e.g., the fingerprint recovered

from yesterday’s bomb matches a fingerprint found in the database, thus identifying a person with intimate knowledge of the bomb. Biometric characteristics are very hard to fake and the systems are difficult to deceive. Biometrics registration consists of gathering the data (fingerprints, iris and facial photographs) on a handheld Tactical Collection Device (TCD). The current TCDs are the Secure Electronic Enrollment Kit (SEEK), used primarily by SOF, and the Handheld Interagency Identity Detection Equipment (HIIDE), which is fielded across the General Purpose Forces (GPF). The data collected by these devices must then be uploaded to the Department of Defense Automated Biometrics Identification System (DoD ABIS) through a base station, usually either the Biometric Automated Toolkit (BAT) or an automated portal. That same TCD is subsequently used to identify or verify and individual by electronically querying and comparing biometrics to those stored in the database. The SF Medic can avail himself of the benefits of biometrics in a number of ways. When providing initial medical screening and evaluation of allied and indigenous personnel, biometrics registration simultaneously accomplishes several tasks. Each individual enrolled adds to the larger body of knowledge or database. Biometrics is a big math word problem; the more enrollments in a particular area or of a particular population, the higher the probability of encountering someone who has already been enrolled in the database. As these participants are enrolled biometrically, they can be screened against existing databases for evidence of previous nefarious activity. For instance, if an individual’s fingerprint shows up as having been found on an Improvised Explosive Device in an earlier incident or even a different operational area, it helps to prevent that potentially hostile element from benefiting from training by the ODA. Alternatively, it

U.S. Army photo by Sgt. Brandon D. Bolick/Released

Figure 1 U.S. Soldier takes a biometric reading of an Iraqi for identification purposes at a checkpoint in the Diyala province of Iraq Aug. 27, 2010. U.S. and Iraqi soldiers operated checkpoints throughout Diyala.

alerts the medic that he is providing care to an enemy combatant or potential threat. That knowledge does not prevent the care being administered, but can reduce the danger to the medic and to the team by insuring they are fully aware of the threat posed by the individual. The data is also useful for subsequent military operations, from positive identification of a casualty to the protection of assets, including medical supplies, through absolutely clear identification of those requiring access or for whom dosage tracking is an issue. Much of the value of biometrics can be increased by close cooperation with the other members of the team, aiding them in their work as they aid the medic in his. The simple expedient of requiring biometric enrollment in return for care provided can help overcome any lingering cultural aversions to enrollment. By tracking those who have received medical care, biometric identification can have a dramatically positive impact by ensuring someone does not receive the same inoculation twice or gets more medicine than they really need. Many people do not understand why the medicine they receive works so well and often have the philosophy, “If some is good, more is better.” Biometrics further allows positive control of the distribution of medical assistance by ensuring that no one receives more than they should. This simple process can insure that required follow-up care is providedin a timely manner and, more importantly, to the right person. When required, the medic can use this capability to keep track of personnel in the medical evacuation system or who have been hospitalized, either within the theater of operations or within the hospital system in general. Just as it is used with human patients, biometrics can help to track veterinary care through enrollment of the owner. Our enemies, comfortable and complacent in their anonymity, will take advantage of our generosity in every instance that they can, while seeking ways to damage us or our services to others. Biometrics can provide a hedge of protection for those operations as well. ODAs routinely find themselves in austere environments and must be prepared to operate with minimal or no support from the theater logistical system. As the team’s on-the-ground responsibilities expand, either through the success of their initial engagement efforts or, at times, due to the inadequacy of the theater logistical system, they may find themselves increasingly reliant on local sources for food, water, sanitation, public health, and health industry resources. The Special Forces Medical Sergeant will often find himself being called upon to provide definitive advice to the detachment commander on procurement of fresh foods and beverages and contracting of food storage facilities. He can also be expected to conduct thorough sanitary inspections of local food establishments in the operational area. He will

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

work closely with other members of the team to achieve the best results. Biometric enrollment of providers will provide an added measure of security to the team by insuring that those providers are positively identified every time they are encountered and can help insure that everyone who arrives at the team with such supplies is who they say they are and has previously been vetted through the biometrics database. There are other ramifications of the versatility of Special Forces ODAs and their frequent geographical proximity to crisis areas. One of those is the need to conduct or to shift to Medical Civil-Military Operations (MCMO), though it is rarely called that, in shaping operations as well as war. MCMO are health-related activities that

is to improve HN capacity to provide public health and medical services to its population, thereby enhancing legitimacy of the HN, enhancing force protection, and accomplishing the Joint Force Commander’s political-military objectives. HSS initiatives during MCMO should emphasize long-term developmental programs that are sustainable by the HN.2 Figure 2 SSG Kevin Dias, an intel analyst for Special Operations Task Force-East, checks biometrics on participants of the first-ever regional medical seminar in Mazar-e Sharif, Balkh province, February 20. The five-day seminar was hosted by the Ministry of Public Health and Special Operations Task Force-East and offered classes to four separate groups of students: medical doctors, midwives and nurses, paramilitary personnel, and local nationals.

Photo courtesy of SGT Katryn Tuton

“establish, enhance, maintain, or influence relations between the joint or coalition force and host nation (HN), multinational governmental authorities, and nongovernmental organizations (NGOs), and the civilian populace in order to facilitate military operations, achieve U.S. operational objectives, and positively impact the health sector. . . . The subsets of MCMO include peacetime medical elements of security cooperation activities, humanitarian assistance (HA), disaster response and disease outbreak response in a permissive environment, pre- conflict health-related civil-military activities, and health related civil-military activities during major campaigns and operations, and postconflict stability operations.”1 The ODA, with the detachment’s 18D as the primary advisor, may find themselves tasked to conduct or support MCMO in activities that build or restore the HN’s capacity in the public health sector. These operations are often conducted in areas where social services have been seriously disrupted, resulting in poor sanitation, inadequate and unsafe food and water (as well as distribution problems), diseases, uncontrolled distribution of hazardous wastes and hazardous materials, and environmental extremes. In this chaotic environment, the Special Forces Medical Sergeant may be tasked to lead the way as his team works on public health activities, to include preventive medicine; personal sanitation and hygiene; safe food and water preparation and handling; infant and child care; preventive dental hygiene; immunizations of humans and animals; veterinary care and behavioral health surveillance and support; development of logistic programs; preventative health measures for local/intrinsic industry; continuing health education programs and medical intelligence and threat analysis; and assistance in upgrading and devising methods for supplying and sustaining existing HN medical infrastructure and facilities. The focus of HSS initiatives during MCMO

Biometrics can play a critical role in such operations even if the HN does not have a biometrics enrollment protocol or database. Humanitarian assistance and other logistical support can be provided for a number of reasons, both natural and man-made. The distribution of such aid, however, should be carefully controlled to ensure everyone gets their proper allotment without anyone being able to stockpile or hoard relief supplies. A simple “biometrics signature” both ensures there will be sufficient supplies of aid and that no one truly benefits from a disaster (and, of course, ensures we do not inadvertently deliver aid to enemies). It should also prevent availability of relief supplies on the black market, which is inimical to both our interests and those of the HN. Biometrics can be used to enroll all recipients of humanitarian assistance to ensure there is no “double dipping” into humanitarian assistance resources. Biometrics as a receipt verification protocol can dramatically limit black marketeering or other fraudulent receipt of relief supplies. Tracking those to whom assistance has been provided is easily verified through fingerprints or iris scans. In the same manner that humanitarian assistance may be controlled by the use of biometrics to prevent profiteering, medical assistance benefits likewise from the same function.

Biometrics in Support of Special Forces Medical Operations

Medical intelligence is produced from the collection, evaluation, and analysis of information concerning the health threats and medical capabilities of foreign countries and non-state players that have immediate or potential impact on policies, plans, or operations. HSS activities may be perceived as prime targets by these groups, especially if these facilities are perceived as making a major contribution to international efforts and/or the HN government. Biometrics as a security screening tool can effectively provide an outer layer of protection to these activities. Medical activities are also vulnerable to theft and raids on medical (CL VIII) supplies by insurgents or terrorists for their own support or to support black market activities. Biometrics can be useful in identifying internal threats or supporting subsequent forensic investigations by providing a database against which to compare collected latent fingerprints and other such evidence. The Special Forces ODA is one of the most versatile operational elements in the military arsenal of the United States. The breadth and depth of its operational expertise in relation to its element size makes it the default answer to a number of operational questions. Some of the most complex issues of our time directly impact or are impacted by the health of individuals and groups of individuals in remote or denied areas. The unique ability of the Special Forces Medical Sergeant, supported by his ODA, to bring order out of chaos is one of the great strengths of our Army. By leveraging the strength

of the Army’s biometrics expertise in this established field of practice, the 18D can better provide that assistance while protecting himself, his unit and his nation. References 1. Joint Publication 4-02, Health Service Support, Paragraph IV.3.b 2. Joint Publication 4-02, Health Service Support, Paragraph IV.3.b

COL (Ret) Mike Kershner has just left his post as Special Advisor for Operations at the Biometrics Identity Management Agency and currently serves as President of Stedman Global LLC. His operational experience has included routine interactions with foreign government leaders in both the strategic planning and operational arenas. COL Kershner has a Bachelor of Science degree from the U.S. Military Academy at West Point, New York, and a Master of Arts in International Relations from Boston University. He attended numerous schools in the course of his 28-year career in the Army, including the Special Forces Officers’ Course (Honor Graduate), Special Forces Combat Dive School (Honor Graduate), Special Forces Military Freefall School, Command and General Staff College and the U.S. Army War College at Carlisle, PA. COL Kershner has extensive international experience, having worked in 56 countries.

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

Forward Assessment of 79 Prehospital Battlefield Tourniquets Used in the Current War David R. King, MD; Gwendolyn van der Wilden, MSC; John F. Kragh, Jr., MD; and Lorne H. Blackbourne, MD

ABSTRACT Introduction: Battlefield tourniquet use can be lifesaving, but most reports are from hospitals with knowledge gaps remaining at the forward surgical team (FST). The quality of tourniquet applications in forward settings remain unknown. The purpose of this case series is to describe observations of tourniquet use at an FST in order to improve clinical performance. Methods: War casualties with tourniquet use presenting to an FST in Afghanistan in 2011 were observed. We identified appliers by training, device effectiveness, injury pattern, and clinical opportunities for improvement. Feedback was given to treating medics. Results: Tourniquet applications (79) were performed by special operations combat medics (47, 59%), flight medics (17, 22%), combat medics (12, 15%), and general surgeons (3, 4%). Most tourniquets were Combat Application Tourniquets (71/79, 90%). With tourniquets in place upon arrival at the FST, most limbs (83%, 54/65) had palpable distal pulses present; 17% were pulseless (11/65). Of all tourniquets, the use was venous in 83% and arterial in 17%. In total, there were 14 arterial injuries, but only 5 had effective arterial tourniquets applied. Discussion: Tourniquets are liberally applied to extremity injuries on the battlefield. 17% were arterial and 83% were venous tourniquets. When ongoing bleeding or distal pulses were appreciated, medics tightened tourniquets under surgeon supervision until distal pulses stopped. Medics were generally surprised at how tight a tourniquet must be to stop arterial flow â&#x20AC;&#x201C; convert a venous tourniquet into an arterial tourniquet. Implications for sustainment training should be considered with regard to this life-saving skill. Keywords: first aid; hemorrhage; extremity; damage control; resuscitation

Introduction Extremity hemorrhage control has dramatically improved on the battlefield in the past decade, largely attributable to the availability and early application of tourniquets to massively bleeding extremity wounds.1-4 Although much

data exists regarding effectiveness of tourniquets in the controlled environment of the civilian hospital,2-12 combat support hospital, or laboratory, little data is available examining the effectiveness of tourniquets placed on the battlefield in the prehospital (Level I) environment. We thought that, although tourniquets were being applied liberally at point-of-injury on the battlefield,13,14 they were not providing optimal control of extremity bleeding. The purpose of the present series is to characterize the effectiveness of prehospital tourniquets in the current war, in a far-forward setting, in order to improve the performance of prehospital providers at a Forward Surgical Team (FST) in Afghanistan.

Methods As part of a quality of care improvement effort during Operation ENDURING FREEDOM, all combat casualties with signs of life such as a palpably detectable pulse15 presenting to an FST at Forward Operating Base Shank (Level II), from August 2011 through November 2011, were identified and examined for presence of a tourniquet. Initial prehospital care for combat casualties included selfaid, buddy care, and care by medics or physicians (Level I). Only casualties evacuated directly from point-of-injury to the FST were included. When tourniquets were identified, the injury mechanism, anatomic location, number of tourniquets, correctness of application as intended, presence of distal pulses, and corresponding vascular injuries were noted. Vascular injuries were identified at surgical exploration, when clinically indicated, or excluded based upon release of the tourniquet and presence of a normal clinical and handheld Doppler auscultation examination of the affected limb. All observations and examinations were made by an FST trauma surgeon. Our battlefield management algorithm for limbs with tourniquets at Level II (FST) is presented in Figure 1. Upon casualty arrival at the FST, immediate real-time feedback was given to the prehospital provider who applied the tourniquet(s) such as at medic handing off casualty to the FST. Discussions often were continued

Figure 1 Management Guideline for Limbs with a Tourniquet at Presentation to Level II on the Battlefield. TQ is tourniquet. Vascular examination is conducted at 10 minutes in order to allow for resuscitation, reperfusion, and resolution of vasospasm. “Operating room” entails surgical exploration to identify and repair vascular injury. The guideline concerns emergent exploration for bleeding or ischemia; many limbs have associated skeletal or other injuries beyond the scope of the guideline, but in absence of bleeding and ischemia, such injuries may be triaged so casualties with bleeding may be treated first.

afterward such as when medics checked in with their casualties at the FST within the next day. Each prehospital provider’s military occupational specialty (MOS) was noted. When presence of the provider who applied the tourniquet was delayed, feedback was given after completion of the mission or operational objective. This report was reviewed by the U.S. Army Institute of Surgical Research Regulatory Affairs Office in July 2012 and was determined to be performance improvement in accordance with good clinical practices.

Results Appliers were 96% medics and 4% surgeons. Tourniquet applications were performed by special operations combat medics (47 applications, 59%), flight medics (17 applications, 22%), combat medics (12 applications, 15%), or general surgeons (3 applications, 4%, Figure 2). Follow-up of casualties was limited to their length of stay at the FST, and no casualty died. During the entire quality improvement effort, no casualty presented with a major vascular injury without a tourniquet in place. Of the 54 combat casualties in this series, 38 had associated injuries involving an organ, cavity, or system other than an extremity. A total of 79 tourniquets were identified on 65 limbs of 54 combat casualties (1.2 devices per limb [79/65], 1.5 devices per casualty [79/54]) arriving at the FST directly

Figure 2 Pie chart of proportions of tourniquet users by job title. Most tourniquets were placed by special operations combat medics (18D, 47 applications, 59%), flight medics (68WF3, 17 applications, 22%), combat medics (military operational specialty [MOS] 68W, 12 applications, 15%), or general surgeons (61J, 3 applications, 4%).

from the point-of-injury. The tourniquets identified were 90% Combat Application Tourniquets (CAT, 71/79), 5% Special Operations Forces Tactical Tourniquets (SOFTT, 4/79), 2.5% ratchet-type tourniquets (2/79), and 2.5% improvised tourniquets (2/79, Figure 3). With tourniquets in place upon arrival at the FST, most limbs (83%, 54/65) had palpable distal pulses present; 17% were pulseless (11/65). Of 10 casualties with 11 pulseless limbs with tourniquets in place, 5 (50%, 5/10) had return of distal pulses upon tourniquet release. No patient with return of bilateral and symmetrically palpable pulses within 10 minutes of tourniquet release had injury of an anatomically named artery such as the popliteal artery.15 Both improvised tourniquets, of the band-andstick design, presented with palpable distal extremity pulses and no vascular injuries identified. Wounding mechanism was explosion with fragmentation in 41 limbs (improvised explosive device, rocketpropelled grenade, hand grenade, or other explosion), gunshot in 21 limbs, and crush in 3 limbs. All limbs had an open soft-tissue defect from fragmentation, gunshot, explosion, or crush (open fractures with degloving injury). Most limbs (45/65, 69%) had only soft-tissue and orthopedic injuries without vascular injury identified. In total, there were 17 limbs with major vascular injury, of which 3 were combined arterial-venous injuries. There were 14 major arterial injuries, but only 5 had no palpable pulse distal to the tourniquet. There were

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

Figure 3 Pie chart of proportions of tourniquets by model. Most tourniquets were the standard issue Combat Application Tourniquet (CAT, 90%). Other included the Special Operations Forces Tactical Tourniquets (SOFTT, 5%), ratchet tourniquets (2.5%), and improvised tourniquets (2.5%).

Figure 4 Clinical photograph of a supine casualty with a left lower extremity wound with three tourniquets for combined popliteal artery and venous injuries confirmed later at surgical exploration. The three tourniquets are placed in no coherent plan as they are so far apart as to not be side by side. Side by side, they act as one wide and effective tourniquet. Separately, they add nothing; together, they work well. Tourniquet width is a key design trait for effectiveness.

3 superficial femoral artery injuries, 1 profunda femoris artery injury, 1 brachial artery injury, 6 popliteal artery injuries, and 3 infra-popliteal arterial injuries at or below the trifurcation. Six major venous injuries were identified: two brachial and four of the popliteal vein. The maximum number of tourniquets per limb was 3 (Figure 4) in a casualty with combined arterial and venous injuries. These three tourniquets were placed far apart from one another, making them act independently as single, narrow devices and not together side-by-side as if one wide device; wider is more effective. The two improvised tourniquets were narrow and too loose; all other tourniquets were applied with the correct technique. Twelve arterial injuries presented with massive bleeding, either before or after tourniquet removal. The remaining 2 arterial injuries presented as ongoing, submassive hemorrhage and persisting distal pulse asymmetry (or total absence of a palpable pulse or Doppler signal) 10 minutes after tourniquet release.

Discussion The main lesson learned in this series of 79 prehospital battlefield tourniquet uses in war is the necessity for continual re-evaluation of the casualty after application of a tourniquet. Just as with serial re-examination following needle decompression of the chest, careful reexamination following tourniquet placement is required to ensure that the tourniquet remains as tight and as hemostatic as originally intended. The current report findings serve as a well evidenced reminder that just as with all clinical interventions, a key is to continually re-assess the casualty. Controlling hemorrhage is priority #1 especially in tactical field care.15 Battlefield medics have an

extremely difficult job in war with many competing goals and priorities, but refocusing on serial reassessment of casualties is required to improve care. Our observations indicate that tourniquets are being applied liberally for extremity wounds in accordance with current military policy. However, of 65 limbs with tourniquets, only 17 had a vascular injury identified, indicating that 74% of limbs had a tourniquet applied without underlying vascular (that is, major arterial or venous injury). On initial review, 74% may seem like an apparent overuse of tourniquets; however, during this same period, no casualty presented with vascular injury without a tourniquet in place, suggesting 100% capture. Because tourniquet use risks minor morbidity and tourniquet absence (when clinically indicated) is lethal,2,4,5,7,15 then tourniquet overuse appears more desirable than missing a life and limb in need of hemorrhage control during evacuation. Use of tourniquets controlled venous bleeding in 83% of uses and arterial bleeding in 17%, meaning that arterial

Forward Assessment of 79 Prehospital Battlefield Tourniquets Used in the Current War

tourniquets also controlled arterial bleeding. A reason for such a low rate of arterial tourniquet use is that although providers apply tourniquets liberally for all wounds to the extremities, only the “squeaky wheel gets the grease”; that is, the most noticeable (visually impressive or severe wounds) bleeding is most likely to get tourniquets tightened properly to both bleeding and pulse absence.11 From the field user of medic’s perspective, liberal use appears practical given the chaos and danger of war with the little time a prehospital provider has to assess and treat wounds, particularly during care under fire as use limits risk to the casualty and recuer.7 Of casualties with an identified arterial injury, only 35% presented with an effective arterial tourniquet, and this rate is near those previously reported.7 There may be reasons for this observation. First, perhaps initially when the casualty was hypotensive, tourniquets were tightened well until there was no bleeding and no pulse; but on resuscitation blood pressure rose, pulses returned, and bleeding passed the tourniquet. Second, by the squeaky wheel premise above, providers may tighten a tourniquet until bleeding slows until it is visually unimpressive and move on to care for other injuries or casualties, thereby inadvertently allowing some ongoing bleeding with a distal pulse – the flood turns to trickle. Third, prehospital assessment of pulse persistence may be poor. The first and second reasons were not directly measured in the present survey but were found in similar surveys, as visual cues can be prioritized instinctively unless training over rides instinct.7,15 For most combat casualties in this series, their treating medics routinely presented with the casualty to the FST. Medics commonly went to the FST to get medical updates for their unit’s personnel section in order to understand dispositions, prognoses, and translate jargon for casualty status as a routine good practice. The personal medical knowledge gained by the medic and surgeon regarding reciprocal, two-way feedback was invaluable to medic, surgeon, and unit. When ongoing limb bleeding or distal pulses were appreciated (generally after undressing the wound), the medics tightened tourniquets under supervision of the surgeon until distal pulses became absent. All medics were surprised) as to how tight a tourniquet must be to stop arterial flow; that is, convert a venous tourniquet into an arterial tourniquet. Opportunities for the prehospital medic and the surgeon to work, teach, and learn together are invaluable and all too rare in war. Venous tourniquet use risks much both morbidity commonly and mortality rarely unless corrected promptly (Figure 5).1,4,5 A comprehensive historical review of emergency tourniquet use recently highlighted the significance of unintentional venous tourniquets.1 For the majority of these 54 casualties, a venous tourniquet was present without vascular injury, which likely resulted in no directly

Figure 5 Clinical photograph of a supine casualty with bilateral lower extremity tourniquets released and loose in place. The limbs have passive venous congestion and reperfusion rubor. Pulses distal were palpable but diminished before release and normal afterward. No vascular injuries were identified. Doppler auscultation was normal.

attributable harm.2-5 Vascular lesions were the fourth most common anatomic indication in the present study at 17%, and arterial injuries have ranged from only 8% to 28% of the injured casualties with emergency tourniquet use in recent wars.6-7 Recent experience may have changed and broadened what was, historically, considered safe as the new evidence shows much use is safe. Additionally, prehospital differentiation of venous vs. arterial bleeding may still be poor.7 While a few studies report high rates of prehospital tourniquet use, none fully address tourniquet effectiveness far forward as at an FST.8-11 Knowledge gaps in tourniquet use are not primarily at the emergency rooms of hospitals but forward as at the point-of-care. The present case series supports continued liberal use as there appears to be little risk, in general, to such use on the modern battlefield given short evacuation times and short ischemic times for the great majority of casualties.15 The limitations of the present case series are many in part due to the design of observing consecutive cases. Having no intervention, control, or follow-up beyond the scope of performance improvement, this case series increases awareness of topics worthy of study, education, and remediation. In summary, prehospital tourniquet use is ubiquitous for extremity injury on the battlefield today, but only 26% of casualties with a vascular injury had an effective arterial tourniquet upon presentation at the FST.2,10,12 All medics who placed the tourniquets were surprised at how tight arterial tourniquets had to be,

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

and they were easily educated with real-time feedback to address the importance of serial reassessment and adjustment of tourniquets during evacuation to control hemorrhage. Degree of tightening to control arterial pulse and serial reassessment skills should be developed for tourniquet users and be reinforced in skill sustainment training.

Author Contributions Dr J. F. Kragh: literature search, study design, data collection, analysis, and interpretation, writing, revision. Gwendolyn van der Wilden: analysis, writing, revision. Dr. L. H. Blackbourne: data analysis, interpretation, writing, revision. JF Kragh, COL (ret), MC, USA, Assistant Professor of Surgery, USUHS, Bethesda, MD. Financial disclosures that might relate to this work: Dr. Kragh is an employee of the U.S. Government and receives institutional support where he works, the U.S. Army Institute of Surgical Research. He has offered feedback on scientific matters at no cost to Operative Experience, M2, Inc., Tiger Surgical, LLC, Tactical Medical Solutions, LLC, Combat Medical Systems, Inc., Composite Resources Inc., Delfi Medical Innovations, Inc., North American Rescue Products LLC, H & H Associates, Inc., Creative & Effective Technologies, Inc., TEMS Solutions, LLC, Blackhawk Products Group, Hemaclear, Tactical Development Group, Compression Works, LLC, Tier-One Quality Solutions, Kforce Government Solutions, CHI Systems, Tactical Emergency And Medical Simulations Training (TeamsT), Athena GTX, Pelagique LLC, RevMedx Inc, and Entrotech, Inc. He has received honoraria for work for the Food and Drug Administration for device consultation. He has received honoraria for trustee work for the non-profit Musculoskeletal Transplant Foundation. He has worked as a technical representative to the U.S. Government’s contracting officer in agreements with Physical Optics Corporation, Resodyn Corporation, International Heart Institute of Montana Foundation, Daemen College, Noble Biomaterials, Inc., Wake Forest Institute of Regenerative Medicine, National Tissue Engineering Center, Pittsburgh Tissue Engineering Initiative, University of Texas Southwestern Medical Center, Arteriocyte, Inc., and Kelly Space and Technology, Inc.

References 1. Kragh JF Jr, Swan KG, Smith DC, Mabry RL, Blackbourne LH. (2012). Historical review of emergency tourniquet use to stop bleeding. American Journal of Surgery; 203(2):242–252. 2. Kragh JF Jr, O’Neill ML, Walters TJ, Jones JA, Baer DG, Gershman LK, Wade CE, Holcomb JB. (2011). Minor

morbidity with emergency tourniquet use to stop bleeding in severe limb trauma: research, history, and reconciling advocates and abolitionists. Military Medicine; 176(7):817–823. 3. Kragh JF Jr. Use of tourniquets and their effects on limb function in the modern combat environment. (2010). Foot and Ankle Clinics; 15(1):23–40. 4. Kragh JF Jr, Littrel ML, Jones JA, Walters TJ, Baer DG, Wade CE, Holcomb JB. Battle casualty survival with emergency tourniquet use to stop limb bleeding. (2011). Journal of Emergency Medicine; 41(6):590–597. 5. Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB. (2008). Practical use of emergency tourniquets to stop bleeding in major limb trauma. (2008). Journal of Trauma and Acute Care Surgery; 64(2 Suppl):S38-49; discussion S49–50. 6. Tien HC, Jung V, Rizoli SB, Acharya SV, MacDonald JC. (2008). An evaluation of tactical combat casualty care interventions in a combat environment. Journal of the American College of Surgeons; 207(2):174–178. 7. Kragh JF, O’Neill ML, Beebe DF, Fox CJ, Beekley AC, Cain JS, Parsons DL, Mabry RL, Blackbourne LH. (2011). Survey of the indications for use of emergency tourniquets. (2011), Journal of Special Operations Medicine; 11(1):30–38. 8. Starnes BW, Beekley AC, Sebesta JA, Andersen CA, Rush RM Jr. (2006). Extremity vascular injuries on the battlefield: tips for surgeons deploying to war. Journal of Trauma and Acute Care Surgery; 60(2):432–442. 9. Lakstein D, Blumenfeld A, Sokolov T, Lin G, Bssorai R, Lynn M, Ben-Abraham R. (2003). Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience. Journal of Trauma and Acute Care Surgery; 54(5 Suppl):S221–S225. 10. Brodie S, Hodgetts TJ, Ollerton J, McLeod J, Lambert P, Mahoney P. (2007). Tourniquet use in combat trauma: UK military experience. Journal of the Royal Army Medical Corps; 153(4):310–313. 11. Beekley AC, Sebesta JA, Blackbourne LH, Herbert GS, Kauvar DS, Baer DG, Walters TJ, Mullenix PS, Holcomb JB, 31st Combat Support Hospital Research Group. (2008). Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. (2008). Journal of Trauma and Acute Care Surgery; 64(2 Suppl):S28-37; discussion S37. 12. Kragh JF Jr, O’Neill ML, Walters TJ, Dubick MA, Baer DG, Wade CE, Holcomb JB, Blackbourne LB. (2011). The Military Emergency Tourniquet Program’s lessons learned with devices and designs. Military Medicine; 176 (10):1144–1152. 13. Kragh JF Jr, Wade CE, Baer DG, Jones JA, Walters TJ, Hsu JR, Wenke JC, Blackbourne LH, Holcomb JB. Fasciotomy rates in Operations Enduring Freedom and Iraqi Freedom: association with injury severity and tourniquet use. (2011). Journal of Orthopaedic Trauma; 25(3):134– 139. 14. Fox CJ, Perkins JG, Kragh JF Jr, Singh NN, Patel B, Ficke JR. Popliteal artery repair in massively transfused military trauma casualties: a pursuit to save life and limb. (2010). Journal of Trauma and Acute Care Surgery; 69 Suppl 1: S123–134.

Forward Assessment of 79 Prehospital Battlefield Tourniquets Used in the Current War

15. Kragh JF Jr, Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, Holcomb JB. Survival with emergency tourniquet use to stop bleeding in major limb trauma. (2009). Ann Surg. 249(1):1–7.

MAJ(P) King is a U.S. Army Reserve trauma surgeon who has deployed with Forward Surgical Teams to Iraq and Afghanistan. He is also an academic trauma surgeon and surgical scientist/researcher at the Massachusetts General Hospital with expertise in hemorrhage control and resuscitation.

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Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

Addressing Maternal Healthcare Needs in the Counterinsurgency Environment Gregory Lang, MD, MPH; Christine E. Lang, MD, MPH

ABSTRACT All pregnant women are at risk of obstetric complications, most of which occur during labor and delivery among women with no previously identified risk factors. More than 95 percent of these deaths occur in developing countries. In sub-Saharan Africa, a region of the world currently experiencing significant humanitarian crises, the lifetime risk of maternal death is one in 30 whereas the lifetime risk in developed countries is one in 2,800.1 The majority of maternal deaths from obstetric complications are due to hemorrhage, eclampsia, sepsis, or obstructed labor, each of which is treatable. Emergency obstetric care is critical to reducing maternal death and disability. SOF medical personnel supporting counterinsurgency (COIN) operations may find themselves in situations where no legitimate agencies are available to provide maternal healthcare. Similarly, SOF medical personnel should be prepared to assist in rebuilding infrastructure and basic services to include the provision for maternal health. This article provides an overview of maternal health in underdeveloped countries; the importance of addressing the unique healthcare needs of women during COIN operations; and how the employment of Female Treatment Teams (FTT) can assist in meeting these needs. A subsequent article will review the basics of prenatal care and life-saving emergency obstetric care, and discusses the essential information and skills that should be taught in a MEDSEM covering maternal healthcare.

Background Across the globe, a woman dies every 90 seconds from complications associated with pregnancy and childbirth. More than half a million women die from medical conditions associated with pregnancy and childbirth each year.1,2 Unfortunately, this number has not declined substantially in over two decades. Based on 2005 data, the average lifetime risk of a woman from an underdeveloped country dying from pregnancy related complications is 300 times greater than for a woman living in an industrialized country.1 No other mortality rate is so

unequal. Due to this disparity, having a child remains among the most serious health risks for women in developing countries. Yet for every woman who dies, another 20 more will have survived an obstetric related injury, but will suffer from severe, often lifelong disability as a result. The number is astonishing: Every year an estimated 10 million women who survive their pregnancies experience adverse outcomes such as vesicovaginal fistula, rectovaginal fistula, or uterine prolapse.3 Around 15 percent of all pregnant women will develop a potentially life-threatening complication that requires skilled medical intervention.4 Most maternal deaths are related to complications that arise during childbirth including postpartum hemorrhage, infection, hypertensive disorders, and prolonged or obstructed labor. Many of the causes of maternal mortality can be prevented or readily treated with basic healthcare in the presence of a skilled birth attendant and through appropriate access to medical providers familiar with emergency obstetric care.4 A recently published index of 164 countries ranked Afghanistan the worst place in the world to be a mother.2 Another eight of the lowest ranking ten countries are located in sub-Saharan Africa where less than half of all births have a skilled attendant present, and on average one in 30 women will die from pregnancy related causes.1,2 According to a global report on midwifery, 58 countries located primarily in Africa and South Asia account for more than 90 percent of the global burden of maternal mortality, and 80 percent of both stillbirths and neonatal mortality.5 Less than 17 percent of the worldâ&#x20AC;&#x2122;s skilled birth attendants are available to care for the pregnant women in these 58 countries.5 Like maternal deaths, the overwhelming majority of neonatal deaths occur in developing countries. Neonatal mortality is the death of a newborn between birth and the first 28 days of life. The health of mothers and newborns is intricately related, and obstetric complications can lead to stillbirth or early neonatal death, which combined are referred to as perinatal deaths. The World Health Organization reported 5.9 million perinatal

deaths in 2004.1 More than 80 percent of neonatal deaths can be attributed to infection, asphyxia, or preterm birth.1 As with pregnant mothers, adequate prenatal care, clean delivery practices, and improved obstetric care provided by a skilled attendant can prevent or alleviate many of the causes of neonatal mortality.

Complex Emergencies Populations affected by armed conflict typically experience severe public health consequences from the breakdown of social structure caused by the disorganized movement of internally displaced persons, food shortages, and the collapse of public health infrastructure. The subsequent crisis that results from the collapse of authority may require an international response and is known as a complex humanitarian emergency. The traditional focus of relief efforts during complex emergencies has been the provision of adequate food, water, shelter, and basic healthcare. Like women anywhere, pregnant mothers caught up in complex emergencies can encounter medical complications associated with pregnancy and childbirth. The available data on maternal and infant health during complex emergencies suggest that poor outcomes are common in many waraffected populations.6 A number of factors can increase the risk of maternal morality in refugee settings. During the initial phase of a complex emergency, pregnant women may become malnourished and anemic and are therefore at higher risk of infectious diseases. They may be exposed to physical and psychological violence. They are often alone and may have to give birth under hazardous conditions. As a result, humanitarian assistance for refugees and internally displaced populations requires particular attention to the common causes of morbidity and mortality in women and infants.

Counterinsurgency and Stability Operations In the current operational environment, military forces can expect to be utilized to preserve security and stability in order to facilitate the re-establishment of civil order and a functional public infrastructure. Counterinsurgency (COIN) doctrine can be summarized as “Shape— Clear—Hold—Build” and may encompass the various military missions and activities conducted in order to maintain or reestablish a safe and secure environment and to provide essential government services, emergency infrastructure reconstruction, and humanitarian relief. Department of Defense Instruction 6006.16, dated 17 May 2010, requires that the military health system, “be prepared to establish, reconstitute and maintain health sector capacity and capability for the indigenous population when indigenous, foreign or U.S. civilian professionals cannot do so.”

It has been said that counterinsurgency is armed social work. Nation-building efforts cannot be successful without adequate attention to the health of the host nation population. In the non-permissive to semi-permissive environment, military forces are often the only personnel interacting with the local populace with little to no support from other International Agencies (IAs) or NonGovernment Organizations (NGOs). As a result, military medical personnel may find themselves required to engage in all levels of medical stability operations from providing direct patient care to the reconstruction or development of host nation healthcare capabilities. In these environments, it is essential to address the needs of the entire population and not to overlook the needs of women.

Women, Counterinsurgency, and Health A successful COIN strategy relies on the popular support of a community and should include the female half of the population. Women play key roles as peacemakers and peacekeepers, and this is perhaps related to the disproportionate amount of harm that both women and children experience in war. In contrast to World War II where civilian casualties were just over half, civilians are now being specifically targeted so that approximately 80 percent of casualties are civilian; of these, nearly 90 percent are women and girls.7 Women and children are increasingly targeted in order to destabilize populations and to destroy the bonds within a society, and it is estimated that they comprise 80 percent of the world’s refugees and displaced persons.8 The essence of COIN is to focus on the entire population, not just the male half. Therefore, it is imperative to recognize the importance of women in rebuilding a society and to integrate their concerns into military lines of operation. Given the opportunity, women will actively participate in conflict prevention and resolution, and their empowerment is inextricably linked to the achievement of COIN objectives. Their collaboration skills, their ability to work across ethnic, political and religious lines for the common good, and their willingness to use available resources for social stabilization and reconstruction make indigenous women essential allies in the counterinsurgency effort. Although most insurgent fighters are men, women are extremely influential in forming the networks that insurgents use for support. Likewise, they are the foundation of social and economic networks that eventually undermine an insurgency. Additionally, women are able to guide the behavior of adolescents who are prone to recruitment by insurgent forces, but efforts to communicate with and understand the needs of the female population are required to leverage their influence over the male population.

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A recently published essay by COL (Ret) John Agoglia, former Director of the Counterinsurgency Training Center in Afghanistan, describes that in some villages the women’s greatest fears are death in pregnancy or loss of children for lack of simple things like midwifery care and basic medical interventions.2 According to a Rand Corporation study of operations following major conflicts, nation-building efforts cannot be successful without adequate attention to healthcare.9 The assessment concluded that health has an independent impact on political, economic, and security objectives during nation-building operations. As U.S. COIN strategy seeks to mesh development and security objectives through activities that enhance the legitimacy of the host nation government, the military must be prepared to meet civilian health requirements during the conduct of stability operations. Some of these activities are designed to improve health infrastructure and others are designed to provide care to civilians in remote or insecure areas. A successful counterinsurgency campaign must promise as well as deliver on guarantees for the security and basic needs of the indigenous population, to include those of women.

Direct Care by Military Medical Personnel The U.S. military has limited experience in the application of non-kinetic actions specifically directed at indigenous women. FM 3-24, Counterinsurgency, addresses the engagement of women only briefly. While commenting that the support of women and families is, “a big step toward mobilizing the populace against the insurgency,” the manual does not go into depth regarding the, “targeted social and economic programs [that] build networks of enlightened self-interest that eventually undermine insurgents.”10 The key non-kinetic effect the military should be seeking in engaging women is to positively influence this half of the population so that they will then be advocates for U.S. efforts and activities. Within the health sector, the potential exists for the provision of military medical support to non-military personnel during stability operations as a way to “target” vulnerable populations such as women and children. Military personnel should only attempt to provide direct medical support where there is no comparable civilian alternative and only when the use of military assets can meet a critical humanitarian need. Even then, medical services should be tailored to local cultural and religious customs and rules. Any care provided should take into account the capabilities and resources of the local community. This often necessitates that it would be inappropriate to initiate medical care for conditions that are expected to require continuing medical supervision and treatment.

Following a complex emergency the primary concerns of the population are food and water, security, and medical care. By virtue of their unique missions, SOF medical personnel are often the only outside sources of interaction with segments of the host nation populace because of security constraints that prohibit other nation-building partners from working in non-permissive, semi-permissive, or remote areas. SOF medical providers may thus find themselves in the unique position of being called upon to provide emergency medical care for isolated groups of an indigenous population. Depending on cultural norms this might be expected to include women. While many medical conditions coexist in men and women and can be treated similarly in either gender, the medical conditions encountered during pregnancy are uniquely female. Often pregnancy related medical problems can be properly treated with basic interventions; however, it is strongly encouraged that only those medical providers who have received adequate training and are proficient in obstetrical life support measures consider providing direct care to a pregnant woman. At no time should any provider practice outside his or her level of competency. For those situations in which it is anticipated that host nation females will require assistance from military medical assets, the SOF Female Treatment Team (FTT) can be an invaluable resource. The FTT concept will be discussed in greater detail later in this article.

Facilitating Host Nation Medical Development The end-state for stability, reconstruction, and development of the health sector as part of a COIN operation is for the host nation to provide culturally and clinically appropriate healthcare to its indigenous populace. While military personnel in an unstable setting may provide essential healthcare services, the provision of direct medical care should be turned over to NGOs or host nation government entities as soon as conditions permit. However, recent experience has demonstrated that the traditional model of separation between the military and the civilian humanitarian relief community is no longer absolute. The Rand study previously mentioned identified poor planning and coordination within and between U.S. government military and civilian agencies, and a lack of an overall health sector reconstruction plan as obstacles leading to failed efforts in Afghanistan.9 Therefore, it is not only appropriate but also necessary for the military to function as an integral partner in the reconstruction of the health sector during all phases of the COIN campaign. The initial focus on health sector reconstruction should directly support the counterinsurgency effort and should incorporate specific programs that address women’s health issues including maternal morbidity and mortality.

Addressing Maternal Healthcare Needs in the Counterinsurgency Environment

Medical stability operations should be directed at culturally acceptable, sustainable interventions that build host nation capabilities including medical staffing, training and education, logistics, and public health programs. Developing programs based on western medical models, while admirable, may not be the most suitable approach. For example, an obstetrics mobile training team conducted a comprehensive assessment at a womenâ&#x20AC;&#x2122;s hospital in Kabul following the death of a patient during an emergency cesarean section and found a lack of basic knowledge and decision-making capabilities.11 Efforts to correct the deficiencies had to be redirected after the team initially attempted to provide advanced level training. Subsequent hands-on instruction with basic equipment and fundamental instruction regarding the management of obstetric emergencies proved to be more successful. Recognizing the expectations and limitations of host nation health sector capabilities is essential to sustainability of training and mentoring programs. Engagement of host nation women in the development of the health sector can lead to more effective programs that may promote a more sustainable peace. Women should be involved in the assessment and project design processes so that their medical concerns and needs will be considered when developing health sector reconstruction plans. Often this will require the presence of female counterinsurgents in order to gain the confidence of the local female population. Recent experience has shown that local women will discuss their gender-specific medical problems with female medics.12 These interactions have led to the development of programs that work with the host nation government to create a sustainable infrastructure for women to provide healthcare to other women. The importance of engaging the female half of the population with regard to security, healthcare, and education has been recognized by ISAF, which directed that all BCTs would have trained Female Engagement Teams (FET) assigned to the unit prior to deployment as of August 2011.

Female Treatment Teams Understanding that a successful COIN strategy relies upon the popular support of women as well as men, the SOF medical community has developed the Female Treatment Team (FTT) to promote health sector development programs available to the female half of an indigenous population. The concept of the FTT dates back to 2009, with the first team deployed in 2010. The FTT model was designed to encourage the education of women and midwives, and it has thus far been limited to operations in Afghanistan. The idea for the FTT evolved out of the SOF Cultural Support Team (CST). Initially, each CST was to include a medic as a member of the four-person team; however, shortages of available, trained personnel

required modifications to the team structure. Ultimately, the FTT was developed to meet the gap in medical capability that was not provided by the CST. The mission of the FTT is to build health capacity at the village level in order to improve womenâ&#x20AC;&#x2122;s healthcare over the long-term. This is accomplished primarily through teaching local women who would otherwise have no access to medical education. In addition to teaching basic skills to female volunteers, the FTTs provide emergency obstetrical training and other continuing medical education courses to village midwives. They emphasize the importance of recognizing the conditions that require the referral of mothers and newborns from the home to the hospital for additional medical support. A SOF FTT is typically attached at the team level to an ODA at a Village Stability Platform (VSP) site. At present, no published doctrine exists for the training or employment of an FTT; however, it is generally composed of two medically trained females with at least one being a physician, PA or NP provider and the other a 68W medic. Working together with the ODA, the FTT can gain access to host nation women in remote villages or semi-permissive environments where NGOs or governmental agencies are unable to administer their programs. The FTTs have the ability to meet face-to-face with women inside their homes in order to determine their level of medical knowledge and their health concerns. The majority of women in Afghanistan have extremely limited access to medical care, and their cultural norms place stringent restrictions upon their interaction with any man outside their family. Through their presence with the ODA, the FTT along with the 18D can serve as the eyes on the ground where USAID or Ministry of Public Health officials are unable to obtain access for security or other reasons. An important role of the FTT is to teach, advise, and assist local providers whenever possible. In the absence of trained village women, the FTT can teach basic hygiene and healthcare to the local populace. The FTT can also promote medical engagements specifically targeting womenâ&#x20AC;&#x2122;s healthcare needs. In several cases the female provider on the FTT has been able to assist with the delivery of a baby, and in one particular situation the FTT provider proved to be instrumental in saving the lives of both mother and baby when she determined that it was necessary for the mother to be evacuated to a facility capable of performing a cesarean section.13 Even though the program is in its infancy, the FTTs have made significant strides and played critical roles in bridging the gender gap through identifying and meeting the healthcare needs of indigenous women. The interactions with female counterinsurgents has even had a positive influence on the male half of the population as illustrated by a

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local elder who commented that, “Your men come to fight, but we know the women are here to help.”14

Maternal Health in Afghanistan The reconstruction of the Afghan health sector provides useful lessons for other countries confronting poverty and insurgency. Afghanistan ranks amongst the countries with the highest maternal and infant mortality rates in the world where about one out of every eight women dies from causes related to pregnancy and childbirth every year and about one in six children dies before the age of five.1,2 As of 2005, only 30 percent of primary care clinics offered basic maternal services, and only 10 percent of hospitals could perform cesarean sections.9 It is not surprising that the Afghan Ministry of Public Health (MoPH) is seeking to assure that health services are equitable and able to meet the urgent reproductive needs of women. Unfortunately, the MoPH lacks the human resources necessary to offer such services. The paucity of trained medical personnel, especially female ones, is a reflection both of the culture and the many years of Taliban control when girls and women were barred from education and employment. Educated women, including midwives, were specifically targeted by the Taliban, who killed and intimidated any who dared to continue their work. A report published in 2011 indicated that skilled attendants were present at less than 15 percent of births in Afghanistan with only 2 midwives available for every 1,000 live births.5 While the training of birth attendants and midwives has increased, their poor distribution has left much of the country underserved with continued record high maternal mortality rates. The risk of maternal mortality is increased with greater remoteness. Numbers of deaths from maternal complications exceeded those from all other causes among women in rural areas where hemorrhage and obstructed labor were the most common causes of mortality.15 Three fourths of infants born alive to mothers who died also died.15 Faced with the poor performance of uncoordinated health sector activities of both civilian and military agencies, the Afghan MoPH defined a package of priority primary care interventions that included prenatal, obstetrical, and postpartum care. Despite ongoing conflict, progress has been made. Between 2002 and 2007, the number of in-clinic deliveries increased five-fold and the infant mortality rate decreased by 22 percent.16 Unfortunately, the military programs typically lack a process for sustainment due to difficulties in transitioning the services to civilian agencies. Linking military COIN strategy to development goals offers the potential to contribute to sustained stability by connecting military actions with improvements in host nation health sector capabilities.

Conclusion At its core, COIN is the struggle for the support of the populace. It is a fact that the welfare of the indigenous population is vital to the success of a COIN operation, and it can be expected that women will constitute roughly half of any nation’s people. Women have greater incentives than men to peacemaking and peacekeeping; therefore, it is both reasonable and necessary to ensure that the medical assets of the counterinsurgent forces address the special healthcare needs of women. Safe motherhood benefits not only women but also their families, community and society and is an essential component of development. The engagement of international military medical forces with the indigenous health sector is inevitable. SOF medical personnel can expect to interact directly with the host nation populace in remote and semi-permissive environments often with few external resources, making it necessary that they are prepared to face challenges in many areas to include gender. References 1. State of the World’s Children 2009: Maternal and Newborn Health. United Nations Children’s Fund, 2008. Retrieved 1 July 2012 from UNICEF website. Website: (http://www.unicef.org/sowc09/). 2. State of the World’s Mothers 2011: Champions for Children. Save the Children, 2011. Retrieved 1 July 2012 from Save the Children website. Website: (http://www.savethe children.org/site/c.8rKLIXMGIpI4E/b.6153061/k.A0BD/ Publications.htm). 3. The World Health Report 2005—make every mother and child count. World Health Organization, 2005. Retrieved 1 July 2012 from World Health Organization website. Web site: (http://www.who.int/reproductivehealth/publications/ maternal_perinatal_health/9241562900/en/). 4. Field-friendly Guide to Integrate Emergency Obstetric Care in Humanitarian Programs. Reproductive Health in Conflict Consortium, 2005. Retrieved 1 July 2012 from Reproductive Health Response in Crises Consortium web site. Website: (http://www.rhrc.org/resources/index.cfm? type=guideline). 5. The State of the World’s Midwifery 2011: Delivering Health, Saving Lives. United Nations Population Fund, 2011. Retrieved 1 July 2012 from UNFPA website. Website: (http:// www.unfpa.org/public/home/publications/pid/10765). 6. McGinn, T. (2000). Reproductive health of war-affected populations: what do we know? International Family Planning Perspectives; 26(4):174–80. 7. Loftus, L.C. (2008). Influencing the forgotten half of the population in counterinsurgency operations. Carlisle, PA, U.S. Army War College. 8. Report on Refugees and Internally Displaced Persons. U.S. Department of State, 2006. Retrieved 1 July 2012 from U.S. Department of State website. Website: (http://www .state.gov/documents/organization/63694.pdf). 9. Jones, S.G., Hilborne, L.H., Anthony, C.R., et al. (2006). Securing health: lessons from nation building missions.

Addressing Maternal Healthcare Needs in the Counterinsurgency Environment

Santa Monica, CA, RAND Center for Domestic and International Health Security. 10. Field Manual 3-24, Counterinsurgency (2006). Washington, DC, Department of the Army, 2006. 11. Thompson, D.F. (2008). The role of medical diplomacy in stabilizing Afghanistan. Defense Horizons; May(63):1–8. 12. Hart, L. (2011, Dec. 10), Babies and bandages: female treatment team educates Afghan women. Retrieved 1 July 2012 from U.S. Central Command website. Website: (http://www.centcom.mil/news/babies-and-bandages-female-treatment-team-educates-afghan-women). 13. ISAF News Release. (2011, Jan. 7), Female treatment team provides health education in Khakrez. Retrieved 1 July 2012 from ISAF website. Website: (http://www.isaf .nato.int/article/isaf-releases/female-treatment-teamprovides-health-education-in-khakrez.html). 14. Pottinger, M., Jilani, H., Russo, C. (2010, Feb. 18), Half-hearted: trying to win Afghanistan without Afghan women. Retrieved 1 July 2012 from Small Wars Journal website. Website: (http://smallwarsjournal.com/jrnl/art/ trying-to-win-afghanistan-without-afghan-women). 15. Bartlet, L.A., Mawj, S., Whitehead, S., et al. (2005). Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999–2002. Lancet; 365:864–70.

16. Loevinsohn, B., Sayed, G.D. (2008). Lessons from the health sector in Afghanistan. JAMA; 300(6):724–6.

LTC Gregory Lang, MD, MPH is board certified in Aerospace Medicine. He is a Senior Flight Surgeon and Diving Medical Officer currently assigned to Eisenhower Army Medical Center at Fort Gordon, GA, where he is completing a residency in Family Medicine. He previously served as a Flight Surgeon in the 2nd Battalion, 160th SOAR(A). He has deployed in support of OEF and OIF. LTC Christine E. Lang, MD, MPH is board certified in both Preventive Medicine and Family Medicine. She is a Flight Surgeon currently assigned to the United States Special Operations Command at Fort Bragg, North Carolina. She previously served as Battalion Surgeon for the 96th Civil Affairs Battalion. She deployed as part of a two-member Female Treatment Team attached to 3rd Special Forces Group in support of OEF.

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

Intensive Skills Week for Military Medical Students Increases Technical Proficiency, Confidence, and Skills to Minimize Negative Stress Genevieve Mueller, MS3; Bonnie Hunt, MS4; Van Wall, MS3; Robert Rush Jr, MD; Alan Molof, DO; Jonathan Schoeff, MD; Ian Wedmore, MD; James Schmid, PA-C; Anthony LaPorta, MD

Abstract The effects of stress induced cortisol on learning and memory is well documented in the literature.1-3 Memory and learning are enhanced at low levels while high levels are detrimental. Repetitive training in stressful situations enables management of the stress response4 as demonstrated by the high intensity training military members undergo to prepare for tactical situations. Appropriate management of one’s stress response is critical in the medical field, as the negative effects of stress can potentially hinder life-saving procedures and treatments. This also applies to physicians-in-training as they learn and practice triage, emergency medicine, and surgical skills prior to graduation. Rocky Vista University’s Military Medicine Honor’s Track (MMHT) held a week long high-intensity emergency medicine and surgical Intensive Skills Week (ISW), facilitated by military and university physicians, to advance students’ skills and maximize training using the Human Worn Partial Surgical Task Simulator (Cut Suit). The short-term goal of the ISW was to overcome negative stress responses to increase confidence, technical and non-technical knowledge, and skill in surgery and emergency medicine in an effort to improve performance as third-year medical students. The long-term goal was to enhance performance and proficiency in residency and future medical practice. The metrics for the short-term goals were the focus of this pilot study. Results show an increase in confidence and decrease in perceived stress as well as statistically significant improvements in technical and non-technical skills and surgical instrumentation knowledge throughout the week. There is a correlative benefit to physician and non-physician military personnel, especially Special Operations Forces (SOF) medical personnel, from developing and implementing similar training programs when live tissue or cadaver models are unavailable or unfeasible. Keywords: Stress, cortisol, medical student, enhanced learning, scenario, high intensity, military medicine

Introduction Rocky Vista University College of Osteopathic Medicine (RVU) is located in Parker, Colorado and in close proximity to Ft. Carson, Buckley Air Force Base, and the United States Air Force Academy. Currently over 100 Army, Navy, and Air Force Health Professionals Scholarship Program (HPSP) students are enrolled at RVU, the second largest military medical student population outside of The Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Maryland as reported by the Office of the Surgeon General. To address the needs of this unique population of medical students RVU has developed a Military Medicine Honors Track (MMHT). HPSP students accepted into the MMHT benefit from two to four additional hours of instruction per week for eighteen months of advanced surgical training and briefs related to current topics in military medicine from experts in the field. Current medical school training provides experience in surgery and emergency medicine, although most medical students find their initial patient care rotations very stressful.5 This stress can be overcome if the students have a firm grasp of patient care procedures and previous training and experience with surgical technique. Training and practice in medicine are inherently stressful and when treating critical patients in trauma situations medical students find themselves under detrimental extreme stress.6-8 Decreasing the stress response to a manageable level is crucial to effective student learning.2-4 This is true not only in hospital settings, but especially in combat and austere settings as experienced by military medical providers.9-15

Review of the Evidence The authors utilized the terms stress, training, student, simulation, and medical to conduct a Medline search for relevant literature. The search returned 63 results. All abstracts were reviewed and manuscripts relevant to the ISW training were selected by the authors. The authors

then used the terms training, students, evaluation, measurement, medical and stress to conduct a Medline search for relevant literature pertaining to evaluation of stress response for medical student training scenarios. The search returned 662 results. The Boolean operator AND was applied and the search returned 32 results. The results were reviewed by the authors for relevance as well as testing and evaluation methods to be used in this study.

Background and Significance A recent study performed by Harvey et al. demonstrates the correlation between stress and learning in trainees by evaluating emergency medicine and general surgery residents (n = 13) in high-stress (HS) and low-stress (LS) trauma resuscitation simulations by measuring their heart rate and salivary cortisol levels at baseline and again in response to the scenarios.8 Post-scenario subjective stress and cortisol levels were higher in the HS scenario compared with the LS scenario (p < 0.05). Checklist performance scores and post-scenario recall were significantly lower in the HS compared with the LS condition (p < 0.05). This demonstrates that, in trainees, some aspects of performance and immediate recall appear to be impaired in complex clinical scenarios in which they exhibit elevated subjective and physiologic stress responses.16 These findings highlight a potential threat to patient safety.17-19 An extensive review article published by LeBlanc in 2009 substantiates the correlation between decreased human performance factors and high stress situations.20 LeBlanc reviewed the available literature for articles pertaining to stress, tension, anxiety, cortisol, cognition, memory, attention, problem solving, decision-making, health professionals, medical students, residents, and physicians. His research revealed that elevated stress levels can impede performance on tasks that require divided attention, working memory, retrieval of information from memory, and decision making. High levels of stress can be detrimental to memory, recall, and performance, they also threaten patient safety. Low levels of stress have been repeatedly proven to enhance memory and performance.21-23 Stress and emotional arousal leads to increased noradrenaline and cortisol levels.23 These increased levels are essential for good cognitive performance when applied during the perception and encoding phases of learning.24-25 Kukolja et al. conducted a study in 2008, which demonstrated a positive association of cortisol responses with item memory and respective spatial context in male subjects age 19–29.24 Stress-induced increases of lateral and prefrontal cortical metabolism and perfusion have been associated with increased vigilance and attention following stressful stimulation.25-26

Course Design Recognizing the need for advanced training based upon the data demonstrating the positive and negative impacts of various levels of stress on learning and performance, RVU MMHT director Dr. Anthony J. LaPorta, MD, FACS, COL (Ret) designed the Intensive Skills Week (ISW) to utilize the Cut Suit along with hyper-realistic scenarios created by Strategic Operations (STOPS) to train second-year medical students (MS2). The primary goal of the ISW was to increase student performance by overcoming negative stress responses to increase confidence, technical and non-technical knowledge, and skills in surgery and emergency medicine in an effort to improve performance as third-year medical students. The long-term goal was to enhance performance and proficiency in residency and future medical practice. The metrics for the short-term goals were the focus of this pilot study. Metrics for evaluation of the long-term goals are under development.

Training Simulator The Cut Suit was developed by STOPS in two versions, one for tactical combat casualty care (TCCC) and the other as a surgical simulator. The TCCC Cut Suit simulates the treatment of the three most common causes of preventable death on the battlefield: hemorrhage from extremity wounds, tension pneumothorax, and airway blockage or compromise in realistic scenarios.9-15 It is designed as an integral part of a simulation system created to introduce the participants to Hyper-Realistic combat scenarios.27 Technological advances in medical modeling and simulation over the years have brought unprecedented realism to military training.24 The introduction of Hyper-Realistic training utilizing “Hollywood-style” special effects enables military training scenarios to achieve a high degree of realism in replicating the battle zone, thus easily blurring the line between simulation and reality.27 The Cut Suit fills a major gap in simulation technology by providing a model for open thoracotomy and laparotomy procedures. The Cut Suit was recently used for field testing by the DARPA Service Chiefs Fellowship to evaluate new surgical instrument prototypes for use in surgical procedures (Figure 1). The following procedures are currently available using the Cut Suit:27 • Extremity tourniquet application and hemorrhage control with wound-packing (Figure 2) • Extremity hemorrhage control with arterial ligation/ clamping (Figure 3) • Surgical cricothyroidotomy (Figure 4) • Chest needle thoracentesis • Tube thoracostomy • Thoracotomy with intra-thoracic exploration and hemorrhage control (Figure 5)

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

Figure 1 MAJ James Schmid demonstrates using the Cut Suit for evaluation of prototype surgical instruments used during an open laparotomy procedure.

Figure 4 Surgical chricothyroidotomy

Figure 5 Surgical chest tube thoracostomy Figure 2 Extremity tourniquet application and hemorrhage control with wound-void packing

Figure 3 Extremity hemorrhage control with arterial ligation/

clamping

• Laporotomy with intra-abdominal exploration and hemorrhage control (Figure 6) • Suturing or stapling of organs, vessels and skin • Urinary catheterization and suprapubic catheterization • Peripheral IV and interosseous (IO) access

Methods Course Scope A pilot weeklong preparatory course for military MS2s was developed and offered for the first time in May, 2012. A total of 22 MS2s enrolled in the course voluntarily through standard registration practices at RVU. Institutional Review Board (IRB) approval was obtained prior to enrolling participants in the course or collecting data. Inclusion criteria required that students were at the end of their second-year and in good academic standing. Participants included 20 HPSP students and two nonmilitary students. USSOCOM TCCC CASEVAC Set Program: A Retrospective and Overview

Figure 6 Laporotomy with intra-abdominal exploration and hemorrhage control.

Course components included team-based problem solving, realistic simulations and scenarios (Figures 7â&#x20AC;&#x201C;8), technical skills practice, interactive didactics, and student presentations on topics related to the training scenarios. A committee consisting of RVU clinical faculty, two RNs, and former general surgery and emergency medicine residency directors generated learning objectives and metrics for the ISW. The core competencies published by the Accreditation Council for Graduate Medical Education (ACGME) were taken into special consideration during curriculum design.28

presented the case to the EM attending physician and proceeded accordingly. If surgical intervention was required, the patient was taken to the operating room while wearing the Cut Suit. Another student acting as surgical resident was first assistant to the attending physician during the operation (Figure 11). Surgical procedures included appendectomy, cholecystectomy, tumor resections, splenectomy, penetrating abdominal trauma, control of hemorrhagic liver, tube thoracostomy, thoracotomy and exploratory laparotomy for traumatic rupture of the aorta. During surgical cases, all students were present, either assisting or observing, and expected to be prepared to discuss all aspects of the case the following day during morning report. Both the ED and the OR scenarios were overseen by corresponding attending physicians who contributed to creating appropriate levels of stress. Figure 8 The Cut Suit allowed for hyper-realistic training scenarios. Here a student is donning the Cut Suit for a trauma simulation. The organs and tissue are shown before the outer skin covers the thorax. Providers are able to perform actual interventions on the suit without risk to the patient.

Figure 7 Realistic scenarios were used to include a MEDEVAC with two simulated IED patients landing at RVU during the training week.

A simulated emergency department (ED) saw 40 patient scenarios throughout the week, encompassing commonly seen cases ranging in acuity from respiratory infections to acute cholecystitis and traumatic burns (Figure 9). Students alternated between the roles of patients and emergency medicine (EM) residents. After performing histories and physicals and ordering appropriate labs and imaging (prepared test results were provided by the patient), patients were triaged for ED management or surgical intervention (Figure 10). The EM resident

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

Figure 9 Patient wearing the Cut Suit for an improvised explosive device trauma scenario. The realistic moulage and ability to perform interventions directly on the patient augmented training intensity.

Figure 11 Students perform an exploratory laparotomy to

assess an acute abdomen. Students assisted the attending surgeon while rotating roles as first assist, OR technician, and medical student.

Figure 10 A student controlled a bleeding extremity during

an emergency department patient who presenting with a compound femur fracture. The bleeding, activated by remote control, helped simulate the stress of an acute hemorrhage.

confident” to 1 = “no confidence” for a list of tasks performed each day. Stress was scaled as a 5 = “extremely stressful” to 1 = “no perceived stress.” Technical and Non-Technical Skills The Cut Suit provided a model for simultaneous assessment of technical skills and non-technical skills required of surgical teams.1 Technical skills evaluated were: suturing, instrument tying, two-hand knot tying, peripheral IV access, tube thoracostomy, and surgical cricothyroidotomy. On the last day of training, students received a Go/No-Go evaluation of technical competency from the attending physicians. Metrics The authors of this paper were most interested in the relationship between stress, confidence and learning proficiency. The ISW also evaluated technical and nontechnical skills, surgical instrumentation knowledge, pathophysiology, and patient management as defined below. Stress and Confidence Evaluation of the impact of stress on learning utilized the student’s perceived stress and confidence levels. These metrics were tracked daily with self-reported, retrospective surveys encompassing the following: Stress level of each training component, total overall stress level, impact of stress on learning, and confidence for task performance. All items were recorded on a five-point Likert scale. Confidence was scaled as 5 = “extremely

Non-technical skills included teamwork, effective and respectful communication, leadership, and performance under stress and were evaluated using 360° evaluations adapted from the ACGME Competencies and Toolbox of Assessment Methods.29 Non-technical skills were evaluated by peers in both patient and co-worker roles, and by attending physicians using a 1–5 rating scale. Surgical Instrumentation Identification Students received didactic and functional instruction in surgical instrument identification throughout the week. Increases in knowledge were evaluated using a fill-in-theblank pre-test and post-test administered on the first and last day of the ISW. These results were then compared to a control group of MS3 students at the completion of their required third-year surgical rotation.

USSOCOM TCCC CASEVAC Set Program: A Retrospective and Overview

Pathophysiology and Patient Management Education in pathophysiology and management of surgical disease was achieved through student presentations on assigned topics and additional instruction provided by the attending physicians (Figure 12). Each student took a 50 point multiple choice pre-test on Monday morning to evaluate baseline knowledge. A repeat 50 point multiple choice test was administered Friday afternoon to evaluate the impact of the ISW course.

Chart 1 Student’s self reported stress and confidence levels

throughout the ISW. Statistical significance was found between Day 1 and Day 5 measures of Stress (p = 0.002) and Confidence (p = 0.034).

Figure 12 Dr. Rush discussed emergency medical triage with

students following a trauma scenario. Attendings used similar opportunities to instruct students during after action reviews.

Chart 2 Combined average daily rating of all students by

peers and attending physicians using 360° Evaluation of five non-technical criteria. Each criteria rated 1–5, total possible rating of 25 points from peers and 25 points from attending physicians, for a combined maximum of 50 points.

Statistical Analysis All items were analyzed in terms of descriptive statistics and reported as means with standard errors (SEs). Significance was determined with α = 0.05. Statistical testing was performed using SAS 9.1 (SAS Institute, Cary, North Carolina) and Microsoft Excel for Mac 14.1.2 (Microsoft Corporation, Redmond, Washington).

Five criteria included (1) working as a member of a team, (2) communicating effectively, (3) being respectful to patient and surgical team, (4) facilitating knowledge to others in the surgical team, and (5) displaying leadership skills. Attending physicians did not complete 360° Evaluations of students on Day 5, as students were being evaluated on specific technical skills by attending physicians at that time.

Results Stress and Confidence An inverse relationship between stress and confidence was demonstrated throughout the ISW. With each day of exposure to stressful training scenarios, students reported feeling incrementally less stressed and more confident (Chart 1). While the daily data suggests an anecdotal change day to day, a comparison of Day 1 to Day 5 demonstrates a statistically significant decrease in stress and increase in confidence, p = 0.002 and p = 0.034 respectively (Table 1). Technical and Non-Technical Skills Student ratings, reflected in the 360° evaluations, increased each day of the ISW, showing modest improvement in attendings and peer perception of medical student’s non-technical skills (Chart 2). Student’s technical skills,

measured as percentage of students to pass a proficiency demonstration, showed a statistically significant increase from 59% ± 23 to 98% ± 4 (p = 0.005) (Table 1).

Surgical Instrumentation Identification The results of the fill-in-the-blank pre- and post-tests show scores increasing from 7% ± 9 to 98% ± 4 (p = < 0.001), and increase of over 90%, over the course of the ISW. A control group of 22 third-year students took the instrument exam after completing the required four-week general surgery third-year core rotation. A statistically

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

Table 1 ISW Pre-test and Post-test analysis using t-test parameters described above.

Surgical Instrumentation Identification (% score)

MS2 Pre-test Ave ± StDv (n = 22)

MS2 Post-test Ave ± StDv (n = 22)

7±9

98 ± 4

MS2 vs MS3 Surgical Instrumentation Identification (% score)

98 ± 4

MS3 Control Ave ± StDv (n = 22)

p Value p = <0.001*

26 ± 11

p = <0.001*^

Day 1 (Pre-test) vs Day 5 (Post-test) Self Reported Stress Levels (1–5 Scale) (n = 20)

2.8 ± 0.8

1.8 ± 0.8

p = 0.002*

Day 1 (Pre-test) vs Day 5 (Post-test) Self Reported confidence Levels (1–5 Scale) (n = 20)

2.4 ± 0.7

3.7 ± 1.6

p = 0.034*

Technical Skill Evaluation (pass/fail, % of passing students)

59 ± 23

98 ± 4

p = 0.005*

43 ±

49 ±

p = 0.003*

Pathophsiology and Patient Management (% score)

Notes: 1 tailed paired t-test, *significant, ^unpaired t-test

significant increased knowledge (p = < 0.001) was demonstrated by the students who completed the ISW (Table 1).

Pathophysiology and Patient Management A modest yet statistically significant improvement in pre- and post-test scores was observed (paired t-test, p < 0.0025) in the pre-test average (43.0%) versus post-test average (49.3%)29 (Table 1).

Discussion This is the pilot ISW course and predictably there are many improvements necessary to make future training more beneficial and efficient as well as improve data collection. The topic of areas of improvement has been extensively reviewed by Hunt et al. The highlights of Hunt’s review focus on the fact this is an initial course and as such, some of the metrics initially decided upon did not accurately reflect the knowledge gained throughout the week.29 This is validated by the modest increases in surgical knowledge and pathophysiology as demonstrated by the 50-point multiple choice pre and post-test. Hunt proposes that the teaching of textbook pathophysiology and surgical knowledge is redundant to the existing medical school curriculum and the ISW is better suited to focus on development of technical and non-technical skills.29 The primary goal of the authors was to show causality between student’s ability to manage stress response and gain confidence moving forward through a weeklong intensive training course. The data suggests that our hypothesis was correct and the short-term goal was

achieved with the ISW, but a more definitive measurement tool is needed to further support this relationship. Several other groups have used salivary cortisol as a point of measure. The authors feel this has promise and plan to evaluate the feasibility and practicality of implementation for next year’s ISW. The foreseen limitations include cost, establishment of accurate baselines, and achieving significance with a low “n” value. The results of the additional metrics show a significant short-term benefit to students who participate in the ISW in all areas analyzed as reported. Interestingly, the comparison of MS2 post-test scores to MS3 control group scores show the ISW better prepared students for surgical rotations by an increased understanding and knowledge of instrumentation, significantly exceeding the preparation achieved in MS3 surgical rotations. The universal improvement demonstrated in all analyzed areas validates the need to continue this course in the future with implemented improvements, as well as its value to future military medical providers. Previous literature clearly demonstrates that preparation for training under simulated stressful environments enhances skill performance in stressful conditions, both tactical military and medical situations. Stress induced cortisol has either detrimental or enhancing effects on preparation, depending on the levels of cortisol. Stress-immersion training allows acclimation stress and decreased levels of the cortisol-response, thus mitigating the potentially detrimental effects of stress on skill performance.

USSOCOM TCCC CASEVAC Set Program: A Retrospective and Overview

MS2 students surveyed after the ISW course expressed they felt more prepared and less intimidated by the situations they would face in the following two years. The authors plan to follow students into their rotation years and evaluate progress through evaluations by preceptors. Ultimately, increases in student confidence and preparedness were the over-arching goals of the ISW course. This, combined with significant improvements in all measured areas, makes the ISW a success.

9. 10.

Considerations for Special Operations The military Special Operations community has embraced this knowledge and implemented hyper-realistic training scenarios to prepare military members for deployments.30 RVU has taken the lead in incorporating these important findings into medical education, proving a stress-immersion emergency medicine and surgical training program for medical students that demonstrates increased proficiency and confidence as students enter third-year clinical training rotations, with implications of more efficient learning in subsequent training phases and increased patient care and safety. Continued collaboration between the Special Operations community and RVU will allow further development of these programs to maximize training and preparation for both military and medical personnel, providing the best possible outcomes in deployment and healthcare. References

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1. Arora S., Sevdalis N., Aggarwal R., Sirimanna P., Darzi A., Kneebone R. (2010). Stress impairs psychomotor performance in novice laparoscopic surgeons. Surgical Endoscopy; 24:2588–2593. 2. Stegeren A. (2009). Imaging stress effects on memory: A review of neuroimaging studies. Canadian Journal of Psychiatry; 54(1):16–27. 3. Harvey A., Nathens A.B., Bandiera G., LeBlanc V.R. (2010) Threat and challenge: cognitive appraisal and stress responses in simulated trauma resuscitations. Medical Education; 44:587–594. 4. Inslicht S.S., Otte C., McCaslin S.E., Apfel B.A., HennHaase C., Metzler T., Yehuda R., Neylan T.C., Marmar C.R. (2011). Cortisol awakening response prospectively predicts peritraumatic and acute stress reactions in police officers. Biological Psychiatry; 70(11):1055–1062. 5. Pugh C.M., Obadina E.T., Aidoo K.A. Fear of causing harm: Use of mannequin-based simulation to decrease student anxiety prior to interacting with female teaching associates. Teaching and Learning in Medicine; 21(2):116– 120. 6. Bellamy, R., Maningas, P., Vayer, J. (1986). Epidemiology of trauma: military experience. Annals of Emergency Medicine; 15(12):1384–1388. 7. Eastridge, B., Hardin, M., Cantrell, J., Oetjen-Gerdes, L., Zubko, T., Mallak, C., Blackbourne, L. (2011). Died of wounds on the battlefield: causation and implications for

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improving combat casualty care. The Journal of Trauma: Injury, Infection, and Critical Care; 71, S4–8. Holcomb, J. McMullin, N., Pearse, L., Caruso, J., Wade, C., Oetjen-Gerdes, L., Champion, R., Lawnick, M., Farr, W., Rodriguez, S., Butler, F. (2007). Causes of death in U.S. Special Operations Forces in the Global War on Terrorism 2001–2004. Annals of Surgery; 245(6):986– 991. Bellamy, R. (2007). A note on American combat mortality in Iraq. Military Medicine; 172(10):1023. Hetzler, M., Risk, G. (2009). Damage control resuscitation for the Special Forces Medic: simplifying and improving prolonged trauma care: Part Two. The Journal of Special Operations Medicine; 9(4):53–62. Holcomb, J. (2003). Fluid resuscitation in modern combat casualty care: lessons learned from Somalia. The Journal of Trauma: Injury, Infection, and Critical Care; 54, S46–S51. Holcomb, J., Stansbury, L., Champion, H., Wade, C., Bellamy, R. (2006). Understanding combat casualty care statistics. The Journal of Trauma: Injury, Infection, and Critical Care; 60(2):397–401. Kragh, J., Swan, K., Smith, D., Mabry, R., Blackbourne, L. (2012). Historical review of emergency tourniquet use to stop bleeding. American Journal of Surgery; 203(2): 242–252. Mabry, R., McManus, J. (2008). Prehospital advances in the management of severe penetrating trauma. Critical Care Medicine, 36(7), S258–66. Risk, G., Hetzler, M. (2009). Damage control resuscitation for the special forces medic: simplifying and improving prolonged trauma care: Part One. The Journal of Special Operations Medicine; 9(3):14–21. Antonoff M.B., Swanson J.S., Green C.A., Mann B.D., Maddaus M.A., D’Cunha J. (2012). The significant impact of a competency-based preparatory course for senior medical students entering surgical residency. Academic Medicine; 87(3):308–319. Fernandez R., Vozenilek J.A., Hegarty C.B., Motola I., Reznek M., Phrampus P.E., Kozlowski S.W.J. (2008). Developing expert medical terms: toward and evidencebased approach. Society for Academic Emergency Medicine; 15:1025–1036. O’Rourke M., Hammond S., O’Flynn S., Boylan G. (2010). The medical student stress profile: A tool for stress audit in medical training. Medical Education; 44: 1027–1037. Mourad M., Kohlwes J., Maselli J., Auerbach A.D. (2010). Supervising the supervisors-procedural training and supervision in internal medicine residency. Journal of General Internal Medicine; 25(4):351–6. Leblanc V.R. (2009). The effects of acute stress on performance: implications for health professions education. Academic Medicine; Oct. 84(10 Suppl):S25–33. Muller M.P., Hansel M., Fichter A., Hardt F., Weber S., Kirschaum C., Ruder S., Walcher F., Kock T., Eich C. (2009). Excellence in pre-performance and stress reduction during two different full-scale simulator training courses: A pilot study. Resuscitation; Aug. 80(8):919–24. Abercrombie H.C., Kalin N.H., Thurow M.E., Rosenkranz M.A., Davidson R.J. (2003). Cortisol variation

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in humans affects memory for emotionally laden and neutral information. Behavioral Neuroscience; Jun. 117(3):505–16. Beckwith B.E., Petros T.V., Scaglione C., Nelson J. (1986). Dose-dependent effects of hydrocortisone on memory in human males. Physiologic Behavior; 36(2):283–6. Kukolja J., Thiel C., Wolf O., Fink G. (2008). Increased cortisol levels in cognitively challenging situations are beneficial in young, but not old subjects. Psychopharmacology; 201:293–304. Kern S., Oakes T.R., Stone C.K., McAuliff E.M., Kirschbaum C., Davidson R.J. (2008). Glucose metabolic changes in the prefrontal cortex are associated with HPA axis response to a psychosocial stressor. Psychoneuro endocrinology; 33:517–529. Wang J., Rao H., Wetmore G.S., Furlan P.M., Korczykowski M., Dinges D.F., Detre J.A. (2005). Perfusion functional MRI reveals cerebral blood flow pattern under psychological stress. Proceedings of the National Academy of Sciences. 102:17804–17809. Segal, Stu. Strategic Operations Products. Retrieved 15 January 2012, from company product website. Website: (http://www.strategic-operations.com/products/cut-suit). Swing S., Bashook P. (2000). ACGME/ABMS Joint Initiative Toolbox of Assessment Methods. ACGME Outcomes Project. Version 1.1:1–19. Hunt B.B., Wall V.G., LaPorta A.J., Moloff A.L., Schoeff J.E., Tieman M., Lea M.S. (2012) New method of early surgical training uses the human-worn partial task surgical simulator in scenario-based stress-immersion training. Journal of Healthcare Simulation, Education, and Training; 3:25–28. Hellums J.S. (2012). A medical training event for Special Forces Medical Sergeants. Journal of Special Operations Medicine; 12(1):56–61.

2LT Genevieve Mueller is currently an HPSP medical student at Rocky Vista University where is she an active member of the University’s Military Medicine Honors Program. She previously worked as a biomedical engineer on USSOCOM funded projects related to battlefield hemostasis, limb regeneration, and hypertrophic scar reduction. Prior to commissioning, she spent 11 years enlisted in the Army Reserve with a Combat Support Hospital. Upon graduation in May 2014 she plans to begin an Army Emergency Medicine residency. Van G. Wall served as an army combat medic from 2003– 2007 before entering medical school. He is currently a third year medical student at RVUCOM in Parker, CO, where he has worked to develop the Military Medical Honors Track and the Emergency and Surgical Procedures course. Bonnie Hunt is currently a fourth-year HPSP medical stu dent at Rocky Vista University College of Osteopathic Medicine in Parker, CO, where she is an active member of

the Military Medicine Honors Track and implementation of the Cut Suit into medical education. She is planning to begin a General Surgery residency with the U.S. Army upon graduation in May 2013. COL Ian Wedmore, MD currently serves as the Emergency Medicine Consultant to the U.S. Army Surgeon General as well as program director for the U.S. Army’s Austere and Wilderness Medicine Fellowship. He has over 18 years experience in USSOCOM with multiple deployments. Alan Moloff DO, MPH retired from the U.S. Army as a COL after 30 years of service. He had numerous assignments to Special Forces and was the Commander of the 212th MASH, U.S. Army Aeromedical Center and the Defense Medical Readiness Training Institute. He is board certified in Aerospace, Undersea, and Disaster Medicine. He is currently a speaker, consultant, and educator for various companies and government organizations regarding military and civilian tactical medicine, all aspects of disaster medicine, and business development. Dr. Anthony J. Laporta, MD, FACS, retired from the U.S. Army as a COL after over 25 years of service. Dr. Laporta has served in every aspect of medical education and is currently the director of Rocky Vista University’s Military Medicine Honors Program MAJ James Schmid, DSc, PAS-EM, PA-C, is currently serving as Emergency Department staff and Program Director for the Army/Baylor Emergency Medicine Physician’s Assistant Fellowship. MAJ Schmid has over 10 years experience with USSOCOM and numerous combat deployments. Prior to commissioning, MAJ Schmid spent 15 years enlisted and served as a Special Forces Senior Medical Sergeant with Operations Detachment Alpha. He has just completed a research fellowship with DARPA. COL Rush, MD is the Chief of Surgery at Madigan Army Medical Center and the Director of Surgical Education for Madigan’s esteemed Andersen Simulation Center, the only Department of Defense education center to be accredited by both the Society for Simulation in Healthcare and the American College of Surgeons. In addition to appointment on the teaching staff in the surgical residency programs at Madigan Army Medical Center, he holds faculty appointments at the Uniformed Services University and the University of Washington. He is heavily involved in improving curricula and simulation platforms for first responders and forward surgical assets on the battlefield. LCDR Jonathan E. Schoeff, MD, FACS is a general surgeon and currently serves as the Deputy Chief of Professional Services for the 1st Medical Batallion, 1st Marine Logistics Group. He can be reached at Jonathan .Schoeff@usmc.mil.

USSOCOM TCCC CASEVAC Set Program: A Retrospective and Overview

Resourcing Interventions Enhance Psychology Support Capabilities in Special Operations Forces LTC Craig A. Myatt, PhD; J.W. Auzenne, MA

abstract This study provides an examination of approaches to United States Government (USG) resourcing interventions on a national scale that enhance psychology support capabilities in the Special Operations Forces (SOF) community. A review of Congressional legislation and resourcing trends in the form of authorizations and appropriations since 2006 demonstrates how Congress supported enhanced psychology support capabilities throughout the Armed Forces and in SOF supporting innovative command interests that address adverse affects of operations tempo behavioral effects (OTBE). The formulation of meaningful metrics to address SOFspecific command interests led to a personnel tempo (PERSTEMPO) analysis in response to findings compiled by the Preservation of the Force and Families (POTFF) Task Force. The review of PERSTEMPO data at subordinate command and unit levels enhances the capability of SOF leaders to develop policy and guidance on training and operational planning that mitigates OTBE and maximizes resourcing authorizations. A major challenge faced by the DoD is in providing behavioral healthcare that meets public and legislative demands while proving suitable and sustainable at all levels of military operations: strategic, operational, and tactical. Current legislative authorizations offer a mechanism of command advocacy for resourced multi-functional program development that enhances psychology support capabilities while reinforcing SOF readiness and performance. Keywords: resourcing interventions, psychology support capabilities, operations tempo behavioral effects (OTBE), personnel tempo (PERSTEMPO), Preservation of the Force and Families (POTFF).

Non-Clinical Interventions in Support of Psychological Fitness Any discussion that introduces the topic of “inter ventions” as they relate to psychological fitness and behavioral health might typically focus on clinical treatment, or therapy, offered in a clinical setting. The current

paradigmatic discussion shifts to non-clinical interventions. The scope of discussion offered in this text focuses less on clinically structured interventions and more on the structured processes of resourced behavioral health support that begin in the legislative branch of the USG and extend through the DoD and Services command channels to Service Members and their families in the SOF community.1,2 Resourcing for psychology support capability in DoD begins with authorizations and allocations in a Congressional budget process that is extremely complex.3 The premise of this text is that resourcing interventions are actions that support revenue planning and expenditure for programs, operations, or activities and that those interventions can be reasonably used to enhance psychology support capabilities uniquely tailored in SOF. The DoD witnessed a surge in threats to the psychological well-being of Servicemembers and their Families throughout Operations Enduring Freedom (OEF), Iraqi Freedom (OIF), and New Dawn. The prevalence of adjustment disorders, anxiety, depression, post-traumatic stress, and traumatic brain injury increased in the military. The incidence of those behavioral health concerns was lower in SOF than in conventional Forces from 2004 through 2011.4 The United States Congress reacted to the initial surge in threats to the psychological well-being of Servicemembers and their Families with responsive legislation that in 2006 began an increase in resourcing interventions across the Services (Table 1).5-11 Those resourcing interventions enhance psychology support capability not only in conventional units, but also in SOF units. The SOF component commands responded quickly to newly developed legislation. As the United States Special Operations Command (USSOCOM) Headquarters identified gaps in the delivery of psychology support capabilities, the Command responded with SOFCIDS/JCIDS (Special Operations Forces Capabilities and Integration Development Systems/Joint Capabilities and Integration Development Systems) structured program development that began with the SOF Resilience Enterprise Program

Table 1 Key Legislative Action Supporting Behavioral Health (2006–2012)

Military-Related Behavioral Health Laws Date

Legislation

January 6, 2006

Public Law 109-63 – National Defense Authorization Act for Fiscal Year 2006, Title VII, Sec. 721: Program for mental health awareness for dependents and pilot project on post traumatic stress disorder

September 29, 2006

House of Representatives Report 109-702 – John Warner National Defense Authorization Act for Fiscal Year 2007, Title VII, Sec. 735: Additional elements of assessment of Department of Defense task force on mental health relating to mental health of members who were deployed in Operation Iraqi Freedom and Operation Enduring Freedom

January 28, 2008

Public Law 110-181 – National Defense Authorization Act for Fiscal Year 2008, Title VII, Sec. 708: Inclusion of mental health care and report on mental health care services

October 14, 2008

Public Law 110-417 – Duncan Hunter National Defense Authorization Act for Fiscal Year 2009, Title VII, Sec. 725: Sense of Congress on research on traumatic brain injury & Sec. 733: Department of Defense task force on the prevention of suicide by members of the Armed Forces

October 28, 2009

Public Law 111-84 – National Defense Authorization Act for Fiscal Year 2010, Title VII, Sec. 714: Plan to increase the mental health capabilities of the Department of Defense & Sec. 726: Independent study on post-traumatic stress disorder efforts

January 5, 2011

House of Representatives Report 1540 – National Defense Authorization Act for Fiscal Year 2012, Title VII, Sec. 702: Mental health assessments for members of the Armed Forces deployed in support of a contingency operation, Sec. 703: Behavioral health support for members of the reserve components of the Armed Forces, & Sec. 711: Codification and improvement of procedures for mental health evaluations for members of the Armed Forces

January 7, 2011

Public Law 111-383 – Ike Skelton National Defense Authorization Act for Fiscal Year 2011, Title VII, Sec. 722: Comprehensive policy on consistent neurological cognitive assessments of members of the Armed Forces before and after deployment & Sec. 723: Assessment of posttraumatic stress disorder by military occupation

and evolved into the Resiliency Enterprise.12 Structured programmatic efforts offered a mechanism of command advocacy for program development and other functional support at the component level. Efforts spearheaded through the USSOCOM Command Chaplain’s Office emerged initially by Chaplain Family Advocacy program design and evolved first into a Pressure on the Force Tiger Team study13 and then later into the POTFF Task Force.14 Legislative action that supported the innovative development of Services programs in support of command interests addressing adverse affects of OTBE contributed meaningfully to the ability of commanders to assess readiness and behavioral health concerns in Servicemembers. The formulation of meaningful metrics to address SOF specific command interests led to a PERSTEMPO analysis in response to findings compiled by the POTFF Task Force.15 The review of PERSTEMPO data as monitored and handled at subordinate command and unit levels enhances the capability of SOF leaders to develop policy and guidance on training and operational planning that helps mitigate OTBE and maximize resourcing authorizations. Consistent with legislative concern and guidance well formulated since 2006, organizations such as the United States Marines Special Operations Command maximized higher headquarters command guidance and support to establish programs enhancing unit and individual performance while remaining responsive to the social needs of Family Members.16

Similar command directed programs exist in the Naval Special Warfare Command17 and the Air Force Special Operations Command.18

Resourcing Interventions As the number of SOF personnel reaches a projected strength of approximately 71,100 by 2015,19 the requirement for resourcing interventions that sustain psychology support capabilities will likely remain in effect based on Congressional legislative interests, DoD support, and Services program development. The bottom-up reality of such top-down legislative and command-driven support establishes resourcing interventions as actions that support revenue planning and expenditure for programs, operations, or activities. The SOF community strategically took advantage of dynamic resourcing opportunities to effectively enhance the delivery of psychology support capabilities, defined as an application of behavioral, cognitive, and social psychological skills intended to improve performance in organizations, groups, or individuals. Psychology support capability in SOF units is an integral part of interdisciplinary team development built into the POTFF.20 To gain an appreciation of how resourcing interventions initiated by Congress strategically impact behavioral health interventions at the unit level in SOF, one can gain insight from an application developed by David Cutler,

Resourcing Interventions Enhance Psychology Support Capabilities in Special Operations Forces

Professor of Economics at Harvard University.21 Cutler generates the premise that strategic behavioral health interventions are delivered at three levels: national, community, and individual. His manuscript identifies a strategic approach that can be applied to understanding how national legislative influence and resourcing interventions sensitive to bottom-up requirements in behavioral health and psychology support capability can effectively institute lasting change agency throughout DoD organizations. Cutler’s work is noteworthy. There is, however, no evidence in the literature that Cutler’s approach directly influenced legislation in Congress or the DoD response to legislation passed in support of military behavioral healthcare issues. In the DoD, Cutler’s levels of intervention are reflected at the national (strategic), organizational (operational), and small unit/ individual (tactical) levels of military organization. Continued legislative action for timely resourcing interventions endorses psychology support capabilities essential for SOF mission-focused leadership interventions at all levels. Resourcing interventions legislated by Congress provide an overall enhancement of psychology support capabilities in SOF units intended to sustain or improve performance at the team level. As authorized funding for an increasing force structure in SOF remains relatively stable through 2013, well-tailored command and leadership interventions will continue to promote the success of psychology support capability. Figure 1 shows funding through 2013 in millions (M) of dollars for: military construction projects (MILCON); research, development, test and evaluation programs (RDT&E); procurement base budget (Proc Base); operations and maintenance (O&M); and overseas contingency operations (OCO).22

Leadership Interventions While much of the Congressional legislation addressing military behavioral health generated since 2006 focuses on clinical psychology capabilities delivered in a clinical setting and coordinated communication between leadership and clinical support services (Table 1), SOF units have a unique capacity to embed psychologists in units outside of a clinical setting. The use of direct psychology support capability in units, and outside of a clinical setting, allows for doctoral trained psychologists and, when applicable, psychology technicians to provide psychology support essential for timely mission-focused leadership interventions. Those leadership interventions are consistent with psychology capability applications endorsed through Services programs such as the U.S. Army Comprehensive Soldier Fitness (CSF) Program.23 Long before OEF and OIF, SOF units recognized the value of incorporating psychology support capabilities in training to enhance mission functioning and performance

Figure 1 USSOCOM Total Obligation Authority (TOA) 2011–2013

at the unit and individual levels. Seminal projects such as Heckler’s24 work as a psychologist involved in unit training with Special Forces elements in the 1980s demonstrate a value added in incorporating psychology capability applications in SOF units at the team and individual levels. The SOF medic, such as a Special Forces 18 Delta in an Operational Detachment-Alpha team (Figure 2),25 also provides psychology support capability that is well worth discussing. The SOF medic offers leadership interventions and direct psychology support consultation with team members that reflects a measure of leadership intervention. That measure of leadership intervention is keenly noted when the medic maintains rapport with an embedded group psychologist and advocates from the bottom-up on behalf of individual team members. The SOF medic serves as an enabler for operational psychology.

Psychology Support Capabilities Morgan Banks demonstrates that the evolution of operational psychology in SOF reinforces a formalized assessment program for screening military members prior to assignment.26 The use of operational psychologists in SOF units outside of a clinical setting provides psychology support capabilities specific to the intense demands seen in SOF units, SOF personnel, and the families of SOF personnel. Legislative actions have encouraged efforts to explore expanding mechanisms for delivery of psychology support capabilities. In the Army, for example, the use of CSF Master Resilience Trainers offers basic leadership applications and techniques derived from well-established psychological approaches.27 The psychological approaches employed are based on behavioral and cognitive psychology principles and theory supported and developed by Karen Reivich at the University of Pennsylvania.28

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Figure 2 Special Forces Operational Detachment â&#x20AC;&#x201C; Alpha (ODA)

Congressional legislative measures have increased command and operational support for expanded use of psychology support capabilities in units. The appropriate and timely use of psychology support capabilities improves communication and interpersonal skills while reducing the stigmatization that can be associated with seeking access to behavioral health care in a clinical setting. The career lifetime management investment that the DoD directs toward all military personnel is high. It is higher in SOF. The use of psychologists in the assessment process and at the unit level helps provide leadership with a qualified perspective on preservation of the Force as it relates to career-life cycle management of individual Service Members and human factors affecting unit readiness.

The Way Ahead There is a meaningful, and quantifiable, return-on-investment for Servicemembers, their Families, the SOF community, and DoD when unit leadership sustains psychology support capabilities in SOF. Cutlerâ&#x20AC;&#x2122;s work suggests that resourcing interventions used to enhance psychology support capability are best implemented when leadership at all levels exercises qualified perspectives that yield clear SOF-specific outcomes. Effective methods of analysis in the SOF community and in conventional forces appear most effective when they are Service specific and tailored by leadership within each component. The formulation for metrics is not universal and may need to remain dynamic as the potential for future resourcing constraints surfaces in mainstream legislative action. Resourcing interventions that enhance behavioral health support throughout DoD serve to enhance psychology support capabilities in SOF. When first-line supervisors,

unit commanders, and organizational leadership are free to employ decision-making that reinforces the allocation of personnel effectively trained to observe and take appropriate action in support of the unit mission and its personnel involved, psychology support capability functions become an inherent aspect of leadership modeling and unit cohesion both in theater and garrison. The use of effective leadership decision-making across a unit can enhance unit resilience. In SOF units, specific skill attributes, such as effective communication techniques and situational awareness of uncharacteristic changes in individual behavior, are psychology support capability functions that can be reinforced through leadership efforts endorsing the use of psychologists embedded in units. A major challenge faced by the DoD is in providing behavioral health care that meets public and legislative demands while proving suitable and sustainable at all levels of military operations: strategic, operational, and tactical. An examination of approaches to USG resourcing interventions on a national scale that impact small units, teams and individuals in the SOF community was long overdue in 2006. Congressional authorization and allocation trends since 2006 support enhanced psychology support capabilities in SOF units. In 2012, with ongoing legislation that directly, or indirectly, endorses psychology support capabilities in SOF units, the POTFF is a well-structured vehicle for the way ahead. The continuation of resourcing interventions that enhance psychology support capabilities in SOF is much warranted. The POTFF offers a mechanism of command advocacy for resourced multi-functional program development that enhances psychology support capabilities and reinforces mission readiness and performance. Ongoing resourcing interventions at the national level will

Resourcing Interventions Enhance Psychology Support Capabilities in Special Operations Forces

continue to serve the SOF community well as legislative intent strategically supports SOF peculiar leadership decision-making that enhances organizational and unit resilience. It is inherent upon unit leadership to demonstrate the mission-focused value added in using psychology support capabilities in SOF units regardless of how a commander decides to define, resource, and utilize that asset. The benefit to SOF commanders, units, personnel, and Service Member Families of effectively utilizing psychology capability support is more closely observed today at the Congressional level than perhaps ever before. Disclaimer The views expressed in this paper are those of the author and do not reflect the official policy or position of the National Defense University, the Department of Defense or the U.S. Government. The content of this document was approved for public release by the National Defense University Public Affairs Office on June 12, 2012. References 1. Streeter, S. (2008, December 2). The Congressional Appropriations Process: An introduction. Congressional Research Service Report No. 7-8653. http://www.merkley .senate.gov/imo/media/doc/appropriations.pdf. 2. Tollestrup, J. (2012). The Congressional Appropriations Process: An Introduction (CRS Report No. 7-0941). 23 February. Retrieved from http://www.fas.org/sgp/crs/misc/ 97-684.pdf. 3. Saturno, J.V. (2004). The Congressional Budget Process: A Brief Overview (CRS Report No. RS20095). 28 Jan uary. Retrieved from http://fpc.state.gov/documents/ organization/34649.pdf. 4. Perdue, C. (2011). Defense medical surveillance system report from the armed forces health surveillance center, 7 March 2011.5. 5. National Defense Authorization Act for Fiscal Year 2006, Pub. L. No. 109-163, 119 Stat. 3338 (2006). Retrieved from http://www.DOD.mil/DODgc/olc/docs/PL109-163 .pdf. 6. John Warner National Defense Authorization Act for Fiscal Year 2007, H.R. Rep. No. 109-702, at 2 (2006). Retrieved from http://www.govtrack.us/congress/bills/109/ hr5122/text. 7. National Defense Authorization Act for Fiscal Year 2008, Pub. L. No. 110-181, 122 Stat. 3 (2008). Retrieved from http://www.DOD.gov/DODgc/olc/docs/pl110-181.pdf. 8. Duncan Hunter National Defense Authorization Act for Fiscal Year 2009, Pub. L. No. 110-417, 122 Stat. 4363 (2008). Retrieved from http://www.DOD.gov/DODgc/ olc/docs/2009NDAA_PL110-417.pdf. 9. National Defense Authorization Act for Fiscal Year 2010, Pub. L. No. 111-84, 123 Stat. 2197 (2009). Retrieved from http://www.intelligence.senate.gov/pdfs/military_act_ 2009.pdf. 10. National Defense Authorization Act for Fiscal Year 2012, H.R. 1540, 112th Cong. (2011). Retrieved from

http://www.gpo.gov/fdsys/pkg/BILLS-112hr1540enr/pdf/ BILLS-112hr1540enr.pdf. 11. Ike Skelton National Defense Authorization Act for Fiscal Year 2011, Pub. L. No. 111-383, 124 Stat. 4137 (2011). Retrieved from http://www.gpo.gov/fdsys/pkg/ PLAW-11publ383/pdf/PLAW-111publ383.pdf. 12. Swann, S. (2011). From the USSOCOM Command Surgeon. Journal of Special Operations Medicine. 11(3), 81–82. 13. Myatt, C. (2011). USSOCOM psychology: Commentary on information requirements and rapid response planning. Journal of Special Operations Medicine. 11(1), 59–60. 14. McRaven, W.H. (2012). Posture Statement of Commander, United States Special Operations Command before the 112th Congress Senate Armed Services Committee. 6 March. Retrieved from http://www.socom.mil/ Documents/2012_SOCOM_POSTURE_STATEMENT .pdf. 15. Zimmerman, F.B. (2012). USSOCOM Taking Care of the Force and Families to the Next Level. April. Tip of the Spear. 30–31. 16. Marine Corps Forces Special Operations Command. (2011). MARSOF. MARSOC Pub 1. 17. Oldham, C. (2012). Interview: Rear Adm. Sean A. Pybus, NAVSPECWARCOM Commander. Defense Media Network. January 2. Retrieved from http://www.defense medianetwork.com/stories/interview-rear-adm-sean-apybus-navspecwarcom-commander/. 18. Richard, L. (2011). AFSOC resilience. Air Force Print News Today. 9 November. Retrieved from http://www .afspc.af.mil/news1/story.asp?id=123274594. 19. McRaven, W.H. (2012). Posture Statement of Commander, United States Special Operations Command before the 112th Congress Senate Armed Services Committee. 6 March. Retrieved from http://www.socom.mil/ Documents/2012_SOCOM_POSTURE_STATEMENT .pdf. 20. Zimmerman, F.B. (2012). USSOCOM taking care of the Force and Families to the next level. April. Tip of the Spear, 30–31. 21. Cutler, D. M. (2002). Behavioral health interventions: what works and why? Manuscript submitted for publication. Retrieved from http://www.economics.harvard.edu/ faculty/cutler/files/interventions_6-02.pdf. 22. Reproduced from U.S. Special Operations Command FY2013 Budget Highlights, February 2012, p. 9. Retrieved from http://www.socom.mil/News/Documents/ USSOCOM_FY_2013_Budget_Highlights.pdf. 23. Pasquarette, J. (2012). Comprehensive soldier fitness: master resilience trainers course. 6 February. Presented at the University of Pennsylvania, Philadelphia, PA. 24. Heckler, R.S. (1992). In Search of the Warrior Spirit: Teaching Awareness Disciplines to the Green Berets. Berkeley, CA: North Atlantic Books. 25. Reproduced from U.S. Army Special Forces Green Berets, April 2012. 26. Banks, L. M. (2006). The history of special operations psychological selection. In A. D. Mangelsdorff, Psychology in the service of national security (pp. 83–95). Washington, DC: American Psychological Association.

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27. Pasquarette, J. (2012). Comprehensive soldier fitness: master resilience trainers course. 6 February. Presented at the University of Pennsylvania, Philadelphia, PA. 28. Reivich, K., & Andrew S. (2003). The resilience factor: 7 keys to finding your inner strength and overcoming life’s hurdles. New York: Three Rivers Press.

LTC Craig A. Myatt serves as Assistant Professor of Behavioral Science in the Strategic Leadership Department at the Industrial College of the Armed Forces, National Defense University. He served previously as the Command Psychologist at the United States Special Operations Command. He is a graduate of the Command and General Staff Officer Course; the Combined Arms Services and Staff School; the U.S. Army Medical Department Officer Advance and Officer Basic Courses; the U.S. Army Aeromedical Psychology Training Course; the Joint Special Operations Staff Officer Course; the Joint Special Operations Medical Orientation Course; the Survival, Evasion, Resistance, and Escape – Level C Course, and the University of Pennsylvania Master Resilience Trainer Course. He earned his PhD in Health Psychology at Walden University with a 2-year pre-doctoral fellowship in the Neuropsychology Section, Department of Neuro-Oncology, at the University of Texas M.D.

Anderson Cancer Center. His other assignments include battalion command of the 145th Medical Logistics Battalion; company command of Delta Company, 232d Medical Battalion; and medical platoon leader for the 2/11th Armored Cavalry Regiment and the 1-52d Infantry (Mechanized). His staff officer assignments include deputy G-4 for Task Force 3 Medical Command (Iraq); observer-controller and trainer in Task Force Bravo, 1st Brigade, 75th Division (Training Support); executive officer of the 10th Battalion, 5th Medical Brigade; assistant S-3 and S-6 in the 228th Combat Support Hospital; biomedical information systems course developer in the Center for Healthcare Education and Studies at the U.S. Army Medical Department Center and School; and biomedical information systems officer in the Office of the Deputy Chief of Staff for Information Management at the United States Army Medical Command. J.W. Auzenne is a graduate intern in the Strategic Leadership and Economics Departments at the Industrial College of the Armed Forces, National Defense University. He earned his Master of Arts in International Affairs from the Bush School of Government and Public Service at Texas A&M University, and his B.B.A. in Finance from Texas A&M’s Mays School of Business.

Resourcing Interventions Enhance Psychology Support Capabilities in Special Operations Forces

War Time Medicine on a Peace Time Mission Steven Reynolds 18D; Ashley Neal Mclemore; Austin Squires 18D

Abstract As we realized the MEDEVAC from JTF-B was not going to happen, the words of instructors from the Joint Special Operations Medical Training Center (JSOMTC) echoed through my head, “Men, pay attention to this. There will be a day when you, as Deltas, will have to sustain a patient for hours, possibly days; this is what separates you from any other medical professional in the military, so shut up and stay awake.” We had heard those words every time we started a new section of Special Forces Medical Sergeants (SFMS) course. Now those words were staring right back at us in the form of the patient’s friends and family. We looked at our patient in the back of that beat up truck and knew we could keep our patient alive. We had the knowledge and the equipment; we just didn’t know how much longer we would have to sustain him.

In January of 2012, Operational Detachment-Alpha (ODA) 2323 began preparations for our Counter Narcotics and Terrorism (CNT) mission to Central America (CENTAM). Moving through Camp Shelby, MS, and then to 7th Special Forces Group at Eglin Air Force Base, FL, our team began its planning phase of the operation. After a few days building pallets and preparing to go to CENTAM, the team was in good spirits as we flew to Soto Cano Air Base near, Comayaqua, Honduras. Soto Cano is a Honduran air base and is also the home to the Honduran Air Force Academy. Soto Cano also shares its gates with Joint Task Force-Bravo (JTF-B), a joint military compound. JTF-B’s mission states: Joint Task Force-Bravo, as guests of our Honduran host-nation partners and the senior representative for USSOUTHCOM at Soto Cano Air Base, conducts and supports joint operations, actions, and activities throughout the joint operations area maintaining a forward presence in order to enhance regional security, stability, and cooperation. After a few days at Soto Cano, our team moved out and to our respective locations. Our ODA was to be a split

team between the two Special Forces battalions of our partner nation. One half would be with the 1st Battalion, in the southern part of the country, and the other half would be with the 15th Battalion in the north. Problems arose quickly as we were splitting up when the senior 18C (Special Forces Engineer), and Senior Non-Commissioned Officer (NCO) for the southern split, had a family emergency back home and was to be flown home, not to return to CENTAM. This meant that our split in the north was to lose a senior NCO. My senior 18D (Special Forces Medical Sergeant) and another junior 18C went to the 1st Battalion with my senior 18D to be the new senior NCO for that split. This meant that I was now the only Delta (18D) on the team, straight out of the Q-course, and with no experience other than civilian medicine. Luckily, I had knowledgeable and experienced Operators with me to answer my questions and to guide me along with team specific tasks. This, along with my training, eased my mind. The training calendar wasn’t too hectic the first month of getting to our battalion. I had run a simple Combat Life Saver (CLS) class for some of the partner nation guys to prepare them to be first-responders to accidents in the area during Semana Santa, the holy week during the time of Easter. Aside from occasional ranges and waiting on the partner nation’s command to start the next Comando course (their Ranger school), the team was trying to find a way to get to our real training objective. The remote Central American village was inaccessible by roads, but our battalion was sending soldiers there by helicopter to support their mission. We knew this village could be an incredible opportunity to get out into the country with the soldiers and conduct training that hadn’t been attempted since the 1980s. We received our other Delta in April. SSG Squires had just completed a Joint Combined Exchange Training (JCET) with 2/20th Group and wanted another run in CENTAM. We already knew each other from the 18D course where we met on Saint Mere drop zone, Fort Bragg, NC, on one of the jumps Deltas performed every two months. There, we also found out we were in the

same company back in Mississippi. For the next month, we ran medical coverage for the 15th, instructed a twoweek Tactical Combat Casualty Care (TCCC) course for the medics of the base, and got equipment and supplies ready for our Field Training Exercise (FTX) to our remote village. Squires would be going out before me to set up the house and assess the area’s medical capabilities. I’d be lying if I didn’t say I was a little upset that he got to go before me, but I placed my mild jealousy aside and knew I’d be out there soon enough. On 11 May the team sat down in the team room to listen to a brief from a LTC about the events in Colombia and to receive our new 180A (Assistant ODA Commander). We hadn’t heard much about him, but SFC Underwood knew him, and that was all we needed to know about this man. We quickly realized we would enjoy CW2 Jett. Unfortunately for Chief, the pleasantries of handshakes and names would have to wait. The team of SSG Hare, SSG Squires, and SSG Francis were ready to load the plane and get into the remote village to start the FTX. Immediately after they jumped into the pre-packed truck and drove to the airfield to meet the State Department pilot. We had coordinated with them to use their PC-6 (a 6–10 passenger, single engine, Short Take Off and Landing) to get our three men and equipment to the village’s tiny airfield. Upon infiltration into our area of training, the team linked up with the Soldiers from the 15th battalion, and the training began. SSG Squires would have the next few weeks to assess the medical capabilities of the area, the school system, and sanitation of the house where the ODA and Honduran soldiers would be living. Assessing the medical capabilities was a task that any Delta would want to know about the area where he was working; however, the school and sanitation assessments would be sent to higher headquarters so a Civil Affairs team could be sent to the location with different supplies. These actions could possibly improve the quality of living in the area. SSG Squires would have his hands full with patients in the area hearing of the “new American doctor” who had medication and knowledge. Some days he would see no patients, and the next day, he would see 15 patients with anything from rashes to muscle aches. Day to day, he was winning the hearts and minds of the locals. While the rest of the team was in conducting the FTX, day-to-day operations were still going on at the 15th Battalion base. We had rifle and pistol ranges, classes, and hopes of starting a new Comando Course loomed in the future. It was just another day before a local stopped SFC Underwood and myself about an animal he had trapped. Well, curiosity got the best of us, and we wanted to see the animal. It was quite the sight at 0700 in the morning to see an anteater tied to a rope, clearly suffering and in pain. We weren’t going to negotiate over a price with the local; we just left and made a phone War Time Medicine on a Peace Time Mission

call to 15th Battalion Logistics Officer (S-4). They had the authority to take animals in distress or endangered animals from the local populace if they were in danger of hurting others or being hurt. It just so happened that this anteater had the padding of her hands torn off from a trap or neglect. So the CPT and some of his men went to the gentleman in town and commandeered the animal from him with no incident. As they brought it back to the base, I was making plans to sedate the animal and clean its paws to be released back into the jungle somewhere in the area. The 15th Battalion has quite the abundance of jungle that would make for an exceptional home to the anteater. I researched anteaters and found that 10– 20mg/kg of Ketamine with an additional 0.1mg/kg of Diazapam is used for the animal in a zoo environment. The following day, this was what I used on the 2kg anteater the next day for the cleaning.

Case 1 I was trying to get some rest for the next day when knocking at the door woke me at 2230. We always had a person at the Operations Center (OpCen) over night to watch sensitive items and monitor the radios for traffic. There stood the CPT and the Base Commander with his jaw in his hand, in apparent pain. A Honduran colonel had a cleaning that afternoon from his usual dentist and complained of radiating pain along his jaw that originated from tooth #31. He also had an amalgam filling placed inside the tooth that afternoon, but did not have pain when he left the dentist’s office. The skin around his jaw and face had no significant findings and he denied any pain originating from his cheek or muscles. He also denied having sensitive gums around the tooth. He described the pain as “electric and radiating” from the tooth. He also denied pain from pressure and percussion applied to the mandible/maxilla. He also had no pain upon palpation of his submandibular, anterior, and posterior lymph nodes. I decided to treat his symptoms with an inferior alveolar nerve block and a buccal nerve block (Figure 1). Using an injection of Xylocaine with Epinephrine 2% at the appropriate sites, the colonel’s pain began to subside. I monitored the colonel for any reactions to the medication, and I also gave him five pills of Tylenol 3 with instructions to take one pill with food every four hours, in order to continue pain management. I then made it clear to make arrangements to see his primary dentist as soon as possible to follow up. He understood all of my instructions and insisted that he would comply. I also asked him to only eat soft foods until his pain subsided or his dentist approved another plan of treatment. He returned two days later saying he was out of pain medication, and he was seeing his dentist that afternoon. I then gave him three Percocet with instructions to take one pill with food every four hours, in order to continue pain management. He saw his regular dentist

Figure 1 Reynolds treating the COL’s pain by performing an Inferior Alveolar Nerve Block.

Figure 2 Reynolds and PN medical assistant cleaning Renee’s wounds sustained from the trap.

that afternoon and was prescribed another medication. We spoke that evening about his unexpected visit to our OPCEN and how he never knew that Deltas could perform dental procedures. The colonel was only a year old to the battlion and had worked with U.S. SF before, but had never been a patient. Treating the colonel that evening was nothing short of ordinary for a Delta, but the trust and faith in our capabilities he had now would stay with him the rest of our time in CENTAM.

Figure 3 One of the injuries before cleaning.

Case 2 After we got the tooth difficulty under control, we were able to turn our attention back to the distressed animal we had commandeered earlier. We sedated the 2kg female anteater using 30mg IM of Ketamine (15mg/kg) and 0.2mg IM of Diazepam (0.1mg/kg). I had one of the partner nation soldiers, who was a part of the medic class we had taught earlier, assist me during the cleaning of the animal’s claws. After the animal was sedated, we began using gauze and clean water to remove gross contaminants and debris (Figure 2). Once we had removed all we could, I started soaking the wounds in a 10:1 solution of water and Betadine for approximately 15 minutes. Once completed, the wounds were scrubbed gently with Betadine and water and then wrapped with non-adherent pads and wrapped in gauze (Figure 3). The partner nation medic and myself monitored the patient every 15–20 minutes during the procedure for heart rate (HR) and respiratory rate (RR) (Figure 4). Monitoring HR and RR proved interesting as my pulse ox wouldn’t fit over her claws. My assistant and I found that using my stethoscope was the best method to record vitals. After both wounds were cleaned and wrapped, I looked through the patient’s coat for other signs of trauma, infections, and parasites. None were found, and the p atient was placed outside in sunlight until alert and able to

Figure 4 Reynolds helping the PN medic to find Renee’s heartbeat.

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

walk. About two hours after the initial sedation, she was alert and walking around the base. She stayed in a tree outside of our team room, still attached to the leash, for the duration of the night and then was retrieved the next morning. The patient had normal behavior and seemed unaffected by the anesthesia. We then removed the gauze and let the patient off the leash. She found a large tree on the compound where she still lives today. Renee has been named an unofficial mascota, or pet, by the base.

Case 3 The ODA members on the FTX had been in the village for almost a month when SSG Squires had his first trauma. A 13-year old male presented with excruciating pain in his lower right leg to the shotgun house, where three ODA members and fifteen Honduran soldiers where living during the FTX. SSG Squires had the boy brought in the fenced area and placed onto a table. He then asked that only one of the people who helped bring the boy remain, as the rest would need to stand outside the fence for security reasons. SSG Squires asked the boy to tell him what happened to cause so much pain. The boy described that he had been playing soccer when another player tackled him. He heard a loud pop, and he immediately couldn’t move his leg. He said it was the worst pain he ever had in his life. Squires then made a full assessment of the boy, finding nothing else to be affected other that the right leg. On closer inspection of the point of impact on the leg, audible crepitus was heard and Squires immediately checked for distal pulse. He couldn’t feel a pedal pulse initially, and he attempted to reduce the fracture with steady traction. He then tried to palpate the pedal pulse again and found the pulse this time. The boy’s leg was then splinted in a position of function, and pulse was again reassessed. SSG Squires began telling the Honduran soldiers to bring him the hard litter for transport to the clinic as he thought about pain management. The boy’s vitals were elevated from the pain, but he was in stable condition. His blood pressure (BP) was 128/84 with a heart rate (HR) of 90bpm. SSG Squires then injected Promthazine 25mg IM and taped one 800mcg Transmucosal Fentanyl applicator to the boy’s right index finger. The litter was brought to table, and the patient was secured to it with extra padding and support around the broken leg. Once secured, Squires removed the Fentanyl from the patient and discarded the rest. After monitoring him for 15 minutes to ensure respiration rate was unaffected, Honduran soldiers then moved the patient to the nearest clinic about two miles away. The Honduran soldiers would take turns carrying the litter through the heat and humidity. Luckily, the clinic had a doctor this particular week that could further help the boy. The doctor received the flow sheet with all interventions written on it and was briefed on what occurred with the patient. War Time Medicine on a Peace Time Mission

It’s easy to forget that a Delta for most remote CENTAM villages is the only medical professional for miles around. This particular patient could have easily permanently lost blood flow to the leg affected and it may have become gangrenous. Amputation is a life-changing event in any country; it’s amplified when you rely on walking as much as the locals in these villages do. With one medically trained person across the road, this patient kept his leg. I remembered hearing these events for the first time and thinking he is extremely lucky to have a Delta right there and a doctor at the clinic. In just a few days, we would meet another very lucky patient who would have two Deltas just a 4-wheeler ride away. I had finally gotten the green light to go to the FTX in our village about the same time Squires was handling the young man’s leg. I had been fighting to get out there for weeks, but the situation wasn’t right back at the 15th Battalion. The battalion needed the medical coverage of a Delta there to support them during ranges and other training. Chief Jett fought to get me out there and fixed the medical situation by having another Delta come to the 15th Battalion to cover in my absence. As soon as I was told I was heading out, I starting packing and planning. Our 18-E (Special Forces Communications Sergeant), SSG Francis, had just switched with SSG Braun as the 18E at the FTX and Francis was back at the 15th. With SSG Francis feeding me information about the conditions, I was able to get an idea of what I could do as another Delta in the area. Day-to-day talks with SSG Squires about what they needed and what I could bring made packing easy as well. My own equipment, more medical supplies, more building supplies, and diet colas were needed to accomplish the mission. On 5 June, I loaded the CH-47 Chinook helicopter with building supplies, medical supplies, and a few diet colas for the ODA. When we landed, I was greeted by my teammates on ATV’s and Honduran soldiers guarding the helicopter-landing zone (HLZ). The HLZ was no more than a borrowed soccer field in front of the house where we would be staying. We unloaded the helicopter, secured the supplies to the ATVs, and drove across a dirt road to our home for the next few weeks. The building was a lifted wooden shotgun house with rooms that were meant for one person, but each had two or more people in them. Everyone had cots that the ODA obtained before the initial push into the village. The partner nation soldiers usually slept on the floor on sheets or whatever they could find on these types of missions and were extremely grateful to be off of the ground. The variety of food choices was limited, with beans and rice being the staple to every meal. Meat was a luxury and in short supply after the ODA and partner nation soldiers had finished off most the water buffalo they killed earlier. The water was being hand pumped from a natural well

on the property and purified using an Aspen Purification System. The Aspen provided clean and potable water for all the Soldiers in the house with plenty to spare for the Honduran soldiers who cooked. We stored the water in six to seven 5-gallon containers in the kitchen with a simple wash station and small table for storing utensils and plates. The kitchen/eating area was a circular hut outside and away from the house that kept the partner nation soldiers from carrying their food into house and attracting even more creatures from nature. Along with the rest of the supplies, I had brought a water pump for the well and piping to build an outdoor shower for the men that would provide a much needed boost for moral and hygiene for an already sweaty and mildly odori ferous group of men. The land around the house was not much over a half acre with a handmade barbwire fence around the perimeter. The ODA had built sandbag watch points for the guards and placed sandbags against the wall facing the only road in the area to increase the Force Protection (ForcePro) of the “compound.” When the Soldiers weren’t conducting training, they were enjoying themselves as anyone does in CENTAM, by playing fútbol. Soccer was a staple of any Latin culture, and the soldiers in the army took it just as seriously. After I got my equipment in order, I was spun up on the current events and training that was being conducted. SSG Squires briefed me on the medical capabilities of the area and possibilities to improve the situation in the future. We were hindered by the fact that no roads led to where we were training and the only infiltration platform was by air assets. After chow, the ODA sat down put out the training schedule with the Honduran Capitan, and they discussed ideas. We had planned events that would take up our week, but our FTX was about to turn into a real scenario in which every person, ODA and partner nation soldier, would execute their role without hesitation or question.

with natural fauna of the area. Everyone had mosquito nets with their cots, but the netting was no match for some of the mosquitoes. I had just gotten to sleep when I heard a phone ringing in the next room. Such things were normal, and I easily fell back into a deep sleep. “Wake up Deltas! Get it on! We got a soldier shot up in town!” 2300: SSG Hare shouted from the room across the hall to alert the med shed, and we began donning our gear. Hare was woken by our partner nation capitan with an initial report that a Honduran naval sailor or soldier had been shot by a local in town. The Captain had made contacts and friends in the town to alert him in case of this type of situation. Quickly, the soldiers and ODA dressed and armed themselves, and separated into groups. SSG Braun had two Honduran soldiers on his ATV and would be the lead element into the town. Following closely behind were Hare and Squires with one partner nation soldier on another ATV. The last ATV had our captain and two other partner nation soldiers acting as security. Two partner nation soldiers and I remained at the house as a reserve element to receive casualties in the event that there was more than one. 2315: All three ATVs left the fence in a cloud of dust, and I began giving instructions to the Honduran soldiers on how we would conduct triage if the situation arose. I showed them the choke point where I would classify the patients, the different areas for the patients, and how to assist me if needed. We also discussed how to maintain security of the area in case civilians started approaching the wire to get a look at what was going on at our house. All of the information would prove moot for the moment as I started to hear an ATV coming down the road. “LETS GO!!”

Case 4 On 9 June our day started with an uneventful buffalo hunt through knee-deep swampland and almost ended the same way. We were tired, wet, and hungry from trudging through difficult terrain, but we were somehow still in high spirits. We had left that morning with the sun coming up and returned to see it set. Food awaited us as we grabbed our plates to discuss the day’s events and tomorrow’s plans. We always had a short team meeting every night to make sure the training schedule was being met and everyone was on the same page. After the meeting, SSG Hare would call SFC Underwood to talk about the schedule and keep the team command in the know on a daily basis. It wasn’t much longer after the evening phone call that we decided to crawl underneath our mosquito nets and listen to a symphony of insects. Silence was a luxury in our house as the walls crawled

2335: SSG Braun found the injured individual lying in a village street with wounds sustained from the Honduran navy. While Braun began rendering care, Hare had returned to the compound to grab me to assist with the only casualty they found during the search. I jumped on the back of the ATV with Hare driving and telling me that at 2330, Braun found a 28-year old Hispanic male lying in the road with two other locals around the male. He then started working on the patient as he called for Squires on the radio to come to his position. SSG Braun, an 18E, was an EMT Intermediate as a civilian and had also received cross training from Deltas in Combat Lifesaver (CLS) and some TCCC. After ensuring security around him and donning gloves, Braun applied a Combat Application Tourniquet (CAT) to the left arm to stop the bleeding from one gunshot wound (GSW) near the brachial artery. He then applied a HyFin Chest Seal

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

to the left pectoral GSW and checked for a good seal. After doing this, he noticed blood from the abdomen and directed a Honduran soldier to apply direct pressure until one of the Deltas arrived with a proper abdominal dressing.

patient was removed from the ATV and placed on the ground with the litter. The local doctor was called by the Honduran Capitan to come and open the clinic, but we would have to wait 20 minutes before he could arrive and open the doors of the clinic. This was about the time when Hare and I arrived on our ATV.

Figure 5 Squires assesses airway while Reynolds preps to

“Get these people back! Get the patient inside!”

start IV

2344: While I was still on the back of the ATV headed towards the action, Squires arrived and took over from Braun. SSG Squires put on gloves and began his assessment of the patient while Braun began pushing partner nation soldiers further out to ensure a greater security perimeter. SSG Squires began looking for life threatening hemorrhaging and found that the GSW to the left ring finger, left forearm GSW just distal and medial to the antecubital fossa (entrance), and a GSW distal to olecranon process (exit) were still slightly bleeding. He then applied another CAT more proximal to the previous tourniquet until all bleeding stopped. After this, he then marked on the patient’s forehead and on the tourniquet the time of 2346. Checking for further signs of hemorrhage, Squires found the abdominal GSW in the left upper quadrant was not being adequately controlled with just the partner nation soldier’s hands. He then applied an abdominal dressing to control the bleeding and continued his assessment. During this time, the patient’s airway was not compromised as evidenced by the fact that the patient had been talking to the partner nation soldier and Squires. At this time, the decision was made to secure the patient to the Talon litter and move the patient. Utilizing an ODA trained medical assistant, Squires rolled the patient onto his side while the partner nation soldier maintained C-spine control. SSG Squires checked for downside wounds and rolled the patient back onto the litter. After assessing all interventions, they moved to patient on ATVs to the nearest clinic. After arriving, the War Time Medicine on a Peace Time Mission

0005: SSG Hare began asking the Delta for a status on the patient to be able to plan for transport. SSG Squires and I decided without surgical intervention, the patient would only have a few hours. The family’s plan was to take a small boat down swamp and creeks at night, to a clinic five hours away. A family member was sent to the boat and found that the motor on the boat wasn’t working. SSG Hare then told the Deltas he would arrange for medical evacuation (MEDEVAC) thru JTF-B. As I started exposing the patient and examining the extremities, Squires found the patient to be awake and oriented but complained of difficulty breathing. The language barrier was a challenge in itself. The language was something to Spanish like Cajun is to French. We could communicate efficiently but we had to use different words than we were taught in the classrooms. With the patient having difficulty breathing, SSG Squires gave the Honduran medic a bag valve mask and instructed the soldier how to clamp and assist breathing correctly. SSG Squires then began his head to toe assessment. He found nothing significant until the chest. He heard diminished breath sounds on the left with hyper resonance and unequal rise and fall. He then performed needle decompression at the second intercostal space, left mid-clavicular line with a 14-gauge needle (Figure 7). After 30–40 seconds, the patient said he felt better breathing for the time being. Vitals at this time were HR 85, RR 12 with assistance, BP 90/palp, with pulses slightly weakened, yet equal. I then started an IV with a 16-gauge cathlon and 1L 0.9% normal saline (NS) bolus wide open to stabilize his blood pressure (Figure 6). Immediately after I secured the IV, the clinic doors opened, and we moved the patient inside off of the street. We knew the clinic didn’t have a lot as far as supplies go, and we would mainly be working out of our aid bags, but any little bit would help. Both of us wanted to use Hextend to help stabilize our patient. We had packed it in a separate truck back for the ATV’s, but the bag was left at our house. Neither of us had Hextend in our personal bags so we continued using NS. 0015: After placing the litter onto the table in the clinic, we immediately started reassessing all of our interventions. At this time, the ABD dressing was starting to show blood on the outer edges of the bandage and had shifted during transport. We removed the dressing and

Figure 6 Squires continues assessment, Reynolds starts IV. It’s important to remember that this total darkness without our head lamps, the flash of the camera gives a false sense of light around us.

pressure, one quarter turn every 20 seconds. Not noticing any bleeding through the pressure dressing, the tourniquet was released and successfully converted. The bolus IV was changed to a 500cc 0.9% NS TKO, and a Foley Catheter was placed to monitor urine output. We received 150cc on the initial output, which was sufficient to let us know that his kidneys were still functioning. Vitals were stable, and we started pain management with Tramadol 100mg IM in the left hip at 0030 given by the doctor of the clinic. Figure 8 Hare coordinating air assets for MEDEVAC.

Figure 7 Squires administering needle decompression inside the clinic.

“Where’s our air?!”

applied a new dressing while observing mild oozing of blood from the wound. Most likely, the patient’s BP was rising to normal during fluid resuscitation, which would definitely be a positive sign for the patient. 0020: SSG Hare informed us that JTF-B was to awaken the MEDEVAC crew to possibly fly out and assist the ODA. The bird would arrive in 2.5 hours, so the decision was made to reduce the tourniquet to only a pressure dressing. We applied Combat Gauze™ to the wound and wrap an ACE™ bandage tightly around the gauze to maintain pressure. After assuring the pressure dressing on the left arm was in the correct position, the tourniquet was released and I slowly spun the dowel, relieving

0040–0300 hrs: Vitals were taken every 15 minutes by Squires or myself during our 30 minute rotations with the patient inside the clinic. At 0300, the patient began to have growing pain in his abdomen. We wanted to give the patient a longer lasting effect of pain management with 25mg promethazine IV from the bag, 15mg morphine IM, and 5mg diazepam IV from the bag. The pain resided, and the waiting game continued with JTF-B and our helicopter. SSG Hare was busy making sure we had a backup plan with State Department assets in case we needed them. 0315: We moved the patient from the clinic to a local’s truck to transport to the HLZ in anticipation of our MEDEVAC landing soon. Right as we started to pull away from the clinic, Hare received word from JTF-B that they would not be flying to our location for numerous reasons. As we realized the MEDEVAC was not going to happen, the words of instructors from the Joint Special Operations Medical Training Center (JSOMTC) echoed through my head, “Men, pay attention to this. There will be a day when you, as Deltas, will have to sustain a patient for hours, possibly days; this is what separates you from any other medical professional in the military, so shut up and stay awake.” We had heard

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

those words every time we started a new section of the Special Forces Medial Sergeants (SFMS) course. Now those words were staring right back at us in the form of the patient’s friends and family. We looked at our patient in the back of that beat up truck and knew we could keep our patient alive. We had the knowledge and the equipment; we just didn’t know how much longer we would have to sustain him. The ODA then received word from the State Department assets that they could support or MEDEVAC and would be landing at our location in two hours. We moved our patient to our compound and set up a secure perimeter around the HLZ (Figure 9).

f inished final rehearsals with the partner nation soldiers. At 0540, we heard the bird over the horizon, which signaled Braun to throw red smoke so the pilots could confirm our HLZ. When the bird landed, I had the partner nation soldiers carry the litter to the helicopter and help me properly secure it. As we gained altitude, the patient’s abdomen became painful again. To alleviate the pain, I taped one 800mcg transmucosal fentanyl a pplicator to the patient’s right index finger, which reduced any pain the patient would have for the duration of the one hour flight. With the patient resting comfortably, I continued to monitor vitals every 15 minutes until we landed (Figure 10, 11).

Figure 9 Squires assesses patient at our house, while Braun

assists.

0350: We changed IV fluid for another 500cc 0.9% NS TKO while monitoring urine output. With the fluid change and the patient’s kidneys functioning, we then mixed and gave 1g cefazolin into the IV bag for preventive medicine. While the patient rested as much as he could, Squires continued to monitor and record vitals every 15 minutes while I prepped my bag to ride the bird with the patient.

Figure 10 Securing patient to the helicopter.

Figure 11 Reynolds arrives at base to transport patient by partner nation military ambulance to local hospital.

“POP SMOKE!” 0530: SSG Braun and Hare had been running all night ensuring security and communications with higher. SSG Hare always seemed to be talking to someone at JTFB, State Department, or Chief Jett. SSG Braun ensured communications never failed and made sure the Deltas had plenty of security around us at all times. Now we could start to relax and wait on the helicopters to land. The HLZ was fully secured and the family was saying goodbye to the patient before we pushed all civilians back another 50 meters from the soccer field. We received word that the bird was less than 10 minutes away as we War Time Medicine on a Peace Time Mission

0640: We landed at the Honduran air base where there was a military ambulance and paramedic ready to take over with transportation. I then quickly briefed the paramedic on what had been done and handed over the

patient’s flow sheet and personal information. As the ambulance drove off, the local command for the State Department and a member of JTF-B greeted me and offered me breakfast. I’ll call that a good ending to a notso-good night in the middle of the jungle.

Figure 13 Boat training with Hare, Francis, Squires and partner nation soldiers and sailors.

The next morning, Chief Jett traveled to my location so we could both go visit the patient and see how his recovery was going. After tracking the patient down in the recovery room, we spoke to him about the night and its events. After hearing his story, I let him call his family from my phone to tell them he was doing well. Considering he had just had abdominal exploratory surgery and was able to walk, I’d say he was doing a lot better than the previous night. At the end of our conversation, he thanked the team and me for help we provided the previous night. He was extremely fortunate to have two 18Ds, experienced Operators, and Honduran soldiers that worked together to save his life (Figure 12). After arriving back at the 15th Battalion, we lost contact with the patient and his family. Unfortunately, I cannot give an accurate update on his health or quality of life. We hope for a speedy recovery for him.

Figure 12 Patient after surgery

After visiting with the patient and allowing him to talk to his family, I was flown back to our FTX to finish the exercise. Twelve days later the team left the FTX, on our own accord, by local supply barge from the town’s dock at first light of day (Figure 13). What would have been a quick 8-hour ride was a 23-hour movement due to the ship stopping at every town along the coastline to drop off supplies to the people that needed them. We made the best out of the ride and enjoyed an occasional nap and took in the beautiful scenery around us. Upon arriving at the dock in the town near our battalion, we unloaded all of our equipment and personnel in the hours before dawn tired and wore down from the tossing ocean. After an amazing sleep it was back to work at the battalion. More training and work was to be done and no one expected a break. We did, after all, volunteer for our job.

The MEDEVAC that transpired in this story was not a glorification of 18Ds, but a timeline of an ODA and partner nation soldiers that worked together to accomplish something phenomenal. SSG Braun, an 18E Communications Sergeant, was the first person to apply life-saving interventions on the patient. By simply placing a tourniquet, he prevented life-sustaining red blood cells from being lost. By applying a chest seal, and ensuring it was correctly applied, he prevented a sucking chest wound. SSG Braun’s willingness to learn, and his civilian medical training played a vital role in the saving of this patient’s life. SSG Hare, an 18B Weapons Sergeant and NCOIC during the FTX, performed command and control (C2) like an experienced officer. It may have to do with the fact that he was once an Army Captain with the Transportation Corp before resigning his commission to become a Special Forces Operator. It was his coordination that led to a successful MEDEVAC, so the Deltas could focus on medicine and not logistics. The Honduran soldiers provided security, support, and translations when needed. They were happy to help save a life of a fellow Honduran, and we still hear the stories about how they did. The people involved at the State Department that allowed us to use their helicopters to evacuate our patient also saved a life. Sending the patient on a boat ride with zero medical support was the next option had the State Department not come through. Overall, this was a collaborative effort from everyone there, not just the Deltas. Honestly, it would’ve been a lot harder to accomplish without the help of my teammates (Figure 14).

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

Figure 14 Exfil Day from our FTX

Case 5 On 17 July Squires and I were staged at Soto Cano for an airborne operation with Honduran Paraquidistas for a wing exchange. The day before and the day of the operation were your standard airborne days of fun, with weather briefs, refreshers, jumpers hit it, operational orders, and parachute landing falls. On 18 July the day of the jump, after Squires and myself had made our jump, we rallied with Chief Jett, who was the DZSO (Drop Zone Safety Officer), to help pull medical coverage with the Air Force medical personnel, TSgt Stanfield and SSgt Canfield. The next stick to jump came out of the CH-47 Chinook, chutes deployed, and we waited for them to land. Not 15 minutes after we jumped from the helicopter, we had a barely conscious 20-year old Honduran male being drug across the drop zone (DZ) by his parachute. We didn’t know we had a patient until the Honduran soldiers around him start screaming, “Auxilio! Medico!” Squires and I jumped in a Gator ATV with the Air Force medics and our aid bags, which we had staged in the DZSO’s truck, and headed to the patient donning our gloves enroute. 0910: We pulled up to the patient, saw no helicopters or jumpers overhead, no immediate life-threatening bleeding, and then assessed his level of consciousness and airway. We then asked one of the Air Force medics to maintain C-Spine control while we started our assessment. The patient was moaning slightly, but only responded to a sternum rub. He was breathing well on his own, but the decision was made to emplace nasopharyngeal airway (NPA). After no LaForte fractures were found, the NPA was measured and a attempt was made to insert it; however, the patient fought the two of us off. After a few attempts, we ceased and the rest of the assessment was conducted (Figure 15). Blood was found in

War Time Medicine on a Peace Time Mission

Figure 15 Assessment of Paraquidista on the drop zone.

the mouth with no threat to the airway. With the patient protecting his own airway, a C-Collar was placed on the patient with Canfield still maintaining C-spine control. I then began a head to toe assessment of the patient while Squires drew 15mg of diazepam to be given IM to calm the patient from struggling and possibly hurting himself or us. In order to properly restrain the patient from moving too much, three or four people at a time were holding his extremities. Abrasions were found on his head, most notably on his left temple. No battle signs or raccoon eyes were found, pupils were equal and reactive to light, and we continued to watch the blood in his mouth, but there seemed to be no active bleeding. Examining his ear canals, I saw no bleeding or bulging tympanic membranes. 0916: The diazepam was injected into the patient’s right deltoid. His breath sounds were strong and clear. I found a possible rib fracture, but no flail chest. I assessed his abdomen while Squires was assessing the extremities and found no crepitus or grimace. We then had a third Delta come on scene to assist. SGT Wright immediately helped the ambulance back up safely to the patient and came with the backboard and straps for the patient. SGT Wright laid the equipment next to the patient and controlled the patient’s legs while Canfield counted down to roll the patient. With the patient on his side, Squires and Wright moved the backboard into position. I then assessed the patient’s back for obvious deformities, fractures, or blood. With no wounds found, we rolled the patient onto the backboard and immediately reassessed his airway and C-Collar (Figure 16). 0924: After being strapped to the board we lifted the patient into the ambulance and Canfield and Stanfield drove the patient to the Medical Element Station where the staff intubated the patient using rapid sequence

Figure 16 Checking for injuries while rolling to backboard.

intubation technique and took X-rays before preparing him to be flown to the hospital. He was flown to the city’s Level One hospital for further treatment shortly afterwards. Our thoughts stay with the soldier and his family during what will be an intensive therapy and recovery period. His road ahead will be arduous and compounded greatly by his living conditions. We hope for the best in his days ahead. I’ve heard that the patient was starting to recover at the hospital, but specifics on his condition were not made know. The Honduran officer that I spoke to seemed confident he would return to duty after the patient took time to properly recover and heal. In closing, I’d like to add a few personal notes. The preceding accounts of ODA 2323 were a joint effort and I hope they have read as such. Nothing that the Deltas performed and accomplished would have been possible without the rest of the team and the Honduran soldiers. These were just a few of the stories that were note-worthy for publication during our CNT mission to CENTAM. Along with these stories, Squires and I performed many debridement of abscesses, stabilized and transported severe knee injuries, acted as first-responders to car accidents we saw while driving in country, sutured countless lacerations, treated local domesticated animals, and assisted the Honduran Air Force during their mass medical evaluations to impoverished towns. These were looked at as simply day-to-day tasks for Deltas. If any 18D read these stories, they should feel proud that the training conducted at the JSOMTC is still and will continue to be one of the best trauma schools in the world. I had the opportunity to meet and work with an extremely experienced and decorated Delta working with the State Department who jokingly called me a “glory hound” for having the chance to tell our story in this journal. He

would say, “Hell man, all you did was the job you were trained to do,” and in that regard, he was absolutely correct. I would never seek glory or accolades from my time here. No Special Forces Operator would ever want something for doing his job the way he was trained to do it. I only took this opportunity originally, to tell others of the great work of an entire ODA and partner nation soldiers that came together to accomplish something during our FTX that no one dared attempt since the 1980s. But with time, more work arose for us and I felt it would be a great addition to the FTX story. So yes, this is my way of getting the message out that other SF guys are working together in other areas of operations (AO) of the world and we’re doing great things. Also, it is important to know that different agencies are working together to accomplish a common mission in an AO that is taken lightly as a deployment in the wake of two wars. I honestly feel like this team came to CENTAM and performed a classic Special Forces mission. The ODA members came together with a dozen Honduran Soldiers on many occasions and acted as a force multiplier. I can’t wait to see what my future deployments and training opportunities have in store for me. Even though I’m still a new guy to the Special Forces culture and way of life, I know that with future teammates like I had on this team, I will learn so much more and take those experiences with me to hopefully become an even better Operator. Special Thanks to ODA 2323

Ashley Neal Mclemore earned an undergraduate and graduate degree in English from Delta State University. She currently resides in the Hampton Roads area of Virginia with her husband where she teaches at Thomas Nelson Community College. SSG Steven Reynolds enlisted in the U.S. Army Reserves as a 92F Petroleum Supply Specialist and attended Basic Training at Fort Jackson, SC and AIT at Fort Lee, VA. In 2007, he transferred to Charlie Company, 2nd Battalion, 20th Special Forces Group (Airborne) for Special Forces Assessment and Selection (SFAS). He was selected from SFAS in November of 2008 and then graduated Airborne School in February of 2009. He graduated the Special Forces Qualification course in August 2011 and was attached to Charlie Company, 2nd Battalion, 20th Special Forces Group (Airborne) where he is still assigned. His first assignment was working with the Reserve Officer Training Corp (ROTC) at Mississippi State University as an assistant instructor until Jan 2012. He first deployment was to CENTAM with ODA 2323 as a Junior Special Forces Medical Sergeant.

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

SSG Austin Squires enlisted in the U.S. Army as a 68W Combat Medic and attended basic training at Fort Jackson SC, and AIT at Fort Sam Houston TX. He then attended Airborne school at Fort Benning, GA in 2007, and then went on for Special Forces Training. After graduation from the Special Forces Qualification Course

War Time Medicine on a Peace Time Mission

SSG Squires went to 20th Special Forces Group 2nd Battalion (C) Company. His First SF assignment was as a Junior Special Forces Medical Sergeant for ODA 2235 that deployed to CENTAM. His second was as a Senior Special Forces Medical Sergeant for ODA 2323 deployed to CENTAM.

Combat Ready Clamp Medic Technique Robert V. Tovmassian, SFC, USA; John F. Kragh, Jr., MD; Michael A. Dubick, PhD; David G. Baer, PhD; Lorne H. Blackbourne, MD

ABSTRACT Background: Junctional hemorrhage control device use on the battlefield might be lifesaving, but little experience is reported. The purpose of the present case report is to detail prehospital use of the Combat Ready Clamp (called the CRoC by its users, Combat Medical Systems, Fayetteville, NC; Instructions for Use, 2010) in casualty care in order to increase awareness of junctional hemorrhage control. Methods: The CRoC was used to control difficult inguinal bleeding on the battlefield for an Afghani man with a hindquarter traumatic amputation. Results: The device promptly controlled exsanguination from a critical injury when placed during rotary-wing casualty evacuation. The flight medic applied the device in 90 seconds. The device performed well without complications to control bleeding. Discussion: The CRoC, a new junctional hemorrhage control device, was used as indicated on the battlefield with mechanical and physiologic success and without device problems. By controlling difficult inguinal bleeding resulting from battlefield trauma, the device facilitated casualty stabilization and delivery to a surgical facility. The device facilitated the ability of a new flight medic to focus his expertise on a critically injured battlefield casualty with demonstrable success.

CRoC as indicated for difficult inguinal bleeding on the battlefield. The CRoC was the first device so indicated (Figure 1).7,8 The CRoC was designed and manufactured to assist a knowledgeable user with the control of exsanguinating hemorrhage from an anatomically complex region. Approximately 80 devices were distributed to Special Operations Forces (SOF) in November 2010. Now approximately 500 CRoCs have been sold and an estimated 125 are in theater, mainly with SOF units. The CRoc has no formal military service-wide training or doctrinal fielding regimens developed as policy has not yet been developed and formalized. The CoTCCC approved the device in 2011 and offered its own guidelines.9,10 There has been little reported on CRoC training or use. Houston physicians at press time notified the CRoC distributor of the first civilian use of a CRoC. The successful emergency use of the CRoC to stop difficult inguinal bleeding prehospital was for one patient in September 2012. The first publishable case presented here was of battlefield use the CRoC that occurred in 2011. The purpose

Keywords: tourniquet, bleeding, shock, prehospital care, emergency medical services

Introduction In the current war in Iraq and Afghanistan, junctional injuriesâ&#x20AC;&#x201D;wounds at the junction of the trunk and its appendagesâ&#x20AC;&#x201D;recently became the most common battlefield cause of potentially preventable death.1-6 The Committee on Tactical Combat Casualty Care (CoTCCC), and the U.S. Defense Health Board made development of a junctional tourniquet a research priority and the U.S. Army Medical Research and Materiel Command made a Request for Information which spurred development of a hemorrhage control device, the CRoC. In 2010, the U.S. Food and Drug Administration (FDA) cleared the

Table 1 Combat Ready Clamp Data

Combat Ready Clamp (CRoC) developer

Combat Medical Systems, LLC, 5845-D Yadkin Road, Fayetteville, NC 28303. www.combatmedicalsystems.com

National Stock Number (NSN)

6515-01-589-9135

US Food and Drug Administration clearance

August 11, 2010, (510(k) Number K102025; vascular clamp, regulatory Class II (two), product code: DXC

Indication labeling

The Combat Ready Clamp is indicated for use in the battlefield to control difficult bleeds in the inguinal area.

Physical Simulator for Combat Ready Clamp (CRoC trainer manikin)

Operative Experience, Inc., 75 Greenhaven Dr., Elkton, MD 21921-7617; telephone: 443-3505686; www.operativeexperience.com

Figure 1 Combat Ready Clamp

Figure 2 Case and Components

The Combat Ready Clamp comes partially assembled in a case with written instructions. The Combat Ready Clamp is a prehospital hemorrhage control device intended for management of difficult inguinal bleeding on the battlefield. It weighs about 1.4 pounds and costs about $445.

of the present case report is to detail prehospital use of the CRoC in casualty care in order to increase awareness of an innovative, and in this case, successful method of junctional hemorrhage control.

Technique: Control Difficult Inguinal Bleeding with a Combat Ready Clamp (CRoC) • Remove the CRoC from its case (Figure 2). • Extend the vertical arm up from its base plate (Figure 3A). • Lift the horizontal arm locking pin and insert the horizontal arm into the vertical arm (Figure 3B). • Insert the T-handle into the horizontal arm head and turn the T-handle clockwise to seat it (Figure 3C). • Snap the disc head onto the tip of the T-handle (Figure 3D). • Push vertical arm locking pin in to slide vertical arm up to a height to fit over casualty (Figure 3E). • Slide the base plate under casualty to target the wound or pressure point (Figure 4A). • Slide the base plate in until the vertical arm touches casualty’s side near the target (Figure 4B). • Put the disc head over the target to be compressed. • Adjust the horizontal arm length by using its locking pin (Figure 4C). • Adjust vertical arm by using locking pin to press disc head onto target to slow bleeding. • Turn the T-handle clockwise to compress the target until bleeding stops (Figure 4D). • Snap the buckle and remove the slack from the strap (Figure 4E). Combat Ready Clamp Medic Technique

• Write the application time on the strap label. • When moving the casualty during CRoC use, be careful not to displace the CRoC. • For litter loading, roll the casualty onto the uninjured side, place litter,and roll the casualty onto litter. • To keep CRoC in place, transport casualty on uninjured side, or pad and raise injured side (Figure 5). • Reassess and adjust casualty and clamp as indicated. • Removal of the CRoC should occur only at a surgical care facility (Figure 6). • To remove: Unsnap the strap buckle (Figure 6A). • Turn T-handle counter-clockwise until disc head clears the casualty (Figure 6B, C). • Roll the casualty slightly onto the uninjured side and slide the CRoC out and away for removal.

Case Report In 2011, an Afghani adult male (approximately 30 years old) was injured in an explosion at a road junction near a village in Kandahar province, in southern Afghanistan. An emergency request for medical care went to a U.S. Army aero-medical evacuation military unit deployed in the area where the injury occurred. The response time of the helicopter team to arrive at the point of injury was several minutes. The casualty’s left hindquarter amputation injury (including lower extremity loss through the groin) was in the proximal inguinal area, too high for regular tourniquet. Upon arrival of the helicopter team, the casualty was alert and oriented but in mild hemorrhagic shock with little active hemorrhage. The casualty was placed into the aircraft, and the flight medic made an effort to relocate remnants of the thigh with his hands in order to apply a regular tourniquet, but the remaining tissue could be neither gathered nor compressed – the

Figure 3 Combat Ready Clamp Assembly 3A Remove parts from case. Extend vertical arm up from base plate.

3B Lift horizontal arm locking pin

and insert horizontal arm.

3C Screw T-handle into horizontal arm head

clockwise until tip is clear.

3D Press the pressure disc onto T-handle tip.

3E Push in vertical arm locking pin to slide vertical arm to

desired position which varies by casualty size.

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

Figure 4 Application 4A Position the base plate under the casualty beneath the desired pressure point. Ensure the vertical arm is in contact with the casualty on wounded side near the wound site.

4C Slide vertical arm down to put pressure disc in contact with the target. The vertical arm is adjusted by pushing in the vertical arm locking pin and sliding the arm downward and reengaging the pin.

4B Adjust the horizontal arm to position the pressure disc above the targeted dressing or wound. The horizontal arm is adjusted by lifting the horizontal arm locking lever and sliding the arm to desired elevation and reengaging the pin.

4D Apply pressure to the target by screwing the T-handle clockwise until the bleeding stops. Stop screwing when the pressure disc is in firm contact with the target.

4E Attach the securing strap. Write the time of application on the strap label and the TCCC Card.

Combat Ready Clamp Medic Technique

Figure 5 Transport: To keep CRoC in place, transport casualty on uninjured side, or pad and raise injured side. Reassess and adjust casualty and clamp as situation dictates.

extent of the wound was too proximal. At aircraft takeoff, hemorrhage from this site became severe and uncontrolled. The medic applied manual pressure first with a hand, then with a knee, obtaining transient hemorrhage control while grasping and preparing his CRoC for use. The onset of hemorrhagic shock with its concomitant deterioration of alertness risked airway compromise. The CRoC was assembled and applied in approximately 90 seconds resulting in prompt and sustained hemorrhage control. A bulky dressing was then placed under the disc head as the wound was larger than the disc head. The point of application of the CRoC and compression (hand and knee) was in proximal control of the external iliac artery just proximal to the inguinal fold. Attention was turned to assessment and management of the patient’s airway, but the patient was sufficiently stabilized and shortly thereafter arrived at an Afghan hospital near Kandahar. Given the few resources at this facility, the Afghanis triaged the casualty to be expectant. The CRoC remained effective throughout its use without problems or complications. The Afghanis removed the device, and the casualty promptly exsanguinated. The flight medic then recovered the CRoC, and it was sanitized and stowed for future use. The CRoC remained with the coalition forces when the unit was replaced upon redeployment. The flight medic managing this case was twice trained in CRoC use. First was as a prior medical sergeant at Special Operations Combat Medic Skills Sustainment Course at Fort Bragg, NC; the second was near Kandahar

in October 2011, with a medical sergeant from the U.S. Army’s Test and Evaluation Command. This medical sergeant gave the CRoC to the flight medic for use by his unit. The unit had not previously considered purchasing a CRoC in part because of limited unit funds, but also due to limited awareness of the CRoC itself, and the type of hemorrhage control. The flight medic who used the CRoC was on his sixth deployment with a total of 39 months of experience as a medic deployed in combat. The flight medic provided an after action review on his CRoC experience. On the CRoC’s design, the medic noted that the disc head to apply pressure may need to be wider to contact a larger surface, to affect a larger area, and thus to be more effective and safe. A training gap in the experience was that the training did not emphasize enough the importance of using an aid— such as a bystander—to apply manual compression for wound hemorrhage control during CRoC assembly by the CRoC-trained user. Otherwise, hemorrhage may be temporarily uncontrolled during assembly and application (about 90 seconds). The review revealed that the user needs to do many things with his hands and mind sometimes for multiple casualties in little time; aid of a helper and a device can free up the user both initially and thereafter. During the unforgiving minute of CRoC need, the user is saturated with tasks such as hemorrhage control, CRoC assembly, and instructing bystanders. As the battlefield is imperfect for best care, the availability and skill of bystanders is routinely inadequate which makes medic self-sufficiency important in this case by CRoC use. The flight medic’s review provided feedback on what other medics experienced in CRoC training; they did not use any CRoC in care. They found the CRoC hard to learn to use properly. Anatomy was complex, exsanguination fast, casualty transfer complicated, and so the medics felt they were likely to fail. They complained that the device was bulkier than a tourniquet and was clumsy in application in that it required new manual skills with additional training. The stark difference between the training experience among the medics and the flight medic indicates that the training quality or quantity may have differed or the attitude of the users differed. The flight medic relayed at his August presentation to the CoTCCC in Florida that increased awareness of the CRoC may increase acquisition of CRoCs for potential use.

Discussion This is the first reported use of the CRoC in a critically injured casualty where a new junctional hemorrhage control device was used as indicated on the battlefield with prehospital success and without device problems.

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

Figure 6 Removal 6A Unsnap strap buckle.

6B Turn T-handle counter-clockwise

until disc head clears casualty.

6C Removal of Combat Ready Clamp should occur only at

surgical care facility. Roll casualty slightly onto uninjured side and slide CRoC out and away for removal.

By describing the technique of use, increased awareness of junctional bleeding, including a personal experience of treating a casualty with difficult-to-control inguinal bleeding on the battlefield, medical leaders and trainers can prepare health care personnel and first responders to become proficient in the device’s use before needing it on a real-world casualty. Preparation and training decrease the time required to assemble and apply the device, decreases the duration and degree of exsanguination, and may decrease morbidity and mortality from such critical injuries. An additional finding of the present case report was that the device worked well in multiple ways. The device operated as intended by controlling difficult inguinal bleeding on the battlefield. The device stabilized the casualty for successful delivery to a surgical facility. The device did its job by decreasing the rate of hemorrhage, keeping a casualty alive for enough time to get him to the local hospital with its surgical capability. The device allowed the flight medic to do his job well, which included using Combat Ready Clamp Medic Technique

a new device under battlefield conditions on a critically injured casualty for his first time; the mechanical success of the first use was just as intended. The need for having an extra set of knowledgeable hands is so common in damage control situations – such as in the present case – that there is an emerging battlefield doctrine, not yet fully enacted, of making two or more medical personnel available in such situations in order to maximize survival rates.11 Devices that substitute for extra hands can help but must be balanced in a Soldier’s load. There are several limitations of the present case report. A case report cannot prove or disprove hypotheses but simply increases awareness of a specific topic like use of a new hemorrhage control device on the battlefield. Conclusions should not be drawn on one observation, but a useful observation can serve as a base for a larger series that may validate new technology and spur faster fielding. The hospital where the casualty was brought had few resources; the severity of the case reported exceeded the resuscitative capacity of the hospital. Given

the decision to triage the casualty as expectant without further resuscitation attempted at the local hospital, safety and effectiveness data of the CRoC was limited to its prehospital use and survival-to-hospital. The duration of use in this case was less than 60 minutes, a time found to be safe.8 Future directions for research include laboratory and field study of the CRoC other junctional hemorrhage control devices for safety and efficacy, junctional bleeding itself, operational implementation of newly fielded devices or interventions, refinements in design of devices, and study of longer durations of use beyond 60 minutes. By reporting a case of junctional hemorrhage in need of control on the battlefield, we hope to increase awareness of hemorrhage control device use with these types of proximal exsanguination injuries. References 1. Holcomb JB, McMullin NR, Pearse L, Caruso J, Wade CE, Oetjen-Gerdes L, Champion HR, Lawnick M, Farr W, Rodriguez S, Butler FK. (2007). Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001–2004. Annals of Surgery. 245:986–991. 2. Kelly JF, Ritenour AE, McLaughlin DF, Bagg KA, Apodaca AN, Mallak CT, Pearse L, Lawnick MM, Champion HR, Wade CE, Holcomb JB. (2008). Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003–2004 versus 2006. Journal of Trauma and Acute Care Surgery. 64(2 Suppl):S21–27. 3. Lesperance K, Martin MJ, Beekley AC, Steele SR. (2008). The significance of penetrating gluteal injuries: an analysis of the Operation Iraqi Freedom experience. Journal of Surgical Education. 65(1):61–66. 4. Blackbourne LH, Mabry R, Sebesta J, Holcomb JH. (2008). Joseph Lister, noncompressible arterial hemorrhage, and the next generation of “tourniquets?” U.S. Army Medical Department Journal. 56–59. 5. Tai NR, Dickson EJ. (2009). Military junctional trauma. Journal of the Royal Army Medical Corps. 155(4):285–292. 6. Kragh JF Jr, Murphy C, Dubick MA, Baer DG, Johnson J, Blackbourne LH. (2011). New tourniquet device concepts for battlefield hemorrhage control. U.S. Army Medical Department Journal. 38–48. 7. Instructions for Use. (2010). Package insert labeling of the Combat Ready Clamp (Combat Medical Systems, Fayetteville, NC). 8. Dubick MA, Kragh JF Jr. (2012). Evaluations of the Combat Ready Clamp to control bleeding in human cadavers, manikins, swine femoral artery hemorrhage model and swine carcasses. U.S. Army Institute of Surgical Research, Institutional Report. 9. Committee on Tactical Combat Casualty Care. Skill Sheet 020507 Combat Ready Clamp, accessed September 10, 2012 http://www.health.mil/Libraries/110808_TCCC _Course_Materials/020507-CRoC-Skill-Sheet-110808 .pdf.

10. Committee on Tactical Combat Casualty Care. Curricu lum 0203PP03 Tactical Field Care 110808. http://www .health.mil/Libraries/110808_TCCC_Course_ Materials/020401-Intro-to-TCCC-IG-110808.pdf; www .health.mil/110808/0203PP03-Tactical-Field-Care -110808.ppt, accessed Spetember 10, 2012. 11. US Army. First to Cut: Trauma Lessons Learned in the Combat Zone, 2d edition, 2012.

Acknowledgements Robert V. Tovmassian’s prior name was Robert S. Thompson, former Civil Affairs Trauma Medical Sergeant. Financial disclosures that might relate to this work: Dr. Kragh is an employee of the U.S. Government and receives institutional support where he works, the U.S. Army Institute of Surgical Research. He has offered free advice on scientific matters at no cost to Operative Experience, M2, Inc., Tiger Surgical, LLC, Tactical Medical Solutions, LLC, Combat Medical Systems, Inc., Composite Resources Inc., Delfi Medical Innovations, Inc., North American Rescue Products LLC, H & H Associates, Inc., Creative & Effective Technologies, Inc., TEMS Solutions, LLC, Blackhawk Products Group, Hemaclear, Tactical Development Group, Compression Works, LLC, Tier-One Quality Solutions, Kforce Government Solutions, CHI Systems, Tactical Emergency And Medical Simulations Training (TeamsT), Athena GTX, Pelagique, LLC, Hawaii Product Development, Inc., RevMedx, Inc., SAM Medical Products, and Entrotech, Inc. He has received honoraria for work for the Food and Drug Administration for device consultation. He has received honoraria for trustee work for the nonprofit Musculoskeletal Transplant Foundation. He has worked as a technical representative to the U.S. Government’s contracting officer in agreements with Physical Optics Corporation, Resodyn Corporation, International Heart Institute of Montana Foundation, Daemen College, Noble Biomaterials, Inc., Wake Forest Institute of Regenerative Medicine, National Tissue Engineering Center, Pittsburgh Tissue Engineering Initiative, University of Texas Southwestern Medical Center, Arteriocyte, Inc., and Kelly Space and Technology, Inc. Funding of this project was with internal funds and not from any of the following organizations: National Institutes of Health (NIH); Wellcome Trust; Howard Hughes Medical Institute (HHMI), or U.S. Army. Chris Murphy of Combat Medical Systems provided the Combat Ready Clamp drawings and instructions. Correspondence provided by Dr. Kragh, U.S. Army Institute of Surgical Research, Fort Sam Houston, TX Study performed at: U.S. Army Institute of Surgical Research.

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

USSOCOM TCCC CASEVAC Set Program A Retrospective and Overview John “Brad” Gilpin

Abstract The United States Special Operations Command (USSOCOM) Tactical Combat Casualty Care (TCCC) Casualty Evacuation (CASEVAC) Set Program was initiated in 2006 as a three-step effort. The initial effort was to develop an improved Individual First Aid Kit (IFAK); this was followed by the development of a Medic bag and culminated with the CASEVAC Set. The intent of the Program is both standardizing the medical load out across SOF components and expanding the skill set of Special Operations Forces (SOF) medical practitioners by providing equipment and training outside the normal parameters of many units. Even though the Set is currently being fielded to a variety of units, there are still personnel unaware of the Set and its capabilities. The goal of this article is to increase awareness of the existence of the program and to promote thought/discussion regarding the expansion of the capabilities of the Advanced Tactical Practitioner (ATP) beyond traditional medical skills. This program is best understood by first looking back to where it originated, and then examining where it is at present.

In the Beginning The USSOCOM and Program Manager-SOF Survival Support and Equipment Systems (PM-SOF SSES) held an Industry Day in October of 2009 at Natick Soldier Systems Center in Natick, Massachusetts. The focus of the event was to “assist with strategic market analysis of products and technologies that may be applicable to our military operating environments and missions at remote, forward deployed locations on land and ships.” This language, taken directly from the original announcement, only hinted at what was to come. They subsequently issued a Statement Of Objectives (SOO) and identified two primary Key Performance Parameters (KPP’s): “1. Preserve the Force and facilitate its reconstitution by reducing preventable battlefield deaths and minimizing effects from injuries. 2. Provide the SOF Medic with the right equipment, developed from the attached Performance

SOF ATP treats an Iraqi SOF Commando in Baghdad (2010).

Specification, at the right time to prevent death and aid in the recovery of SOF Battlefield trauma casualties.” (Emphasis added) Reducing battlefield deaths and minimizing effects of injuries has been the stated goal of all medical programs since the inception of the Tactical Combat Casualty Care (TCCC) program and was not unexpected. It is the second objective that would define the uniqueness of this program. The intent to standardize medical equipment across SOF assets and to expand the base skill set of ATP’s by addressing issues such as vehicle and building extrications and high-angle rescue as a medical problem was something relatively new. Envisioned was a full spectrum systems approach to the equipment set in lieu of restricting contents to traditional medical items. The idea that SOF works in austere environments and has to perform autonomous rescue, sometimes to just access the patient or move the patient to a treatment area drove this new approach to the Set. This was to be a medical capability that placed as much emphasis on ropes and angle grinders as it did on tourniquets and IV fluids. The initial Industry Day was open to any vendor who produced or sold an item that could be potentially contained in the Set as well as being open to any company that was interested in the role of Prime Integrator. The

Prime Integrator title was a designation that would be given to the Awardee. The job of the Prime Integrator was to coordinate the identification and acquisition of all Set contents and to manage all administrative and logistical tasks related to getting the assembled kits into the field. Given the breadth of the envisioned Set capabilities, this was to be no small task. In addition, the Prime Integrator was responsible for providing New Equipment Training (NET) courses to all primary personnel receiving the Set. The Industry Day included group briefings, opportunities to discuss current utilization and applications of equipment with USSOCOM medical and force modernization personnel and one-on-one scheduled meetings with Program Office personnel to discuss issues specific to a company’s approach to the Set. The Industry Day was followed by a final opportunity to query the Program Office in early 2010, and the Request For Proposal (RFP) was issued shortly thereafter. The RFP was “on the street” (the Program Office’s terminology) for a 30-day period at the end of which proposals were due. The initial submittals were limited to paper responses laying out Prime Integrators proposed set design theories, contents and capabilities. These initial submittals were then reviewed by the Program Office for three primary criteria: (1) best performance of the kit, (2) past performance of similar efforts, and (3) price, representing best reasonable value to the government. The process, up to this point, had admittedly followed standard acquisition procedure. If standard protocols had been followed, the Program Office would have selected an awardee based on the submission responses, and sets would have been built and fielded. Every person reading this has received some piece of equipment at some point in their career that made them wonder if the person who chose it had ever actually done the job that the equipment was purchased to accomplish. Fortunately, USSOCOM has advanced beyond traditional acquisition methodology and the Program now moved into an operational testing and end user evaluation phase.

Operations Command (MARSOC), Naval Special Warfare Command (NSW), and United States Army Special Operations Command (USASOC). Each Test Operator was provided with a laptop and the appropriate programs to make daily evaluation notes and to grade the Set’s performance. After the two-day training period, the Prime Integrator candidate was restricted from the testing area other than during a specified early morning set-up/replenishment period and an evening breakdown/repair period. During the day, the Test Operators utilized the PDM set in monitored scenarios designed by the Senior Medical Representatives of each component command and executed by the Program Office. This identical procedure was followed during the next two weeks for each of the other Prime Integrator candidates. The three week training period was dominated by sub-zero weather conditions and snow. This testing environment helped detect deficiencies in several pieces of equipment related to cold weather use. At the end of the three week test, the Sets were shipped to a contracted training facility outside of Memphis, TN for a repeat of the three week procedure to be held in March/April of 2011. A group of sixteen different Test Operators was drawn from the same four components as in the prior test. This location, while providing a much more temperate climate, offered its own set of challenges. This testing period focused on utilizing the kits in and around water/mud/sand environments and, again, helped to uncover problems with some items.

Contract Award Following the two Operational Testing periods, the Program Officers returned to Tampa, FL, and reviewed the observations of the Test Operators in conjunction with

Operational Testing Phase Following the paper submittals, the Program Office selected three Prime Integrator candidates in mid-2010. These three candidates were then funded to produce three Product Demonstration Model (PDM) Sets each. These PDM’s were shipped to the 10th Special Forces Group (Airborne) compound at Fort Carson, CO, for a round of operational testing in January/February 2011. Each Prime Integrator candidate was scheduled to be on site for a one-week period. On the first two days of the week, the Prime Integrator was allowed to provide instruction to a group of fifteen Test Operators/Evaluators. These fifteen Test Operators were from Air Force Special Operations Command (AFSOC), Marine Corps Special

During field testing, the E3 module was used to conduct a point lift of a M109 Paladin (27.5 tons!).

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

the data they had already collected. A five-year Indefinite Delivery Indefinite Quantity (IDIQ) contract was then awarded to the winning candidate with a potential funding amount of $50 million. The contract awardee was Tribalco, LLC, based in Bethesda, MD. Tribalco, while new to the tactical medicine arena, has had a long and successful history of providing integrated solutions and critical services to the military and federal government agencies in communication and information technology applications. Tribalco, understanding that expertise in SOF operations in general and TCCC systems in particular were essential, brought on board a recently separated 18D from 5th Special Forces Group who had just returned from a deployment in Iraq as their internal Program Manager (PM). Additionally, Tribalco teamed with several retired AFSOC Pararescuemen (PJ’s) to support the Set configuration development. It was this internal PM and the PJ’s that drove the design and contents of the winning submission based directly on the needs experienced during numerous combat tours and rescue operations. The PM, along with other ATPs, makes up the staff that supports the Set update, NET, and fielding procedures.

scalable based upon mission profile. With a modular design, the SOF medic could determine which capabilities might be required for a specific mission and only take those portions of the set onto the field. All items in the Set were to be packaged so that they were man-portable (less than 55 lbs) recognizing that target off-sets and extended foot movements were likely. Tribalco dubbed their winning submission the Tribalco Integrated Casualty Solution (TICS) and met or exceeded all design parameters of the Program. The goal was to deliver a pre-staged capability that enabled the operator to customize each module or sub-assembly for unique mission requirements. The TICS modules come packaged in roto-molded environmentally secure transit cases. The cases are palletizable by virtue of inter-locking features on the tops and bottoms of each case and are also air droppable.

All components of the TICS come contained in seven (7) cases suitable for palletizing or airdrop operations. The TICS cases meet A series Container Delivery System (CDS) requirements. The Tribalco Integrated Casualty System (TICS) contains every item necessary to treat and transport multiple casualties from the Point of Injury to Definitive Care.

CASEVAC Set Design From the outset, the Program Office had directed that the Set be separated into four Performance Categories (Kits) with subset modules. These four performance categories were designated as Extraction (E), Mobility (M), Transportation (T) and Sustainment (S). Of interest was that the performance specifications dictated not only that the systems allow for use across the spectrum of SOF military vehicles, airframes and watercraft, but that it also allow for use in indigenous modes of transportation. This last requirement seems to be a recognition of the sometimes unusual nature of the current conflict. Another required design parameter was that the eventual Set be modular/

Of note is that the Modules’ nylon packs are delivered in a camouflage pattern designated by each component, and assembled and packaged in each case in accordance with the “Grab and Go” requirement outlined by the Program Office. In other words, once the Set is transported to the forward area, there is no need for the medic to reconfigure the contents from the cases to prepare them to be taken into the field. When the case is opened, all contents are already packaged into backpack carriers ready to be lifted out and deployed. This also means that the cases can be used for storage of the kit when it is not in the field thus protecting contents from environmental damage.

Extraction Modules The Extraction category is broken down into modules E-1, E-2, and E-3. E-1 provides for patient packaging via

USSOCOM TCCC CASEVAC Set Program: A Retrospective and Overview

a PJ Sked device, and accompanying hardware to allow for an immobilized patient to be lifted vertically or horizontally. E-2 provides all required ropes, rigging, and climbing devices to provide fall prevention/protection as well as to perform high-angle rescues. E-3 is the most unusual module to find in a “medical kit.” The contents of E-3 include a collapsible sledge, a collapsible halligan tool, 36 volt reciprocating saw, an angle grinder, plus a manually operated hydraulic cutter/ spreader (Jaws of Life). The utility of these manual tools was validated during the Operational Testing when these items were used to remove a door from a salvaged Mine Resistant Ambush Protected (MRAP) armored vehicle in under four minutes. Given the ubiquity of Improvised Explosive Device attacks and the resultant issues of accessing patients in collapsed buildings or damaged armored vehicles, the time for extraction of patients to become a medical issue has come. After all, if you cannot reach the patient how can you treat them?

Mobility Modules The Mobility category was broken down into two modules (M-1 and M-2). M-1 provides for patient carry and features the All Platform Evacuation (APE™) litter as well as an absorbent patient litter system (APLS) absorbent patient pad capable of containing up to 4.5 liters of fluid alleviating leakage onto vehicle floors during transport. M-1 also contains a variety of medical supplies to support patient care beyond the initial point of injury. M-2 supports M-1 and augments patient care with a variety of diverse items. Straps that allow the litter to be secured in any manner of vehicle, airframe or watercraft are included. This module also contains a variety of small items such as a rescue knife and a MPLS Helmet Light intended to enhance the ATP’s ability to provide care.

Transportation Modules The original Performance Work Statement dictated that the Transportation Performance Category provide

Modules E-1 and E-2 provide all necessary equipment for horizontal and vertical patient rigging and lifts along with harnesses and tools for personnel fall protection/prevention.

E-3 contains tools (battery and manual hydraulic, no generator or compressor required) and self-contained air bags to allow operators to access patients trapped in vehicles or structures.

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

users also required a wall-mountable soft case for use in rotary wing aircraft. The design team worked with the desired dimensional areas and developed the Mobility Optimized First Aid Kit (MOFAK) case, which allows almost all of the Transportation Kit items to be secured in a suitcase style carrier that can be suspended vertically and opened to reveal all contents. In keeping with the original intent of having the entire kit be man-packable, a flatbed-style backpack carrier is supplied that will allow for foot movement of the Transportation modules when needed.

M (Mobility) Modules M-1 and M-2 provides a quad-folding litter and patient care supplies designed around the MARCH protocol.

advanced patient monitoring and care capabilities in self-contained modules. Going back to the original intent of designing a kit that would work in any vehicle, the Transportation modules allow the ATP to convert any platform into an ALS ambulance. This ability is critical given that SOF is often without a dedicated medical vehicle platform. T-1/2, T-3/4, T-5 and T-6 modules make up this performance category. This category presented the TICS designers with the most complex technical challenge given that they desired to mount the electronics equipment in such a manner that it was instantly accessible and usable while still being protected from the external environment. The operational experiences of the Tribalco Program Manager led him to believe that the devices needed to be mounted with all attachments pre-positioned (i.e. patient breathing circuit already hooked into the ventilator) in lieu of requiring set up at the onset of care. Most of the cases supplied from the device manufacturers were not designed with the austere SOF environment in mind and either did not allow for storage with peripheral attachments in place or were not sufficiently rugged to survive in the battlefield environment. Carbon-fiber hard cases were custom built with several innovative features including the ability to lock the cases together stacked horizontally or vertically and the ability to remove the case doors and secure them to the exterior of the case if desired. The case interior contains all devices with peripheral attachments in place such that the medic only needs to turn on the power to the device in order to initiate care. While the hard cases proved ideal for the majority of vehicle applications, end

T (Transportation) Modules T-1 and T-2 provide advanced patient monitoring capability. The module contents can be placed in either the custom carbon-fiber hard cases or in a hanging soft case (MOFAK, on the right) that was specifically requested for aviation platforms.

The T-1/2 Module contains Advanced Cardiac Life Support (ACLS) items and comes standard with the Tempus IC™ patient monitor; however, the case will accept other monitors such as the ProPaq® MD. In addition to the primary monitor, this module contains devices to monitor patient temperature, cardiac output and an automated external defibrillator. ACLS medications are contained in a pouch on the interior of the case door and the entire pouch can be instantly removed when needed. The T-3/4 Module provides for advanced airway and fluid management. This module contains a Simplified Automated Ventilator (SAVe), Glidescope® Ranger video laryngoscope, pressure infuser, fluid warmer, and a Golden Hour® thermal container to allow for transport of blood products. This module also has a removable pouch on the door interior that contains a variety of endotracheal tubes and intubation supplies. A Saros™ oxygen concentrator allows for administration of therapeutic oxygen to the patient without the dangers associated with pressurized flammable gas on the battlefield. The Saros™ comes with a mounting system that allows it to be affixed to the top or side of the hard cases, secured in the MOFAK or attached directly to the patient litter.

USSOCOM TCCC CASEVAC Set Program: A Retrospective and Overview

The T-5 soft case contains hypothermia management materials including a Hypothermia Prevention and Management Kit (HPMK) blanket and a Geratherm® powered warming blanket along with a 2590 battery and cables allowing the blanket to be run on battery power or from a variety of AC or DC sources. T-6 contains a variety of straps allowing for universal attachment/securing of the Transportation Module hard cases in any type of vehicle. Also included in T6 is the GD Itronix 2000™ ruggedized, wireless computer, capable of recording and forwarding key casualty vital statistics and personal information to follow-on care providers. When connected to a PR-117 or similar radio, the GD 2000™ is able to transmit all patient information in a secure manner. Again drawing on his operational experience, the PM developed a carrier for the computer that mounts to the medic’s body armor and incorporates a flip-down privacy screen to eliminate light signature. The last category, Sustainment, contains the items that would most traditionally be considered as a standard medical kit. However, the TICS designers sought to leverage their operational experience to improve wherever possible. The Sustainment Category is intended to add bulk supplies and additional capabilities to the overall Set allowing for the care of 2 to 5 patients for up to 24 hours. The S-1 Module is built around a custom pack system that unfolds into a supply sheet form that allows for wall hanging. The individual packs on the sheet have semi-clear windows and are removable so that, for example, the S-1 pack could be laid out at a Mass Casualty (MASCAL) incident and the Individual First Aid Kit (IFAK) pouches removed and utilized for patient care. In addition to the four self-contained IFAK pouches, the S-1 also has pouches for respiratory, wound care, IV fluids, and hypothermia supplies. It should be noted that the TICS comes fully stocked with all supplies and a spreadsheet is provided at delivery that allows for medical expiration dates and contents to be tracked. All items in the TICS have been individually NSN’d for ease of resupply.

S-1 also has a Mantis tri-fold evacuation board and a Gamow bag to add additional evacuation and treatment capabilities. Included with S-1 is a Medical Supply Chest which is a roto-molded case that, when the top is removed, can be stood on end, and has five pull out drawers of medical supplies that can be used for resupply or in a clinic type environment. Yet another item added based directly on the deployment experience of the designers is a personally worn Tactical Medic – Inter Communication System (TM-ICS). This communication system was designed specifically for U.S. military caregivers and to be compatible with MICH headsets. The TM-ICS is a portable, body-worn, intercom system with an in-line capability for two users and includes user-controlled volume. In addition to being used between patients and caregivers, it can also be used between caregivers (i.e. at patient hand off to a flight medic) enabling clear communication in noisy environments independent of radio systems. S-2 utilizes the same foldout wall mountable design as the S-1 Module bag, but this module, while also containing IFAK’s and other items, places an emphasis on airway management supplies. This module provides supplies for basic mechanical ventilation up through advanced surgical airway procedures. The final item in the Sustainment Category is the individual medic pack. Rather than going with a Commercial Off The Shelf item, the designers once again relied on their operational experience and consultations with commercial nylon designers to develop an innovative bag different from any of the other submissions. From the harness system that integrates directly with the medic’s body armor to the user-configurable internal pouch system, the DA Med Bag has numerous unique features.

NET As part of the contract deliverable, Tribalco and Roco Rescue (a recognized provider of training to USSOCOM units) provide a one-week New Equipment Training

S (Sustainment) Modules S-1 and S-2 provide bulk supplies needed to treat multiple casualties for 3 to 5 days in addition to items such as a Gamow Bag to treat altitude sickness and a tri-folding backboard.

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

The four IFAK’s in Module S-1 contain the needed contents for Point Of Injury care of a single trauma patient in accordance with TCCC guidelines.

Part of the S-2 module, the DA Med Bag integrates with the soldier’s body armor and the interior pockets are completely user configurable based on an ATP’s needs.

(NET) program to familiarize personnel with the TICS contents and capabilities. The NET program focuses largely on high-angle rescue, rigging and extrication procedures given that these are new skills to most participants. The course is hosted at Roco’s training facility in Baton Rouge, LA.

Conclusion

Set Modifications It is important to understand that this Set is an on-going program and that modifications to the design and contents are anticipated based on emerging technologies and changes in combat conditions/threats/locations and direct interaction with the Committee for Tactical Combat Casualty Care. Any end user who wishes to submit a modification should forward their suggestion to the senior medical representative in their unit. The suggestion should then be sent to the Program Office where it will be presented at a bi-annual meeting. All four components are represented at these meetings and any modifications are voted on for inclusion into the kit.

Unit Acquisition and Fielding Units interested in acquiring the TICS Sets, Kits or Modules should contact PM SOF SSES for details. Once a unit’s request is approved, the Program Office transmits the order to Tribalco and the Set, Kit, and/or Module is assembled. From there it is shipped to a Government warehouse prior to being shipped to the requesting unit. To date, at the time of delivery, both a representative of the Prime Integrator, and PM-SOF SSES are present and a 100% inspection is performed prior to sign over.

The USSOCOM TCCC CASEVAC Set program has, in a very short time for a government acquisition program, gone from concept to a functional fielded capability. Sets have already been delivered to units in all four components and Sets are operational in theatre. Due largely to the Program Office’s efforts in running a robust competitive testing process, USSOCOM units are now provided with the best equipment, training, and technologies available to reduce preventable combat fatalities. Perhaps most exciting of all, the program has helped to widen the USASOC, AFSOC, MARSOC, and NSW ATP’s skill set to include rescue, extrication and advanced transportation care capabilities. Disclosure The author has worked from the commercial sector on the TCCC CASEVAC Program from its onset, and currently has a consulting relationship with the Prime Integrator. The author receives no direct monetary compensation related to the sales of the Set from the Prime Integrator, from any sub-vendors or from the U.S. Government. J. “Brad” Gilpin was previously employed by the U.S. Government and served as a medic for a national-level Special Response Team. He is currently the President of FDL Group, LLC, which develops on-line based multimedia training and certification programs for medical device manufacturers.

USSOCOM TCCC CASEVAC Set Program: A Retrospective and Overview

Redefining Technical Rescue and Casualty Care for SOF: Part 1 McKay S.D., EMT-P; Johnston J., EMT-P, 18D; Callaway D.W., MD, MPA

Abstract Trauma care in the tactical environment is complex; it requires a unique blend of situational awareness, foresight, medical skill, multitasking, and physical strength. Rescue is a critical, but often over-looked, component of nearly all tactical trauma casualty management. Successful fullspectrum casualty management requires proficiency in four areas: casualty access, assessment, stabilization, and extraction. When complex rescue situations arise (casualty removal from roof tops, mountain terrain, collapsed structures, wells, or a karez), casualty care often becomes further complicated. Special Operations units have historically looked to civilian technical rescue techniques and equipment to fill this “rescue gap.” Similar to the evolution of pre-hospital military medicine from civilian guidelines (e.g. Advanced Trauma Life Support) (ATLS)) to an evidence-based, tactical-specific guideline (Tactical Combat Casualty Care (TCCC)), an evolution is required within the rescue paradigm. This shift from civilian-based technical rescue guidelines towards an Operational Rescue™ capability allows tactical variables such as minimal equipment, low light/night vision goggles (NVG) considerations, enemy threats, and variable evacuation times to permeate through the individual rescue skill set. Just as with TCCC, in which the principles of casualty care remain consistent, the practices must be adapted to end-users environment, so it is with rescue.

Tactical Combat Casualty Care provided threat-based principles of trauma care that redefined the trauma assessment and stabilization phases of casualty management in the tactical environment. Tactical Combat Casualty Care focuses on eliminating the potentially preventable causes of death on the battlefield. By training every warrior in the principles of TCCC, the U.S. military has reduced combat mortality to the lowest levels in recorded history.1-5 Tactical combat casualty care is now considered the pre-hospital standard of care and is utilized by all Services with great success because every operational person has a quantifiable casualty care capability.6,7

However, the principles of TCCC are predicated on an ability to access the casualty and, ultimately evacuate the casualty to higher echelons of care.8 During this same period of great advances for casualty care, units have continued to try to apply civilian technical rescue practices to a tactical and operational rescue problem. This practice, just like trying to utilize Advanced Cardiac Life Support (ACLS) on the battlefield before TCCC, quite often results in a capability gap when the rescue problem presents in the middle of a tactical operation. Since every operational person has a standing rescue requirement to remove himself/herself and others from hazards in remote and often dangerous environments, every operational person needs to have an operational rescue capability. Observations of training, review of mission after action report’s (AAR’s), and ad hoc discussions with returning SOF units indicate that there exists a significant gap in terms of how first responders access and extract casualties in the tactical environment. The dynamic changing of the tactical landscape for SOF personnel presents new and asymmetric rescue challenges for the unit consisting of urban rooftops, vehicle entrapment, collapsed structure, below-grade wells/karez extrication, high altitude mountain regions, and various water features. This work suggests that there exists a requirement within the Special Operations community to develop principles of rescue and to build appropriate tactics, techniques and procedures (TTPs) for the operational environment. This paper provides an overview of operational rescue, discusses existing rescue standards, provides a gap analysis based upon existing threats, and proposes a starting point for developing best practices for rescue in the operational and tactical environment.

Gap Analysis: Existing technical rescue training is over-reliant on civilian standards Rescue on the modern battlefield is increasing complex. The increased power of modern munitions, large scale deployment of armored vehicles, necessity of vertical

small unit combat in low intensity conflicts, and enemy tactics of targeting response personnel mandate new approaches to accessing and extracting casualties. Several shortcomings in rescue have been recognized over the last few years. First is the near total reliance on civilian experience and equipment to develop operational rescue training and TTPs. Though civilian standards offer a solid starting point, after ten years of conflict, training and operations we still use these TTPs, largely without modification. Special Operations Forces as a whole has yet to effectively examine battlefield threats, analyze AARs and develop operationally based rescue TTPs specific to modern combat. Second, there is a lack of successful rescue related research and development (R&D) in the SOF community. There exists a wide variety of kit utilized in the current operational space, much of which adheres to civilian rescue specifications set forth by the National Fire Protection Association guidelines for General, or “G” rated rescue. Most of this kit meets the key performance parameters of fire-rescue personnel responding to traditional technical rescue calls, not SOF personnel working in an entirely different area of operation with significantly different threats and organic assets. Finally, valuable pre-deployment time is being consumed by rescue training that is not specifically threat-based or, at times, operationally relevant. Current training also does not use a ground up or phased approach that trains a team of individuals that will be working together in the operational environment (i.e. an Operational Detachment Alpha (ODA)). As a result, skills may be taught and equipment purchased without creating a demonstrable rescue capability. As with the evolution of pre-hospital battlefield trauma care from pure civilian ATLS to threat-based TCCC, technical rescue must undergo a transition. A basic understanding

of civilian rescue standards is an important starting point. Armed with knowledge of the history, purpose, strengths and weaknesses of these standards, the individual unit can build a robust, full spectrum operational rescue program.

The Civilian Standards: National Fire Protection Association (NFPA) The primary standard setting organization in the civilian response world is the National Fire Protection Association (NFPA). The NFPA is a publisher of consensus standards that primarily deal with fire and life safety, create professional qualifications for firefighters and technical rescuers, and provide a common foundation and vernacular of minimum standards for which civilian technical rescue organizations can adhere. Committee members consist of end users, manufacturers, professional trainers, and academics. There are U.S. military personnel on a few of the committees; however, these personnel are primarily associated with military fire service operations. Currently, the Department of Defense (DoD) has endorsed the NFPA guidelines as the early standard for rescue within tactical environments. Examining NFPA is an appropriate first step in the development of operationally relevant rescue protocols. However, too often, the NFPA label is stamped like a blank check, encouraging procurement officials to purchase equipment without adequate due diligence. As with early military medicine based solely upon civilian trauma guidelines, NFPA standards were designed for distinctly different mission profiles, limiting application within full-spectrum rescue. There are three NFPA standards that are relevant for SOF practitioners to understand: 1. NFPA 1983, Standard on Life Safety Rope and Equipment for Emergency Services 2. NFPA 1006, Standard for Technical Rescuer Professional Qualifications 3. NFPA 1670, Standard on Operations and Training for Technical Search and Rescue Incidents

NFPA 19839

Rollover incidents create multiple rescue obstacles to include, casualty access, extrication, and fire suppression.

NFPA 1983, 6th Ed. defines design and strength specifications for life safety equipment manufactures. The standard includes detailed testing and production requirements to ensure compliance. National Fire Protection Association 1983 is frequently misinterpreted, especially outside of the dedicated fire rescue community, and utilized to make equipment and training selections outside of the technical rescue environment. It is important to note that NFPA 1983 is NOT an end-user standard; it is a manufacturer’s standard.

Redefining Technical Rescue and Casualty Care for SOF: Part 1

Despite operational limitations, NFPA 1983 does provide a valuable starting point. NFPA 1983, similar to ANSI (American National Standards Institute) or UIAA (Union Internationale Dees Association D’Alpinisme), provides a respected, external, theoretically unbiased, testing standards for rescue equipment construction and strength. This validation provides administrative, accounting, training, and policy benefits for large systems (such as the DoD) and to newcomers to the rescue arena. However, the power is in the NFPA metrics, not the NFPA stamp. There is exceptional equipment on the market by respectable manufactures that is not NFPA 1983 tested. Barriers include NFPA irrelevance to utilization (e.g. Alpine or mountaineering utilization), gear designed for specific missions (e.g. NFPA 1983 does not cover fall protection in general industry), and economic constraints (a company must pay to have the NFPA stamp placed on its individual gear, thus increasing the price to the end-user). For example, the Petzl Micro Traxion does not have a NFPA 1983 certification, but is utilized extensively in the professional climbing, mountaineering, and canyoneering communities, and provides an extremely valuable capability in the operational environment.

Retrievable anchor, vertical simu-lower, Rescuer and Casualty counter balance rescue

Though a “certified” product may be desired for certain applications, it may not be practical. End users should be familiar with NFPA 1983 standards and use them as a comparison reference in gear selection. This provides a solid starting point to determine whether the product’s strength and testing guidelines are in-line with the known manufacturer’s standard.

NFPA 1006 NFPA 1983 section 1.1.5 states: “This standard shall not specify requirements for any rope or associated equipment designed for mountain rescue, cave rescue, lead climbing operations, or where expected hazards and situations dictate other performance requirements.” In the SOF mission profile, “expected hazards and situations” frequently “dictate other performance requirements.” As our current conflict continues and broadens, more operations are being conducted in mountainous environments and austere desert terrain. These missions require a unique skill set that accounts for ongoing threats, while incorporating multiple disciplines of access and rescue to include mountain rescue and lead climbing techniques. It is this standard that was chosen as a requirement in the Special Operations Forces Casualty Evacuation (SOF CASEVAC) Performance Specification document (section 4.1.2.1.2, 12 March 2010).

NFPA 1006 is part of the professional qualifications series contained within NFPA. Established in 1994, the committee has maintained their commitment to establish credible rescuer qualifications without tying the hands of the Authority Having Jurisdiction (AHJ). The most important change to NFPA 1006 occurred in 2008 when the layout of the standard was changed to fall in line with other NFPA pro-qual standards. NFPA 1006 is one of the most applicable standards for USSOCOM. The power of NFPA 1006 is that it does not specify particular technique or equipment in any of the standards. The standard is laid out in basic job performance requirement (JPR) fashion. The JPR is described and then supported with the requisite skills and knowledge required to master the requirement. This is where the Special Operations community can benefit from the standard. For example, Chapter 6 - Rope, Level 1, 6.1.1 is the JPR for the rescuer to be able to construct a multiple-point anchor. In a traditional fire-rescue rope rescue course, this would be accomplished using webbing

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

slings or a length of rope. However, in SOF, your multiple-point anchor could consist of climbing cams, nuts, another operator, or cordelette. The standard is flexible enough for instructors to tailor their program to the operational environment. NFPA 1006 also gives the AHJ flexibility in selecting equipment to complete the JPR. Structural collapse training predominately consists of rescuers learning how to construct and apply the various FEMA wood shoring systems. Numerous USSOCOM units have attended this training; however, we would argue how applicable is this? How many times has the U.S. military loaded a cache of lumber to be sent to the Hindu Kush, or Kandahar for the purpose of searching a collapsed building? How many SOF teams have designated “cut teams” prepared and equipped to begin constructing the needed elaborate shoring with this lumber once delivered? The 1006 committee identifies that there are end-users that may have a different equipment need and/or approach. A good analogy is to think of the skills learned in NFPA 1006 as a toolbox; each skill is a tool in that toolbox. While some of the tools will be used on most rescues, some tools will not be applicable. This is up to the trained rescuer to decide. The NFPA does have sample toolkits in the Annex of the standard. However, these tool kits are for information purposes only and are not part of the standard requirement. The AHJ defines components of the toolkit. For example, during a SOF collapse rescue response, the rescue toolkit may only consist of organic and natural assets found at the collapse scene. An often confusing example of NFPA 1006 in practice relates to the NFPA and System Safety Factors (SSF). NFPA does not specify a SSF (the overall safety factor once all system components are in place, e.g. rope, knots, hardware, and software) for a rope system. The committee on professional qualifications (NFPA 1006) recognizes that only the AHJ can identify the operating parameters of its technical rescue team. A rescue team that only works in an urban low angle environment has the luxury of SSF’s of 10:1 or more. As the rescue moves to a high-angle rural environment, or as the tactical threat level increases, that SSF could be lowered to 5:1 (or less). To put this into perspective a regimental size force may state a 8:1 SSF, while smaller recon size or reduced signature element may allow a lower SSF due to operational requirements. Each organization should allow for a range within the SSF spectrum in order to maintain response flexibility based on operational demands. The SSF issue highlights the difficulty in applying civilian standards en bloc to the SOF environment. NFPA 1983 is frequently cited (incorrectly) as requiring a 15:1 SSF. This is only true for the safety factor (SF) of the

referred life-safety rope. A 1/2" rope has a required p breaking strength of 9,000 lbs (40kN). The original writers of the standard felt that a 600 lb load was typical of a 2-person rescue (includes victim, rescuer and equipment). Through simple division we can calculate a 15:1 safety factor; note this is different than a SSF. The 15:1 safety factor is a manufacturer requirement and only applies to an unknotted rope, not to the entire system. Unless you are making rope, this 15:1 safety factor does not apply. As a side note, the safety factor for the aircraft industry is 1.5:1, while human space travel is 1.4:1. It stands to reason that fundamental expertise in the areas of engineering analysis, physics, redundant safety, and a thorough comprehension of full spectrum application are a prerequisite for such a narrow factor of safety. A final benefit of NFPA 1006 is the “Core + 1” minimum requirement for certification. There are nine different disciplines of rescue addressed in 1006 to include; rope rescue, surface water rescue, vehicle and machinery rescue, confined space rescue, structural collapse rescue, trench rescue, subterranean rescue, dive rescue, and wilderness rescue. Prior to going after a certification in any of the above-mentioned disciplines a “core” capability is achieved. These general job performance requirements (the “core”) are found in Chapter 5 of NFPA 1006. Any unit, based on their current area of operations and mission profile, can select those specialties or disciplines they deem mission critical. If at any time, the AO and/or mission profile changes, it is an easy “plug and play” capability to enhance their individual certification into other disciplines since the “core” has already been obtained.

NFPA 167011 NFPA 1670, 3rd Edition (4th Edition in publication) is the Standard on Operations and Training for Technical Search and Rescue Incidents. There are several relevant sections of 1670 worth discussing. 1.1.1 “The standard shall identify and establish functional capability for conducting operations at technical search and rescue incidents while minimizing threats to rescuers.” 1.1.2 “The requirements of this standard shall apply to organizations that provide response to technical search and rescue incidents, including those not regulated by government mandates.” 1.1.3 “If is not the intent of this document to be applied to individuals and their associated skills and/or qualifications.”

Redefining Technical Rescue and Casualty Care for SOF: Part 1

While the scope is fairly straight forward, it is worth noting that NFPA specifically calls for this standard to apply to any organization that provides rescue services to include law enforcement (A1.1.2). As stated in the scope, the primary purpose of NFPA 1670 is to create a system whereby the AHJ can assess technical rescue hazards within the response area and to identify the AHJ’s level of operational capability. As an example, when we conduct an evaluation on a team’s operational capability we use NFPA 1670 as a template. NFPA 1670 breaks operational capability into three distinctive categories: • Awareness • Operations • Technician An awareness capability is designed to protect untrained personnel by educating them on the hazards associated with a technical rescue incident. Awareness personnel also receive instruction on identifying the appropriate resources and establishing an adequate command system to receive those resources. NFPA 1670 describes capability for many facets of technical rescue to include rope, structural collapse, confined space, vehicle and machinery extrication, water (surface, swift, dive), wilderness search and rescue, trench, cave, and finally, mines. The operations level allows the team to perform certain types of rescues per the standard. For instance an operations level rope rescue team may perform high-angle and low-angle rescues when the victim is at the height of the rescuers (i.e., the victim has been carried to the bottom of the vertical face and must be hauled or raised. The technician level is considered the highest level of capability. Technician level teams are capable of performing rescues in the “hot zone,” and utilize specialized equipment and techniques. In contrast to the previous rope rescue example, a technician level team can perform mid-face pickoffs, and use tensioned rope systems. Does the standard require all team members to be qualified to the operational capability? The answer is no. With the exception of Chapter 7 Confined Space, the standard does not state how many personnel are needed to make up the team. Confined space includes this information due to specific OSHA confined space entry requirements. Obviously, common sense must prevail. A team will not pass a rope rescue operations level evaluation where one member is trained to rope Level 1 under NFPA 1006. The team must have adequate resources to function at the level they wish to attain.

Although not previously mentioned in the “relevant” NFPA guidelines, but at least deserves an honorable mention due to its direct correlation to SOF rescue is NFPA 1407. NFPA 1407 is the Standard for Training Fire Service Rapid Interventions Crews. The term rapid intervention crew (RIC/RIT) describes a fire service element whose sole responsibility is to rescue their own, other firefighters who get into trouble whether it is disorientation, entanglement, or building collapse. This team deploys immediately and aggressively once any one of multiple criteria are met, primarily a “mayday” from an interior fire suppression crew. Due to the extreme circumstances that these rescues are preformed under, there is no handcuffing of the rescuers by rigid standards. The training reflects the capabilities needed to intervene effectively during this type of crisis, often with limited equipment and personnel. Incorporating the methodology of this standard is a must for Special Operations units. It allows units to train for a true executable capability based on a P-A-C-E (Primary, Alternate, Contingency, Emergency) mindset.

Operational Rescue™ Requirements for SOF Developing relevant techniques and principles for casualty access and extraction is critical for SOF. There are certain universal operational rescue principles for conducting all the various disciplines (rope rescue, confined space, structural collapse, etc.), which remain relatively consistent such as redundant safety processes, emphasis on simple techniques that transcend terrain, and extensive utilization of organic and natural assets. However, successful implementation requires a tiered response depending on many factors such as training, equipment, personnel on hand, environmental context, and mission profile. Operational Rescue™ requirements should be developed based on unit specific tasks and current operational environments. However, these requirements should build upon basic principles and concepts derived from examining current threats and real operational capabilities. This strategy allows for a reasonable plan to be put in place for contingencies. Casualty access is the pivotal point in rescue. The rescue usually involves an unplanned for situation in a very fluid environment complicated by factors such as enemy contact, limited organic rescue assets and variable capabilities. Lack of proper management results in an uncoordinated and dangerous response. A basic understanding of rescue for high-frequency-high threat scenarios (e.g., accessing vehicles, horizontal and vertical movement, and post-blast collapse) is vital. Training on specific threats using basic techniques and equipment must be done prior to developing more advanced TTP’s. This can be as basic as running rehearsals of opening an RG v ehicle door with

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

the provided safety wrench and securing the weight of the door with tubular nylon as if it were on its side. Often these basic techniques are the quickest and most effective on the battlefield. Their simplicity makes them more resistance to failure than other specialty kits or equipment that may not perform as effectively under stress due to damage, poor PM, or set up times. Further, this prevents reliance on specific techniques with specialized equipment (i.e., rescuing a teammate fallen into a well using pre-packaged rope kit vs. using elements common on the battlefield like a section of tubular nylon or weapon slings) and allows creative problem solving. Casualty Extraction is a dynamic process defined as movement of the casualty from point of injury to the next casualty management point (e.g., casualty collection point (CCP), evacuation vehicle, battalion aid station/ combat support hospital (BAS/CSH), etc.). The process of planning an extraction begins during the access phase and permeates throughout the assessment and stabilization components of casualty management. Certain injuries (e.g. a spinal column trauma) and certain interventions (e.g., tourniquet or chest needle decompression) shape extraction techniques. Casualty access and extraction considerations should include: 1. Initial securing of the casualty for movement: This will vary based on threat level, distance to next care point, mission profile, manpower, etc. This may include fire suppression, utilization of securing device, or simply a “grab and go.” 2. Type of movement: horizontal, vertical, confined space/ limited access, combination 3. Concept of phased movements • < 10 meters: In a high threat environment, moving casualty to first point of cover may entail one or two-man drag, ”grab and go” technique is typically preferred over webbing or drag device due to limited exposure on “x”, and deployment of security personnel. Utilization of small muscle groups such as forearms and biceps may work, but fatigue quickly and affect fine motor skills post-rescue. • 10–50 meters: Longer movements take a larger toll on rescuers and require a degree of planning. This is where a simple webbing loop or drag strap becomes helpful to decrease the casualty’s coefficient of friction and to gain a slight offset to better leverage rescuer’s weight to gain momentum. • > 50 meters: Should utilize litters, friction reduction devices, possibly multiple rescuers. Type and extent of injury: For example, vertical lowering with an individual harness is less than ideal with p elvic

injuries and should be avoided if possible. The ability to combine a “non-load rated” patient immobilization device (i.e. litter) a “load rated” patient extraction device (i.e. XS-1 or tubular webbing) creates a vertical extraction capability.

Planning and Preparation Planning and preparatory training for operational rescue is a key. The applicability of equipment as well as the focus and audience for training is paramount for appropriate application on the battlefield. Many factors must be incorporated into the proper outfitting and application for contingency operations. We encourage all end-users to create a template for their specific operational parameters for all equipment and technique selection with an end-goal of a leaner profile and robust capability asset. Select each piece of gear you intend on using for rescue not just for it’s individual capabilities, but for how it performs within the system and how it articulates with other pieces of gear. The end-user should not assume that all rope and all hardware will function flawlessly when used as a system. As mentioned earlier, a phased approach would best fit the force. This approach would look at the current threats to the force and then plan according much like using mission, enemy, time, terrain, and troops (METT-T) planning checklist; however, on an Operational Rescue™ contingency format. Basic battle drills of hatch opening by both normal wrench unlocking methods and forcible entry methods would be a primary planned contingency for troops operating with RG series vehicles or mine resistant ambush protected (MRAPs) along areas of road that were prone to give way and cause a vehicle roll over. After the access the drill would continue with basic recovery of unconscious personnel using standard one-inch tubular nylon. Once the basic necessities for contingency planning can be effectively executed by all on the team then more advance techniques and equipment can be trained on. Often when planning for contingencies one finds that either the equipment is readily available or not available at all. This is why the basics play such an important role. In cases where the equipment is available it quickly adds weight and cube space to the package. Most large-scale rescue equipment that the military has adapted has come from the civilian TTP’s, usually from the fire rescue/vehicle extrication templates. Often this equipment is based on one function and power or advantage (e.g., hydraulic, battery, fuel, etc.). In these civilian agencies weight and cube space are at a maxim when responding to a rescue in a fifteen-ton vehicle. The same can be said on

Redefining Technical Rescue and Casualty Care for SOF: Part 1

techniques used and commonly trained on by the military. Countless sedans and SUV cars have been cut up by troops training on vehicle extrication; however, these by no means are the actual vehicles they are driving in an everyday combat theater. This inherently is the problem that the same requirements and considerations that needed in civilian rescue are not the same for operational rescue on the battlefield. One last and probably the most important aspect of crossing over TTP’s is the leadership, knowledge, and experience. Civilian rescue crew are specifically trained and focused in their trainings. They respond fresh to a call for help outside their team. When they respond the team has a predetermined leadership and role assignments that allows them to effect a rescue. In an operational rescue environment the call for help and the rescuers are all in the same and potentially deadly battlefield environment under the same conditions. In the case of an ODA one third or more of the team can become victims. In this environment it is unrealistic to expect the team to react in the same style or training as civilian-based organizations because of their small numbers and the randomness in which team members become casualties. Rescue is never conducted in a vacuum. It is a tactical and a team problem that requires small unit training. Operational rescue training conducted solely at an individual level (i.e. just the two medics on an ODA) may teach skills, but does not create a capability. Much like a mass casualty (MASCAL) situation, there are many jobs that have to be managed in a rescue (e.g., security, casualty movement, communication, tactical C2, etc.). Small unit training grounded in the basic principles of Operational Rescue™ and incorporating tactical leadership, decisionmaking, personal accountability, and multi-tasking is critical to preparing our warriors for rescue on the battlefield.

Conclusion Like TCCC, Operational Rescue™ is a basic Soldier, Sailor, Marine, and Airman survival skill. In high-threat environments, rescue and casualty care are intimately linked. Reports show that access to the casualty and extraction of the casualty are playing major roles in the provision of adequate TCCC. If rescuers cannot reach the casualty, they cannot stabilize. If rescuers cannot extract the casualty to higher echelons of care, the parameters of TCCC interventions and damage control resuscitation are stretched. Each SOF unit will have unique mission profiles and organic assets. Therefore, each unit should perform internal capability gap analysis specific to rescue and fullspectrum casualty management. NFPA can and should add an organizational structure and professionalism to

any unit’s training profile. NFPA guidelines (1983, 1006, 1670, and 1407) should be viewed as separate maps to orient and guide an organization and/or individual to their specific end goal identified by their gap analysis. Units should not underestimate the power of the AHJ clauses in determining individual requirements. Due to the wide spectrum of specialties within USSOCOM, each individual unit (and probably in some cases separate elements within a unit) should designate their own AHJ that defines capabilities, equipment, and techniques. To have a single point AHJ for all of USSOCOM would be impractical due the wide variances of mission profiles and key performance parameters of individual units.

Recommendations 1. SOF Commands should be held accountable for creating a rescue capability: Operational rescue is an individual and team skill, but command responsibility. 2. Each component of a SOF command should define the basic standards for operational rescue based upon the principles above and develop TTPs based off threat-based operational requirements and past experiences from the forces on the ground. This can be done in consultation with NFPA Guidelines, but should integrate Operational Rescue™ experts and not focus on civilian or industrial TTPs. 3. Sustainable training is critical. Training programs should consider the formation of mobile training teams that incorporate unit-specific threats, equipment limitations, rapid translation of battlefield lessons learned, multi-modal training (e.g. online prep aration with heavy practical application on MTT arrival) and frequent updates. 4. Equipment selection process should be chosen based off of battlefield requirements and warrior feedback. 5. Technique and equipment evaluation/selection should include execution under stress and sympathetic nervous system activation. 6. Operational Rescue™ should be integrated into TCCC training modules at the team level. References 1. Lairet J.R., Bebarta V.S., Burns C.J., Lairet K.F., Rasmussen T.E., Renz E.M., King B.T., Fernandez W., Gerhardt R., Butler F., DuBose J., Cestero R., Salinas J., Torres P., Minnick J., Blackbourne L.H. (2012). Prehospital interventions performed in a combat zone: A prospective multicenter study of 1,003 combat wounded. J Trauma Acute Care Surg; Aug; 73(2 Suppl 1):S38–42. 2. Kotwal R.S., Montgomery H.R., Mechler K.K. (2011). A prehospital trauma registry for tactical combat casualty care. J Spec Oper Med; Summer; 11(3):127–8. 3. Gerhardt R.T. (2011). Prehospital and emergency care research at the U.S. Army Institute of Surgical Research:

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

enabling the next great leap in combat casualty survival. U.S. Army Med Dep J. Apr-Jun:82–6. 4. Butler F.K. (2010). Tactical combat casualty care: update 2009. J Trauma; Jul; 69 Suppl 1:S10–3. Review. 5. Holcomb J.B., Stansbury L.G., Champion H.R., Wade C., Bellamy R.F. (2006). Understanding combat casualty care statistics. J Trauma; Feb; 60(2):397–401. 6. Kotwal R.S., Montgomery H.R., Kotwal B.M., Champion H.R., Butler F.K. Jr, Mabry R.L., Cain J.S., Blackbourne L.H., Mechler K.K., Holcomb J.B. (2011). Eliminating preventable death on the battlefield. Arch Surg; Dec; 146(12):1350–8. Epub 2011 Aug 15. 7. Deal V.T., McDowell D., Benson P., Iddins B., Gluck G., Griffay A., Lutz R., Pennardt A., Kane S., Gilpatrick S., Bowling F.Y., Paisley J.T., Williamson J.R., Kiely R., Anderson P., Frasier B.A., Moore R., Bakken H., Burlingame B.S., Hammesfahr R., Hesse R.W., Holcomb J.B., Johnson T.R., Morgan B., Talbot T.S., Wedmore I. (2010). Tactical combat casualty care February 2010. Direct from the battlefield: TCCC lessons learned in Iraq and Afghanistan. J Spec Oper Med; Summer; 10(3):77– 119. 8. Butler F.K. Jr, Holcomb J.B., Giebner S.D., McSwain N.E., Bagian J. (2007). Tactical combat casualty care 2007: evolving concepts and battlefield experience. Mil Med; Nov; 172(11 Suppl):1–19. 9. NFPA 1983, Standard on Life Safety Rope and Equipment for Emergency Services, 2012– 6th edition. 10. NFPA 1006, Standard for Technical Rescuer Professional Qualifications, 2008 edition. 11. NFPA 1670, Standard on Operations and Training for Technical Search and Rescue Incidents, 2009 edition.

Sean D. McKay, EMT-P currently works with The Asymmetric Combat Institute as an associate and member. Mr. McKay served as a firefighter/paramedic and SWAT Rescue-Medic Team Leader on the West Coast of

Florida until December 2006. Mr. McKay develops, consults, and instructs multiple Operational Rescue courses within USSOCOM and instructs for the National Tactical Officer’s Association. Mr. McKay speaks throughout the United States on non-standard rescue, and was presented the Civilian Special Operations Medic of the year at the 2009 Special Operations Medical Association (SOMA) Conference. Mr. McKay also sits on the Executive Board for the Committee for Tactical Emergency Casualty Care (C-TECC). MSG James Johnston, EMT-P, 18D is a Special Forces Team Sergeant in the United States Army Special Operations Command (USASOC) with 13 years of SOF experience to include seven combat rotations to OIF/OEF as an 18D. Prior to active duty service, James was career firefighter and worked in both Fire and Rescue companies for six years. Corresponding Author David W. Callaway, MD, MPA is an Associate Professor of Emergency Medicine at Carolinas Medical Center, Charlotte, NC, where he serves as faculty in the Global Emergency Medicine and EMS Divisions. He is the CEO of Operational Medicine International, LLC a veteran owned company that provides civil military coordination in austere crisis zones. Dr. Callaway is also the Medical Director for the Asymmetric Combat Institute and works closely with local, regional, federal and DOD Special Operations teams. Division of Operational and Disaster Medicine Carolinas Medical Center, Charlotte NC David.callaway@carolinas.org

Redefining Technical Rescue and Casualty Care for SOF: Part 1

Making the Jump … Transitioning from Military to Civilian Paramedicine Mike Smith, BS, MICP

ontrary to what Special Forces warrior medics may think, you just can’t do Spec Ops forever. Even if there were no other factors, just consider repetitive HALO jumps; logic alone would dictate that if you do enough of those, you will be continually compacted as vertebral discs get hammered flatter and flatter over time. By the time your old 36" inseam turns into a 28", you’ve got to know that your days are numbered. Either you start liking big cuffs in your pants, or the next jump you might make may be to civilian medicine. In this piece, I’d like to provide some helpful information for Special Operations Forces (SOF) warrior medics who wish to develop and execute a plan to successfully transition from military to civilian medicine. Many years ago I watched a good friend who was an 18D wind up working as an Emergency Department (ED) tech because there was no formal pathway to move a combat medic into civilian medicine. Without that pathway, the system took extraordinarily talented military field practitioners such as my friend, and channeled them into employment opportunities as operating room (OR) and ED techs, which barely pays a livable wage. I never forgot how the system failed my friend after a long career serving his country. At the very least, it was gross misuse of a rocksolid clinician and a real waste of talent. Thankfully today, there are very doable pathways that allow combat medics the opportunity to build on their military platform while filling in practice elements that are commonly seen more in the civilian world of emergency medical services (EMS) systems such as cardiac emergencies and the associated pharmacology, pediatric emergencies, the continuous circle of patient transfers to and from extended care facilities and hospitals that provide care to the ever aging members of our population. I would be remiss if I failed to mention behavioral emergencies with or without drug and/or alcohol abuse. These are just some of the gaps in practice that may need beefing up for military medics to be successful in the civilian EMS setting.

Much of what I will be sharing is based primarily on the selection criteria for admission to the Paramedic Education Program at Tacoma Community College, where I served as the Program Chair and Lead Instructor for over 20 years. While portions of those criteria are certainly venue specific, the vast majority are consistent or similar to the criteria of other Paramedic Programs nationwide. If you have Advanced Tactical Practitioner (ATP) credentials, capitalize on them. With current ATP credentials, a letter from a Battalion Surgeon or Medical Director may be all that is required to qualify you to challenge the National Registry paramedic test battery (written and practical examinations). However, this examination process still poses several significant challenges. When preparing for the written, take the time to review any current paramedic text. It is essential to keep in mind that the Registry written is focused on confirming if the practitioner has an adequate fund of knowledge to be deemed “entry level competent”. DO NOT base your answers on your current field practice. This is a BOOK test, based on current EMS education standards. As such, the longer you have been practitioner, the more challenging it becomes to provide the “book” answer rather than an answer based on “how you do your job in the field.” The Registry practical skills testing can also be daunting, as it evaluates the performance of 11 skills in a sterile, lab setting. My recommendation for any ATP credentialed practitioner is to do some form of refresher training on the skill set before walking in to take the practical. Ideally, instructors who are experienced Registry evaluators should teach this training. If you don’t have ATP credentials, obtain and maintain your civilian credentials. Several years ago, there was a real push to get Soldiers working in medicine civilian credentials through the National Registry. Those credentials alone provided incredible horizontal mobility for the combat medic leaving the service who wanted to continue to work in the medical field in the civilian world. If you are a Soldier fortunate enough to have

obtained emergency medical technician (EMT) EMTBasic (EMT-B) or EMT-Intermediate (EMT-I) credentials through the Registry (or have state issued credentials), it is essential that you continually maintain those credentials, including the entire time you are completing your training as a Paramedic. National Registry credentials expire on March 31st of each year. If you have Registry credentials that need renewal, your first and simplest option is to take a refresher course specific to your certification level. You will commonly find refresher courses offered in pretty tight time frames over a week to tenday period. Upon completion, you have met the majority of what is required for recertification. Depending on the volume of National Registry providers working in a given geographic area, refresher courses can be either quite difficult or quite easy to find. If you are in an area where refresher courses are few and far between, your next best option is to “cobble together” the required education and skills components. With this approach, you can get recertified by thoroughly and routinely documenting the various and sundry continuing education activities you get during your time as a soldier over any three-year certification period. Case studies, situation debriefs, base station meetings, grand rounds, skills labs, etc. can all be documented as line items on your reregistration form. The key to making this method work is to make certain that upon completing a given class or skills activity, you get out your reregistration form and log in the topic or skill(s), hours accrued and the date of the event. This is far easier than sitting down the third week of March and trying to do a total recall all the continuing education that you have acquired over the last three years. You do not need to provide any classroom sessions or skills training documentation other than the signed and completed reregistration form to the Registry along with your fee, unless you get audited. Should that occur, you must provide whatever documentation i.e. your certificates of completion for classes you have attended or your skills sign off sheet for practical skills events, as required by Registry policy. If you have yet to obtain your National Registry EMTB or EMT-I credentials yet, and the opportunity to do so exists, do it. It is worth the time and energy to make that happen if for no other reason than more than 40 states across the country that will offer you some form of reciprocity if you have current Registry credentials in hand. At my Program, you can come with either State OR National Registry credentials, but again, it is mission critical to understand that you must maintain either your EMT-B or EMT-I credentials throughout the entire time you are in Paramedic training. Expect those requirements to be in place at most programs as proof of current licensure provides evidence of your ongoing, current competency while you are getting additional education and training to attain new skills and abilities.

If you are looking for an entire course, EMT-B is frequently offered in part-time, evening formats due to students needs such as; 9 to 5 regular working folks with day jobs who want to work as volunteer firefighters in their off time, and as such need an EMT-B certification as part of the job requirement. For that group, night classes fill the niche. EMT-B is usually offered in either a one quarter or occasionally, a one-semester format. EMT-I training can be more difficult to complete in the civilian world, as this is a pretty small, splinter market for folks looking to obtain this credential, with most of them being in rural settings. That being said, EMTI’s can often get phlebotomy jobs in a hospital setting. Providing adequate documentation of your military training can often get you the option to “test out” of EMT-I training by simply demonstrating previous training and then demonstrating proficiency on a practical skills examination. Document your patient contacts. The documentation of actual patient contacts is very important, as it quantifies your work as a practitioner in the field setting. For my program, this line item alone represents 10% of the total admission points on the selection grid. Without a doubt, this documentation is much easier to acquire while you are still on active duty. Once you have out-processed, this information often becomes somewhere between difficult and impossible to obtain. You do not have to have this figure documented down to a call, but rather a good faith estimate will usually suffice. Let’s say you were deployed once for 9 months and once for 12 months. During your deployments, we will say that you saw an average of 20 injured patients a month. 20 per month times 21 months = 420 patient contacts. Have a Battalion Surgeon or Physician’s Assistant (PA) put the documentation together for you on letterhead stationary. At my program, Battalion Aid Station/Sick Call contacts do not count towards field contacts, though it may at other programs. Nor does ED tech or OR tech contacts. Field contacts are what count towards your overall admission points, at least at my program. Because of the relatively high weight of this item on the selection grid (10% of total points), the inability to document field contacts is unfortunately often a deal breaker in a competitive admission process. Organize/transfer your college credits; Finish your degree. If you have taken any coursework during your time as a Soldier that earned you college credits, try to get them transferred into a single institution if possible, and then have a transcript evaluation/degree audit completed. This will tell you what “usable credits” you have, in addition to telling you where you are in regard to completing a degree. Ideally that should be a transfer degree (Associate of Arts and Sciences, or in some cases, an Associates of Applied Science) rather that a Technical

Making the Jump …Transitioning from Military to Civilian Paramedicine

Arts or Fire Science degrees. Neither of those two degrees transfers particularly well, and in the end can cost you lots of lost time energy and money. For example, many 4 years schools will only allow you to transfer 15 credits of technical arts credits. If you came to the table with 60 technical arts credits, you basically lose 3 quarters of credits that have to be made up. If you can’t get all your credits transferred to one institution, the Transcript Evaluator at the institution where you plan to attend Paramedic Training or simply complete your degree will evaluate them college by college, telling you what will and will not transfer. It is just more tedious and time consuming to do on a college-by-college basis, but is definitely doable. If you’ve really been diligent with your college work and can hammer out a Bachelor’s of Science (BS) , that can be a real plus, and serve as a great foundation for your future in the civilian world of paramedicine, more so if you decide to pursue graduate education at the Master’s or PhD level. Obtain letters of recommendation. From my personal perspective, I would rather see letters of recommendation from somewhere who is intimately familiar with your work as a medical practitioner than from a senior command officer. Someone who has seen you work regularly on a day-by-day basis, within a “boots on ground” format can really provide helpful and insightful commentary with his or her recommendations. Contrary to what many people think, a good letter of recommendation speaks to both your strengths as well as areas needing improvement i.e. “does excellent patient assessments, and demonstrates outstanding critical thinking skills, but can use work with documentation and short reports.” A truthful letter helps clarify exactly what you bring to the table and helps the training program meet your individual needs. Connect with, and STAY connected with your Veterans Affairs (VA) representative. Without question, getting in touch with a knowledgeable, high-end VA rep, can really smooth out the bumps in the road as you make the transition from the military to the civilian world. You truly have access to fantastic education and training benefits, but the path that gets the most out of your benefits can be challenging both to map out and to follow. Some r eally important information you will want to obtain from your VA rep includes: (1) finding out which colleges, community colleges and technical schools have the highest dropout rates so you can avoid them. Student success is what you are looking for, so seek out a Paramedic Program that is nationally accredited by CoAEMSP, and ask to see their annual report. That document must be updated annually as part of the accreditation process, and will clearly identify how well any given Paramedic

Program actually does their job. (2) Getting information of the pros and cons of attending a community college or public university vs. a for-profit institution. There are certainly quality Paramedic programs offered by both groups, and there are clearly underperformers on both sides of the equation as well. But there are often significant differences philosophically as to how they each deliver education and training services they provide as well as with tuition rates. A quality VA rep will also help you avoid for-profit institutions that often embody the triad of problems that have traditionally plagued these programs: high tuition, high drop out rates, and poor job placement for graduates. (3) Identifying the schools that have hybrid or online components. At face value, online classes appear easy, but they are not. A person, who will NOT discipline themselves to routinely and actively put time into their online class, completing all assignments and participating in group work as required is at very high risk to fail right out of the chute. That is no way to kick-start your transition to civilian medicine. Truth is, online isn’t the optimal delivery model for everybody. Think about how you “like to learn” as well as “how you learn best,” and then actively look for a program that will deliver the requisite education and training you need in as close to a spot-on-match delivery model as you can find. That is arguably the single most significant variable in regard to increasing the likelihood of you having a successful education experience, and obtaining the credentials you need in hand when you head out into the civilian job market. There are many Paramedic training institutions out there to choose from. Invest some time to visit and talk with program faculty and if possible, sit in on a class and meet some of their students. Make certain that ANY program you consider is CoAEMSP accredited, because the National Registry will cease to test graduates from non-accredited Paramedic programs in 2013. National Registry credentials are the single most important factor in horizontal movement into civilian paramedicine.

Conclusion The military medical practitioner that takes the time to put together a judicious education plan, and is then disciplined to execute that plan can have close to a seamless transition into civilian paramedicine. Two of the most important elements of that process include maintaining detailed records i.e., documentation of all college coursework and continuing education events, documentation of patient contacts, letters of recommendation, etc. as well as connecting with a knowledgeable VA representative, and maintaining open lines of communication with them as you make the jump to civilian medicine.

Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

Mike Smith, BS, MICP is the Director of Clinical Education and Lead Instructor for the Paramedic Education Program at Tacoma Community College. He has 40 years experience in EMS, which includes 20 years of street time as a Paramedic. His experience includes the following platforms: Hospital based, Fire based, Third-service, and

private provider. Mike has over 250 publications including work on nine textbooks, being a lead author on one and the sole author of another (ACLS for EMT-Bâ&#x20AC;&#x2122;s) and presents at 12 to 15 EMS conferences a year. Lastly, he writes the monthly column Beyond the Books for EMS World Magazine.

Making the Jump â&#x20AC;ŚTransitioning from Military to Civilian Paramedicine

Commentary on Redefining Technical Rescue and Casualty Care for SOF: Part 1 Jeff Matthews

s a civilian technical rescuer for over 21 years, I am honored to have the opportunity to comment on the article submitted to JSOM. There is much confusion in the global application of NFPA standards. Fire/rescue (both military and civilian), law enforcement, and industrial rescue teams all struggle to adopt the correct standards into their RFP’s and or training requirements. Having read the article, Redefining Technical Rescue and Casualty Care for SOF: Part 1, the authors are right on the mark with the application of NFPA standards in the SOF community.

The Urban Assault Rescue Kit and Combat “Z” from SPEER (Distributed by North American Rescue). These are fullspectrum rescue kits, with small profiles, utilizing a mix of equipment from multiple disciplines of rescue.

First, NFPA 1983 is a manufactures standard; it does not apply to an end-user and does not apply to equipment that is used in mountain rescue, cave rescue or lead climbing, or where expected hazards and situations dictate other performance requirements. The article correctly notes the scope of NFPA 1983 as being a requirement for the equipment that would be used in a typical urban or rural rescue; for example, a window washer trapped on the side of a high-rise building. The most critical piece of the NFPA 1983 scope is the phrase, “. . . where expected hazards and situations dictate other performance requirements.” While NFPA 1983 does support thorough testing and construction requirements, some of the requirements simply go beyond what would

be usable in rapidly evolving and dynamic situations. As an example a 30-meter length of 12.5mm (1/2") NFPA “G” rated lifeline weighs approximately 3.2kg; whereas a 7.5mm cord weighs in at 1.33kg. Obviously, the smaller diameter rope is lighter and will pack tighter. The discussion on NFPA 1006 is also 100% correct. NFPA 1006 is a professional qualification standard based on the needs of civilian rescuers. The authors give a spoton example where JPR 6.1.1 (Rope Level I – Anchors) can be adapted to meet a SOF operational requirement. It is my professional opinion that SOF should examine NFPA 1006 General Requirements, Rope, Confined Space, Trench Rescue, Structural Collapse and Vehicle Machinery Extrication and use this information to create custom JPR’s for Operational Rescue. Finally, NFPA 1670 details an operational capability map for rescue teams; the key words being “rescue team.” NFPA 1670 is sometimes confused as being a professional qualification. We have received RFP’s asking for the course to certify an individual to NFPA 1670. This is clearly an incorrect application of the standard. Primarily, NFPA 1670 was meant as a way to define an organizations level of capability. I use this standard when asked to perform rescue team evaluations. As an example a Rope Rescue Operations level team should be capable of removing a victim from a rooftop using a patient packaging device, and a lowering system. While my background is not in SOF, I have been a contract trainer and SME in technical rescue for nearly 15 years and have had the honor to work directly with federal response teams as well as USSOCOM assets. This has given me a unique perspective as to how the civilian standards are being adopted by “outside the box” teams. Jeff Matthews is a 21-year veteran of the fire/rescue service and currently serves as an operations Captain with the Charlotte, NC Fire Department. He is a voting member of the NFPA 1006 committee and the President of Technical Rescue Consultants.

1831

COL Lorne H Blackbourne, MC, USA The Army Medical Department Journal, April–June 2011

ABSTRACT Background: The year 1831 was very significant to the advancement of medical technology. It was the year of the first documented use of an intravenous fluid. It was administered to increase the intravascular volume to treat the signs and symptoms of hypovolemia. In 1831, during the cholera epidemic in England, Drs Thomas Latta and Robert Lewins of London injected a saline solution guided by the pulse of hypovolemic cholera patients. Since this introduction of a saline-based intravenous fluid, how has the medical technology advanced that we are using prehospital on the battlefield prior to getting combat wounded to a surgical facility? While the technology to locate, track, and destroy our enemies has taken huge strides since 1831, our prehospital technology to help save life and limb has not kept pace. Satellites, global positioning systems, unmanned aerial vehicles, and lasers are just a few of the new technologies placed on the modern battlefield; the modern Combat Medic is, on the other hand, using technology that has barely advanced since 1831. Highlighting the technologic advances in combat arms to the individual Medic level, one only need look at the Medic’s semiautomatic sidearm, assault rifle (with electronic sights/laser), and night vision goggles, and then compare them to the flintlock rifle and flintlock pistol used in 1831. To illustrate the “technological divide,” we must look at the medical technology available to Combat Medics today. Guided by the tenets of Tactical Combat Casualty Care (TCCC), the training of Medics today has greatly improved. The equipment manufactured for use by combat Medics is lighter and is engineered with great advances. In contrast, when analyzed by comparing anatomic injury diagnostic and treatment capabilities, the actual technology of the diagnostic and treatment options available on the battlefield does not reveal many great advances since 1831.

A Significant Cervical Spine Fracture: Think of the Airway

Paula Cleiman, MD; Joe Nemeth, MD; and Phyllis Vetere, MD The Journal of Emergency Medicine, Vol. 42, No. 2

ABSTRACT Background: Airway compromise is a potential complication of significant cervical spine injury. Objectives: To alert emergency physicians to be aware of possible airway collapse after serious cervical spine injury. Case Report: We report a case of an 87-year-old man who presented to the emergency department with an unstable cervical spine fracture after a fall. He subsequently developed complete upper airway obstruction from prevertebral soft tissue swelling, requiring a cricothyrotomy after a failed intubation attempt. Conclusion: Patients with significant blunt cervical spine trauma can be at high risk for upper airway compromise. Keywords: cervical spine; airway; trauma; surgical airway; cricothyrotomy

Localized Control of Exsanguinating Arterial Hemorrhage: An Experimental Model

M. Brent Haick; Oscar J. Abilez; Bonnie L. Johnson; Chengpei Xu; Charles A. Taylor; Norman M. Rich; Christopher K. Zarins Research conducted under grant W81XWH-06-2-0001 from the Defense Advanced Research Projects Agency

ABSTRACT Background: To develop an arterial injury model for testing hemostatic devices at well-defined high and low bleeding rates. Material and method: A side-hole arterial injury was created in the carotid artery of sheep. Shed blood was collected in a jugular venous reservoir and bleeding rate at the site of arterial injury was controlled by regulating outflow resistance from the venous reservoir. Two models were studied: uncontrolled exsanguinating hemorrhage and bleeding at controlled rates with blood return to maintain hemodynamic stability. Transcutaneous Duplex ultrasound was used to characterize ultrasound signature at various bleeding rates. Results: A 2.5mm arterial sidehole resulted in exsanguinating hemorrhage with an initial bleeding rate of 400ml/min, which without resuscitation, decreased to below 100ml/min in 5 minutes. After 17 minutes, bleeding from the injury site stopped and the animal had lost 60% of total blood volume. Reinfusion of shed blood maintained normal hemodynamics and both high and low bleeding rates could be maintained without hemorrhagic shock. Bleeding rate at the arterial injury site was held at 395 Âą 78ml/min for 8 minutes, 110 Âą 11ml/min for 15 minutes, and 12 Âą 1ml/min for 12 minutes. Doppler flow signatures at the site of injury were characterized by high peak and end-diastolic flow velocities at the bleeding site, which varied with the rate of hemorrhage. Conclusion: We have developed a hemodynamically stable model of acute arterial injury, which can be used to evaluate diagnostic and treatment methods focused on control of the arterial injury site. Keywords: arterial injury model, bleeding rate, arterial hemorrhage rate, Doppler ultrasound signature

Randomized Objective Comparison of Live Tissue Training Versus Stimulators for Emergency Procedures CAPT Andrew B. Hall, MD The American Surgeon, May 2011

ABSTRACT There is a lack of objective analysis comparing live tissue and simulator training. This article aims to objectively determine the difference in outcomes. Twenty-four Air Force volunteers without prior experience performing emergency procedures were randomly assigned to receive training in tub thoracostomy (chest tube) and cricothyroidotomy training on either a pig model (Sus scrofa domestica) of on the TraumaMan simulator. One week posttraining, students were tested on human cadavers with objective and subjective results recorded. Average completion time for tub thoracostomy in the animal model group was 2 minutes 4 seconds and 1 minute 51 seconds in the simulator group with a mean difference of 12 seconds (P = 0.74). Average completion time for cricothyroidotomy in the animal model group was 2 minutes 35 seconds and 3 minutes 29 seconds in the simulator group with a mean difference of 53 seconds (P = 0.32). Overall confidence was 9 per cent higher in the animal trained group (P = 0.42). Success rate of cricothyroidotomy was 75 per cent in the animal model group and 58 per cent in the simulator-trained group (P = 0.67). Success rate of chest tube placement was 92 per cent in the animal group and 83 per cent in the simulator group (P = 1.00). There was no statistically significant difference in chest tube and cricothyroidotomy outcomes or confidence in the groups trained with live animal models or simulators at the 95 per cent confidence interval. Trends suggest a possible difference, but the number of cadavers required to reach greater than 95 per cent statistical confidence prohibit continuation of the study.

Placement of Tibial Intraosseous Infusion Devices

COL H. Theodore Harcke , MC USA; Lt Col Geoffrey Crawley, USAF MC; MAJ Robert Mabry, MC USA; Lt Col (Sel) Edward Mazuchowski, USAF MC Military Medicine, Vol. 176, July 2011

ABSTRACT Post-mortem preautopsy multidetector computed tomography was used to assess the placement of tibial intraosseous infusion needle in 52 cases of battlefield trauma deaths for which medical intervention included the use of the technique. In 58 (95%) of 61 needles, the tip was positioned in medullary bone. All 3 (5%) unsuccessful placements were in the left leg, and the needle was not directed perpendicular to the medial tibial cortex as recommended. Considering the nature of military trauma and the environmental conditions under which care is rendered, military medical personnel appear to be highly successful in the placement of tibial intraosseous infusion needles.

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Cervical Collars are Insufficient for Immobilizing an Unstable Cervical Spine Injury

MaryBeth Horodyski, EDD; Christian P. DiPaola, MD; Bryan P Conrad, PhD; and Glenn R. Rechtine, II, MD The Journal of Emergency Medicine, Vol. 41, No. 5, pp. 513â&#x20AC;&#x201C;519, 2011

ABSTRACT Background: Cervical orthoses are commonly used for extrication, transportation, and definitive immobilization for cervical trauma patients. Various designs have been tested frequently in young, healthy individuals. To date, no one has reported the effectiveness of collar immobilization in the presence of an unstable mid-cervical spine. Study Objectives: To determine the extent to which cervical orthoses immobilize the cervical spine in a cadaveric model with and without a spinal instability. Methods: This study used a repeated-measures design to quantify motion on multiple axes. Five lightly embalmed cadavers with no history of cervical pathology were used. An electromagnetic motion-tracking system captured segmental motion at C5-C6 while the spine was maneuvered through the range of motion in each plane. Testing was carried out in intact conditions after a global instability was created at C5-C6. Three collar conditions were tested: a one-piece extraction collar (Ambu Inc., Linthicum, MD), a two-piece collar (Aspen Sierra, Aspen Medical Products, Irvine, CA), and no collar. Gardner-Wells tongs were affixed to the skull and used to apply motion in flexion-extension, lateral bending, and rotation. Statistical analysis was carried out to evaluate the conditions: collar use by instability (3x2). Results: Neither the one-nor the two-piece collar was effective at significantly reducing segmental motion in the stable or unstable condition. There was dramatically more motion in the unstable state, as would be expected. Conclusion: Although using a cervical collar is better than to immobilization, collars do not effectively reduce motion in an unstable cervical spine cadaver model. Further study is needed to develop other immobilization techniques that will adequately immobilize an injured, unstable cervical spine. Keywords: cervical injury; immobilization; cervical collars; prehospital care, trauma

Wartime Spine Injuries: Understanding the Improvised Explosive Device and Biophysics of Blast Trauma Daniel G. Kang, MD; Ronald A. Lehman, Jr., MD; and Eugene J. Carragee, MD The Spine Journal, 2012

ABSTRACT Background: The improvised explosive device (IED) has been the most significant threat by terrorists worldwide. Blast trauma has produced a wide pattern of combat spinal column injuries not commonly experienced in the civilian community. Unfortunately, explosion-related injuries have also become a widespread reality of civilian life throughout the world, and civilian medical providers who are involved in emergency trauma care must be prepared to manage casualties from terrorist attacks using high-energy explosive devices. Treatment decisions for complex spine injuries after blast trauma require special planning, taking into consideration many different factors and the complicated multiple organ system injuries not normally experienced at most civilian trauma centers. Therefore, an understanding about the effects of blast trauma by spine surgeons in the community has become imperative, as the battlefield has been brought closer to home in many countries through domestic terrorism and mass casualty situations, with the lines blurred between military and civilian trauma. We set out to provide the spine surgeon with a brief overview on the use of IEDs for terrorism and the current conflicts in Iraq and Afghanistan and also a perspective on the biophysics of blast trauma. Keywords: Improvised explosive device; Blast trauma; Blast injury; Blast biophysics; Combat spine injury; Wartime spine injury

Emergent Cricothyroidotomies for Trauma: Training Considerations

David R. King MD; Michael P. Ogilvie MD; George Velmahos MD, PhD; Hasan B. Alam MD; Marc A. deMoya MD; Susan R. Wilcox MD; Ali Y. Mejaddam MD; Gwendolyn M. Van Der Wilden MD; Oscar A. Birkhan MD; and Karim Fikry MD American Journal of Emergency Medicine, 2011

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ABSTRACT Background: Emergent cricothyroidotomy remains an uncommon, but life-saving, core procedural training requirement for emergency medicine (EM) physician training. We hypothesized that although most cricothyroidotomies for trauma occur in the emergency department (ED), they are usually performed by surgeons. Methods: We conducted a retrospective analysis of all emergent cricothyroidotomies for trauma presentations performed at 2 large level I trauma centers over 10 years. Operators and assistants for all procedures were identified, as well as mechanism of injury and patient demographics were examined. Results: Fifty-four cricothyroidotomies were analyzed. Patients had a mean age of 50 years, 80% were male, and 90% presented as a result of blunt trauma. The most common primary operator was a surgeon (n = 47, 87%), followed by an emergency medical services (EMS) provider (n = 6, 11%) and an EM physician (n = 1, 2%). In all cases, except those performed by EMS, the operator or assistant was an attending surgeon. All EMS procedures resulted in serious complications compared with in-hospital procedures (P < .0001). Conclusions: (1) Prehospital cricothyroidotomy results in serious complications. (2) Despite the ubiquitous presence of EM physicians in the ED, all cricothyroidotomies were performed by a surgeon, which may present opportunities for training improvement.

Historical Review of Emergency Tourniquet Use to Stop Bleeding

John F. Kragh Jr, Col.,MC; Kenneth G. Swan, Col. (RET), USAR, MC; Dale C. Smith, Ph.D; Robert L. Mabry, LTC, MC, USA; Lorne H. Blackbourne, Col., MC, USA The American Journal of Surgery, 2012 (203):242–252

ABSTRACT Background: Although a common first aid topic, emergency tourniquets to stop bleeding are controversial because there is little experience on which to guide use. Absent an adequate historical analysis, we have researched development of emergency tourniquets from antiquity to the present. Methods: We selected sources emphasizing historical development of tourniquets from books and databases such as PubMed. Results: The history of the emergency tourniquet is long and disjointed, mainly written by hospital surgeons with little accounting, until recently, of the needs of forward medics near the point injury. Many investigators often are unaware of the breadth of the tourniquet’s history and voice opinions based on anecdotal observations. Conclusions: Reporting the historical development of tourniquet use allowed us to recognize disparate problems investigators discuss but do not recognize, such as venous tourniquet use. We relate past observations with recent observations for use by subsequent investigators.

Should Antifibrinolytics Be Given in all Patients with Trauma?

Marcel Levi Current Opinion in Anaesthesiology, 2012 Jun; 25 (3):385–8

ABSTRACT Purpose of review: Hemorrhage is the second most important cause of death in patients with trauma, contributing to approximately 30% of trauma-related mortality. Pharmacological prohemostatic agents may be useful adjunctive treatment options in patients with severe blood loss. Recent findings: Tranexamic acid was evaluated in a large international randomized controlled study in patients with trauma and severe blood loss. The drug was shown to reduce death due to bleeding, provided the treatment was given within 3 hours after injury. Tranexamic acid treatment did not result in serious adverse events nor thrombotic complications. Summary: In view of this efficacy and safety of this relatively cheap and simple drug, it may be recommended to put tranexamic acid in the first (maybe even prehospital) line of management of patients with severe traumatic hemorrhage. Keywords: antifibrinolytics, hemorrhage, prohemostatic drugs, tranexamic acid, trauma

The Effect of Vehicle Protection on Spine Injuries in Military Conflict

Daniel R. Possley, DO, MS; James A. Blair, MD; Brett A. Freedman, MD; Andrew J. Schoenfeld, MD; Ronald A. Lehman, MD; Joseph R. Hsu, MD; and the Skeletal Trauma Research Consortium (STReC) The Spine Journal, 2012

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ABSTRACT Background: To evaluate the effect of critical time periods in vehicle protection on spine injuries. Purpose: To characterize the effect of method of movement on and around the battlefield during Operation Enduring Freedom and Operation Iraqi Freedom from 2001 to 2009 in terms of its impact on the incidence and severity of spinal fractures sustained in combat. Study Design/Setting: Retrospective study. Patient Sample: Mounted and dismounted American servicemembers who were injured during combat. Methods: Extracted medical records of servicemembers identified in the Joint Theater Trauma Registry from October 2001 to December 2009. Methods of movement were defined as mounted or dismounted. Two time periods were compared. Cohorts were created for 2 x 2 analysis based on method of movement and the time period in which the injury occurred. Time period 1 and 2 were separated by April 1, 2007, which correlates with the initial fielding of the modern class of uparmored fighting vehicles with thickened underbelly armor and a V-shaped hull. Our four comparison groups were Dismounted in Time Period 1 (D1), Dismounted in Time Period 2 (D2), Mounted in Time Period 1 (M1), and Mounted in Time Period 2 (M2). Results: In total, 1,819 spine fractures occurred over the entire study period. Four hundred seventy-two fractures (26%) were sustained in 145 servicemembers who were mounted at the time of injury, and 1,347 (74%) were sustained by 404 servicemembers who were dismounted (p < .0005). The incidence of fractures in the dismounted cohort (D1 + D2) was significantly higher than in the mounted cohort (M1+M2) in both time periods (D1 vs. M1, 13.75 vs. 3.95/10,000 warrior-years [p < .001] and D2 vs. M2, 11.15 vs. 4.89/10,000 warrior-years [p < .0001]). In both the mounted and dismounted groups, the thoracolumbar (TL) junction was the most common site of injury (36.1%). Fractures to the TL junction (T10–L3) increased significantly from Time Period 1 to 2 (34% vs. 40% of all fractures, respectively, p5.03). Thoracolumbar fractures were significantly more severe in that there were more Arbeitsgemeinschaft fur osynthesefragen/Magerl Type A injuries versus all TL fractures, 1.75 versus 2.68/10,000 or 27% of all spine fractures in Time Period 1.

Comparison of Novel Hemostatic Gauzes to QUIKCLOT Combat Gauze in a Standardized Swine Model of Uncontrolled Hemorrhage Jason M. Rall, PhD; Jennifer M. Cox; Adam Songer, MD; James A. Comeaux; J. Scot Estep, DVM; Ramon F. Cestero, MD, FACS; James D. Ross, PhD Naval Medical Research Unit San Antonio Technical Report #TR-2012-22

ABSTRACT Problem: Uncontrolled hemorrhage is one of the leading causes of death in the battlefield. The development, testing, and application of novel hemostatic dressings may lead to a reduction of prehospital mortality through enhanced point of injury hemostatic control. Objective: This study aimed to determine the efficacy of currently available hemostatic dressings as compared to the current Committee for Tactical Combat Casualty Care Guidelines standard of treatment for hemorrhage control (QuikClot Combat Gauze-QCG). Approach: This study utilized the Department of Defense consensus swine model for uncontrolled hemorrhage. Briefly, Yorkshire swine were anesthetized and instrumented for telemetry. Following a femoral cut-down, a 6mm punch injury was created in the femoral artery and free bleeding was allowed to occur for 45 seconds. For each swine, one of five hemostatic gauzes (QCG, QuikClot Combat Gauze XL-QCX, Celox Trauma Gauze-CTG, Celox Gauze-CEL, or ChitoGauze-HCG) was packed into the wound site. Direct pressure (3 min) was then applied, and the animals were rapidly resuscitated to achieve and maintain a MAP ≥ 60mmHg for 150 minutes or until death. Animal survival, hemostasis, and blood loss were assessed as primary endpoints. Findings: Animals had an average weight of 36.6 ± 2.2kg, a mean arterial pressure of 67.5 ± 8.2, and pretreatment blood loss of 15.4 ± 3.1ml/kg. 60% of QCG-treated animals (controls) survived through the entire 150-minute observation period. QCX, CEL, and HCG demonstrated higher rates of survival when compared to QCG (70%, 90%, and 70% respectively). Immediate hemostasis was achieved in 30% of QCG applications, 80% of QCX, 70% of CEL, 60% of HCG, and 30% of CTG-treated animals. Posttreatment blood loss varied from an average of 64ml/kg with CTG to 29ml/kg with CEL, but no significant difference amongst groups was observed. Conclusions: Novel FDA-approved hemostatic dressings exist that perform equally to the current standard of care based on hemostasis, survival, and blood loss measured in the DoD concensus model of swine femoral uncontrolled hemorrhage. One product, QCX was identified as outperforming the current standard in achieving immediate hemostasis, while two products, QCX and CEL were identified as outperforming the current standard in achieving 10-minute hemostasis. These results suggest that the current standard for point-of-injury hemorrhage control (QCG) may need to be re-evaluated or alternatively the standard of care expanded to include QCX, CEL, CTG and HCG. Abstracts from Current Literature

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Intraosseous Versus Intravenous Vascular Access During Out-of-Hospital Cardiac Arrest: A Randomized Controlled Trial Rosalyn Reades, MD, Jonathan R. Studnek, PhD, NREMT-P, Steven Vandeventer, EMT-P, John Garrett, MD Annals of Emergency Medicine, 511, Vol. 58, No. 6, December 2011

ABSTRACT Study objective: Intraosseous needle insertion during out-of-hospital cardiac arrest is rapidly replacing peripheral intravenous routes in the out-of-hospital setting. However, there are few data directly comparing the effectiveness of intraosseous needle insertions with peripheral intravenous insertions during out-of-hospital cardiac arrest. The objective of this study is to determine whether there is a difference in the frequency of first attempt success between humeral intraosseous, tibial intraosseous, and peripheral intravenous insertions during out-of-hospital cardiac arrest. Methods: This was a randomized trial of adult patients experiencing a nontraumatic out-of-hospital cardiac arrest in which resuscitation efforts were initiated. Patients were randomized to one of 3 routes of vascular access: tibial intraosseous, humeral intraosseous, or peripheral intravenous. Paramedics received intensive training and exposure to all 3 methods before study initiation. The primary outcome was first-attempt success, defined as secure needle position in the marrow cavity or a peripheral vein, with normal fluid flow. Needle dislodgement during resuscitation was coded as a failure to maintain vascular access. Results: There were 182 patients enrolled, with 64 (35%) assigned to tibial intraosseous, 51 (28%) humeral intraosseous, and 67 (37%) peripheral intravenous access. Demographic characteristics were similar among patients in the 3 study arms. There were 130 (71%) patients who experienced initial vascular access success, with 17 (9%) needles becoming dislodged, for an overall frequency of first-attempt success of 113 (62%). Individuals randomized to tibial intraosseous access were more likely to experience a successful first attempt at vascular access (91%; 95% confidence interval [CI] 83% to 98%) compared with either humeral intraosseous access (51%; 95% CI 37% to 65%) or peripheral intravenous access (43%; 95% CI 31% to 55%) groups. Time to initial success was significantly shorter for individuals assigned to the tibial intraosseous access group (4.6 minutes; interquartile range 3.6 to 6.2 minutes) compared with those assigned to the humeral intraosseous access group (7.0 minutes; interquartile range 3.9 to 10.0 minutes), and neither time was significantly different from that of the peripheral intravenous access group (5.8 minutes; interquartile range 4.1 to 8.0 minutes). Conclusion: Tibial intraosseous access was found to have the highest first-attempt success for vascular access and the most rapid time to vascular access during out-of-hospital cardiac arrest compared with peripheral intravenous and humeral intraosseous access.

Hextend and 7.5% Hypertonic Saline With Dextran are Equivalent to Lactated Ringer’s in a Swine Model of Initial Resuscitation of Uncontrolled Hemorrhagic Shock Gordon M. Riha, MD; Nicholas R. Kunio, MD; Philbert Y. Van, M; Gregory J. Hamilton, BS; Ross Anderson, BS; Jerome A. Differding, MPH; and Martin A. Schreiber, MD The Journal of TRAUMA® Injury, Infection, and Critical Care, Vol. 71, No. 6, December 2011

ABSTRACT Background: The optimal fluid strategy for the early treatment of trauma patients remains highly debated. Our objective was to determine the efficacy of an initial bolus of resuscitative fluids used in military and civilian settings on the physiologic response to uncontrolled hemorrhagic shock in a prospective, randomized, blinded animal study. Methods: Fifty anesthetized swine underwent central venous and arterial catheterization followed by celiotomy. Grade V liver injury was performed, followed by 30 minutes of uncontrolled hemorrhage. Then, liver packing was completed, and fluid resuscitation was initiated over 12 minutes with 2L normal saline (NS), 2L Lactated Ringer’s (LR), 250mL 7.5% hypertonic saline with 3% Dextran (HTS), 500mL Hextend (HEX), or no fluid (NF). Animals were monitored for 2 hours postinjury. Blood loss after initial hemorrhage, mean arterial pressure (MAP), tissue oxygen saturation (StO2), hematocrit, pH, base excess, and lactate were measured at baseline, 1 hour, and 2 hours. Results: NF group had less post-treatment blood loss compared with other groups. MAP and StO2 for HEX, HTS, and LR at 1 hour and 2 hours were similar and higher than NF. MAP and StO2 did not differ between NS and NF, but NS resulted in decreased pH and base excess. Conclusions: Withholding resuscitative fluid results in the least amount of posttreatment blood loss. In clinically used volumes, HEX and HTS are equivalent to LR with regard to physiologic outcomes and superior to NF. NS did not provide a measurable improvement in outcome compared with NF and resulted in increased acidosis. Keywords: Resuscitation, Hemorrhage, Shock, Animal model

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Major Complications, Mortality, and Resource Utilization After Open Abdominal Surgery 0.9% Saline Compared to Plasma-Lyte Andrew D. Shaw, MB, FRCA, FCCM; Sean M. Bagshaw, MD; Stuart L. Goldstein, MD; Lynette A. Scherer, MD; Michael Duan, MS; Carol R. Schermer, MD; and John A. Kellum, MD Annals of Surgery, Vol. 255, No. 5, May 2012

ABSTRACT Objective: To assess the association of 0.9% saline use versus a calciumfree physiologically balanced crystalloid solution with major morbidity and clinical resource use after abdominal surgery. Background: 0.9% saline, which results in a hyperchloremic acidosis after infusion, is frequently used to replace volume losses after major surgery. Methods: An observational study using the Premier Perspective Comparative Database was performed to evaluate adult patients undergoing major open abdominal surgery who received either 0.9% saline (30,994 patients) or a balanced crystalloid solution (926 patients) on the day of surgery. The primary outcome was major morbidity and secondary outcomes included minor complications and acidosis-related interventions. Outcomes were evaluated using multivariable logistic regression and propensity scoring models. Results: For the entire cohort, the in-hospital mortality was 5.6% in the saline group and 2.9% in the balanced group (P < 0.001). One or more major complications occurred in 33.7% of the saline group and 23% of the balanced group (P < 0.001). In the 3:1 propensity-matched sample, treatment with balanced fluid was associated with fewer complications (odds ratio 0.79; 95% confidence interval 0.66–0.97). Postoperative infection (P = 0.006), renal failure requiring dialysis (P < 0.001), blood transfusion (P < 0.001), electrolyte disturbance (P = 0.046), acidosis investigation (P < 0.001), and intervention (P = 0.02) were all more frequent in patients receiving 0.9% saline. Conclusions: Among hospitals in the Premier Perspective Database, the use of a calcium-free balanced crystalloid for replacement of fluid losses on the day of major surgery was associated with less postoperative morbidity than 0.9% saline.

An Analysis of Battlefield Cricothyrotomy in Iraq and Afghanistan

Robert L Mabry, MD; Alan Frankfurt, MD Journal of Special Operations Medicine, 2012 Spring; 12(1):17–23.

ABSTRACT Objective: Historical review of modern military conflicts suggests that airway compromise accounts for 1–2% of total combat fatalities. This study examines the specific intervention of pre-hospital cricothyrotomy (PC) in the military setting using the largest studies of civilian medics performing PC as historical controls. The goal of this paper is to help define optimal airway management strategies, tools and techniques for use in the military pre-hospital setting. Methods: This retrospective chart review examined all patients presenting to combat support hospitals following prehospital cricothyrotomy during combat operations in Iraq and Afghanistan during a 22-month period. A PC was determined “successful” if it was documented as functional on arrival to the hospital. All PC complications that were documented in the patients’ record were also noted in the review. Results: Two thirds of the patients died. The most common injuries were caused by explosions, followed by gunshot wounds (GSW) and blunt trauma. Eighty-two percent of the casualties had injures to face, neck or head. Those injured by gunshot wounds to the head or thorax all died. The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Pre-hospital cricothyrotomy was documented as successful in 68% of the cases while 26% of the PC’s failed to cannulate the trachea. In 6% of cases the patient was pronounced dead on arrival without documentation of PC function. The majority of PC’s (62%) were performed by combat medics at the point of injury. Physicians and physician assistants (PA) were more successful performing PC than medics with a 15% versus a 33% failure rate. Complications were not significantly different than those found in civilian PC studies, including incorrect anatomic placement, excessive bleeding, air leak and right main stem placement. Conclusions: The majority of patients who underwent PC died (66%). The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Military medics have a 33% failure rate when performing this procedure compared to 15% for physicians and physician assistants. Minor complications occurred in 21% of cases. The survival rate and complication rates are similar to previous civilian studies of medics performing PC. However the failure rate for military medics is three to five times higher than comparable civilian studies. Further study is required to define the optimal equipment, technique, and training required for combat medics to master this infrequently performed but lifesaving procedure.

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from the SEMA

to the charter. Two fundamental “The Ground Truth” changes were discussed, proposed, At the time of writing, many big and voted into the charter. First was picture decisions are being made on for the JMEAC to assume the role, the role of SOF and USSOCOM on MSG Harold R. Montgomery mission and tasks of the Curriculum the global scale and for many years Requirements Board (CRB). Second, to come. I certainly cannot go into USSOCOM in order to absorb the CRB mission, the details in this forum. However, Senior Enlisted Medical Advisor the JMEAC membership would need I recommend all of the SOF medical to be modified to maintain the repOperators get spun up on how the resentation that was provided to the future changes are going to affect CRB. To understand these changes, you must underyour unit, mission, and individual role. stand what the CRB was in years prior. The CRB was In an effort to get ahead of the game on this grand en- previously defined and tasked as follows: Be composed deavor of change, many of the senior medical leaders of operational level medical personnel from SOF units. throughout SOCOM have been moving to set the stage. Maintain the SOF Interoperable Combat Medic Critical One of these movements was to update and publish the Task List (CTL) delineating the minimum medical skills USSOCOM Directive 350-29 (SOF Baseline Interoper- and knowledge required of SOF Combat Medics. Review able Medical Training Standards), which hit the street of the CTL will be as directed by the USSOCOM/SG. on 07 September 2012. By no means is the document perfect. In all honestly, we have already started work on The new JMEAC Mission and Role is as follows: the next revision. I challenge you to get hold of the docu• Provide a consultation forum, with a senior enlisted ment, read it, and provide viable feedback. leadership perspective, to the Component Surgeons, Curriculum and Examination Board (CEB), and the One significant piece of the new 350-29 is re-alignment Biomedical Initiative Steering Committee (BISC) that of some of the medical work effort throughout SOCOM. addresses recruitment, retention, education, training, In the following discussion, I will go into some details on modernization, research and development, morale, the part that directly relates to the SOF enlisted medical and welfare concernment within the Joint Special Opforce. That part is the JMEAC. erations Forces Medical dominion. • To create and/or update the Advanced Tactical ParaJoint Medical Enlisted Advisory Council (JMEAC) medic (ATP) Critical Task List (CTL) on behalf of the USSOCOM Command Surgeon. This document The JMEAC has been in existence in some incarnation serves as the unifying requirements and reference docfor 15+ years. I say incarnation because it has taken ument for the standard skills and abilities expected of different roles over the span of time to include simple the Advanced Tactical Paramedic. advisory panel for the medical officers to a group dedicated to changing SOF Medicine. The entity has been • To consolidate medical initial and sustainment training resourcing requirements for USSOCOM commandated since the old SOCOM Regulation 40-2 up ponents; provide recommended guidance to SG and through the newly published USSOCOM Directive 350executive agency for implementation. “Provide a US29 (07 September 12). In this update, I wanted to bring SOCOM medical training requirements and resourceverybody up-to-date on the recent modifications and ing recommendation” re-energizing of the JMEAC. • To preside over enlisted medical certification revocation hearings and to make final disposition of these In December of 2011, the JMEAC (as defined by the cases, as a jury of professional peers. The board also 2008 version of 350-29) met to discuss proposed changes

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has a tertiary purpose to add or remove enlisted military occupation representatives to either the JMEAC or the CEB, specifically when new military occupation specialties (MOS), naval enlisted classifications (NEC), or Air Force Specialty Codes (AFSC) are developed or eliminated by the larger military services. The new JMEAC membership is as follows: The JMEAC meets at least three times a year to address the issues within its scope and mission. Often, the JMEAC will meet in conjunction with other events such as the Special Operations Medical Association (SOMA), or Medical Health Services Research Symposium MHSRS (formerly ATACCC), or when the BISC or CEB is meeting. Each meeting agenda is based on addressing hot current issues, but the JMEAC will also function on a cyclic basis. The JMEAC cycle of work priorities include reviewing/modifying the ATP critical task review, reviewing/making recommendations for the

From the SEMA

SOCM curriculum, reviewing CEB products (TMEPs or exam questions), and projecting future requirements (class seats, RDT&E priorities, and SOF enlisted career management). It is in every SOF medical Operatorâ&#x20AC;&#x2122;s best interest to identify who represents you and your unit or skill set. Every SOF enlisted medical Operator should be represented by someone. Voice your opinions and concerns to that person so they can bring them to the bigger table. Every one of us has a stake and need to take ownership of our part of the program. It is the only way we can move it forward. As always, I want to take a moment to recognize the SOF Medical Operators. As I write this and as you read this, somewhere there is a SOF medical Operator doing their job. Someone is on target saving a life right now! Keep him in mind and your prayers in everything we do!

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more important. Clearly, it is already o anyone who has been watching the important for those going to remote television news from the Middle East Warner D.“Rocky”Farr, MD locations and countries. Therefore, if as of late can extrapolate what I have COL, USA someone does not meet “MOD11” been doing! Times continue to be busy guidance for some condition, it is for and forces come and go. No particular SOCCENT/CFSOCC a reason. This MOD 11 also applies to complaints from me, after nearly twelve Surgeon civilian government employees, conyears of war, I think we have it down. See you at the Special Operations Medical Association in tractors, Red Cross Volunteers—all who go to the USCENTCOM AOR. Many of those categories also have Tampa, 15–18 December 2012. Could well be my last. retired ID cards and impact the theater medical system One subject worth covering is U.S. Central Command doubly. Note that all uniformed members must first (USCENTCOM) Medical Waivers. I am the waiver au- meet their service standards, not being medical boarded, thority for all deploying SOF and SOF enablers bound etc. If you have someone who does not meet those stanfor SOF assignments to the CENTCOM AOR who dards then they need a waiver. It does not matter if their do not meet the USCENTCOM Medical Standards. local doc says they can go to war (on that medicine) or The only exception is neuropsychiatric waivers they are their service medical system thinks its fine for them to done by the USCENTCOM Command Surgeon. The go to war; if they are SOF or SOF supporters coming to USCENTCOM medical standards are contained in what SOF in the CENTCOM AOR, they still need a waiver they usually refer to as “MOD 11.” That is actually a from the SOCCENT Command Surgeon (that is me). USCENTCOM message that came out that explains in Emailing me, directly (warner.farr@soccent.centcom.mil) detail whom is mentally and physically qualified to go is fine. MOD 11 mentions this office and those contact to theater and what they need to take with them. The methods work also: The SOCCENT Surgeon’s Office email is SOCCENT.SG@SOCCENT.CENTCOM.MIL. Addireal title is: tionally, the commercial phone number is: 813.828.4352, USCENTCOM 021922Z DEC 11 MOD ELEVEN TO DSN: 312.968.4315. USCENTCOM INDIVIDUAL PROTECTION AND Realize that you need to give me a good reason to overINDIVIDUAL-UNIT DEPLOYMENT POLICY rule the guidance contained in MOD 11. Some of the Deployment means anything longer than 15 days. So things that raise red flags are chronic drugs not in the all required immunizations, physical standards, drugs, USCENTCOM formulary, heavy narcotics, drugs requirrequirements to carry a supply, eyeglasses, CBRNE, con- ing refrigeration, medical equipment requiring electricity, tact lenses, hearing aids, pre- and post-deployment sur- medical equipment requiring medical maintenance supveys, unit mascots and pets, laboratory testing, malaria port (they ain’t gonna tune up your implanted defibrilprophylaxis, it is all in there. One of the goals of the lator!), and the list goes on. So, send me a good clinical USCENTCOM Command Surgeon (that is not me) is summary, containing sufficient medicine to base a decinot to overburden the medical system in theater with sion, evidence of chain of command support, and the unit complicated medical cases to worry about and try to surgeon’s assessment. I am HAPPY to try to get someone support while they have trauma on their mind. As the deployed. Do not hesitate to ask! medical infrastructure gets smaller this will become even

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ATO Special Operations Headby the NATO SOF Medicine Research quarters medical section remains Workshops and other efforts under focused on helping SOF partners im NSMDI, are pushing forward with their prove their medical systems. The re own initiatives, demonstrating the posiDan Irizarry, MD newed NATO SOF Medicine Developtive effects of the overall program and LTC, MC, USA(A) ment Initiative (NSMDI) contract saw the dedication of the nations to improve NATO Special Operations tremendous growth this fall, enabling themselves and each other. For example, Headquarters significant program expansion, with at the last NATO SOF Research WorkMedical Advisor re sidual benefits to the nations over shop on combat medical simulation and the next 12 months. The nations have embraced the first training, it was recommended that NATO SOF elements NSMDI course offering, the Special Operations Medical adopt the Military Prehospital Trauma Life Support Leaders Course (SOMLC), with two highly successful Program as an introductory course for all NATO SOF iterations. The October 2012 course is full and has a medics. The Irish Ranger Battalion is leading the way in waiting list. The second NSMDI course to be launched, establishing a military PHTLS program for their nation the NATO SOF Medical Engagement and Partnering this winter, which will not only improve their internal Course (SMEPC), is scheduled for pilot execution 8–12 capability, but also provide a valuable training resource October 2012. The SMEPC is a collaborative effort pre- to their conventional counterparts. Meanwhile, the Norpared by representatives from Sweden, Australia and the dic nations of Finland, Sweden, Denmark, and Norway United States, with experts from SOF and academia. An are pushing forward with the creation of the Nordic SOF overview of the course was published recently in a previ- medic whose capabilities will be based on the 164 tasks ous edition of JSOM. The course is designed to grow a identified as critical for NATO SOF Combat Medics nation’s capability to employ medical assets to enable (NSOCMS) at the October 2011 NATO SOF Medicine military partnering and engagement missions augment- Research Workshop. Germany has been very successful ing the SOF commander’s military assistance campaign in implementing the NSHQ assisted Tactical Combat Caoptions. The course considers multiple areas of opera- sualty Care train the trainer program. At NSHQ, we are tions, but is highly focused at the requirements to part- postured to begin construction of the NATO SOF Mediner forces in Afghanistan. Course attendance will enable cal Education and Research Center (MERC) at SHAPE, a nation’s access to specially designed medical training Belgium. The MERC, the new home for all NSMDI tools being developed over the next 12 months for part- courses, will be outfitted with classrooms and combat nering with Afghan National Police forces. Other NS- medical simulation laboratories designed for personnel MDI courses under development this year will include training as well as testing of SOF medical equipment for the Advanced SOF Medical Leaders Course, Special Op- the Alliance SOF. Overall, the nations are doing great erations Surgical Team Course and the Combat Medical things to improve their SOF medical systems, which will Simulation Course. Taken in total, these courses create translate to lives saved on the battlefield and improved a program of instruction that will enable a nation’s SOF mission success. I encourage you to get engaged in the medical leaders, enlisted and officer, to improve and process as we work together in building a Global SOF maximize their nation’s SOF medical systems. Some na- capability that is poised to meet the asymmetric threats tions, enabled by the influences and connections created of tomorrow.

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TCCC Memos July 26, 2012 from: DEFENSE HEALTH BOARD 7700 ARLINGTON BOULEVARD, SUITE 5101 FALLS CHURCH, VA 22042-5101 FOR: JONATHAN WOODSON, MD, ASSISTANT SECRETARY OF DEFENSE (HEALTH AFFAIRS) SUBJECT: Management of Traumatic Brain Injury in Tactical Combat Casualty Care 2012-04 EXECUTIVE SUMMARY Of 355,425 diagnoses of traumatic brain injury (TBI) between 2000 and 2011, 45,131 were moderate, severe or penetrating.1 The Department of Defense (DoD) has made significant advancements in expanding guidance regarding the treatment of Servicemembers with mild TBI (mTBI), but limited guidance exists for the treatment of casualties with severe TBI, especially on the battlefield. The Tactical Combat Casualty Care (TCCC) Guidelines are currently the standard used for training medics and many other deploying medical providers. As such, the Defense Health Board (DHB) recommends amending the TCCC Guidelines to include guidance for the treatment of casualties with suspected moderate/severe TBI, simply defined as penetrating brain injury or head injury with altered level of consciousness. This report provides an overview of the issue and the recommended additions to the TCCC Guidelines, as provided by the Committee on Tactical Combat Casualty Care (CoTCCC), and subsequently approved by the Trauma and Injury Subcommittee and DHB. OVERVIEW OF THE ISSUE In October 2007, DoD established a formal definition of TBI as â&#x20AC;&#x153;a traumatically induced structural injury and/or physiologic disruption of brain function as a result of (the) external force.â&#x20AC;?2 Current DoD initiatives include detailed clinical practice guidelines (CPGs) and increased provider training. The remaining gaps are the treatment of casualties with moderate to severe TBI at the point of injury and during transport. During this time, moderate brain injury can evolve into severe brain injury and casualties are at risk of secondary brain injury, which occurs most often in casualties with moderate/severe TBI.3 To prevent secondary brain injury, which worsens outcome and increases mortality from moderate/severe TBI, treatment of suspected moderate/severe TBI should begin as soon as possible.4 TACTICAL COMBAT CASUALTY CARE GUIDELINES The TCCC Guidelines are a set of trauma care guidelines customized for use in the prehospital combat setting. The Guidelines identify three stages of care: (1) Care under Fire; (2) Tactical Field Care; and (3) Tactical Evacuation (TACEVAC) Care. TCCC is currently used in training for medics by all Services in DoD and by many U.S. coalition partners.5,6 The CoTCCC, a work group of the DHB Trauma and Injury Subcommittee, performs a quarterly review of current evidence demonstrating the successes and shortcomings of the TCCC Guidelines, and considers proposed updates and revisions.5,6 The current TCCC Guidelines provide limited guidance for the management of casualties with moderate/severe TBI and lack a dedicated section for this issue. METHODOLOGY The CoTCCC recently reviewed the TCCC Guidelines to ensure they reflect the current best practice for the prehospital treatment of casualties with moderate/severe TBI. Overall, the available evidence base regarding prehospital and combat TBI management best practices is weak, with published studies often citing low quality or primarily anecdotal evidence. The Brain Trauma Foundation (BTF) rigorously evaluated the available evidence and developed guidelines based on the best available evidence. These guidelines are available in the Guidelines for Prehospital Management of Traumatic Brain Injury, 2nd edition, released in 2007 and the Guidelines for Field Management of Combat-Related Head Trauma, released in 2005.* The Joint Theater Trauma System (JTTS) CPG for the Management of Patients with Severe Head Trauma provides additional guidance. The CoTCCC reviewed these guidelines in addition to select medical literature that addresses prehospital management of patients with severe head trauma. Trauma and Injury Subcommittee and CoTCCC member Dr. Mel Otten led the review. Based on his assessment, he

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proposed changes to the TCCC Guidelines to the CoTCCC on 14 November 2012. Additional input was garnered from Dr. Donald Marion (Defense Centers of Excellence for Psychological Health and TBI (DCoE)), CAPT Paul Hammer (Director of DCoE), Dr. George ‘Peach’ Taylor (Deputy Assistant Secretary of Defense (Force Health Protection and Readiness)), Dr. Alan Frankfurt (anesthesiologist), and CAPT David Tarantino, (Headquarters Marine Corps). Where possible, this report provides the quality of evidence and strength of recommendations as assessed by BTF, as well as additional evidence published since the release of the BTF guidelines. Note: *Of note, the committee that developed the Guidelines included two CoTCCC members. At the 7 February 2012 CoTCCC meeting, Dr. Otten presented proposed revisions to the guidelines as well as feedback from TBI subject matter experts. The members deliberated and amended the proposed changes on 7–8 February 2012. The CoTCCC agreed by unanimous vote on 8 February 2012 to forward its recommendations to the Trauma and Injury Subcommittee for review. The Trauma and Injury Subcommittee subsequently passed the recommended changes later that day. On June 25, 2012, Dr. Otten presented the proposed recommendation to the DHB, after which the Board discussed the recommended changes and voted to provide this recommendation report to the Assistant Secretary of Defense (Health Affairs). An overview of the Board’s discussion is provided later in this report. EVIDENCE Prevention of secondary brain injury involves aggressive treatment to prevent hypoxia and hypotension. The primary elements of prehospital care for casualties with severe TBI are to avoid hypotension (systolic blood pressure (SBP) < 90mmHg) and hypoxemia (oxygen saturation < 90%).3,4,7 These recommendations are in the current TCCC Guidelines and have been the cornerstone of the TCCC Curriculum for casualties with severe TBI since 2003. These and additional considerations for casualties with severe or penetrating head injury which are recommended for inclusion in the TCCC Guidelines are reviewed in further detail below. Hypotension and Hypoxemia Hypoxemia and hypotension may worsen outcomes for casualties with moderate/severe TBI. In its Guidelines for the Prehospital Management of Severe Traumatic Brain Injury (Second Edition), BTF recommends that patients with moderate/severe TBI be monitored for hypoxemia via pulse oximetry (defined as less than 90 percent arterial hemoglobin oxygen saturation) and hypotension (defined as less than 90mmHg SBP) using the most accurate means available.3 These recommendations are consistent BTF’s Guidelines for Field Management of Combat-Related Head Trauma.7 BTF categorized the strength of these recommendations as weak and the quality of evidence as low (primarily from Class III studies and indirect evidence).3 However, since the guidelines were published in 2007, additional published articles, as well as the TITS CPG for Management of Patients with Severe Head Trauma, have supported these recommendations (note: the JITS CPG recommends that blood oxygen saturation be maintained at greater than 93 percent).8-11 Medics do not currently carry oxygen in their combat medical sets, but oxygen may be available at Casualty Collection Points established for larger military operations. As such, the CoTCCC recommends adding a note to the Tactical Field Care section stating that medics should use oxygen if available. Fluid Resuscitation The TCCC Guidelines currently indicate a modified fluid resuscitation regimen for casualties suffering from both shock and TBI. In these casualties, unconsciousness or altered mental status may be caused by either head injury or hypovolemic shock. Both BTF guidelines recommend hypertonic saline resuscitation, as it may help reduce cerebral edema and intracranial pressure (ICP) and correct hypotension (NOTE: the evidence quality is low, from Class II studies with contradictory findings, and the recommendation strength is classified as weak).3,7 BTF’s Guidelines for Field Management of Combat-Related Head Trauma indicate that fluids should not be instituted in the presence of a strong radial pulse (indicating that the patient is likely not in hemorrhagic shock).7 Since these guidelines were published, Strandvik conducted a systematic review and concluded that hypertonic saline solutions are effective in restoring blood pressure in patients with hemorrhagic shock and in reducing ICP.12 Another systematic review by Meyer et. al. concludes that hypertonic saline improves ICP.l3 Bulger et. al. conducted a large randomized, blinded, placebo-controlled trial of the early administration of hypertonic fluids on patients with presumed severe TBI, without evidence of hypovolemic shock; study authors found no benefit in giving hypertonic fluids over normal saline.14 Rockswold et. al. conducted a prospective study in a controlled hospital environment on patients with severe TBI and found that hypertonic saline decreased ICP and improved cerebral perfusion pressure (CPP) and brain tissue oxygen tension.14 The evidence is consistent with the current TCCC Guidelines; additionally, the CoTCCC recommends including the use of hypertonic saline for resuscitation in patients with TBI in the proposed new section of the TCCC Guidelines dedicated to TBI management.

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Opioids Adverse effects of opioid analgesic medications include respiratory depression and hypotension,16 which may worsen outcomes following TBI.3,17 Because of this risk, there has been a long-standing warning in the TCCC Curriculum and the Pre-Hospital Trauma Life Support Manual (Military Edition) regarding the use of these agents in casualties with pulmonary dysfunction, shock, or altered state of consciousness.5 Upon reviewing the current TCCC Guidelines, CoTCCC members agreed that such a warning should also be included in the TCCC Guidelines. Hypothermia Two retrospective studies of trauma patients admitted to U.S. hospitals have demonstrated that nontherapeutic hypothermia has a statistically significant negative impact on mortality in patients with TB1.18,19 Because the TCCC Guidelines address hypothermia prevention in detail, no additions are recommended regarding this factor. Head Elevation Although neither of the BTF Guidelines recommend head elevation, low-level evidence suggesting that head elevation may help decrease ICP (based on studies conducted in a hospital environment) has warranted its inclusion in the JTTS CPG.10 The evidence for this recommendation primarily comes from two small randomized controlled trials and case series studies. Meyer et. al. conducted a systematic review of literature found in several databases between 1980 and 2008, in which they categorized the evidence that 30 degree head elevation decreases elevated ICP and increases CPP as level II (findings supported by a single randomized controlled trial of at least fair quality).20 Since negative effects of the positioning are unlikely, the CoTCCC recommends that elevation of the casualty’s head by 30 degrees be included in the TCCC Guidelines for casualties with suspected severe TBI. Hyperventilation Routine hyperventilation of casualties with TBI in the absence of impending cerebral herniation has been noted by multiple authors to be either of no benefit or to be harmful (it may decrease cerebral blood flow). It is not recommended by BTF and a Cochrane Review concluded that there is not enough evidence to determine whether it improves outcomes for people with TBI.3,7,8,11,21 As such, the CoTCCC supports BTF’s recommendation that hyperventilation should be avoided unless there is evidence of impending cerebral herniation.3 Because hyperventilation causes cerebral vasoconstriction, medics may use it as a temporizing measure to reduce ICP in the event there is evidence of cerebral herniation. BTF’s recommendations suggest that asymmetric, unilateral or bilateral dilated pupils may indicate cerebral herniation.3,7 However, BTF notes that the strength of this recommendation is weak, lacking adequate sensitivity and specificity to predict the injury pattern or clinical course, citing low quality evidence from Class III studies and indirect evidence.3,8, † Periods of hyperventilation should be as brief as possible. BTF indicates that the strength of this recommendation is weak, and the quality of evidence is low (primarily from Class III studies.3,7,8 Capnography should be used whenever available to maintain the end-tidal CO2 between 30 and 35.3,8 A respiratory rate of 20 (breaths per minute) may be used in the absence of capnography.7 The highest fraction of inspired oxygen (Fi02) possible should be used for hyperventilation in casualties with signs of impending cerebral herniation. Hyperoxia causes cerebral vasoconstriction independently of the effects of hypocapnia.22,23 Hyperoxia has been shown to increase cerebral tissue oxygenation23 and to improve neurochemical markers suggesting an increase in cerebral oxidative metabolism in casualties with severe head injury.24-27 Note: †BTF recommends in both its prehospital and combat-trauma guidelines that the Glasgow Coma Scale (GCS) be assessed in addition to pupil examination; however, CoTCCC members felt it would be too challenging for medics to remember, especially since a study of Emergency Medicine Technicians-Basic found that few could correctly calculate the GCS without a reference card or immediately following training.7 No studies have been published validating the use of the GCS in the military prehospital setting. Current TCCC documentation on DA Form 7656 uses AVPU (Alert, arousable to Voice, Pain, or Unarousable), a standard prehospital neurological assessment scheme. Antibiotics The Guidelines for the Prevention of Infections Associated with Combat-Related Injuries, 2011 Update indicate that various guidelines and animal studies support the premise that early administration of antimicrobials can delay the onset of infection and are beneficial. These guidelines also state that retrospective reviews and expert opinion support post-injury antimicrobials for the prevention of infection in casualties with penetrating brain injury.28 Further, the Guidelines for the Management of Penetrating Brain Injury (2001) note that “If Class I and II evidence supports the use of antibiotics in a clean wound made under controlled conditions, the use of antibiotics in a grossly contaminated penetrating wound appears justified.”29 Based on these guidelines, the authors of the Guidelines for Field Management of Combat-Related Head Trauma offer the same recommendation. CoTCCC members agreed TCCC Updates

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that antibiotics are not necessary for closed head injury, but should be given to individuals with penetrating head injury.10 DELIBERATIONS As noted above, Dr. Otten presented the recommended changes to the Board at its meeting on June 25, 2012. The DHB members discussed the recommended changes to the Guidelines at length and strongly concurred with the findings and recommendations of the Trauma and Injury Subcommittee. They also agreed that the GCS is likely not practical in a theater setting and that AVPU would be sufficient despite previous recommendations from the BTF that GCS should be used. Members noted that the lack of prehospital data in theater (a preliminary report from the U.S. Army Institute of Surgical Research suggest that information is collected for only 15 percent of casualties) is an ongoing problem that should be addressed to increase the prehospital care evidence base, including for TBI management in the field. CONCLUSION The DHB concludes that the changes to the TCCC Guidelines proposed by the CoTCCC and approved by the Trauma and Injury Subcommittee reflect the best available evidence and most important aspects of prehospital care for casualties with moderate/severe TBI based on the consensus-derived opinion of CoTCCC and Trauma and Injury Subcommittee members. Because the DHB notes a paucity of robust evidence-based research regarding prehospital (and battlefield) treatment of suspected severe TBI, the Board further recommends that the DoD make priorities prehospital data collection and additional research regarding prehospital management of moderate/severe TBI. RECOMMENDATIONS The Board recommends that DoD incorporate the following changes regarding the management of moderate/severe TBI to the TCCC Guidelines (additions are underlined below). These additions will help combat medics, corpsmen, and Pararescuemen recognize and treat impending cerebral herniation in TBI casualties on the battlefield and during evacuation.

Tactical Field Care 3. Breathing a. In a casualty with progressive respiratory distress and known or suspected torso trauma, consider a tension pneumothorax and decompress the chest on the side of the injury with a 14-gauge, 3.25 inch needle/catheter unit inserted in the second intercostal space at the midclavicular line. Ensure that the needle entry into the chest is not medial to the nipple line and is not directed towards the heart. b. All open and/or sucking chest wounds should be treated by immediately applying an occlusive material to cover the defect and securing it in place. Monitor the casualty for the potential development of a subsequent tension pneumothorax. c. Casualties with moderate/severe TEl should be given supplemental oxygen when available to maintain an oxygen saturation > 90%. 10. Monitoring Pulse oximetry should be available as an adjunct to clinical monitoring. All individuals with moderate/severe TBI should be monitored with pulse oximetry. Readings may be misleading in the settings of shock or marked hypothennia. 13. Provide analgesia as necessary. a. Able to fight: These medications should be carried by the combatant and self-administered as soon as possible after the wound is sustained. – Mobic, 15mg PO once a day – Tylenol, 650mg bilayer caplet, 2 PO every 8 hours b. Unable to fight: Note: Have naloxone readily available whenever administering opiates. – Does not otherwise require IV 110 access – Oral transmucosal fentanyl citrate (OTFC), 800ug transbuccally – Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety measure – Reassess in 15 minutes. – Add second lozenge, in other cheek, as necessary to control severe pain.

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– Monitor for respiratory depression. – IV or I0 access obtained: – Morphine sulfate, 5mg IV/IO – Reassess in 10 minutes. – Repeat dose every 10 minutes as necessary to control severe pain. – Monitor for respiratory depression – Promethazine, 25mg IV /IM/IO every 6 hours as needed for nausea or for synergistic analgesic effect. Note: Narcotic analgesia should be avoided in casualties with respiratory distress, decreased oxygen saturation, shock, or decreased level of consciousness.

Tactical Evacuation (TACEVAC) Care New #6. Traumatic Brain Injury a. Casualties with moderate/severe TBI should be monitored for: 1) decreases in level of consciousness 2) pupillary dilation 3) SBP should be >90mmHg 4) 02 sat > 90 5) Hypothermia 6) PC02 (If capnography is available, maintain between 35–40mmHg) 7) Penetrating head trauma (if present, administer antibiotics) Assume a spinal (neck) injury until cleared b. Unilateral pupillary dilation accompanied by a decreased level of consciousness may signify impending cerebral herniation; if these signs occur, take the following actions to decrease intracranial pressure: 1) Administer 250cc of 3 or 5% hypertonic saline bolus. 2) Elevate the casualty’s head 30 degrees. 3) Hyperventilate the casualty. a) Respiratory rate 20 b) Capnography should be used to maintain the end-tidal C02 between 30-35 c) The highest oxygen concentration (FI02) possible should be used for hyperventilation. Notes: – Do not hyperventilate unless signs of impending herniation are present. – Casualties may be hyperventilated with oxygen using the bag-valve-mask technique. 10. Monitoring Institute pulse oximetry and other electronic monitoring of vital signs, if indicated. All individuals with moderate/severe TBI should be monitored with pulse oximetry. (BTF 2007) 13. Provide analgesia as necessary. a. Able to fight: These medications should be carried by the combatant and self-administered as soon as possible after the wound is sustained. – Mobic, 15mg PO once a day – Tylenol, 650mg bilayer caplet, 2 PO every 8 hours b. Unable to fight: Note: Have naloxone readily available whenever administering opiates. – Does not otherwise require IV/IO access – Oral transmucosal fentanyl citrate (OTFC), 800ug transbuccally – Recommend taping lozenge-on-a-stick to casualty’s finger as an added safety measure – Reassess in 15 minutes – Add second lozenge, in other cheek, as necessary to control severe pain. – Monitor for respiratory depression. – IV or 10 access obtained: – Morphine sulfate, 5mg IV/IO – Reassess in 10 minutes. – Repeat dose every 10 minutes as necessary to control severe pain.

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– Monitor for respiratory depression – Promethazine, 25mg IV/IM/IO every 6 hours as needed for nausea or for synergistic analgesic effect Note: Narcotic analgesia should be avoided in casualties with respiratory distress, decreased oxygen saturation, shock, or decreased level of consciousness.

THE DEFENSE HEALTH BOARD Nancy Dickey, MD DHB President WORKS CITED 1. Current TBI Numbers, Defense and Veterans Brain Injury Center. Accessed 26 March 2012. http://www.dvbic.orgffBINumbers.aspx. 2. Gibson D, Helmick K, Jaffee M, et al. “Traumatic Brain Injury Care in the Department of Defense,” Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, September 2009. Available at: http://www.dcoe.health .mil/Content/Navigation/Documents/Traumatic%20Brain%20Injury %20Care%20in%20the%20Department%20of%20 Defense.pdf. 3. Brain Trauma Foundation Writing Team. Guidelines for Prehospital Management of Traumatic Brain Injury 2nd edition. Prehospital Emergency Care 2007; 12(1):SI–S53. 4. Stiver SI, Manley GT. Prehospital management of traumatic brain injury. Neurosurg Focus 2008; 2S(4):ES 5. Butler FK, Giebner SD, McSwain N, et al., eds. Prehospital Trauma Life Support Manual: Military Version. 7th ed. St. Louis: Mosby; 2010. 6. Eastridge BJ, Mabry RL, Blackbourne LH, et. al. We don’t know what we don’t know: prehospital data in combat casualty care. The United States Army Medical Department Journal 2011; Apr-Jun: 1–14. 7. Knuth T, Letarte PB, Ling G, et. al. Guidelines for the field management of combat-related head trauma. Brain Trauma Foundation (Supported by a grant from the Defense and Veterans Brain Injury Center): New York, NY: 2005. 8. Minardi J, Crocco T. Management of traumatic brain injury: first link in chain of survival. Mt Sinai J Med 2009; 76:138– 44. 9. Wolfe TJ, Torbey MT. Management of intracranial pressure. Current Neurology and Neuroscience Reports 2009; 9: 477–85. 10. Joint theater trauma system clinical practice guideline: management of patients with severe head trauma; July 2010. 11. Blackboume LH, Cole J, Mabry R, et al: The “silent killer”: hyperventilation in the brain injured. The United States Army Medical Department Journal 2008; Jan-Mar:50–55. 12. Strandvik GF: Hypertonic saline in critical care: A review of the literature and guidelines for use in hypotensive states and raised intracranial pressure. Anaesthesia 2009;64:990–1003. 13. Meyer MJ, Megyesi J, Meythaler J, et al. acute management of acquired brain injury Part II: An evidence-based review of pharmacological interventions. Brain Injury 2010; 24(5):706–21. 14. Bulger EM, May S, Brasel KJ, et al: Out-of-hospital hypertonic resuscitation following severe traumatic brain injury. JAMA 2010; 304(13):1455–64. 15. Rockswold GL, Solid CA, Paredes-Andrade E, et al: Hypertonic saline and its effect on intracranial pressure, cerebral perfusion pressure, and brain tissue oxygen. Neurosurgery 2009; 65(6):1035–42. 16. Benyamin R, Trescot AM, Datta S. Opioid complications and side-effects. Pain Physician 2008; 11:S105–S120. 17. Walters FJM. Neuropharmacology -Intracranial Pressure and Cerebral Blood Flow. Pharmacology 1998; 9, article 7. Available at: http://www.nda.ox.ac.uk/wfsa/html/u09/u09_019.htm. Accessed 23 March 2012. 18. Jeremitsky E, Omert L, Dunham M, et al. Harbirigers of poor outcome the day after severe brain injury; hypothermia, hypoxia, and hypoperfusion. J Trauma 2003; 54:312-19. 19. Konstantinidis A, Inaba K, Dubose J, et al: The impact of nontherapeutic hypothermia on outcomes after severe traumatic brain injury. J Trauma 2011; 71(6):1627–31. 20. Meyer M, Megyesi J, Meythaler J. Acute management of acquired brain injury Part 1: An evidence-based review of nonpharmacological interventions. Brain Injury 2010; 24:694–705. 21. Roberts I, Schierout O. Hyperventilation therapy for acute traumatic brain injury. Cochrane database of systematic reviews 1997; Issue 4, Art. No.: CD0005666. (Review assessed as up-to-date 6 Jan 2008). 22. Floyd T, Clark J, Gelfand R, et al. Independent cerebral vasoconstrictive effects of hyperoxia and accompanying arterial hypocapnia at l ATA. J Appl Physiol 2003; 95:245–61. 23. Tisdall MM, Taylor C, Tachtisidis I, et al. The effect of cerebral tissue oxygenation index of changes in the concentrations of inspired oxygen and end-tidal carbon dioxide in healthy adult volunteers. Anesth Analg 2009; 109(3):906–13.

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24. Tolias CM, Reinert M, Seiler R, et al. Normobaric hyperoxia-induced improvement in cerebral metabolism and reduction in intracranial pressure in patients with severe head injury: A prospective historical cohort-matched study. J Neurosurg 2004; 101:435–444. 25. Tolias CM, Kwnaria A, Bullock MR. Letter to the Editor: Hyperoxia and traumatic brain injury. J Neurosurg 2009; 110:607–609. 26. Bergsneider M, Hovda DA, Lee SM, et al. Dissociation of cerebral glucose metabolism and level of consciousness during the period of metabolic depression following human traumatic brain injury. J. Neurotrauma 2000; 1:389–401. 27. Bergsneider M, Hovda DA, Shalmon E, et al. Cerebral hyperglycolysis following severe traumatic brain injury in humans: A positron emission tomography study. J. Neurosurg. 1997; 86:241–251. 28. Hospenthal DR, Murray CK, Andersen RC, et al. Guidelines for the prevention of infections associated with combatrelated injuries: 2011 update-endorsed by the Infectious Diseases Society of American and the Surgical Infection Society. J Trauma 2011; 71(2):S210–S234. 29. Antibiotic prophylaxis for penetrating brain injury. J Trauma; 51:S34–S40.

ADDITIONAL REFERENCES Brain Trauma Foundation: Guidelines for the management of severe traumatic brain injury. 3rd Edition. J Neurotrauma 2007. 24:S I–S I 06. Cap AP, Spinella PC: Severity of head injury is associated with increased risk of coagulopathy in combat casualties. J Trauma 20II; 71:S78–SSI. Champion HR: Combat fluid resuscitation: introduction and overview of conferences. J Trauma 2003; 54(5, suppl):7. Chi J, Knudson M, Vassar M, et al. Prehospital hypoxia affects outcome in patients with traumatic brain injury: A prospective multicenter study. J Trauma 2006; 61:1134–1141. Dubose J, Kobayashi L, Lozornio A, et al. Clinical experience using 5% hypertonic saline as a safe alternative fluid for use in trauma. J Trauma 2010; 68:1172-1177. Defense and Veterans Brain Injury Center Working Group – clinical practice guidelines for the management of mild traumatic brain injury in military operations settings; 2006. Feldman Z, Kanter M, Robertson C, et al. Effect of head evaluation on intracranial pressure, cerebral perfusion pressure, and cerebral blood flow in head-injured patients. J Neurosurg 1992; 76:207–11. Fessler R, Diaz F: The management of cerebral perfusion pressure and intracranial pressure after severe head injury. Ann Emerg Med 1993; 22:99S–1003. Holcomb J. Fluid resuscitation in modem combat casualty care: lessons learned in Somalia. J Trauma 2003; 54:S46–51. Ivaseu F, Howells G, Junn F. et al. Predictors of mortality in trauma patients with intracranial hemorrhage on pre-injury aspirin or clopidogrel. J Trauma 2008; 65:785–788. Ling G, Rhee P, Ecklund J. Surgical innovations arising from the Iraq and Afghanistan wars. Annu Rev Med 2010; 61:457–468. Manley G, Knudson M, Morabito D. Hypotension, hypoxia, and head injury. Arch Surg 2001; 136: 1118–1123. Moraine J, Berre J, Melot C. Is cerebral perfusion pressure a major determinant of cerebral blood flow during head elevation in comatose patients with severe intracranial lesions? J Neurosurg 2000; 92:606–614. Memorandum, Defense Health Board to Assistant Secretary ofDefense (Health Affairs), Combat Ready Clamp; 23 Sept 2011. Memorandum, Defense Health Board to Assistant Secretary of Defense (Health Affairs), Fluid Resuscitation in TCCC, 10 Dec 2010. Memorandum, Defense Health Board to Assistant Secretary of Defense (Health Affairs), Tranexarnic Acid; 23 Sept 2011. Rickard A: Hypertonic Sodium Solution versus Mannitol in Reducing ICP in Traumatic Brain Injury. Emerg Med J 2011; 28:75–76. Salehpour F, Bazzazi A, Porhomayon J, Nader N. Correlation between coagulopatby and outcome in severe head trauma in neurointensive care and trauma units. J Crit Care 2011; Epub ahead of print. Stahel P, Smith W, Moore E. Current trends in resuscitation strategy for the multiply injured patient. Int J Care Injured 2009; 40(Suppl 4):S27–S35. Timmons S: Current trends in neurotrauma care. Crit Care Med 2010; 38:S431–S444. Torre-Healy A, Marko N, Well R. Hyperosmolar therapy for intracranial hypertension. Neurocril Care 2011; Epub ahead of print. Wafaisade A, Lefering R, Tjardes T, et al. Acute coagulopathy in isolated blunt traumatic brain injury. Neurocrit Care 2010; 12:211–19.

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July 6, 2012 from: DEFENSE HEALTH BOARD 7700 ARLINGTON BOULEVARD, SUITE 5101 FALLS CHURCH, VA 22042-5101 FOR: JONATHAN WOODSON, MD, ASSISTANT SECRETARY OF DEFENSE (HEALTH AFFAIRS) SUBJECT: Needle Decompression of Tension Pneumothorax Tactical Combat Casualty Care Guideline Recommendations 2012-05 EXECUTIVE SUMMARY The Defense Health Board (DHB) submitted a report to the Assistant Secretary of Defense (Health Affairs) (ASD(HA)) on 11 October 2011, recommending changes to the TCCC Guidelines pertaining to tension pneumothorax (TP). The Board recommended that the Department of Defense (DoD) amend the TCCC Guidelines to include performing bilateral needle decompression (ND) at the second intercostal space (ICS) along the midclavicular line (MCL) for any casualty in cardiorespiratory arrest with known or suspected torso trauma. Case report findings and feedback from the field highlight a lack of consensus surrounding ND techniques, including reported failure rates for ND. Inadequate needle length, improper technique, and muscle mass of casualties may be contributing to high ND failure rates, emphasizing the need to consider alternative ND techniques. As such, the Board is issuing this updated report, which includes utilizing the fourth or fifth ICS along the anterior axillary line (AAL) as an additional site for ND. BACKGROUND Unrelieved TPs contribute to preventable deaths in U.S. combat casualties.1,2 Historical data available from the Vietnam Wound Data and Munitions Effectiveness Team show that TPs caused three to four percent of combat fatalities.3 Despite existing need, a lack of consensus exists on the optimal technique for performing ND.4 TCCC Guidelines currently recommend performing ND at the second ICS along the MCL; however, civilian studies report a wide range of ND failure rates ranging from four to 65 percent.4,5,6 Alternate sites and longer needles may increase the likelihood of success. Anatomic and chest wall thickness (CWT) analyses suggest that a preferable site may be an ICS located more laterally and away from the heart. The American College of Surgeons Advanced Trauma Life Support (ATLS) Program recommends the fourth or fifth ICS along the AAL as primary site for chest tube insertion 7,5,8,6 Based upon these recommendations, the Prehospital Trauma Life Support (PHTLS) Manual/TCCC Curriculum has historically recommended the fourth or fifth ICS AAL as potential alternative sites for ND.9 However, this recommendation has not been part of the TCCC Guideline section. The TCCC Guidelines are a set of trauma care guidelines customized for use in the pre-hospital combat setting. TCCC is currently used in training for medics by all Services in the DoD and by many U.S. coalition partners. 1 The CoTCCC performs a quarterly review of current evidence demonstrating the successes and shortcomings of the TCCC Guidelines, and considers proposed updates and revisions.10 METHODOLOGY CoTCCC member Dr. David Callaway conducted an extensive literature review to determine the optimal site for conducting needle decompression. At the 1 May 2012 CoTCCC meeting, he proposed that the TCCC Guidelines offer an additional site for ND. The members deliberated and amended the proposed changes on 1â&#x20AC;&#x201C;2 May 2012. The CoTCCC agreed by unanimous vote on 2 May 2012, to forward its recommendations to the Trauma and Injury Subcommittee for review. The Trauma and Injury Subcommittee subsequently passed the proposed amendments. On 25 June 2012, the DHB deliberated the proposed recommendations and approved they be forwarded to the ASD(HA). This report includes the findings of the review as well as an evaluation of levels of evidence in accordance with the Oxford Centre for Evidence-Based Medicine (CEBM) method.11 FINDINGS Thoracic injuries are one of the leading causes of death in trauma casualties. Accumulation of extrapleural air compresses intrathoracic blood vessels promoting hypoxemia and the collapse of cardiovascular activity.1,12 Failure of an attempted ND can have life threatening complications.13 The level of evidence supporting ND research is primarily level four, consisting of case reports based on predominantly prehospital ND performed both in theater and in the civilian sector. Evidence supporting alternative ND sites is generally between levels three and four according to OCEBM and focuses on anatomical analysis.

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Location of Needle Decompression Site The current TCCC Guidelines specify performing ND at the second ICS along the MCL. Despite this, multiple studies have shown that in practice, medics frequently place the ND more medially, putting internal organs at risk.13,14 In a small study of civilian paramedics (n = 18), 44 percent (n = 8) placed ND medial to the MCL.13 As such, ATLS advises alternative placement in the fourth or fifth ICS along the AAL has been suggested to reduce the risk of complications.6 By using a more lateral ND placement, it is less likely that any internal organs may be punctured, as these organs are located more medially within the thoracic cavity. A more lateral site for ND may be easier for medics to find on casualties. The fifth ICS is located at the level of the nipple in young, fit males. The AAL is located at approximately the lateral aspect of the pectoralis major muscle, making this location easy to identify in a field or Tactical Evacuation (TACEVAC) environment. A lateral location may also be faster and safer given body armor configuration and ability to reassess the status of the TP.

Catheter Length Catheter length remains a highly variable component in the successful execution of ND. In the literature, catheter length ranges from 4–8cm. Multiple CWT studies advise that a 5cm long needle may be too short to reliably reach the pleural space at either the second ICS at the MCL or the fourth or fifth ICS AAL and is not suitable for optimal use in ND.1,4 The majority of these studies used civilian volunteers, retrospective trauma database analysis and cadavers to measure the mean chest wall thickness. This population of cadavers and civilians may have thinner chest walls than Servicemembers due to the physical training of Servicemembers and the degradation of tissue in cadavers. However, Harcke’s 2007 study of military males also supported the need for longer catheters.1 Current TCCC Guidelines recommend the use of an 8cm needle for ND. Though several CT- based CWT thickness studies showed increased CWT laterally, this difference was not found to be statically significant and would not be operationally relevant if an 8cm needle was utilized.6 Therefore, the CoTCCC recommends continued utilization of the 14g, 3.25 inch (8cm) catheter at the second ICS MCL or the fourth or fifth ICS at the AAL.

Needle Decompression Complication. Although rare and unusual, life-threatening complications may be associated with ND. Multiple studies demonstrate difficulty with proper site identification and catheter placement utilizing the anterior approach.5,15,16 Due to the proximity of the second ICS along the MCL, artery injury has been observed as a complication of ND. One case report noted laceration of the subclavian artery from an attempted ND. Additional case reports note the development of hemopneumothoraces following ND.8,15 Possible explanations for the failure of ND to relieve TP include: • • • •

Inadequate training and improper technique Needle length Catheter kinking Muscle mass of casualty

The tactical environment further complicates the use of ND. Challenges result in exposing the ND site, as medics must remove any equipment or body armor covering the chest. Removal of these protective layers puts the casualty at risk for exposure. Using a more easily identifiable lateral location may be faster than attempting to locate a medial ND site. CONCLUSIONS Currently, needle decompression is recommended as a Combat Lifesaver (CLS), Combat Medic (CM), and Combat Paramedic (CPM) Level Skill. Two major practice guidelines, Prehospital Trauma Life Support (PHTLS) and Special Operations Forces Tactics, Techniques and Procedures (SOF TTP), recommend fourth or fifth ICS AAL as acceptable alternative site for needle decompression of tension pneumothoraces. Non-inferiority: No definitive literature was found that establishes the superiority of the second intercostal space at the MCL over the fourth or fifth intercostal site at the AAL as the preferred site for needle decompression of a

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presumed tension pneumothorax. Further, studies evaluating chest wall thickness are mixed when evaluating the difference in chest wall thickness at the second ICS anteriorly vs. the fourth or fifth ICS at the AAL. Most current data suggests that the 8cm catheter placed at the fourth or fifth ICS at the AAL will be effective for the majority of casualties. Potential Superiority: The fourth or fifth ICS at the AAL is more remote from the heart and great vessels and may reduce the incidence of complications from needle decompression. In addition, it may offer distinct tactical advantages that improve successful execution of the procedure. Conclusion: The fourth or fifth intercostal space at the AAL is an acceptable alternate site for needle decompression. RECOMMENDATIONS The Board recommends DoD incorporate the following text allowing the fourth or fifth ICS at the AAL as alternative sites for needle decompression, into the TCCC Tactical Field Care and TACEVAC Guidelines (proposed additions are underlined):

Tactical Field Care: 3. Breathing a. In a casualty with progressive respiratory distress and known or suspected torso trauma, consider a tension pneumothrax and decompress the chest on the side of the injury with a 14-gauge, 3.25 inch (8cm) needle/ catheter unit inserted in the second intercostal space at the midclavicular line. Ensure that the needle entry into the chest is not medial to the nipple line and is not directed towards the heart. An acceptable alternate site is the 4th or 5th intercostal space at the anterior axillary line (AAL). b. All open and/or sucking chest wounds should be treated by immediately applying an occlusive material to cover the defect and securing it in place. Monitor the casualty for the potential development of a subsequent tension pneumothorax. 18. Cardiopulmonary resuscitation (CPR) Resuscitation on the battlefield for victims of blast or penetrating trauma who have no pulse, no ventilations, and no other signs of life will not be successful and should not be attempted. However, casualties with torso trauma or polytrauma who have no pulse or respirations during TFC should have bilateral needle decompression performed to ensure they do not have a tension pneumothorax prior to discontinuation of care. The procedure is the same as described in section 3 above.

Tactical Evacuation Care: 2. Breathing a. In a casualty with progressive respiratory distress and known or suspected torso trauma, consider a tension pneumotorax and decompress the chest on the side of the injury with a 14-gauge, 3.25 inch (8cm) needle/ catheter unit inserted in the second intercostal space at the midclavicular line. Ensure that the needle entry into the chest is not medial to the nipple line and is not directed towards the heart. An acceptable alternate site is the 4th or 5th intercostal space at the anterior axillary line (AAL). b. Consider chest tube insertion if no improvement and/or long transport is anticipated. c. Most combat casualties do not require supplemental oxygen, but administration of oxygen may be of benefit for the following types of casualties: – Low oxygen saturation by pulse oximetry – Injuries associated with impaired oxygenation – Unconscious casualty – Casualty with TBI (maintain oxygen saturation > 90%) – Casualty in shock Casualty at altitude d. All open and/or sucking chest wounds should be treated by immediately applying an occlusive material to cover the defect and securing it in place. Monitor the casualty for the potential development of a subsequent tension pneumothorax. 17. CPR in TACEVAC Care

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a. Casualties with torso trauma or polytrauma who have no pulse or respirations during TACEVAC should have bilateral needle decompression performed to ensure they do not have a tension pneumothorax. The procedure is the same as described in section 2 above. b. CPR may be attempted during this phase of care if the casualty does not have obviously fatal wounds and will be arriving at a facility with a surgical capability within a short period of time. CPR should not be done at the expense of compromising the mission or denying lifesaving care to other casualties.

Because definitive evidence does not exist regarding the superiority of either the second ICS at the MCL or the fourth or fifth ICS at the AAL, every effort should be made to collect evidence regarding comparative effectiveness of the two sites in order for inform future guidelines. The above recommendations were unanimously approved.

THE DEFENSE HEALTH BOARD Nancy Dickey, MD DHB President WORKS CITED 1. Harcke H.T.; Pearse L.A.; Levy, A.D., et al. Chest wall thickness in military personnel: Implications for needle thoracentesis in tension pneumothorax. Mil Med 2007; 172:1260–1263. 2. Holcomb, J.B.; McManus, J.G.; Kerr, S.T., et al. Needle versus tube thoracostomy in a swine model of traumatic tension hemopneumpothorax Prehosp Emerg Care 2009; 13:18–27. 3. McPherson, J.J.; Feigin, D.S.; and Bellamy R.F. Prevalence of tension pneumothorax in fatally wounded combat casualties. J Trauma 2006; 60:573–578. 4. Zengerink, I.; Brink, P.R.; Laupland, K.B., et al. Needle thoracostomy in the treatment of tension pneumothorax in trauma patients: What size needle? J Trauma 2008; 64:111–114. 5. Inaba, K.; Branco, B.; Eckstein, M.; et al. Optimal positioning for emergent needle thoracostomy: a cadaver-based study. J Trauma 2011; 71:1099–1103. 6. Sanchez, L.; Straszewski, S.; Saghir, A.; et al. Anterior versus lateral needle decompression of tension pneumothorax: comparison by computed tomography chest wall measurement. Acad Emerg Med 2011; Epub ahead of print. 7. Ball, C.; Wyrzykowski, A.; Kirkpatrick, A., et al. Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length. Can J Surg 2010; 53:184–188. 8. Riwoe, D.; Poncia, H. Subclavian artery laceration: A serious complication of needle decompression. Emerg Med Australasia 2011; 23:651–653. 9. Butler, F.K. Jr; Giebner, S.D.; McSwain, N., et al. eds. Prehospital Trauma Life Support Manual, Military Edition. 7th ed. Philadelphia: Mosby/JEMS, 2010. Print. 10. Eastridge, B.J.; Mabry, R.L.; Blackbourne, L.H.; Butler F.K. We don’t know what we don’t know: prehospital data in combat casualty care. The United States Army Medical Department Journal 2011; April-June: 11–14. 11. OCEBM Levels of Evidence Working Group. The OXFORD 2011 Levels of Evidence. Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653. Accessed on May 24, 2012. 12. Davis, D.P.; Pettit, K.; Rom C.D., et al. The safety and efficacy of prehospital needle and tube thoracostomy by aeromedical personnel. Prehosp Emerg Care 2005; 9:191–197. 13. Netto, F.A.; Shulman, H.; Rizoli, S.B., et al. Are needle decompressions for tension pneumothraces being performed appropriately for appropriate indications? Am J Emerg Med 2008; 26:597–602. 14. Tien, H.C.; Jung, V.; Rizoli, S.B.; Acharya, S.V., et al. An evaluation of tactical combat casualty care interventions in a combat environment. J Am Coll Surg 2008; 207:174–178. 15. Rawlins, R.; Brown, K.M.; Carr, C.S.; et al. Life-threatening hemorrhage after anterior needle aspiration of pneumothoraces: A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Emerg Med J 2003; 20:383–384. 16. Ferrie, E.P.; Collum, N., and McGovern, S. The right place in the right space? Awareness of site for needle thoracentesis. Emerg Med J 2005; 22:788–89.

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ADDITIONAL REFERENCES Beckett, A.; Savage, E.; Pannell, D., et al. Needle decompression for tension pneumothorax in tactical combat casualty care: Do catheters placed in the midaxillary line kink more often than those in the midclavicular line? J Trauma 2011;71:S408–S412. McLean, A.; Richard, M.; Crandall, C.; Marinaro, J. Ultrasound determination of chest wall thickness: implications for needle thoracostomy. Am J Emerg Med 2010; Epub ahead of print. Britten, S.; and Palmer, S.H. Chest wall thickness may limit adequate drainage of tension pneumothorax by needle thoracentesis. J Accid Emerg Med 1996; 13:426–427 Britten, S.; Palmer, S.H.; Snow, T.M. Needle thoracocentesis in tension pneumothorax: insufficient cannula length and potential failure. Injury 1996; 27:321–322. Butler, F.K. Tactical combat casualty care: update 2009; J Trauma 2010; 69:S10–S13. Butler, K.L.; Best, I.M.; Weaver, L.; Bumpers, H.L. Pulmonary artery injury and cardiac tamponade after needle decompression of a suspected tension pneumothorax. J Trauma 2003; 54:610–611. Butler, F.K.; Hagmann, J.; Butler E.G. Tactical combat casualty care in special operations. Mil Med 161; Supplement; August 1996. Cullinane, D.C.; Morris, J.A.; Bass, J.G.; Rutherford, E.J. Needle thoracostomy may not be indicated in the trauma patient. Injury 2001; 32:749–752. Dickey, N.; Jenkins, D.: Needle decompression of tension pneumothorax and cardiopulmonary resuscitation: Tactical combat casualty care guidelines recommendation. Defense Health Board memorandum 2011–08; 11 Oct 2011. Eckstein, M.; Suyehara, D. Needle thoracostomy in the prehospital setting. Prehosp Emerg Care 1998; 2:132–135. Givens, M.L; Ayoyye, K.; Manifold, C. Needle thoracostomy: implications of computed tomography chest wall thickness. Acad Emerg Med 2004; 11:211–213 Holcomb, J.B.; McMullen, N.R.; Pearse, L.; Caruso, J.; Wade, C.E.; Oetjen-Gerdes, L.; Champion, H.R.; Lawnick, M.; Farr, W.; Rodriguez, S.; Butler, F.K. Causes of death in special operations forces in the Global War on Terror. Annals of Surgery 2007; 245:986–991. Korteek, J.B.; Al Turki ,S.A.; Ali, J., et al. Advanced trauma life support, 8th edition, the evidence for change. J Trauma 2008; 64:1638–1650 Mistry, N.; Bleetman, A.; Roberts, K. Chest decompression during the resuscitation of patients in prehospital traumatic cardiac arrest. Emerg Med J 2009; 26(10):738–740. Rathinam, S.; Beetman, A.; Steyn, R.S.: Needle thoracostomy in treatment of a tension pneumothorax. J Trauma 2008; 65:964. Stevens, R.L.; Rochester, A.A. Busko, J., et al: Needle thoracostomy for tension pneumothorax: failure predicted by chest computed tomography. Prehosp Emerg Care 2009; 13:14–17. Sztajnkrycer, M.: Needle thoracostomy by non-medical law enforcement personnel: preliminary data on knowledge retention. Prehosp Disaster Med 2009; 23(6):553–557. Wax, D.B.; Leibowitz, A.B. Radiologic assessment of potential sites for needle decompression of a tension pneumothorx. Anesth Analg 2007; 105:1385–1388.

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Table 1 Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence

Question

Step 1 (Level 1*)

Step 2 (Level 2*)

Step 3 (Level 3*)

How common is the problem? Local and current random sample surveys (or censuses)

Systematic review of surveys that allow matching to local circumstances**

Local non-random sample**

Is this diagnostic or monitoring test accurate? (Diagnosis)

Systematic review of cross sectional studies with consistently applied reference standard and blinding

Individual cross sectional studies with consistently applied reference standard and blinding

Non-consecutive studies, or studies without consistently applied reference standards**

What will happen if we do not add a therapy? (Prognosis)

Systematic review of inception cohort studies

Inception cohort studies

Cohort study or control arm of randomized trial*

Does this intervention help? (Treatment Benefits)

Systematic review of randomized trials or n-of-1 trials

Randomized trial or observational study with dramatic effect

Non-randomized controlled cohort/follow-up study**

What are the COMMON harms? (Treatment Harms)

Systematic review of randomized trials, systematic review of nested case-control studies, n¬of-1 trial with the patient you are raising the question about, or observational study with dramatic effect

Individual randomized trial or (exceptionally) observational study with dramatic effect

Non-randomized controlled cohort/follow-up study (post-marketing surveillance) provided there are sufficient numbers to rule out a common harm. (For longterm harms the duration of follow-up must be sufficient.)**

Systematic review of randomized trials

Randomized trial

Non -randomized controlled cohort/follow-up study**

What are the RARE harms? (Treatment Harms) • Systematic review of randomized trials or n-of-1 trial • Randomized trial or (exceptionally) observational study with dramatic effect Is this (early detection) test worthwhile?

Notes: *Level may be graded down on the basis of study quality, imprecision, indirectness (study PICO does not match questions PICO), because of inconsistency between studies, or because the absolute effect size is very small; Level may be graded up if there is a large or very large effect size. **As always, a systematic review is generally better than an individual study. Sources: How to Cite the Levels of Evidence Table OCEBM Levels of Evidence Working Group*. “The Oxford 2011 Levels of Evidence.” Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653 *OCEBM Table of Evidence Working Group = Jeremy Howick, Iain Chalmers (James Lind Library), Paul Glasziou, Trish Greenhalgh, Carl Heneghan, Alessandro Liberati, Ivan Moschetti, Bob Phillips, Hazel Thornton, Olive Goddard and Mary Hodgkinson

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TCCC Abstracts The Effects of Standardized Trauma Training on Prehospital Pain Control: Have Pain Medication Administration Rates Increased on the Battlefield? Bowman W.J.; Nesbitt M.E.; Therien S.P. J Trauma Acute Care Surg. 2012 Aug; 73(2 Suppl 1):S43–8 ABSTRACT Background: The US Military has served in some of the most austere locations in the world. In this ever-changing environment, units are organized into smaller elements operating in very remote areas. This often results in longer evacuation times, which can lead to a delay in pain management if treatment is not initiated in the prehospital setting. Early pain control has become an increasingly crucial military prehospital task and must be controlled from the pain-initiating event. The individual services developed their standardized trauma training based on the recommendations by Frank Butler and the Defense Health Board Committee on Tactical Combat Casualty Care. This training stresses evidence-based treatment modalities, including pain control, derived from casualty injury analysis. Inadequate early pain control may lead to multiple acute and potentially chronic effects. These effects encompass a wide range from changes in blood pressure to delayed wound healing and posttraumatic stress disorder. Therefore, it is essential that pain be addressed in the prehospital environment. Methods: Institutional Review Board approval was obtained to conduct a retrospective Joint Theater Trauma Registry comparative study evaluating whether standardized trauma training increased prehospital pain medication administration between 2007 and 2009. These years were selected on the basis of mandatory training initiation dates and available Joint Theater Trauma Registry records. Records were analyzed for all US prehospital trauma cases with documented pain medication administration from Operations ENDURING FREEDOM and IRAQI FREEDOM for the specified years. Results: Data analysis revealed 232 patients available for review (102 for 2007 and 130 for 2009). A statistically significant prehospital pain treatment increase was noted, from 3.1% in 2007 to 6.7% in 2009 (p < 0.0005; 95% confidence interval, 2.39–4.93). Conclusion: Standardized trauma training has increased the administration of prehospital pain medication and the awareness of the importance of early pain control. Level of Evidence: Therapeutic study, level IV. PMID: 22847093 [PubMed - in process]

The Efficacy of Combat Gauze in Extreme Physiologic Conditions

Causey M.W.; McVay D.P.; Miller S.; Beekley A.; Martin M. J Surg Res. 2012 Oct; 177(2):301–5. Epub 2012 Jun 29

ABSTRACT Introduction: Combat Gauze (CG) is currently the most widely used hemostatic dressing in combat. The testing of CG was initially performed in healthy and physiologically normal animals. The goal this study was to assess the efficacy in a model of severe acidosis and coagulopathy. Methods: To obtain an acidotic and coagulopathic model, Yorkshire swine sustained 35% blood volume hemorrhage followed by a 50-min supraceliac aortic ischemia-reperfusion injury with 6-h resuscitation (epinephrine to keep mean arterial pressure > 40 and intravenous fluids to keep central venous pressure > 4). We created a femoral artery injury and randomized the animals to CG versus a standard gauze (SG) dressing. We performed rotational thromboelastography with both CG and SG. Results: Using our model, 17 anesthetized Yorkshire swine developed appropriately significant coagulopathy, acidosis, and anemia. The SG failure rate was 100% on the first application and worked once on the second application. Combat Gauze was successful in achieving hemostasis 93% of the time on the first application and had 100% success with the second application. Rotational thromboelastography demonstrated that the only difference was a decreased clotting time with CG compared with SG (P = 0.012). Conclusions: Combat Gauze significantly outperforms standard gauze dressings in a model of major vascular hemorrhage in acidotic and coagulopathic conditions. This effect appears to result from a decreased time lag between activation and first detectable clotting. Combat Gauze appears to maintain its efficacy even in the setting of severe acidosis and coagulopathy for the control of hemorrhage from vascular injury. PMID: 22785361 [PubMed – in process]

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Sublingua Buprenorphine in Acute Pain Management: A Double-blind Randomized Clinical Trial Jalili, M.; Fathi, M.; Moradi-Lakeh, M.; Zehtabchi, S. Annals of Emergency Medicine, 2012 Apr; 59(4):276–80. Epub 2011 Nov 23 ABSTRACT Study Objective: We compare the efficacy and safety of sublingual buprenorphine versus intravenous morphine sulfate in emergency department adults with acute bone fracture. Methods: Enrolled patients received buprenorphine 0.4mg sublingually or morphine 5mg intravenously in this double-blind, double-dummy, randomized controlled trial. Patients graded their pain with a standard 11-point numeric rating scale before medication administration and 30 and 60 minutes after, and we recorded adverse reactions. Results: We analyzed 44 and 45 patients in the buprenorphine and morphine groups, respectively. Mean pain scores were similar at 30 minutes (5.0 versus 5.0; difference 0; 95% confidence interval –0.6 to 0.8) and at 60 minutes (2.2 versus 2.2; difference 0; 95% confidence interval –0.3 to 0.3). Adverse effects observed within 30 minutes were nausea (14% versus 12%), dizziness (14% versus 22%), and hypotension (4% versus 18%). Conclusion: For adults with acute fractures, buprenorphine 0.4mg sublingually is as effective and safe as morphine 5mg intravenously. PMID: 22115823 [PubMed – indexed for MEDLINE]

Morphine and Ketamine is Superior to Morphine Alone For Out-of-Hospital Trauma Analgesia: A Randomized Controlled Trial Jennings, P.A.; Cameron, P.; Bernard, S.; Walker, T.; Jolley, D.; Fitzgerald, M.; Masci, K. Annals of Emergency Medicine 2012 Jun; 59(6):497–503. Epub 2012 Jan 13 ABSTRACT Study Objective: We assess the efficacy of intravenous ketamine compared with intravenous morphine in reducing pain in adults with significant out-of-hospital traumatic pain. Methods: This study was an out-of-hospital, prospective, randomized, controlled, open-label study. Patients with trauma and a verbal pain score of greater than 5 after 5mg intravenous morphine were eligible for enrollment. Patients allocated to the ketamine group received a bolus of 10 or 20mg, followed by 10mg every 3 minutes thereafter. Patients allocated to the morphine alone group received 5mg intravenously every 5 minutes until pain free. Pain scores were measured at baseline and at hospital arrival. Results: A total of 135 patients were enrolled between December 2007 and July 2010. There were no differences between the groups at baseline. After the initial 5-mg dose of intravenous morphine, patients allocated to ketamine received a mean of 40.6mg (SD 25mg) of ketamine. Patients allocated to morphine alone received a mean of 14.4mg (SD 9.4mg) of morphine. The mean pain score change was –5.6 (95% confidence interval [CI] –6.2 to –5.0) in the ketamine group compared with –3.2 (95% CI –3.7 to –2.7) in the morphine group. The difference in mean pain score change was –2.4 (95% CI –3.2 to –1.6) points. The intravenous morphine group had 9 of 65 (14%; 95% CI 6% to 25%) adverse effects reported (most commonly nausea [6/65; 9%]) compared with 27 of 70 (39%; 95% CI 27% to 51%) in the ketamine group (most commonly disorientation [8/70; 11%]). Conclusion: Intravenous morphine plus ketamine for out-ofhospital adult trauma patients provides analgesia superior to that of intravenous morphine alone but was associated with an increase in the rate of minor adverse effects. PMID: 22243959 [PubMed – indexed for MEDLINE]

Traumatic Brain Injury and Hemorrhagic Shock: Evaluation of Different Resuscitation Strategies in a Large Animal Model of Combined Insults Jin, G.; DeMoya, M.A.; Duggan, M.; Knightly, T.; Mejaddam, A.Y; Hwabejire, J.; Lu, J.; Smith, W.M.; Kasotakis, G.; Velmahos, G.C.; Socrate, S.; Alam, H.B. Shock. 2012 Jul; 38(1):49–5 ABSTRACT Traumatic brain injury (TBI) and hemorrhagic shock (HS) are the leading causes of trauma-related mortality and morbidity. Combination of TBI and HS (TBI + HS) is highly lethal, and the optimal resuscitation strategy for this combined insult remains unclear. A critical limitation is the lack of suitable large animal models to test different treatment strategies. We have developed a clinically relevant large animal model of TBI + HS, which was used to evaluate the impact of different treatments on brain lesion size and associated edema. Yorkshire swine (42–50 kg) were instrumented to measure hemodynamic parameters and intracranial pressure. A computer-controlled cortical impact device was used to create a TBI through a 20mm craniotomy: 15mm cylindrical tip impactor at 4 m/s TCCC Updates

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velocity, 100-ms dwell time, and 12mm penetration depth. Volume-controlled hemorrhage was started (40% blood volume) concurrent with the TBI. After 2 h of shock, animals were randomized to one of three resuscitation groups (n = 5/group): (a) normal saline (NS); (b) 6% hetastarch, Hextend (Hex); and (c) fresh frozen plasma (FFP). Volumes of Hex and FFP matched the shed blood, whereas NS was three times the volume. After 6 h of postresuscitation monitoring, brains were sectioned into 5mm slices and stained with TTC (2,3,5-triphenyltetrazolium chloride) to quantify the lesion size and brain swelling. Combination of 40% blood loss with cortical impact and a period of shock (2 h) resulted in a highly reproducible brain injury. Total fluid requirements were lower in the Hex and FFP groups. Lesion size and brain swelling in the FFP group (2,160 ± 202.63 mm and 22% ± 1.0%, respectively) were significantly smaller than those in the NS group (3,285 ± 130.8 mm3 and 37% ± 1.6%, respectively) (P < 0.05). Hex treatment decreased the swelling (29% ± 1.6%) without reducing the lesion size. Early administration of FFP reduces the size of brain lesion and associated swelling in a large animal model of TBI + HS. In contrast, artificial colloid (Hex) decreases swelling without reducing the actual size of the brain lesion. PMID: 22575994 [PubMed – indexed for MEDLINE

Fifty-four Emergent Cricothyroidotomies: Are Surgeons Reluctant Teachers?

King, D.; Ogilvie, M.; Michailidou, M.; Velmahos, G.; Alam, H.; deMoya, M.; Fikry, K. Scand J Surg. 2012; 101(1):13–5

ABSTRACT Background: Emergent cricothyroidotomy remains an uncommon, but life-saving, core procedural training requirement for emergency medicine (EM) physician training. We hypothesized that, although most cricothyroidotomies occur in the emergency department (ED), they are rarely performed by EM physicians. Methods: We conducted a retrospective analysis of all emergent cricothyroidotomies performed at two large level one trauma centers over 10 years. Operators and assistants for all procedures were identified, as well as mechanism of injury and patient demographics were examined. Results: Fifty-four cricothyroidotomies were performed. Patients were: mean age of 50, 80% male and 90% blunt trauma. The most common primary operator was a surgeon (n = 47, 87%), followed by an Emergency Medical Services (EMS) provider (n = 6, 11%) and a EM physician (n = 1, 2%). In all cases, except those performed by EMS, the operator or assistant was an attending surgeon. All EMS procedures resulted in serious complications compared to in-hospital procedures (p < 0.0001). Conclusions: (1) Pre-hospital cricothyroidotomy results in serious complications. (2) Despite the ubiquitous presence of emergency medicine physicians in the ED, all crico-thyroidotomies were performed by a surgeon, which may represent a serious emergency medicine training deficiency. PMID: 22414462 [PubMed – indexed for MEDLINE]

A Biomechanical Comparison Between the Thoracolumbosacral Surface Contact Area (SCA) of a Standard Backboard With Other Rigid Immobilization Surfaces Kosashvili, Y.; Backstein, D.; Ziv, Y.B.; Safir, O.; Blumenfeld, A; Mirovsky, Y. J Trauma. 2009 Jan; 66(1):191–4 ABSTRACT Introduction: Backboards are routinely used to protect the spine of trauma patients during transportation. Nevertheless, little is known about the biomechanical properties of this type of immobilization. Objectives: To evaluate the mechanical support of the thoracolumbosacral spine provided by a standard backboard in comparison with various rigid immobilization surfaces, by examining their respective surface contact area (SCA).Materials: SCAs comparisons of a standard aluminum backboard, a rigid military stretcher, an aluminum backboard covered by blanket, 3 and 5cm thickness foam, and a cushioned stretcher were made using 12 volunteers. The evaluation was performed by a computer-mediated system that generated a diagram indicating pressure distribution and SCA score in each volunteer. These data were compared with a medical grade mattress, which served as the control group. Results: The median backboard’s SCA was 14.6 ± 5.5 times smaller than the stretcher’s SCA (range 4.6–28, average 15, p < 0.001). Its median SCA was essentially doubled by covering it by a standard military blanket and tripled when covered by 3cm layer of foam. Using a 5-cm layer of foam increased the backboard’s SCA by 11 times. Cushioning the stretcher beneath the lumbar spine and the hamstrings by folded blankets, significantly improved its median SCA (96 ± 31.1, range 36–125, average 89.7). Conclusions: The backboard’s SCA was significantly inferior to all

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the other surfaces. Although no dynamic evaluation was performed, these data imply that backboards need to be appropriately cushioned or alternate surfaces should be employed to improve the mechanical support during trauma patient transportation. Level of evidence: Level I. PMID: 19131824 [PubMed – indexed for MEDLINE]

Use of a Novel Abdominal Aortic Tourniquet to Reduce or Eliminate Flow in the Common Femoral Artery in Human Subjects Lyon, M.; Shiver, S.A.; Greenfield, E.M.; Reynolds, B.Z.; Lerner, E.B.; Wedmore, I.S., Schwartz, R.B. J Trauma Acute Care Surg. 2012 Aug; 73(2 Suppl 1):S103–5 ABSTRACT Background: Penetrating injuries of proximal femoral and iliac vessels are a common cause of death on the battlefield. Previous studies have shown that by applying 80 lb to 140 lb of pressure externally over the distal abdominal aorta, flow can be ceased in the common femoral artery (CFA). It has also been demonstrated that in a porcine model, an externally applied pneumatic abdominal aortic tourniquet (AAT) can occlude the aorta and inferior vena cava for 60 minutes without bowel injury or significant potassium elevations. The objectives of this study were (1) determine if AAT use in humans results in flow cessation in the CFA, (2) measure the pressure required to cease flow in the CFA, and (3) measure discomfort associated with application of the AAT. Methods: Pulse wave Doppler measurements were taken in supine volunteers at the right CFA. The AAT was placed just above the iliac crests over the anterior abdomen. The AAT was inflated using a hand pump with an integrated manometer. Measurements were taken every 30mmHg. Discomfort was measured using a 10-point pain scale. Results: In all subjects, flow was reduced in the CFA. Flow ceased in seven of nine subjects at a median pressure of 180mmHg (150–230mmHg). Median discomfort at ceasing of flow was 7 (3–10), returning to 0 after device removal. Conclusion: The AAT device was effective at reducing flow in the CFA and ceased flow in most of the subjects. Application of the device was associated with discomfort varying from moderate to severe and resolving with device removal. PMID: 22847077 [PubMed – in process]

Impact of Critical Care-trained Flight Paramedics on Casualty Survival During Helicopter Evacuation in the Current War in Afghanistan Mabry, R.L.; Apodaca, A.; Penrod, J.; Orman, J.A.; Gerhardt, R.T.; Dorlac, W.C. J Trauma Acute Care Surg. 2012 Aug; 73(2 Suppl 1):S32–7 ABSTRACT Background: The U.S. Army pioneered medical evacuation (MEDEVAC) by helicopter, yet its system remains essentially unchanged since the Vietnam era. Care is provided by a single combat medic credentialed at the Emergency Medical Technician – Basic level. Treatment protocols, documentation, medical direction, and quality improvement processes are not standardized and vary significantly across U.S. Army helicopter evacuation units. This is in contrast to helicopter emergency medical services that operate within the United States. Current civilian helicopter evacuation platforms are routinely staffed by critical care-trained flight paramedics (CCFP) or comparably trained flight nurses who operate under trained EMS physician medical direction using formalized protocols, standardized patient care documentation, and rigorous quality improvement processes. This study compares mortality of patients with injury from trauma between the US Army’s standard helicopter evacuation system staffed with medics at the Emergency Medical Technician – Basic level (standard MEDEVAC) and one staffed with experienced CCFP using adopted civilian helicopter emergency medical services practices. Methods: This is a retrospective study of a natural experiment. Using data from the Joint Theater Trauma Registry, 48-hour mortality for severely injured patients (injury severity score ≥ 16) was compared between patients transported by standard MEDEVAC units and CCFP air ambulance units. Results: The 48-hour mortality for the CCFP-treated patients was 8% compared to15% for the standard MEDEVAC patients. After adjustment for covariates, the CCFP system was associated with a 66% lower estimated risk of 48-hour mortality compared to the standard MEDEVAC system. Conclusions: These findings demonstrate that using an air ambulance system based on modern civilian helicopter EMS practice was associated with a lower estimated risk of 48-hour mortality among severely injured patients in a combat setting. Level of Evidence: Therapeutic study, level II. PMID: 22847091 [PubMed – in process]

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Anatomic Distribution and Mortality of Arterial Injury in the Wars in Afghanistan and Iraq with Comparison to a Civilian Benchmark Markov, N.P.; Dubose, J.J.; Scott, D.; Propper, B.W.; Clouse, W.D.; Thompson, B.; Blackbourne, L.H.; Rasmussen, T.E. Vasc Surg. 2012 Sep; 56(3):728–36. Epub 2012 Jul 13 ABSTRACT Objective: The purpose of this study was to examine the anatomic distribution and associated mortality of combatrelated vascular injuries comparing them to a contemporary civilian standard. Design: The Joint Trauma Theater Registry (JTTR) was queried to identify patients with major compressible arterial injury (CAI) and noncompressible arterial injury (NCAI) sites, and their outcomes, among casualties in Iraq and Afghanistan from 2003 to 2006. The National Trauma Data Bank (NTDB) was then queried over the same time frame to identify civilian trauma patients with similar arterial injuries. Propensity score-based matching was used to create matched patient cohorts from both populations for analysis. Results: Registry queries identified 380 patients from the JTTR and 7020 patients from the NTDB who met inclusion criteria. Propensity score matching for age, elevated Injury Severity Score (ISS; >15), and hypotension on arrival (systolic blood pressure [SBP] <90) resulted in 167 matched patients from each registry.The predominating mechanism of injury among matched JTTR patients was explosive events (73.1%), whereas penetrating injury was more common in the NTDB group (61.7%). In the matched cohorts, the incidence of NCAI did not differ (22.2% JTTR vs. 26.6% NTDB; P = .372), but the NTDB patients had a higher incidence of CAI (73.7% vs. 59.3%; P = .005). The JTTR cohort was also found to have a higher incidence of associated venous injury (57.5% vs. 23.4%; P < .001). Overall, the matched JTTR cohort had a lower mortality than NTDB counterparts (4.2% vs. 12.6%; P = .006), a finding that was also noted among patients with NCAI (10.8% vs. 36.4%; P = .008). There was no difference in mortality between matched JTTR and NTDB patients with CAI overall (2.0% vs. 4.1%; P = .465), or among those presenting with Glasgow Coma Scale (GCS) < 8 (28.6% vs. 40.0%; P = 1.00) or shock (SBP < 90; 10.5% vs. 7.7%; P = 1.00). The JTTR mortality rate among patients with CAI was, however, lower among patients with ISS >15 compared with civilian matched counterparts (10.7% vs. 42.4%; P = .006). Conclusions: Mortality of injured service personnel who reach a medical treatment facility after major arterial injury compares favorably to a matched civilian standard. Acceptable mortality rates within the military cohort are related to key aspects of an organized Joint Trauma System, including prehospital tactical combat casualty care, rapid medical evacuation to forward surgical capability, and implementation of clinical practice guidelines. Aspects of this comprehensive combat casualty care strategy may translate and be of value to management of arterial injury in the civilian sector. PMID: 22795520 [PubMed – in process]

Does Needle Thoracostomy Provide Adequate and Effective Decompression of TensionPneumothorax? Martin, M.; Satterly, S.; Inaba, K.; Blair, K. J Trauma Acute Care Surg. 2012 Aug 17 [Epub ahead of print] ABSTRACT Background: Tension pneumothorax (tPTX) is a common and potentially fatal event after thoracic trauma. Needle decompression is the currently accepted first-line intervention but has not been well validated. The purpose of this study was to evaluate the effectiveness of a properly placed and patent needle thoracostomy (NT) compared with standard tube thoracostomy (TT) in a swine model of tPTX. Methods: Six adult swine underwent instrumentation and creation of tPTX using thoracic CO2 insufflation via a balloon trocar. A continued 1 L/min insufflation was maintained to simulate an ongoing air leak. The efficacy and failure rate of NT (14 gauge) compared with TT (34F) was assessed in two separate arms: (1) tPTX with hemodynamic compromise and (2) tPTX until pulseless electrical activity (PEA) obtained. Hemodynamics was assessed at 1 and 5 minutes after each intervention. Results: A reliable and highly reproducible tPTX was created in all animals with a mean insufflation volume of 2441mL. tPTX resulted in the systolic blood pressure declining 54% from baseline (128–58mm Hg), cardiac output declining by 77% (7–1.6 L/min), and equalization of central venous pressure and wedge pressures. In the first arm, there were 19 tPTX events treated with NT placement. All NTs were patent on initial placement, but 5 (26%) demonstrated mechanical failure (due to kinking, obstruction, or dislodgment) within 5 minutes of placement, all associated with hemodynamic decline. Among the 14 NTs that remained patent at 5 minutes, 6 (43%) failed to relieve tension physiology for an overall failure rate of 58%. Decompression with TT was successful in relieving tPTX in 100%. In the second arm, there were 21 tPTX with PEA events treated initially with either NT (n = 14) or TT (n = 7). The NT failed to

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restore perfusion in nine events (64%), whereas TT was successful in 100% of events as a primary intervention and restored perfusion as a rescue intervention in eight of the nine NT failures (88%). Conclusion: Thoracic insufflation produced a reliable and easily controlled model of tPTX. NT was associated with high failure rates for relief of tension physiology and for treatment of tPTX-induced PEA and was due to both mechanical failure and inadequate tPTX evacuation. This performance data should be considered in future NT guideline development and equipment design. PMID: 22902737 [PubMed – as supplied by publisher]

Improvised Explosive Device Related Pelvi-Perineal Trauma: Anatomic Injuries and Surgical Management Mossadegh, S.; Tai, N.; Midwinter, M.; Parker, P. J Trauma Acute Care Surg. 2012 Aug; 73(2 Suppl 1):S24–31 ABSTRACT Background: Pelviperineal injuries, primarily due to blast mechanisms, are becoming the signature injury pattern on operations in Afghanistan. This study set out to define these injuries and to refine our team-based surgical resuscitation strategies to provide a resuscitation-debridement-diversion didactic on our Military Operational Surgical Training predeployment course to optimize our field care of these injuries. Methods: A retrospective study of the UK Joint Theatre Trauma Registry was performed looking at consecutive data from January 2003 to December 2010, identifying patients with perineal injuries. Data abstracted included patient demographics, mechanism of injury, Injury Severity Score (ISS), management, and outcomes. Result: Of 2204 UK military trauma patients, 118 (5.4%) had a recorded perineal injury and 56 (47%) died. Pelvic fractures were identified in 63 (53%) of 118 patients of which only 17 (27%) of 63 survived. Mortality rates were significantly different between the combined perineal and pelvic fracture group compared with the pelvic fractures or perineal injuries alone (107 [41%] of 261 and 11 [18%] of 56, respectively, p < 0.001). The median (interquartile range) ISS for all patients was 38 (29–57). The ISS for those with pelvic fractures were significantly higher than those with perineal injuries alone, 50 (38–71) versus 30 (15–35) (p < 0.001). Conclusion: Improvised explosive device-related perineal injuries with pelvic fractures had the highest rate of mortality compared with perineal injuries alone. Early aggressive resuscitation (activation of the massive hemorrhage protocol) is essential to survival in this cohort. Our recommendations are uncompromising initial debridement, immediate fecal diversion, and early enteral feeding. Level of Evidence: Epidemiologic study, level III. PMID: 22847089 [PubMed – in process]

A Novel Sponge-based Wound Stasis Dressing to Treat Lethal Noncompressible Hemorrhage

Mueller, G.R.; Pineda, T.J.; Xie, H.X.; Teach, J.S.; Barofsky, A.D.; Schmid, J.R.; Gregory, K.W. J Trauma Acute Care Surg. 2012 Aug; 73(2 Suppl 1):S134–9

ABSTRACT Background: Noncompressible hemorrhage is the leading cause of preventable death caused by hemorrhage on the battlefield. Currently, there are no hemostatic agents with the ability to control noncompressible hemorrhage. A wound stasis dressing based upon rapidly expanding cellulose minisponges (MS) was developed and tested in a lethal noncompressible model in swine, by fully transecting subclavian artery and vein. MS were compared with conventional hemostasis dressings, Combat Gauze (CG), in a randomized comparison. Methods: Sixteen 40kg swine underwent transection of the subclavian artery and vein through a 4.5cm aperture. After 30-second free bleeding, randomly selected MS or CG (n = 8 per group) were administered by an independent medical officer.The wound cavity was filled with either MS + no external pressure or one CG + one KERLIX gauze with 3 minutes of external pressure. One reapplication was allowed for CG. Mean arterial pressure was maintained at 60 mm Hg with 500mL Hextend and lactated Ringer’s solution intravenously administered up to a maximum of 10L until study termination at 1 hour. Results: Mean pretreatment blood loss was similar for MS (719mL) and CG (702mL). Primary end points, namely, hemostasis at 4 minutes (MS, 75%; CG, 25%; p = 0.13), hemostasis at 60 minutes (MS, 100%; CG, 25%; p = 0.007), and survival at 60 minutes (MS, 100%; CG, 37.5%; p = 0.026), were improved with MS as were secondary end points, namely, total blood loss (MS, 118mL; CG 1,242mL; p =0.021) and length of application time (MS, 25 seconds; CG, 420 seconds; p =0.004). Conclusion: The use of MS is a novel approach for the rapid, simple treatment of severe noncompressible hemorrhage, which provided statistically significant improvement in hemostasis and survival 60 minutes after injury and a large reduction in blood loss, resuscitation fluid requirement, and medic treatment time compared with conventional hemorrhage control dressings in a swine model. PMID: 22847084 [PubMed – in process]

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Lightweight Noninvasive Trauma Monitor for Early Indication of Central Hypovolemia and Tissue Acidosis: A Review Soller, B.R.; Zou, F.; Ryan, K.L.; Rickards, C.A. Ward, K.; Convertino. V.A. J Trauma Acute Care Surg. 2012 Aug; 73(2 Suppl 1):S106–11 ABSTRACT Background: Hemorrhage is a major cause of soldier death; it must be quickly identified and appropriately treated. We developed a prototype patient monitor that noninvasively and continuously determines muscle oxygen saturation (SmO2), muscle pH (pHm), and a regional assessment of blood volume (HbT) using near-infrared spectroscopy. Previous demonstration in a model of progressive central hypovolemia induced by lower body negative pressure (LBNP) showed that SmO2 provided an early indication of impending hemodynamic instability in humans. In this review, we expand the number of subjects and provide an overview of the relationship between the muscle and sublingual microcirculation in this model of compensated shock. Methods: Healthy human volunteers (n = 30) underwent progressive LBNP in 5 minute intervals. Standard vital signs, along with stroke volume (SV), total peripheral resistance, functional capillary density, SmO2, HbT, and pHm were measured continuously throughout the study. Results and Discussion: SmO2 and SV significantly decreased during the first level of central hypovolemia (–15mm Hg LBNP), whereas vital signs were later indicators of impending cardiovascular collapse. SmO2 declined with SV and inversely with total peripheral resistance throughout LBNP. HbT was correlated with declining functional capillary density, suggesting vasoconstriction as a cause for decreased SmO2 and subsequently decreased pHm. Clinical Translation: The monitor has been miniaturized to a 58g solid-state sensor that is currently being evaluated on patients with dengue hemorrhagic fever. Early results demonstrate significant decreases in SmO2 similar to those observed with progressive reductions in central blood volume. As such, this technology has the potential to (1) provide a monitoring capability for both non-traumatic and traumatic hemorrhage and (2) help combat medics triage casualties and monitor patients during lengthy transport from combat areas. PMID: 22847078 [PubMed – in process]

Donor Performance of Combat Readiness Skills of Special Forces Soldiers are Maintained Immediately After Whole Blood Donation: A Study to Support the Development of a Prehospital Fresh Whole Blood Transfusion Program Strandenes G, Skogrand H, Spinella PC, Hervig T, Rein EB. Transfusion. 2012 Jun 28. doi: 10.1111/j.1537–2995.2012.03767.x [Epub ahead of print] ABSTRACT Background: Bleeding is a major cause of death in combat settings, and combat casualties in shock may benefit from fresh whole blood (FWB) transfusion. “Buddy transfusion” is a well-known lifesaving intervention, but little is known about donor combat safety aspects immediately after blood donation. The objectives of this study were to explore the effects of donation of 1 unit of blood on physical and combat-related performance among active duty Soldiers. We also investigated the feasibility of a short training program to teach nonmedics buddy transfusion. Study Design and Methods: Twenty-five fit male soldiers from a special forces unit were divided into three groups and tested on 1) a Bruce protocol treadmill stress test, push-ups, and pull-ups; 2) a 50-round rapid pistol shooting test; and 3) an uphill hiking exercise carrying a 20kg backpack. After baseline testing, the Soldiers performed the tests again (2–6 min) after donating 450mL of blood. The training program included blood collection and reinfusion procedures and we measured success rate of venipuncture, time for blood collection, and success in placing sternal intraosseous needle and reinfusing 1 unit of autologous blood. Results: We did not find any significant decrease in performance either in physical or in shooting performance after donating blood. Nonmedic soldiers had a 100% success rate in blood collection and also infusion on fellow Soldiers after a short introduction to the procedures. Conclusion: This study supports the fact that buddy transfusion may be feasible for healthy well-trained soldiers and does not decrease donor combat performance under ideal circumstances. © 2012 American Association of Blood Banks. PMID: 22738468 [PubMed – as supplied by publisher]

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Tactical Emergency Casualty Care (TECC) Update, Winter 2012

Reed Smith, MD; David Callaway, MD, MPA; Geoff Shapiro, EMT-P; Brendan Hartford, EMT-B The Committee for Tactical Emergency Care has continued to work on the development of the evidenced-based high-threat prehospital trauma care guidelines. C-TECC members are integrating TECC for all levels of providers in all high-risk operational medical scenarios. We have made significant advances in our outreach are beginning to see TECC develop inertia of its own. Over the last few months, members of C-TECC have worked closely with DHS/FEMA on the development and delivery of a second day in the Joint Counter Terrorism Awareness Workshop Series (JCTAWS) to concentrate on medical system response. Sponsored and developed by The National Counterterrorism Center (NCTC), the U.S. Department of Homeland Security (DHS), and the Federal Bureau of Investigation (FBI), the purpose of the JCTAWS is to examine preparedness levels at state and local governments to prevent or respond to an attack similar to the one carried out in Mumbai, India in November 2008. JCTAWS brings together federal, state, local, and private sector stakeholders from the first-responder community and individuals representing security, medical, communications, hospitality, transit, and other relevant communities, in order to understand the full implications of a Mumbai-style attack.Â Each workshop centers on a 24-hour scenario in which multiple coordinated assaults occur. Participating representatives from law enforcement, fire service, emergency management, and even the private sector gauge their respective response capabilities and determine the efficiency of their resources. For each city, a summary report is issued and an overarching JCTAWS executive summary is planned that identifies trends, lessons learned from active shooter incidents, and best practices for responding to such occurrences. A common theme that developed out of the 2011 and early 2012 JCTAWS sessions was the need for additional concentration, planning, and coordination on the medical system response, from non-medical first responders to pre-hospital providers and on through hospital care. In response to this identified gap, FEMA and C-TECC, along with faculty from the CDC Tale of Our Cities Program, have developed an integrated operational medical Day 2 for JCTAWS. In this session, the Tactical Emergency Casualty Care Guidelines are emphasized for use by all first responders, both medical and non-medical, in response to complex coordinated terrorist attacks, with an emphasis on the need for non-tactical responders to employ these guidelines in the immediate care of the wounded instead of relying on the traditional tactical law enforcement and tactical EMS response. The first session of this Day 2 was well received at the Los Angeles JCTAWS in August, and will be a feature of the Las Vegas and Atlanta JCTAWS later in the year. Additionally, members of C-TECC continue to develop and teach TECC courses for first-responders and firstreceivers throughout the local and federal government agencies. Members of the Executive Committee recently delivered TECC training to federal law enforcement personnel within the Department of Homeland Security; these members also were directly involved in TECC training for first-responders for the Democratic National Convention in Charlotte, NC and remained operational throughout the high profile event. Several Guidelines Committee members have recently completed a project training many of the Northern Virginia hospital emergency department first-receivers in the concept of TECC to improve awareness, preparedness, and allow for improved transition of care among first-responders and the hospital staff during mass casualty. TECC training and awareness initiatives continue throughout California, and several members from the Guidelines Committee and Board of Advisors have been instrumental in keeping C-TECC and the National TEMS Initiative Committee coordinated in their efforts in conjunction with the C-TECC/NTIC Teaming Agreement put in place in August. C-TECC members continue to work closely with the Inter-Agency Board, including efforts to begin the process of placing TECC medical care items such as tourniquets and pressure bandages on the approved equipment list. A large-scale UASI-funded initiative in

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the Northern Virginia region to teach TECC to area patrol officers and provide them with TECC ‘blow-out’ trauma kits is near completion, and training should begin in the near future to implement this important program. The next Full Committee meeting of C-TECC has been scheduled once again in conjunction with, and with the support of, the Special Operations Medical Association (SOMA). This meeting will be held on Tuesday 18 December 2012, during the 2012 SOMA conference in Tampa, FL, and will be open door for the majority of the session throughout the day to allow for greater involvement and interaction with the SOMA membership. This meeting is also open to the public and will have built in time for public comment; we look forward to significant feedback from TECC end-users. The agenda in December will include discussion of recent events that relate to the need for TECC implementation. The Guidelines update will concentrate on identifying areas that need review and possible revision. We anticipate lively discussion on the need for stronger guidance on traumatic brain injury and plan on concentrating on developing specific recommendations for the civilian populations, such as pediatric and geriatrics, that are not traditionally included in the Tactical Combat Casualty Care guidelines. These discussions will set the research agenda for 2013 that will possibly result in changes to the Guidelines at the May 2013 meeting in Seattle. As always, please refer to the Committee website, www.C-TECC.org, for any additional information and/or comments.

Current and Future Implications of the National TEMS Initiative and Council

Philip A. Carmona, 18Z/D, RN, NREMT-P

The National Tactical Emergency Medical Support Initiative and Council (NTIC) was established to standardize the curricular standards for the training of tactical medicine practitioners in the United States. The project began when a group of tactical medical practitioners from the National Tactical Officers Association and the Center of Operational Medicine-Georgia Health Sciences University observed the highly variable types of tactical medical curricula and their instructors varying competence and experience and noted the problems engendered by these issues. In summary, no standard existed for tactical medical practice in the United States. These two agencies facilitated the gathering of highly experienced tactical medical providers from across the country. The group meeting in the Washington, DC, area derived domains for the Medical Provider EMT through Physician and Tactical Operator. What remains to be done are the domains for Patrol Officer, Team Commander, and Medical Director. These will be done through meetings in the upcoming months. Following that, the plan is for the council functions to update the domains as needed and assist in and support tactical medical activities nationwide. It is important to note that the intent will not be to dictate the scope of practice/standard of care or protocols for providers in the United States. The NTIC acts through 17 domains and their Terminal, enabling learning objectives. Any tactical medical schoolhouse can then crosswalk the 17 domains against their respective curricula. Scope of Practice/Standards of Care and Protocols can have a significant degree of variance in the non-military area of practice. This is not only with respect to different levels of licensure, but also with respect to the considerable differences from state to state and even within counties, municipalities, and agencies. For example, there are tactical paramedics in some federal non-military agencies that have “advanced practice” capabilities and their scope of practice/standard of care and protocols reflect their level of practice. The NTIC, however, will define a standard of tactical medical training with domains, Terminal Learning Objectives, Enabling Learning Objectives. The scope of practice/standard of care, and protocols will be left to the local jurisdictions. The 17 domains in the five practice areas have already provided guidance, and will continue to do so, for the tactical medical curricula review of existing programs, and in the establishment of new programs. Several states have inquired and are examining the NTIC in their quest to establish standards for the training of their tactical medical personnel. Additionally, the Board of Critical Care Transport Paramedic Certification (BCCTPC) recently convened a body of tactical medical subject matter experts in order to develop a National Tactical Paramedic Examination. This organization wrote and maintains the Critical Care Paramedic Exam and the Flight Paramedic Exam; this is a standard right of passage for military medics of the 160th Special Operations Aviation Regiment (SOAR). The SOF

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community is a stakeholder in the Tactical Paramedic Exam and the 17 domains of the NTIC are the cornerstones of the new exam currently being developed by the BCCTPC. Given the body of subject matter experts and the scientific method of derivation, the indications are that the NTIC will find increased utility in the growing field of TEMS. The work continues and when completed, the finished product will be formally published, followed by maintenance and management by the National TEMS Council.

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battle-tested, life-saving medical device is entering its final stages of development and is ready to be added to the existing arsenal of cutting edge medical technologies available to Warfighters, hospital clinicians and emergency medical service providers.

The FASTCombat™ is the latest and most advanced Interosseous (IO) device anticipated for clearance by regulatory agencies and released by Pyng Medical (www.pyng .com) into the marketplace in Spring, 2013. “The device removes all guess work to establishing access for fluid resuscitation, administering required medications, and replaces the older FAST1® that has been in use by military medics and physicians since the early 2000’s,” said Pyng’s Chief Executive Officer, Mark Hodge. Retired Army Colonel and Special Forces physician, Al Moloff, MD, said, “The FASTCombat™ is an easy to use, rapid and effective device for initiating vascular access under the most demanding conditions on the battlefield.” Dr. Moloff continued, “The new FASTCombat™ is about one-third lighter, and smaller, than the FAST1®, and will come in a smaller more compact container. It will require about one-half of the pressure needed to deploy the FAST1®, to rapidly, safely and effectively insert the needle into the bone marrow of the sternum. Virtually any medication, drug or fluid, including whole blood, can be given via IO. The rate of flow is comparable to peripheral IV’s (intravenous) and can be used with gravity flow, manual pressure, or a pressure infuser.”

How it began Interosseous technology emerged onto the medical scene circa 1922 (Drinker CK, et al: The circulation in the mammalian bone marrow. American Journal of Physiology, 1922), as a means of fluid replacement in pediatric patients. Low blood volume, and low blood pressure resulting from trauma make access to patients’ veins in some cases difficult if not impossible. However, infusion of life-saving fluids through the marrow of the bone showed remarkable results. The procedure was adopted for battlefield use in WWII, as well as Korea and Vietnam. Little was done to advance the technology until

The FASTCombat™ Device Pyng Medical introduced the FAST1®, the first hand-held mechanical device, which was approved for military use in the early 2000’s. Since then, Pyng’s FAST1® has become the favorite and mainstay of interosseous infusion on the battlefield, as well as in hospital and pre-hospital environments.

How it works “Think of bone marrow as a non-collapsible vein,” says Dr. Moloff. “The sternal bone marrow is a readily accessible and physiologically active tissue that allows any fluid or medication to be rapidly moved to the heart and blood circulation.” Original IO technology involved manually boring a hole through the outer layer of hard bone to reach the softer and more porous marrow. In 1932 this meant accessing the marrow of the cranium; in later years large bore stainless steel catheters were used

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to access marrow in the long bones of the legs, e.g., the tibia, or femur. The specific target of the FASTCombat™ is the manubrium portion of the sternum. The FASTCombat™ is a stand-alone device that automatically releases the needle accessing the marrow. The user simply places the device on the casualty using easily and readily identifiable anatomical landmarks, and pushes the device toward the chest – the FASTCombat™ does the rest. It determines the correct depth, pierces the outer cortical bone, and seats the catheter firmly into the marrow. The medical provider completes the task by connecting the fluids to the FASTCombat™ system and monitors the rate of the fluids absorbed by the marrow. It is an amazing invention.”

Does it work? “Absolutely,” said Dr. David Morehouse of 2SRG, an independent researcher who conducted testing on the new devices throughout 2010, 2011 and 2012. “I was deeply impressed by the company’s desire to be the best in every measurable area with these devices. They have improved their device with each generation, improving ergonomics, reliability, and tactical packaging. When considering what color to make the FASTCombat™, they did not simply decide on the color black. Instead, they set about testing various materials, textures, and colors, under low light, no light, using night vision goggles, infrared, and thermal imagery, to determine which combinations provided the highest visibility to the user. Handle ergonomics and textures were tested in blood and other body fluids to ensure maximum grip, in order to facilitate accurate placement by the user. They left nothing to assumption. Even the tactical packaging selection took on a life of its own, with Pyng engineers taking into consideration every imaginable scenario a medic might encounter while on mission. They wanted to ensure the device was protected without adding weight and cube and that opening the packaging would be a simple process during difficult mission conditions. It was the most impressive and comprehensive development testing I’ve seen.”

saving lives on the battlefield. Pyng has carefully considered the correct training protocols and merged them with state of the art training aids.”

How to get it Tens of thousands of FAST1® IO devices are already in the inventory for NATO Coalition and U.S. Forces. Units can purchase the existing device via National Stock Number (6515-01-536-9363), or, check the Pyng Medical website at www.pyng.com for information about how to buy the current device, and place orders for the new FASTCombat™ when they are available for sale. “We expect to provide the superior IO solution that best meets the specific needs of the combat medics and corpsmen, or the emergency medicine provider (EMS) at a price comparable to devices offered today,” said Nadine Sidqueland, Pyng’s Vice-President for Global Sales and Marketing. The new FASTCombat™ will have a civilian hospital pre-hospital partner in Pyng’s new FASTResponder™. It is an identical device in every way with the exception of the packaging and the color scheme. In the FASTResponder™ these design attributes are tailored to the needs of the civilian medical community. Ergonomically and functionally, the FASTCombat™ and F ASTResponder™ devices are identical; however, they are marked and packaged to accommodate slightly different procurement, inventory, and storage considerations.

“Training materials and training systems is another area where Pyng chose not to be rivaled,” Dr. Morehouse continued. “Users of the new FASTCombat™ will have available one of the most advanced training systems possible.” Pyng’s CEO, Mark Hodge stated, “We know that training is everything when it comes to saving life on the battlefield. We have carefully outlined appropriate training protocols and merged them into a comprehensive training program designed to maximize success with this new device.” Dr. Moloff stated, “Fundamental initial training as well as realistic scenario based sustainment and pre-deployment training is critical to mission accomplishment and Medical Technology Updates

The FASTResponder™ Device

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How it will affect battlefield care On the battlefield, the new FASTCombat™ device will allow combat medics and corpsmen to safely, effectively, and rapidly administer fluids and medications under adverse field conditions. The design of this new device not only makes it more compact, but easy to learn, and use. Certainty is a key design characteristic in both the new FASTCombat™ and the FASTResponder™. Both devices are smaller and lighter than the FAST1®. There are fewer steps needed to use the devices so it is easier to train someone to use them with greater learning retention. To be offered separately, the new training system is a complete, durable, cost effective training tool, designed to enhance any medical training program. The FASTCombat™ and the FASTResponder™ have their intended populations; however, both can be used on the battlefield, in civilian and military pre-hospital care, the emergency department, and as a “code cart” adjunct. FASTCombat™ and Tactical Cylinder Packaging

David Morehouse, PhD, an Independent Researcher for Strategic Survivability Research Group, LLC (2SRG), of Las Vegas, NV.

FASTCombat™ and FASTResponder™ – identical except for color scheme and packaging

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Journal of Special Operations Medicine Volume 12, Edition 4/Winter 2012

(photo right) Protective Detail members practicing TCCC and evacuation of casualties in Baghdad, Iraq, 2007. Photo courtesy of C.N. Sargent

(photo below) Preparing our interpreter for MEDEVAC after he experienced a seizure while working as the Senior Medical Person (Corpsman) with the British RAF in Kandahar Afghanistan. Photo courtesy of Shawn Buxton, NREMT-P, EMT-T, USN

(photo above) MAJ Andrew Morgan identifies an Afghan boy with a cleft palate as a candidate for surgical repair by a US Forward Surgical Team while deployed to Kandahar, Afghanistan with 3rd Special Forces Group (Airborne). Photo courtesy of SFC John Dominguez, CA LNO

(photo left) Protective Detail Special Operations Medic in Iraq discuss with translator care of wound after cleaning and dressing a burn on an Iraqi medic civilians leg, Baghdad, Iraq, 2008. Photo courtesy of C.N. Sargent

(photo left) A Civil Affairs medic from the 96th CA Bn., 95th CA Bde., prepares a vaccine to be administered to livestock during a veterinary capabilities mission in Tursaq, Iraq, March 31, 2009. The Civil Affairs team, along with U.S. Special Forces Soldiers, Iraqi SWAT and local doctors, vaccinated more than 500 animals and provided medicine for nearly 6,000 more. Photo courtesy of U.S. Army Special Operations Command (photo below) Our latest medical course in cooperation to our U.S. partners. This was an Advanced Trauma Course, dedicated to our doctors. I was the only Czech Army paramedic in the course. Photo courtesy of WO1st class Jaroslav Duchon, Czech Army EMT-P and medical instructor

(photo above) A Special Forces medic treats an Iraqi woman and a young baby for their illnesses. The woman had typical health problems that included itchy scalp and pains in the stomach. The baby had an issue with its eye. The patients are all family members of the ISWAT soldiers. The Special Forces doctor works daily to treat any Iraqi SWAT and their family members as a way to build repour with the Iraqi security personnel. He said there is nothing better you can do than to treat their families and them. Photo courtesy of U.S. Army Special Operations Command (photo right) SFC John Dominguez treating a Philippine Marine who was burned during training. The result was seven days of wound care, pain control, and debridement of dead tissue. Photo courtesy of SFC John Dominguez, CA LNO

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Winter 2012 Volume 12, Edition 4 ISSN: 1553-9768

™ The Only Peer Reviewed Journal that Brings Together the International Interests of First-Responders in the SOF Medical and TEMS Community 16 AthenaGTX 139 BioStat 144 BoundTree Medical 71 Chinook Medical Gear 28 CMS 108 CTOMS 97 Marks Training Group 38 MinXray C4 North American Rescue 27 PerSys Medical C3 SKEDCO 134 SOMA 131 Special Forces Advanced Mountain Operations School 59 Speer Operationals 135 SRA International Inc. C2 Tactical Medical Solutions 9 Tribalco xii Z Medica ii ZOLL

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Special Forces Aidman’s Pledge As a Special Forces Aidman of the United States Army, I pledge my honor and my conscience to the service of my country and the art of medicine. I recognize the responsibility, which may be placed upon me for the health, and even lives, of others. I confess the limitation of my skill and knowledge in the caring for the sick and injured. I promise to follow the maxim “Primum non-nocere” (“First, thou shalt do no harm”), and to seek the assistance of more competent medical authority whenever it is available. These confidences, which come to me in my attendance on the sick, I will treat as secret. I recognize my responsibility to impart to others who seek the service of medicine such knowledge of its art and practice as I possess, and I resolve to continue to improve my capability to this purpose. As an American Soldier, I have determined ultimately to place above all considerations of self the mission of my team and the cause of my nation.

Pararescue Creed I was that which others did not want to be. I went where others feared to go, and did what others failed to do. I asked nothing from those who gave nothing, And reluctantly accepted the thought of eternal loneliness . . . should I fail. I have seen the face of terror; felt the stinging cold of fear, and enjoyed the sweet taste of a moment's love. I have cried, pained, and hoped . . . but most of all, I have lived times others would say best forgotten. Always I will be able to say, that I was proud of what I was: a PJ. It is my duty as a Pararescueman to save a life and to aid the injured. I will perform my assigned duties quickly and efficiently, placing these duties before personal desires and comforts. These things I do, “That Others May Live.”

A Navy Poem I’m the one called “doc” . . . I shall not walk in your footsteps, but I will walk by your side. I shall not walk in your image, I’ve earned my own title of pride. We’ve answered the call together, on sea and foreign land. When the cry for help was given, I’ve been there right at hand. Whether I am on the ocean or in the jungle wearing greens, Giving aid to my fellow man, be it Sailors or Marines. So the next time you see a corpsman and you think of calling him “squid,” think of the job he’s doing as those before him did. And if you ever have to go out there and your life is on the block, Look at the one right next to you . . . I’m the one called “doc.” —Harry D. Penny, Jr. USN Copyright 1975