Journal of special operations medicine : a peer reviewed journal for SOF medical professionals最新文献

Exertional heat stroke (EHS) is a medical emergency characterized by elevated body temperature and central nervous system dysfunction, and it can include dizziness, confusion and loss of consciousness, as well as long-term organ and tissue damage. EHS is distinct from classic, or passive, heat stroke and is most commonly observed during intense physical activity in warfighters, athletes, and laborers. EHS is an ongoing non-combat threat that represents a risk to both the health and readiness of military personnel. Potential risk factors and their mitigation have been the subject of investigation for decades. One risk factor that is often mentioned in the literature, but not well quantified, is that of individual motivation to excel, wherein highly trained military personnel and athletes exert themselves beyond their physiological limits because of a desire to complete tasks and goals. The motivation to excel in tasks with high standards of achievement, such as those within elite military schools, appears to create an environment in which a disproportionately high number of exertional heat illness casualties occur. Here, we review existing biomedical literature to provide information about EHS in the context of motivation as a risk factor and then discuss five cases of EHS treated at Martin Army Community Hospital at Fort Moore, GA, from 2020 to 2022. In our discussion of the cases, we explore the influence of motivation on each occurrence. The findings from this case series provide further evidence of motivation to excel as a risk factor for EHS and highlight the need for creative strategies to mitigate this risk.

Aggregate statistics can provide intra-conflict and inter-conflict mortality comparisons and trends within and between U.S. combat operations. However, capturing individual-level data to evaluate medical and non-medical factors that influence combat casualty mortality has historically proven difficult. The Department of Defense (DoD) Trauma Registry, developed as an integral component of the Joint Trauma System during recent conflicts in Afghanistan and Iraq, has amassed individual-level data that have afforded greater opportunity for a variety of analyses and comparisons. Although aggregate statistics are easily calculated and commonly used across the DoD, other issues that require consideration include the impact of individual medical interventions, non-medical factors, non-battle-injured casualties, and incomplete or missing medical data, especially for prehospital care and forward surgical team care. Needed are novel methods to address these issues in order to provide a clearer interpretation of aggregate statistics and to highlight solutions that will ultimately increase survival and eliminate preventable death on the battlefield. Although many U.S. military combat fatalities sustain injuries deemed non-survivable, survival among these casualties might be improved using primary and secondary prevention strategies that prevent injury or reduce injury severity. The current commentary proposes adjustments to traditional aggregate combat casualty care statistics by integrating statistics from the DoD Military Trauma Mortality Review process as conducted by the Joint Trauma System and Armed Forces Medical Examiner System.

Background: Medical training and evaluation are important for mission readiness in the pararescue career field. Because evaluation methods are not standardized, evaluation methods must align with training objectives. We propose an alternative evaluation method and discuss relevant factors when designing military medical evaluation metrics.

Methods: We compared two evaluation methods, the traditional checklist (TC) method used in the pararescue apprentice course and an alternative weighted checklist (AWC) method like that used at the U.S. Army static line jumpmaster course. The AWC allows up to two minor errors, while critical task errors result in autofailure. We recorded 168 medical scenarios during two Apprentice course classes and retroactively compared the two evaluation methods.

Results: Despite the possibility of auto-failure with the AWC, there was no significant difference between the two evaluation methods, and both showed similar overall pass rates (TC=50% pass, AWC=48.8% pass, p=.41). The two evaluation methods yielded the same result for 147 out of 168 scenarios (87.5%).

Conclusions: The AWC method strongly emphasizes critical tasks without significantly increasing failures. It may provide additional benefits by being more closely aligned with our training objectives while providing quantifiable data for a longitudinal review of student performance.

Background: The development of acute traumatic coagulopathy is associated with increased mortality and morbidity in patients with battlefield traumatic injuries. Currently, the incidence of acute traumatic coagulopathy in the Role 1 setting is unclear.

Methods: We queried the Prehospital Trauma Registry (PHTR) module of the Department of Defense Trauma Registry (DoDTR) for all encounters from inception through May 2019. The PHTR captures data on Role 1 prehospital care. Data from the PHTR was linked to the DoDTR to analyze laboratory data and patient outcomes using descriptive statistics. We defined coagulopathy as an international normalized ratio (INR) of ≥1.5 or platelet count ≤150×109/L.

Results: A total of 595 patients met the inclusion criteria; 36% (212) met our definition for coagulopathy, with 31% (185) carrying low platelet numbers, 11% (68) showing an elevated INR, and 7% (41) with both. The baseline (no coagulopathy) cohort had a mean INR of 1.10 (95% CI 1.09-1.12) versus 1.38 (95% CI 1.33-1.43) in the coagulopathic cohort. The mean platelet count was 218 (95% CI 213-223) ×109/L in the baseline cohort versus 117 (95% CI 110-125) ×109/L in the coagulopathic cohort.

Conclusions: Our findings indicate a high incidence of coagulopathy in trauma patients. Approximately one-third of wounded patients had laboratory evidence of coagulopathy upon presentation to a forward medical care facility. Advanced diagnostic facilities are therefore needed to facilitate early diagnosis of acute traumatic coagulopathy. Blood products with a long shelf life can aid in early correction.

Special Operations Servicemembers presenting with palpitations, pre-syncope, or exertional syncope during rigorous physical training are often experiencing a benign condition; however, life-threatening etiologies should be considered. We describe a 43-year-old Special Operator who presented to his medics during selection physical assessment testing with palpitations and lightheadedness, with a subsequent workup revealing arrhythmogenic right ventricular cardiomyopathy (ARVC). His initial electrocardiogram was unremarkable without characteristic ARVC changes. Outpatient evaluation with ambulatory cardiac monitoring recorded numerous episodes of non-sustained ventricular tachycardia. Transthoracic echocardiography demonstrated findings concerning for ARVC, with subsequent cardiac MRI confirming the diagnosis via the 2020 Padua criteria. Management includes activity modification, class III anti-arrhythmic medications, and possible placement of an implantable cardioverter defibrillator to prevent sudden cardiac death. This case demonstrates the importance of maintaining high clinical suspicion for rare diagnoses that present with exertional palpitations, such as arrhythmogenic right ventricular cardiomyopathy, in even our fittest Special Operators.

During distributed maritime operations, individual components of the naval force are more geographically dispersed. As the U.S. Navy further develops this concept, smaller vessels may be operating at a significant time and distance away from more advanced medical capabilities. Therefore, during both current and future contested Distributed Maritime Operations, Role 1 maritime caregivers such as Independent Duty Corpsman will have to manage patients for prolonged periods of time. This manuscript presents an innovative approach to teaching complex operational medicine concepts (including Prolonged Casualty Care [PCC]) to austere Role 1 maritime caregivers using a hypothetical scenario involving a patient with sepsis and septic shock. The scenario incorporates the Joint Trauma System PCC Clinical Practice Guidelines (CPG) and other standard references. The scenario includes a stem clinical vignette, expected clinical changes for the affected patient at specific time points (e.g., time 0, 1, 2, and 48h), and expected interventions based on the PCC CPG and available shipboard equipment. Epidemiology of sepsis in the deployed environment is also reviewed. This process also identifies opportunities to improve training, clinical skills sustainment, and standard shipboard medical supplies.

Background: This study assessed omega-3 fatty acid (O3FA) status, previous brain injury risk exposures, and associations between O3FA status and risk exposures among active-duty military personnel.

Methods: O3FA status was measured by a Holman omega-3 blood test. A survey was conducted to assess brain injury risk history and dietary O3FA factors.

Results: More than 50% of the participants had high-risk status, based on an omega-3 index (O3I) <4%, while less than 2% of the participants recorded low-risk O3I (>8%). O3FA supplementation (p<.001, Cramer's V=0.342) and fish consumption (p<.001, Cramer's V=0.210) were positively correlated with O3FA status. Only 5 O3FA supplement users (n=97 [5.2%]) had a low-risk O3I status, while all nonusers (n=223) had moderateto high-risk O3I status.

Conclusions: Supplementing with O3FA was associated with better O3I status in this population. However, only a few participants achieved optimal O3I status even when taking an O3FA supplement. Participants who ate fish and did not supplement were in the moderateor high-risk O3I groups.

Background: Conducted electrical weapons (CEWs) are nonlethal weapons used in tactical environments. Tactical EMS (TEMS) operators provide patient care in environments where CEWs are present. CEWs may produce a spark that can be a source of ignition. When supplemental oxygen is in use by a TEMS operator, the flammability risk from the CEW is unknown.

Methods: We measured oxygen levels over 20 minutes in an enclosed space with a supplemental oxygen source maximally flowing. Measurements were taken at various distances from the oxygen source to establish baseline concentrations. These concentrations were replicated within a plexiglass box where a CEW was activated to create a sparking arc between probes embedded in a fresh swine shoulder (with skin intact). Various flammable materials, typically found in a patient care setting were used as potential fuel sources.

Results: The highest oxygen levels were achieved directly at the source. At 15cm from the source, the maximum oxygen concentration was 31.5%. Within the box, ignition was only achieved at oxygen concentrations greater than 45% and only when human hair was present as fuel. No ignition was achieved at oxygen levels below this regardless of the tested fuel present.

Conclusion: Ignition from a CEW is possible at supplemental oxygen levels greater than 45% when human hair is present. In an enclosed space, oxygen concentration levels of 45% are only present within 15cm of a flush rate oxygen source. The likelihood of CEW-caused ignition in such settings with supplemental oxygen in use is extremely low.