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

Introduction: Preventing temperature stress on medication for prehospital medical care is a challenge, especially in re-source-limited environments like the Arctic. Most medication used by military prehospital providers is intended for storage between 15 and 25°C-defined as "controlled temperature." The primary objective of this study was to demonstrate the feasibility of storing medication within controlled parameters by a lightweight, highly mobile, and self-supporting Role 1 Medical Treatment Facility during cold weather operations.

Methods: Within a standard cooling container, we placed three 1L water bottles filled with boiling water, which were reheated every morning. Over a period of 264 hours, we measured the inside and outside temperatures of the container and analyzed whether the inside temperature remained within the speci-fied parameters using two TempTale™ 4 temperature loggers.

Results: We collected a total of 264 hours of data. The ambi-ent temperature was outside the controlled temperature range 94.5% of the time (248.5 hours). We recorded a minimum temperature of -12.5°C (9.5°F) and a maximum temperature of 27.3°C (81.1°F). The temperature measured inside the cool-ing container was within the controlled temperature range for 67.8% of the time (178.3 hours), with a minimum tempera-ture of 6.2°C (43.2°F) and a maximum temperature of 36.7°C (98.1°F).

Conclusion: The shift in focus to arctic military op-erations must be accompanied by efforts to optimize military arctic medical preparedness. During arctic warfare one of the biggest challenges is the low and uncontrollable temperature which can create significant stress on medical equipment. The demonstrated low-tech, easy-to-deploy solution is a first step to keep medication within controlled parameters in a mini-mally equipped Role 1 Medical Treatment Facility without reliance on running vehicles or electric/fuel-powered heating. This method not only lowered the team's logistical load but also reduced their thermal signature. This study paves the way for more research toward robust medical readiness in arctic military operations.

Wound infections represent an increasing risk in combat trauma, especially in prolonged casualty care conditions char-acterized by evacuation delays and resource scarcity. This risk is compounded by multidrug-resistant organisms, which are difficult to detect and treat in austere settings. This article introduces a "Ruck-Truck-House-Plane" model for infection control and wound management in prolonged casualty care (Role 1) and prolonged care (beyond Role 1) environments. This original approach includes practical procedures and de-cision-making from point of injury to tertiary care transfer. It emphasizes early decontamination, phased surgical care, re-mote microbial diagnostics, and antimicrobial stewardship to reduce morbidity and mortality in modern warfare.

Tactical Combat Casualty Care (TCCC) guidelines have his-torically recommended antibiotics for combat wounds due to potential delays in evacuation and wound contamination. The currently recommended agents, moxifloxacin (oral) and ertap-enem (parenteral), have not been recently reviewed. This paper documents the findings of a multidisciplinary panel convened in 2023 to re-evaluate TCCC antibiotic recommendations con-sidering current antibiotic options, emerging data regarding multi-drug resistance (MDR), and evolving combat wound microbiology. The panel addressed four key questions through literature review and expert discussion: the optimal timing for antibiotic administration, whether recommendations change for invasive procedures, the inclusion of topical antibiotics, and the need to update antibiotic choices. The review reaffirmed the importance of early antibiotic administration, recommended antibiotic prophylaxis for any invasive procedure in the TCCC setting, found insufficient evidence to recommend topical an-tibiotics at this time, and proposed updates to the antibiotic choices based on factors like spectrum, side effects, stability, dosing, and cost. The panel recommends changing the oral antibiotic to cefadroxil (preferred) or cephalexin (alternative) and the parenteral antibiotic to ceftriaxone. In light of these changes in TCCC antibiotics, considerations should be made within Prolonged Casualty Care guidelines for the narrower spectrum of antibiotics and surveillance for unanticipated in-creases in specific injury patterns such as post-traumatic en-dophthalmitis, open fractures, or abdominal injuries.

Tourniquets have proven lifesaving in modern combat, particularly during the Global War on Terror, where rapid evacuation often mitigated the risks of prolonged and non-medically indicated application. However, in future large scale combat operations (LSCOs), prolonged field care and delayed evacuation will be common. Without timely reassessment, medically unnecessary or ineffective tourniquets may lead to avoidable morbidity, including limb loss, rhabdomyolysis, and compartment syndrome. Data from U.S. and Ukrainian surgical teams reveal tourniquet reassessment, conversion, and optimization are not being practiced in the field to effectively control hemorrhage. Despite this, current TCCC doctrine lacks sufficient emphasis on tourniquet reassessment, conversion (TC), and optimization (TO)-especially among non-medical personnel. This paper calls for doctrinal change to classify tourniquet reassessment, TC, and TO as Tier 1 (All Service Member) skills. We recommend updating TCCC training, emphasizing reassessment within 2 hours of application, incorporating TC/TO into training lanes, and revising the DD1380 TCCC card to document these interventions. Preparing for LSCOs requires shifting from the "fire-and-forget" mindset. Equipping all service members with the skills to reassess and manage tourniquets appropriately can reduce preventable morbidity and preserve lives in prolonged care environments without compromising the proven benefits of rapid hemorrhage control.

As the U.S. Navy further develops the concept of distributed maritime operations (DMOs), where individual components of the naval force will be more geographically dispersed, smaller vessels may be operating at a significant time and distance from more advanced medical capabilities. Therefore, Role 1 maritime caregivers will need to manage injured and disease non-battle injury patients for prolonged periods during current and future contested DMOs. We developed a hypothetical burn injury patient scenario to present an innovative approach to teaching complex operational medicine concepts including austere burn resuscitation, wound care, and Prolonged Casualty Care (PCC) to austere Role 1 maritime caregivers using the Joint Trauma System PCC and Tactical Combat Casualty Care clinical practice guidelines (CPGs) and other standard references. The format includes basic epidemiology of burn injury in the operational maritime environment. The scenario includes a stem clinical vignette, followed by expected clinical changes for the affected patient at specific time points (e.g., time 0, 1 hour, 2 hours, and 48 hours) with expected interventions based on the PCC CPG, appropriate guidelines, and available standard shipboard equipment. Through this process, opportunities to improve both training, clinical skills sustainment, and standard shipboard medical supplies are identified.

Calcium is vital for coagulation and hemodynamic stability, with hypocalcemia correlating to higher mortality in trauma patients. Trauma-induced hypocalcemia is a critical issue in battlefield medicine, affecting both coagulation and cardiovas-cular function in severely injured individuals by exacerbating the effects of the lethal triad. TCCC is based on strategies to prevent and manage hemorrhage and shock, including the use of blood products and the administration of calcium to avoid citrate toxicity. However, there remains debate about whether calcium supplementation should be universally recommended, even in scenarios where blood products are unavailable. This paper examines evidence surrounding the inclusion of cal-cium in military trauma care protocols, weighing the benefits against potential risks and challenges.

Objectives: Low fibrinogen contributes to poor outcomes in patients with traumatic coagulopathy. Empiric fibrinogen replacement is not supported. Early identification of patients at high risk of hypofibrinogenemia may enable targeted support. We sought to identify prehospital variables associated with hypofibrinogenemia at emergency department (ED) arrival.

Methods: We retrospectively reviewed health records (January 2015 to August 2019) of consecutive patients transported by helicopter EMS to two trauma centers who received one or more units of packed red blood cells (pRBCs) during transport. The primary outcome was first ED fibrinogen level transformed into a binomial variable (<1.6g/L or ≥1.6g/L) for the 65 patients analyzed. Direct multivariable logistic regression examined the independent variables (hypotension, shock index (SI), and systolic blood pressure). Odds ratios and 95% CIs were reported.

Results: Hypotension after first pRBC transfusion was significantly associated with low ED first fibrinogen level, P=.03, with 6.6 (1.1-40.15) times greater odds of fibrinogen <1.6g/L. Hypotension post-transfusion was also associated with ED first international normalized ratio (INR) >1.5, P=.013, with those cases having 17.5 (1.8-169.2) greater odds of INR >1.5. Additionally, an EDSI ≥1.5 had 8.9 (1.9-42.6) times greater odds of fibrinogen <1.6g/L than those with an EDSI <1, P=.006. Compared with the EDSI 1-1.49 group, those with an EDSI ≥1.5 had 6.9 times greater odds of having fibrinogen <1.6g/L, P=.02, OR=6.9 (1.3-36.1).

Conclusion: In major trauma patients transported by helicopter EMS, persistent hypotension after the first blood transfusion and an initial EDSI ≥1.5 were both associated with low fibrinogen levels.

Background: The Belgian Defense introduced an integrative and immersive model of an educational program in 2021 specifically dedicated to combat medic certification. The primary objective of the study was to compare final theoretical and practical results between emergency medical technician (EMT) and non-EMT candidates.

Methods: This longitudinal cohort monocentric study, conducted in 2021 and 2022, analyzed all theoretical and practical examination results collected by the instructors, evaluators and Exercise Controllers. Two main domains (theoretical and practical total scores) and three sub-domains (MED LEADER, MED PROVIDER, TAC LEADER) were specifically explored.

Results: One hundred thirty-seven combat medic candidates for an advanced EMT certification were recruited, with a mean age of 30.3 years and a mean seniority of 8.9 years. Clinically naïve, non-EMT candidates represented 62.8% of the population. Clinically exposed EMT candidates did not demonstrate superiority in any domains or subdomains when compared to non-EMT candidates.

Discussion: Some intrinsic parameters of the course could explain the non-superiority of the clinically exposed group. Compensating intrinsic motivation and situational awareness should be further explored in the clinically naïve group.

Conclusion: Non-EMT candidates were able to score robustly, similar to their EMT counterparts, in an integrative, hyper-realistic, and immersive course promoting multilevel processing.

We describe an Army Officer with infectious endocarditis af-ter being hospitalized with a heat injury while participating in Special Forces Assessment and Selection. A 26-year-old other-wise healthy male presented with a fever, skin lesions, and pain at his IV site after a recent hospitalization. He was admitted on intravenous antibiotics due to suspicion of bacteremia and was eventually diagnosed with MRSA endocarditis. The pa-tient required months of antibiotics and left brachial vein exci-sion for source control. After multiple readmissions for MRSA bacteremia over the following 2 years, the patient was placed on daily prophylactic doxycycline. Due to complications from his condition, the patient was medically retired from the Army. When the tactical setting allows, prehospital providers must practice aseptic techniques and advocate for their patients when other providers lack awareness of the impact of field environments.