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

Background: The resuscitative endovascular balloon occlusion of the aorta (REBOA) technique controls abdominal, pelvic, junctional, and postpartum hemorrhage via aortic endoclamping. There are no protocols or clear indications guiding REBOA use in a two-tiered prehospital emergency medical system, as found in France. We conducted a Delphi study to clarify the indications and contraindications for REBOA application in such a system.

Methods: We performed a Delphi study in three rounds with an international group of doctors with REBOA expertise and clinical experience (members of the EndoVascular and Trauma Management Society). Based on the consensus answers, complemented by existing data in the literature, we developed a protocol for REBOA use in a medicalized prehospital setting.

Results: We identified 10 questions that were not answered in the literature and submitted them to 21 experts. Over three rounds, consensus was reached on these 10 questions. The most important ones were "In your opinion, in a hemorrhagic patient, vascularly well-filled and whose hemodynamics remain unstable with 3mg/h of norepinephrine, should we inflate a REBOA to prevent the patients death and get them to the operating room alive?" and "In the case of REBOA placement (zone I) in the prehospital setting, would you agree that the maximum occlusion duration is approximately 30 minutes, with a partial or intermittent occlusion when possible?"

Conclusion: We propose a protocol for REBOA use in a medicalized prehospital setting. This protocol clarifies that hemorrhagic shock, despite a noradrenaline (also known as norepinephrine) dose of 0.6µg/kg/min, is considered too serious for the patient to be transported to the trauma center without REBOA. Moreover, it clarifies that a zone 1 REBOA should be inflated for maximum 30 minutes and with a partial occlusion strategy, if possible. This protocol should be updated based on feedback following the establishment of prehospital REBOA and large randomized studies.

Training needs of Special Operations Forces (SOF) medics were surveyed and new training initiatives have been created to meet their needs. SOF medics perform an array of medical procedures in austere environments with minimal supervision. Medical skills decay over time after initial training and the perceived training needs of active SOF medics were unclear. To fill this gap, active SOF medics (n=57) completed a survey that included confidence ratings and indications of whether additional training would make them more proficient in 70 medical knowledge and procedural skills, assembled into categories by a panel of experts (airway, trauma, neuro, differential diagnosis, administrative, infection, critical care, environmental, other). Data were analyzed with analysis of variance (ANOVA) and nonparametric statistics at P<.05. Confidence was highest in the trauma, administrative, and airway categories, and lowest in the infection, differential diagnosis, and neuro categories (P<.05 or less). Categories indicating the greatest need for additional training were environmental and critical care, while those indicating lowest need were the airway and trauma categories (P=.05). Additional training was endorsed by >75% of participants in each category. SOF medics also wanted additional training in all areas, preferably hands-on with live patients in realistic scenarios, taught by experienced medics. Findings highlight the training needs of SOF medics and demonstrate the value of bottom-up feedback toward optimizing sustainment training. Based on present findings, two TACMED (Tactical Medicine) Divisions at the SOF Echelon III level were created to meet the sustainment training needs of SOF medics.

Introduction: Mass casualty events (MASCALs) in the combat environment, which involve large numbers of casualties that overwhelm immediately available resources, are fundamentally chaotic and dynamic and inherently dangerous. Formal triage systems use diagnostic algorithms, colored markers, and four or more named categories. We hypothesized that formal triage systems are inadequately trained and practiced and too complex to successfully implement in true MASCAL events. This retrospective analysis evaluates the real-world application of triage systems in prehospital military MASCALs and other aspects of MASCAL management.

Methods: We surveyed Special Operations Forces (SOF) medics known to us who have participated in military prehospital MASCALs and analyzed them. Aggregated data describing the scope of the incidents, the use of formal triage algorithms and colored markers, the number of categories, and the interventions on scene were analyzed using descriptive statistics, and lessons learned were consolidated.

Results: From 1996 to 2022 we identified 29 MASCALs that were managed by military medics in the prehospital setting. There was a median of three providers (range 1-85) and 15 casualties (range 6-519) per event. Four or more formal triage categories were used in only one event. Colored markers and formal algorithms were not used. Life-saving interventions were performed in 27 of 29 (93%) missions and blood transfusions were performed in four (17%) MASCALs. The top lessons learned were: 1) security and accountability are cornerstones of MASCAL management; 2) casualty movement is a priority; 3) intuitive triage categories are the default; 4) life-saving interventions are performed as time and tactics permit.

Conclusion: Formal triage systems requiring the use ofdiagnostic algorithms, colored tags, and four or five categories are seldom implemented in real-world military prehospital MASCAL management. The training of field triage should be simplified and pragmatic, as exemplified by these instances.

Rapid and effective tourniquet application is crucial in life-threatening limb hemorrhage to minimize mortality. However, the widespread availability of counterfeit tourniquets is a growing concern, as these devices may lack essential quality control measures, potentially compromising patient care. We describe one case where the delayed mechanical failure of a Combat Application Tourniquet (CAT)-like tourniquet caused the death of a Ukrainian soldier during evacuation to an urban trauma center. In April 2022, a 19-year-old male underwent a bilateral below-the-knee amputation from an antipersonnel landmine. Massive hemorrhage prompted the use of bilateral CAT-like tourniquets. During transportation, the right tourniquet's windlass broke, resulting in a brisk hemorrhage. Due to the high patient-to-healthcare-personnel ratio, the bleeding remained unaddressed for an unknown amount of time, resulting in death from hemorrhagic shock. This study underscores the need for robust quality control measures and the establishment of strict regulations against deploying counterfeit tourniquets to avoid preventable deaths.

In the third installment of the "Lest We Forget" series, the authors discuss a critical advance-vascular repair, pioneered by Dr. Carl Hughes-in the care of the war-wounded during the Korean War. This article reviews the management of large vessel injuries in wartime, the challenges and advances in military medicine during the Korean War, and the application of these lessons to current practices.

Building on our strategic framework and operational model, we will discuss findings from our ethnographic study entitled, "The Impact of Catastrophic Injury Exposure on Resilience in Special Operations Surgical Teams (SOST)." Our goal is to establish that medical-martial creativity supports Special Operation Forces (SOF) medics' ability to fluidly modulate pressure amid real-time military medical decision-making in austere environments. We will use qualitative quotes to explore how SOST medics express medical-martial creativity in support of unconventional resilience. We continue to highlight tactical engagement by using bag sets as a metaphor for understanding the practical performance of this social determinant. To achieve our goals, we will: 1) define the social determinant of medical-martial creativity and provide a brief background on creativity; 2) thematize various ways in which medical-martial creativity is optimized or degraded; and 3) relate tactical engagement with medical-martial creativity to our metaphor of bag sets. We conclude by gesturing to how medical-martial creativity enables SOF medics' ingenuity, which allows them to freely maneuver complex real-time decision-making to support SOF mission success.

Separate evidence-based, best practice guidelines and recommendations exist for the prehospital management of traumatic injuries sustained in combat settings and those encountered during high-threat civilian operational incidents. The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) Tactical Medic Program is a mature operational medicine asset supporting high-threat federal law enforcement operations. The ATF conducted an audit of its agency-issued tactical medic bags with regards to completeness, as defined by authorized medical protocols, which are aligned with current Tactical Combat Casualty Care and Tactical Emergency Casualty Care guidelines.

Lumbar paraspinal muscle compartment syndrome is an uncommon, rapidly progressive, and potentially devastating injury with fewer than 40 cases reported in the literature. It initially mimics nonemergent causes of low back pain, disproportionately affects young men, and is most often secondary to acute physical exertion. The disease process is commonly associated with rhabdomyolysis. Diagnostic tools include physical examination, measurement of lactate and creatine kinase levels, MRI, and direct compartment pressure measurement. While medical and nonoperative management strategies have been explored, the gold standard for treatment is emergent lumbar fasciotomy. Opioid and non-steroidal pain management, as well as physical therapy, are the mainstays of post-treatment recovery, with many surgical patients reporting complete symptom resolution at long-term follow-up. This article discusses the case of a 27-year-old, male, active-duty, Special Operations Aviation Soldier who presented to the emergency department and was found to have lumbar paraspinal muscle compartment syndrome.

Introduction: Maximizing the capabilities of available lowflow oxygen is key to providing adequate oxygen to prevent/treat hypoxemia and conserve oxygen. We designed a closed-circuit system that allows rebreathing of gases while scrubbing carbon dioxide (CO2) in conjunction with portable mechanical ventilators in a bench model.

Methods: We evaluated the system using two portable mechanical ventilators currently deployed by the Department of Defense-Zoll 731 and AutoMedx SAVe II-over a range of ventilator settings and lung models, using 1 and 3L/min low-flow oxygen into a reservoir bag. We measured peak inspired oxygen concentration (FiO2), CO2-absorbent life, gas temperature and humidity, and the effect of airway suctioning and ventilator disconnection on FiO2 on ground and at altitude.

Results: FiO2 was =0.9 across all ventilator settings and altitudes using both oxygen flows. CO2-absorbent life was >7 hours. Airway humidity range was 87%-97%. Mean airway temperature was 25.4°C (SD 0.5°C). Ten-second suctioning reduced FiO2 22%-48%. Thirtysecond ventilator disconnect reduced FiO2 29%-63% depending on oxygen flow used.

Conclusion: Use of a rebreathing system with mechanical ventilation has the potential for oxygen conservation but requires diligent monitoring of inspired FiO2 and CO2 to avoid negative consequences.