Medical journal (Fort Sam Houston, Tex.)最新文献

Several published case reports describe the intentional ingestion of cyclotrimethylenetrinitramine, more commonly referred to as Composite-4 (C4), by military personnel. This putty-like explosive material, used for breaching operations, can produce euphoric effects through polyisobutylene; however, the additional ingredient of Research Department Explosive (RDX), or "Cyclonite," can cause significant central nervous system disruption resulting in seizures. We report a unique case cluster of active-duty personnel with intentional C4 ingestion and wide-ranging symptoms, including seizures. Unit personnel discovered this cluster after progressive patient presentations. This report illustrates the spectrum of C4 ingestion effects, as well as the need for investigation to ensure prompt medical evaluation and management of those suspected of consumption.

Background: Tension pneumothorax is a prominent cause of potentially survivable death on the battlefield. Field management for suspected tension pneumothorax is immediate needle thoracostomy (NT). Recent data noted higher NT success rates and ease of insertion at the fifth intercostal space, anterior axillary line (5th ICS AAL), leading to an amendment of the Committee on Tactical Combat Casualty Care recommendations on managing suspected tension pneumothorax to include the 5th ICS AAL as a viable alternative site for NT placement. The objective of this study was to assess the overall accuracy, speed, and ease of NT site selection and compare these outcomes between the second intercostal space, midclavicular line (2nd ICS MCL) and 5th ICS AAL among a cohort of Army medics.

Methods: We designed a prospective, observational, comparative study and recruited a convenience sample of US Army medics from a single military installation to localize and mark the anatomic location where they would perform an NT at the 2nd ICS MCL and 5th ICS AAL on 6 live human models. The marked site was compared for accuracy to an optimal site predetermined by investigators. We assessed the primary outcome of accuracy via concordance with the predetermined NT site location at the 2nd ICS MCL and 5th ICS MCL. Secondarily, we compared time to final site marking and the influence of model body mass index (BMI) and gender on accuracy of selection between sites.

Results: A total of 15 participants performed 360 NT site selections. We found a significant difference between participants' ability to accurately target the 2nd ICS MCL compared to the 5th ICS AAL (42.2% versus 10% respectively, p is less than 0.001). The overall accuracy rate among all NT site selections was 26.1%. We also found a significant difference in time-to-site identification between the 2nd ICS MCL and 5th ICS AAL in favor of the 2nd ICS MCL (median [IQR] 9 [7.8] seconds versus 12 [12] seconds, p is less than 0.001).

Conclusions: US Army medics may be more accurate and faster at identifying the 2nd ICS MCL when compared to the 5th ICS AAL. However, overall site selection accuracy is unacceptably low, highlighting an opportunity to enhance training for this procedure.

Ligamentous injuries of the knee occur in the military, but constitute an overwhelmingly disproportionate number of medical discharges, which can be due to prolonged recovery through traditional use of physical therapy (PT) and other non-operative modalities. The use of platelet-rich plasma (PRP) may substantially increase the speed of recovery and patient outcomes but is little explored for less common isolated ligamentous injuries, such as the lateral collateral ligament, especially in active-duty populations. We describe the use of PRP in a young, otherwise healthy active-duty male to treat an isolated LCL injury with significant positive outcomes. These findings support consideration for early use of PRP in similar cases to improve recovery timelines and aid in return to duty.

Background: The second leading cause of preventable battlefield death involves airway management. Tactical combat casualty care (TCCC) guidelines emphasize combat casualty airway, breathing and respiratory evaluation, including respiratory rate (RR) measurement. The current standard of practice for the US Army medics is to measure the RR by manual counting. Manual counting methods are operator-dependent, and medics face situational stressors limiting accurate measurement of RR in combat settings. To date, no published studies evaluate alternate methods of RR measurement by medics. The purpose of this study is to compare RR assessment by medics against waveform capnography and commercial finger pulse oximeters with continuous plethysmography.

Materials and methods: We conducted a prospective, observational study to compare Army medic RR assessments against plethysmography and waveform capnography RR. Assessments were performed prior to and following exertion at 30 and 60 seconds with both the pulse oximeter (NSN 6515-01-655-9412) and defibrillator monitor (NSN 6515-01-607-8629), followed by end-user surveys.

Results: Of the 40 medics enrolled over a 4-month period, most were male (85%), and reported between less than 5 years of military and medical experience. The mean manual RR reported by medics at rest did not significantly differ from waveform capnography (14.05 versus 13.98, p is equal to 0.523); however, mean manual RR reported by medics on post-exertional subjects was significantly lower than waveform capnography (25.62 versus 29.77, p is less than 0.001). Time to medic-obtained RR was slower than the pulse oximeter (NSN 6515-01-655-9412) both at rest (-7.37 seconds, p is less than 0.001) and at exertion (-6.50 seconds, p is less than 0.001). While the mean difference in RR between the pulse oximeter (NSN 6515-01-655-9412) and waveform capnography in models at rest at 30 seconds was statistically significant (-1.38, p is less than 0.001). There was no overall statistically significant differences in RR between the pulse oximeter (NSN 6515-01-655-9412) and waveform capnography in models at exertion at 30 seconds and at rest and exertion at 60 seconds.

Conclusion: Resting RR measurement did not differ significantly; however, medic-obtained RR considerably deviated from both pulse oximeters and waveform capnography at elevated rates. Existing commercial pulse oximeters with RR plethysmography do not differ significantly from waveform capnography and should be investigated further for consideration in fielding across the force for RR assessment.

Admissions processes for graduate health professions, including physician assistant (PA) and medical school, were built over time through trial and error. Admissions process research was not common until the early 1990s, and it seemingly began because the system of admitting applicants solely on the basis of the highest academic metrics resulted in unacceptable attrition rates. Recognizing interpersonal attributes were unique from academic metrics and critical to success in medical education, admissions interviews were added as a component of the admissions process and have since become nearly ubiquitous for medical and PA applicants. Understanding the history of admissions interviews informs ways to optimize admissions processes for the future. The PA profession was originally comprised entirely of military veterans with extensive medical training during their service; the number of service members and veterans matriculating has significantly decreased and is not reflective of the percentage of veterans in the US. Most PA programs receive applications in excess of available seats; yet, based on the 2019 PAEA Curriculum Report, the all-cause attrition rate is 7.4%. Given the large pool of applicants available to select from, it is valuable to identify students who will succeed and graduate. This is especially critical for the Interservice Physician Assistant Program, the US Military's PA program, to optimize force readiness by ensuring sufficient PAs are available. Utilizing a holistic admissions process, considered best practice in admissions, is an evidence-based way to decrease attrition and support increased diversity, including increasing the number of veterans becoming PAs, by considering the breadth of an applicant's life experiences, personal attributes, and academic metrics. The outcomes of admissions interviews are high-stakes for the program and applicants, as they are often the final step prior to admissions decisions. Additionally, there is considerable overlap between the principles of admissions interviews and job interviews, the latter of which may occur as a military PA's career unfolds and they are considered for special assignments. Though numerous different interview modalities exist, multiple mini-interviews (MMI) are highly-structured, effective, and are supportive of a holistic admissions approach. Through examining historical admissions trends, identifying a modern way to select applicants through holistic admissions can support decreased student deceleration and attrition and increased diversity, optimizing force readiness and supporting the success of the PA profession into the future.

Background: Controversy exists regarding the optimal methods of employing ultrasound to enhance vascular access. A novel user interface which dynamically displays transverse (short) and longitudinal (long) planes simultaneously was developed to optimize ultrasound-guided vascular access. This study aimed to assess the impact of this novel biplane axis technology on central venous access performance.

Methods: Eighteen volunteer emergency medicine resident physicians and physician assistants were recruited from a single center to participate in this prospective, randomized crossover study. Following a brief instructional video, participants were randomized to perform ultrasound-guided vascular access using either short-axis or biplane axis approaches first, followed by the opposite technique following a brief washout period. Time to cannulation was the primary outcome measure. Secondary outcome measures included success rate, posterior wall and arterial puncture rates, time to scout, number of attempts, number of needle redirections, participant cannulization and visualization confidence, and interface preference.

Results: Short-axis imaged approach was associated with a significantly shorter time to cannulation (34.9 seconds versus 17.6, p is less than 0.001) and time to scout (30 versus 49 seconds, p is equal to 0.008) when compared to biplaneaxis imaging approach. No significant differences were noted when comparing first pass success, number of attempts, number of redirections, and posterior wall and arterial wall puncture. Participants' cannulation/visualization confidence and axis preference both favored the short-axis imaging approach.

Conclusion: Further studies are needed to assess the clinical value of novel biplane axis ultrasound imaging in the performance of ultrasound-guided procedures.

Background: Introduction: The purpose of this review is to explore intermittent fasting (IF) versus continuous energy restriction as a treatment of Type 2 Diabetes Mellitus (T2DM). The precursor to diabetes is obesity, which currently threatens the Department of Defense's ability to retain and recruit adequate service members. Intermittent fasting may be an adjunct for prevention of obesity and diabetes in the armed forces.

Objectives: Weight loss and lifestyle modification are long-standing treatments for T2DM. The objective of this review is to compare IF to continuous energy restriction.

Methods: PubMed was searched from August 2013 to March 2022 for systematic reviews, randomized controlled trials, clinical trials, and case series. Inclusion criteria were studies which monitored HbA1C, fasting glucose levels, diagnosis of T2DM, ages 18-75, and a body mass index (BMI) greater than or equal to 25 kg/m2. Eight articles met these criteria and were selected. These 8 articles were separated into Categories A and B for this review. Category A includes randomized controlled trials (RCTs), and Category B consists of pilot studies and clinical trials.

Results: Intermittent fasting proved to have commensurate decreases in HbA1C and BMI compared to the control group, but not to a statistically significant degree. It cannot be said that IF is better than continuous energy restriction.

Conclusion: More research is needed on this topic as 1 in 11 people suffer from T2DM. The benefits of IF are apparent, but there is not enough breadth of research available to affect clinical guidelines.

A nationwide surgeon shortage, particularly with general surgeons and trauma surgeons, continues to plague the civilian and military systems readiness. To fill this shortcoming, we provide a narrative review describing current and potential uses of augmented reality and virtual reality (AR/VR) for synthetic training environments which could significantly improve the Army's wartime medical readiness through improved skills of surgeons and non-surgeon providers. Multiple studies demonstrate the potential benefits of AR/VR in cost, time, and critical medical skills for enhanced care delivery. While encouraging, the novelty and relative youth of AR/VR platforms requires further prospective validation as the data for its use as a training adjunct is limited. Nevertheless, state of the art simulated training platforms like AR/VR which mimic surgical trauma cases and review critical surgical skills could help enable a transformation of non-surgeon providers to quickly augment current surgeon personnel shortages.

Creatine supplementation has not been researched for Traumatic Brain Injury (TBI) extensively, but studies suggest potential as a neuroprotective agent and potential treatment for brain-injury complications. Patients suffering from TBI experience mitochondrial dysfunction, neuropsychological burden, and deficits in cognitive performance due to malperformance of brain creatine levels, diminished brain Adenosine Triphosphate (ATP) levels, glutamate toxicity, and oxidative stress. In this systemic review, the current available research is reviewed to examine the effects of creatine on common sequalae of TBI within children, adolescents, and mice. Past and present data still lacks the knowledge of creatine supplementation for the adult population and military members during TBI. PubMed was searched for studies which assessed the correlation between creatine supplementation of TBI complications. The search strategy yielded 40 results, of which 15 articles were included in this systemic review. The results of the review supported an apparent understanding creatine does offer an obvious benefit to patients suffering from TBI and post-injury complications under specific guidelines. Time and dose dependent metabolic alterations seem to be only exceptionally prevalent when given as a prophylaxis or if given acutely. Results are only clinically significant after a month of supplementation. Although patients may need many therapeutic treatments to recover from TBI, especially in acute resuscitation, creatine shows superior efficacy as a neuroprotective agent in battling the chronic manifestations which lead to oxidative stress and cognitive function post brain injury.

There is a significant threat to global health security due to synthetic opioids, illicitly manufactured fentanyl (IMF), and nefarious uses of pharmaceutical based agents (PBA). Since 2014, increased distribution of synthetic opioids including IMF into the US through China, India, and Mexico has resulted in devastating consequences to the average street drug user. Additionally, clandestine lab operations for pill manufacturing and distribution have increased, along with unintentional drug overdoses due to drugs being laced with fentanyl or some other synthetic opioid derivative. Naloxone has been shown to be an effective and useful tool for reversing signs and symptoms of synthetic opioid overdose, though additional doses may be required depending on the analog. In addition to the risk of overdose in US civilians, other state actors have utilized fentanyl and its analogs as incapacitants resulting in significant numbers of casualties. The National Guard Weapons of Mass Destruction-Civil Support Teams (WMD-CST) have been on the front lines supporting federal law enforcement agencies with hazard identification and assessment. Physician Assistants (PA) are assigned to these units and provide the necessary skills and expertise to keep on scene personnel safe. This article aims to dispel some of the rumors and myths surrounding fentanyl in an effort to educate first receivers, first responders, and hospital providers. Lastly, this article provides a review of synthetic opioid production, overdose, hazards, treatment/countermeasures, decontamination for responders, and the potential use of synthetic opioids as WMDs.