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

Airway management is one of the most challenging problems in prehospital combat casualty care. Airway assessment and intervention are second only to hemorrhage control in priority in the initial treatment of trauma patients, and airway compromise continues to account for approximately 1 in 10 preventable battlefield deaths. Combat medics often provide care in no- or low-light conditions, surrounded by the chaos of combat, and with the limited dexterity that accompanies bulky body armor, gloves, and heavy equipment. Far-forward medical care is also limited by available resources, which are often only what a combat medic can fit in the aid bag. Therefore, a procedure such as airway management that currently requires a high degree of skill becomes substantially more complex. Improved airway devices are listed among the top five in a comprehensive list of battlefield research and development priorities by the Defense Health Board, yet the challenge of airway management has received little investment compared to other causes of preventable battlefield death such as exsanguinating hemorrhage and traumatic brain injury.

Pulmonary contusions are a common injury in both military and civilian trauma patients. In austere and resource-limited settings common to deployment, military physicians may be limited on their ability diagnose or differentiate this entity from other traumatic injuries. We describe the use of ultrasound for the identification of pulmonary contusion in a patient with a gunshot wound while performing an extended Focused Assessment with Sonography (eFAST). The utility of ultrasound in polytraumatic patients stretches far beyond the initial FAST exam and can drastically inform clinical decision making and treatment.

Background: Failed airway management is the second leading cause of preventable death on the battlefield. The prehospital trauma registry (PHTR) after action-review (AAR) allows for unique perspectives and an enhanced analysis of interventions performed. We analyzed AAR comments related to airway interventions performed in deployed settings to examine and identify trends in challenges related to airway management in combat.

Design and methods: We analyzed all AAR comments included for airway interventions reported in the Joint Trauma System PHTR. We applied unstructured qualitative methods to analyze themes within these reports and generated descriptive statistics to summarize findings related to airway management.

Results: Out of 705 total casualty encounters in the PHTR system between January 2013 and September 2014, 117 (16.6%) had a documented airway intervention. From this sample, 17 (14.5%) had accompanying AAR comments for review. Most patients were identified as host nation casualties (94%, n =16), male (88%, n = 15), and prioritized as urgent evacuation (100%, n = 17). Twenty-five airway interventions were described in the AAR comments, the most being endotracheal intubation (52%, n = 13), followed by ventilation management (28%, n = 7), and cricothyroidotomy (12%, n = 3). Comments indicated difficulties with surgical procedures and suboptimal anatomy identification.

Conclusions: AAR comments focused primarily on cricothyroidotomy, endotracheal intubation, and ventilation management, citing needs for improvement in technique and anatomy identification. Future efforts should focus on training methods for these interventions and increased emphasis on AAR completion.

Introduction: Retrobulbar hemorrhage (RBH) occurs in only 0.45% of ocular trauma, but failure to provide timely lateral canthotomy and cantholysis (LCC) risks permanent visual deficits. With ocular trauma rates as high as 8.5-10% amongst modern combat injuries, and more than 2,000 severe eye injuries documented over a 10 year span, this concern increases.12-15 However, given infrequent RBH occurrence in the non-combat environment, emergency medicine residents trained in stateside settings may not receive adequate LCC exposure prior to military deployment. Simulators should be evaluated for procedural confidence compared to expensive and cumbersome traditional live tissue training (LTT) options. We seek to compare procedural confidence and usability of emergency medicine military residents performing LCC on a novel simulator to those using LTT.

Methods: This study randomized 32 emergency physician and physician assistant residents to perform LCC on a simulator or LTT model. All received a standardized brief on RBH recognition and LCC, then completed an 11-question survey using a 100-mm visual numerical rating scale about their ability to correctly identify RBH and perform LCC. The survey was repeated after LCC completion. All volunteers additionally completed a 10-question survey utilizing a 5-point Likert scale on the usability of the model to which they were randomized.

Results: No significant difference in reported confidence changes between groups was found; however, significant increases were found across all reported confidence measures between pre- and post-trainer use in the overall sample population. LCC simulator users reported significantly higher usability in 7 of 10 ratings.

Conclusion: The lack of a statistically significant difference between groups in procedural confidence suggests artificial LCC simulators may offer an attractive alternative to logistically-complicated porcine models. Further research is needed to evaluate non-inferiority and procedural performance.

Introduction: The Joint Readiness Training Center (JRTC) offers a laboratory for study of combat casualty care delivery during brigade-sized collective training exercises. We describe the casualty outcomes during largescale combat operations as part of a JRTC rotation.

Methods: During JRTC rotation 20-02, 2/4 Infantry Brigade Combat Team (IBCT) participated in force on force operations as part of a joint and multinational task force. Medical assets available included a Role II associated with the Brigade Support Medical Company and Role I facilities associated with six subordinate battalion elements. Observers, coaches, and trainers (OCTs) categorized all casualties as killed in action (KIA) or wounded in action (WIA). OCTs categorized WIA casualties as died of wounds (DOW) based upon time elapsed from time of injury to transportation to successive roles of care within time standards, dependent upon the severity of injuries. We portrayed our DOW rates using descriptive statistics.

Results: Force on force operations spanned 14 days. The task organization comprised 3,820 persons. Casualties included 642 KIA and 1061 WIA. Of the WIA, 502 (47.3%) dies from their wounds. The primary reason for DOW was evacuation delay from point of injury (POI) to military treatment facility (MTF) (443 casualties, 88.2%). An additional 40 casualties DOW at the Role 1 (8.0%) and 10 died at Role II (2.0%). Nine casualties (1.8%) DOW due to improper care rendered.

Discussion: Casualty DOW during simulated large-scale combat operations are overwhelmingly due to evacuation delays from POI. Medical readiness for near-peer force on force operations depends upon shared understanding across medical and non-medical personnel of casualty movement through echelons of care on the battlefield.

Background: Blood products are often a life-saving intervention for both traumatic and medical indications. The United States Indo-Pacific Command (INDOPACOM) is the largest Geographic Combat Command (GCC). Procurement of blood products that meet the US military healthcare standards throughout this region is challenging. Yet, the frequency to which this life-saving intervention is administered remains unclear. We seek to describe blood product administration throughout INDOPACOM.

Methods: This is a secondary analysis of a previously described dataset from the US Transportation Command (TRANSCOM) Regulating Command and Control and Evacuation System (TRAC2ES) from 2008 to 2018.

Results: Between 2008 and 2018, there were 4,217 cases in TRAC2ES originating within INDOPACOM, of which 173 (4%) cases involved blood product transfusion. The largest percentage for patients receiving a blood transfusion was 19-29 years old (29%), followed by patients under a year (21%). Most (66%) of the patients classified as male. Almost half of the patients (49%) were dependents of members of service in parallel with the young patient ages. Anemia (23%) and trauma (20%) , mostly non-combat related, were the largest proportions of indications. The common blood product used was packed red cells (72%) followed by fresh frozen plasma (16%).

Conclusions: Blood products were administered to nearly 1 out of every 25 patients transported within INDOPACOM, which highlights the need for reliable methods for obtaining and maintaining blood products. Given INDOPACOM's vast area of responsibility and possibility for a peer-to-peer war, finding optimal methods to transport and store blood and blood products is imperative.

For the past 25 years, the San Antonio Uniformed Services Health Education Consortium (SAUSHEC) Emergency Medicine Residency has used an end-of-shift evaluation (ESE) to provide formative feedback and assess resident progress. The instrument has evolved from a simple half-sheet of paper to a more complex electronic milestones assessment. The length and detail of the evaluation form has grown appreciably, but the precise impact of these changes on the effectiveness of formative feedback unknown. The authors present a narrative description of the evolution of this instrument in response to changing requirements and efforts to optimize its utility. Our experiences over the past quarter-century are presented in the context of now-common utilization of similar evaluation tools among emergency medicine (EM) training programs. The evolution of our ESE instrument may be of historical interest to EM educators and provide examples for those seeking to develop or adapt their own evaluation tools.

Introduction: Airway obstruction is the second leading cause of potentially preventable death on the battlefield. Endotracheal intubation is a critical skill needed by emergency military physicians to manage these patients. Our objective is to describe the development of the Defense Registry for Emergency Airway Management (DREAM) at Brooke Army Medical Center (BAMC), a level 1 trauma center over a 7-month period.

Methods: Emergency physicians (EP) performing endotracheal intubations in the BAMC emergency department (ED) completed standardized data collection forms with information about each event. Trained study team members extracted additional data from the medical records. We cross-referenced each intubation with patient tracking systems in the department and would fill in missing variables through interview with the intubating operator and/or medical records review.

Results: The study period comprised January through July 2020. During the study period emergency physicians (EP) performed a total of 74 intubations. Reasons for intubation were related to trauma for 47 patients (64%) and medical conditions for 26 patients (36%). The median age was 51 (interquartile range 30-72) and most were male 48 (65.7%). Difficult airway characteristics encountered included blood in the airway (26%), facial trauma (23%), and airway obstruction (1%). Most intubations utilized video laryngoscopy, and the most frequently used airway devices were Macintosh-shaped (45%) and hyperangulated-shaped (41%). Overall, firstpass success rate was 93% (69) with majority of intubations performed by second-year emergency residents (61%) followed by first-year residents (28%).

Conclusions: Most DREAM intubations were related to traumatic injuries. The most frequently encountered difficult airway characteristics were blood in airway and facial trauma. Most intubations were conducted using video laryngoscopy with a high first-pass success rate similar to other published studies. Expansion of the registry to other military emergency departments would enable a data-driven solution for development of individual critical task lists.

Introduction: The US Army's transition from counterinsurgency operations to preparation for large-scale combat operations is likely to bring unique access to care challenges on the battlefield. Ruggedized computer systems exist that allow forward medical personnel to establish telehealth connections with rear-based specialists. We describe our use of one such device during simulated force on force operations at the Joint Readiness Training Center (JRTC).

Methods: Our infantry brigade combat team brought a telehealth device to JRTC 20-02. The device comprised a mobile laptop and peripheral medical devices. We used the Warfighter Information Network-Tactical Increment 2 Tactical Communications Node (TCN) to establish communication between the device and external entities. We sought to establish connectivity in the Fort Polk, LA, cantonment area as part of reception, staging, onward movement, and integration operations.

Results: We successfully executed video calls from the field utilizing the telehealth device at the JRTC rear aid station and the local military treatment facility on Fort Polk, LA. We also executed calls to our home station military treatment facility on Fort Carson, CO. Each of these calls lasted approximately five minutes with sustained high-quality video and audio feeds.

Conclusions: Our experience provides proof of concept that telehealth may enable rear-based medical personnel to expand the medical capabilities of medics based forward in the battlespace. Telehealth devices may prove feasible for use with strictly tactical communications architecture in the kinetic setting of large scale combat operations.

Military working dogs (MWD) deploy with diverse tasks. Given significant utilization in Central Command (CENTCOM) for combat operations, the majority of MWD medical literature centers on combat trauma from this theater. Other commands, to include Indo-Pacific Command (INDOPACOM) and Africa Command (AFRICOM) utilize MWDs for low-intensity operations. To date, there is no analysis of medical evacuations of MWDs from the INDOPACOM and AFRICOM theaters. We seek to analyze MWD medical evacuations from these theaters utilizing the Transportation Command (TRANSCOM) Regulating and Command and Control Evacuation System (TRAC2ES).

Methods: We performed a retrospective review of all TRAC2ES medical records for MWD medical evacuations from the INDOPACOM and AFRICOM theaters conducted between January 2008 and December 2018. We abstracted free text data entry in TRAC2ES for diagnostic and therapeutic interventions performed prior to movement requests.

Results: MWD evacuations constituted 0.2% (n=10) of 4,217 documented medical evacuations from INDOPACOM and 0.3% (n=3) of 962 individually documented medical evacuations from AFRICOM. Most were routine precedence (n=8). All MWDs were evacuated for disease and non-battle injury including bone (n=4) and dental (n=2) fractures. Some had more than one provisional diagnosis and/or poly trauma. Analgesia was the most common intervention prior to evacuation (n=4).

Conclusions: MWDs accounted for a small proportion of TRAC2ES evacuations in AFRICOM and INDOPACOM theaters from 2008-2018, most due to non-battle traumatic injuries. Future studies should consider more focused MWD medical evaluations in these theaters to develop a broader understanding of medical treatment trends.