Military surgeon最新文献

Introduction: With the management and oversight of MTFs moving under the authority of the Defense Health Agency, coupled with a careful examination of the composition of uniformed medical personnel, it is imperative to ensure that active duty servicewomen who are in deployed settings receive timely, appropriate, and quality health care. This study sought to examine the amount and types of gynecological and obstetric care provided in the deployed setting and to examine that data by the socioeconomic and demographic characteristics of the women receiving that care.

Materials and methods: Using the Military Health System's Theater Medical Data Store, we identified women aged 15 to 54 years old who received care at a theater-based MTF between 2013 and 2020. Within our study population, we subsequently identified obstetric and gynecologic (OBGYN) health services during the study period, and ran descriptive statistics on patient demographics (age group, race, rank, and U.S. military branch of service) and OBGYN health services. Patient age was assessed at the time of data extraction and race was categorized as Black, White, Other, and Unknown. The military branch of service was categorized as Army, Navy/Marines, Air Force, and Other. Rank was used as a proxy for socioeconomic status and categorized as Junior Enlisted, Senior Enlisted, Junior Officer, Senior Officer, Warrant Officer, and Other. Multivariable logistic regressions were also conducted and used to assess the odds of OBGYN health service utilization, with all patient demographics included as predictor variables.

Results: A total of 490,482 women were identified and received OBGYN health services at theater-based MTFs between 2013 and 2020. The majority of our population consisted of women aged 25 to 34 years (56.98%), associated with a Junior Enlisted rank (39.27%) and with the Navy/Marines (37.27%). Race was severely underreported, with 51.58% associated with an unknown race; however, 20.88% of our population were White women, 16.81% were Black women, and 10.72% of women identified their race as Other. The top five diagnoses for women seen in the deployed environment were for a contraceptive prescription (12.13%), followed by sexually transmitted infection (STI) screening (8.14%), breast disorder (7.89%), GYN exam (6.86%), and menstrual abnormalities (6.35%). Compared to White women, Black women had higher odds of seeking the contraceptive prescription (3.03 OR, 2.91-3.17 95% CI), obtaining STI screening (5.34 OR, 5.16-5.54 95% CI), being seen for a breast disorder (4.88 OR, 4.71-5.06 95% CI), GYN exam (3.21 OR, 3.10-3.32 95% CI), and menstrual abnormalities (3.71 OR, 3.58-3.85 95% CI).

Conclusions: Almost consistently, senior officers were more likely to receive OBGYN services during deployment. Policymakers and health-care providers need to identify interventions to close this care gap, particularly i

We present the case of a tracheal injury that occurred during a Maze procedure performed via sternotomy that was not initially detected by ventilator air leak, but rather by the visual presence of gas bubbles escaping the trachea during chest irrigation. Careful investigation and machine check did reveal a subsequent air leak that would have otherwise been overlooked. Furthermore, the use of intraoperative bronchoscopy was essential in guiding and confirming surgical repair. This case underscores the need for ongoing vigilance and suggests the utility of chest irrigation with Valsalva maneuvers after procedures performed in the vicinity of the trachea to exclude injury.

Introduction: The beneficial effect of rivastigmine, an acetylcholinesterase inhibitor (AChEi), which increases levels of acetylcholine (ACh), was first reported in 2013. This paper replicates those findings and reports sustained symptom remission.

Methods and materials: The high-frequency (HF) component of heart rate variability (HRV) is a measure of cholinergic withdrawal and was measured using a Zephyr Bioharness HR monitor, pre- and post-commencement of treatment. Data analysis was performed using Kubios HRV software. PTSD symptom severity was assessed using the Post-Traumatic Checklist-Civilian (PCL-C).

Results: Low HF HRV was observed in both patients before rivastigmine treatment and reductions in PCL-C scores paralleled increases in HF HRV values. Follow-up revealed low HF HRV values in both patients despite PCL-C scores indicating remission. Sympathetic nervous system hyperactivity was observed in one patient, just before a suicide attempt. Following rivastigmine treatment, the patient had no further suicidal ideation or attempts. Another patient reported worsening of her PTSD symptoms in the peri-menstrual period, which was abolished by rivastigmine. She also experienced symptom relapse following prolonged infections.

Conclusion: Low HF HRV has been reported in PTSD patients, but findings have been inconsistent. Cholinergic withdrawal could explain the disturbances in sleep, learning, and memory seen in PTSD patients. The relapse of symptoms following prolonged infection implicates the immune system as a possible initiator of the disorder. ACh and estrogen have anti-inflammatory properties, supporting a possible role of inflammation in initiating PTSD. The effect of rivastigmine treatment should be tested in properly controlled clinical trials.

Retaining lessons learned from Critical Care Air Transport (CCAT) missions is essential given the recent decrease in operational currency among CCAT personnel. The objective of this case series was to identify and analyze logistical lessons learned from recent critical care transports involving foreign medical treatment facilities with sufficient detail for the CCAT community to incorporate these lessons into future readiness and sustainment training. The provider from each mission submitted a mission narrative with lessons learned. A qualitative analysis of lessons learned described themes from the lessons, as well as similarities and differences from included missions. Three missions were reviewed and four distinct mission stages were identified: (1) pre-mission, (2) at U.S. aircraft, (3) away from U.S. aircraft, and (4) post-mission. Pre-mission lessons learned included the need for professional civilian attire for deployed CCAT teams and the limited availability of pre-mission clinical information. Lessons learned at the aircraft included the following: the need for flexible mission timelines, coordinate and pre-plan transitions with foreign medical teams when possible, and plan for difficult environmental conditions if flight line transfer is required. Lessons learned away from the aircraft included communication challenges between CCAT and the aircraft, contingency planning for narcotic transports, and equipment interoperability issues. Post-mission lessons learned included the need for written communication to disseminate information to the CCAT community. This case series described logistical challenges that present during transport missions involving foreign hospitals. This published series will enable dissemination to the en route care community for possible incorporation into future training.

Introduction: COVID-19 shutdowns in many research facilities across North America impacted preclinical trauma-related research and development. Shutdown limited the speed and resources available for large animal experiments necessary for advancing medical devices and technologies. However, the pandemic led to the rapid adoption and expansion of videoconferencing in social circles, workplaces, and primary care health settings. Here, we describe the use of simple videoconferencing equipment to plan and carry out 3 total weeks of large animal experiments with a large, cross-continent, interdisciplinary team testing a novel technology in swine models of noncompressible intraabdominal hemorrhage and junctional hemorrhage.

Materials and methods: Animal experiments using swine were scheduled over 3 weeks in February and March 2021 to take place in Toronto, Canada. All relevant animal protocols and COVID-19 site-specific risk assessments were completed and approved by the responsible institutional committees. Experiments were conducted by connecting 12 total research personnel from 3 sites by a simple video conferencing setup which included low-cost, high-definition webcams and standard smartphones streaming to Zoom.

Results: Video conferencing allowed for 3 weeks of trauma experiments to take place at the height of Toronto's third peak of COVID-19 cases. Up to 3 experiments were completed for models requiring 6 hours of monitoring, and up to 5 experiments were completed for models requiring 3 hours of monitoring. The large amount of digital data collected during these experiments was rapidly shared with our network of collaborators, who analyzed results and interpreted findings in real time.

Conclusions: The system described in this paper has the potential to reduce costs of trauma animal model development and allow for rapid testing and implementation of life-saving devices in settings with limited onsite personnel as experienced during the COVID-19 pandemic.

Background: Traumatic brain injury (TBI) is a significant concern to the military health system (MHS) and a signature wound of America's current conflict. To address the influx of patients with military-related TBI, the Department of Defense has partnered with the Fisher Foundation and the Intrepid Fallen Heroes Fund to establish the National Intrepid Center of Excellence and satellite network of Intrepid Spirit Centers. The purpose of this study is to review the prevalence of disease and geographic density of TBI among active duty, National Guard, reservist, and retired military populations in order to inform decision-making around the development of additional Intrepid Spirit Centers.

Methods: We used the MHS Data Repository to perform a cross-sectional examination to assess the prevalence of TBI among active duty, National Guard, reservist, and retired military personnel from fiscal years (FY) 2016 to 2019. Statistical analyses included descriptive statistics on patient demographics and the prevalence of TBI.

Results: We identified a total of 3,221,682 active duty, National Guard, reservists, and retired military personnel in the U.S. Army, Air Force, Navy, and Marine Corps during FY 2016 to 2019; 59.5% were active duty personnel, 23.1% were Retirees, and 17.4% were National Guard and reservists. A total of 72,002 were found to have a TBI-related diagnosis. Texas, North Carolina, and California had the highest case counts for TBI. High prevalence of TBI was found in Bexar County, TX, Muscogee County, GA, Okaloosa County, FL, San Diego County, CA, and Virginia Beach City, VA.

Conclusions: Additional Intrepid Spirit Centers are warranted to better meet the needs of active duty, active and inactive National Guard and reservists, and retired military personnel in locations including San Antonio, TX, and Columbus, GA. These locations currently have the medical infrastructure necessary to facilitate the care of wounded warriors and return to duty ensuring the health of the Nation's fighting force and veterans.

Introduction: Pectoralis major tendon tears are an injury pattern often treated in military populations. Although the majority of pectoralis major tendon tears occur during eccentric loading as in bench press weightlifting, military service members may also experience this injury from a blunt injury and traction force produced by static line entanglement during airborne operations. Although these injuries rarely occur in isolation, associated injury patterns have not been investigated previously.

Materials and methods: After obtaining institutional review board approval, medical records were reviewed for all patients who underwent surgical repair of a pectoralis major tendon tear sustained during static line parachuting at a single institution. Radiology imaging, operative notes, and outpatient medical records were examined to determine concomitant injury patterns for each patient identified over a 4-year study period.

Results: Twenty-five service members met the study inclusion criteria. All patients underwent presurgical magnetic resonance imaging. Of these 25 service members, 10 (40%) presented with a total of 13 concomitant injuries identified on physical exams or imaging studies. The most common associated injuries were injuries to the biceps brachii and a partial tear of the anterior deltoid. Biceps brachii injuries consisted of muscle contusion proximal long head tendon rupture, proximal short head tendon rupture, partial muscle laceration, and complete muscle transection. Additional concomitant injuries included transection of coracobrachialis, a partial tear of the inferior subscapularis tendon, antecubital fossa laceration, an avulsion fracture of the sublime tubercle, and an avulsion fracture of the coracoid process.

Conclusions: Military static line airborne operations pose a unique risk of pectoralis major tendon tear. Unlike the more common bench press weightlifting tear mechanism, pectoralis major tendon tears associated with static line mechanism present with a concomitant injury in 40% of cases, with the most common associated injury occurring about the biceps brachii. Treating providers should have a high index of suspicion for concomitant injuries when treating pectoralis major tendon tears from this specific mechanism of injury.

Introduction: Hypocalcemia at hospital presentation is associated with increased mortality in trauma patients with hemorrhagic shock. The 2019 updates to the Joint Trauma System Damage Control Resuscitation (DCR) Clinical Practice Guideline recommend calcium supplementation for ionized calcium (iCa) measurements <1.2 mmol/L. Ionized calcium goals for en route critical care (ERCC) following DCR are less defined, and the impact of in-flight hypocalcemia events among critically injured combat wounded is unknown. This study aimed to describe the association between hypocalcemia and mortality for combat-wounded with brain injury and polytrauma requiring transport by Critical Care Air Transport Teams (CCATT).

Methods: We performed a secondary analysis of a retrospective cohort of patients with moderate-to-severe traumatic brain injury transported by CCATT out of combat theater between January 2007 and May 2014. Additional inclusion criteria included polytrauma and at least one documented in-flight iCa measurement. We categorized exposures based on the minimum in-flight iCa measurement as severe hypocalcemia (iCa <0.9 mmol/L), hypocalcemia (iCa 0.9-1.11 mmol/L), and never hypocalcemic (iCa ≥1.12 mmol/L). The primary outcome measure was mortality. We calculated descriptive statistics and performed multivariate logistic regression to assess the association between hypocalcemia and mortality.

Results: We analyzed 190 subjects, with a median age of 24 years (interquartile range [IQR] 21 to 29 years) and 97.7% male gender. Explosive injuries (82.1%) and gunshot wounds (6.3%) were the most common mechanisms of injury. The median injury severity score was 34 (IQR 27 to 43). During the flight, 11.6% of patients had severe hypocalcemia, and 39.5% had hypocalcemia. Among patients with any hypocalcemia measurement in-flight (n = 97), 41.2% had hypocalcemia on pre-flight iCa, 28.9% received blood products in-flight, and 23.7% received in-flight calcium supplementation. Only 32.4% of patients with hypocalcemia or severe hypocalcemia in the setting of vasopressor administration received in-flight calcium supplementation. There was no significant difference in mortality between severe hypocalcemia (9.1%), hypocalcemia (5.3%), and never hypocalcemic (3.2%) patients even after controlling for pre-flight variables.

Conclusion: In-flight hypocalcemia events were common among critically ill combat-wounded polytrauma patients transported by CCATT but were not associated with differences in mortality. Future training should emphasize the need for calcium correction among ERCC patients requiring vasopressors. Future studies with larger sample sizes of patients receiving ERCC are needed to assess the association between in-flight calcium supplementation with clinical outcomes.