Experience With Prehospital Damage Control Capability in Modern Conflict: Results From Surgical Resuscitation Team Use.

BACKGROUND: Early resuscitation and damage control surgery (DCS) are critical components of modern combat casualty care. Early and effective DCS capabilities can be delivered in a variety of settings through the use of a mobile surgical resuscitation team (SRT). METHODS: Twelve years of after-action reports from SRTs were reviewed. Demographics, interventions, and outcomes were analyzed. RESULTS: Data from 190 casualties (185 human, five canine) were reviewed. Among human casualties, 12 had no signs of life at intercept and did not survive. Of the remaining 173 human casualties, 96.0% were male and 90.8% sustained penetrating injuries. Interventions by the SRT included intravascular access (50.9%) and advanced airway establishment (29.5%). Resuscitation included whole blood (3.5%), packed red blood cells (20.8%), and thawed plasma (11.0%). Surgery was provided for 63 of the 173 human casualties (36.4%), including damage control laparotomy (23.8%) and arterial injury shunting or repair (19.0%). SRTs were effectively used to augment an existing medical treatment facility (70.5%), to facilitate casualty transport (13.3%), as an independent surgical entity at a forward ground structure (9.2%), and in mobile response directly to the point of injury (6.9%). Overall survival was 97.1%. CONCLUSION: An SRT provides a unique DCS capability that can be successfully used in a variety of flexible roles.

The effects of combat-related mild traumatic brain injury (mTBI): Does blast mTBI history matter?

BACKGROUND: The effects of mild traumatic brain injury (mTBI) have received significant attention since the beginning of the conflicts in Afghanistan and Iraq. Surprisingly, little is known about the temporal nature of neurocognitive impairment, mTBI, and posttraumatic stress (PTS) symptoms following combat-related mTBI. It is also unclear as to the role that blast exposure history has on mTBI and PTS impairments and symptoms. The purposes of this study were to examine prospectively the effects of mTBI on neurocognitive performance as well as mTBI and PTS symptoms among US Army Special Operations Command personnel and to study the influence of history of blast mTBI on these effects. METHODS: Eighty US Army Special Operations Command personnel with (n = 19) and without (n = 61) a history of blast-related mTBI completed the military version of the Immediate Post-concussion Assessment Cognitive Test (ImPACT), Post Concussion Symptom Scale (PCSS), and the PTSD Checklist (PCL) at baseline as well as 1 day to 7 days and 8 days to 20 days following a combat-related mTBI. RESULTS: Results indicated that verbal memory (p = 0.002) and processing speed (p = 0.003) scores were significantly lower and mTBI symptoms (p = 0.001) were significantly higher at 1 day to 7 days after injury compared with both baseline and 8 days to 20 days after injury. PTS remained stable across the three periods. Participants with a history of blast mTBI demonstrated lower verbal memory at 1 day to 7 days after mTBI compared with participants without a history of blast mTBI (p = 0.02). CONCLUSION: Decreases in neurocognitive performance and increased mTBI symptoms are evident in the first 1 day to 7 days following combat-related mTBI, and a history of blast-related mTBI may influence these effects. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level II.

Injury epidemiology of U.S. Army Special Operations forces.

Musculoskeletal injuries have long been a problem in general purpose forces, yet anecdotal evidence provided by medical, human performance, and training leadership suggests musculoskeletal injuries are also a readiness impediment to Special Operations Forces (SOF). The purpose of this study was to describe the injury epidemiology of SOF utilizing self-reported injury histories. Data were collected on 106 SOF (age: 31.7 ± 5.3 years, height: 179.0 ± 5.5 cm, mass: 85.9 ± 10.9 kg) for 1 year before the date of laboratory testing and filtered for total injuries and those with the potential to be preventable based on injury type, activity, and mechanism. The frequency of musculoskeletal injuries was 24.5 injuries per 100 subjects per year for total injuries and 18.9 injuries per 100 subjects per year for preventable injuries. The incidence of musculoskeletal injuries was 20.8 injured subjects per 100 subjects per year for total injuries and 16.0 injured subjects per 100 subjects per year for preventable injuries. Preventable musculoskeletal injuries comprised 76.9% of total injuries. Physical training (PT) was the most reported activity for total/preventable injuries (PT Command Organized: 46.2%/60.0%, PT Noncommand Organized: 7.7%/10.0%, PT Unknown: 3.8%/5.0%). Musculoskeletal injuries impede optimal physical readiness/tactical training in the SOF community. The data suggest a significant proportion of injuries are classified as preventable and may be mitigated with human performance programs.

Residual effects of combat-related mild traumatic brain injury.

Mild traumatic brain injury (mTBI) has gained considerable notoriety during the past decade of conflict in Afghanistan and Iraq. However, the relationship between combat-related mTBI and residual mTBI symptoms, post-traumatic stress disorder (PTSD) symptoms, and neurocognitive deficits remains unclear. The purpose of the study was to compare residual mTBI and PTSD symptoms, and neurocognitive deficits among U.S. Army Special Operations Command (USASOC) personnel with diagnosed blunt, blast, and blast-blunt combination mTBIs. This study involved a retrospective medical records review of 27,169 USASOC personnel who completed a military version of the Immediate Post-Concussion Assessment Cognitive Test (ImPACT), Post-Concussion Symptom Scale (PCSS), and PTSD Checklist (PCL) between November 2009 and December 2011. Of the 22,203 personnel who met criteria for the study, 2,813 (12.7%) had a diagnosis of at least one mTBI. A total of 28% (n=410) of USASOC personnel with a history of diagnosed mTBI reported clinical levels of PTSD symptoms. Personnel with a history of diagnosed blunt (OR=3.58), blast (OR=4.23) or combination (OR=5.73) mTBI were at significantly (p=0.001) greater risk of reporting clinical levels of PTSD symptoms than those with no history of mTBI. A dose-response gradient for exposure to blast/combination mTBI on clinical levels of PTSD symptoms was also significant (p=0.001). Individuals with blast/combination mTBIs scored higher in residual mTBI (p=0.001) and PTSD symptoms (p=0.001), and performed worse on tests of visual memory (p=0.001), and reaction time (p=0.001) than those with blunt or no mTBI history. Individuals with combination mTBIs scored lower in verbal memory (p=0.02) than those with blunt mTBIs. Residual PTSD and mTBI symptoms appear to be more prevalent in personnel with blast mTBI. A dose-response gradient for blast mTBI and symptoms suggests that repeated exposures to these injuries may have lingering effects.

Special operator level clinical ultrasound: an experience in application and training.

Over the past few decades, ultrasound has evolved from a radiology and subspecialist-centric instrument, to a common tool for bedside testing in a variety of specialties. The SOF community is now recognizing the relevancy of training medics to employ this technology for multiple clinical indications in the austere operating environment. In the Fall 2008 issue of Journal of Special Operations Medicine two of the authors described the concept of training SOF medics to employ portable ultrasound as a diagnostic aid. After over two years of concerted effort, the authors trained 29 out of 40 medics of a Special Forces battalion. Retrospective analysis of the quality assurance data for ultrasound studies conducted placed the 109 studies into six categories, allowing inference of trends in clinical indication for ultrasound exams as determined by the SOF medic-ultrasonographer. The resulting distribution suggests that indications for fractures and superficial applications are as prevalent as those for focused abdominal sonography in trauma (FAST) and pneumothorax exams. This analysis focuses on Special Operator Level Clinical Ultrasound (SOLCUS), an ultrasound training curriculum specifically for SOF medics, and helps appropriately prioritize its objectives. Despite the success of this experience, there are several issues requiring resolution before being able to integrate ultrasound training and fielding into the SOF medical armamentarium.

Conspicuous angiotropism of malignant melanoma involving the brain: implications for extravascular migratory metastasis.

Angiotropism is the presence of tumor cells closely apposed to the abluminal surfaces of blood and lymphatic vessels without intravasation. Previous studies have strongly suggested that angiotropism in melanoma could be a marker for extravascular migratory metastasis, the migration of tumor cells along the external surfaces of vessels. We describe for the first time a patient with malignant melanoma of the brain most likely metastatic, which was floridly angiotropic as evidenced by extensive spread of melanoma cells along the external surfaces of brain microvessels. The location of this angiotropic melanoma in the brain, together with the analogies between extravascular migratory metastasis and the neoplastic glial invasion of the nervous system, reinforces the hypothesis of extravascular migration of melanoma cells as a means of tumor spread, particularly along the abluminal surfaces of vessels, in the brain and in other organs.