Leveling the Battlefield: Development of a Pre-Deployment Vascular Access Curriculum for the Nonsurgical Provider.

INTRODUCTION: Timely vascular access is critical, as hemorrhage is the number one cause of death on the battlefield. Anecdotal evidence in the Military Health System identified an operationally relevant procedural skills gap in vascular access, and data exist in civilian literature showing high rates of iatrogenic injuries when lack of robust procedural opportunity exists. Multiple pre-deployment training courses are available for surgical providers, but no comprehensive pre-deployment vascular access training exists for non-surgical providers. METHODS: This mixed-method review aimed to find relevant, operationally focused, vascular access training publications. A literature review was done to identify both relevant military clinical practice guidelines (CPGs) and full text articles. Reviewers also investigated available pre-deployment trainings for both surgeons and non-surgeons in which course administrators were contacted and details regarding the courses were described. RESULTS: We identified seven full-text articles and four CPGs. Two existing surgical training programs and Army, Navy, and Air Force pre-deployment training standards for non-surgeons were evaluated. CONCLUSION: A cost-effective and accessible pre-deployment curriculum utilizing reviewed literature in a "learn, do, perfect" structure is suggested, building on pre-existing structures while incorporating remotely accessible didactics, hands-on practice with portable simulation models, and live-feedback training.

Too Hot to Handle: Early Temperature Management and Unique Treatment of Hyperpyrexia in SARS-CoV2 Encephalopathy.

A 45-year-old otherwise healthy active duty male was admitted to the medical intensive care unit for severe acute respiratory syndrome-coronavirus 2 (SARS-CoV2) encephalopathy associated with hyperpyrexia. Magnetic resonance imaging findings demonstrated cytotoxic lesions primarily at the midline of the splenium of corpus callosum (CLOCC). Similar cases involving hyperpyrexia in the setting of SARS-CoV2 infection have demonstrated exceedingly high-mortality outcomes. Three mechanisms exist as to the likely underlying pathophysiology of SARS-CoV2-induced hyperpyrexia: direct brain injury, persistent immune dysregulation of cytokines, and vascular thrombosis. To date, no cases have reported imaging findings consistent with SARS-CoV2-induced brain injury leading to hyperpyrexia. Magnetic resonance imaging findings in this case, however, may finally elucidate the underlying mechanism for hyperpyrexia in this population. Magnetic resonance imaging findings in this case show diffusion restriction of the corpus callosum without evidence of any Central Nervous System (CNS) vessel abnormality. Given that hyperpyrexia has a clear association with increased mortality and morbidity in the SARS-CoV2 infected population, the decision to initiate steroids and remdesivir regardless of respiratory status was made for the concern for severe SARS-CoV2 infection as demonstrated by the CLOCC. Additional cases will be needed to assess their potential use as a radiological marker of disease burden.

A Quantitative and Qualitative Literature Analysis of the Orthopedic Surgeons' Experience: Reflecting on 20 Years in the Global War on Terror.

INTRODUCTION: After over 20 years of war in the Middle East, orthopedic injuries have been among the most prevalent combat-related injuries, accounting for 14% of all surgical procedures at Role 2/3 (R2/R3) facilities according to the DoD Trauma Registry. To further delineate the role of the deployed orthopedic surgeon on the modern battlefield, a retrospective review was performed highlighting both quantitative and qualitative analysis factors associated with orthopedic surgical care during the war in the Middle East. METHODS: A retrospective review was conducted of orthopedic surgeons in the Middle East from 2001 to 2021. A comprehensive literature search was conducted using the PubMed and Embase databases using a two-reviewer strategy. Articles were compiled and reviewed using Covidence. Inclusion criteria included journal articles focusing on orthopedic injuries sustained during the Global War on Terror (GWoT) in an adult U.S. Military population. In the event of a conflict, a third author would determine the relevance of the article. For the remaining articles, a full-text review was conducted to extract relevant predetermined quantitative data, and the Delphi consensus method was then utilized to highlight relevant qualitative themes. RESULTS: The initial search yielded 1,226 potentially relevant articles. In all, 40 studies ultimately met the eligibility criteria. With the consultation of previously deployed orthopedic surgeons at the Walter Reed National Military Medical Center, a retrospective thematic analysis of the 40 studies revealed five themes encompassing the orthopedic surgeons experience throughout GWoT. These themes include unique mechanisms of orthopedic injury compared to previous war injuries due to novel weaponry, differences in interventions depending on R2 versus R3 locations, differences in injuries from those seen in civilian settings, the maintained emphasis on humanitarian aspect of an orthopedic surgeon's mission, and lastly relation of pre-deployment training to perceived deployed success of the orthopedic surgeons. From this extensive review, we found that explosive mechanisms of injury were greatly increased when compared to previous conflicts and were the etiology for the majority of orthopedic injuries sustained. With the increase of complex explosive injuries in the setting of improved body armor and overall survival, R2/3 facilities showed an increased demand for orthopedic intervention including debridement, amputations, and external fixation. Combat injuries sustained during the GWoT differ in the complications, management, and complexity when compared to civilian trauma. "Humanitarian" cases made up a significant number of operative cases for the deployed orthopedic surgeon. Lastly, heterogeneous training opportunities were available prior to deployment (fellowship, combat extremity surgical courses, and dedicated pre-deployment training), and the most commonly identified useful training was learning additional soft-tissue coverage techniques. CONCLUSION: These major themes indicate an emphasis on pre-deployment training and the strategic positioning of orthopedic surgeons to reflect the changing landscape of musculoskeletal trauma care. Moving forward, these authors recommend analyzing the comfort and perceived capability of orthopedic surgeons in these unique military environments to best prepare for a changing operational format and the possibility of future peer-peer conflicts that will likely lead to a lack of medical evacuation and prolonged field care.

Ocular Trauma and Traumatic Brain Injury on the Battlefield: A Systematic Review After 20 Years of Fighting the Global War on Terror.

INTRODUCTION: Operations Iraqi Freedom and Enduring Freedom saw higher rates of combat ocular trauma (COT) than any past U.S. conflict. The improvised explosive device, the signature weapon of the conflicts, as well as improved personal protective equipment and combat medical care all attributed to COT being the fourth most common injury sustained by wounded U.S. service members. This review describes the epidemiology, mechanisms, and treatment patterns and discusses the relationship of traumatic brain injuries (TBIs) to ocular injuries sustained by U.S. service members during the War on Terror. MATERIALS AND METHODS: A mixed-methods review of the literature was conducted by extracting data from PubMed, Embase, and Cochrane research databases between December 15, 2020, and January 25, 2021, using the COVIDENCE review management software. RESULTS: Of 827 articles for review, 50 were deemed relevant. Articles were separated using the Birmingham Eye Trauma Terminology into open globe, closed globe, mixed/injury management only, and TBI. Seventeen articles were found to discuss data pertaining to particular databases. Overall, six articles discussed open-globe injuries in the setting of overall COT with a reported rate of 38-64%. Three articles discussed closed-globe injuries in the context of overall COT with a rate of 39-47%. Numerous articles discussed the relationship between COT and TBI. Within the Walter Reed Ocular Trauma Database, 40% of patients with ocular trauma had concomitant TBI. Additionally, the visual sequelae of ocular trauma ranged from 9% to 50% among reporting studies. Other ocular injury patterns receiving attention include neuro-ophthalmic and oculoplastic injuries. By far the most common mechanism of COT was blast injury (64-84%), with improvised explosive devices (IEDs) accounting for 51-69% of ocular injuries. Among the large reporting databases, 41-45% of COT required surgical treatment with an overall enucleation rate of 12-17%. CONCLUSIONS: The Global War on Terrorism saw an evolution in the types of ocular injuries sustained by U.S. service members compared to previous conflicts. The widespread use of IEDs led to injury patterns not encountered in previous conflicts. Weapons of today utilize blast and shrapnel as the mechanism for destruction. Sequelae such as TBIs and complicated head and neck trauma have pushed innovation in the field of ophthalmology. Improvements in medical technology and personal protective equipment have resulted in not only survival of previously life-threatening injuries, but also a greater chance of severe loss of vision. By analyzing ocular injury data from the trauma literature, improvements in education and training can lead to improvements in point-of-injury care and eye protection for the next generation of warfighters.

Analgesia and Sedation in the Prehospital Setting A Critical Care Viewpoint.

Pain is one of the most common complaints of battlefield casualties, and unique considerations apply in the tactical environment when managing the pain of wounded service members. The resource constraints commonly experienced in an operational setting, plus the likelihood of prolonged casualty care by medics or corpsmen on future battlefields, necessitates a review of analgesia and sedation in the prehospital setting. Four clinical scenarios highlight the spectrum of analgesia and sedation that may be necessary in this prehospital and/or austere environment.

Analgesia and Sedation for Tactical Combat Casualty Care: TCCC Proposed Change 21-02.

Analgesia in the military prehospital setting is one of the most essential elements of caring for casualties wounded in combat. The goals of casualty care is to expedite the delivery of life-saving interventions, preserve tactical conditions, and prevent morbidity and mortality. The Tactical Combat Casualty Care (TCCC) Triple Option Analgesia guideline provided a simplified approach to analgesia in the prehospital combat setting using the options of combat medication pack, oral transmucosal fentanyl, or ketamine. This review will address the following issues related to analgesia on the battlefield: 1. The development of additional pain management strategies. 2. Recommended changes to dosing strategies of medications such as ketamine. 3. Recognition of the tiers within TCCC and guidelines for higher-level providers to use a wider range of analgesia and sedation techniques. 4. An option for sedation in casualties that require procedures. This review also acknowledges the next step of care: Prolonged Casualty Care (PCC). Specific questions addressed in this update include: 1) What additional analgesic options are appropriate for combat casualties? 2) What is the optimal dose of ketamine? 3) What sedation regimen is appropriate for combat casualties?

A systematic review of emergency department based HIV testing and linkage to care initiatives in low resource settings.

INTRODUCTION: Only 45% of people currently living with HIV infection in sub-Saharan Africa are aware of their HIV status. Unmet testing needs may be addressed by utilizing the Emergency Department (ED) as an innovative testing venue in low and middle-income countries (LMICs). The purpose of this review is to examine the burden of HIV infection described in EDs in LMICs, with a focus on summarizing the implementation of various ED-based HIV testing strategies. METHODOLOGY AND RESULTS: We performed a systematic review of Pubmed, Embase, Scopus, Web of Science and the Cochrane Library on June 12, 2016. A three-concept search was employed with emergency medicine (e.g., Emergency department, emergency medical services), HIV/AIDS (e.g., human immunodeficiency virus, acquired immunodeficiency syndrome), and LMIC terms (e.g., developing country, under developed countries, specific country names). The search returned 2026 unique articles. Of these, thirteen met inclusion criteria and were included in the final review. There was a large variation in the reported prevalence of HIV infection in the ED population ranging from to 2.14% in India to 43.3% in Uganda. The proportion HIV positive patients with previously undiagnosed infection ranged from 90% to 65.22%. CONCLUSION: In the United States ED-based HIV testing strategies have been front and center at curbing the HIV epidemic. The limited number of ED-based studies we observed in this study may represent the paucity of HIV testing in this venue in LMICs. All of the studies in this review demonstrated a high prevalence of HIV infection in the ED and an extraordinarily high percentage of previously undiagnosed HIV infection. Although the numbers of published reports are few, these diverse studies imply that in HIV endemic low resource settings EDs carry a large burden of undiagnosed HIV infections and may offer a unique testing venue.

Funding global emergency medicine research-from seed grants to NIH support.

BACKGROUND: Funding for global health has grown significantly over the past two decades. Numerous funding opportunities for international development and research work exist; however, they can be difficult to navigate. The 2013 Academic Emergency Medicine consensus conference on global health and emergency care identified the need to strengthen global emergency care research funding, solidify existing funding streams, and expand funding sources. RESULTS: This piece focuses on the various federal funding opportunities available to support emergency physicians conducting international research from seed funding to large institutional grants. In particular, we focus on the application and review processes for the Fulbright and Fogarty programs, National Institutes of Health (NIH) Career development awards, and the Medical Education Partnership Initiative (MEPI), including tips and pathways through each application process. CONCLUSIONS: Lastly, the paper provides an index that may be used as a guide in determining whether the amount of funding provided by a grant is worth the effort in applying.

A hospital-based palliative care service for patients with advanced organ failure in sub-Saharan Africa reduces admissions and increases home death rates.

CONTEXT: Despite emerging data of cost savings under palliative care in various regions, no such data have been generated in response to the high burden of terminal illness in Africa. OBJECTIVES: This evaluation of a novel hospital-based palliative care service for patients with advanced organ failure in urban South Africa aimed to determine whether the service reduces admissions and increases home death rates compared with the same fixed time period of standard hospital care. METHODS: Data on admissions and place of death were extracted from routine hospital activity records for a fixed period before death, using standard patient daily expense rates. Data from the first 56 consecutive deaths under the new service (intervention group) were compared with 48 consecutive deaths among patients immediately before the new service (historical controls). RESULTS: Among the intervention and control patients, 40 of 56 (71.4%) and 47 of 48 (97.9%), respectively, had at least one admission (P < 0.001). The mean number of admissions for the intervention and control groups was 1.39 and 1.98, respectively (P < 0.001). The mean total number of days spent admitted for intervention and control groups was 4.52 and 9.3 days, respectively (P < 0.001). For the intervention and control patients, a total of 253 and 447 admission days were recorded, respectively, with formal costs of $587 and $1209, respectively. For the intervention and control groups, home death was achieved by 33 of 56 (58.9%) and nine of 48 (18.8%), respectively (P ≤ 0.001). CONCLUSION: These data demonstrate that an outpatient hospital-based service reduced admissions and improved the rate of home deaths and offers a feasible and cost-effective model for such settings.

Methamphetamine causes sustained depression in cerebral blood flow.

The use prevalence of the highly addictive psychostimulant methamphetamine (MA) has been steadily increasing over the past decade. MA abuse has been associated with both transient and permanent alterations in cerebral blood flow (CBF), hemorrhage, cerebrovascular accidents and death. To understand MA-induced changes in CBF, we exposed C56BL/6 mice to an acute bolus of MA (5mg/kg MA, delivered IP). This elicited a biphasic CBF response, characterized by an initial transient increase (~ 5 minutes) followed by a prolonged decrease (~ 30 minutes) of approximately 25% relative to baseline CBF--as measured by laser Doppler flowmetry over the somatosensory cortex. To assess if this was due to catecholamine derived vasoconstriction, phentolamine, an α-adrenergic antagonist was administered prior to MA treatment. This reduced the initial increase in CBF but failed to prevent the subsequent, sustained decrease in CBF. Consistent with prior reports, MA caused a transient increase in mean arterial blood pressure, body temperature and respiratory rate. Elevated respiratory rate resulted in hypocapnia. When respiratory rate was controlled by artificially ventilating mice, blood PaCO(2) levels after MA exposure remained unchanged from physiologic levels, and the MA-induced decrease in CBF was abolished. In vivo two-photon imaging of cerebral blood vessels revealed sustained MA-induced vasoconstriction of pial arterioles, consistent with laser Doppler flowmetry data. These findings show that even a single, acute exposure to MA can result in profound changes in CBF, with potentially deleterious consequences for brain function.