Red line the red line: Optimizing emergency medicine physicians and surgeons collaborative roles on trauma teams.

ABSTRACT: It has long been the standard for surgical and EM teams to both be present upon patient arrival and work together for the sickest trauma patients, yielding improved outcomes. It is important to dismantle divisive perceptions, confront system constraints, and promote new strategies that optimize the engagement of trauma team members. The focus should be on the patient, whose injury care starts with prevention and extends seamlessly through prehospital, hospital and rehabilitation.The authors address several myths that impact collaborative teamwork among emergency medicine physician and surgeons.Leaders, especially at GME sites, need to foster collaborative relationships, rather than adversarial. The red line mentality is a divisive construct that should be dismantled.

The Impact of Progressive Simulation-Based Training on Tourniquet Application.

The Advanced Combat Medical Experience (ACME) is a progressive simulation-based training held for second-year medical students at the Uniformed Services University (USU). This study explored the impact of participating in ACME on students' tourniquet application skills. A panel of emergency medicine physician experts developed an assessment to evaluate the participants' performance. Trained raters then scored students' tourniquet application performance before and after participating in ACME. We conducted a Wilcoxon signed-rank test to detect any significant difference in the participants' pretest and posttest ratings as well as time it took them to apply the tourniquet. Our results indicated a significant difference in the pre- and posttest ratings of students as well as the time it took them to apply the tourniquet. This study confirms the effectiveness of progressive simulation-based education for teaching TCCC skills to military medical trainees.

Force Health Protection Education: A Pilot Approach to Applying Military Frameworks to Service Member Health Education.

Ensuring Force Health Protection (FHP) is one of the most critical priorities in the DoD; however, there is no systematic approach for individual service members to address their own FHP. This paper outlines the FHP Education workshop, a model program fielded at 3rd Special Forces Group, Fort Bragg, NC, which applies military processes, principles, and frameworks to teaching special operations forces operators and enablers how to address their own FHP by identifying and mitigating threats to health and performance in the military operational environment. The FHP Education workshop has the potential to be a well-received and impactful program that offers a proactive, whole of person, community-based preventive system aligned with the Total Force Fitness framework to enable individual service members to conduct FHP.

Total Force Fitness Summit 2021: Maximizing the Health and Well-being of Service Members and Their Families.

Total Force Fitness (TFF) is a multidomain, holistic framework that provides the Department of Defense (DoD) with the capability to assess, promote, and sustain human performance optimization across the full spectrum of components key to meeting mission requirements. On September 14 and 15, 2021, in Bethesda, MD, The Consortium for Health and Military Performance convened a second TFF Summit with the goal of promoting the mission of optimizing the health and well-being of our service members across their careers. Participants included scientists, clinicians, educators, public health professionals, and military leaders from all the services. The current operating picture of TFF within the DoD was described, and then working groups were convened to address issues related to (1) delivering full spectrum health and performance services; (2) advocacy, awareness, and empowerment; (3) research; (4) education; and (5) standardization, branding, and metrics. The outcomes of the summit included recommendations that operational leadership and a consolidated and joint approach are required for TFF to be successful, and TFF must be regarded as an integral part of the National Defense, Security, and Military Strategy. To that end, TFF should be aligned within OUSD(P&R), not the Military Health System, so it extends beyond the medical setting and fully supports mission readiness and performance. Importantly, we must be proactive and teach new recruits about the TFF holistic approach to sustain optimal performance across their careers.

Total Force Fitness Standardization: Leveraging Policy and Metrics to Inform and Accelerate Implementation.

Total Force Fitness (TFF) metrics inform leaders at every level as they develop and evaluate policies, practices, and programs that enable soldiers, airmen, sailors, marines, guardians, and operators to achieve human performance optimization in all eight domains as defined by the TFF framework. The Standardization Workgroup was a facilitated discussion breakout session among a group of uniquely informed and engaged attendees who were invited to be part of the TFF summit that was hosted in Bethesda, Maryland, on September 14 and 15, 2021. The Standardization Workgroup explored the 2018 TFF shift in perspective to consider human performance optimization in the context of a military unit's fitness for missions and identified several challenges, opportunities, and action items for improving the implementation and sustainment of TFF throughout the services. Key opportunities and recommendations synthesized from the workgroup discussion include the following: Creating true ownership of TFF by an entity with authority and engagement across the services; creating divisions of labor and assigning champion organizations with distinct areas of responsibility related to metric development, data accessibility, line-leader decision support, and data-driven policy and program review; leveraging and expanding the use of data repositories, secure data clouds, and artificial intelligence platforms to support a robust and integrated learning health and performance system; and prioritizing the operational line-leader stakeholder engagement at every stage of metric development and refinement as they are ultimately responsible for and have direct influence over the fitness of the individual service member and readiness to deploy of the military unit.

Occupational and Environmental Challenges for Women.

ABSTRACT: The prevalence of women in the global workforce is increasing. Women increasingly participate in nontraditional employment settings in previously male-dominated industries and manually intensive professions, such as military service, emergency response, health care, aviation, space, agriculture, and technical trades. Limited occupational and environmental hazard data specific to women exist for these work environments. Physiologic and biomechanical differences between sexes create unique workplace challenges specific to women. This article will summarize challenges confronting women working in nontraditional employment and identify strategies to mitigate risk within these populations.

Females Engaged in Elite Training Previously Only Open to Males: Exploring the Variables of Successful Outcomes.

To date, there has been no analysis of the skills or attributes predicting success in female trainees who undergo traditionally male elite military training. This retrospective case control study characterized variables specific to females in the Special Operations Combat Medic course. 20/39 males and 15/38 females successfully completed the course. Several objective variables of interest including height and body weight, marital status, dependents, and physical fitness scores revealed trends but marital status and dependents were the only variables that achieved statistical significance. Exploration of subjective measures also highlighted potential trends in upper body strength and personal versus behavioral issues. These variables should be explored further for applicability to altering selection criteria or adjusting training conditions to mitigate sex disparities without altering standards of performance or creating an imbalance of resource investment for intended returns. The variables identified in this sample can be explored in other populations as females are integrated in other previously closed realms of military service.

Use of the TRH Stimulation Test to Assess Long Term Changes of Thyroid Function in an Olympic Athlete.

This case report presents the utility of the thyroid-releasing hormone (TRH) stimulation test for assessing endocrine disease in athletes. On two occasions, 4 years apart (1992 and 1996), a TRH stimulation test was performed to corroborate clinical symptoms and observation. On the first occasion, the patient's symptoms were not attributed to thyroid disease. He was treated for a sinus infection with amoxicillin/clavulanate 500 mg three times per day for 1 wk. On the second occasion, thyroid disease was confirmed and treatment with 100-µg L-thyroxine was initiated. Baseline screening and TRH stimulation testing were used at both assessment time points. Baseline screen for TSH was 2.2 and 1.2 uUI·mL and stimulated TSH was at 15.2 uUI·mL at 30 min and 30.6 uUI·mL at 45 min for the first (1992) and second (1996) assessment, respectively. Patient was positive on the second visit for antithyroglobulin antibodies at 70 IU·mL (normal, 0-59 IU·mL). Three months postdiagnosis, TSH was 0.66 uIU·mL and the patient was asymptomatic. At the most recent visit, 20 years and 4 months later, no symptomology was reported and TSH was 0.55 uIU·mL A greater understanding of the interaction between stress and end organ function is warranted in occupations undergoing unique stressors.

Emergency Physicians at War.

Operation Enduring Freedom (OEF-A) in Afghanistan and Operation Iraqi Freedom (OIF) represent the first major, sustained wars in which emergency physicians (EPs) fully participated as an integrated part of the military's health system. EPs proved invaluable in the deployments, and they frequently used the full spectrum of trauma and medical care skills. The roles EPs served expanded over the years of the conflicts and demonstrated the unique skill set of emergency medicine (EM) training. EPs supported elite special operations units, served in medical command positions, and developed and staffed flying intensive care units. EPs have brought their combat experience home to civilian practice. This narrative review summarizes the history, contributions, and lessons learned by EPs during OEF-A/OIF and describes changes to daily clinical practice of EM derived from the combat environment.

Integrating Chemical Biological, Radiologic, and Nuclear (CBRN) Protocols Into TCCC Introduction of a Conceptual Model - TCCC + CBRN = (MARCHE)2.

The authors would like to introduce TCCC [Tactical Combat Casualty Care] + CBRN [chemical, biological, radiological, and nuclear] = (MARCHE)2 as a conceptual model to frame the response to CBRN events. This model is not intended to replace existing and well-established literature on CBRNE events but rather to serve as a response tool that is an adjunct to agent specific resources.

CHAMP Symposium on Androgens, Anabolic Steroids, and Related Substances: What We Know and What We Need to Know.

The Consortium of Health and Military Performance hosted a symposium in April 2015 entitled "Androgens, Anabolic Steroids, and Related Substances: What We Know and What We Need to Know" in response to concerns from the field regarding Anabolic Androgenic Steroids use by U.S. service members. The symposium was attended by military and civilian subject-matter experts in sports medicine and anabolic steroids and was held at the United Service Organizations (Naval Support Activity Bethesda) in Bethesda, Maryland. The expert panel was charged to define the way ahead in terms of androgen use, education, research, relevant policies and guidelines, and other concerns with particular relevancy to Special Operations Forces. The conference concluded with the following recommendations on these several key issues (1) connecting with users, (2) education and intervention, (3) knowledge and research gaps, and (4) establishing an information clearinghouse and clinical repository.

Androgens and Androgen Derivatives: Science, Myths, and Theories: Explored From a Special Operations Perspective.

Androgen use outside of legitimate medical therapy is a perceived concern that is drawing attention across military and specifically Special Operations Forces (SOF) communities. For leadership and the medical community to properly address the issue and relate to those individuals who are using or considering use, it will be crucial to understand the scope of the problem. Limited data suggest that the prevalence of androgen use may be increasing, and inferences made from the scientific literature suggest that SOF may be a population of concern. While risks of androgen use are well known, there are little data specific to military performance that can be applied to a rigorous risk:benefit analysis, allowing myths and poorly supported theories to perpetuate within the community. Further efforts to define the potential benefits balanced against the short- and long-term risks should be undertaken. Providers within the SOF community should arm themselves with information to engage androgen users and leadership in meaningful discussion regarding androgen use.

MEDCAN-GRO: Medical Capacity for African Nations - Growing Regional Operability A Case Study in Special Operations Forces Capacity Building.

Medical Capacity for African Nations-Growing Regional Operability (MEDCAN-GRO) is a framework for addressing healthcare engagements that are intended to provide sustainable capacity building with partner nations. MEDCAN-GRO provides SOF units with a model that can be scaled to partner nation needs and aligned with the goals of the TSOC in an effort to enhance partner nation security.

Bites, stings, and rigors: clinical considerations in African operations.

The natural health threats in Africa pose daunting clinical challenges for any provider, as evidenced by the current Ebola epidemic in West Africa, but the threat is multiplied for the Special Operations provider on the continent who faces these challenges with limited resources and the tyranny of distance. The majority of operationally significant health risks can be mitigated by strict adherence to a comprehensive force health protection plan. The simplest, yet most effective, technique for preventing mosquito-borne diseases is the prevention of mosquito bites with repellent, bed nets, and appropriate clothing in addition to chemoprophylaxis. Some of the more likely or lethal infectious diseases encountered on the continent include malaria, Chikungunya, dengue, human immunodeficiency virus, and Ebola. Venomous snakes pose a particular challenge since the treatment can be as deadly as the injury. Providers supporting African operations should educate themselves on the clinical characteristics of possible envenomations in their area while promoting snake avoidance as the primary mitigation measure. To succeed in Africa, the Special Operations provider must consider how to meet these challenges in an environment where there may not be reliable evacuation, hospitalization, or logistics channels.

This is Africa: an introduction to medical operations on the African continent.

This article regarding Special Operations Forces (SOF) medical operations in Africa is an introduction to a follow-on series of articles that will address in more detail pertinent medical topics which pertain to operations on the African continent. Medical operations in Africa require dynamic and systematic approaches that consider the myriad challenges, yet offer flexible solutions applied as situations and environments dictate. We believe this series of articles will be of high interest to readers and provide key information that will be germane to future SOF operations.

Toxic bradycardias in the critically ill poisoned patient.

Cardiovascular drugs are a common cause of poisoning, and toxic bradycardias can be refractory to standard ACLS protocols. It is important to consider appropriate antidotes and adjunctive therapies in the care of the poisoned patient in order to maximize outcomes. While rigorous studies are lacking in regards to treatment of toxic bradycardias, there are small studies and case reports to help guide clinicians' choices in caring for the poisoned patient. Antidotes, pressor support, and extracorporeal therapy are some of the treatment options for the care of these patients. It is important to make informed therapeutic decisions with an understanding of the available evidence, and consultation with a toxicologist and/or regional Poison Control Center should be considered early in the course of treatment.

Use of RIFLE criteria to predict the severity and prognosis of acute kidney injury in emergency department patients with rhabdomyolysis.

BACKGROUND: RIFLE criteria (Risk, Injury, Failure, Loss, End-stage) have not been evaluated in Emergency Department (ED) patients at risk of acute kidney injury (AKI). AKI occurs in rhabdomyolysis. STUDY OBJECTIVES: To use RIFLE criteria to stratify the severity of AKI and predict prognosis in ED patients with acute rhabdomyolysis. METHODS: This is a retrospective study of consecutive patients with rhabdomyolysis over a 44-month period. Data included ED admission anion gap, blood urea nitrogen (BUN), calcium, phosphate, potassium, urinalysis, toxicology screen, and hematocrit. Creatine kinase, creatinines, and hematocrits were followed serially. Hospital length of stay (LOS) and need for dialysis were also recorded. RESULTS: RIFLE categories were calculated for 135 patients. At admission, 60 (44%) had no AKI, 20 (15%) had Risk, 32 (24%) had Injury, and 23 (17%) had Failure. These categories were significantly associated with increasing magnitude of volume depletion, potassium, phosphate, BUN, and the anion gap. They predicted differences in LOS, dialysis, discharge creatinine, and the rate of normalization of the admission creatinine. Mortality was low (2%), as was morbidity. Only 8/132 surviving patients (6%) were discharged with a creatinine >2 mg/dL. CONCLUSIONS: The RIFLE categories correlated significantly with known markers of rhabdomyolysis and AKI. They also predicted LOS, dialysis, renal morbidity, and the timing of recovery. RIFLE criteria could be used to predict the outcome of ED patients and facilitate admission and discharge decisions.

Renal complications in oncologic patients.

Acute renal failure (ARF) can be one of the many complications associated with malignancy and, unfortunately, often harbors a worse prognosis for the afflicted patient. Insult to the kidneys can occur for a variety of reasons in the oncologic patient. This article focuses on several of these etiologies, such as tumor lysis syndrome (TLS) and thrombotic microangiopathy (TMA), which are unique threats faced by the oncologic patient.

Eschmann introducer through laryngeal mask airway: a cadaveric trial of an alternate means of rescue intubation.

STUDY OBJECTIVE: Laryngeal mask airways (LMAs) are often used as airway rescue devices where laryngoscopy is difficult. The LMA does not protect the airway and is preferably replaced with a cuffed endotracheal tube. There are reports of cases where an Eschmann tracheal tube introducer (ETTI) was successfully used to bridge between a standard LMA and an endotracheal tube. This project was designed to determine whether an Eschmann stylet can reliably be passed through an LMA into the trachea as a means of rescue intubation. METHODS: Nineteen emergency medicine residents and attending physicians, who were participants in a cadaveric airway course, placed and inflated a size 4 LMA (The Laryngeal Mask Company Ltd., San Diego, CA) on each of six unembalmed human cadavers in the usual fashion. They then attempted to pass a lubricated, 15 Fr, reusable, coude-tipped ETTI (Portex, Smiths Medical, Keene, NH)) through the airspace/handle of the inflated LMA. The LMA was then deflated and removed while the ETTI was held in place. Investigators then determined the location of the ETTI by laryngoscopy. RESULTS: Of 114 attempts at the rescue procedure, 59 resulted in placement of the bougie into the trachea, yielding an overall success rate of 52% (95% CI 48%-56%). There were no significant differences in performance based on level of training of residents or years of experience of attending physicians. CONCLUSIONS: While not a primary difficult airway option, the use of a ETTI as a bridge device between LMA and endotracheal tube was successful about 50% of the time.