Telementorship in Underway Naval Operations: Leveraging Operational Virtual Health for Tactical Combat Casualty Care.

BACKGROUND: Virtual health (VH) may enhance mentorship to remote first responders. We evaluated the feasibility of synchronous bidirectional VH to mentor life-saving procedures performed by deployed novice providers. METHODS: Video teleconferencing (VTC) was established between the USNS Mercy (T-AH 19) underway in the Pacific Ocean to Naval Medical Center San Diego using surgeon teleconsultation. The adult simulated clinical vignette included injuries following a shipboard explosion with subsequent fire. The pediatric simulated vignette included injuries that resulted from an improvised explosive device (IED) blast. Using VTC, augmented reality (AR) goggles, and airway simulation equipment, corpsmen (HMs) received visual cues to perform advanced life-saving procedures. RESULTS: In adult scenarios, 100% of novice hospital HMs performed tasks on first attempt (n = 12). Mean time for tourniquet placement was 46 seconds (standard deviation [SD], 19 seconds); needle thoracostomy, 70 seconds (SD, 67 seconds); tube thoracostomy, 313 seconds (SD, 152 seconds); and cricothyroidotomy, 274 seconds (SD, 82 seconds). In pediatric scenarios, 100% of novice HMs performed tasks on first attempt (n = 5). Mean time for tube thoracostomy completion was 532 seconds (SD, 109 seconds). CONCLUSION: VH can enhance the training and delivery of trauma care during prolonged field care in resource-limited settings.

Carcinoma Ex-Pleomorphic Adenoma Diagnosis During Global Health Engagement Operations.

INTRODUCTION: In global health engagement settings, performance of oncologic surgery is evaluated by understanding the host nation healthcare capacity to include inpatient care support and the available postoperative adjunctive therapy to include chemotherapy and radiation therapy. MATERIALS AND METHODS: We present a case during Pacific Partnership 2018 of a patientwith a malignant facial mass diagnosed postoperatively. A literature review was conducted, searching specifically for cases related to pleomorphic adenoma (PA), carcinoma ex-PA, cases of misdiagnosis, and global health engagement operations. RESULTS: The patient presented without constitutional symptoms, clinical lymphadenopathy, or cranial nerve VII weakness with a preoperative host nation diagnosis of a benign salivary neoplasm (PA). Postoperatively, a gross total resection of the mass was diagnosed as high-grade adenocarcinoma-a carcinoma ex-PA of the parotid gland. Oncologic staging was noted to be advanced at T3N0, and the patient was referred back to the host nation surgeons for radiation oncology consultation and clinical surveillance to follow. DISCUSSION: Diagnosis of carcinoma ex-PA-a rare form of salivary gland malignancy-is not always straightforward because of its high degree of cellular heterogeneity, leading to inconsistencies in preoperative sampling results. This case addresses the preoperative diagnostic challenges associated with this type of malignancy, different types of possible treatment modalities aimed at reducing postoperative morbidity, and the preoperative and postoperative challenges that are critical to address during health engagement operations.

The role of computed tomography and magnetic resonance imaging for preoperative pediatric cochlear implantation work-up in academic institutions.

OBJECTIVE: The goal of the study is to investigate the association of pertinent preoperative temporal bone computed tomography (CT) and brain magnetic resonance imaging (MRI) results and intraoperative surgical findings and complications of pediatric cochlear implantation reported in academic settings. METHODS: This is a retrospective review of cochlear implant patients who received a pre-operative temporal bone CT and MRI of the brain between 2005 and 2012 at academic pediatric otolaryngology practices within children's hospitals in the United States and France. Scans were reviewed in a double-blind fashion and compared to intraoperative findings. RESULTS: 91 children were analyzed (mean age 5.54 +/- 0.58 years). A small facial recess identified on CT was associated with difficult insertion of electrodes (P = 0.0003). A prominent sigmoid sinus noted on CT was associated of difficult insertion of electrodes (P = 0.01), iatrogenic tegmen dehiscence (P = 0.005), as well as difficult round window access (P = 0.025). No specific CT finding was found to be associated with external auditory canal injury, perilymphatic gusher, or iatrogenic facial nerve injury. MRI brain and internal auditory canal findings were not predictive of surgical outcomes. CONCLUSIONS: Preoperative CT and MRI remain an important planning tool for pediatric cochlear implantation, particularly in academic institutions. The findings of our study demonstrate that a detailed assessment of both preoperative CT and MRI are valuable for teaching and surgical planning.

Serious Inhalation Injuries From Military Operations in Afghanistan, Iraq, and Syria.

OBJECTIVE: To characterize serious inhalation injuries seen during recent military operations, and assess whether bronchoscopic severity findings were associated with clinical presentation and outcomes. METHODS: Service members who suffered inhalation injuries while deployed to Iraq, Afghanistan, or Syria from 2001-2018 were identified using ICD-9 and 10 codes from the Expeditionary Medical Encounter Database (EMED), which is abstracted from patient records in forward-deployed medical facilities. Further information including demographics, mechanism of injury, mortality, total burn surface area (TBSA), degree of facial burn, total Injury Severity Score (ISS), and first post-injury bronchoscopy notes were collected. Patients were excluded with ISS less than 16 or without sufficient details regarding bronchoscopy. Injuries were grouped based on bronchoscopic Abbreviated Injury Scores (AIS) into low-grade (AIS of 1), moderate-grade (AIS of 2), or high-grade (AIS of 3 or 4). RESULTS: 91 patients met inclusion criteria, with no significant differences in age, gender, paygrade, or service branch between degrees of injury. There were no statistical correlations between grade of injury and battle versus non-battle injury, blast versus non-blast mechanism, TBSA, or degree of facial burn. High-grade injuries had significantly higher ISS than low or moderate-grade injuries. After adjusting for ISS, the odds ratio of death was 10.4 (95% CI 1.47 to 74.53) for those with high-grade and 3.7 (95% CI 0.45 to 32.30) for those with moderate-grade compared to low-grade injuries. CONCLUSION: In this cohort of deployed military members with inhalation injuries, initial bronchoscopic severity findings are strongly associated with mortality even after adjusting for ISS. The AIS may be an important prognostic tool in all of those with serious inhalation injuries.

Telemedicine Proof of Concept and Cost Savings During Underway Naval Operations.

Objectives: With military service members stationed around the world aboard ships and remote fixed facilities, subspecialty care frequently occurs outside of the TRICARE network, the health care program of the United States Department of Defense Military Health System, including foreign hospitals. Furthermore, usage aboard U.S. Navy ships has been limited in scope. This has direct costs associated with the medical care rendered and indirect costs such as difficulty navigating medical systems, access to records, and appropriate follow-up. Telemedicine has expanded access to otolaryngologic care where coverage has been deficient, with overall costs that are not well defined. This study aims to demonstrate the ability of consult management aboard a deployed U.S. Navy ship and to determine the direct costs associated with the use of an HIPAA-compliant, store-and-forward telemedicine system available to overseas medical providers to obtain specialty consultation at a tertiary care military treatment facility. Study Design: Retrospective case series. Methods: We reviewed consults submitted through the system from February 2018 to May 2018. Consult management was performed remotely by a deployed otolaryngologist in various locations underway and in port in the Pacific Rim. The direct cost associated with each consult was compared with the cost had the patient been treated in the host nation. Results: During the deployment, there were eight consults submitted and directed to a neurotologist/skull base surgeon for an opinion. The estimated cost for treating these patients overseas was $124,037, while the estimated cost of retaining the patients in the Military Health System was $27,330. Extrapolated to a 12-month period, the cost savings of this program could be over $400,000. Conclusions: Telemedicine consultation has the ability to be initiated and managed remotely-expanding access to subspecialty physicians by service members stationed around the world. Furthermore, it has the potential for substantial cost savings within the military health care system along with intangible benefits that sustain the military health care system downstream.

Effectiveness of an Advanced Airway Training "Boot Camp" for Family Medicine Physician Trainees.

OBJECTIVE: This course was designed to characterize the impact of a curriculum for training family medicine physicians in advanced airway techniques with respect to intubation performance and learner confidence. METHODS: A training course was introduced into the curriculum in a single-group pretest-posttest model at a community family medicine residency program. Training consisted of a didactic teaching session on airway management and hands-on skill session with direct laryngoscopy (DL) and video-assisted laryngoscopy (VAL) on normal and difficult airway simulators. Participants were scored with the Intubation Difficulty Scale and completed surveys before and after the training. RESULTS: Twenty-eight residents of all levels participated. The mean time to successful intubation was significantly decreased after training from 51.96 to 23.71 seconds for DL and from 27.89 to 17.07 seconds for VAL. Participant scores with the Intubation Difficulty Scale were also significantly improved for DL and VAL. All participants rated their comfort levels with both techniques as high following training. DISCUSSION: Advanced airway management is a critical skill for any physician involved in caring for critically ill patients, though few trainees receive formal training. Addition of an airway training course with simulation and hands-on experience can improve trainee proficiency and comfort with advanced airway techniques. IMPLICATIONS FOR PRACTICE: Training on airway management should be included in the curriculum for trainees who require the requisite skills and knowledge necessary for advanced airway interventions. This introductory project demonstrates the efficacy and feasibility of a relatively brief training as part of a family medicine residency curriculum.

The increasing cost of pediatric otolaryngology care.

INTRODUCTION: Defining the costs associated with healthcare is vital to determining and understanding ways to reduce costs and improve quality of healthcare delivery. The objective of the present study was to identify the current public health burden of inpatient admissions for conditions commonly treated by pediatric otolaryngologists and compare trends in healthcare utilization with other common surgical diagnoses. METHODS: A retrospective cohort study using the Kids' Inpatient Database for pediatric discharges in the United States from 2000 to 2012. A list of the top 500 admission diagnoses was identified and subsequently grouped into surgical diagnoses typically managed by otolaryngologists and those managed by any other surgical discipline with the top 10 in each category included. Database analyses generated national estimates of summary statistics and comparison of trends over the twelve-year period. RESULTS: Of the top pediatric admission diagnoses, the most common conditions managed by surgical specialties involved inflammatory or infectious causes. Hospital charges significantly increased during this time across all diagnoses. On average, the charges for otolaryngologic diagnoses increased by 37.13% while costs increased by almost 12%. In comparison, the charges for non-otolaryngologic diagnoses increased by 35.87% and the costs by 10.43%. CONCLUSIONS: The public health impact and rising costs of healthcare are substantial. It is of critical significance that the healthcare system be aware of opportunities and lessons that may be learned across specialties to identify the primary drivers of healthcare cost while maintaining high quality standards for patient care.

Cost and Healthcare Utilization Among Non-Elderly Head and Neck Cancer Patients in the Military Health System, a Single-Payer Universal Health Care Model.

INTRODUCTION: Examining costs and utilization in a single-payer universal health care system provides information on fiscal and resource burdens associated with head and neck cancer (HNC). Here, we examine trends in the Department of Defense (DoD) HNC population with respect to: (1) reimbursed annual costs and (2) patterns and predictors of health care utilization in military only, civilian only, and both systems of care (mixed model). MATERIALS AND METHODS: A retrospective, cross-sectional study was conducted using TRICARE claims data from fiscal years 2007 through 2014 for reimbursement of ambulatory, inpatient, and pharmacy charges. The study was approved by the Defense Health Agency Office of Privacy and Civil Liberties as exempt from institutional review board full review. The population was all beneficiaries, age 18-64, with a primary ICD-9 diagnosis of HNC, on average, 2,944 HNC cases per year. The outcomes of regression models were total reimbursed health care cost, and counts of ambulatory visits, hospitalizations, and bed days. The predictors were fiscal year, demographic variables, hospice use, type and geographic region of TRICARE enrollment, use of military or civilian care or mixed use, cancer treatment modalities, the number of physical and mental health comorbid conditions, and tobacco use. A priori, null hypotheses were assumed. RESULTS: Per annual average, 61% of the HNC population was age 55-64, and 69% were males. About 6% accessed military facilities only for all health care, 60% accessed civilian only, and 34% accessed both military and civilian facilities. Patients who only accessed military care had earlier stage disease as indicated by rates of single modality treatment and hospice use; military care only and mixed use had similar rates of combination treatment and hospice use. The average cost per patient per year was $14,050 for civilian care only, $13,036 for military care only, and $29,338 for mixed use of both systems. The strongest predictors of higher cost were chemotherapy, radiation therapy, head and neck surgery, hospice care, and mixed-use care. The strongest predictors of health care utilization were chemotherapy, use of hospice, the number of physical and mental health comorbidities, radiation therapy, head and neck surgery, and system of care. CONCLUSIONS: To a single payer, the use of a single system of care exclusively among HNC patients is more cost-effective than use of a mixed-use system. The results suggest an over-utilization of ambulatory care services when both military and civilian care are accessed. Further investigation is needed to assess coordination between systems of care and improved efficiencies with respect to the cost and apparent over-utilization of health care services.

Head and neck surgical reconstruction in Operation Iraqi Freedom and Operation Enduring Freedom-Afghanistan: A systematic review.

Historically, head and neck injuries constituted 16 to 20% of all nonfatal combat injuries. However, advances in body and vehicle armor in the context of the use of ambushes and improvised explosive devices by enemy combatants have resulted in fewer fatalities from head and neck wounds, and thus the incidence of nonfatal head and neck injuries has risen to as high as 52%. Despite this increase, data regarding specific injury distributions, surgical cases, and approaches to repair are lacking in the current literature. We conducted a study to systematically review the current literature regarding head and neck injuries and reconstructions during Operation Iraqi Freedom and Operation Enduring Freedom-Afghanistan. We found 44 articles that met our inclusion criteria. These articles covered 17,461 head and neck wounds sustained by 12,105 patients. Superficial soft-tissue facial injuries were most common wounds (31.7% of cases), followed by wounds to the neck (25.2%) and midface (17.9%). The 44 articles listed 5,122 discrete surgical reports covering 5,758 procedures. Of these procedures, simple facial laceration repairs (25.2%) and ophthalmologic surgeries (12.1%) were the most common soft-tissue repairs, and mandibular reconstructions (11.3%) were the most common type of bony reconstruction. Major flap reconstructions for coverage were required in only 0.4% of procedures. This information will be valuable for educating those involved in otolaryngology training programs, as well as civilian otolaryngologists regarding the types of injury patterns they should expect to see and treat in the returning veteran population.

Mandibular Degloving: A Case Report and Literature Review.

BACKGROUND: Degloving injuries of the extremities are well documented; however, there are few reports of degloving injuries to the mandible. A literature review demonstrates several cases of mandibular degloving in pediatric patients. However, no isolated mandibular degloving injuries have been reported in adults. CASE REPORT: We report a case of a 21-year-old male who presented to the emergency department with facial trauma after a motorcycle accident. Initial examination of the head and neck showed ecchymosis and edema overlying the left periorbital area, eye closure secondary to periorbital edema, upper eyelid and lower eyelid superficial lacerations, as well as a left oral commissural and lower intraoral lacerations. Following completion of maxillofacial computed tomography after primary and secondary survey, the intraoral lesion was found to be a degloving injury of the mandible. This injury was irrigated with bacitracin and betadine before closure. It was ultimately closed in a layered fashion with deep layers reconstructing the sheared attachments of the overlying tissue to the periosteum, followed by gingivobuccal mucosal apposition superficially. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Facial trauma is a common presentation in the emergency department. It is important that the emergency physician complete a thorough head and neck evaluation, including the oral mucosa and gingivobuccal sulcus, as mandibular degloving injuries may be occult. Without a high level of suspicion, such lesions may be missed, increasing the risk of subsequent infection and obligate healing by secondary intention leading to increased morbidity.

Does Combat Hearing Preservation Equipment Affect Balance?

OBJECTIVES: (1) To investigate whether the occlusion effect and hearing attenuation produced by 3M Combat Arms Ear Plugs (CAEP) affects balance when compared to no hearing protection and (2) to investigate whether the occlusion effect and noise-canceling capabilities of the Nacre QuietPro system affects balance when compared to no hearing protection. METHODS: This prospective study collected pilot data for investigation of mechanisms of balance. 20 subjects with normal hearing and no vestibular dysfunction were tested with blackened goggles in three conditions-no hearing protection, CAEP, and with the Nacre QuietPro. RESULTS: A static posturogrpahy forceplate was used to measure center of gravity angular acceleration for a period of 20 seconds. The order of the conditions tested was randomized for each individual. Mean angular acceleration and standard deviation (degrees/second) of the three conditions were: (1) no hearing protection (control), 0.65 + 0.19, (2) CAEP, 0.69 + 0.23, and (3) QuietPro, 0.70 + 0.20 (one-way analysis of variance [ANOVA], df = 2, F = 0.38, p = 0.706). CONCLUSIONS: The components of an intact balance system include a variety of neural inputs, to include vesitbuloocular, vestibulospinal, and labyrinthine afferents. Both the CAEP and Nacre QuietPro are hearing preservation devices utilized during Operation Iraqi Freedom and Operation Enduring Freedom in Afghanistan. Our pilot data show no decrement in balance with utilization of these combat hearing preservation devices.

Pediatric Trainees Managing a Difficult Airway: Comparison of Laryngeal Mask Airway, Direct, and Video-Assisted Laryngoscopy.

OBJECTIVE: Difficult airway management is a key skill required by all pediatric physicians, yet training on multiple modalities is lacking. The objective of this study was to compare the rate of, and time to, successful advanced infant airway placement with direct laryngoscopy, video-assisted laryngoscopy, and laryngeal mask airway (LMA) in a difficult airway simulator. This study is the first to compare the success with 3 methods for difficult airway management among pediatric trainees. STUDY DESIGN: Randomized crossover pilot study. SETTING: Tertiary academic medical center. METHODS: Twenty-two pediatric residents, interns, and medical students were tested. Participants were provided 1 training session by faculty using a normal infant manikin. Subjects then performed all 3 of the aforementioned advanced airway modalities in a randomized order on a difficult airway model of a Robin sequence. Success was defined as confirmed endotracheal intubation or correct LMA placement by the testing instructor in ≤120 seconds. RESULTS: Direct laryngoscopy demonstrated a significantly higher placement success rate (77.3%) than video-assisted laryngoscopy (36.4%, P = .0117) and LMA (31.8%, P = .0039). Video-assisted laryngoscopy required a significantly longer amount of time during successful intubations (84.8 seconds; 95% CI, 59.4-110.1) versus direct laryngoscopy (44.9 seconds; 95% CI, 33.8-55.9) and LMA placement (36.6 seconds; 95% CI, 24.7-48.4). CONCLUSIONS: Pediatric trainees demonstrated significantly higher success using direct laryngoscopy in a difficult airway simulator model. However, given the potential lifesaving implications of advanced airway adjuncts, including video-assisted laryngoscopy and LMA placement, more extensive training on adjunctive airway management techniques may be useful for trainees.

Surgery for Otitis Media in a Universal Health Care Model: Socioeconomic Status and Race/Ethnicity Effects.

OBJECTIVES: (1) To determine the association between socioeconomic status (SES), race/ethnicity, and other demographic risk factors in surgically managed otitis media within a model of universal health care. 2) To determine quality of life (QOL) outcomes of surgically managed otitis media in this model. SETTING: Tertiary academic medical center. STUDY DESIGN: Prospective cohort study. METHODS: A prospective study was conducted between June 2011 and December 2012 with dependent children of military families. TRICARE provides equal access to care among all beneficiaries regardless of a wide range of annual incomes. Caretakers of children scheduled for bilateral myringotomy and tympanostomy tube (BMT) placement were administered a demographic survey, as well as OM-6 QOL instrument preoperatively and 6 weeks postoperatively. A control group who did not undergo BMT was also administered both the survey and OM-6 for comparison. RESULTS: Two hundred forty patients were enrolled (120 surgical patients and 120 controls). Logistic regression demonstrated age younger than 6 years old (P < .001), day care attendance (P < .001), and non-Hispanic Caucasian race (P = .022) to be associated with surgery. Surgical QOL outcomes demonstrated a significant improvement in otitis media-6 (OM-6) scores after surgical management from 3.00 (95% confidence interval [CI], 2.79-3.20) to 1.35 (95% CI, 1.22-1.47). CONCLUSION: In a universal health care model serving more than 2 million children, previously reported proxies of low SES as well as minority race/ethnicity were not associated with surgically managed otitis media contrary to reported literature. Caucasian race, young age, and day care attendance were associated with surgery. Surgery improved QOL outcomes 6 weeks postoperatively.

Difficult airway management for novice physicians: a randomized trial comparing direct and video-assisted laryngoscopy.

OBJECTIVES: To detect a difference in (1) intubation success and (2) successful intubation times between novice physicians using a Macintosh-style or video-assisted laryngoscope on a difficult airway manikin. STUDY DESIGN: Prospective randomized trial. SETTING: Academic, tertiary medical center. METHODS: Forty first-year residents across a variety of disciplines with fewer than 5 total live intubations were recruited for the study. Testing took place during orientation prior to commencement of clinical duties. The entire group was provided training by faculty otolaryngologists and anesthesiologists using both laryngoscope types on a manikin airway simulator in a standard intubating scenario. Subjects were then randomized into 2 testing groups, using either a Macintosh laryngoscope or video-assisted laryngoscope in a difficult intubation scenario. The difficult airway simulation entailed oral cavity/oropharyngeal obstruction using inflation of the tongue, as well as cervical spine immobilization with a rigid collar preventing extension and elevation of the head and limiting oral cavity opening. Success was defined as a confirmed endotracheal intubation by the testing instructor in 120 seconds or less. RESULTS: The Macintosh laryngoscope group (n = 19) had an intubation success rate of 47.4% with a mean intubation time of 69.0 seconds (95% confidence interval [CI]: 52.7, 85.2). The video-assisted group (n = 21) demonstrated a significantly higher success rate of 100% (P < .0001) and a decreased mean intubation time of 23.1 seconds (95% CI: 18.4, 27.8; P < .0001). The mean difference in success rate between groups was 52.6% (95% CI: 30.0%, 75.3%). CONCLUSIONS: Novice physicians with little to no prior intubation experience showed significantly higher intubation success with lower intubation times using a video-assisted laryngoscope in a difficult airway manikin simulator.

Respiratory distress of the newborn: congenital laryngeal atresia.

Congenital laryngeal atresia is a rare cause of respiratory distress of the newborn. The defect may be isolated or occur in association with other congenital abnormalities, notably the presence of a tracheoesophageal fistula, esophageal atresia, encephalocele, or Congenital High Airway Obstructive Syndrome (CHAOS). We present the case of a newborn with no identified intrapartum abnormalities with respiratory distress at birth secondary to near-complete laryngeal atresia. Management included tracheostomy, repeated endoscopic incisions, and serial balloon dilatations employing the topical use of Mitomycin C. Seven year follow-up was significant for mobilization of the true vocal cords bilaterally, as well as successful decannulation.

Pediatric supraglottoplasty.

Laryngomalacia is the most common congenital laryngeal abnormality, as well as the most common cause of stridor in infants. Laryngomalacia presents as a wide spectrum of disease from mild noisy breathing with feeding to life-threatening airway obstruction and failure to thrive. The stridor associated with laryngomalacia is generally inspiratory in nature from supraglottic airway collapse. Supraglottoplasty refers to a group of procedures used for the surgical management of laryngomalacia. In this chapter, the authors review laryngomalacia and describe the surgical techniques of supraglottoplasty.

Investigation of breast cancer using two-dimensional MRS.

Proton (1H) MRS enables non-invasive biochemical assay with the potential to characterize malignant, benign and healthy breast tissues. In vitro studies using perchloric acid extracts and ex vivo magic angle spinning spectroscopy of intact biopsy tissues have been used to identify detectable metabolic alterations in breast cancer. The challenges of 1H MRS in vivo include low sensitivity and significant overlap of resonances due to limited chemical shift dispersion and significant inhomogeneous broadening at most clinical magnetic field strengths. Improvement in spectral resolution can be achieved in vivo and in vitro by recording the MR spectra spread over more than one dimension, thus facilitating unambiguous assignment of metabolite and lipid resonances in breast cancer. This article reviews the recent progress with two-dimensional MRS of breast cancer in vitro, ex vivo and in vivo. The discussion includes unambiguous detection of saturated and unsaturated fatty acids, as well as choline-containing groups such as free choline, phosphocholine, glycerophosphocholine and ethanolamines using two-dimensional MRS. In addition, characterization of invasive ductal carcinomas and healthy fatty/glandular breast tissues non-invasively using the classification and regression tree (CART) analysis of two-dimensional MRS data is reviewed.