An Example of 3-D Printing for Expeditionary Medicine: The Air Force Retractor.

INTRODUCTION: Future challenges for the U.S. Department of Defense (DoD) include operating in a contested environment against near-peer adversaries. Providing casualty care in an anti-access/area denial (A2/AD) region would be potentially challenged by impaired logistical ability to reconstitute supplies or adapt to evolving needs. Additive manufacturing (AM), also known as 3D printing, offers an ability to regenerate stocked items as well as modify them or even create novel products de novo. MATERIALS AND METHODS: This article discusses relevant technology and applications for deployed medical forces. Additionally, as proof of concept, we outline our design process for a novel 3D-printed surgical retractor. RESULTS: Our "Air Force Retractor" prototype highlights the potential of using AM to create or augment surgical instruments downrange. CONCLUSIONS: This paper encourages further investigation of the use of AM/3D printing downrange to create surgical instruments and medical supplies in austere, A2/AD, and other logistically challenging environments. Not only would this support regeneration of supplies, but also modification and even creation of novel products to adapt to changing needs. If 3D files could be created of common surgical instruments for print on designated resins downrange, and FDA approval obtained, an online library of files could be created for easy access to DoD members across the globe to support our nation's commitment to provide the best possible care for service members any time, any place.

Brachial plexus injury management in military casualties: who, what, when, why, and how.

The Global War on Terrorism has achieved an unprecedented 90% casualty survival rate because of far forward surgical support, rapid transport, and body armor. Despite the remarkable protection body armor affords, peripheral nerve injuries continue to occur. The brachial plexus in particular is still susceptible to penetrating trauma through the axilla as well as blunt mechanisms. We report 1,818 individuals with reported cases of peripheral nerve injury, 97 of which had brachial plexus injury incident from Operation Iraqi Freedom and Operation Enduring Freedom. We suspect that true prevalence is higher as initial focus on vascular and orthopedic reconstruction in complex shoulder injuries may overlook brachial plexus lesions. Accordingly, emergency physicians, general and orthopedic trauma surgeons, and vascular surgeons should all consider the possibility of brachial plexus and other peripheral nerve injury for early and appropriate referral to surgeons (plastic, orthopedic, or neurosurgical) for further evaluation and reconstruction. The latter group should be familiar with appropriate modern diagnostic and initial as well as salvage therapeutic options.

The rise of Chinese military medicine: opportunity for mercy ship, not gunboat, diplomacy.

Recent exchanges between the United States and China at the presidential and cabinet level have emphasized the need for an enhanced military-to-military relationship to further mutual understanding and promote cooperation. This article explores the historic context of military medical relations between the two nations as well as the rationale and opportunities for increased interaction through medical diplomacy. Specific areas for potential collaboration are discussed with recommendations for future action.

The diagnostic challenge of Hansen's disease.

Hansen's disease (HD), formerly referred to as leprosy, actively infects more than 250,000 persons worldwide, with over 2 million currently being treated for sequelae. Over 150 cases are annually reported in the U.S. Although transmission of Hansen's disease to military personnel is rare, physicians caring for those who deploy abroad should be aware of the diagnostic challenges and therapeutic aspects of the disease, as well as its implication for continued military service. Additionally, with U.S. involvement in humanitarian efforts abroad, many military physicians will encounter this condition in indigenous populations. Because of its relative rarity in the U.S. and its protean manifestations, diagnosis is generally delayed 6-12 months, leading to potentially irreversible sequelae. Therefore the clinician should be aware of the presentation of HD as well as the key steps to procuring a diagnosis. This paper reports a case of HD encountered in an active duty, native-born U.S. Air Force aviator.

Use of radial artery perforator flap from burn-injured tissues.

The hands and forearms are frequent sites of burn injury, and due to the high concentration of superficial tendons, bones, and joints, flaps are frequently needed to cover defects in these areas. We present a patient who suffered remote electrical injury to the right forearm which later developed into an open wound with exposed tendon. Successful coverage of this defect was accomplished with an islanded fasciocutaneous flap based on perforating arterial branches of the radial artery, which was harvested from an area of burn injury. Surgical treatment of hand and forearm wounds with axial pedicled flaps from areas of burn injury have been reported, but to our knowledge no reports describe the use of perforator flaps.

Radiation injury and the hand surgeon.

The human hand has been affected by ionizing radiation accidents than any other organ. Hand surgeons should understand the pathophysiology and appropriate management of various types of radiation injury. This article outlines the history and epidemiology of ionizing radiation injury to the hand, basic aspects of radiobiology, and principles of management for injury resulting from fluoroscopy, nuclear accidents or weapons, and other sources.

Military aviators, special operations forces, and causal malaria prophylaxis.

U.S. military aviators are currently restricted to the use of chloroquine or doxycycline for malaria prophylaxis. Ground forces are allowed the additional option of taking mefloquine. These medications are begun before deployment, must be taken for 4 weeks after leaving the malarious area, and primaquine must be added to the regimen the last 2 of those 4 weeks. Compliance with this regimen is often poor, especially in populations who travel abroad frequently for short periods of time. Causal malaria prophylaxis offers potential benefits of decreased length of postdeployment regimens and obviates the need for a second medication for terminal prophylaxis. Potential obstacles include adverse drug reactions, cost, and rapid development of resistance to new medications by Plasmodium species, which should be weighed against the risks to health and mission success in each deployment.