Page 8 - JSOM Winter 2019

CASE REPORTS and a high rate of prehospital death at approximately 97% of
The Combined Joint Special Operations Task Force-Afghanistan combat deaths. The data also demonstrate relatively few cases of
Surgeon partnered with the Afghan National Army Special Opera- long-term disability from ANASOC soldiers wounded in action.
tions Command (ANASOC) Surgeon to complete medical screen- In Leveraging Combat Casualty Reporting in the Afghan National
ing of a repatriated ANASOC soldier following a 2019 combined Army Special Operations Command for Evidence-Based Changes
raid on a Taliban prison that freed 35 prisoners of war (POWs). in the ANASOC School of Excellence, the authors used these
Medical Screening of a Repatriated Afghan National Army Special conclusions to create a Combined Joint Special Operations Task
Operations Command Prisoner of War discusses the presentation Force-Afghanistan (CJSOTF-A) working group that recommended
and management of the ANASOC POW while also providing a changes to the medical curriculum at the ANASOC School of Ex-
literature review of common pathologies within the POW popula- cellence. These recommendations centered on an increased empha-
tion. The purpose of this document is to address a unique aspect sis on bleeding control to prevent death from hemorrhagic shock.
of military medicine in the expectation that future military pro-
viders are prepared to receive repatriated soldiers and prepared to Treating hemorrhagic shock is challenging, the pathology is com-
care for fellow prisoners should they themselves become captured. plex, and time is critical. Treatment requires resources in mental
bandwidth (i.e., focused attention), drugs and blood products,
Shewanella algae is a unique bacterium largely documented in equipment, and personnel. Providers must focus on treatment
skin and soft tissue infections (SSTIs) with a wide range of pre- options in order of priority while also maintaining a dynamic as-
sentations from gas-producing necrotizing fasciitis to osteomyeli- sessment of the patient’s response to treatment and considering
tis. Seawater exposure to lower extremity ulcers and wounds is potential differential diagnoses. In this process, the cognitive load
most often correlated with infection, which has been documented is substantial. To avoid errors of clinical reasoning and practical
in causing complications of bacteremia, sepsis, and infective en- errors of commission, omission, or becoming fixated, it is neces-
docarditis. Further complicating treatment is poor response to sary to use evidence-based treatment recommendations that are
most empiric regimens prior to definitive diagnosis and an un- concise, in priority order, and easily recalled. This is particularly
even response to antibiotics, including documented resistance to the case in the austere, remote, or tactical environment. A simple
carbapenem. Severe Lower Body Swelling and Bacteremia Sec- mnemonic acronym, SMART, is presented in Getting “SMART” on
ondary to Shewanella algae Bacteremia During Basic Underwater Shock Treatment: An Evidence-Based Mnemonic Acronym for the
Demolition SEAL Training documents the presentation of a Basic Initial Management of Hemorrhage in Trauma.
Under water Demolition SEAL (BUD/S) training candidate who
presented acutely for complaints of severe lower body swelling Performance enhancement coaching poses significant benefits
and abrasions during “Hell Week” and was found to have poly- to individuals and organizations, such as improved job satisfac-
microbial bacteremia with Staphylococcus aureus, Enterococcus, tion and goal achievement. Given their training and experience
and S algae. in assessment and feedback, operational psychologists assigned
to Special Operations units are uniquely positioned to provide
TCCC CRITICAL DECISION CASE STUDIES performance enhancement coaching tailored to Operators and
1 August 2018 enablers. Performance Enhancement Assessment and Coaching
in US Army Special Operations: Rapidly Enhancing Performance
Through Targeted, Tailored Feedback details a preliminary pro-
FEATURE ARTICLES gram evaluation was conducted of the Performance Enhancement
2019 Recommended Limb Tourniquets in Tactical Combat Casualty Assessment and Coaching Program. Performance enhancement
Care: Military and civilian trauma can be distinctly different but coaching delivers considerable value for Special Operations per-
the leading cause of trauma deaths in the prehospital environment, sonnel and their organizations in relatively minimal time. Oper-
extremity hemorrhage, does not discriminate. The current paper ational psychologist coaches assigned to Special Operations units
is the most comprehensive review of limb tourniquets employable can leverage their assessment skills to provide targeted, tailored
in the tactical combat casualty care environment and provides the performance enhancement coaching and increase value to their
first update to the CoTCCC-recommended limb tourniquets since organizations.
2005. This review also highlights the lack of unbiased data, of-
ficial reporting mechanism, and official studies with established The Potential Use of the Abdominal Aortic Junctional Tourniquet
®
criteria for evaluating tourniquets. Upon review of the data, the in a Military Population: A Review of Requirement, Effectiveness,
CoTCCC voted to update the recommendations in April 2019. and Usability: Resuscitative endovascular balloon occlusion of the
aorta is an often-quoted potential solution; however, this invasive
In Interoperable Readiness to Use Tourniquets by One’s Familiarity strategy requires a high skill level alongside a significant failure
With Different Models, the authors conclude that “The user’s fa- and complication rate. The Abdominal Aortic Junctional Tourni-
®
miliarity with the tourniquet model was associated with improved quet (AAJT) is a noninvasive potential adjunct for the manage-
interoperability including a timesaving benefit. If multiple models ment of hemorrhage below the level of the aortic bifurcation with
are fielded, then organizations may plan on extra spending, sup- published case reports of successful use in prehospital blast and
plying, training, and managing.” gunshot wounds. The evidence surrounding the AAJT is reviewed,
and potential uses in the military setting are suggested.
The Afghan National Army Special Operations Command
( ANASOC) uses several documents for casualty reporting. By an- Intravenous (IV) tranexamic acid (TXA) is an adjunct for resusci-
alyzing these documents from a period of March to December tation in hemorrhagic shock; however, IV access in these patients
2018, the authors demonstrate the predominance of gunshot fa- may be difficult or impossible. Intraosseous (IO) or intramuscu-
talities within ANASOC at approximately 63% of combat deaths lar (IM) administration could be quickly performed with minimal

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