Page 83 - JSOM Fall 2020

Ketamine Administration by
Special Operations Medical Personnel During Training Mishaps

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Andrew D. Fisher, MD, LP *; Darin S. Schwartz, BSN, MSSS, PhD Student ;
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Christopher Petersen, BBA, NRP ; Stephen E. Meyer, AS, NRP, DiMM ;
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Joseph N. Thielemann, SO-ATP, FP-C ; Theodore T. Redman, MD, MPH ; Stephen Rush, MD 7
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ABSTRACT
Background: Opioids can have adverse effects on casualties Introduction
in hemorrhagic shock. In 2014, the Committee on Tactical Providing appropriate analgesia is an important aspect of car-
Combat Casualty Care (CoTCCC) recommended the use of ing for the combat wounded. For nearly 150 years dating back
ketamine at the point of injury (POI). Despite these recom- to the Civil War through the wars in Iraq and Afghanistan,
mendations the adherence is moderate at best. Poor use may the US military relied on morphine as the primary analgesic
stem from a lack of access to use ketamine during training. at the point-of-injury (POI). Opioids, particularly morphine,
The United States Special Operations Command (USSOCOM) can have adverse effects on patients in hemorrhagic shock.
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is often in a unique position, they maintain narcotics for use To change the dynamics, in 2014, the Committee on Tactical
during all training events and operations. The goal of this work Combat Casualty Care (CoTCCC) developed guidelines for
is to demonstrate that ketamine is safe and effective in both the use of ketamine at the POI. 1
training and operational environments. Methods: This was a
retrospective, observational performance improvement project Despite the CoTCCC recommendations for the use of ket-
within United States Special Operations Command and Air amine in hemorrhagic shock at the POI, the adherence is sub-
Combat Command that included the US Army’s 75th Ranger optimal. Some of the problem stems from a lack of access to
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Regiment, 160th Special Operations Aviation Regiment, and use ketamine during training creating a lack of familiarity and
US Air Force Pararescue. Descriptive statistics were used to comfort amongst medics. This may be attributable to several
calculate the doses per administration to include the inter- issues including untrusting or inexperienced medical directors
quartile range (IQR), standard deviation (SD) and the range of who are often general medical officers, to hospital pharmacies
likely doses using a 95% confidence interval (CI). A Wilcoxon and medical logisticians whose only experience with ketamine
signed-rank test was used to compare the mean pre-ketamine might be knowledge of illicit use, as well as the overall proce-
pain scores to the mean post-ketamine on a 0-to-10 pain scale. dural, regulatory and logistical challenges of obtaining proper
Results: From July 2010 to October 2017, there was a total medical items for both training and combat.
of 34 patients; all were male. A total of 22 (64.7%) received
intravenous ketamine and 12 (35.3%) received intramuscu- The United States Special Operations Command (USSOCOM)
lar ketamine and 8 (23.5%) received intranasal ketamine. is often in a unique position because they internally manage
The mean number of ketamine doses via all routes admin- most of their medical training and logistics. This allows them
istered to patients was 1.88 (SD 1.094) and the mean total to maintain narcotics for use during training events and op-
dose of all ketamine administration was 90.29mg (95% CI, erations. Limited data has shown ketamine to be efficacious
70.09–110.49). The mean initial dose of all ketamine adminis- in combat, but there are no data supporting its use in the
tration was 47.35mg (95% CI, 38.52–56.18). The median pre- military training environment. We undertook this review to
ketamine pain scale for casualties was noted to be 8.0 (IQR demonstrate that ketamine is also safe and effective in train-
3) and the median post-ketamine pain scale was 0.0 (IQR 3). ing environments. In turn, we hope to influence allowance
Conclusion: Ketamine appears to be safe and effective for use of conventional force medics to the use of ketamine during
during military training accidents. Military units should con- training events and hopefully help to improve adherence to the
sider allowing their medics to carry and use as needed.
CoTCCC guidelines during operations.
Keywords: ketamine; opioids; training; war-related injuries;
analgesia Methods
This was a retrospective, observational performance improve-
ment project within United States Special Operations Command
*Correspondence to anfisher@salud.unm.edu
1 Dr Fisher is affiliated with Medical Command, Texas Army National Guard, Austin, TX; Department of Surgery, University of New Mexico
School of Medicine, Albuquerque, NM; and Prehospital Research and Innovation in Military Expeditionary Environments (PRIME2).
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2 Mr Schwartz is affiliated with the Dreeben School of Education, University of the Incarnate Word, San Antonio, TX. Mr Petersen is affiliated
with Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; and 103rd Rescue Squadron (103 RQS), New York Air National Guard,
Westhampton Beach, NY. SSG Meyer is affiliated with the 2nd Battalion, 75th Ranger Regiment, Fort Lewis, WA. Mr Thielemann is affiliated
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with 160th Special Operations Aviation Regiment, Fort Campbell, KY. Dr Redman is affiliated with Prehospital Research and Innovation in
Military Expeditionary Environments (PRIME2); 160th Special Operations Aviation Regiment, Fort Campbell, KY; and Uniformed Services
University of the Health Sciences, Bethesda, MD. Dr Rush is affiliated with 103rd Rescue Squadron (103 RQS), New York Air National Guard,
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Westhampton Beach, NY.
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