Page 41 - JSOM Summer 2025

the gunner’s hatch in –40°C (–40°F) temperatures. He is indefinitely as long as reliable power is available. The device
litter-bound, unresponsive to verbal stimuli, and his core is often used in conjunction with a five-gallon bucket to im-
temperature is 31.7°C (89.2°F). A hypothermia wrap is con- merse the frozen extremity in the heated circulating water
structed with his sleep system and an HPMK, and warmed bath. Bleach may be used at 0.5–2ppm (mg/L) to mitigate bac-
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IV crystalloids are provided. Ambient temperatures in the terial growth during prolonged periods of preheated water.
Role 1 are 4°C (40°F), and after one hour of treatment, the Aloe vera and ibuprofen may also be stored with the sous vide
casualty’s condition has minimally improved. in the five-gallon bucket for an all-in-one freezing cold injury
(FCI) kit (Figure 2). The sous vide device is the standard of
Hypothermia treatment capabilities are limited in organic care for frostbite in the 11th Airborne Division and multiple
equipment sets. TCCC guidelines recommend using the emergency departments in the state of Alaska. However, like
HPMK for the prevention and treatment of cold weather inju- the Bair Hugger, it is not included in standard medical equip-
ries. The included method of active rewarming in an HPMK is ment sets, reducing access for Soldiers suffering from frostbite.
the Ready-Heat (TechTrade, Orlando, FL), a chemical 4-panel
blanket. These chemical heaters have difficulty activating as
ambient temperatures drop below –18°C (0°F). Also included
in the HPMK is a reflective vapor barrier. While acceptable
for passive rewarming, it is unlikely that endogenous thermo- FIGURE 2 An 11th Airborne
frostbite kit: A 5-gallon bucket,
genesis will be sufficient in the AoECE. This limitation can be sous vide, extension cord, and (Image courtesy of CPT David Reynhout)
exacerbated as casualties progress through echelons of care. ibuprofen. Aloe vera and bleach
The current tentage for a Role 1 or Role 2 struggles to main- may be added if available.
tain temperature in extreme cold environments. During a 2021
training exercise, a 25th Infantry Division Role 2 never ex-
ceeded 11°C (51°F), far from the 27°C (80°F) standard for a
trauma bay. 7 Additionally, there is no standardized practice for the early
grading of freezing injury (i.e., Cauchy frostbite grading).
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The JTS hypothermia CPG recommends IV fluids, tradition- Army Regulation 40-501 provides guidance on profiling;
ally warmed to 40°C (104°F), as an adjunct treatment of hy- however, it does not integrate objective physiological metrics
pothermia. Several IV warmers have been issued in equipment to guide profile creation. Soldiers diagnosed with any degree
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sets, namely the Buddy Lite (Belmont Medical Technologies, of frostbite are placed on a permanent profile, labeling them
Billerica, MA) or Thermal Angels (Estill Medical Technologies, as at risk for future cold-weather injury regardless of clinical
Dallas, TX). Neither of these have demonstrated the ability to assessment or clinician judgment. Because of the reliance on
reach the target temperature of 40°C (104°F). A 2021 study Soldier symptom reporting for FCI, this policy inadvertently
examined four standard-issue U.S. Army IV heaters at a range allows Soldiers to preferentially withhold symptoms when
of altitudes, flow rates, and temperature fluids; none could profiles may hamper career progression. The creation of an
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reach 37°C (98.6°F). Both the Thermal Angel and Buddy FCI physiological recovery pathway that is logistically sim-
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Lite achieved 32°C (89.6°F) less than 20% of the time. With plistic yet scientifically informed will significantly improve the
current equipment, active rewarming through IV fluids is not current return-to-duty pathway.
possible. As a final option, the hypothermia CPG recommends
3M Bair Huggers (Solventum, Eden Prairie, MN) for active Descriptive ICD-10 coding, profiling, and evidence-based
rewarming. The authors have implemented these with the 2nd guidelines to oversee FCIs and non-freezing cold injuries
Brigade 11th Airborne with great success in several AoECE (NFCI) are not currently managed under a specialty center
exercises. Unfortunately, Bair Huggers are not included on the like the Army Heat Center. Establishing a high-reliability or-
Modified Table of Organization and Equipment, making their ganization for the AoECE (i.e., AoECE Injury Center) would
acquisition difficult for Arctic-aligned units. support standardizing care and data collection to inform the
force and improve DoD policy for timely disposition and force
regeneration. The United Kingdom’s Cold Injury Clinic (CIC),
Freezing and Non-freezing Cold Injury Considerations
which provides FCI and NFCI care pathways within the UK
Scenario 3 Ministry of Defence, could be a reference point for developing
A 37-year-old artilleryman presents to the brigade casu- a U.S. cold weather center.
alty collection point immediately following a mass tacti-
cal airborne operation in –29°C (–20°F) temperatures. He Freezing Cold Injury: A Proposal for Return to Duty
complains of numbness in his distal fingers. He is pro- Guidelines to Preserve the Fighting Strength
vided hand warmers and instructed to put on his arctic
mittens. He presents 48 hours later to the Role 2 with con- Scenario 4
tinued numbness, blisters, and a woody induration in his During an airborne operation with an ambient tem-
distal fingers. He is diagnosed with full-thickness frostbite perature of –27°C (–15°F), a company of paratroopers
and evacuated to the next echelon of care. is isolated overnight without appropriate cold-weather
equipment. Twenty paratroopers report a mix of hand
Operations in AoECE increase the frequency of frostbite and foot redness, numbness, and paresthesias. They are
during military operations. Off-the-shelf water-circulating initially screened by unit medics and then present to the
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food warmers, such as a sous vide, have been used successfully Role 1 for further cold-weather injury evaluation.
to treat frostbite in both civilian and military settings. 11–13 The
sous vide device can be set to the desired therapeutic tempera- Cold-weather injuries as non-battle injuries are resource- and
ture of 39–40°C (102–104°F) and maintain that temperature manpower-intensive. Identifying frostbite can be a slow and

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