Page 80 - JSOM Summer 2025

An Ongoing Series

GWOT Lessons Learned

Metal in Africa

David C. Cantong, BS *; Matthew A. Bergens, MR ;
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Isabella R. McKinney, BS ; Mark Shapiro, MD ;
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Ricky M. Ditzel Jr., BSHS ; Rachel E. Bridwell, MD 6
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ABSTRACT
Intra-articular metallic foreign bodies can cause both short- On Continent
and long-term outcome complications, from range of motion
limitations to plumbism. Locating retained metallic foreign During a deployment to Africa, my team conducted marks-
bodies can be challenging on physical exam alone due to un- manship training for a partner force at a flat range. I was po-
expected trajectory of the object, though ultrasound can sig- sitioned between the left and middle stations when I heard the
nificantly aid in identification, especially in resource-limited call for a medic. As a ceasefire was established, I grabbed my
environments. During a deployment to AFRICOM, a Special bag and visually inspected my teammate as he ran up to me,
Operations Forces Operator had an intra-articular round re- identifying a hole in his pants with blood. I sat him on the back
tained during marksmanship, requiring consultation with both of a Toyota Hilux, so I could better assess his injury. After lift-
medical directors and specialists and eventual removal of the ing his pant leg, I observed a small 2-cm wound on the lateral
foreign body; strong advocation for removal allowed for both side slightly below his left knee. The wound was not bleeding
preserved range of motion as well as return to duty in the de- heavily, though it was oozing blood. After exposing the whole
ployed location. leg and confirming that there was no life- threatening hemor-
rhage, my next concern was damage to bone and ligaments,
as well as intra-articular movement. After cleaning his knee,
Keywords: SOFtoSOM; shrapnel; ultrasound; resource-limited I irrigated the open area with 2L of 0.9% sodium chloride
environment; foreign body
from intravenous bags and bandaged him with Kerlix and Ace
Wrap until we got back to my clinic. I administered a combat
wound medication pack (CWMP; 1000mg acetaminophen,
Introduction
400mg moxifloxacin, and 15mg meloxicam) and conducted a
While conducting partner force weapons training, my team- telemedicine consultation with my medical director, an emer-
mate was struck by a steel fragment from a target. From the gency medicine physician, to brief my plan and discuss our
point of injury through surgery, I advocated for my patient options for wound exploration. If I were unable to reach my
and addressed his concerns by consulting with physicians and medical director, I still planned to administer a CWMP and
physical therapists. His small wound could have developed start a course of antibiotics to prevent infection. After discuss-
into an intra-articular infection necessitating evacuation, em- ing courses of action with my medical director, I used sterile
phasizing the importance of early telemedicine consultation. technique to explore the wound. Although the entrance wound
Although I had received a peripheral nerve block ultrasound was not directly on the knee, its proximity made me hesitant to
course prior to deployment, I did not use my tools in this novel expose the joint to outside infection. This could result in struc-
situation. I could have used my point-of-care ultrasound to tural damage, septic arthritis, or osteomyelitis. I was unable
locate the steel fragment in the absence of radiography. to palpate the steel fragment. After entering the wound to a
*Correspondence to david.c.cantong@gmail.com
2
1 David C. Cantong is affiliated with U.S. Army 1st Special Forces Command (Airborne), Ft. Bragg, NC. Matthew A. Bergens is a medical student
affiliated with Duke University School of Medicine. Isabella R. McKinney is affiliated with the Center for Neurotechnology and Neuro recovery,
3
Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA. Dr. Mark Shapiro, MD, FACS is an acute
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care surgeon affiliated with Ragged Edge Solutions and the U.S. Air Force Ground Surgical Teams. Ricky M. Ditzel Jr. is a medical student affili-
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ated with Rush Medical College, Chicago, IL. Dr. Rachel E. Bridwell is an emergency physician affiliated with the U.S. Army Special Operations
Aviation Command, Ft. Bragg, NC, the Department of Emergency Medicine, Madigan Army Medical Center, Joint Base Lewis- McChord, WA,
and Uniformed Services University of the Health Sciences, Bethesda, MD.
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