DTIC ADA533752: Journal of Special Operations Medicine. Volume 9, Edition 3, Summer 2009

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1. REPORT DATE 3. DATES COVERED
2009 2. REPORT TYPE 00-00-2009 to 00-00-2009
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Journal of Special Operations Medicine. Volume 9, Edition 3, Summer
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2009
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Journal of Special Operations Medicine
EXECUTIVEEDITOR MANAGING EDITOR
Deal, Virgil T. MD, FACS Landers, Michelle DuGuay, MBA, BSN
[email protected] [email protected]
MEDICALEDITOR
Gilpatrick, Scott, APA-C, DMO
ASSISTANTEDITOR CONTRIBUTINGEDITOR
Parsons, Deborah A., BSN Schissel, Daniel J., MD
(“Picture This” Med Quiz)
CME MANAGERS
Kharod, Chetan U. MD, MPH -- USUHS CME Sponsor
Officers Enlisted
Landers, Michelle DuGuay, MBA, BSN McDowell, Doug, PA-C
[email protected] [email protected]
EDITORIAL BOARD
Ackerman, Bret T., DO Holcomb, John B., MD
Anders, Frank A., MD Kauvar, David S., MD
Antonacci Mark A., MD Kersch, Thomas J., MD
Baer David G., PhD Keenan, Kevin N., MD
Baskin, Toney W., MD, FACS Kirby, Thomas R., OD
Black, Ian H., MD Kleiner Douglas M., PhD
Bower, Eric A., MD, PhD, FACP LaPointe, Robert L., SMSgt (Ret)
Briggs, Steven L., PA-C Llewellyn, Craig H., MD
Bruno, Eric C., MD Lorraine, James R., BSN
Cloonan, Clifford C., MD Lutz, Robert H., MD
Coldwell, Douglas M., PH.D., M.D. Mason, Thomas J. MD
Davis, William J., COL (Ret) McAtee, John M., PA-C
Deuster Patricia A., PhD, MPH McManus, John G., MD
Diebold, Carroll J. , MD Mouri, Michael P., MD, DDS
Doherty, Michael C., BA, MEPC, MSS Murray Clinton K., MD, FACP
Flinn, Scott D., MD Ong, Richardo C., MD
Fudge, James M., DVM, MPVM Ostergaard, Cary A., MD
Gandy, John J., MD Pennardt, Andre M., MD
Garsha, Larry S., MD Peterson, Robert D., MD
Gephart, William, PA-S Riley, Kevin F., PhD, MSC
Gerber, Fredrick E., MMAS Risk, Gregory C., MD
Giebner, Steven D., MD Rosenthal, Michael D. PT, DSc
Giles, James T., DVM Taylor Wesley M. DVM
Greydanus, Dominique J., EMT-P Tubbs, Lori A., MS, RD
Goss, Donald L.,DPT, OCS, ATC, CSCS VanWagner, William, PA-C
Godbee, Dan C., MD Wedmore, Ian S., MD, FACEP
Harris, Kevin D., DPT, OCS, CSCS Wightman, John M., EMT-T/P, MD
Hammesfahr, Rick, MD Yevich, Steven J., MD
TEXT EDITORS
Ackermann, Bret T. DO, FACEP Hesse, Robert W., RN, CFRN, FP-C
Boysen, Hans Kleiner, Douglas M.
Doherty, Michael C., BA, MEPC, MSS Mayberry, Robert, RN, CFRN, EMT-P
Gephart, William J., PA-S Parsons, Deborah A., BSN
Godbee, Dan C., MD, FS, DMO Peterson, Robert D., MD
VanWagner, William, PA-C
Journal of Special Operations Medicine Volume 9, Edition 3 / Summer 09
An18Ddewormsacamelduringa“VetCap”inShkihn,Afghanistan.
ISSN 1553-9768
FromtheEditor
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FromtheEditor
Contents
Summer 09 Volume 9, Edition 3
FEATURE ARTICLES Editorials 79
LTCCraigMyatt,PhD;DouglasC.Johnson,PhD
FieldEvaluationandManagementofNon-BattleRelated 1
KneeandAnkleInjuriesbytheATPintheAustere
Environment:PartThree
BookReviews 81
J.F.RickHammesfahr,MD
● Blackburn’sHeadhunters
NATOSOFTransformationandtheDevelopmentof 7 ● TheBattleofMogadishu:FirsthandAccountsfromtheMen
NATOSOFMedicalDoctrineandPolicy.
ofTaskForceRanger
LTCG.RhettWallace,MDFAAFP
DamageControlResuscitationfortheSpecialForces 14
FromtheUSSOCOMCommandSurgeon 86
Medic: SimplifyingandImprovingProlongedTrauma
Care:PartOne COLTomDeal
COLGregoryRiskMD;MichaelR.Hetzler18D
ComponentSurgeons 87
ReviewArticleoftheUseofEarlyHypothermiainthe
22
TreatmentofTraumaticBrainInjuries COLPeterBenson USASOC
JessArcureBS,MSc;EricE.HarrisonMD BrigGen(S)BartIddins AFSOC
EmergencyLateralCanthotomyandCantholysis: CAPTJaySourbeer NAVSPECWAR
26
ASimpleProceduretoPreserveVisionfromSight CAPTAnthonyGriffay MARSOC
ThreateningOrbitalHemorrhage
CPTStevenRoyBallard,MD;COLRobertW.Enzenauer, TSOCSurgeons 92
MD,MPH;Col(Ret)ThomasO’Donnell,MD;JamesC.
COLRockyFarr SOCCENT
Fleming,MD;COLGregoryRisk,MD,MPH,FACEP;
AaronN.Waite,MD COLFrankNewton SOCPAC
Tinnitus,aMilitaryEpidemic…IsHyperbaricOxygen 33
USASFCSurgeon 96
TherapytheAnswer?
LCDRThomasM.Baldwin,MD,MPT
LTCAndrewLanders
BrainNatriureticPeptideLevelsinSixBasicUnderwa-
44
terDemolitions/SEALRecruitsPresentingwithSwim-
NATOSurgeon 97
mingInducedPulmonaryEdema(SIPE)
LCDRDamonShearer(DMO/UMO)MD LTCRhettWallace
CDRRichardMahon(DMO/UMO)MD
USSOCOMPsychologist 99
AbstractsfromCurrent Literature 51
LTCCraigMyatt,PhD
PreviouslyPublished 59
USSOCOMVeterinarian 101
● CentralRetinalVeinOcclusioninanArmyRangerwith
Glucose-6-PhosphateDehydrogenaseDeficiency LTCBillBosworth,DVM
● ShouldWeTeachEverySoldierHowtoStartanIV?
● PsychologicalResilienceandPostdeploymentSocialSup- NeedtoKnow 104
portProtectAgainstTraumaticStressandDepressive
NavySafeHarbor
SymptomsinSoldiersReturningFromOperationsEndur-
ingFreedomandIraqiFreedom
● PsychosocialBuffersofTraumaticStress,DepressiveSymp- SOFReadingList 105
toms,andPsychosocialDifficultiesinVeteransofOpera-
tionsEnduringFreedomandIraqiFreedom:TheRoleof EducationalResources 121
Resilience,UnitSupport,andPostdeploymentSocial
Support PhotoGallery 127
Meet theJSOM Staff 129
SubmissionCriteria 130
JournalofSpecialOperationsMedicine Volume9,Edition3/Summer09
Field Evaluation and Management of Non-Battle
Related Knee and Ankle Injuries by the ATP in the
Austere Environment — Part Three
JF Rick Hammesfahr, MD
Editor’sNote: PartThreeconsistsofankleinjuryevaluationandtaping.
PartTwo(tapingproceduresforthevariouskneeinjuries)waspublishedintheJSOMSpring09,Vol9Ed2.
PartOne(evaluationofkneeinjuries)waspublishedintheJSOMWinter09,Vol9Ed1.
ANKLE
The most commonly injured ankle ligament is
theanteriortalo-fibularligament (ATFL) located atthe
anterolateralaspectoftheankle(Figure58).
Figure59: Plantarflexionandinversionof
the ankle leads to abnormal stretching and
tearingoftheanteriortalo-fibularligament
(ATFL).
Whenintact,theATFLgoesfromthedistalas-
Figure 58: Anterior talo-fibular ligament loca-
pectofthefibulatothetalus. Inthisposition,itactsas
tionattheanterolateralaspectoftheankle.
a checkrein to prevent abnormal posterior subluxation
ofthetibiarelativetothetalus(Figure60).
With respect to ankle sprains and injury to the
ATFL,thetypicalmechanismofinjuryinvolvesaforced
motion that is best described as a plantarflexion – in-
versiondeformingforce(Figure59).
Thisinjuryisoftenaccompaniedbyahistoryof
apop;thepatientoftenstatesthattheyrolledtheirankle;
thereispainandswellingwiththemostintenseareaof
symptomslocatedattheanterolateralaspectoftheankle.
Figure 60: Intact AFTL prevents
subluxation of the tibia and fibular
complexrelativetothetalus.
FieldEvaluationandManagementofNon-BattleRelatedKneeandAnkleInjuriesbytheATPinthe
1
AustereEnvironment—PartThree
In testing for stability of theATFL, which is a
major stabilizer of the ankle, an anterior drawer test is
performed. This is done much like the anterior drawer
test of the knee. The knee is flexed to 90 degrees and
thefootisstabilized(Figure61). Byapplyingananteri-
orlydirectedforcetothecalcaneus,orbystabilizingthe
foot,andthenapplyingaposteriorlydirectedforcetothe
tibia,thestabilityofthelateralankleligamentsaretested.
Figure63:TornATFLwithposteriortibiaandfibulasub-
luxation. Althoughxraystressviewsareshownforteach-
ingpurposes,theposterior“clunk”asthebonessubluxis
readilyfeltandmaybevisualizedinmostpatients.
The treatment for an ankle sprain is to prevent
the deforming forces of plantarflexion and inversion.
This is performed by taping the ankle followed by ad-
Figure61:Anteriordrawertestoftheankle. Witha ministrationofnon-steroidalanti-inflammatorymedica-
posteriorlydirectedforceappliedtothetibia,andwith tion. Further evaluation upon return to base is
thefootstabilized,thereisnosubluxationofthetibia absolutely required. Most likely the mission can be
andfibulaposterioronthetalus.
completed.
IftheATFListorn,thetibiaandfibulawillsub- ANKLETAPING
lux posteriorly (Figure 62 and 63). It should be noted Justaswiththeknee,thetapingattheanklebe-
that this test should always be performed with the knee gins with applying anchoring strips. The anchoring
flexed. With the knee extended, there is false stability stripsareusuallyoverlappedbyapproximately30-50%.
whendoingthetest. Thistapingmethodisdemonstratedusingtwocolorsof
tapesothattheoverlapandpositionofthetapemaybe
better appreciated. As with taping the knee, the skin
shouldbecleananddry. Ifpossible,shavethehairprior
to tape application. However, tape should NOTbe ap-
pliedoveropenwounds.
Startbyplacingtheankleintheneutralposition,
perpendiculartothelowerleg(Figure64).
Figure62:TornATFLwithposteriortibiaand
fibularsubluxationonthetalusafterapplying
aposteriorlydirectedforce.
Figure 64: Start with the ankle perpendicular to the
forelegandevertedifpossible.
JournalofSpecialOperationsMedicine Volume9,Edition3/Summer09
2
The circumferential anchoring strips are ap-
plied with approximately a 30%-50% overlap (Figure
65). Stripsareappliedatthemetatarsalphalangealre-
giondistallyaswellasapproximatelyhalfwayupthe
foreleg.
Figure67:Secondhindfootanchoringstripapplied.
After two of these strips have been applied,
U-shaped strips are applied beginning at the medial
Figure65:Proximalanddistalanchoringstrips. aspectofthefootandthencontinuingposteriortothe
ankle, ending at the distal lateral aspect of the foot.
Thisaidsinstabilityofforefootadductionandaidsin
stabilityofinversion(Figure68and69).
Followingthebasicanchoringstrips,U-shaped
strips are applied. When applying these strips, start
proximally and medially. As the tape is applied, the
hindfoot is pulled into eversion, to decrease the stress
onthedamagedATFLregion. Thisallowsforstability
oftheanklewithrespecttoinversionandeversion(Fig-
ure66and67).
Figure68:Initialhorizontalfoot/ankleanchoringstrip.
Figure66:Pulltapestripsfrommedialtolateralto
evertthehindfoot.
Figure 69: Second horizontal foot/ankle anchoring
strip.
FieldEvaluationandManagementofNon-BattleRelatedKneeandAnkleInjuriesbytheATPinthe
3
AustereEnvironment—PartThree
After completion of these two strips, the an-
choring strips (or heel lock taping) to specifically re-
sist inversion are applied. The tape is started at the
medialaspectoftheankle(Figure70).
Figure72: Pulltheankleintoeversionasthetapeis
appliedtothelateralborderoftheheelandankle.
Finally,continuetopulltheheelintoeversionas
the tapeis pulledto the medialside of the foreleg (Fig-
Figure70:Startattheproximalmedialanklewiththe ure73).
heellocktapestrip.
Pull the tape across the plantar aspect of the
heel(Figure71),
Figure 73: Completed application of the heel lock
tapestrip.
The heel lock tape strip essentially pulls the
ankle into a position of eversion which takes the stress
offthedamagedligaments. Oncethefirstheellockstrip
Figure71:Plantarapplicationoftheheellock.
isapplied,threeorfourmorearethenplaced(Figure74-
76).
As the tape is pulled proximally and laterally
acrossthelateralborderoftheheelandankle,theheel
andankleshouldbeevertedtofurtherincreasetheef-
ficiencyoftheheellocktapestripandtherebydecrease
anystressontheinjuredATFLregion(Figure72).
Figure74: Completionofsecondheellockstrip.
JournalofSpecialOperationsMedicine Volume9,Edition3/Summer09
4
Indoingso,alltheskinisclosedandcovered
with tape with the exception of the open area at the
heel. This is done because ankle injuries are associ-
ated with a lot of swelling. If there are any breaks in
the tape and if skin is allowed to “peek” through the
tape,thisareawilldevelopaverypainfultapeblister,
which in the austere environment runs the risk of be-
cominginfected(Figure78).
Figure75:Startingthethirdheellockstrip.
Figure78:Completetapingwiththeheelleftopen.
This type of taping results in excellent stabil-
ityoftheanklejoint. Obviously,thepatientcannotre-
turn to totally normal activities although he should
remainfunctional.
Figure76:Completionoffourheellockstrips.
Toappreciatetheamountofstabilitythattap-
ingprovides,lookattheamountofinversionpossible
in the untaped ankle (Figure 79) as opposed to the
Oncethesestripshavebeenapplied,additional tapedankle(Figure80).
circumferentialstripsareapplied(Figure77).
Figure 77: Circumferential anchoring strips applied
totheforelegandfoot.
Figure79:Significantinversionofuntapedankle.
FieldEvaluationandManagementofNon-BattleRelatedKneeandAnkleInjuriesbytheATPinthe
5
AustereEnvironment—PartThree