Helicopter Crashes in the Deployed Combat Setting: The Department of Defense Trauma Registry Experience.

BACKGROUND: Military helicopter mishaps frequently lead to multiple casualty events with complex injury patterns. Data specific to this mechanism of injury in the deployed setting are limited. We describe injury patterns associated with helicopter crashes. MATERIALS AND METHODS: This is a secondary analysis of a Department of Defense Trauma Registry (DODTR) dataset from 2007 to 2020 seeking to describe prehospital care within all theaters in the registry. We searched within the dataset for casualties injured by helicopter crash. A serious injury was defined by an abbreviated injury scale of =3 by body region. RESULTS: We identified 120 casualties injured by helicopter crash within the dataset. Most were Army (64%), the median age was 30 (interquartile range [IQR] 26-35), and most were male (98%), enlisted service members made up the largest cohort (47%), with most injuries occurring during Operation Enduring Freedom (69%). Only 2 were classified as battle injuries. The median injury severity score was 9 (IQR 4-22). Serious injuries by body region are the following: thorax (27%), head/neck (17%), extremities (17%), abdomen (11%), facial (3%), and skin/superficial (1%). The most common prehospital interventions focused on hypothermia prevention/management (62%) and cervical spine stabilization (32%). Most patients survived to hospital discharge (98%). CONCLUSIONS: Serious injuries to the thorax were most common. Survival was high, although better data capture systems are needed to study deaths that occur prehospital that do not reach military treatment facilities with surgical care to optimize planning and outcomes. The high proportion of nonbattle injuries highlights the risks associated with helicopters in general.

Generating Competent Special Operations Clinicians From Military Graduate Medical Education.

Units within the Special Operations Forces (SOF) community require medically competent and operationally proficient medical providers (physicians, physician assistants, and nurse practitioners, among others) to support complex mission sets. The expectations placed on providers who successfully assess for and are selected into these units are high. These providers are not only expected to be experts in their respective subspecialities, but also to serve as staff officers, provide medical direction for SOF medics, serve as medical advisors to the command team, and provide direct medical support for kinetic operations. They are expected to perform these functions with little oversight and guidance and when geographically separated from higher units. Graduates from military Graduate Medical Education (GME) programs are extremely well-educated and can provide high quality medical care. However, they often find themselves ill-prepared for the extra demands placed upon them by the Special Operations community due to a lack of operational exposure. The authors of this paper recognized this gap and propose that the Joint Emergency Medicine Exercise (JEMX) model can help augment the body of knowledge required to perform well as a provider in a Special Operations unit.

Preparing Emergency Physicians for the Next War: Residency Capstone Training in Prolonged Casualty Care.

OBJECTIVE: As the landscape and resources of combat operations change and become more unpredictable, the ability to provide prolonged combat casualty care in austere environments will become increasingly important. Prolonged casualty care (PCC) (until recently, prolonged field care [PFC]) is an emerging niche of military medicine that requires specific and dedicated training within our military medical education curricula for providers at all levels. That training should incorporate both didactic classroom instruction and high-fidelity, hands-on, full-scale training in order to prepare providers for delivering care beyond the standard doctrinal timelines employed in recent combat operations. A resolute commitment to training providers in the application of the core principles of PCC will improve the combat readiness of providers and decrease the morbidity and mortality of combat casualties. Carl R. Darnall Army Medical Center's Emergency Medicine Residency Training Program Joint Emergency Medicine Training Exercise is an example of high value training in all facets of military medicine, including prolonged casualty care.

The Myths of Uncontrolled Emergence Reactions and Consideration to Stop Mandatory, Protocolled Midazolam Coadministration With Ketamine.

Ketamine continues to demonstrate its utility and safety in the austere and prehospital environment, but myths persist regarding the frequency of behavioral disturbances and unpleasant reactions. These myths have led to protocolled midazolam co-administration. Properties of midazolam and other benzodiazepines have the potential to cause significant morbidity and potential mortality. Because of this risk, benzodiazepines should only be administered when the treating provider determines that the patient's symptoms warrant it. We also present evidence that agitation and altered mental status (AMS) encountered with ketamine occurs during titration of lower pain control regimens and is much less likely to occur with higher doses. As such, in most prehospital situations, the treatment for this "incomplete dissociation" is more ketamine, not the addition of a potentially dangerous benzodiazepine.

Anterior Mediastinal Mass Causing Intermittent Atrial Fibrillation.

Mediastinal masses are a rare finding in the emergency department and typically present with vague chest complaints such as chest discomfort, chest pain, or dyspnea. Rarely do these tumors present with dysrhythmias, and when dysrhythmias are present, they typically arise secondary to endocrine or metabolic effects exerted by the tumor. Here we report a case of a patient who presented to the emergency department with atrial fibrillation with rapid ventricular response, concomitant with a history of recurrent palpitations that were previously aborted with self-induced vagal maneuvers. Upon further investigation, the patient had an anterior mediastinal mass, diagnosed as a thymoma, suspected to be contributing to his presenting dysrhythmia through mass effect.

Nicotine Toxicity Secondary to Aftermarket Modifications to a Vaping Device.

Electronic cigarettes continue to rise in popularity as a reportedly safe alternative to standard cigarette smoking. Their use has become common in our society and specifically in our young active duty population. This cigarette smoking alternative has come under recent scrutiny with the discovery of e-cigarette or vaping product use-associated lung injury. However, there is another potential risk associated with vaping: the relative ease at which vaping devices can be modified has allowed a growing community of users to invent novel ways of delivering higher concentrations of nicotine. Here, we describe two cases of active duty patients who presented to an emergency department with clinical nicotine toxicity after using a heavily modified e-cigarette.

Prehospital Intervention Analysis of Helicopter Crashes in Afghanistan.

BACKGROUND: Based on isolated case reports, military helicopter mishaps often result in multiple critical casualties leading to complicated stabilization and evacuation by healthcare providers. The aim of this retrospective descriptive analysis is to describe the incidence of common prehospital injuries associated with rotary wing crashes in order to improve mission planning and casualty survivability. METHODS: This is a secondary analysis of data from the Prehospital Trauma Registry and the Department of Defense Trauma Registry (DoDTR) from April 2003 through May 2019. We searched within our dataset for all encounters involving aviation crashes. RESULTS: From April 2003 through May 2019 there were 1,357 casualty encounters in the Prehospital Trauma Registry. There were 12 casualties identified injured by aircraft crash, of which, 10 were linkable to the DoDTR for outcome data. All encounters for this sub analysis occurred in Afghanistan in 2014, all were US military service members, and a majority were enlisted conventional forces. Most prehospital interventions focused on hemorrhage control, to include limb tourniquets (n=3), pressure dressings (n=2), and pelvic splint (n=1). One patient received a cervical collar and two patients received temperature control with a hypothermia kit. CONCLUSIONS: In this case series, hemorrhage control and extremity stabilization accounted for the majority of prehospital interventions. Larger datasets are needed to validate findings and extrapolate it into mission planning.

Toxicity From Blue Lotus (Nymphaea caerulea) After Ingestion or Inhalation: A Case Series.

Plant extracts and other novel psychoactives can be ingested, vaped, injected, or insufflated. This includes products such as extracts from the blue lotus flower (Nypmhaea caerulea), which is known to produce euphoria and hallucinations at high doses. Blue lotus is sold in several forms, including dried plant material, teas, and extracts for use in electronic cigarettes. Because newer generations of electronic cigarettes can deliver a variety of substances, practitioners need to be mindful of toxicity from a growing number of psychoactives, some of which are not detectable by standard urine drug screens. This case series describes five active duty patients who presented to the emergency department with altered mental status following the use of blue lotus products, four after vaping and one after making an infused beverage. Patients displayed similar symptoms, including sedation and perceptual disturbances. The patients in our series were successfully managed with supportive measures without the need for sedating agents. Recognizing and identifying new trends in substance use can help to provide directions in undifferentiated altered mental status.

Melon with a Twist: A Case of Nicotine Overdose After Ingestion and Aspiration of Vape Liquid.

We present the case of an active duty 21-year-old male with severe hypoxic respiratory failure after accidentally ingesting, and subsequently aspirating, vaping liquid while intoxicated. Because of the increasing prevalence of vaping devices, this case highlights a unique risk of vape liquids with concentrated nicotine levels and appetizing labels and aromas. Vaping-associated pulmonary injury has been previously described in multiple publications, but unlike those patients with pathology after inhaling vaping products, our patient ingested and subsequently aspirated the highly nicotinic substance. Most vape liquid products have enough nicotine to result in significant toxicity, which most concerningly can lead to nicotine-induced respiratory failure. This patient's hypoxia appeared to be multifactorial as a result of both nicotine toxicity and aspiration, but ultimately treatment of both focused on supportive measures.In addition to understanding nicotine toxicity, this patient's hypoxia secondary to agitation and aspiration requiring emergent airway management illustrates the importance of understanding the technique of Delayed Sequence Intubation and its proper application in the critical airway algorithm. By treating preoxygenation as a procedure, the patient received adequate oxygenation resulting in successful intubation without harmful desaturation during the procedure.Given the prevalence of tobacco use in the military as well as the increasing popularity of vaping devices, future military providers have a responsibility to their patients to be prepared for similar case presentations. Fortunately, this case demonstrates that when managed properly, otherwise healthy patients without comorbidities often recover without significant long-term sequelae.

Community hospital experience in the emergency management of COVID-19: Preventing morbidity and preserving resources.

An incredible amount of information has been published regarding inpatient management of patients with COVID-19. Although this is vitally important, critical interventions that occur in the emergency department (ED) can have a profound impact on the individual patient and the healthcare system as a whole.  Much has been written regarding care in large centers, but there has been little discussion regarding similar patients in community settings. Prior to the pandemic, large centers were able to accept patients that outstripped the resources in community hospital settings, but currently we foresee that many community centers will begin to manage more complex cases without referral. As physicians in a medium-sized community academic center, we aim to enumerate community-hospital-relevant guidance for ED care that focuses on adherence to available evidence-based medicine, including early aggressive supplemental oxygenation, awake proning, and methods to improve oxygenation and ultimately delay intubation as long as safely possible.  Equally importantly, it was recognized early that adjustments to medication regimens (eg, sedation) and personal protective equipment (PPE) use must be made in the ED to conserve those same resources for long-term use in inpatient units and improve the functionality of the hospital system as a whole. It is our hope that this article may serve as a framework for similar community-based hospitals to create their own protocols to optimize resource utilization, staff safety, and patient care.