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.

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.

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.