More Than a Bruise: Two Cases of Morel-Lavallée Lesions in Active Duty Soldiers.

Soft tissue injuries are common in the military, generally producing simple hematomas without the need for intensive evaluation and management. In certain situations, a shearing effect between fascial planes whereby a disruption of the vasculature and lymphatic systems creates a "closed degloving injury" is more generally referred to as a Morel-Lavallée Lesion (MLL). With a consistent pool of blood, lymph, and pieces of soft tissue, an M7LL can cause significant poor cosmesis, chronic pain, and risk secondary infection if left undetected and untreated. Proper diagnosis can be made through the effective use of ultrasound and, if detected early enough, through conservative measures to include needle aspiration and compression sleeves. Prior cases describe chronic MLLs existing for extended periods of time, in some cases years, requiring operative intervention, and in some cases poor outcomes. We present two cases of active duty soldiers presenting with seemingly innocuous injuries found on closer evaluation to have MLL, treated in one case with needle aspiration and compression, in the other with operative management.

Comparison of DripAssist to Traditional Method for Achieving Rate Infusions by U.S. Army Medics.

Literature finds improper intravenous (IV) infusion rates as the most common cause of medication administration errors (MAE). Calculating drip rates and manipulating roller clamps while counting drops within the drip chamber to manage IV infusions - known as the traditional method (TM) - increases the likelihood of IV MAEs compared to electronic infusion pumps. The DripAssist, a novel in-line device, allows users to monitor and adjust infusion rates without calculating rates or counting drops. We conducted a prospective, randomized, crossover study with a convenience sample of U.S. Army medics initiating infusion rates using the DripAssist and the TM. Investigators randomized participants to start with the TM or DripAssist and achieve three specific infusions using an in vitro model. The primary outcome was the time to achieve the desired infusion rate measured in seconds. Secondary outcomes included drip rate accuracy and volume infused over one hour. End user feedback included method confidence on a 100-point Bandura scale and appraisal using a five-point Likert item. Twenty-two medics demonstrated faster time to achieve infusion rates with the DripAssist over TM (median 146.5 seconds vs. 207.5 seconds, p = .003). A sequence effect noted faster time to achieve desired infusion rates with the TM after completing infusions with DripAssist (p = .033). The DripAssist demonstrated significantly improved accuracy for drip rate and volume administered over one hour compared to TM (median rate error: 5% versus 46%, p <.001; median volume percentage error: 26.5% versus 65%, p <.001). The DripAssist had significantly higher user confidence (median 80 vs. 47.5, p <.001) and was perceived as easier to use (median 4 vs. 2, p = <.001) and more likely to be learned, remembered, and performed by a medic (median 5 vs. 3, p <.001). Most participants (90%) preferred the DripAssist for establishing a rate-specific infusion. The DripAssist demonstrated significantly faster time to achieve infusion rates, improved accuracy, and increased user confidence. Sequence effects may confound time data. We recommend further studies of the DripAssist by prehospital medical personnel in more austere environments.

Impact of a Novel Biplane User Interface on Ultrasound-Guided Vascular Access Performance: A Prospective, Randomized, Crossover Study.

BACKGROUND: Controversy exists regarding the optimal methods of employing ultrasound to enhance vascular access. A novel user interface which dynamically displays transverse (short) and longitudinal (long) planes simultaneously was developed to optimize ultrasound-guided vascular access. This study aimed to assess the impact of this novel biplane axis technology on central venous access performance. METHODS: Eighteen volunteer emergency medicine resident physicians and physician assistants were recruited from a single center to participate in this prospective, randomized crossover study. Following a brief instructional video, participants were randomized to perform ultrasound-guided vascular access using either short-axis or biplane axis approaches first, followed by the opposite technique following a brief washout period. Time to cannulation was the primary outcome measure. Secondary outcome measures included success rate, posterior wall and arterial puncture rates, time to scout, number of attempts, number of needle redirections, participant cannulization and visualization confidence, and interface preference. RESULTS: Short-axis imaged approach was associated with a significantly shorter time to cannulation (34.9 seconds versus 17.6, p is less than 0.001) and time to scout (30 versus 49 seconds, p is equal to 0.008) when compared to biplaneaxis imaging approach. No significant differences were noted when comparing first pass success, number of attempts, number of redirections, and posterior wall and arterial wall puncture. Participants' cannulation/visualization confidence and axis preference both favored the short-axis imaging approach. CONCLUSION: Further studies are needed to assess the clinical value of novel biplane axis ultrasound imaging in the performance of ultrasound-guided procedures.

Improvised Management of Polycythemia Vera Using Whole Blood Transfusion Kits.

Polycythemia vera (PV) is a frequent myeloproliferative disease resulting in excessive red blood cells, white blood cells, and platelets rarely identified in military populations. Increased blood viscosity and platelets can lead to fatal myocardial infarction and stroke. Historically, regimented phlebotomy managed this condition, but modern medicinal advances now are utilized. These immunosuppressive medications are generally incompatible with active-duty service and can lead to medical discharge. Phlebotomy therefore is critical for readiness and health; however, this can be challenging in resource-limited environments, necessitating effective improvisation. We describe an active-duty Soldier with PV symptoms consisting of substernal chest pressure, bilateral lower extremity paresthesias, and persistent pruritic neck rash. He had an elevated hematocrit (Hct) of 47%, necessitating phlebotomy and posing a challenge to his primary care team. The local emergency medicine team employed blood collection bags from whole blood (WB) transfusion kits, including proven volume estimation methods, to routinely draw one unit of blood and effectively manage this condition. This is the first reported case in military literature of PV managed with improvised field resources and techniques.

Special Operations Medics Test the Novel iView Video Laryngoscope: A Prospective, Randomized, Crossover Trial.

BACKGROUND: Airway compromise is the second leading cause of preventable death on the battlefield. Special operations medic comprise the majority of medics trained to perform endotracheal intubation (ETI), mostly by way of direct laryngoscopy (DL). The iView is a disposable, low-cost video laryngoscopy (VL) device, enabling its distribution to prehospital medical providers. We seek to compare time to intubation between DL and iView VL among special operations combat medics (SOCM). METHODS: We conducted a prospective, randomized, crossover trial. We enrolled special operations medics assigned to Joint Base Lewis McChord, WA. We randomized subjects to first performing VL or DL. Subjects performed a total of 10 ETI, 5 by VL and 5 by DL, on adult airway manikins. The primary outcome was time (in seconds) for ETI completion. RESULTS: A total of 32 medics completed 160 with DL ETIs and 160 VL ETIs. A total of 10 of 32 (31.3%) medics reported no previous experience with VL devices. We found a significant difference in time to intubation between VL and DL (20.4 (95% CI 20.6 - 26.1) seconds versus 23.4 (95% CI 18.7 - 22.2) seconds; p = 0.03) in favor of VL. All VL attempts were successful while 96.9% of DL were successful (p = 0.10). With respect to end-user appraisal of devices, a significant number of medics preferred the iView VL over DL (23 versus 9; p is less than 0.00001). Additionally, medics considered iView VL easier to use (5 [5-6] versus 5 [4-5]; p=0.0004) and easier to learn, remember, and perform by combat medics (5 [5-5] versus 4 [4-5]; p=0.008). CONCLUSIONS: Special operations medics naïve to VL rapidly learned how to effectively utilize iView VL, as evidenced by a significant difference in time to intubation in favor of iView VL. Additionally, most medics favored iView VL and considered it easy to use, learn, and remember.