Chapter 9 prehospital tourniquets: review, recommendations, and future research.

The tourniquet is a simple device that has been used since the Middle Ages. Although different variations have been designed throughout its history, the simplicity of design has remained. The history of tourniquets follows two distinct paths--the operating room and the prehospital setting. From the earliest recorded history, tourniquets have been used for surgical procedures which were originally to amputate war-ravaged limbs and then to create a bloodless field for routine limb surgery. This history has continued uninterrupted since the early 1900s with continued research to foster advances in knowledge. The history of tourniquets in the prehospital setting, however, has not progressed as smoothly. The debate regarding the use of a tourniquet to save a life from excessive limb hemorrhage began in the 1600s, and continues to this day. This chapter will explore the prehospital use of tourniquets, which may shed some light on where this debate originated. The current state of the knowledge regarding tourniquets will then be discussed with a focus on prehospital use, using the operating room literature when needed to fill knowledge gaps. The chapter will conclude with recommendations for prehospital tourniquet use and some areas for future research. Tourniquets are used for operative procedures within accepted clinical guidelines throughout the world as the standard of care. Current science supports a similar stance for the use of prehospital tourniquets within clinical guidelines.

A model for patient-centered Army primary care.

This pilot evaluated a novel method of primary care delivery in a military family practice setting. A registered nurse, registered nurse case manager, and primary care provider formed the patient management team. Approximately 2,500 empanelled patients participated in a pilot program that applied a patient-centered approach to primary care. The pilot tracked outcome measures, which included (1) panel size, (2) access to care, (3) care utilization, (4) continuity of care, (5) nurse and provider productivity, (6) Healthcare Effectiveness Data and Information Set measures, and (7) satisfaction measures. When compared to the standard family practice clinic, the patients in the pilot were able to access the family practice clinic more frequently (p < 0.05), were less seen in the urgent care (p < 0.05), and had a lower no-show rate (p < 0.001) for scheduled appointments. The providers were able to see their own empanelled patients significantly more frequently (p < 0.05) and virtually all Healthcare Effectiveness Data and Information Set markers improved with colon cancer screening, low-density lipoprotein annual exams, low-density lipoprotein control, and breast cancer screening/mammogram being significantly improved over the comparison group (p < 0.05). These results suggest a change in staffing and a focus on patient-centered care can significantly improve outpatient care access and population health maintenance.

Deployment experiences of Army nurse practitioners.

Army Nurse Practitioners (NPs) provide immediate and lifesaving care during combat operations. The most recent conflicts of Operation Iraqi Freedom and Operation Enduring Freedom have seen an increasing number of NP deployments. The uniqueness of these conflicts has also seen NPs being used in nontraditional roles. This study surveyed 50 Army NPs with deployment experience to explore and elucidate their clinical practices in a combat environment. Over 70% reported seeing greater than 11 patients a day with the top three diagnoses of musculoskeletal/soft tissue (noncombat), spinal pain (mechanical, sciatica), and gastrointestinal complaints. Over 74% reported having a physician available for collaboration, but 50% reported providing independent emergency care and 58% treating life-threatening injuries. The NPs in this study report standard credentialing privileges with most care falling within this realm. However, a few report nontraditional roles such as hospital admitting privileges. This study adds to the growing body of knowledge on NP practice in a combat environment, which shows increased decision making and advanced clinical skills. NPs are battlefield multipliers who bring additional skills and abilities to the combat environment.

A Novel Stress Fracture Rehabilitation Program: A Pilot Study.

INTRODUCTION: Stress fractures (SFx) of the tibia are common and limit military readiness, but there is presently no scientifically validated program that objectively fosters tibia SFx rehabilitation. Therefore, this pilot study evaluated the feasibility of a Graduated Exercise Program (GEP) based on the theory that programmed rest between exercise bouts improves the osteogenic response, which may enhance rehabilitation and military readiness. METHODS: Participants were randomly assigned to the GEP or standard-of-care exercise program. Both programs use a walk-jog-run progression, but the GEP splits daily exercise into morning and evening episodes and provides 5 days of programmed rest after each stage is completed. The GEP included autonomy support to foster program adherence. Outcome measures included adherence, subjective and ActiGraph-validated objective assessments of exercise duration and intensity, pain assessments, and autonomy support assessments. Participants offered suggestions for program improvement. RESULTS: Quantitative findings were mixed, but more importantly, this pilot study showed that the measurement, support, and self-reporting parameters were feasible, with high compliance by participants. Barriers to recruitment and retention were identified, along with solutions to overcome these barriers, starting with obtaining unit support for GEP participation. CONCLUSION: This pilot study demonstrated the feasibility of a GEP with autonomy support, along with challenges and their solutions, providing the foundation for a formal large-sample study.

Resource utilization in the management of young patients with syncope in a combat theater of operations.

UNLABELLED: Clinical features of young patients presenting with syncope have been underreported. METHODS: Retrospective review using U.S. Military Health System's Theater Medical Data Store and Joint Medical Workstation identified patients evaluated for syncope from January 2005 to October 2007 while deployed to a combat zone. RESULTS: We identified 848 patients with syncope. The majority (80.8%) were under the age of 40. The diagnostic yield of the ECG was 2.0%. In those <40 years, there were no head CTs or transthoracic echocardiograms that identified a cause of syncope. There was no difference in evacuation out of theater between those <40 years and those >40 years (10.8% vs. 8.6%, p = 0.08). Patients with a prior episode of syncope were more likely to undergo medical evacuation outside of the combat zone (16.0% vs. 7.7%, p < 0.01). DISCUSSION: Evacuation of those <40 years to facilities with advanced imaging did not add diagnostic information.

Scrotal pathology in the outpatient setting in Operation Iraqi Freedom.

The purpose of this study was to describe the incidence and pathology of scrotal pain among military men deployed in Operation Iraqi Freedom. It is a retrospective review of patients seen by the urology service at a U.S. Army combat support hospital (CSH) in Iraq from March 29, 2007 to August 12, 2007. Of the 222 outpatient visits to the urology service 81 (36%) had 1 or more scrotal complaints for a total of 90 scrotal-related problems. The vast majority (86%) were found to have epididymitis. Scrotal sonograms on these patients found only 1 patient with a testicular neoplasm. Varicocele (6.2%), spermatocele (4.9%), and hydrocele (2.5%) accounted for the remaining scrotal findings. Urologic referrals for scrotal problems are common in the deployed environment. We feel the best treatment for chronic scrotal pain in theater is conservative with urologic referral in patients who fail their initial course of therapy.

Creatine kinase BB isoenzyme blood levels in trauma patients with suspected mild traumatic brain injury.

This pilot study sought to determine if creatine kinase isoenzyme BB (CK-BB) levels might serve as a biological marker of injury severity in mild TBI (mTBI). This was a retrospective study of 64 soldiers with suspected mTBI seen in a combat support hospital in Mosul between March and August of 2007. Four of the 64 total samples were positive for CK-BB. One major trauma patient had a negative CK-BB. This yields a sensitivity of 11% and a specificity of 97%. Military Acute Concussion Evaluation (MACE) scores collected also did not appear to reflect extent of injury. Although the low sensitivity of CK-BB from this study does not support its use as an early marker of suspected mTBI, the result is not conclusive given the small sample and the possibility of isoenzyme degradation during transport. Although limited, the data collected on MACE scores warrant additional evaluation of whether this measure is clinically relevant.

The Impact of Cigarette Smoking on the Formation of Heterotopic Ossification Among Service Members With a Traumatic Amputation.

BACKGROUND: Heterotopic ossification (HO), the abnormal formation of lamellar bone in soft nonosseous tissue, has been identified as a potential complication following a traumatic amputation or traumatic brain injury (TBI). HO occurs at a dramatically higher rate among military casualties than among civilian casualties. Most investigators agree that in order for HO to form three conditions must be present: (1) osteogenic precursor cells, (2) an inducing agent or event, and 3) an environment conducive to ostoegenesis. Therefore impacting on any of these three conditions should impact on the formation of HO. Anecdotal clinical reports seem to show a decreased incidence of HO among cigarette smokers. The negative effect of smoking on bone growth as well as poor healing overall is well established in the literature. It makes intuitive sense that tobacco smoking would negatively impact on an environment conducive for HO. A review of the literature found no published work that evaluated a possible link between HO and tobacco use. This study sought to determine if a relationship exists between tobacco use and the formation of HO. METHODS: A retrospective data review was conducted of military medical records for service members (SMs) who have experienced a traumatic amputation. Cases were matched to controls on the basis of factors known to be associated with the development of HO including age, gender, comorbid TBI, and deployment status. Bivariate logistic regression models were used to test for associations between age, gender, TBI, and deployment status with tobacco use. RESULTS: A total of 3,132 records of SMs with an amputation were included for analysis with 18% overall developing HO. Those that developed HO were more likely to be younger, have sustained a TBI and to use tobacco compared to those that did not develop HO. An odds ratio analysis found that SMs who experienced a deployment-related traumatic amputation were 7.34 times more likely, SMs with a TBI were 6.45 times more likely, and smokers were 1.27 times more likely to develop HO when compared to nondeployment-related amputations. Older age and female gender were found to be protective against developing HO. In the final model after matching on potential confounders, tobacco use was not related to HO among this sample. DISCUSSION: The incidence of HO among SMs with a traumatic amputation or TBI was similar to that found in other research. Also found in this study and supported in the literature is age as a confounder for HO and the prevalence of tobacco use among SMs who have deployed. However, female gender as protective against the development of HO was an unexpected finding mainly because there are so few studies of SMs with traumatic amputations including women in the analysis. In the final analysis, given all the literature on the negative impact of smoking on bone healing, it seems counterintuitive that HO formation is unrelated to smoking status. The methodology used in this study has inherent limitations and a prospective study should be conducted to validate results.

The Role of Army Nurse Practitioners Supporting Wars in Iraq and Afghanistan.

Family nurse practitioners are an essential member of the military medical team. They were incorporated into the Army medical system almost as soon as there was an academic program to develop the role in primary care settings. The role for nurse practitioners during deployment has not been as clear. Even though they have been around for 50 years, the specific role nurse practitioners provide is still evolving. This article explores the incorporation of nurse practitioners into Army medicine with a focus on deployed medicine. Nurse practitioners have been shown to be very versatile providers with the requisite skill sets to meet the demands of the combat environment and are able to substitute for other medical assets that are critically short due to sustained conflict. Clarifying the value a nurse practitioner brings to medical care in the combat environment is essential to insure all assets are being employed to provide the best medical care to the US fighting force.

Improving the adoption of evidence-based practice among nurses in Army outpatient medical treatment facilities.

This quality improvement project implemented and evaluated an evidence-based practice (EBP) program at two Army outpatient health care facilities. The EBP program consisted of five implementation strategies that aimed to inculcate EBP into organizational culture as well as nursing practice and culture. A conceptual model of the "Diffusion of Innovations" theory was adapted to explain the application of the program. The Institutional Review Boards at Walter Reed National Military Medical Center and Duke University School of Medicine reviewed and exempted this quality improvement project. A pretest-posttest design was used with four instruments at each facility. The EBP program was successful in enhancing organizational culture and readiness for EBP (p < 0.01) and nursing staff's belief about the value of EBP and their ability to implement it (p < 0.05). Another indicator that the EBP program achieved its goals was the significant difference (p = 0.002) in the movement of the outpatient health care facilities toward an EBP culture. These results suggest that this EBP program may be an effective method for empowering outpatient nursing staff with the knowledge and tools necessary to use evidence-based nursing practice.