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olhamada
12-09-2009, 09:25
Anyone else going to SOMA at the end of the week?

If so, would you like to tag-team to summarize relevant and frontline information presented?

Let me know, and we can "divide and conquer".

I think it would be a great resource to others on this board.

Papa Zero Three
12-09-2009, 09:46
I won't be going but some of my friends will be there. Stop by booth #22 and sign up for the M4 they are raffling off. You can check it out HERE. (http://archive.constantcontact.com/fs001/1102660244590/archive/1102823785973.html)

olhamada
12-09-2009, 12:24
Thanks Papa Zero Three. Will do.

Incidentally, here's the agenda. http://www.trueresearch.org/soma/2009/files/2009_web_program_book.pdf

This year's focus is on "Medical Lessons Learned from the Asymmetrical Battlefield".

The conference begins Saturday, ends Tuesday, and will be followed by the Blast Conference on Wednesday.

If you are not going and there's anything specific you need or want from the conference, PM me (please limit this to 18-series and medical personnel).

olhamada
12-13-2009, 17:54
I first went to SOMA in 1994 when it was still at Bragg. This year marks my fourth conference. I can't believe how large it's become and it just keeps getting bigger.

In 1994, with very few deployments, there couldn't have been more than a couple hundred people. This year it looks like we're pushing 1,000 despite a very demanding op tempo. The number of foreign nationals is impressive. I've seen many from Israel, Sweden, Canada, Germany, the UK, etc....

I'm not going to cover every lecture, but want to pull out a few pertinent points from the most important ones as far as operational and tactical medicine is concerned.

There is no syllabus (hardcopy or CD/DVD/USB), there are no lecture notes, and there are no handouts. So all my info is based on rapid fire note taking and may be incomplete.

So not to create a separate thread for each lecture and gum up the board, I'll instead post all notes here in this thread. However, I'll have a separate post with title within this thread for each lecture covered. (If that's acceptable to the moderators).

Please feel free to chime in.

Peregrino
12-13-2009, 19:40
I'm not going to cover every lecture, but want to pull out a few pertinent points from the most important ones as far as operational and tactical medicine is concerned.

There is no syllabus (hardcopy or CD/DVD/USB), there are no lecture notes, and there are no handouts. So all my info is based on rapid fire note taking and may be incomplete.

So not to create a separate thread for each lecture and gum up the board, I'll instead post all notes here in this thread. However, I'll have a separate post with title within this thread for each lecture covered. (If that's acceptable to the moderators).

Please feel free to chime in.

Doc - Cleared Hot! Thanks for your willingness to share. P.

olhamada
12-13-2009, 20:27
Roger that, Peregrino.

Presenter: MSG Henry Lukacs, German Army, Special Operations
Lecture: Medical Lessons Learned – Northern Afghanistan

Discussion of lessons learned during/after IED attack in Konduz. IED attack was used to set up ambush, but instead of stopping in kill zone, convoy of ANA and German SOF punched through, stopped after about 100 meters, set up perimeter to engage threats, evaluate casualties. Ambush was aborted since target force kept rolling. Resulted in several severe injuries (amputations, facial fractures, extremity fractures), and other minor injuries. No damage to body armor or underlying body parts. During casualty evaluation and stabilization, non-combat trained personnel succumbed to psychological stressors and collapsed causing SOF medics to have to evaluate/respond to imminent threats, attend to injured soldiers, and attend to collapsed physician. Air evacuation assets were distant and off-line, no support readily available, and CASEVAC took much longer than necessary.

Lessons Learned:
- Accompanying medical personnel should have combat training and experience so they are an asset and not a liability (everyone on the battlefield is a combatant – my own addition)
- MEDEVAC and support should be online prior to mission initiation and possibility of hostile engagement
- Punch through ambush to limit hostile fire effects
- Body armor saves lives
- Tourniquets save lives

olhamada
12-13-2009, 20:36
Presenter: COL Virgil Deal, USSOCOM Surgeon
Lecture: USSOCOM Surgeon’s Update

Great lecture regarding plan and intent to improve 18-series training, organization, and equipping. Discussed goal of increasing level of physical performance to exceed that of NFL athletes (by increasing current levels of physical readiness and operator performance by at least 20%). Also wants to improve current ability of repairing and restoring injured soldiers to peak readiness.

Pursuing the addition of SOF specific codes/identifiers for medical support personnel and AMEDD officers.

olhamada
12-13-2009, 20:59
Presenter: CAPT Joe Rappold, MD, FACS, USN
Lecture: Platinum Ten Minutes vs. Golden Hour – Experience From Afghanistan

Current AOR OEF survival is 96% - unprecedented in the history of warfare. At this point, must consider diminishing returns for investments made – primarily with regard to medical personnel as current op tempo is unsustainable with such a shallow pond from which to draw personnel (demand greatly exceeds supply).

Primary reasons for such great survival rates – airway management, chest decompression, and use of tourniquets. Tourniquet use has saved more lives than any other intervention.

Good surgical judgment comes from experience, and experience comes from bad surgical judgment.

Used analogy of fighter pilot with desk job for 6 months wouldn’t be allowed back up in bad weather/hostile environment without remedial training. Yet, we have surgeons operating without the necessary experience or requisite volume to assure good outcomes. Diminishing and perishable skill set. Need to assure proper training, experience, and maintenance of surgical volume of our surgeons.

Better to spend 70 minutes getting patient to the right place, than to spend 50 minutes getting patient to the wrong place.

olhamada
12-13-2009, 21:40
Presenter: LTC Robert Forsten, MD – USASOC Command Psychiatrist
Lecture: PTSD in the SOF Community – Dx and Tx

PTSD is under-diagnosed. Long history of PTSD in combat soldiers. See it in historical documents from ancient times. Many in SOF community refuse to admit symptoms as they are perceived as psychological weakness. Abnormally hightens situational awareness on return to CONUS – doors banging, cars backfiring, people crowding, etc…. Patients become angry, aggressive, suspicious.

Physiologically, we see that in times of increased stress, adrenaline and cortical production/release is significantly increased which in turn significantly increases detailed memory formation.

Treatment includes behavioral therapy, counseling, and pharmacologic. First line pharmacologic therapy includes Paxil or Zoloft. Second line therapy includes Desyrel, Remeron, Wellbutrin, or Buspar. Tertiary therapy includes Minipress, Inderal, and atypical antipsychotics.

Differentiate between PTSD and TBI.

Assistance available though Military OneSource. Other assistance through www.strongbonds.org and www.army.mil/csf.

olhamada
12-13-2009, 22:05
Presenter: COL Lorne Blackbourne, MD – Commander USAISR
Lecture: Decreasing KIA on the Battlefield

How do we decrease KIA and DOW (Died Of Wounds) on the battlefield? Eighty percent of KIA/DOW is due to hemorrhage. Ten percent is due to airway compromise. Remaining 10% is due to other pathology.

With regard to hemorrhage, 50% is due to torso injuries, 20% from axillary, neck, and subclavian injuries, and 30% from extremity injuries.

To reduce KIA/DOW most dramatically, we must focus on managing truncal penetrating trauma in the prehospital phase. Intervention includes injury prevention, mechanical hemorrhage control, and intravascular volume replacement.

The average human body contains approximately 5 liters of blood. A decrease in blood pressure is seen after a loss of 1/3 or about 1.5 liters. Irreversible shock occurs after a loss of ˝ the total volume or about 2.5 liters. This was first published in Lancet in 1831. In the field, Hextend and LR are used for volume replacement.

The deadly triad leading to Severe Ischemic Threshold is Acidosis, Hypothermia, and Coagulopathy. Determining factors include volume of blood lost, time since injury, and injury burden.

Once the patient reaches the CSH, goals and intervention change to replacing intravascular volume while correcting or at least not worsening coagulopathy. Must switch from Hextend and crystalloid/colloid to whole blood and FFP.

NEJM published article showing this – Immediate vs. Delayed Fluid Resuscitation for Hypotensive Penetrating Torso Trauma. http://content.nejm.org/cgi/content/abstract/331/17/1105 For hypotensive patients with penetrating torso injuries, delay of aggressive fluid resuscitation until operative intervention improves the outcome.

Crystalloid/Colloid = Coagulopathy. Coagulopathy = Death. Plasma = Survival.

RBCs dilute clotting factors. Platelets are too fragile. Fibrinogen not very effective. Plasma is just right. For increased survival, dried plasma is necessary on the battlefield, and should be available to operators and utilized.

olhamada
12-13-2009, 23:13
Presenter: COL Chester C. Buckenmaier, MD - WRAMC
Lecture: Acute Pain in Medicine in the Field

Deployed to Afghanistan with the British. US would not allow him to provide pain management necessary.

Level 1 (Battlefield) – Ketamine IV/nasal, Fentanyl lollipops, Morphine, Splinting, Reassurance. No intrathecal morphine because of bimodal respiratory depression.

Level 2/3 (FST/CSH) – OR, blood products, diagnostic imaging, ICU, regional anesthesia, Acute Pain Service. In all US soldiers in whom pain management was started and/or regional pain management catheters were placed, these efforts were stopped and catheters were pulled when they arrived at US CSH in Bagram.

For Brits – (US) Military Pain Infusion System, nerve stimulation, ultrasound, IV paracetamol (acetaminophen), IV diclofenac. De-emphasize opiods secondary to overuse, abuse, and dependence.

Level 4 (Landstuhl) – US soldiers arrived in agony. Morphine wouldn’t hold. Flight nurses didn’t know what to do since docs at Bagram discontinued effective pain management efforts. Many consequences of untreated pain – especially psychological.

Level 5 – (CONUS)

Relief of pain and suffering is our primary objective and obligation as physicians.

FREE Textbook – Military Advanced Regional Anesthesia and Analgesia www.dvpmi.org

olhamada
12-13-2009, 23:36
Presenter: LTC Robert F. Malsby, DO – Womack AMC
Lecture: Application of Military Medicine in Counter Insurgency (COIN) Operations

Do you know what MEDCAP stands for? (Most don’t). Developed in 1960’s as joint effort between US Embassy in Saigon and USAID. Stands for Medical Civic Action Program. Guidance FM 3-0 Operations and FM 3-24 Counter Insurgency.

COIN operations driven by HN government legitimacy in eyes of the people, continuity and sustainability of operations, and unity of effort.

Afghani lifespan, even after 8 years of US presence, is still 43 years.

What makes a difference in health of Afghani’s? NOT tx of HTN, CAD, DM, LBP, etc…. What makes a difference is potable water, immunizing children, nutrition, handwashing, vector control, and sterile infant delivery methods.

98G
12-14-2009, 07:06
Thanks for taking the time and effort to document and share these. My team hopes to start FDA testing shortly on a technology implementation that would address wound care and pain management.

Any insights from SOMA that addressed:
• Antimicrobial wound protection
• Tissue regeneration
• Accelerated wound healing
• Pain relief during wound healing
• Control of bleeding
that you may have discussed off line or were not the main thread but discussed in the briefings you attended would be appreciated (and from anyone else who attended.)

When I am closer to publishing -- current white paper is under NDA only, I will check with the administrator to see if it warrants its own thread. For now, if agreed, it fits well with the topics covered at SOMA.

Again, thank you for taking the time to share this information.

olhamada
12-14-2009, 10:42
Presenter: SGT Cory Beato – 18D, 5/19th SFG, (A)
Lecture: Medical Lessons from Urban Warfare in Afghanistan

Reviewed firefight at Governor’s mansion in Khowst, convoy back to FB Salerno, convoy back into Khowst, and engagement of hostiles on 2nd story of 3-story corner building. Innocents on street and on 3rd floor. Salerno 6 km from site of engagements via good roads.

Hostiles well trained using tactical movements to avoid direct line of sight (stand off), and direct engagement (multiple grenades down stairwell). Hostiles intent on self-sacrifice during jihad. Multiple well constructed suicide vests found. Multiple friendly casualties.

Lessons learned:
- Disseminate CCP location to all parties
- Security/Crowd Control around CCP
- Organize CASEVAC with all parties (reminiscent of German SOF lessons learned)
- Consider tactical conditions when providing TCC
- Don’t lose track of your wounded guys in the system. Get them back to the firebase ASAP.
- Utilize non-military organizations for medical training for indigenous friendlies (ANA) and females.

olhamada
12-14-2009, 10:55
Thanks for taking the time and effort to document and share these. My team hopes to start FDA testing shortly on a technology implementation that would address wound care and pain management.

Any insights from SOMA that addressed:
• Antimicrobial wound protection
• Tissue regeneration
• Accelerated wound healing
• Pain relief during wound healing
• Control of bleeding
that you may have discussed off line or were not the main thread but discussed in the briefings you attended would be appreciated (and from anyone else who attended.)

When I am closer to publishing -- current white paper is under NDA only, I will check with the administrator to see if it warrants its own thread. For now, if agreed, it fits well with the topics covered at SOMA.

Again, thank you for taking the time to share this information.


You are certianly welcome.

I didn't get this from SOMA, but I was watching MSNBC last night and they did a piece on the Wake Forest Institute of Regenerative Medicine. Pretty incredible stuff. They are the first to develop and grow human tissue and organs, and are transplanting both. Check them out. http://www.wfubmc.edu/wfirm/

Regarding antibicrobial wound protection, check out NuvaDerm. Bandage that kills MRSA on contact. http://www.nuvadermva.com/nuvaderm.html

olhamada
12-16-2009, 12:43
Presenter: Lt Col. Nick Withers MD – CCFP Canadian Forces Health Services GRP HQ
Lecture: Canadian Forces Approach to TC3

Canadian Forces number 70,000 with a Reserve of 30,000. 900 Med Techs. Tri-service and interchangeable. Budget $20 billion.

Compare to US – 3 million soldiers (AC/RC) with a budget of $480 billion.

CCC Training has three levels – Military Standard First Aid, Combat First Aid, and TCCC (11 day course).

Med Techs are all qualified as civilian Primary Care Paramedics and can advance their skills via three routes – Advanced Emergency Care, Tac Med Training, and/or PA.

TCCC 11 day course is broken down into 2 phases. Phase 1 includes topics such as Human Performance in TCCC, Critical Thinking, TCCC Paradigm (TCCC bubble, extraction techniques, Pluck lab, Tactical lab), Tactical training, Shooting, Live tissue training (swine). Phase 2 topics include the field portion and Mass Casualty.

Use the MARCHE acronym – Massive hemorrhage control, Airway, Respiratory control, Circulatory control, Hypothermia, and Eye trauma/Everything else.

For C-spine injuries, use the NEXUS criteria or the Canadian C-spine rules.

Re shock – use Hypertonic Saline 7.5% or Dextran 6%. 250 ml IV/IO q 10-15 min x 2.

Abx – Minofloxin 400 mq po q 24 hrs, Cefoxitin 2 g IV/IO/IM q 8 hrs, or Clinda 600 mg IV/IO/IM q 8 hrs (PCN alolergic).

olhamada
12-16-2009, 12:56
Presenter: MAJ Andrew Morgan, MD, FS, DMO – 1/3 SFG, (A) Battalion Surgeon
Lecture: Special Operator Level – Clinical Ultrasound for the Field

USG in SOF – increases diagnostic accuracy in the field, lightweight, versatile, force multiplier, portable, cost effective, affordable, SOF medics make very capable ultrasonographers.

Trained 28, 18Ds and 2 PAs in 6 sessions. 15 hours average. Saw huge benefit in diagnosis of pneumothoracies, fractures, abcesses, etc.. in soldiers and indigenous personnel. Not training to do fetal anatomical surveys, renal scans, ECHOs – just emergency diagnosis.

Saved money, increased availability (vs HUGE XR machines that take an entire pallet to transport vs a backpack), improved response and trust of indigenous personnel. Price $40,000 vs $1.2 million for XR.

Used ACEP methods for training (American College of Emergency Medicine) for FAST exam. Seeking approval from USASOC.

Calling it SOLCUS (Special Operator Level Clinical Ultrasound).