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The Unofficial Newsletter Recognizing the Efforts of the Joint Trauma System to Improve Trauma Care.

4th Quarter 2015, Volume 8 Issue 2

The Next Great Adventure in

Trauma Care Data Collection

MERCuRY Medevac En Route Care Registry

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COL Kirby Gross, USA , MC. Departing JTS Director

MOVING FORWARD

This is my last opportunity as director to thank the JTS team for ongoing contribu-tions to improving combat casualty care outcomes. As JTS Director, I had the oppor-tunity to interface with other organizations and individuals on behalf of JTS. Interac-tions occur most frequently by e-mail cor-respondence and teleconference; howev-er, the interactions often involve face to face encounters. The number of journeys requiring face to face encounters over the past year has been 20 – NATO (2), UK (2), non-NATO (2), civilian meetings (5), and military medical meetings (9).

The number of meetings reflects the amount of interest in the JTS. Another measure of interest in JTS products are requests for information. Susan West, Data Analysis Branch Chief, identified 17 types of organizations which request information. This is not the number of individual re-quests, but 17 different types of organiza-tions with unique regulatory requirements.

JTS responds to present needs of the DoD, but also recognizes the need to contribute to the development of the next genera-tions of combat casualty care providers and clinical investigators. This obligation is

met by teaching junior clinicians at SAMMC as well as teaching faculty and formalized training courses such as Ad-vanced Trauma Life Support, Advanced Trauma Operative Management and Ad-vanced Surgical Skills Exposure in Trau-ma. The increase in the breadth of our activities at JTS reflects the increased awareness of JTS by those like-minded organizations and leaders who seek to improve combat casualty care outcomes. The increase in scope of activities is also due to the excellent reputation earned by the JTS as a result of your tremendous contributions.

Thanks again to all for your commitment to the mission.

COL Kirby Gross distinguished himself through exceptionally meritorious service to the US Army from March 2006 to February 2016. During this time, he served in a succession of positions of greater importance and responsibility, culminating at the Trauma Consultant to the Office of the Surgeon General and the Director of the JTS. Other positions of signifi-cant leadership include: Commander of the 772nd Forward Surgical Team – Operation Iraqi Freedom (OIF); Chief of Surgery of the 10th Combat Support Hospital; and medical support of Special Operations.

COL Gross influenced Army and DoD policy and program recommendations to the Chief of Staff, Army; the Vice Chief of Staff, Army; and the Combatant Commanders on a monthly basis. His advice reflected the depth and breadth of his considerable experience and affected future programs and policy that will carry the DoD through the end of sustained combat operations. COL Gross relentlessly focused on battlefield care and saving lives in both OIF and Operation Enduring Freedom (OEF) by utilizing his experience to expand prehospital/point of injury (POI) evacuation trauma care guidelines; through training of military providers; by conducting research to reduce morbidity and mortality of our warri-ors; and by deploying seven times for a cumulative 50 months.

As the Director of the JTS, which contains over 116,000 records in its DoDTR, COL Gross deployed to Iraq and Afghanistan two times as Theater Director; he helped train 15 theater teams, which grew from seven members in 2004 to 17 members in 2014; helped develop 44 CPGs; and conducted a comprehensive review of the CPGs, which decreased variation in deployed trauma care; and he contributed to the military trauma system manual for the American College of Surgeons. In this role, COL Gross was a driving force in preparing medical personnel to meet the challenges of battlefield operations, ensuring they had the skills necessary to provide optimum care to casualties. He also published in peer reviewed journals; presented at national trauma academic societies, increasing the knowledge of providers on the advances of trauma care. COL Gross was recognized as a clinical expert by receiving the “A” Proficiency Designator. He has directly touched the lives of hundreds of surgeons and indirectly the lives of thousands of patients. He has done this through his tireless efforts to educate and train the military surgeons of the future, his leadership in na-tional organizations, his scholar-ly publications and presenta-tions, and through his skill as a surgeon. In each of these roles, COL Gross’ exceptionally out-standing service, tireless devo-tion to duty, strong love of this country, and intense desire to serve the Soldiers who protect it, reflect great credit on him, the US Army Medical Command and the US Army.

COL Michael Wirt, ISR Commander, presents COL Kirby Gross with an ISR coin.

H ONO RIN G CO L G ROSS “COL Gross brought a unique perspective from his many years in private practice and his enthu-siasm for our mission was very contagious. There was never a day he was not excited to serve this great nation and never a meal he did not like,” said Dominique "Dom" Greydanus, MBA, Program Manager/Administrative Officer. In COL Gross’ words: “You know what we have here at the Joint Trauma System? We have agitators, those who are not willing to accept anything less than perfection. We know we've come a long way in im-proving lives on the battlefield, but guess what? There is still plenty more to improve and that's what we are continuing to do today. “ Paraphrased by Dallas Burelison, MBA, Education Branch Chief.

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Times: They are a Changin’ [These musings are brought to you courtesy of Cynthia, whose insistence and persistence ulti-mately wore down my resistance. So here goes my first ever Director’s Column….]

“May you live in interesting times.”

This is an old Chinese curse, and if you know anything about the several millennia of Chinese history you would agree that interesting times were usually bad – fam-ine, war, plague, street mimes – the list is endless.

Well, I appear to have succeeded to the JTS Directorship during interesting times. And while we may not be dealing with famine or plague, there is still a war. It is a time of change and uncertainty for us. Will we move organizationally (but fortunately not physically) to DHA? Stay within the ISR? When will we find out? How will the DCoEs integrate their registries? Where IS Waldo? All of these are, at this time, unan-swered questions. Or to be more accurate, have different answers depending on whom you ask. I certainly don’t have the answers, but rest assured I am making

DIRECTOR’S NOTES

Mary Ann look for them. And being a trauma surgeon, my philosophy is to hope for the best but prepare for the worst. Over the coming months we will plan for all eventualities.

So we must turn to yet another oriental proverb: “Must float like leaf in stream of life.” (Well, a Vietnamese general said it in the movie “The Ladykillers,” so it must be true.) The leaf may not control the direc-tion or the destination but float it must, lest it be overcome by events. Wherever we end up and however things reorgan-ize in this phase of the restructuring of the Military Health System, we still have a job to do and we will continue to do it with the unparalleled excellence that eve-ryone has come to expect from the JTS. Over the last year alone, under COL Gross’ guidance, the JTS won the MEDCOM Wolfpack Award, the AMSUS Force Health Protection Award, and the Major Jonathan Letterman Award.

So BRAVO ZULU to everyone! (Sorry, you’re going to have to get used to Navy jargon in the Director’s column.) Note that these are all unit awards, not awards to a single individual. JTS has been doing great things for years before I showed up, and one hallmark of any well-functioning enterprise with a clear mission is that a change in leadership does not turn every-thing upside down.

So we can all expect to stay busy. While there are relatively few new patient rec-ords to abstract (a good thing for those down range in harm’s way), there are plenty to re-abstract, we are discovering new sources of trauma data, and there are data holes to fill in the DoDTR. The prehospital and medevac/MERCuRy pro-jects must grow. Requests for data and analysis will continue. We have other COCOMs to conquer, and CPGs to publish.

So we do live in interesting times, but I’m pretty sure we’re up to the task. I’ll have to get back to you about the mimes.

CAPT Zsolt Stockinger, MC, USN JTS Director

JTS is proud to announce it is the receipt of the 8th Annual Major Johnathan Letterman Medical Excel-lence Award for excellence in battle field medicine and outcomes. COL Kirby Gross, former JTS Direc-tor, accepted the award on behalf of the JTS at the Letterman Awards dinner October 8th. Letterman winners are recognized for their innova-tive efforts in civilian emergency or combat casualty care. They work toward improving outcomes for patients with catastrophic injuries and draw on to-day’s cutting edge medical technology to develop new ways to assist Armed Forces members or civil-ians who have suffered severe disfiguring wounds. In this case, JTS has helped drive the innovation, implementation and adoption of devices and techniques that increase a trauma patient’s chance of survival. “By selecting JTS to receive this award, senior military medical leaders acknowledge the impact of JTS,” said COL Gross. “Both MAJ Letterman and JTS brought improvement in battlefield medicine by influencing the system of care. The work of JTS is not complete; much opportunity for improvement in combat casualty care remains.” The MAJ Jonathan Letterman Awards are sponsored by the National Museum of Civil War Medicine (NMCWM). Nominees are submitted to NMCWM and honorees are selected by two US Army Major Generals, one US Army Lieutenant General, one US Navy Captain and the NMCWM Executive Director.

JTS WJTS WJTS W INSINSINS PPPRESTIGOUSRESTIGOUSRESTIGOUS LLLETTERMANETTERMANETTERMAN MEDICALMEDICALMEDICAL EEEXCELLENCEXCELLENCEXCELLENCE AAAWARDWARDWARD

WWWARRIORSARRIORSARRIORS EEEXTENDXTENDXTEND SSSPECIALPECIALPECIAL TTTHANKHANKHANK YYYOUOUOU TOTOTO JTSJTSJTS

JTS was recently honored by those special warriors who dedicate their lives to our pre-serving our freedom and safeguarding our families at home and abroad. The plaque bore this moving message. JTS members “have exemplified them-selves in the execution of our global mission to maintain the health and welfare of personnel in order to disrupt, dismantle and destroy terrorist threat, deny enemy sanctuary and exhaust every possible means to implement mission driven solu-tions to enable every officer and operator the abil-ity to effectively execute their specialized skills at an optimum level for maximum success.”

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Recovering Encryptions Keys

to View Old Emails

By Mary Jo Glunz-Bartz, JTS Information Manager

Are you due to get a new CAC?

Do you receive/send encrypted email?

Are you converting from contractor to civilian or civilian to contractor?

Are you moving from one service to another?

Then you need to know about Public and Private Keys and the effect on encrypted email.

Public Key Infrastructure (PKI) certificates and their re-spective keys are embedded in the integrated circuit chip on a Common Access Card (CAC). When obtaining a new CAC, a new email encryption certificate is generated and previously encrypted email is inaccessible. To read older emails, you must recover your previous encryption key(s).

There are two keys. The public key is used to encrypt email and a matching private key is used to decrypt email. En-crypted email can only be opened with the private encryp-tion key that matches the public encryption key originally used to encrypt the email. DoD PKI established the key escrow and recovery process to recover email encryption keys associated with previous CACs. You can recover your encryption keys either manually through this page. When logging in, use your regular logon; do not use the email certificate. I just renewed my CAC and was asked by the clerk if I wanted to recover my keys. At the time I said I didn’t have anything I needed to access. I was proven wrong the next day. Fortunately, the clerk handed me a flyer with instruc-tions. It was easy and I had the capability to go back to every CAC I’ve had since I came to JTS in 2007. Did I say it was easy?

For information: https://afpki.lackland.af.mil/html/keyrecovery.cfm

News 1 of 3

JTS is buzzing about MERCuRY, yet few have a sol-id grasp of the project. The translated acronym Military En Route Care Registry provides some insight, but fails to illus-trate the big picture, and there is so much more to the story.

MERCuRY grew out of the need to collect more Med-evac data and to fill existing gaps in the collection of trauma care data of patients in transit.

There are inconsistencies in the collection meth-ods and terminology between services and transport means.

There is no means to consolidate data from all transit movement into a central database.

There is no process to retrospectively evaluate and analyze en route care.

MERCuRY will also satisfy the informational require-ments of the Golden Hour rapid evacuation initiative to measure the effectiveness of the program.

To resolve the matter, leaders from Air Force and Ar-my units put their heads together and decided a sin-gle en route registry was in order. The proof-of-concept, En Route Registry, was programmed for a limited collection data set and then expanded to in-clude Critical Care Air Transport Teams (CCATT).

DoDTR was chosen because it is recognized for its ability to support specialized collection of data (read: medical specialty registries) and with the capability for systematic review and analysis leading to perfor-

mance improvement and quality assurance.

MERCuRY will collect and store clinical data from en route movement of patients worldwide from six dispar-ate data sources.

MERCuRY will capture en

route trauma care from the following sources.

En Route (prototype)

Golden Hour (declassified)

Theater Medical Evacuation

Two CCATT

USAF Aerospace Medicine

These databases can be queried for clinical event review, performance improvement, and high-value innovation. MERCuRY will contain data from past transports, link directly with the DODTR to review long-term clinical outcomes, and be used as a mod-el for possible prospective collection of data for medical and trauma patients.

As MERCuRY Program Manager Col Stacy Shackel-ford explains it: “This project is a long overdue effort to collect detailed data on en route care. MERCuRY will be the most detailed database ever created for evacuation at all levels and support re-search by collecting massive amounts of retrospec-tive data. We are also simultaneously developing a prospective process in order to capture this data real-time going forward to be used as a powerful Quality Improvement tool.”

By Mary Jo Glunz-Bartz, JTS Information Manager

MERCMERCMERCUUURY ERY ERY EXPECTEDXPECTEDXPECTED TOTOTO DDDELIVERELIVERELIVER UUUNPARALLELEDNPARALLELEDNPARALLELED SSSINGLEINGLEINGLE SSSOURCEOURCEOURCE DDDATAATAATA AAAGGREGATIONGGREGATIONGGREGATION CCCAPABILITIESAPABILITIESAPABILITIES

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The JTS played a prominent role in the White House’s Stop the Bleed Forum in Washington, D.C. October 6th. The initiative is a joint effort among several government agencies and the private sector to give citizens the tools they need to help in an emergency situation and knowledge to stop life threatening bleeding. The nation-al campaign includes prehospital measures recommend-ed by the JTS and Tactical Combat Casualty Care (TCCC) to control external hemorrhage to increase an injured person’s chance of survival.

According to the White House, The goal of this initiative is to build national resilience by empowering the general public to be aware of the simple steps that can be taken to stop or slow life threatening bleeding, and to pro-mote the general public’s access to Bleeding Control Kits

in public spaces, while they travel, and in the home. Working with the private sector and nonprofit organi-zations, the Stop the Bleed Campaign will put knowledge gained by first responders and our military, into the hands of the public to help save lives. The town officials of Davie, Florida were invited to partici-pate in the White House event. Davie was recognized as one of the leading municipalities that has already added severe bleeding kits to community rescuers.

JTS accomplishments in trauma care are monumental to improved external hemorrhage control interventions, particularly tourniquets and hemostatic dressings, in the US Military. These military advances in external hemor-rhage control were the basis for the White House Stop the Bleed Campaign. With these tools, bystanders will be able to do what medical officials say is the most criti-cal task in the moments after an injury: keep the victim from bleeding to death. Similar to the use of CPR or automatic defibrillators, improving public awareness about how to stop severe bleeding and expanding per-sonal and public access to Bleeding Control Kits can be the difference between life and death. The kits typical-ly CAT or SOFT-T tourniquets and hemostatic dress-ings, protective gloves and elastic bandages. Dr. Jonathan Woodson, a featured speaker, emphasized those first on the scene, even before professional first responders, can make all the difference during what he calls the “miracle minute.” He drove this point home in his speech by pointing out that in the 10 minutes it would take him to finish his speech an injured person would bleed to death from an injury from a large artery or vein if someone did not stop the bleeding.

JTS’ own prehospital trauma expert, Dr. Frank Butler, MD, has been involved in this effort since its inception in

(L-R): COL (Retired) John Holcomb, former USAISR Commander , Col Jeff Bailey, Director for Surgical Services at WRNMMC, COL Kevin O'Connor , Physician to the Vice-President, COL Bob Mabry, Robert Woods Johnson Congressional Fellow, CAPT (Retired) Frank Butler - Chairman of the Committee on TCCC, Dr. Dave Marcozzi - Former White House Staffer for Medical Policy

White House Stop the Bleed Campaign to Advance Civilian Emergency Care Based on JTS’ Trauma Care Guidelines and Innovations

1993 when he penned the original TCCC paper. The docu-ment is a product of a combined research effort per-formed by the Special Operations medical community and Uniformed Services University of the Heath Services, a JTS data sharing partner. The Stop the Bleed campaign was founded on these TCCC principles.

The TCCC measures were implemented in Denver, Colora-do where six lives were saved in two years.

“The improvements in battlefield trauma care pioneered by the Committee on Tactical Combat Casualty Care and the JTS have saved the lives of thousands of wounded warriors. It has been an incredible honor to be part of this great team,” said Butler.

T C C C C O U R S E T R E A T M E N T G O A L S

Hemorrhage control

Tourniquet application

Direct pressure

Topical hemostatic agent use

Wound packing

Airway management

Nasopharyngeal airway

Cricothyroidotomy

Supraglottic airway devices

Endotracheal intubation

Breathing

Treat open pneumothorax

Recognize and treat tension pneumothorax

Circulation

Intravenous/intraosseous access

Fluid resuscitation

Junctional hemorrhage control (tourniquet application)

Medication administration

Analgesics: fentanyl, morphine, ketamine

Antibiotics

Tranexamic acid

Blood product administration

Fracture Splinting

News 2 of 3

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Coming Soon to DoDTR: ICD-10 Compliance New Coding System Promises to Deliver Detailed

Data & Ease Performance Improvement Measures

JTS is currently in the process of upgrading the DoDTR to incor-porate the mandatory International Classification of Diseases Revision –10 (ICD-10) HIPAA transaction code sets for diagnosis in accordance with the 01 Oct 2015 deadline. ICD-9 coding will remain in the background to facilitate the maintenance of exist-ing ICD-9 coded records. The upgraded DoDTR will also offer PCS coding.

ICD-10 provides much-needed updates to medical terminology and disease classification, as well as codes that allow for compar-ison of mortality and morbidity data.

ICD-10 offers an extensive set of diagnosis codes—about 68,000 to ICD-9’s 14,000. In this case, more is definitely better. More codes mean concise diagnoses. Medical providers can more accurately document clinical information. ICD-9’s limited number of codes produced indistinct, limited patient data. Specific data translates into more granular data analysis.

AHIMA and the eHealth Initiative (eHI) have released results from their third annual survey of healthcare providers to assess the ICD-10 transition's anticipated impact. More respondents than last year said they believe ICD-10 will make it easier to perform activities such as analyzing and reporting measures on performance, quality, and safety or collecting and exchanging health information

“The new coding system will allow unparalleled specificity in Diagnoses and Procedure coding, and will continue to allow the JTS to remain at the forefront of trauma injury classification, pa-tient care tracking, and evaluation of outcomes,” said Phil Sartin, Data Acquisition Branch Chief.

In the words of COL Kirby Gross, the JTS is most visible for two things: the Combat Casu-alty Care Curriculum Conference and the Clini-cal Practice Guidelines (CPGs). Trauma care professionals look to JTS for latest infor-mation on trauma care instruction, tech-niques, pharmaceutical guidance, and sup-porting innovations. The JTS CPGs deliver the complete package. Maintaining the CPGs is essential to producing the game-changing guidelines.

The JTS Education team is taking advantage of this time of transition to update the entire collection of the CPGs which now totals 44. JTS Director CAPT Zsolt Stockinger and Educa-tion Branch Chief Dallas Burelison are leading the effort. This feat would not be possible without the support and commitment of sen-ior tri-service members and coalition partners. Over 240 Subject Matter Experts contributed to this formidable task.

“Now that the operational tempo has de-clined with the transition of Operation Endur-ing Freedom into Operation Freedom's Senti-nel, it is the logical time to update the CPGs to reflect our accumulated global war on terror-ism experience, and to revise them to no long-er be specific to the US Central Command area of operations. This is particularly im-portant as JTS works with other Combatant Commands (COCOMs) like Pacific Command to develop their own trauma systems,” said CAPT Stockinger.

A refined approach to the sharing and distri-bution of CPGs will give COCOMs the ability to rapidly disseminate to their respective areas

of operations and provide quality indicators to measure effectiveness.

The updated CPGs will make their publishing debut in a prominent journal. A special Mili-tary Medicine supplement will feature the most pertinent CPGs this spring. CAPT Stock-inger explains just how important publication is to the successful adoption and application of the CPGs.

"Publishing the CPGs as articles in the Military Medicine is important for two reasons. First, dozens if not hundreds of individuals assist in the writing of the CPGs, most outside of the JTS, none of whom has ever received public credit for the contribution. These contribu-tors will finally receive the recognition they deserve, and I have no doubt that formal au-thorship opportunities will generate help with future CPG updates,” said CAPT Stock-inger.

“Second, the CPGs will now be available in searchable peer-reviewed medical literature, the source to which most medical profession-als turn for guidance or justification. Citing literature carries much more weight in the medical community than does citing a web-site or a military instruction, particularly on the civilian side. And just like Tactical Combat Casualty Care, the publication of CPGs can be used to disseminate applicable medical knowledge from the military to the civilian sector."

According to the New York Times, mankind has only been at peace for 8% of recorded human history. At this rate, the CPGs will con-tinue to be a needed and valued resource.

CPG Collection Updated to Deliver Game-Changing Trauma Care Instructions, Techniques

News 3 of 3

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TCCC UPDATE

The failure rate for surgical airways performed during battlefield trauma care has been reported to be 33%. 1

LTC (P) Bob Mabry recently published the results of a research project in which US Army combat medics were found to perform surgical airways on human cadavers with 100% success using the CricKey surgical airway device, compared with a 70% first-pass success rate using the stand-ard technique. They were also able to perform a surgical airway significantly fast-er with the CricKey as com-pared to a con-trol group that performed surgical airways without using this device (34 seconds vs 65 seconds). 2

A proposed change to the TCCC Guide-lines to add the use of the CricKey as the preferred technique for surgical airways was recently reviewed by the TCCC Working Group and approved by

the required two-third or more of the voting members of the Committee of the TCCC (CoTCCC).

The position paper for this change to the TCCC Guidelines has been ap-proved for publication by USAISR. It will be published shortly in the Jour-nal of Special Operations Medicine.

The training slides to support this change have been developed by Dr. Stephen Giebner, the CoTCCC Devel-opmental Editor and forwarded to the TCCC Distribution Group. The CricKey change slides will be incorpo-rated into the 2015 version of the TCCC for Medical Personnel curricu-lum. Both that curriculum and the TCCC for All Combatants curriculum are being updated and will be availa-ble in the near future.

Thanks to LTC Bob Mabry and his team for developing this update.

References 1. Mabry RL. An analysis of battlefield crico-thyroidotomy in Iraq and Afghanistan. J Spec Oper Med. 2012;12:17–23.

2. Mabry RL, Nichols MC, Shiner DC, et al. A comparison of two open surgical cricothy-roidotomy techniques by military medics us-ing a cadaver model. Ann Emerg Med. 2014;63:1–5.

The CoTCCC has evaluated the Ab-dominal Aortic and Junctional Tour-niquet (AAJT) for potential use in TCCC.

No human or animal data were found that document the safety and efficacy of the AAJT when it is ap-plied to the abdomen in the pres-ence of an unrepaired vascular injury proximal to the site of aortic occlu-sion. Entrance wounds for high ve-locity projectiles or blast fragment do not reliably predict the internal course of the bullet(s) or the frag-ment(s).

Further, recent research performed at the US Army Institute of Surgical Research evaluating the effect of aortic occlusion by the CRoC and the AAJT have noted adverse effects with a 2-hour application time. In the AAJT study, Dr. Kheirabadi studied a two-hour application of the AAJT in six spontaneously breathing pigs. His conclusions were that “The ischemia-induced hemodynamic and metabol-ic changes from the two-hour AAJT application were more severe than those measured with other JTQs (previously studied) and were life-

threatening in spontaneously breath-ing subjects. Cardiopulmonary sup-port appears necessary at the time of release of AAJT to prevent hyperkale-mia-induced respiratory or cardiac arrest.” (Dr. Bijan Kheirabadi – ab-stract submitted for MHSRS)

In light of the above and after discus-sion with the JTS leadership, further evaluation of the AAJT for use in TCCC will be suspended. This decision is subject to change as new data be-come available or if the recommenda-tions for use of this device are modi-fied by its manufacturer. Note: Dr. Frank K. Butler, Jr, CoTCCC Chairman provides the TCCC updates.

C RICK EY S URGIC AL A IRWAY

D EVIC E A DDED TO TCCC

G UIDE LINE S

A B D O M I N A L A O R T I C

J U N C T I O N A L T O U R N I Q U E T

E V A L UA T E D B Y C O T C C C

CricKey prototype using a Cook Melker cannula.

Abdominal Aortic and Junctional Tourniquet

TCCC UPDATE

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The Pacesetter Honors Exemplary Performance

The Pacesetter program recognizes and honors JTS staff members who set the pace for the organization’s standard of excellence. Pacesetters lead by example, demon-strate a positive attitude when faced with challenges, and are known for their collaborative spirit. They take pride in their work and it shows in the product. Each quarter, JTS leadership selects professionals whose behaviors and work ethics support or further the mission, goals, values and initiatives of JTS.

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EEENSURINGNSURINGNSURING EEEXCELLENCEXCELLENCEXCELLENCE INININ DDDOOODTR DTR DTR

DDDATAATAATA IIINTEGRITYNTEGRITYNTEGRITY & A& A& ACQUIS ITIONCQUIS ITIONCQUIS ITION

Phil Sartin, Data Acquisition Branch (DAB) Chief, joined the JTS in 2007, bring-ing significant trauma registry knowledge and experience from his work at Landstuhl Regional Medical Center (LRMC). As the former Director of Trauma Informatics of the LRMC Trauma Program, where he oversaw the develop-ment of its trauma registry, Phil was well positioned to steer the DoDTR in the right evolutionary path. He was instrumental in identifying the user require-ments, defining the business rules and developing acquisition support tools. Phil also oversaw user end development and testing of the DoDTR.

Phil’s first position with the JTS was the Data Acquisition Branch’s Level 5 Data and Quality Manager. Phil was charged with and implemented the JTS Level 5 program, establishing trauma nursing coordinators at satellite offices in 10 High Trauma Volume Army Medical Treatment Facilities in the continental US. This program facilitated the capture of outcome data as patients transitioned through the continuum of care. The program thrived under his leadership.

In May of 2009, Phil advanced to the role of Branch Data and Quality manager. He has created a number of applications to facilitate work flow in the DAB. Of all his accomplishments, Phil is most proud of the efforts to streamline the acquisition process through the ongoing development of the DoDTR as well as the development of standardized processes and tools, such as the Data Element Database and the Quality Assurance Tracking Application. Phil stat-ed, “These resources are living, flexible tools which have adapted to our ever evolving trauma system/registry requirements and have provided a founda-tion for consistency in data acquisition with assets spread across the globe.”

In July of 2014, Phil once again transitioned within the organization to the position of acting DAB Branch Chief and eventually Branch Chief as he transitioned to civil service in Jun 2015.

“He has assisted in developing the DoDTR practic-es and has been the driving force and continuity behind the education and training for the last cou-ple of years, particularly the transition between the store and forward and web implementation,” said JTS Deputy Director Mary Ann Spott.

During his tenure, Phil has taught trauma abstrac-tion and Report Writer to generations of deployed JTTS personnel.

“His Report Writer expertise is second to none, often creating specialty cus-tom reports on short notice to assist our deployed colleagues,” said Renee Greer, MOTR Branch Chief. “His attention to detail and testing plans have saved hundreds of man-hours of rework. Phil is so good at data management that sometimes new personnel forget Phil is a trauma nurse to the core.”

This fall, Phil organized a team of subject matter experts for developing and providing DoDTR ICD-10 implementation training to JTS staff and DoDTR us-ers. The implementation of ICD-10 within the DoDTR will continue to advance the system’s capability to detail our population’s distinct injury patterns, the provided care, and performance improvement evaluation of outcomes.

After all these years, Phil remains fascinated with the rapid impact JTS has on trauma care.

“With the combined resources of our system including acquisition, analysis, performance improvement, and automation, we have been able rapidly pro-duce feedback to customers within our continuum to standardize and im-prove trauma care. It has been a privilege to work with so many dedicated personnel who strive to maintain this capability on a daily basis,” said Phil.

Pacesetter Phil Sartin, DAB Branch Chief

By Cynthia R. Kurkowski, JTS News Editor

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Laser Danger

The benefits of laser technology comes with disadvantages if precautions are not taken. As the Dazzler debuts in civilian police forces and becomes commonplace at security checks, educating the public about the risk of eye injury is critical.

Lasers are critical components of a va-riety of military activities, including range finding, target designation, live-fire simulation, and escalation of force (EOF) security warnings. Unfortunate-ly, the increasing use of laser-based technology also increases the potential for ocular injuries. Reports indicate that many of these incidents were the result of lasers being used as signaling devices towards fellow soldiers or as props for jokes (e.g., “lightsaber” bat-tles). 1 As the majority of laser eye inju-ries are due to the improper operation of laser devices or misuse, it is im-portant that military personnel and civilians have a clear understanding of the proper use, control and hazards of lasers.

Contrary to popular misconception, the majority of laser exposures, or illu-minations, do not result in ocular inju-ry. Nevertheless, the momentary dis-traction following a laser illumination still can have devastating effects, par-ticularly on the performance of critical military tasks (e.g., aiming a weapon and operating vehicles and aircrafts).2 In recognition of such consequences, it is a federal offense to aim a laser at an aircraft in the U.S., subject to a fine and imprisonment.3

Serious ocular injury is uncommon. Damage from a visible laser requires a

combination of sufficient power and time exposure to cause true damage. The permanence and severity of laser-induced ocular damage primarily de-pends upon characteristics of the laser. Power is reliant on both the power of the laser as well as the dis-tance from the target. For military visible lasers like the green beam des-ignator (GBD-III) or “dazzler,” the nominal ocular hazard dis-tance (NOHD, or the danger zone) is gener-ally on the or-der of 50m.

Military lasers are often clas-sified by wave-length (visible or invisible) and power. Lasers with wavelengths in the “visible” spectrum are often used in EOF activities and immediate-ly convey the message “I see you and have you in my sights.” A common example is the “dazzler” often used at security checkpoints and on pa-trols.5 Only wavelengths of light in the visible and near infrared spec-trums are capable of damaging the retina, thus producing more severe ocular injuries. 4

The risk of ocular injury typically in-creases with the power of the laser, though the same amount of damage could be produced using less power if the laser energy is emitted in short-er, more concentrated pulses, the dwell time is increased or the diame-ter of the laser beam (i.e., spot size) is decreased.6 The distance of a laser from its target is also important, as

the laser is better able to be concentrat-ed on one spot on the retina at closer distances. 7

The beam has to hit the eye and stay there for quite a bit of time (a few seconds, with

more time required for further dis-tances). It's very rare that a sweeping laser exposure will cause injury.

Invisible lasers (e.g., range finders) are generally more powerful and emit a very short concentrated burst of laser. Each pulse is typically power-ful enough to cause some damage and doesn't have to dwell on the reti-na as long. Accidental exposure can cause near-immediate injury. Vision

drops abruptly and stays down (it might even get progressively worse, quickly). Most invisible laser injuries are self-induced accidents.

The non-military dazzler version ap-proved by the FDA for use by law en-forcement officers has a output of 200 milliwatts (0.200 watts), compared to the military grade green laser output of 532 nanometers (5.32 watts).

Atmospheric conditions (e.g., rain or fog), certain protective devices (e.g., flight masks), and eye-related charac-teristics (e.g., blink reflex and pupil size) also affect the potential for laser-related ocular damage, primarily by redirecting the laser beam or control-ling the amount of energy absorbed by the eye. Additionally, the use of certain optical devices such as binocu-lars or sighting instruments may in-crease the risk of ocular injury by mag-nifying the power of the laser beam.

Visual symptoms following a laser ex-posure are often limited to the eye’s normal response to bright light, most notably temporary dazzle or flash-blindness that typically resolves within minutes. Individuals with true laser injuries often report seeing a flash fol-lowed by a sudden and severe de-crease in visual acuity. 4, 8

(Continued on page 17)

By Robert Mazzoli & Devon Oskvig, Vision Center of Excellence

10

We are so attached to our iPhones we forget the radiation warnings of the early cell phone days.

A new study concluded that damage caused by cell phone radiation to human DNA over long pe-riods increases the risk of suffering not only head-aches, fatigues and skin disorders, but also can-cer. For example, using your cell phone for just 20 minutes a day for five years increased threefold the risk of one type of brain tumor, and using the cell phone an hour a day for four years upped the risk of some tumors three to five times, research-er Igor Yakymenko said. The study analyzes the oxidative effects of low-intensity radio frequency radiation (RFR) in living cells. 1

That confirms what interphone researchers from 13 countries found in a 2008 study sponsored by the International Agency for Research on Cancer. They found the chance of getting a brain tumor—specifically on the side of the head where you use the phone—goes up as much as 40 percent for adults after a decade of cell-phone use. We are entering the fourth generation of cell phone use.

That is why communities such as Berkeley, California are stepping up public awareness efforts with its Right to Know Ordinance which requires cell phone retailers to inform consumers they may exceed the federal guidelines for Radio Frequency Radiation (RFR) exposure by carrying a cell phone on your person (in your shirt pocket, pants, or bra). Under this new set of guidelines, Berkeley lawmakers are heightening the level of con-cern surrounding mobile devices. The warning must clarify the potential risk is greater for children. The child’s reportedly brain absorbs twice the radiation as the adult’s brain. Moreover, any metal (e.g., dental fillings, earrings, eyeglass frames) could increase the radiation absorption.

The new ordinance “outs” the inadequate Specific Absorption Rate (SAR) standard to the public. When the SAR which includes the acceptable RFR rate was determined back in 1996, the FCC based it on the assumption that consumers carry their cell phones in a manufacturer-approved holder designed to keep the phone a minimum distance from the body. (Turns out the purpose for those leather carrier cases sold everywhere was more than just convenience.) The assumption is false. Today’s slim cell phone design makes it easy for people for carry them in their pockets, socks and bras.

SAR certification has come under scrutiny for its shortcomings. Official, consistent standardized SAR testing procedures for FCC compliance do not exist. The agency relies on industry organiza-tions (e.g., ANSI, IEEE) and private ventures for SAR testing procedures. Regulations governing the SAR testing are 50 years old. They were de-rived from levels determined in the 1960s during early research of radiation hazards. The FCC ad-mits it struggles to match testing requirements with constantly changing cellular technologies. Cell phones are tested against artificial materials, not humans, animals or biological materials. Add to that popular wearables and Bluetooth technol-ogies which people wear around the clock do not even require SAR testing.

“If industry does not want to advise people about the fact that phones are not tested next to the body, then they should get the FCC to change its requirements for radiation testing,” said Environ-mental Health Trust's Senior Medical Advisor, Dr.

Robert Morris, MD, Ph.D. “They cannot do this because, if phones were tested next to the body, they would be found to emit too much radiation to pass current standards.”

The FCC requires wireless phones to have SAR levels no greater than 1.6 watts per kilo-gram. When all transmitters are working, the SAR value increases. Simultaneous use is the norm rather than the exception given today’s cell phone operator who talks, texts and surfs the Internet. Phone manufacturers are not required by law to disclose this simultaneous SAR. The FCC’s downplay of the simultaneous SAR illustrates how outdat-ed the SAR standard is.

Finding your phone’s SAR is a feat of patience and persistence. The rate is not conven-iently displayed. In fact, it is not displayed on your phone, listed in product literature, or published in most manuals. To find out your SAR, you must know the phone’s FCC iden-tification (FCC ID) in order to look up the phone’s SAR on the FCC website. You can find the FCC ID number on the phone case of the phone, usually hidden under the battery. Once you have the number, you go to Equipment Authorization section of the FCC web-site and perform a “FCC ID Search.” A list of documents appears. You have to dig

(Continued on page 11)

CAUTION : U SE CELL PHONE AT YOUR OWN R I SK New Ev idence Renews Old Fears o f Radiat ion Po i son ing , Cancer

By Cynthia R. Kurkowski, JTS News Editor

Left: Thermographic image of the head without radiation exposure.

Right: Thermographic image of the head after 15-minute cell phone call. Yellow and

red areas indicate thermal (heating) effect that can cause health effect.

11

through the documents to find the SAR compliance and certification infor-mation. I found the SAR listed in the con-clusion of the SAR testing reports. The FCC did not list my ZTE’s documentation. I had to Google the phone model num-ber and FCC ID to find documents listing the SAR value. The ZTE SAR did fall well under the acceptable 1.6 watts/kilogram rate for both next to head and near the body. Further investigation, however, revealed the higher end cell phones like the iPhone barely squeak past over the acceptable RF rate by .01 in simultaneous mode, which brings us back to why those radiation warnings are so im-portant.

Recent studies show low intensity RFR contributes to cell mutation, aka cancer growth. Among 100 currently available peer-reviewed studies dealing with oxi-dative effects of low-intensity RFR, 93 confirmed that RFR induces oxidative effects in biological systems. Analysis demonstrates low-intensity RFR is an expressive oxidative agent for living cells

with a high pathogenic potential and that the oxidative stress induced by RFR expo-sure should be recognized as one of the primary mechanisms of the biological activity of this kind of radiation. It is well established that oxidative stress is associated with carcinogenesis. For instance, the oxidative stress elicited by Membrane-Type1 Matrix Metalloproteinase is implicated in both the pathogenesis and progression of prostate cancer.2

Similarly, experimental evidences of cancer expansion in rodents caused by long-term low-intensity RFR exposure were published.3 Activation of Ornithine decarboxylase (ODC) was detected in RFR-exposed cells. ODC is involved in processes of cell growth and differentiation, and its activity is increased in tumor cells.4 Although overexpres-sion of ODC is not sufficient for tumorigenic transformation, an increased activity of this enzyme was shown to promote the development of tumors from pre-tumor cells.5

Other studies found ODC is also overexpressed in breast cancer tissues and cell lines compared with non-tumor tissues and normal breast epithelial cells. There was a posi-tive correlation between the level of ODC mRNA and the staging of tumors. 6

“The International Agency for Research on Cancer (IARC, part of the World Health Or-ganization) has concluded that the radiation they [cell phones] emit is a possible cause

(Continued from page 10)

Think twice before stashing that cell phone in your bra. Dr. Lisa Bailey, a Bay Area breast surgeon, reports “some very unusual breast cancers” in women who carried their cell phones in their bras. In some cases, the cancerous areas were suspiciously shaped like cell phones. Breast cancer is also impacting more women in their early twenties – a rare occurrence in the past.

Pocketing the cell phone in your jeans can cause reproductive complications and prostate cancer. Studies in Aus-tralia and India have found men who use cell phones most frequently (and keep them in their pants pocket) had lower sperm counts than those who used cell phones less often.

L A D I E S

G E N T L E M E N

of cancer. Those cases might take decades to develop. So, if there is a risk, we won't know for sure until tens of thousands of people have died,” said Morris.

“In the meantime, it seems prudent to reduce exposures, especially when doing so can involve something as simple as using headphones. Improving consumers' access to warnings about potential risks, warnings that are already in the phones, is a no brainer. Why is industry fighting this?"

To understand how radio frequency electronic magnetic fields impact your health, check out PowerWatch. http://www.powerwatch.org.uk/rf/phones.asp

References

1 Yakymenko I1, Tsybulin O, Sidorik E, Henshel D, Kyrylenko O, Kyrylenko S. Electromagn Biol Med. 2015 Aug 19:1-16. Oxidative mechanisms of biological activity of low-intensity radiofrequency radia-tion.

2 Nguyen, H. L., Zucker, S., Zarrabi, K., et al. (2011). Oxidative stress and prostate cancer progres-sion are elicited by membrane-type 1 matrix metalloproteinase. Mol. Cancer Res. 9:1305–1318

3 Chou, C. K., Guy, A. W., Kunz, L. L., et al. (1992). Long-term, low-level microwave irradiation of rats. Bioelectromagnetics 13:469–496 [CrossRef] [ISI]

4 Hoyto, A., Juutilainen, J., Naarala, J. (2007). Ornithine decarboxylase activity is affected in prima-ry astrocytes but not in secondary cell lines exposed to 872 MHz RF radiation. Int. J. Radiat. Biol. 83:367–374

5 Clifford, A., Morgan, D., Yuspa, S. H., et al. (1995). Role of ornithine decarboxylase in epidermal tumorigenesis. Cancer Res. 55:1680–1686 [ISI]

http://ehtrust.org/how-the-ny-times-and-cnn-bungled-a-basic-cell-phone-safety-story/

6. ODC & Breast cancer study: Role of ornithine decarboxylase in breast cancer. Deng W1, Jiang X, Mei Y, Sun J, Ma R, Liu X, Sun H, Tian H, Sun X. Acta Biochim Biophys Sin (Shanghai). 2008 Mar;40(3):235-43. http://informahealthcare.com/doi/full/10.3109/15368378.2015.1043557

12

“Flu shots are here!” messages signal flu season is officially here . The season extends through May 21, 2016.

While flu seasons can vary in severity, people 65 years and older usually bear the greatest burden of severe flu disease. It is estimated that this group repre-sents 80-90%of seasonal flu-related deaths, and 50-70% of the hospitalizations. In Texas there were 16 influenza-associated pediatric deaths last influenza sea-son. Over 31% of the children were vaccinated with the 14-15 influenza vaccine. The past season was moderately severe. CDC estimated last year’s flu vaccine reduced an individual's risk of visiting a doctor due to flu by only 23%. Keep in mind, 2014-15 flu vaccine was not a good match for the season’s dominant virus.

“Even in a good year, the flu vaccine isn’t as good as most of our vaccines. Its efficacy is around the 60, 65 percent range, which is, you might say, passable, but not what we would like,” said CDC Director Thomas Frieden.

There are several flu vaccine options for the 2015-2016 flu seasons.

Intramuscular (IM) vaccines will be available in both trivalent and quadri-valent formulations. (High dose vaccines, which are IM vaccines, will all be trivalent this season.)

For people who are 18 through 64 years old, a jet injector can be used for delivery of one particular trivalent flu vaccine (AFLURIA® by bioCSL Inc.).

Nasal spray vaccines will all be quadrivalent this season. Intradermal vaccine will all be quadrivalent.

The safety of Live Attenuated Influenza Vaccine (LAIV) in persons with other

underlying medical conditions that might predispose them to complications after wild-type influenza virus infection (e.g., chronic pulmonary, cardiovascu-lar [except isolated hypertension], renal, hepatic, neurologic, hematologic, or metabolic disorders [including diabetes mellitus]) has not been established.

Nasal vaccine sprays containing LAIV should not be used by:

1. Persons aged <2 years or >49 years.

2. Children aged 2 through 17 years who are receiving aspirin or aspirin-containing products.

3. Persons who have experienced severe allergic reactions to the vaccine or

any of its components, or to a previous dose of any influenza vaccine.

4. Pregnant women.

5. Immunocompromised persons.

6. Persons with a history of egg allergy.

7. Children aged 2-4 years who have asthma or a wheezing episode noted in

the medical record within the past 12 months, or for whom parents report that a health care provider stated that they had wheezing or asthma with-in the last 12 months.

8. Persons of any age with asthma are at increased risk for wheezing after

administration of LAIV.

9. Persons who have taken influenza antiviral medications within the previ-

ous 48 hours.

For 2015–16, U.S.-licensed trivalent influenza vaccines will contain hemaggluti-nin (HA) derived from an A/California/7/2009 (H1N1)-like virus, an A/Switzerland/9715293/2013 (H3N2)-like virus, and a B/Phuket/3073/2013-like (Yamagata lineage) virus. Quadrivalent influenza vaccines will contain these vaccine viruses, and a B/Brisbane/60/2008-like (Victoria lineage) virus, which is the same Victoria lineage virus used in 2013–14 and 2014–15.

What you should know about this flu season’s vaccine. http://www.cdc.gov/flu/about/season/flu-season-2015-2016.htm

Track the flu season week by week. http://www.washingtonpost.com/graphics/health/flu-tracker/

CDC: “Take 3 actions to fight the flu.”

CDC recommends a yearly flu vaccine as the first and most important step in protecting against flu viruses.

Everyday preventive actions may slow the spread of germs that cause respiratory (nose, throat, and lungs) illnesses, like flu. While sick, limit contact with others. Cover your cough or sneeze. Wash your hands!

If you get the flu, there are prescription antiviral drugs that can treat your illness. Early treatment is especially important.

By Maria G. Dominguez, R.N.COHN-S/CM & Cynthia R. Kurkowski, JTS News Editor

13

JTS partners with several industry leading organiza-tions to foster advances in medical care. Perhaps one of its most productive partnerships is with the Trauma Infectious Disease Outcomes Study (TIDOS) based at Uniformed Services University (USU). TI-DOS is an observational cohort study which evalu-ates infection-associated clinical outcomes in hospi-talized medical evacuees following traumatic injury.

TIDOS’s primary objectives are to describe trauma-related infectious disease epidemiology, evaluate short- and long-term outcomes (with a five year fol-low-up), and identify risk factors generating evi-dence to improve prevention and management. TI-DOS findings are enabling medical professionals to develop effective treatments of infectious diseases (IDs). Critical to the TIDOS analyses is Department of Defense Trauma Registry (DoDTR) data.

TIDOS grew out of the need to improve the under-standing of clinical outcomes related to infectious complications of combat trauma. During periods in 2010-2012, the invasive fungal wound infections (IFIs) incidence rates were as high as 10-12% for intensive care unit admissions at Landstuhl Regional Medical Center (LRMC) in Germany (where patients received care after medical evacuation from combat zone prior to transfer back to the United States). The rates coincided with high blast casualty rates. In ad-dition, the increasing rates of infections secondary to multidrug-resistant organisms were of particular concern. TIDOS investigators led the investigation into the unexpected outbreak of IFIs using data ob-tained from the DoDTR/TIDOS infectious disease (ID) module.

A Memorandum of Understanding between JTS,

ing IFIs. TIDOS analyses have since confirmed the independent IFI risk factors cited in the JTS CPG, in-cluding blast injuries sustained while on foot patrol, traumatic above knee amputations, and large-volume (>20 units) blood transfusions within the first 24 hours after injury. In addition, a local CPG was implemented at LRMC, which greatly reduced diagnosis time and treatment initiation as confirmed through process improvement analysis by the TIDOS team. Furthermore, a TIDOS analysis demonstrated the significant negative impact of IFIs on the timing of wound closure and healing. Aggressive surgical debridements remain the primary therapy accompa-nied by empiric systemic antifungal therapy when there is strong suspicion of an IFI. Other recommen-dations include:

Early tissue sampling for wound histopathology and fungal cultures.

Early consultation with infectious disease spe-cialists.

Coordination with surgical pathology and clini-cal microbiology.

IFI work by TIDOS investigators (supported by DoDTR data) has included risk factor analysis, syn-dromic classification, wound microbiology, and or-thopedic outcomes. In one investigation, TIDOS ana-lyzed potential predictors for the development of IFI among wounded warriors and confirmed an inde-pendent association with blast injuries (odds ratio [OR]: 5.7; 95% confidence interval [CI]: 1.1-29.6), dis-mounted at the time of injury (OR: 8.5; CI: 1.2-59.8), sustaining traumatic above knee amputation (OR:

(Continued on page 14)

U.S. Army Institute of Surgical Research, and the Uniformed Services University of the Health Sci-ences [on behalf of the USU Infectious Disease Clinical Research Program (IDCRP)] led to the de-velopment of the supplemental ID module of the DoDTR in 2009. The TIDOS project completed co-hort enrollment earlier this year following cessa-tion of combat operations. Infection-related data were collected on over 6,000 LRMC trauma patient admissions of which approximately 2,690 trans-ferred to a participating TIDOS clinical site in the United States. In addition, over 1,350 patients have been enrolled in the TIDOS cohort for long-term follow-up through the DoD and Veteran Affairs healthcare systems.

TIDOS IFI experts contributed to the JTS Clinical Practice Guideline (CPG) for preventing and treat-

By M. Leigh Carson, MS, Medical / Scientific Writer, TIDOS

14

4.1; CI: 1.3-12.7) and requiring more than 20 units of packed red blood cells within 24 hours of injury (OR: 7.09; CI: 2.5-19.7).1 Findings are noted in the IFI CPG.

TIDOS investigators recently published an invited review in Current Fungal Infection Reports highlight-ing new areas of combat-related IFI knowledge and clinical management.3

In addition, a recent study evaluated orthopedic out-comes among patients with diagnosed IFIs. Wounds with IFIs had significantly delayed wound healing as evidenced by a longer duration from injury to wound closure (median of 16 days with IFI patients versus 9 days with non-IFI patients). The IFI patients also had a significantly greater proportion of amputation proximal level revisions (15% versus 3%). These data are the first to conclusively demonstrate the adverse impact fungal infections have on wound healing and patient recovery.

Another recent study on IFI wound microbiology confirmed the pathogenic nature of mucormycosis

(Continued from page 13) by demonstrating that wounds with mold from the order Mucorales have a significantly longer dura-tion to wound closure compared to wounds with non-Mucorales mold infections (median of 17 days versus 13 days). The analysis showed the polymi-crobial nature of fungal-infected wounds with 30% of the IFI wounds having multidrug-resistant or-ganisms isolated at the time of infection work-up.2

TIDOS and JTS support performance improvement initiatives such as examining adherence to antimi-crobial prophylaxis, the use of antibiotics to pre-vent infections at the surgical site, in response to traumatic injuries. When adherence within 48 hours of injury to the CPG published in 2008 was evaluated, the overall compliance rate was 75%.4 A recent analysis assessed compliance with the 2011 CPG over a five-year period and found significant improvements in adherence, particularly with open fractures (34% to 77%) and maxillofacial injuries (50% to 76%), primarily due to significant reduction in the use of expanded gram-negative coverage.5 The latest study evaluates patient clinical out-comes related to antimicrobial prophylaxis.

On 29 Sep 2015, the JTS was proud to recognize Ms. Barbara Isner on her retirement. Barbara has been a Health Information Specialist with the Data Acquisition Branch for the last 6 years. Her hard work and dedication to the improvement of trauma care will be long remembered. We wish her fair winds and following seas as she embarks on her next adventure.

TIDOS will continue to leverage data analyses across DoDTR supplemental modules, such as the Military Orthopaedic Trauma Registry, and collaborate with ISR scientists to examine wound microbiology and the role of biofilms in chronic infections.

References

1. Rodriguez C, Weintrob AC, Shah J, et al. Risk factors associat-ed with invasive fungal infections in combat trauma. Surgical Infections. 2014; 15(5):521-526.

2. Warkentien TE, Shaikh F, Weintrob AC, et al. Impact of Mu-corales and Other Invasive Molds on Clinical Outcomes of Polymicrobial Traumatic Wound Infections. Journal of Clinical Microbiology. 2015 53(7): 2262-2270.

3. Tribble DR and Rodriguez CJ. Combat-Related Invasive Fungal Wound Infections. Current Fungal Infection Reports 2014; 8(4):277-286.

4. Lloyd BA, Weintrob AC, Hinkle M, et al. Adherence to Pub-lished Antimicrobial Prophylaxis Guidelines for Wounded Ser-vice Members in the Ongoing Conflicts in Southwest Asia. Military Medicine. 2014; 179(3):324-328.

5. Lloyd BA, Murray CK, Bradley W, et al. Variation in Post-Injury Antibiotic Prophylaxis Patterns over Five Years in a Combat Zone. Military Health System Research Symposium, 17-20 August 2014, Fort Lauderdale, FL.

H A I L S A N D F A R E W E L L S

Newcomers/Conversions Job Title/Position

Carlos Cosme-Thillet Clinical Nurse Abstractor DAB Group

Adrianne Coward Nurse Data Analysis MOTR Group

Gregory Dokken Nurse Analyst

Eugenio Garcia Nurse Analyst

Socorro Garcia Nurse Analyst

James Mason IT Automation Branch Chief

Jeannette May Trauma Registry HIM Specialist (Coder), MERCuRY

Mary Perez

Previously in DAB

Clinical Nurse Abstractor

MOTR Group

COL Samual Sauer Director of En Route Care

Col Stacy Shackelford Director of Performance Improvement

Monica Thomas Trauma Registry HIM Specialist (Coder), MERCuRY

Barbara Isner Retires with JTS

Warm Wishes for New Adventures

Please welcome our new JTS colleagues!

Barbara Isner, Health Information Specialist

15

Clinical Practice Guidelines (CPGs) have officially support-ed the US military medical community since WWII when a then world-famous surgeon with The US Surgeon Gen-eral’s Office took it upon himself to tackle the challenge of standardizing care and treatment of battle casualties. The US trailed in its adoption of standard guidelines for theater trauma injuries. The use of guidelines was not new. According to our own CAPT Zsolt Stockinger, the English established its standard hospital practices during the English Civil War in 1642. There was, however, a lack of consistent, official guidelines for US combat medics.

Lt. Col. Michael DeBakey, MC, Surgical Consultant, penned Circular Letter No. 178 (dated 23 October 1943) which transformed medical response and treatment across the continuum of care and established the tradi-tion of clinical practice guidelines. Circular Letter No. 178 set the parameters still followed today by first respond-ers, transporters, nurses and surgeons. In fact, the letter served as the first CPG.

Prior to that, Major General Norman T. Kirk, the first or-thopaedic surgeon to be named US Surgeon General, had advocated the use of clinical practice guidelines. Kirk was responsible for numerous improvements in military trauma care, including guidelines for amputation and an enhanced system of stateside rehabilitation. He was one of the first US surgeons to focus on the continu-ity of care to track treatment at the point of injury to stateside hospital efforts.

In the Circular Letter which directed the official publish-ing and use of CPGs for combat-related injuries during US wartimes, eBakey wrote: “The purpose of this letter is to provide broad policies and certain guiding principles on the care of the wounded in theaters of operation. Modification in accordance with existing conditions and changing circumstances may be necessary.”

Historically, Circular Letters from the Surgeon General's Office were used to provide information and guidance on the proper methods and procedures for surgical and medical care of sick and wounded soldiers. They were often transitory in nature and not intended to provide

guidance such as that contained in Army Regulations or Field Manuals. Circular Letters were a quick way of disseminating information throughout the Medical Department.

Mainly derived from surgical experiences in the North African and Mediterranean Theaters of Operations and the various Pacific theaters to date, Circular Letter 178 outlined procedures that were to be followed in handling various types of casualties. As more experi-ence was gained with more extensive combat opera-tions and large casualty flows after the invasion of

C P G S : A L O N G T R A D I T I O N O F T R A U M A C A R E

Europe in 1944, DeBakey drew heavily on the efforts in the Fifth US Army and Mediterranean Theater of Opera-tions where standardization of procedures for handling combat casualties was the most advanced.

High-level evacuation instructions helped first respond-ers prioritize cases, prep patients and provide immediate medical treatment when possible. Wound treatment cov-ered soft parts, head, chest, abdomen, extremities, burns, and amputations. The first CPG even established the criteria for performing surgery in forward operating hospitals for surgery-or-death cases.

Then, in 1945, the Technical Bulletin Med 147, Notes on Care of Battle Casualties, elevated the CPG to its official stature by defining roles and responsibilities and cover-ing general principles and policies. The 18-page bulletin provided detailed procedures for a wide range of treat-ments and surgeries for the most pervasive battlefield injuries. Its format closely resembles today’s CPG.

Today’s tri-service deployed trauma system developed and distributed its first CPGs in 2004. The initial eight CPGs focused on clinical issues specific to theater (Intratheater Transport) and clinical issues which occur frequently in theater (Blunt Abdominal Trauma, Damage Control Resuscitation, Pelvic Fracture, Trauma Airway Management, Vascular Injury and Urologic Trauma) which may require unique management due to the aus-tere environment.

Circular Letter No. 178 http://history.amedd.army.mil/booksdocs/wwii/StandarizedCare/CL178.htm

The Technical Bulletin Med 147 can be read in its entirety at http://history.amedd.army.mil/booksdocs/wwii/StandarizedCare/TBMED147.pdf

Reference: Standardizing Care & Treatment of Battle Cas-ualties, John Greenwood, Ph.D., Chief, Office of Medical History, Office of The Surgeon General, US Army.

Source: National Archives and Records Administration, Record Group 112, Records of the US Army Surgeon Gen-eral, WW II, SGO Circular Letters, 1942-43.

______________________________________

______________________________________

By Cynthia R. Kurkowski, JTS News Editor

16

Training and experience, particularly at the Role 2 (R2) level, have been identified as critical elements to increas-ing the survivability rate of our wounded warriors. Yet there is a lack of evidence about the impact of Role 2 medical resources in the combat theater.

Given the definition of the R2 element varies by ser-vice, unit, country and operational requirements, consistent data collection is tricky. A R2 element is a medical capability which augments or enhances oth-er assets (e.g., ASMC) by conduct of lifesaving surgi-cal interventions and damage control resuscitation.

The few published reports documenting the activities and performance of R2 elements during Operation Enduring Freedom or Operation Iraqi Freedom indi-cate insufficient information concerning patients and the clinical interventions associated with R2 facilities to allow for proper training of future teams. Optimal preparation for these healthcare providers is to ex-pose them prior to deployment to as many trauma situations as possible with which they may be in-volved. To do so requires knowing the specifics of the trauma situations. No systematic and comprehen-sive evaluation of R2 utilization had been conducted until recently when a team led by LTC Elizabeth A. Mann-Salinas, PhD, RN, FCCM, began examining the DoDTR’s R2 registry. Without analysis of this infor-mation, military planners and medical leaders are un-able to best allocate resources in future operations.

Mann-Salinas hopes to understand the impact of R2 utilization during the Afghanistan conflict and beyond, with emphasis on patient outcomes and provider competency. The study will help define the critical skills and knowledge necessary to significantly improve readiness by matching the right medical intervention with the appropriate life-saving skill.

The team is retrospectively reviewing de-identified data of more than 15,000 patients extracted from

the R2 Registry. They are focusing on patients who receive treatment at a military medical treatment facility and who meet all the following inclusion criteria: 1) adult trauma patients (defined as age 18 years or older at time of injury); 2) deployed in Oper-ation Enduring Freedom; 3) trauma-eligible patients based on the R2 Registry Record Inclusion Criteria defined as battle injury (BI) and non-battle injury (NBI); and 4) wounded in year 2008 or later.

Mann-Salinas’ initial review of R2 data uncovered the following limitations.

R2 Registry does not provide data prior to 2008.

Navy/Marine R2 data sets are included.

Data was entered by clinical staff untrained in JTS data entry.

Other missing data includes:

Injury severity scores

Primary injury mechanism

Most significant injury

The initial review of R2 Registry will drive future analyses and integration of additional data sources such as Center for Army Lessons Learned resources and the Joint Lessons Learned Information System.

Long term, the team will perform a systematic re-view of all medical combat training and preparation; determine optimal curriculum for each skill type; develop a validated knowledge assessment instru-ment; and create an evidence-based competency assessment program.

(Continued on page 17)

R O L E 2 R E G I S T R Y S T U D Y A I M S T O F I L L

I N F O R M A T I O N A L G A P S T O E N H A N C E

T R A I N I N G A N D R E A D I N E S S

Role 2

Mobile Survival

Team/Medical

Clinic

DCR

DCS

MT

(Some RAD

Basic Lab)

Surgeon

Anesthesia

RN

Medic

Role 2 Players

Army Medical Company

Forward Surgical Team

Forward Support Battalion

Main Support Battalion

Multifunctional Medical Battalion

Air Force Aeromedical Staging Facility

Mobile Field Surgical Team

Small Portable Expeditionary Aeromedical Rapid Response

Expeditionary Medical Support (EMEDS, Basic or +10)

Navy Casualty Receiving and Treatment Ship

Fleet Surgical Team

Expeditionary Resuscitative Surgical System

USMC Surgical Company

Forward Resuscitative Surgical System

By Cynthia R. Kurkowski, JTS News Editor

17

T H E R O L E 2 P R O J E C T T E A M LTC Elizabeth A. Mann-Salinas, PhD, RN, FCCM Tuan D. Le, MD, PhD

Col. Jeffrey A. Bailey, MD

Mary Ann Spott, MPA, MSIS, MBA

CAPT Zsolt T. Stockinger, MD

COL Michael D. Wirt, MD

Surg. Capt. Rory Rickard, PhD, FRCS

COL Kirby R. Gross, MD Col Stacy A. Shackelford, MC

The research will help the Defense Health Agency to better formulate policies, procedures, and guide-lines for the employment of Role 2 medical assets in present and future conflicts. It will allow policy mak-ers to consider doctrine, organization, training, leadership, material, and safety principles in the most efficient and effective use of those assets and will assist operational and medical commanders in preparing those assets for employment.

The team’s findings will also make their way into the future implementations of the Role 2 Registry which will attempt to fill the informational gaps identified by the Role 2 project.

(Continued from page 16)

Team leader LTC Elizabeth Mann-Salinas accompanies Dr. Tuan Le, Statistician, a key contributor to the findings.

Common symptoms and clinical findings of laser-related ocular injuries include:

Protracted reduced visual acuity

Lingering flash blindness or glare

Photophobia

Red visual haze

Eye pain or tenderness

Scotomas: A blind spot or blind area in the field of vision

Ocular surface burns

Chorioretinal (retinal) burns

Retinal hemorrhage

Extensive retinal scarring with neovasculariza-tion

Vitreous hemorrhage

Macular pucker and cysts 8,9

Laser exposure should be examined by an ocular specialist within 24 hours of exposure. Visual acui-ty and Amsler grid testing should be performed to assess for changes in vision; fundus photography, fluorescein angiography, and optical coherence tomography are recommended to assess retinal damage.6 The treatment of laser-induced eye inju-ries is generally limited to medical management, with surgical intervention when indicated.2

Anti-inflammatory medicines like steroids (i.e. prednisone) and non-steroidals (i.e. naproxen, in-domethacin) have been shown to help mitigate the damage or prevent the spread of damage if not prevent permanent damage. If damage oc-curs, there are some medications that we might administer as intraocular injections to help miti-gate the extent of the injury.

Unintentional laser injuries can be avoided with the use of proper safety equipment, an operation-al understanding of the laser being used, safety training and responsible comportment by military

(Continued from page 9)

personnel. Laser devices should only be used

for the sole purpose in which they were intended and always within the specified Nominal Ocular Haz-ard Distance. 10 Laser protective eyewear can be effective, however, laser protection requires special lenses which are specific to the wavelength of the laser threat. 11

There are two lessons to be taken from this article: 1) Permanent laser-induced eye injury is not com-mon, and 2) Laser injury can be prevented. Take pre-cautions. Never look directly into a laser. It’s that simple.

References

1. Available at http://www.military.com/video/forces/army/humor-epic-lightsaber-battle-in-iraq/1490048241001/

2. Headquarters, Department of the Army. (1990). Department of the Army Field Manual 8-50, Prevention and medical man-agement of laser injuries. Washington, DC: Department of the Army

3. 18 U.S.C. § 39A (2012). Aiming a laser pointer at an aircraft.

4. Harris MD, Lincoln AE, Amoroso PJ, Stuck B, Sliney D. Laser eye injuries in military occupations. Aviat Space Environ Med. 2003 Sep; 74(9):947-52

5. Svan, J.H. & Druzin, H. (2009). Military sees rise in eye injuries from lasers. Available at http://www.stripes.com/news/military-sees-rise-in-eye-injuries-from-lasers-1.92467

6. Hollified, R.D. (1997). Ocular laser injuries. Ophthalmic Care of the Combat Casualty, 41(2): 431-439

7. Barkana, Y., Belkin, M. (2000). Laser eye injuries. Survey of Ophthalmology, 44(6):459-78

8. Mainster, M. A., Stuck, B. E., & Brown, J. (2004). Assessment of alleged retinal laser injuries. Archives of Ophthalmology, 122(8), 1210-1217

9. Hudson, S. J. (1998). Eye injuries from laser exposure: a re-view. Aviation, Space, and Environmental Medicine, 69(5): 519-524.

10. De Luca, D., Delfino, I., & Lepore, M. (2012). Laser safety stan-dards and measurements of hazard parameters for medical lasers. International Journal of Optics and Applications, 2(6), 80-86

11. Seet, B., Wong, T.Y. (2001). Military laser weapons: current controver-

sies. Ophthalmic Epidemiology, 8(4):215-26

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P r o j e c t : B e s t F i t f o r S u r g i c a l Wo r k l o a d a t Va r i o u s E c h e l o n s o f P r e h o s p i t a l C a r e

I N T E R N ’ S R E S E A R C H F I N D I N G S W I L L H E L P M I L I TA R Y M E D I C A L F A C I L I T I E S P R E PA R E F O R F U T U R E W O R K L OA D S

Claire Caldwell returned to JTS this past summer to con-tinue the research she began in 2014 during her initial summer internship. Her project, Best Fit for Surgical Workload at Various Echelons of Prehospital Care, stemmed from the inadequate numerical evidence to support surgical workload preparation in deployed situa-tions. Standard medical units/force structure and training recommendations are typically used, but susceptible to mismatch of resources. The discrepancy results in the under or over supply of personnel and equipment. It can even cause insufficient medical skill sets can cost lives or hinder recovery. Claire's work is the first ever analysis of surgical workload at all echelons of care across the entire spectrum of the Global War on Terrorism.

This time around Claire focused on analyzing, interpreting and sharing the data she previously compiled and catego-rized. Using medical data collected during the Operation Enduring Freedom and Operation Iraqi Freedom conflicts, Claire sought to predict work-loads — procedure types and fre-quency — En Route Care Provid-ers through the continuum to Role 3 military medical locations may expect to experience in thea-ter. Matching data to known op-erational tempo, population at risk and casualty estimates ena-bles service leaders to successful-ly allocate resources and train personnel for future military oper-ations. It turns out Role 2 and Role 3 display very similar work-load trends and procedural ratios. This finding may ena-ble Role 2 and 3 training to be combined.

Claire presented her findings at the 2015 Military Health System Research Symposium in Fort Lauderdale, Florida in August, and plans to submit the research for publica-

tion in a scientific journal. She also expects to pre-sent at AMSUS in December.

“The biggest challenge of this project was accept-ing that the data wasn't perfect, complete, or al-ways accurate. I fixed what data I could and dumped data that was beyond repair and kept moving. Inaccurate initial data from the DoDTR means subsequent data analyses will be inaccurate as well, and that was something I struggled to ac-cept,” said Claire. “Our findings are not 100% repre-sentative of what actually happened, however, they are the best representation we have based on the available data.”

Claire’s time at JTS taught her to be open to new experiences and look at research and medicine from different perspectives. She said she hadn’t even considered presenting the project to the MHSRS until CAPT Stockinger submitted the ab-

stract and it was approved. CAPT Zsolt Stockinger mentored the A&M cadet during her return internship.

“Although I was nervous of pre-senting my finding, I am glad I had the experience of doing so, and was able to see the other advances in military medicine,” Claire said.

Claire walked away from JTS with a high respect for data analysis.

“There is an immense value to keeping accurate records. Not all of the discoveries happen in a lab on a bench. The data analyses can be just as valuable, if not more,” she concluded.

Claire is studying for her Bachelor's in Allied Health at Tex-as A&M University-College Station. Next summer will find her at nursing school.

References

1. Chambers, Lowell W., D J. Green, Bruce L. Gillingham, Ken-neth Sample, Peter Rhee, Carlos Brown, Stacy Brethauer, Thomas Nelson, Nalan Narine, Bruce Baker, and H R. Bohman. "The Experience of the US Marine Corps Surgical Shock Trauma Platoon With 417 Operative Combat Casual-ties During a 12 Month Period of Operation Iraqi Free-dom." The Journal of Trauma: Injury, Infection, and Critical Care 60 (2006): 1155-164. Print.

2. Shen-Gunther, Jane, Richard Ellison, Charles Kuhens, Christo-pher J. Roach, and Steve Jarrard. "Operation Enduring Free-dom: Trends in Combat Casualty Care by Forward Surgical Teams Deployed to Afghanistan." Military Medicine 176 (2011): 67-78. Print.

E v a l u a t i o n f a c t o r s

534,651 total procedures

ICD-9 codes grouped into 29 categories (e.g., abdominal, amputation, craniotomy, soft tissue)

Entire spectrum of deployed trauma care: Role 1, Role 2 (forward surgical), and Role 3 (theater hospital)

Procedure totals calculated by proce-dure type, skill set & echelon of care

Claire presents her findings at the MHSRS.

By Cynthia R. Kurkowski, JTS News Editor

19

Validating the Military Injury Severity Score (mISS). A retrospective review of DoDTR data will determine whether mISS is a better predictor of combat-mortality than the Injury Severity Score (ISS) and the New Injury Severity Score (NISS). Findings will be presented at the EAST 2016, and a manuscript is under preparation for the Journal of Trauma and Acute Care Surgery. Team: COL Kirby Gross, MD and Tuan Le, PhD. Refining the Trauma and Injury Severity Score (TRISS). This study aims to use the DoDTR data to calculate comprehensive trauma and injury severity score (cTRISS) co-efficients with comprehensive methods going beyond the original TRISS method. Intro-duced in 1981, TRISS determines the probability of a patient’s survival based on revised trauma score, injury severity score and patient's age. Team: COL Kirby Gross, MD and Tuan Le, PhD. Combat Casualty Care/Case Fatality Rate. This is an analysis of trends in severity of com-bat casualty and mortality rates in Afghanistan from 2001 to 2014. Findings were: (1) the case fatality rate declined substantially, primarily due to less killed in action, despite in-creases in the severity of combat injuries; (2) The implementation of damage control resuscitation, tourniquet application, and “Golden Hour” rapid evacuation policy likely contributed to these reductions in mortality. An abstract from this study has been ac-cepted for the December AMSUS poster presentation. A manuscript is under prepara-tion. Team: COL. Kirby Gross, MD; Tuan D. Le, PhD; Jean A. Orman, ScD, MPH; CAPT Zsolt Stockinger, MD; and Col. Jeffrey Bailey, MD. Physician Compliance Rate. The aim of this PI study was to retrospectively analyze pro-vider compliance once year post-implementation of JTS CPGs. The analysis hypothe-sized that CPGs disseminated by JTS and the CENTCOM Joint Theater Trauma Systems (JTTS) team led to a decrease in the variability of management of combat trauma pa-tients. Ten CPGs were selected: battle/non-battle injury documentation resuscitation record, burn care, cervical spine evaluation, cervical and thoracolumbar spine injury, compartment syndrome and fasciotomy, emergent resuscitative thoracotomy, fresh whole blood, infection control, post splenectomy vaccinations, and wartime vascular injury. For these 10 CPGs, 25 of the included PI measures were selected and identified by specialty area and type of procedure. The PI inclusion criteria classifications are high or low in complexity, observability, and trialability. The first findings will be presented at the December AMSUS. Team: CAP Zsolt Stockinger, MD and Dallas Burelison, MBA. The Impact of the Evolution of Military Hardware and Preventive Measures on the Inci-dence of Burn Injury in Combat 2001-2014. A retrospective review of de-identified DoDTR data and perineal burn data from USAISR Burn Center was performed. “MRAP impact on injury pattern: Trends in combat-related burn incidence and severity” was presented at the AMEDD at War: Lessons Learned in September. Analysis results sug-gest that burn incidence has declined dramatically over time after 2007. The lower inci-dence rates of burns after 2007 and lower likelihood of severe burns after 2007 sug-gests that MRAPs had a positive impact on burn prevention in OIF/OEF. Future studies will provide a detailed analysis of the impact MRAPs had on burn prevention and surviv-al. Team: LTC Wylan Peterson, MD; Tuan D. Le, PhD; COL Kirby Gross, MD; CAPT Zsolt Stockinger, MD; LTC Kevin Chung, MD, FCCM; COL Booker King, MD; COL Michael Wirt, MD; and COL Lorne Blackbourne, MD.

Combat Related Perineal Burns. One related study to the above proposal is “Association of time to bacteremia and mortality in burn patients” Team: MAJ John Graybill; Tuan Le, PhD; LTC Kevin Chung, MD; and Jeffrey Howard, MD. MRAP Impact in injury pattern: Trends in combat-related burn incidence and severity. A performance improvement analysis presented at the AMEDD at War: Lessons Learned in September. A manuscript is under preparation. Team: LTC Wylan Peterson, MD and Tuan D. Lee, PhD. Golden Hour. An analysis of data from DoDTR, AFMES and Casualty Flight database suggests rapid evacuation of critically injured casualties resulted in a reduction of KIA mortality, and that this reduction led to overall reductions in mortality in the time peri-od following Secretary of Defense Gates mandate that casualties in Afghanistan be transported to a medical treatment facility within one [golden] hour. The findings were published in JAMA Surgery. http://archsurg.jamanetwork.com/article.aspx?articleid=2446845 Team: Russ S. Kotwal, MD, MPH; Jeffrey T. Howard, PhD; Jean A. Orman, ScD, MPH; Bruce W. Tarpey, BS; Jeffrey A. Bailey, MD; Robert L. Mabry, MD; and COL Kirby R. Gross, MD. Long-term Outcomes Following Trauma. The analysis focused on a trauma casualty cohort from DoDTR, combined with data from other DoD sources (e.g., AFMES, DHA) with long-term follow-up on patients diagnosed with chronic diseases (hypertension, diabetes, cardiovascular disease and chronic kidney disease). The study found that exposure to trauma is linked to significantly increased risk of all four of these chronic diseases as far out as 8-10 years following the initial injury. Furthermore, the risk fol-lows a dose-response relationship with injury severity, such that higher ISS equates to higher risk of each of these diseases. The results, Retrospective Analysis of Long Term Outcomes after Combat Injury: A Hidden Cost of War, were published on the Circulation website in September. Team: Jeffrey Howard, MD; Jean A. Orman, ScD, MPH; and LTC Kevin Chung, MD Evaluation of Role 2 Medical Resources in the Afghanistan Combat Theater: Past, Pre-sent, and Future. A retrospective review of DoDTR Role 2 data was conducted on the type of patients treated, procedure conducted, and associated patient outcomes. The purpose of this project was to conduct a preliminary review of the R2R to understand trauma patient epidemiology and related interventions at these facilities to inform optimal provider readiness for deployment. UK and Israel recently joined the project to conduct comparative studies. LTC Mann-Salinas presented her initial findings at the MHSRS this past August and plans to share them at the EAST 2016. The related study, The Impact of Tourniquet Use on Mortality and Shock for Patients Arriving at US Role 2 Surgical Facilities in Afghanistan,” is ready to submit to a peer-review journal. For more information, read the Role 2 article. Team: LTC Elizabeth A. Mann-Salinas, PhD, RN, FCCM; Tuan D. Le, PhD; Col. Jeffrey A. Bailey, MD; Mary Ann Spott, MPA, MSIS, MBA; CAPT Zsolt T. Stockinger, MD; COL Michael D. Wirt, MD; COL Kirby R. Gross, MD; and Col Stacy A. Shackelford, MC. Editorial Note: Team members listed are ISR or JTS staff members.

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ARTICLES SUBMISSION

JTS Newsletter Editor

Cynthia R. Kurkowski

Data Automation Branch

(210) 539-7756

Cynthia.R.Kurkowski.Ctr@mail.mil

3698 Chambers Pass

Building 3611 - BHT1

JBSA Fort Sam Houston

TX 78234-6315

A b o u t T h e J o i n t T r a u m a S y s t e m M I S S I O N : O P T I M I Z I N G C O M B A T C A S U A L T Y C A R E

The mission of the Joint Trauma System (JTS) is to improve trauma care delivery and patient outcomes across the con-tinuum of care utilizing continuous performance improvement (PI) and evidence-based medicine driven by the concur-rent collection and analysis of data maintained in the Department of Defense Trauma Registry (DoDTR). The JTS is a division of the U.S. Army Institute of Surgical Research (USAISR) which is part of the U.S. Army Medical Research and Materiel Command and is collocated with Brooke Army Medical Center. The USAISR is dedicated to both laboratory and clinical trauma research. Its mission is optimizing combat casualty care by providing requirements-driven combat casualty care medical solutions and products for injured soldiers, from self-aid through definitive care across the full spectrum of military operations; provide state-of-the-art trauma, burn, and critical care to DoD beneficiaries around the world and civilians in our trauma region; and provide a Burn Flight Team.

On AKO/DKO: https://www.us.army.mil/suite/page/131956 On the Internet: http://www.usaisr.amedd.army.mil

COMING SOON to the Combat Casualty Care Curriculum Conference The JTS offers clinicians, nurses, and medics the opportunity to acquire Continu-ing Education credits on a weekly basis. The telemedicine conference was de-veloped to increase the knowledge-base of clinicians, nurses, medics, and other non-healthcare providers while deployed. The dual technical platforms of land line telephones and Defense Collaboration Services are used to connect far for-ward providers throughout the continuum of care.

If you would like to join the conference, please contact the JTS Education Branch Chief Dallas Burelison at dallas.r.burelison.ctr@mail.mil

JTS Combat Casualty Care Curriculum Line up

22-Oct-15: Clinical Investigations in Theater (PI vs. Research)

29-Oct-15: Translating Military to Civilian Advancements

5-Nov-15: Invasive Fungal Infection

12-Nov-15: Trauma Training Platforms

19-Nov-15: Prolonged Field Care

3-Dec-15: AFMES

10 Dec 15: Trauma Anesthesia CPG

17 Dec 15: Post Traumatic Stress Disorder; Hyper metabolic state in severe TBI patients

7 Jan 16: Dismounted Complex Battle Injuries (DCBI) CPG

14 Jan 16: Military / Civilian Trauma Systems

21 Jan 16: JTAPIC

28 Jan 16: Genito-Urinary Injuries