Avi Shina

Prehospital use of hemostatic dressings by the Israel Defense Forces Medical Corps: A case series of 122 patients.

BACKGROUND Hemostatic dressings are advanced topical dressings designed to control hemorrhage by enhancing clot formation. These dressings may be effective when used on injuries sustained in junctional zones. The Israeli Defense Forces Medical Corps (IDF-MC) chose to equip its medical personnel with the QuikClot Combat Gauze. There is a paucity of data describing clinical use and results of hemostatic dressing especially at the point of injury. The purpose of this article was to report the IDF-MC experience with prehospital use of the QuikClot Combat Gauze in junctional zones in a case series retrieved from the IDF Trauma Registry. METHODS All IDF Trauma Registry documented cases of prehospital use of hemostatic dressings in the IDF-MC between January 2009 and September 2014 were retrieved. Data collection included injury mechanism, wound location, reported success of hemostatic dressing, tourniquet use, lifesaving interventions, mortality, and caregiver identity. RESULTS A total of 122 patients on whom 133 hemostatic dressings were applied were identified. Median age was 22 years. Of the patients, 118 (96.7%) were male and 2 (1.6%) were female (missing, n = 2). Injury mechanism was penetrating in 104 (85.2%), blunt in 4 (3.3%), and combined in 14 (11.5%) patients. Seven patients (5.9%) died. Thirty-seven dressings (27.8%) were used for junctional hemorrhage control (pelvis, shoulder, axilla, buttocks, groin, neck), and 92 dressings (72.1%) were placed in nonjunctional areas (missing, n = 4). Nonjunctional dressings included 63 (47.4%) applied to the extremities, 14 (10.5%) to the back, and 4 (3%) to the head. Hemostatic dressing application was reported as successful in 88.6% (31 of 35 available; missing, n = 2) of junctional hemorrhage applications and in 91.9% (57 of 62 available; missing, n = 1) of extremity hemorrhage applications. CONCLUSION Hemostatic dressings seem to be an effective tool for junctional hemorrhage control and should be considered as a second-line treatment for extremity hemorrhage control at the point of injury. LEVEL OF EVIDENCE Therapeutic study, level V.

Intravenous access in the prehospital settings: What can be learned from point-of-injury experience.

BACKGROUND Intravenous (IV) access has an essential role in the care provided for trauma patients, allowing for transfusion of blood products, fluids, and drugs. Decisions should be made regarding the necessity of IV access while considering cost-benefit of the procedure in terms of delayed evacuation times. METHODS A retrospective review of all trauma patients in whom at least one attempt at IV access was performed were reviewed. Data were abstracted from the Israeli Defense Force Trauma Registry. RESULTS Of 7,476 patients, 1,082 patients who had at least one documented attempt at IV access between January 1997 and April 2013 were included in this study. Overall cumulative success rate at IV access was 82%. Success rates for IV access were 86%, 68%, 63%, 50%, 20% for the first, second, third, fourth, and fifth attempts, respectively. The first and second attempts accounted for 96% of the successful procedures. Mortality in patients for whom IV access was successful was 13%; mortality in patients for whom IV access was not successful was 35%. CONCLUSION The success rate of IV access declined with each subsequent attempt. There was minimal improvement of overall success rate seen after the second attempt. Our findings suggest that the inability to obtain peripheral venous access is associated with severe injuries. These finding support a policy of limiting the number of venous access attempts to two attempts, followed by a reevaluation of need for parenteral access. Improved training of combat medics and paramedics might marginally increase the success rates of IV access. Point-of-injury data, used for ongoing learning and research, form the ground for improving combat casualty care and thus help saving lives. LEVEL OF EVIDENCE Therapeutic study, level IV.

Confidence–Competence Mismatch and Reasons for Failure of Non-Medical Tourniquet Users

Abstract Objective: Tourniquet application is a lifesaving skill taught worldwide in first aid bleeding control courses. We observed performance among non-medical users of tourniquets in their confidence, competence, and reasons for failure. Methods: 179 Israeli military recruits without prior medical training underwent their standard first aid course where they learned Combat Application Tourniquet (CAT; Composite Resources, Rock Hill, SC, USA) use. After course completion, they self-reported confidence in tourniquet use. User performance was assessed 7–14 days later using a HapMed™ mannequin that assessed time, pressure, and blood loss. Competent performance required in aggregate: 1) use with pressure of 200 mmHg or more, 2) hemorrhage volume of less than 638 mL, and 3) correct placement of the tourniquet. For failed performance, a reason for failure was reported independently by both the user and an expert observer. Results: 45 of 179 user performances (25%) were competent. Users who reported high confidence had only a slightly higher chance of achieving competence in tourniquet application (r = 0.17, p = 0.022). The most common reason for failure was excess slack in the CATs strap (experts 55%, users 39%), and too few turns of the windlass (23% and 31%, respectively) was the second most common reason. Expert and user evaluations had poor agreement (κ = 0.44, 95% CI 0.32–0.56). Conclusion: The most common reason for failed use of tourniquets among non-medical users was excess slack in the tourniquet strap. Users self-evaluated their performance inaccurately and demonstrated a confidence-competence mismatch. These pitfalls in performance may help tourniquet instructors improve training of caregivers.

Self-Perceived Emotional Distress and Diabetes Risk Among Young Men

INTRODUCTION There are mixed data regarding the effect of emotional distress on diabetes risk, especially among young adults. This study assessed the effect of self-perceived emotional distress on diabetes incidence among young men. METHODS Incident diabetes during a mean follow-up of 6.3 (4.3) years was assessed among 32,586 men (mean age, 31.0 [5.6] years) of the Metabolic, Lifestyle, and Nutrition Assessment in Young Adults cohort with no history of diabetes between 1995 and 2011. Emotional distress was assessed by asking participants as part of a computerized questionnaire: Are you preoccupied by worries or concerns that affect your overall wellbeing? Time-dependent Cox models were applied. Data analysis took place between 2014 and 2015. RESULTS There were 723 cases of diabetes during 206,382 person-years. The presence of distress was associated with a 53% higher incidence of diabetes (95% CI=1.08, 2.18, p=0.017) after adjustment for age, BMI, fasting plasma glucose, family history of diabetes, triglyceride and high-density lipoprotein cholesterol levels, education, cognitive performance, white blood cell count, physical activity, and sleep quality. These results persisted when distress, BMI, physical activity, and smoking status were treated as time-dependent variables (hazard ratio=1.66, 95% CI=1.21, 2.17, p=0.002). An adjusted hazard ratio of 2.14 (95% CI=1.04, 4.47, p=0.041) for incident diabetes was observed among participants persistently reporting emotional distress compared with those persistently denying it. CONCLUSIONS Sustained emotional distress contributes to the development of diabetes among young and apparently healthy men in a time-dependent manner. These findings warrant awareness by primary caregivers when stratifying diabetes risk.

Prehospital administration of freeze-dried plasma, is it the solution for trauma casualties?

BACKGROUND Hemorrhage is the leading cause of possible preventable death in the battlefield. There is an increasing evidence for the effectiveness of blood component therapy in general, and plasma infusion in particular but their use is less applicable in the prehospital setting due to logistic difficulties. Israeli Defense Force has implemented the use of freeze-dried plasma (FDP) at the point of injury (POI), this adoption of FDP use entailed doubts regarding the feasibility and effectiveness of this practice. In this article, we present our experience with the use of FDP at the POI and prehospital setting regarding the feasibility, safety, adverse reactions, and adherence to clinical practice guidelines. METHODS This is a descriptive retrospective cohort study based on all casualties receiving FDP during January 2013 to June 2016. The study describes the injury, treatment, and outcome characteristics from POI until hospital discharge. RESULTS During the study period, 109 casualties received FDP. The majority were men, aged 18 years to 35 years. Multiple severe injuries were found in almost half of the casualties, 78% had penetrating injury, and more than half were involved in a multicasualty event. Eighty-three percent were treated with one unit of FDP, 13% with two units, and 4% casualties with three units, nine patients (8.2%) were also treated in the prehospital setting with packed red blood cells. Fifty-seven percent fulfilled at least one criterion for the administration of FDP. Lifesaving interventions were required in 64%. In five (4.6%) cases, there were difficulties with FDP administration. Side effects were reported in one female patient. CONCLUSION This study supports the usage feasibility of FDP at the POI and in the prehospital setting. Further adjustment of the clinical practice guidelines is required basing it not only on pathophysiologic parameters but also on clinical judgment. Further investigation of the available data is required to learn about the effectiveness of FDP at POI. Level of Evidence Retrospective case series study, level IV.BACKGROUND Hemorrhage, is the leading cause of possible preventable death in the battlefield. There is an increasing evidence for the effectiveness of blood component therapy in general, and plasma infusion in particular but their use is less applicable in the pre-hospital setting due to logistic difficulties. Israeli Defense Force has implemented the use of freeze dried plasma (FDP) at the point of injury (POI), this adoption of FDP use entailed doubts regarding the feasibility and effectiveness of this practice. In this manuscript we present our experience with the use of FDP at the POI and pre-hospital setting regarding the feasibility, safety, adverse reactions and adherence to clinical practice guidelines (CPG). METHODS This is a descriptive retrospective cohort study based on all casualties receiving FDP during January 2013 to June 2016. The study describes the injury, treatment and outcome characteristics from POI until hospital discharge. RESULTS During the study period 109 casualties received FDP. The majority were male, aged 18-35 years old. Multiple severe injuries, were found in almost half of the casualties, 78% had penetrating injury and more than half were involved in a multi casualty event. 83% were treated with one unit of FDP, 13% with two units and 4% casualties with three units, nine patients (8.2%) were also treated in the prehospital setting with PRBC. 57% fulfilled at least one criteria for the administration of FDP. Lifesaving interventions were required in 64%. In five cases (4.6%) there were difficulties with FDP administration, Side effects were reported in one female patient. CONCLUSION This study supports the usage feasibility of FDP at the POI and in the pre-hospital setting. Further adjustment of the CPG is required basing it not only on patho-physiological parameters but also on clinical judgment. Further investigation of the available data is required in order to learn about the effectiveness of FDP at POI. LEVEL OF EVIDENCE Level IV retrospective case series study.

Point of injury tourniquet application during Operation Protective Edge - what de we learn?

BACKGROUND Hemorrhage is a leading cause of preventable death on the battlefield. Timely tourniquet application to massively bleeding extremity wounds is critical for casualty survival albeit with reported adverse effects to extremity integrity. The aim of this study was to describe the immediate- and short-term outcomes of point of injury (POI) tourniquet applications during “Operation Protective Edge” (OPE). METHODS A case series study regarding tourniquet application at the POI during OPE was collected. The data gathered included reports by medical providers at the POI, aerial and land evacuation vehicles, and receiving hospitals. Variables collected included, the number of tourniquet applications, caregiver level, tourniquet type, limb characters, tourniquet effectiveness, in-hospital procedures, complications, and short-term limb outcome. RESULTS During OPE, the Israeli Defense Forces Medical Corps treated 704 casualties. Of these, 90 casualties were treated with 119 tourniquets of which 79 survived. Penetrating trauma was the mechanism of injury in 97.8% (88 of 90) of the casualties. Injuries sustained from improvised explosive devices and shrapnel were related to the use of more than one tourniquet per casualty and per limb (p = 0.034). The success rate of the first tourniquet was reported to be 70% (84 of 119), regardless of caregiver level (p = 0.56), tourniquet type (p = 0.16), or limb characters (p = 0.48). Twenty-seven (25.7%) of 105 of the tourniquets were converted to direct pressure dressings enroute to receiving hospitals two of the conversions failed and thus a new tourniquet was applied. Fasciotomy was performed on eight casualties (a single limb in each). Vascular injury was presumed to be the indication for fasciotomy in three of these cases, in the other five limbs (6%, 5 of 85), no vascular involvement was discovered during surgery, and the fasciotomy is suspected as tourniquet related. 7%) 6 of 85) suffered from neurological sequela that could not be explained by their primary injury. Total complication rate was 11.7% (10 of 85) (one patient had both fasciotomy and neural complication without vascular injury). CONCLUSION Tourniquet use on the battlefield is a simple method of eliminating preventable death, we believe that clinical practice guidelines should promote liberal use of tourniquets by trained combatants and medical personnel with abilities to convert to direct pressure hemorrhage control when possible since an unjustified tourniquet application risks low rates minor morbidity, whereas a justifiable tourniquet not applied may be lethal. LEVEL OF EVIDENCE Epidemiologic study, level III; Therapeutic study, level IV.

Comparison of Two Intraosseous Devices: The NIO Versus the EZ-IO by Novice Users-A Randomized Cross Over Trial

Abstract Background: During resuscitation in the field, intraosseous (IO) access may be achieved using a variety of available devices, often attempted by inexperienced users. Aim: We sought to examine the success rate and ease-of-use ratings of an IO device, the NIO® (New Intraosseous Persys Medical, Houston, TX, USA) in comparison to the Arrow® EZ-IO® (Teleflex Medical Research Triangle Park, NC, USA) by novice users. Methods: We performed a randomized crossover trial. The study model was a porcine hind leg which was cut distally in order to expose the marrow. The Study population was composed of pre-graduate medical students without prior experience in IO use, all designated future field physicians. The students underwent instruction and practiced the use of both devices. After practice completion, each student attempted a single IO insertion with both devices sequentially in randomized fashion. Success was defined as a flow of fluid through the bone marrow after a single IO attempt. Investigators which determined the success rate were blinded to the used device. Results: 50 users (33 males, 17 females) participated in the trial, mean age of 21.7 years (±1). NIO users were successful in 92% (46/50) attempts while EZ-IO user success rate was 88% (44/50). NIO success rates were comparable to those of EZ-IO (p = NS). Results were similar when examining only the initial device used. Median score of ease of use was 4 (5 point Likert scale) in both devices (p = NS). 54% (27/50) of the participants preferred using the EZ-IO over the NIO (p = NS). Conclusion: Novice users were equally successful in establishing IO access with the NIO® in comparison to the EZ-IO® in a porcine model.

Preparation of medical personnel for an early response humanitarian mission – lessons learned from the Israeli defense forces field hospital in the Philippines

IntroductionHumanitarian aid provision and early medical response missions to areas ravaged by natural disasters are as essential nowadays as in the past, and medical personnel play a pivotal role in these delegations.Case descriptionIn November 2013, tropical cyclone Haiyan (Yolanda) slammed the Philippines archipelago, leaving more than an estimated 6000 dead in its wake while demolishing vital infrastructure and affecting the life of an estimated 25 million locals. The Israeli Defense Forces (IDF) rapidly constructed and sent a humanitarian aid delegation which included a field hospital deployment with medical capabilities from diverse specialty fields.Discussion and evaluationThe purpose of this article is to summarize our experience in the preparation process of medical personnel before and during deployment. We offer a simple, practical and structured checklist that will assist the medical specialist in preparation for his mission.ConclusionPreparation of medical personnel for humanitarian aid medical missions is a complex and vital task that might be better accomplished with thorough briefing and structured checklists which begin with addressing of personal safety and other daily needs of the staff.