H. Theodore Harcke

Chest Wall Thickness in Military Personnel: Implications for Needle Thoracentesis in Tension Pneumothorax

Needle thoracentesis is an emergency procedure to relieve tension pneumothorax. Published recommendations suggest use of angiocatheters or needles in the 5-cm range for emergency treatment. Multidetector computed tomography scans from 100 virtual autopsy cases were used to determine chest wall thickness in deployed male military personnel. Measurement was made in the second right intercostal space at the midclavicular line. The mean horizontal thickness was 5.36 cm (SD = 1.19 cm) with angled (perpendicular) thickness slightly less with a mean of 4.86 cm (SD 1.10 cm). Thickness was generally greater than previously reported. An 8-cm angiocatheter would have reached the pleural space in 99% of subjects in this series. Recommended procedures for needle thoracentesis to relieve tension pneumothorax should be adapted to reflect use of an angiocatheter or needle of sufficient length.

Radiology in a hostile environment: experience in Afghanistan.

Imaging equipment deployed with the combat support hospital in Afghanistan represented new technology not previously used in a hostile environment for a prolonged period. In general, the equipment performed well in a stationary location. Having computed tomography and ultrasound scans, in addition to plain radiographs, was very helpful for patient care. Redundancy of digital radiography and ultrasound systems proved prudent. It is recommended that a radiologist continue to be sent with the combat support hospital, particularly when computed tomography and ultrasound systems are in the deployment package. This report acquaints the medical community with information to aid in the planning and performance of future deployments that bring digital imaging to the battlespace.

Analysis of Recovered Tourniquets From Casualties of Operation Enduring Freedom and Operation New Dawn

BACKGROUND Tourniquet use recently became common in war, but knowledge gaps remain regarding analysis of recovered devices. The purpose of this study was to analyze tourniquets to identify opportunities for improved training. METHODS We analyzed tourniquets recovered from deceased service members serving in support of recent combat operations by a team at Dover Air Force Base from 2010 to 2012. Device makes and models, breakage, deformation, band routing, and windlass turn numbers were counted. RESULTS We recovered 824 tourniquets; 390 were used in care and 434 were carried unused. Most tourniquets were recommended by the Committee on Tactical Combat Casualty Care (Combat Application Tourniquet [CAT] or Special Operations Forces Tactical Tourniquet). The band was routed once through the buckle in 37% of used CATs, twice in 62%, and 1% had none. For tourniquets with data, the windlass turn number averaged 3.2 (range, 0-9). The CAT windlass turn number was associated positively with tourniquet deformation as moderate or severe deformation began at 2 turns, increased in likelihood stepwise with each turn, and became omnipresent at 7 or more. CONCLUSIONS Tourniquet counts, band routings, windlass turn numbers, and deformation rates are candidate topics for instructors to refine training.

Computed tomography of craniofacial trauma at a combat support hospital in Afghanistan.

Complex craniofacial injuries are encountered among both soldiers and civilians in combat zones. Computed tomography is a necessary and effective tool for the evaluation and treatment of these injuries in the forward-deployed combat support hospital.

Placement of Tibial Intraosseous Infusion Devices

Post-mortem preautopsy multidetector computed tomography was used to assess the placement of tibial intraosseous infusion needles in 52 cases of battlefield trauma deaths for which medical intervention included the use of the technique. In 58 (95%) of 61 needles, the tip was positioned in medullary bone. All 3 (5%) unsuccessful placements were in the left leg, and the needle was not directed perpendicular to the medial tibial cortex as recommended. Considering the nature of military trauma and the environmental conditions under which care is rendered, military medical personnel appear to be highly successful in the placement of tibial intraosseous infusion needles.

Imaging body armor.

This study examined the feasibility of performing radiographic studies on patients wearing standard-issue body armor. The Kevlar helmet, fragmentation vest, demining suit sleeve, and armor plate were studied with plain film and computed tomography in a simulated casualty situation. We found that the military helmet contains metal screws and metal clips in the headband, but diagnostic computed tomographic images can be obtained. Kevlar, the principal component of soft armor, has favorable photon attenuation characteristics. Plate armor of composite material also did not limit radiographic studies. Therefore, when medically advantageous, patients can be examined radiographically while wearing standard military body armor. Civilian emergency rooms should be aware of these observations because law enforcement officers wear similar protective armor.

Forensic imaging-guided recovery of nuclear DNA from the spinal cord*.

Abstract:  Our objective is to document the recovery of DNA from the spinal cord or surrounding dura mater in 11 cases of severely burned human remains. Radiographs established that portions of charred tissue contained spine segments. Multidetector computed tomography (MDCT) revealed that each spine specimen contained an intact spinal cord remnant. A full DNA profile was obtained from seven specimens using spinal cord dura mater in six specimens and spinal cord medulla in one specimen. A partial profile was obtained from four specimens (spinal cord dura mater, 2; spinal cord medulla, 2). Bone and muscle surrounding the spinal cord appear to insulate nucleic acid containing tissue from critical thermal degradation. The spinal cord, which is easily identified by MDCT examination of remains and easily recovered at the postmortem examination, can be a source of DNA with extraction yields comparable with other tissue sources. Specimens of dura mater are preferable as processing time is faster than bone.

Observational Case Series: An Algorithm Incorporating Multidetector Computed Tomography in the Medicolegal Investigation of Human Remains after a Natural Disaster

An algorithm incorporating multidetector computed tomography (MDCT), digital radiographs, and external examination was used to triage cases for noninvasive or complete autopsy after a natural disaster. The algorithm was applied to 27 individuals who died during or soon after the earthquake that struck the Republic of Haiti on January 12, 2010. Of the 27 cases reviewed, 7 (26%) required a complete autopsy to determine cause and manner of death. In the remaining 20 (74%), cause and manner of death were determined with a reasonable degree of medical certainty after review of circumstances, an external examination, and postmortem imaging by MDCT and digital radiography (noninvasive autopsy). MDCT was particularly useful in detecting skeletal fractures caused by blunt force injury which were not evident on digital radiographs. The algorithm incorporating postmortem MDCT can be useful in the triage of human remains for autopsy after a natural disaster.

Disease and nonbattle injury in the combat zone

Given the current tempo of military operations in the global war on terror, the military radiologist must be prepared to diagnose surgical and medical conditions. The imaging of blunt and penetrating trauma remains the critical mission. However, a more challenging part of the day’s work involves the imaging of medical diseases encountered in the third world. The majority of such entities are infectious in nature, but unusual presentations of congenital diseases are common. It is important for the deployed radiologist to have knowledge of diseases and conditions not ordinarily seen in the USA and to have a high index of suspicion for unusual processes.

Computed Tomographic Findings in Unsuspected Aortic Dissection and Adult Polycystic Kidney Disease

The coexistence of adult polycystic kidney disease and aortic dissection should be recognized by forensic pathologists and radiologists. Two cases with postmortem computed tomography prior to autopsy illustrate the appearance of polycystic kidneys and the hemorrhage patterns that provide clues to the presence and approximate location of the aortic dissections. Optimal imaging technique is discussed.