A Multiyear Analysis of the Clinical Encounters of the ATF Tactical Medical Program

BACKGROUND

The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) Tactical Medical Program provides tactical medical support for ATF's tactical Special Response Teams (SRTs) and investigative National Response Teams (NRTs) through the deployment of specially trained ATF Agent-Medics. All patient care activities are centrally coordinated through ATF Headquarters.

METHODS

A retrospective analysis of de-identified patient care reports (PCRs) from the ATF Tactical Medical Program from 2009 to 2012 was performed. Clinical and operational data were extracted from PCRs and were entered into a database by the research team. Descriptive and summative analyses were performed to assess patient type, law enforcement incident type, chief complaint, and interventions performed.

RESULTS

Analysis was performed on the 254 charts. Nearly half (114; 44.9%) of patients encountered during the study period were law enforcement officers. High-risk warrant service was associated with one third (85; 33.5%) of the ATF medics' clinical encounters. The most common chief complaints of patients encountered were musculoskeletal pain/injury (57; 22.4%) and wounds/lacerations (57; 22.4%), followed by heat illness (17; 6.7%). The most common intervention was wound care (61; 26.9%), followed by control of bleeding with direct pressure (43; 18.9%). The most common medications administered were ibuprofen (28; 25.2%), topical antibiotic (12; 10.8%), and acetaminophen (12;10.8%).

CONCLUSION

This multiyear analysis represents an important contribution to the growing body of scientific literature surrounding tactical medicine. The results of this analysis demonstrate a continued need for expanded scope of practice training, as well as enhanced treatment protocols for tactical medics.

Clinical encounters in tactical medicine: a mission-specific analysis of the Maryland State Police experience

INTRODUCTION

The Maryland State Police (MSP) Tactical Medical Unit (TMU) provides tactical emergency medical support (TEMS) through the deployment of specially trained state trooper tactical paramedics. The MSP TMU maintains an operational database of all mission related medical activity. This information constitutes a robust dataset derived from real world operational medicine experiences.

METHODS

A retrospective analysis of de-identified entries from the MSP TMU operational response database was performed for the 5-year period of 2007?2013. A summative analysis of missions, as well as a subgroup analysis of types of patients encountered, was performed to further characterize patient encounters based on the type of law enforcement tactical mission.

RESULTS

Analysis was performed on 1,042 tactical missions, of which there were 367 total patient encounters during the study period. The majority (67%; 246/367) of patients encountered were law enforcement tactical team personnel. The most frequently occurring mission, by type, was high-risk warrant service, accounting for 45% (470/1,042) of all missions in this series. Law enforcement training support missions comprised 25% (259/1,042), and 15% (157/1,042) of all missions in the database were medical standbys for law enforcement operations. The highest number of patient contacts were associated with training activities, resulting in 29% (108/367) of clinical encounters. The next most common mission associated with patient encounters was high-risk warrant service (24%; 88/367).

CONCLUSION

The 5-year analysis conducted in this study represents the largest known retrospective assessment of a state police tactical medical program. Training activities resulted in the highest number of patient encounters by this program, with law enforcement/tactical team personnel comprising the majority of patient encounters. The majority of chief complaints encountered were non?life threatening and reinforce the need for expanded scope of practice training and enhanced treatment protocols for tactical medics.

Management of open chest wounds in tactical emergency casualty care: application of vented versus nonvented chest seals

The 2014 midyear, full meeting of the Committee for Tactical Emergency Combat Care (C-TECC) was hosted by the Johns Hopkins University Center for Law Enforcement Medicine on June 9 and 10 in Baltimore, Maryland. As the C-TECC guidelines are increasingly recognized as the best-practice recommendations for civilian, high-threat, prehospital trauma response, a focused guidelines discussion occurred to develop best-practice recommendations for the management of open chest wounds, specifically regarding the application of vented and nonvented chest seals.

Perinatal testosterone exposure and maternal care effects on the female rat's development and sexual behaviour

Natural variations in maternal care have profound influences on offspring behaviour, brain activity and hormone release. Measuring the amount of time that a rat dam spends licking/grooming (LG) her pups during their first week of life allows for characterisation of distinctive Low, Mid and High LG phenotypes. We have previously found that female offspring of High LG mothers are less sexually receptive, less motivated to mate and show a later onset of puberty relative to Low LG offspring. Given that High LG females are exposed to greater levels of testosterone in utero, we hypothesise that differences in sexual behaviour between High and Low LG female offspring are driven in part by differences in prenatal hormone exposure. To test this hypothesis, pregnant dams pre-characterised as Low, Mid, or High LG mothers were implanted with testosterone or placebo on gestational day (GD) 16. Offspring body weight and anogenital index were assessed at GD 21 and in adulthood. Age of vaginal opening and oestrous cyclicity were assessed to determine the timing of pubertal onset. Testosterone exposure removed the difference between LG phenotypes in pubertal onset by delaying vaginal opening and the appearance of first pro-oestrus. In adulthood, sexual behaviour in a paced mating chamber after sham surgery or ovariectomy with steroid-replacement was examined. Our findings show that Low, Mid and High LG female offspring are differentially affected by perinatal testosterone exposure, and that this exposure removes the precocial pubertal onset of Low LG offspring and increases the sexual proceptivity and receptivity of High LG offspring. These results suggest that maternal programming of the female reproductive system may be mediated, in part, through differences in perinatal testosterone exposure, instead of solely through maternal behaviour.

A novel intervention for decreasing hospital crowding following the blizzards of 2010

Recent evidence demonstrates that emergency department (ED) and inpatient hospital crowding contributes to unsafe patient care. The blizzards of 2010 produced conditions that prohibited the safe discharge of admitted inpatients and were identified as a major factor in crowding of the ED at Howard County General Hospital (HCGH). At one point, admitted patients occupied 35 of the 36 treatment beds in the ED. A novel intervention was conceived and created that used the resources of Howard County Fire and Rescue (HCFR) to transport discharged patients from the inpatient floors to their home, thereby decreasing ED boarding and crowding. Throughout the 12-hour operation, HCFR personnel transported 13 patients from hospital inpatient floors to their home, and two ED interfacility transports were performed. In addition, HCFR units conducted one rescue and successful resuscitation of a patient with a sudden cardiac arrest during a 911 emergency call. During this call, HCFR and HCGH also coordinated the emergency transport of an interventional cardiologist through the blizzard to HCGH to perform emergency cardiac catheterization. At the end of the operational period, the ED had regained all but four beds pending inpatient admission. These efforts fortified a strong partnership between a community hospital and local fire department to facilitate the expeditious discharge and disposition of inpatients during the blizzards of 2010 to decrease crowding.

The challenges with NOTES retroperitoneal access in humans

BACKGROUND

Animal studies have supported natural orifice transluminal endoscopic surgery (NOTES) retroperitoneal access. NOTES also may offer unique retroperitoneal access in humans.

OBJECTIVES

This study was designed to assess the feasibility of endoscopic transgastric and transrectal retroperitoneal access in a cadaver model using prone and supine positioning, and to compare NOTES retroperitoneal examination with endoscopic ultrasound.

METHODS

Using a multidisciplinary team, this institutional review board-approved study evaluated transgastric and transrectal retroperitoneal examination in six cadavers (3 male, 3 female; body mass index range, 25-37 kg/m(2)). Endoscopic ultrasound retroperitoneal examination preceded NOTES access. Transgastric Access: Using a prototype dual channel endoscope, a needle knife gastrotomy was created on the preantral posterior gastric wall. Retroperitoneal examination specifically targeted the pancreas and surrounding structures with the cadaver supine and prone. Transrectal Access: Using the same endoscope, a posterior needle knife rectotomy distal to the upper valve of Houston provided extraluminal access. Retroperitoneal examination proceeded with the cadaver prone and supine. Open dissection followed procedure completion.

RESULTS

Access into the retroperitoneum succeeded at all sites. Significant challenges locating identifiable landmarks were faced-mostly transrectal and improved transgastric prone. All cadavers, despite body mass index or sex, had significant retroperitoneal adipose tissue limiting the endoscopic view.

CONCLUSIONS

Although porcine studies have highlighted successful NOTES retroperitoneal procedures, the abundant human retroperitoneal adipose tissue challenged the translation of porcine research to humans. Additionally, although access to the retroperitoneal space and dissection within this space were accomplished easily, the appearance of cadaveric tissue and lack of blood flow made confident landmark identification impossible. Further study should continue in this area and focus on confident landmark identification for directed dissection. In a cadaveric model, this would best be improved by pre-NOTES anatomic marking or active perfusion of vasculature along with consideration of direct entry into the retroperitoneum from a targeted intraperitoneal site in clinical patients.

Endoscopic retrograde cholangiopancreatography using a single-balloon enteroscope in patients with altered Roux-en-Y anatomy

BACKGROUND AND STUDY AIMS

Endoscopic retrograde cholangiopancreatography (ERCP) is challenging to perform in patients with postsurgical gastrointestinal anatomy. We assessed the diagnostic and therapeutic success rates using single-balloon enteroscopy in patients with Roux-en-Y anastomosis.

PATIENTS AND METHODS

Patients who underwent single-balloon ERCP between April 2008 and February 2010 were retrospectively identified using a computerized endoscopy database. Diagnostic success was defined as successful duct cannulation or securing the diagnosis, and therapeutic success was defined as the ability to successfully carry out endoscopic therapy. Complications of ERCP were defined according to standard criteria.

RESULTS

A total of 50 patients (34-male, mean age 57 years, range 19 - 85 years) with Roux-en-Y anastomosis underwent ERCP using a single-balloon enteroscope on 56 occasions. Indications for ERCP were cholestasis, acute cholangitis, recurrent primary sclerosing cholangitis with strictures, and choledocholithiasis. Overall diagnostic success was achieved in 39 / 56 cases (70 %). Therapeutic success was achieved in 21/23 cases (91 %). In 16 cases therapeutic intervention was not required. Therapeutic interventions included balloon dilation of strictures (n = 14), retrieval of retained biliopancreatic stents (n = 5), biliary stone extraction (n = 2), insertion of biliopancreatic stents (n = 4), and biliary and pancreatic sphincterotomy (n = 5). No major complications occurred. Importantly, in 22 / 56 procedures (39 %) a prior attempt at ERCP failed using conventional colonoscopes; single-balloon ERCP was successful in 15 / 22 (68 %) of these cases.

CONCLUSIONS

Single-balloon ERCP is feasible in patients with complex postsurgical Roux-en-Y anastomosis, allows diagnostic evaluation and therapeutic intervention in patients with pancreaticobiliary disease, and is a useful salvage technique in the majority of patients in whom ERCP using colonoscopies has failed.

The role of endoscopic ultrasound for loco-regional staging of rectal cancer

Rectal cancer is projected to have the 10th highest incidence of cancer in the United States in 2009, with 40 870 estimated new cases this year. The prognosis for patients with rectal cancer is directly related to several factors, with the most important, based on current data, the extent of primary tumor invasion, the number of lymph nodes involved, involvement of the circumferential resection margin, and the presence of metastases. Contemporary therapy is dependent upon pre-surgical diagnostic imaging modalities, which influence the indication for neoadjuvant therapy and the decision process concerning the appropriate surgical approach. A comprehensive overview based on the currently available evidence of endoscopic ultrasound imaging in the loco-regional assessment of primary de novo rectal cancer evaluation following neoadjuvant therapy and post operative disease surveillance is presented. Relevant ano-rectal anatomy, staging systems for rectal cancer and alternative radiological staging strategies are also presented.

Endoscopic transpapillary gallbladder drainage: 10-year single center experience

AIM

A subset of patients with acute cholecystitis is severely ill and extremely high-risk to undergo cholecystectomy. Data on the use of endoscopic transpapillary gallbladder drainage (ETGBD) in the treatment of acute cholecystitis are limited. This article reviews the 10-year experience of ETGBD at Mayo Clinic and evaluated patient and procedure characteristics.

METHODS

A retrospective review of the endoscopy database from 1998-2007 was performed to identify patients who had undergone ETGBD. Clinical information and procedure details were abstracted from the electronic medical record.

RESULTS

Fifty one patients underwent ETGBD for acute cholecystitis between 1998 to July 2007. The mean age was 62+/-19 years and 67% of patients were males. The median number of comorbid medical conditions was two (range 0-5) and 27% had underlying diabetes mellitus. Acute calculous cholecystitis was the predominant indication for ETGBD (78%). A gallbladder stent was used in 33 (65%) patients, nasocholecystic drain in 14 (27%) patients, and both in four patients (8%). Bleeding (4%) and sedation-related complications (4%) were the most common complications noted. Among patients who underwent cholecystectomy, the majority (76%) needed an open procedure. The median time to cholecystectomy was 15 days (range 1-352 days). Four patients (8%) succumbed to septic shock during their hospitalization.

CONCLUSIONS

ETGBD is a valuable alternative therapeutic modality for the treatment of patients with acute cholecystitis who are at high-risk for early cholecystectomy, and/or those who have contraindications to percutaneous gallbladder drainage.

Endoscopic ultrasound (EUS) guided access and therapy of pancreatico-biliary disorders

Endoscopic ultrasound (EUS) has evolved from a purely diagnostic imaging modality to one that allows therapeutic intervention. It now serves as a viable alternative, and at times is preferred, to percutaneous and surgical techniques for obtaining biliary and pancreatic duct access and for providing drainage. EUS guided intervention is usually performed following failed endoscopic retrograde cholangiopancreatography (ERCP) or as an option for patients who decline surgical intervention or in poor operative candidates. Published data demonstrate overall technical success in 83% of patients with 12% experiencing a procedure related complication. New techniques and equipment must be developed to simplify and abbreviate the procedures, to limit complications, and improve outcomes. In addition, longitudinal data are needed to determine the long-term outcomes and role of EUS guided pancreaticobiliary intervention.

Pancreatic stent prophylaxis of post endoscopic retrograde cholangiopancreatography pancreatitis: spontaneous migration rates and clinical outcomes

AIM

Pancreatic duct (PD) stents diminish the risk of post endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk patients; 3 Fr stents are reported to spontaneously migrate at a significantly higher rate than 5 Fr stents in a cohort of mostly sphincter of Oddi (SOD) patients. We sought to assess spontaneous migration rates of 5 Fr and 7 Fr stents and effectiveness in preventing PEP in a diverse group of high risk patients.

METHODS

A total of 4,332 ERCP exams performed between January 2002 and August 2005 were reviewed to identify patients undergoing PD stent placement. Follow-up was obtained from electronic medical records and contact with referring MDs. Plain abdominal radiographs were used to document stent passage.

RESULTS

PD stents for PEP prophylaxis were placed in 246 exams (232 patients) undergoing: PD (major or minor) sphincterotomy (84), ampullectomy (50), SOD (46), bile duct precut (35), papillary stenosis balloon dilation (9) and difficult cannulation (8). Stents placed: 218 5-Fr (140 were 3 cm long and 78 =or> 5 cm long) and 28 7-Fr (12 were 3 cm long, 16=or> 5cm long). Follow-up was available in 197 (171 5-Fr, 26 7-Fr) of 246 placements (80%). Twenty of 171 5-Fr stents were electively removed via EGD within=or< 24 h per endoscopist preference and were not included in analysis; 128 of the remaining 151 5-Fr stents (85%) spontaneously migrated by (or within) median of 8 days and 23 failed to pass and required EGD removal. Of 26 7-Fr stents one was electively removed =or< 24 h later; of the remaining 25, 15 (60%) spontaneously migrated by median of 16 days, 10 required EGD removal. The spontaneous migration rate of 5 Fr stents was: 1) significantly higher than 7 Fr stents; 2) significantly higher than the previously reported 67% passage rate of 5 Fr stents; and 3) similar to the previously reported 86% passage rate of 3 Fr stents. PEP occurred in 15% (n=36: 24 mild, 11 moderate, 1 severe).

CONCLUSION

The spontaneous dislodgement rate of 5 Fr stents in patients where the indication is primarily non-SOD is approximately 85% - significantly higher than previously reported and similar to the reported rate of spontaneous dislodgement of 3 Fr stents in SOD patients; 5 Fr stents migrate spontaneously earlier and more frequently than 7 Fr stents.

Frequency of visualization of presumed celiac ganglia by endoscopic ultrasound

BACKGROUND AND STUDY AIMS

Celiac ganglia can be visualized by endoscopic ultrasound (EUS). It is unknown how often ganglia are visualized during EUS, and what clinical factors are associated with ganglion visualization. The aim of this study was to prospectively evaluate the frequency of visualization of presumed celiac ganglia by EUS and to identify factors that predict their visualization.

PATIENTS AND METHODS

Clinical, demographic, EUS, and cytologic data were collected prospectively from 200 unselected patients who were undergoing EUS in a tertiary referral centre. When presumed celiac ganglia were visualized, their size, number, location, and echo features were noted. When presumed ganglia were aspirated, the results of cytology were recorded.

RESULTS

The most common indication for EUS was investigation of a pancreatic mass or cyst (25 %). Presumed celiac ganglia were identified in 81 % of patients overall. Logistic regression analysis determined that female sex and having no prior history of gastrointestinal surgery were independently associated with ganglion visualization. Among patients whose ganglia were visualized, more ganglia were seen per patient with linear echo endoscopes (2, range 0 - 5) than with radial echo endoscopes (1, range 0 - 4) ( P = 0.001). Presumed celiac ganglia were aspirated in 10 patients; and cytologic examination revealed neural ganglia in all of these.

CONCLUSIONS

Celiac ganglia can be visualized by EUS in most patients who undergo upper gastrointestinal EUS examinations, and are best seen with linear-array echo endoscopes. Ganglia can usually be differentiated from lymph nodes on the basis of their endosonographic appearance.