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Those medical providers deployed to remote countries and tasked with caring for military personnel must diagnose and treat diseases and nonbattle injuries that result from exposures rarely seen in developed countries. Military providers must also function with limited resources and a lack of access to physician specialists, to include medical toxicologists. There have been limited published approaches to addressing this clinical gap for medical toxicology. To address this void, the US Army Medical Department deployed an electronic mail telemedicine system to provide teleconsultations for remote health-care providers worldwide, including Iraq and Afghanistan. This study aimed to describe the types and the frequency of toxicology teleconsultation and consultant responses using electronic mail to assist physicians serving in resource-limited locations. This was a retrospective observational study in which an unblinded data extractor independently reviewed all medical toxicology email consultations. Using a previously developed data collection worksheet, the extractor recorded the type of question asked by the consultant (overdose case, envenomation, occupational exposure, etc.) and the duration of time from when the teleconsultation was placed until the consultant replied. The extractor also recorded if the patient was adult or pediatric and if the patient was US military, US contractor, or local national. The extractor also recorded how often the toxicologist provided the consulting physician with information, resources, or protocols to aid in the management of future cases. In addition, for clinical teleconsultations, the extractor documented the frequency that the consulted toxicologist (i) provided a differential diagnosis or specific diagnosis, (ii) provided specific management guidelines for a patient, and (iii) recommended to evacuate or not evacuate a patient. The results were analyzed using descriptive statistics. Of the 99 consultations evaluated, the most common consultation was for snake envenomation ...

INTRODUCTION: Cyanide is a deadly poison, particularly with oral exposure where larger doses can occur before symptoms develop. Prior studies and multiple governmentagencies highlight oral cyanide as an agent with the potential for use in a terrorist attack. Currently, there are no FDA approved antidotes specific to oralcyanide. An oral countermeasure that can neutralize and prevent absorption of cyanide from the GI tract after oral exposure is needed. Our objective was toevaluate the efficacy of oral sodium thiosulfate on survival and clinical outcomes in a large, swine model of severe cyanide toxicity. METHODS: Swine (45-55kg) were instrumented, sedated, and stabilized. Potassium cyanide (8 mg/kg KCN) in saline was delivered as a one-time bolus via an orogastric tube. Three minutes after cyanide, animals randomized to the treatment group received sodium thiosulfate (510 mg/kg, 3.25 M solution) via orogastric tube. Our primary outcome was survival at 60 minutes after exposure. We compared survival between groups by log-rank, Mantel-Cox analysis and trended labs and vital signs. RESULTS: At baseline and time of treatment all animals had similar weights, vital signs, and laboratory values. Survival at 60 min was 100% in treated animals compared to 0% in the control group (p=0.0027). Animals in the control group became apneic and subsequently died by 35.0 min (20.2,48.5) after cyanide exposure. Mean arterial pressure was significantly higher in the treatment group compared to controls (p=0.008). Blood lactate (p=0.02) and oxygen saturation (p=0.02) were also significantly different between treatment and control groups at study end. CONCLUSION: Oral administration of sodium thiosulfate improved survival, blood pressure, respirations, and blood lactate concentrations in a large animal model of acute oral cyanide toxicity.

INTRODUCTION: With personnel scattered throughout a continent 3 times larger than the United States, a lack of mature medical facilities necessitates a significant transportation network for medical evacuation in US Africa Command (AFRICOM). We describe medical evacuations analyzed from the US Air Force Transportation Command Regulating and Command & Control Evacuation System (TRAC2ES). METHODS: We performed a retrospective review of all TRAC2ES medical records for medical evacuations from the AFRICOM theater of operations conducted between January 1, 2008 and December 31, 2018. We abstracted free text data entry in TRAC2ES for diagnostic and therapeutic interventions performed prior to the patient movement request. RESULTS: During this time, there were 963 cases recorded in TRAC2ES originating within AFRICOM. 961 records were complete for analysis. Most patients were male (82%) and military personnel (92%). Most transports originated in Djibouti (72%), and Germany (93%) was the most common destination. Medical evacuations were largely routine (66%), and routine evacuations were proportionally highest amongst US military personnel compared to all other groups. A small portion of patients were evacuated for battle injuries (4%), compared to non-battle injury (33%) and disease (63%). Within disease, the largest proportion of patient complaints centered on gastrointestinal symptoms (13%), behavioral health (11%) and chest pain (8%). Prior to evacuation, only 55% of patients were document as receiving any medication. Pain control was documented in 21% of cases, most commonly being NSAIDs (7%). DISCUSSION: Extremely low numbers of battle injuries highlight the unique nature of AFRICOM operations compared to areas with more intense combat operations. Limitations of the dataset highlight the need for a data collection mandate within AFRICOM as within other areas for optimization and performance improvement.

INTRODUCTION: The United States (US) military has expanded its area of operations into Africa. This medically immature theater is spread across a large region where prolonged field care (PFC) events are likely to occur. We describe trauma cases reported in the Africa Command (AFRICOM) area of operations to date within the Department of Defense Trauma Registry (DODTR). METHODS: We queried the DODTR for all subjects evacuated from the AFRICOM area of operations from January 2002 to June 2017. RESULTS: There were 49 subjects in the registry during our time frame from AFRICOM. Most of the evacuations came from Djibouti (53%). The median age was 29 years, most evacuees being male (92%). Non-battle injuries accounted for most of the injuries (82%), and most were US military (90%). All battle injuries were gunshot wounds (GSW). Composite injury scores were low (median 4, IQR 4–9.5). All subjects survived to hospital discharge. GSWs (22%) and sports injuries (24%) accounted for most evacuations. Serious injuries most frequently involved the extremities (18%) and the thorax (12%). The most frequent major injuries were open fractures (22%) and abdominal injuries (10%). The most frequent facility-based interventions performed were wound debridement (29%) and fracture/joint dislocation reduction (22%). DISCUSSION: Based on this dataset, most of the injuries from AFRICOM were non-battle injuries. All battle injuries were GSWs. Our study highlights the differences in casualty care needs in this region which contrast the primary explosive-based injuries seen within United States Central Command (CENTCOM) operations. The limitations of this dataset highlight the potential value of a Joint Trauma Service (JTS) data collection mandate and resource support for units within this region to facilitate targeted improvements in medical care.

INTRODUCTION: Between 2001 and 2009, opioid analgesic prescriptions in the Military Health System quadrupled to 3.8 million. The sheer quantity of opioid analgesics available sets the stage for issues related to misuse, abuse, and diversion. To address this issue, the Department of Defense implemented several directives and clinical guidelines to improve access to appropriate pain care and safe opioid prescribing. Unfortunately, little has been done to characterize changing patterns of opioid use in active duty service members (ADSM), so little is known about how combat operations and military health care policy may have influenced this significant problem. We examined changes in opioid use for ADSM between 2006 and 2014, compared trends with the civilian population, and explored the potential role of military-specific factors in changes in opioid use in the Military Health System. MATERIALS AND METHODS: After obtaining Institutional Review Board approval, administrative prescription records (Pharmacy Data Transaction Records) for non-deployed ADSM were used to determine the number of opioid prescriptions dispensed each year and the proportion of ADSM who received at least one prescription per month between 2006 and 2014. Based on the observation and the literature, we identified December 2011 as the demarcation point (the optimal point to identify the downturn in opioid use) and used it to compare opioid use trends before and after. We used an autoregressive forecast model to verify changes in opioid use patterns before and after 2011. Several interrupted time series models examined whether military system-level factors were associated with changes in opioid use. RESULTS: Between 2006 and 2014, 1,516,979 ADSM filled 7,119,945 opioid prescriptions, either in military treatment facilities or purchased through TRICARE. Both active duty and civilian populations showed signs of decreasing use after 2011, but this change was much more pronounced among ADSM. The forecast model showed a significant difference after ...