Combat Support Hospital Research Articles

Magnitudes of Decline on Automated Neuropsychological Assessment Metrics Subtest Scores Relative to Predeployment Baseline Performance Among Service Members Evaluated for Traumatic Brain Injury in Iraq

: Identify the proportion of service members demonstrating declines in Automated Neuropsychological Assessment Metrics (ANAM) scores as part of a traumatic brain injury (TBI) evaluation conducted while deployed to Iraq. : Although TBI has been associated with poorer performance on cognitive test in the general population and military combatants, little is known about the proportion of service members demonstrating declines in ANAM scores after TBI. : Military personnel (N = 116) referred to a combat support hospital for TBI evaluation in Iraq underwent a standardized intake evaluation including computerized neurocognitive testing, psychological and physical health questionnaires, a clinical interview, and a physical examination by a physician. Predeployment and postinjury cognitive performance among service members with and without a TBI diagnosis was compared. : A significantly larger proportion of patients with TBI demonstrated greater declines in speed across all ANAM subtests compared with patients with no TBI. Differences in accuracy scores among patients with TBI relative to patients without TBI were nonsignificant. Patients with TBI also demonstrated greater than minimal declines on throughput Simple Reaction Time, Procedural Reaction Time, Code Substitution-Learning, and Spatial Memory scores, with no significant differences on Code Substitution-Delayed or Mathematical Processing (MATH). A similar pattern was seen among individuals examined within 72 hours of index injury. : Assessment of cognitive impairment following TBI in a combat zone may assist providers in making treatment recommendations for service members with mild TBI.

Prehospital Burn Management in a Combat Zone

Objective. The purpose of this article is to provide a descriptive study of the management of burns in the prehospital setting of a combat zone. Methods. A retrospective chart review was performed of U.S. casualties with >20% total-body-surface-area thermal burns, transported from the site of injury to Ibn Sina Combat Support Hospital (CSH) between January 1, 2006, and August 30, 2009. Results. Ibn Sina CSH received 225 burn casualties between January 2006 and August 2009. Of these, 48 met the inclusion criteria. The mean Injury Severity Score was 31.7 (range 4 to 75). Prehospital vascular access was obtained in 24 casualties (50%), and 20 of the casualties received fluid resuscitation. Out of the 48 casualties enrolled, 28 (58.3%) did not receive prehospital fluid resuscitation. Of the casualties who received fluid resuscitation, nearly all received volumes in excess of the guidelines established by the American Burn Association and those recommended by the Committee for Tactical Combat Casualty Care. With regard to pain management in the prehospital setting, 13 casualties (27.1%) received pain medication. Conclusions. With regard to the prehospital fluid resuscitation of primary thermal injury in the combat zone, two extremes were noted. The first group did not receive any fluid resuscitation; the second group was resuscitated with fluid volumes higher than those expected if established guidelines were utilized. Pain management was not uniformly provided to major burn casualties, even in several with vascular access. These observations support improved education of prehospital personnel serving in a combat zone.

Thirty Consecutive Uses of a Hemostatic Bandage at a US Army Combat Support Hospital and Forward Surgical Team in Operation Iraqi Freedom

Topical hemostatic agents have generated intense research interest in recent years, prompted in part by the demands of wartime medicine. Numerous animal studies demonstrate variable degrees of efficacy of a variety of agents; however, little clinical data are available in severely traumatized patients. This report describes 30 consecutive uses of the modified rapid deployment hemostat (MRDH) during combat operations in Operation Iraqi Freedom. In a prospective observational fashion, traumatized patients presenting to a combat support hospital or a forward surgical team with difficult to control hemorrhage (due to anatomy, limited resources, or tactical environment) had the MRDH applied to severely bleeding wounds. Basic demographics, wounding mechanism, wound characteristics, circumstances, and efficacy were recorded. Presence of a clinical coagulopathy was also noted. Thirty hemostatic bandages were applied to 19 patients with a wide variety of wounds. All but one application occurred in the operating room. The demographics were mean age 27 years (range, 9-55 years), 95% male, 68% penetrating or fragmentation, and four casualties had a clinical coagulopathy. Hemostasis was achieved following application of the hemostatic agent in 16 of 19 wounds. Rebleeding occurred upon removal in three cases. In all cases, the patient failed conventional interventions at hemostasis before the hemostat was applied. This is the single largest description of the clinical efficacy of the MRDH and the first description during combat operations. The MRDH bandage was an effective hemostat for temporarily controlling hemorrhage in difficult circumstances. Caution should be exercised when removing the dressing as rebleeding may occur.

Advising and Assisting an Iraqi Army Medical Clinic: Observations of a U.S. Military Support Mission

Medical civil-military operations are important for deployed military medical units engaged in counter-insurgency missions. There are few reports on military support for a host nation's military medical infrastructure, and we describe an initiative of the 21st Combat Support Hospital in 2010 during the postsurge phase of Operation Iraqi Freedom and Operation New Dawn. The goal was to incrementally improve the quality of care provided by Iraqi 7th Army medical personnel using existing clinic infrastructure and a low budget. Direct bedside teaching to include screening and treatment of ambulatory patients (sick call), focused pharmacy and medical supply system support, medical records documentation, and basic infection control compliance were the objectives. Lessons learned include the requirement to implement culturally relevant changes, maintain focus on system processes, and maximize education and mentorship through multiple modalities. In summary, a combat hospital can successfully implement an advise and assist mission with minimal external resources.

On the Front Lines of Patient Safety: Implementation and Evaluation of Team Training in Iraq

Team training has been identified as a key strategy for reducing medical errors and building a culture of safety in health care. Communication and coordination skills can serve as barriers to potential errors, as in the modern deployed U.S. Military Healthcare System (MHS), which emphasizes rapid movement of critically injured patients to facilities capable of providing definitive care. A team training intervention--TeamSTEPPS--was implemented on a large scale during one of the most intense phases of the conflict in Iraq. This evaluation of the program constituted the first undertaken in a combat theater of operations. IMPLEMENTING TEAMSTEPPS IN IRAQ: The Baghdad combat support hospital (CSH) conducted continuous operations from a fixed facility for a 13-month deployment--between November 2007 and December 2008. The TeamSTEPPS implementation in Iraq began at this facility and spread throughout the combat theater of operations. Teamwork training was implemented in two primary training sessions, followed up with reinforcement of team behaviors on the unit by hospital leadership. A total of 153 patient safety reports were submitted during the 13 months reviewed, 94 before TeamSTEPPS implementation and 59 afterwards. After training, there were significant decreases in the rates of communication-related errors, medication and transfusion errors, and needlestick incidents. There was a significant decrease in the rate of incidents coded communication as the primary teamwork skill that could have potentially prevented the event. Process improvement programs such as TeamSTEPPS implementation can be conducted under the extremely austere conditions of a CSH in a combat zone. Teamwork training decreased medical errors in the CSH while deployed in the combat theater in Iraq.

High-velocity penetrating thoracic trauma with suspected cardiac involvement in a combat support hospital

The most common cardiac injuries in the United States are blunt trauma from motor vehicle accidents or low-velocity trauma from stabbings. During military conflict, high-velocity injuries, including gunshot wounds (GSW) and fragment injury from improvised explosive devices (IED), are relatively more common. This is a retrospective review of cases with high-velocity penetrating injury and suspected myocardial involvement during a 6-month period in Baghdad, Iraq, at a United States Army hospital during Operation Iraqi Freedom. Eleven cases survived to admission (GSW in 5, IED in 6). The mean age of the all-male cohort was 27 years (range, 3-54 years). Eight of the 11 patients (73%) were victims of polytrauma. The entrance involved the right ventricle (n = 3), right atrium (n = 2), left ventricle (n = 1), or mediastinum and pericardial reflections (n = 5). Echocardiography was performed in all 11 patients. In 7 patients, no foreign body was identifiable, and in 2 patients the foreign body was identified within the pericardial fat pad. Three patients were identified as having a suspected ventricular septal defect, ranging in size from 2 to 8 mm. The most common electrocardiographic abnormality was atrioventricular block and right bundle branch block. In 4 patients, the management of the chest injury was nonsurgical, and in 1 patient the treatment was a chest tube only. Four of the patients underwent median sternotomy, 1 underwent emergent lateral thoracotomy, and 1 underwent an infradiaphragmatic approach. This case series is too small to draw definitive conclusions; however, a multidisciplinary approach to high-velocity injuries with potential for cardiac involvement augments preoperative assessment for myocardial injury and may allow selective nonoperative management.

Does Ketamine Improve Postoperative Analgesia? More Questions Than Answers

Our unit found that the use of ketamine as an anesthetic to be extremely beneficial when faced with a large number of casualties, and a limited amount of medical supplies… . patients did not require intubation, or any supplemental oxygen. We saved our meager stocks of medical supplies such as endotracheal tubes, anesthesia circuits and cylinders of oxygen. We also saved OR time….MAJ Mark Meeks, MD 86th Combat Support Hospital, Operation Iraqi Freedom 2003 In the last decade, there has been a resurgence of ketamine use both in the military medicine and in the civilian setting. Discovered in 1962, ketamine was officially released for clinical use in 1970 as an anesthetic but quickly developed a bad reputation when military physicians in Vietnam and others reported severe adverse effects including psychotomimetic phenomenon. For over 30 years, ketamine was relegated to use only for the induction of anesthesia in special circumstances including hypotensive patients and those suffering severe asthma or chronic obstructive pulmonary disease (COPD) exacerbations. Only recently did authors debunk several myths attributable to ketamine including the degree of emergence reactions, hallucinations, elevations of intracranial pressure, and lowering seizure threshold [1,2]. The resurgence of use is likely related to this and several other potentially advantageous factors. For example, ketamine is versatile and can be administered through multiple routes including oral, rectal, nasal, intravenous, intramuscular, epidural, or intrathecal. Ketamine also possesses most of the characteristics of an ideal anesthetic including a dose-dependent effect to produce analgesia, amnesia, loss of consciousness, suppression of the stress response, and akinesia. Moreover, with respect to analgesia, ketamine has been found to effect both the central and peripheral …

Minor Morbidity With Emergency Tourniquet Use to Stop Bleeding in Severe Limb Trauma: Research, History, and Reconciling Advocates and Abolitionists

In prior reports of active data collection, we demonstrated that early use of emergency tourniquets is associated with improved survival and only minor morbidity. To check these new and important results, we continued critical evaluation of tourniquet use for 6 more months in the current study to see if results were consistent. We continued a prospective survey of casualties and their records at a combat support hospital in Baghdad who had tourniquets used at a combat hospital in Baghdad (NCT00517166 at ClinicalTrials.gov). After comparable methods were verified for both the first and current studies, we report the results of 499 patients who had 862 tourniquets applied on 651 limbs. The clinical results were consistent. No limbs were lost from tourniquet use. We found that morbidity was minor in light of major survival benefits consistent with prior reports.

Impact of Improved Combat Casualty Care on Combat Wounded Undergoing Exploratory Laparotomy and Massive Transfusion

Studies have shown decreased mortality after improvements in combat casualty care, including increased fresh frozen plasma (FFP):red blood cell (RBC) ratios. The objective was to evaluate the evolution and impact of improved combat casualty care at different time periods of combat operations. A retrospective review was performed at one combat support hospital in Iraq of patients requiring both massive transfusion (≥ 10 units RBC in 24 hours) and exploratory laparotomy. Patients were divided into two cohorts based on year wounded: C1 between December 2003 and June 2004, and C2 between September 2007 and May 2008. Admission data, amount of blood products and fluid transfused, and 48 hour mortality were compared. Statistical significance was set at p < 0.05. There was decreased mortality in C2 (47% vs. 20%). Patients arrived warmer with higher hemoglobin. They were transfused more RBC and FFP in the emergency department (5 units ± 3 units vs. 2 units ± 2 units; 3 units ± 2 units vs. 0 units ± 1 units, respectively) and received less crystalloid in operating room (3.3 L ± 2.2 L vs. 8.5 L ± 4.9 L). The FFP:RBC ratio was also closer to 1:1 in C2 (0.775 ± 0.32 vs. 0.511 ± 0.21). The combination of improved prehospital care, trauma systems approach, performance improvement projects, and improved transfusion or resuscitation practices have led to a 50% decrease in mortality for this critically injured population. We are now transfusing blood products in a ratio more consistent with 1 FFP to 1 RBC. Simultaneously, crystalloid use has decreased by 61%, all of which is consistent with hemostatic resuscitation principles.

Admission hypo- or hyperthermia and survival after trauma in civilian and military environments

BackgroundIn the care of patients with traumatic injuries, focus is placed on hypothermia secondary to its deleterious impact on the coagulation cascade. However, there is scant information on the mortality effect of hyperthermia.Study objectivesWe hypothesized that both hypothermia and hyperthermia are associated with decreased survival in patients with traumatic injuries. Furthermore, we hypothesized that in the military setting, the incidence of hyperthermia would be greater compared to the civilian environment and thus contributing to an increase in mortality.MethodsRegistries compared were the National Trauma Data Bank (NTDB), three civilian Level I trauma centers, and military combat support hospitals. The NTDB was used as a reference to define hypothermia and hyperthermia based upon survival. Admission temperature and outcome were known for 4,093 civilian and 4,394 military records.ResultsHypothermia was defined as < 36°C and hyperthermia > 38°C as mortality increased outside this range. The overall mortality rates were 3.5% for civilians and 2.5% for military (p < 0.05). Of civilians, 9.3% (382) were hypothermic and 2.2% (92) hyperthermic. The incidence of hypothermia in the military patients was 6.0% (263) and for hyperthermia the incidence was 7.4% (327). Irrespective of group, patients with hypothermia or hyperthermia had an increased mortality compared to those with normal temperatures, ([for civilian:military ] hypothermia 12%:11%; normal 2%:2%; hyperthermia 14%:4%).ConclusionCare of the victim with traumatic injuries emphasizes avoidance of hypothermia; however, hyperthermia is also detrimental. The presence of hypothermia or hyperthermia should be considered in the initial treatment of the patient with traumatic injuries.

Evaluation and management of combat-related spinal injuries: a review based on recent experiences

The current approach to the evaluation and treatment of military casualties in the Global War on Terror is informed by medical experience from prior conflicts and combat encounters from the last 10 years. In an effort to standardize the care provided to military casualties in the ongoing conflicts, the Department of Defense (DoD) has published Clinical Practice Guidelines (CPGs) that deal specifically with the combat casualty sustaining a spinal injury. However, the combat experience with spine injuries in the present conflicts remains incompletely described. To describe the CPGs for the care of the combat casualty with suspected spine injuries and discuss them in light of the published military experience with combat-related spinal trauma. Literature review. A literature review was conducted regarding published works that discussed the incidence, epidemiology, and management of combat-related spinal trauma. The CPGs, established by the DoD, are discussed in light of actual military experiences with spine trauma, the present situation in the forward surgical teams and combat support hospitals treating casualties in theater, and recent publications in the field of spine surgery. In the conventional wars fought by the United States between 1950 and 1991 (Korea, Vietnam, Gulf War I), the incidence of spine injuries remained close to 1% of all combat casualties. However, in the Global War on Terror, the enemy has relied on implements of asymmetric warfare, including sniper attacks, ambush, roadside bombs, and improvised explosive devices. The increase in explosive mechanisms of injury has elevated the number of soldiers exposed to blunt force trauma and, consequently, recent publications reported the highest incidence of combat-related spinal injuries in American military history. Wounded soldiers are expeditiously evacuated through the echelons of care but typically do not receive surgical management in theater. The current CPGs for the care of soldiers with combat-related spinal injuries should be re-examined in light of data regarding the increasing number of spine injuries, new injury patterns, such as lumbosacral dissociation and low lumbar burst fractures, and recent reports within the field of spine surgery as a whole. American and coalition forces are sustaining the highest spine combat casualty rates in recorded history and previously unseen injuries are being encountered with increased frequency. While the CPGs provide useful direction in terms of the evaluation and management of combat casualties with spine injuries, such recommendations may warrant periodic re-evaluation in light of recent combat experiences and evolving scientific evidence within the spine literature.

Predictors of Post‐Traumatic Headache Severity Among Deployed Military Personnel

The current study used a cross-sectional observational design to evaluate the relationship between psychological, physiological, and contextual factors and headache severity among 133 deployed military personnel and 4 civilian contractors diagnosed with mild traumatic brain injury (mTBI) referred to a combat support hospital in Iraq. Although TBI and headache sequelae have been documented for military combatants, little is known about factors associated with headache severity. Military personnel (n = 157) and civilian (n = 4) contractors referred to a combat support hospital in Iraq underwent a standardized intake evaluation which included computerized neurocognitive testing, psychological and physical health questionnaires, a clinical interview, and a physical examination by a physician. Results of zero-inflated Poisson regression modeling suggest that insomnia is associated with increased likelihood for endorsement of any headache, but loss of consciousness, post-traumatic stress disorder symptoms, and slowed reaction time only are predictive of headache severity. Among the subset of patients presenting to the combat support hospital within 7 days of mTBI (n = 101), number of TBI symptoms demonstrated a non-significant trend toward increased likelihood of headache endorsement of any kind, with loss of consciousness, post-traumatic stress disorder, and slowed reaction time demonstrating significant relationships with headache severity. Knowledge of predictors of post-concussive headache onset and severity may assist clinicians in making important decisions regarding treatment recommendations for veterans with mTBI.

Pediatric Trauma BIG Score: Predicting Mortality in Children After Military and Civilian Trauma

To develop a validated mortality prediction score for children with traumatic injuries. We identified all children (<18 years of age) in the US military established Joint Theater Trauma Registry from 2002 to 2009 who were admitted to combat-support hospitals with traumatic injuries in Iraq and Afghanistan. We identified factors associated with mortality using univariate and then multivariate regression modeling. The developed mortality prediction score was then validated on a data set of pediatric patients (≤ 18 years of age) from the German Trauma Registry, 2002-2007. Admission base deficit, international normalized ratio, and Glasgow Coma Scale were independently associated with mortality in 707 patients from the derivation set and 1101 patients in the validation set. These variables were combined into the pediatric "BIG" score (base deficit + [2.5 × international normalized ratio] + [15 - Glasgow Coma Scale), which were each calculated to have an area under the curve of 0.89 (95% confidence interval: 0.83-0.95) and 0.89 (95% confidence interval: 0.87-0.92) on the derivation and validation sets, respectively. The pediatric trauma BIG score is a simple method that can be performed rapidly on admission to evaluate severity of illness and predict mortality in children with traumatic injuries. The score has been shown to be accurate in both penetrating-injury and blunt-injury populations and may have significant utility in comparing severity of injury in future pediatric trauma research and quality-assurance studies. In addition, this score may be used to determine inclusion criteria on admission for prospective studies when accurately estimating the mortality for sample size calculation is required.

“Einsatzchirurgie”—experiences of German military surgeons in Afghanistan

In 2010, the world witnessed 32 wars and other armed conflicts. Epidemiological analyses of mechanisms and patterns of injury of soldiers sent into these conflicts can be utilised to identify the surgical expertise that is required in a combat setting providing important parameters to adjust medical infrastructure and training requirements for future Military Surgeons. Today in 2011, the German Bundeswehr runs a combat support hospital (role 3) in Mazar-e-Sharif in Northern Afghanistan providing a multidisciplinary capability profile. Furthermore, there are two role 2 medical treatment facilities (rescue centres) in Kunduz and Feyzabad for life-saving procedures and damage control operations in order to enable rapid evacuation to a higher level of care. Epidemiological analyses of injury patterns and mechanisms have shown that 2,299 soldiers of the coalition forces have been killed in Afghanistan until January 15, 2011. Of these, 21.4% died in non-hostile action (2010). The leading causes of injury were explosive devices (up to 60%) followed by gunshot wounds. Chest or abdominal injuries (40%) and traumatic brain injuries (35%) were the main causes of death for soldiers killed in action. The analysis of all surgical procedures performed in Northern Afghanistan demonstrates that most of the patients who underwent surgery until 2009 were local civilians. Most of these operations involved osteosynthesis and soft tissue debridement. Due to the recently aggravated tactical situation within the theatre, a significant increase of mass casualty situations and combat-related injuries was noticed. The casualties in this military conflict present with injury patterns that are not seen in routine surgical practice at home. In an era of increasing surgical sub-specialisation, the deployed military surgeon needs to acquire and maintain a wide range of skills including a variety of surgical fields. In order to create this kind of military surgeon, the so-called DUO plus model for the training of military surgeons (specialisation general surgery plus a second sub-specialisation either in visceral surgery or orthopaedics/trauma surgery) has been developed in the Joint Medical Service of the German Bundeswehr. Other relevant skills, such as emergency neurotraumatology, battlefield surgery with integrated oral and craniomaxillofacial surgery, and emergency gynaecology are also integrated into this concept and will be addressed in special courses. On successful completion of this training programme, military surgeons will be officially appointed as "Einsatzchirurg" for a duration of 5 years. After this time, it will be obligatory to renew this "combat ready" status. The buildings and materials in German military medical treatment facilities provide for excellent working conditions. The training programme for military surgeons in its end-2010 version has been designed specifically with data about injury pattern and non-battle diseases as well as the political situation and professional requirements in the civilian sphere in mind.

A Casualty Tracking System Modeled After Air Traffic Control Methodology Employed in a Combat Support Hospital in Iraq

A Casualty Tracking System Modeled After Air Traffic Control Methodology Employed in a Combat Support Hospital in Iraq

Advanced Airwaymanagement In Combat Casualties By Medics At The Point Of Injury: A Sub-Group Analysis Of The Reach Study

background: Optimal airway management protocols for the prehospital battlefield setting have not been defined. Airway management strategies in this environment must take into account the injury patterns, the environment and training requirements of military prehospital providers.This is a post-hoc, sub-group analysis of the Registry of Emergency Airways Arriving at Combat Hospitals or REACH database. This study examines only those patients who had advanced airways placed for trauma by an enlisted military medic at the point of injury. results: Twenty (100%) of the patients had a traumatic injury, 19 (95%) were male, and 13 (65%) had a gun shot wounds (GSWs) as the mechanism of injury. The majority, 12 (60%) patients had an esophageal-tracheal airway device placed. Of the remaining patients, four (20%) underwent endotracheal intubation, three (15%) had a surgical cricothyroidotomy performed, and one (5%) had a Laryngeal Mask Airway (LMA) placed. Seventeen (85%) of the twenty patients were dead on arrival or died shortly after arrival at the Combat Support Hospital (CSH). All of the patients that died had a Glasgow Coma Scale (GCS) of three upon arrival. The Glasgow Coma Scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma. Three patients in this group survived to transfer from the CSH. Two of the transfers were lost to follow up, one with a GSW to the head and GCS of three, the other with a GCS of five from injuries sustained in an explosion. The third patient had a surgical cricothyroidotomy (SC) performed in the field for an expanding neck hematoma and recovered fully following surgery. conclusions: Casualties that tolerate invasive airway management without sedation in the context of trauma prognosticates a very high mortality. Airway management algorithms for military providers should reflect the casualties encountered on the battlefield not patients in cardiac arrest which predominate in the civilian EMS airway management practice. Further data are needed to understand the injuries encountered on the battlefield and to develop airway management solutions that optimize outcomes of patients with battlefield trauma.

Prevalence of Methicillin-ResistantStaphylococcus aureusin a Combat Support Hospital in Iraq

Methicillin-resistant Staphylococcus aureus (MRSA) in health-care settings results in life-threatening infections. We examined the incidence of MRSA at the combat support hospital located at the Ibn Sina Hospital in Baghdad, Iraq. We compiled isolate data from 2005 to 2009 characterizing antibiotic susceptibilities, annual trends, patient populations, infection sites, and hospital locations. Approximately 46.1% of S. aureus were MRSA, with increase in numbers of yearly isolates. MRSA was isolated in higher numbers from U.S. military personnel. Non-U.S. patient isolates displayed higher antibiotic susceptibility compared to U.S. military personnel isolates. Outpatient clinic, forward operating bases, and intermediate care ward 1 isolated the most MRSA. Common isolation sites were wound and skin cultures. Community-acquired MRSA was likely present in 291 out of 303 isolates based on antibiotic susceptibility. Our data suggests that most MRSA were community-acquired with limited nosocomial spread. We recommend increases in combat support hospital molecular lab capability to rapidly identify both MRSA categories.

PCR for Rapid Diagnosis of Acute Q Fever at a Combat Support Hospital in Iraq

Acute Q fever is occasionally seen in U.S. military service members deployed to Iraq. Diagnosis relies on serology, which is not available in the combat zone. Improved diagnostic modalities are needed. We performed a pilot study investigating whether Joint Biological Agent Identification and Diagnostic System (JBAIDS), a ruggedized, deployable polymerase chain reaction (PCR) platform, might be useful in the diagnosis of acute Q fever. Patients presenting to a Combat Support Hospital in Iraq with undifferentiated fever had blood drawn for Q fever PCR and these results were compared with serology. PCR was positive in 6 of 9 patients with acute Q fever by serology and negative in all 9 patients with negative serology. These results suggest that PCR using the JBAIDS platform could be of use in the diagnosis of Q fever in deployed settings. Further research into this modality is warranted.

Characteristics of Medical-Surgical Patients at the 86th Combat Support Hospital During Operation Iraqi Freedom

A descriptive study was performed of the U.S. and coalition forces patients admitted to the Intermediate Care Ward (ICW) of the 86th Combat Support Hospital (CSH) in Baghdad, Iraq (2007-2009). A prospective study was conducted of the patients admitted to the ward between April 12 and July 19, 2008. Three hundred and fifty three patients were included in the study. Characteristics of the patients admitted during a 3-month period of the deployment of the 86th CSH in Iraq, as well as the types of illnesses and injuries most commonly seen are reported. Implications for nurses preparing to deploy as well as implications for future research are discussed.

Comparison of Concussive Symptoms, Cognitive Performance, and Psychological Symptoms Between Acute Blast-Versus Nonblast-Induced Mild Traumatic Brain Injury

Blast-related head injuries are one of the most prevalent injuries among military personnel deployed in service of Operation Iraqi Freedom. Although several studies have evaluated symptoms after blast injury in military personnel, few studies compared them to nonblast injuries or measured symptoms within the acute stage after traumatic brain injury (TBI). Knowledge of acute symptoms will help deployed clinicians make important decisions regarding recommendations for treatment and return to duty. Furthermore, differences more apparent during the acute stage might suggest important predictors of the long-term trajectory of recovery. This study evaluated concussive, psychological, and cognitive symptoms in military personnel and civilian contractors (N = 82) diagnosed with mild TBI (mTBI) at a combat support hospital in Iraq. Participants completed a clinical interview, the Automated Neuropsychological Assessment Metric (ANAM), PTSD Checklist-Military Version (PCL-M), Behavioral Health Measure (BHM), and Insomnia Severity Index (ISI) within 72 hr of injury. Results suggest that there are few differences in concussive symptoms, psychological symptoms, and neurocognitive performance between blast and nonblast mTBIs, although clinically significant impairment in cognitive reaction time for both blast and nonblast groups is observed. Reductions in ANAM accuracy were related to duration of loss of consciousness, not injury mechanism.