For 20 years, the Journal of Special Operations Medicine (JSOM) has been the only published venue that brings together military SOF, civilian Tactical EMS, and federal Department of Justice agencies with tactical medical assets. Originally established by the Command Surgeon's Office of the United States Special Operations Command (USSOCOM-SG), we have grown into one of the world's most renowned peer-reviewed medical journals, now subscribed to in 80 countries. Be informed. Stay Informed. Subscribe today!
Journal of Special Operations Medicine (JSOM) Newsletter
01 November 2020 - Issue 184

The literature continues to provide strong support for the early use of tranexamic acid (TXA) in severely injured trauma patients. Questions persist, however, regarding the optimal medical and tactical/logistical use, timing, and dose of this medication, both from the published TXA literature and from the TCCC user community. The use of TXA has been explored outside of trauma, new dosing strategies have been pursued, and expansion of retrospective use data has grown as well. These questions emphasize the need for a reexamination of TXA by the CoTCCC. The most significant updates to the TCCC Guidelines are (i) including significant traumatic brain injury (TBI) as an indication for TXA, (ii) changing the dosing protocol to a single 2g IV/IO administration, and (iii) recommending TXA administration via slow IV/IO push.

November 2020 JSOM Feature Article
Ketamine Administration by Special Operations Medical Personnel During Training Mishaps
Fisher AD, Schwartz DS, Petersen CD, Meyer SE, Thielemann JN, Redman TT, Rush SC. 20(3). 81 - 86.
(Journal Article)

Background: Opioids can have adverse effects on casualties in hemorrhagic shock. In 2014, the Committee on Tactical Combat Casualty Care (CoTCCC) recommended the use of ketamine at the point of injury (POI). Despite these recommendations the adherence is moderate at best. Poor use may stem from a lack of access to use ketamine during training. The United States Special Operations Command (USSOCOM) is often in a unique position, they maintain narcotics for use during all training events and operations. The goal of this work is to demonstrate that ketamine is safe and effective in both training and operational environments. Methods: This was a retrospective, observational performance improvement project within United States Special Operations Command and Air Combat Command that included the US Army's 75th Ranger Regiment, 160th Special Operations Aviation Regiment, and US Air Force Pararescue. Descriptive statistics were used to calculate the doses per administration to include the interquartile range (IQR), standard deviation (SD) and the range of likely doses using a 95% confidence interval (CI). A Wilcoxon signed-rank test was used to compare the mean pre-ketamine pain scores to the mean post-ketamine on a 0-to-10 pain scale. Results: From July 2010 to October 2017, there was a total of 34 patients; all were male. A total of 22 (64.7%) received intravenous ketamine and 12 (35.3%) received intramuscular ketamine and 8 (23.5%) received intranasal ketamine. The mean number of ketamine doses via all routes administered to patients was 1.88 (SD 1.094) and the mean total dose of all ketamine administration was 90.29mg (95% CI, 70.09-110.49). The mean initial dose of all ketamine administration was 47.35mg (95% CI, 38.52-56.18). The median preketamine pain scale for casualties was noted to be 8.0 (IQR 3) and the median post-ketamine pain scale was 0.0 (IQR 3). Conclusion: Ketamine appears to be safe and effective for use during military training accidents. Military units should consider allowing their medics to carry and use as needed.

Keywords: ketamine; opioids; training; war-related injuries; analgesia

The Journal Of Special Operations Medicine Podcast
The JSOM podcast digs deeper into the articles and subjects that matter to our readers. Our podcast hosts, Captains Alex Merkle and Josh Randles, tackle articles from the journal based on merit, interest, and application for operators in the field. In addition, the podcast features a special, not to be missed Interview Series with leaders, doctors, and authors.
Podcast News And Updates
Fall 2020

In this episode of the JSOM Podcast, Alex and Josh discuss the articles "Ketamine Administration by Special Operations Medical Personnel During Training Mishaps". Guest Rico Pesce breaks down the article, "Far Forward Gaps in Hemorrhagic Shock and Prolonged Field Care: An Update of ALM Fluid Therapy for Field Use."
Alex and Josh also discuss, "Management of Critically Injured Burn Patients During an Open Ocean Parachute Rescue Mission."

Fisher AD, Schwartz DS, Petersen CD, Meyer SE, Thielemann JN, Redman TT, Rush SC

Staak BP, DeSoucy ES, Petersen CD, Smith J, Hartman M, Rush SC
Guest: Rico Pesce

Dobson GP, Letson HL

Highlights From The 20th Anniverseary JSOM Interview Series:
MAJ Andrew Fisher, MS-4, PA-C, LP for a great review of pre-hospital whole blood in the military; where we are now and how we got there. He reminds us that, "everything old is new again." The first whole blood transfusion research was done by the military in 1940 (Armed Forces Blood Program) and was used extensively in WWII and the Korean War. But times change and lessons learned are lost to the sands of time as one generation of peacetime military surgeons hands off the reigns to the next. Listen here.

World-renowned tourniquet expert Dr. John Kragh. In this interview, Dr. Kragh takes us through his history in becoming a tourniquet expert as well as detailing the evolution of tourniquet use in combat situations as a battalion surgeon in Southwest Asia. Tourniquet use has evolved considerably even during the 20-years since the JSOM has been in publication. Be sure to read Dr. Kragh's contributions to this quarter's journal as a companion to this interview. Listen here.

CMSgt Michael Rubio, currently the commandant of the 351st Special Warfare Training Squadron of the PJ schoolhouse at Kirkland AFB. It's a great opportunity to hear from the best about how PJ training has changed during the past 20 years, and get a glimpse of where it is heading in the future. You can listen here. Look for another episode later this month.
JSOM Podcast
Wilderness Medical Society
In an effort to broaden and strengthen our ties with the Wilderness Medical Society and all who work in the wilderness medicine community, our webmaster and podcast hosts will be partnering with the organization to share more information and crossover content between our podcast platforms.

The mission of the Wilderness Medical Society is to encourage, foster, support, or conduct activities to improve the scientific knowledge of the membership and general public in human health activities in a wilderness environment.

The Journal of Special Operations Medicine has long partnered with the WMS in a shared science program as we understand the importance of sharing information with all who work in various forms of unconventional medicine.
Aero Healthcare

AERO Healthcare specializes in the manufacturing and distribution of best-in-class healthcare solutions across the world for several decades. These include, but are not limited to, first aid supplies, bleeding control device simulators, CPR training products & consumables, medical device simulators, AEDs, AED trainers and related supplies. We manufacture products in twenty-two countries and partner with distributors throughout North America, Europe, and Asia Pacific. We are unconditionally committed to our strategic partners’ distribution channels with quality product and sales support programs. Now we are very excited to introduce to the AERO family our newest line of RapidStop bleed control products that are 100% engineered and manufactured in the USA.

A Message from VxL Enterprises 
Seeking Medical Professionals with Top Secret Clearance

VxL Enterprises is a veteran owned small business global services organization specializing in the provision of comprehensive critical support to the U.S Government, providing medical and security support solutions in both high and low threat environments. Combining science, intelligence, and realworld experience, we provide lasting, reliable solutions to operational and training needs in support of U.S. missions, stabilization efforts, and security operations around the world. VxL prides itself as our services are developed with an acute focus on measurable quality, reliability, and risk avoidance and absolute customer satisfaction. We are currently seeking qualified medical professionals for the following positions (see attached document). Medical professionals applying MUST HAVE TOP SECRET CLEARANCE TO QUALIFY. Please submit email inquires to [email protected]


When it comes to junctional or truncal wounds on the battlefield, there has never been a truly effective means of controlling hemorrhage. No hemostatic agent or dressing has proven to be ideal for these types of trauma scenarios. Injury patterns during Operations Iraqi Freedom and Enduring Freedom highlighted this capability gap. During these conflicts, exsanguination from junctional (neck, axilla and groin) wounds was responsible for over 19% of the combat fatalities from potentially survivable wounds.1 Not surprisingly, after-action reports from medics returning from the battlefield in 2006-2008 clearly described the need for a better tool to control difficult bleeding. They requested a “fire and forget” solution that could apply a dressing to a wound and instantly achieve hemostasis, similar to Fix-aFlat® for punctured tires.
Institutional Subscribers And Re-subscribers
The JSOM is incredibly grateful to have the support of many institutions around the world. We would like to thank our recent institutional subscribers and re-subscribers for their support by acknowledging them in our eNewsletter and, when applicable, sharing their social media information. We reached a milestone, surpassing 50 institutions! We currently have 54 active institutional subscriptions, reaching a potential 59,000+ readers!

This edition, we welcome back 2 subscribers

Swedish Armed Forces, Orebro
Hong Kong Police Force Library

Visit for a full list of institutions that are currently subscribing to the JSOM. We are beginning a campaign to expand our institutional subscriptions. If you think your company would benefit from an institutional subscription, let us know! We'll be happy to talk to you and get the ball rolling. You don't have to be a university or medical center to subscribe - we have many EMS units, government agencies, and military medical units both in the United States and abroad.

Are you on the list? Great! Need to know how to access our resources? You can either contact your head librarian, or shoot an email to [email protected].

Institutions receive either a print copy of our journal, digital access, or both. Digital subscribers have unlimited access to our full compendium of articles, journals, and the ATP-P. If you are a student, researcher, doctor, or other medical professional at one of these institutions, please contact your librarian for login details. Additionally, the digital resources are typically available 2-3 weeks ahead of print publication.

If your institution is not on the list and you would like more information about our institutional access, contact our subscriptions manager, Dr. Scott Graverson.
Photo of the Week
Paratroopers assigned to the 82nd Airborne Division receive the Best of the Best Award on Oct. 23, 2020, Fort Bragg, NC. The paratroopers were being awarded for their battle readiness and excellence in the field.
(Photo by US Army PV2 Vincent A. Levelev)

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