Ch.23 - Grocery Store Contingency and Ch.24 - Medicine Vs. Art (The Warper)

Free download. Book file PDF easily for everyone and every device. You can download and read online Ch.23 - Grocery Store Contingency and Ch.24 - Medicine Vs. Art (The Warper) file PDF Book only if you are registered here. And also you can download or read online all Book PDF file that related with Ch.23 - Grocery Store Contingency and Ch.24 - Medicine Vs. Art (The Warper) book. Happy reading Ch.23 - Grocery Store Contingency and Ch.24 - Medicine Vs. Art (The Warper) Bookeveryone. Download file Free Book PDF Ch.23 - Grocery Store Contingency and Ch.24 - Medicine Vs. Art (The Warper) at Complete PDF Library. This Book have some digital formats such us :paperbook, ebook, kindle, epub, fb2 and another formats. Here is The CompletePDF Book Library. It's free to register here to get Book file PDF Ch.23 - Grocery Store Contingency and Ch.24 - Medicine Vs. Art (The Warper) Pocket Guide.

Ambient air quality sampling. Air emissions monitoring. Use of groundwater and surface waters for cooling tower use. Composting product. Model demonstration composting facility. Definitions applicable to sections 22as to 22au, inclusive. Rescission of contract by cooperating developer of wood-burning facility. Payments by electric public service company includable as part of rate base. Grass clippings prohibited from disposal at resources recovery facilities or solid waste facilities. Disposal options for certain types of bulky waste.

Resources recovery facility plan for disposal of special waste and processed construction and demolition waste. Use of crushed recycled glass as cover material. Issuance of permit for solid waste facility located near housing development. Determination of need for ash residue disposal area operated by state quasi-public agencies. Submission of information. Certain processed wood and wood fuel excluded from regulation as solid waste. Biomedical waste. Disposal requirements.

Categories of materials not to be considered solid waste. Use of solids that are by-products of water treatment processes. Certain lamp recycling facilities to be considered volume reduction plants. Beneficial use of solid waste. General permit. Individual authorization. Labeling of products containing mercury. Information to be provided concerning electric lamps containing mercury and management of spent lamps. Universal waste rule. Fluorescent lamps. Equipment containing mercury.

Demonstration resource recovery systems or improved solid waste facilities. Solid waste management plans for state and local or regional authorities. Closing of municipal landfill; plan required. Grants to municipal and regional authorities for plan preparation. Approval of solid waste disposal contracts. Contracts between municipalities and solid waste facilities.

Disposal of biomedical waste by generators. Commissioner to administer and control funds. Review of applications for federal funds. Department to apply for and receive funds. Cooperation and agreements with federal government. Grants to reduce solid waste volume reduction and disposal operation costs.

State aid to municipal and regional authorities for volume reduction plants and landfill operations. Grants to municipal or regional authorities for improvements of waste disposal facilities. Grants to municipalities for resources recovery facilities. Grants to municipalities for resources recovery facilities operating on June 1, Grants from Municipal Tipping Fee Fund. Municipal provisions for solid waste disposal. Toxic or hazardous waste disposal. Recycling goal. Municipal representative. Report to commissioner. Program deficiencies.

Designation by municipality of areas for solid waste disposal. Designation of areas for items generated from residential properties. Registration of solid waste collectors. Reports by solid waste collectors. Payments to municipalities by operators of solid waste land disposal facilities. Notification to collectors re items required to be recycled. Warning notices. Notification to municipalities re delinquent tipping fees. Municpal glass collection pilot program.

Contracts with regard to solid waste management. Operating committees declared to be public instrumentalities and political subdivisions of the state. Disposal of solid waste collected from state facilities. Grants to resource recovery authorities for feasibility studies and development expenses for a resource recovery system or incinerator. Funds for preliminary feasibility studies of energy recovery systems or incinerators by governmental entities.

Study and construction of resource recovery systems at certain state mental health hospitals. Contracts for purchase of steam or electricity from systems. Penalty for violations placing another in imminent danger of death or bodily injury. Penalty for illegal disposal of biomedical waste. Municipal enforcement of solid waste disposal laws. Recycling of source-separated organic materials. Municipal solid waste management plan. State-wide solid waste management plan. Source reduction component. Disposal at out-of-state facilities.

Recycle CT Foundation, Inc. Consistency with plan. Polystyrene packaging. Regulations re operating procedures for resources recovery facilities. Solid waste assessment. Penalty imposed for nonpayment. Assessment on solid waste processed at resources recovery facility or mixed municipal solid waste landfill. Hearing and appeal. List of municipalities without contracts to dispose of solid waste. Solicitation of solid waste from municipalities on list prepared by commissioner.

Applicability of certain sections to resources recovery facilities.

Inspection of resources recovery facilities. Appointment of resources recovery facility inspector by municipality or group of municipalities. Regulations re qualifications. Chief elected official's right of access to facility for inspection of premises and review of records. Time allowed for response to complaints.

JSOM - Journal of Special Operations Medicine - author index

Independent management audits of resources recovery facilities. Public education on risk assessment and risk management. Studies of dioxin levels in area of proposed resources recovery facilities. Municipal solid waste recycling program.

Summary:The Well of Ascension

Advisory council. Revisions to state-wide solid waste management plan concerning recycling. Public hearing. Regulations designating items required to be recycled. Separation of items designated for recycling. Prohibition on combining previously segregated designated recyclable items. Municipal provisions for recycling. Orders to municipalities to deliver recyclable items to regional intermediate processing centers if no revision to solid waste management plan delivered. Orders if local processing not implemented. Recyclable items prohibited in landfills and resources recovery facilities.

Noncompliance with recycling strategy. Eligibility of single municipalities and certain regional solid waste authorities or operating committees for funds made available by Commissioner of Energy and Environmental Protection. Commercial establishment. Municipal curbside or backyard collection of designated recyclable items. Exempt municipalities. Collector curbside or backyard collection of designated recyclable items. Exempt collectors.

Recycling receptacles for designated recyclable items at common gathering venues. Solid waste contract requirement for provision re collection of designated recyclable items. Opportunities for recycling infrastructure investment program. Beverage containers: Refund value; exceptions; labeling and design requirements. Registration of redemption centers. Payment of refund value by dealers and distributors. Handling fee. Special account of deposit initiator. Reimbursement payment. Deposit in General Fund. Subtraction of deficiency. Treatment as tax. Credit for containers donated for charitable purpose.

Exemption for small manufacturers re beverage containers containing noncarbonated beverages. Implementation delay re beverage containers containing noncarbonated beverages. Legislative findings and declaration of policy. Duties of commissioner re litter control and recycling. Littering or dumping prohibited. Forfeiture of vehicles used in violation of certain environmental laws. Reward for information re illegal dumping. Collection of civil penalties by state or municipalities.

Sale of certain beverage containers prohibited. Symbols indicating packaging is recyclable or made of recycled material. Regulations re packaging material. Plastic bags and paper bags at retail establishments. Public education program on waste reduction. Sale of packaging components or packaging composed of lead, cadmium, mercury or hexavalent chromium.

Exempt packages and packaging components. Referral to Attorney General. Recommendations by department. Recycling of nickel-cadmium batteries contained in consumer products. Sale of nickel-cadmium batteries contained in consumer products. Recycling of mercuric oxide batteries. Notice by retailers. Program for the collection of mercuric oxide batteries at senior citizen centers. Sale of alkaline manganese batteries. Deposit for batteries.

Disposal by retailer. Written notice. Acceptance of batteries by wholesalers. Warnings and citations. Publishers: Use of newsprint with recycled content. Publishers: Failure to achieve percentages. Printers: Use of newsprint with recycled content. Printers: Failure to achieve percentages. Deposit of revenue into General Fund. Alternative standards for recycled newsprint. Directory publishers: Use of directory stock with recycled fiber. Directory publishers: Failure to achieve percentages. Inclusion of expenses when determining rates. Directory publishers: Recycling goals.

For the purposes of this chapter and chapter b:. Where more than one generator is located in the same building, each individual business entity shall be considered a separate generator;. History: June, act replaced commissioner and department of health with commissioner and department of environmental protection; P. History: P. Section 22ab is repealed, effective October 1, He shall examine all existing or proposed solid waste facilities and provide for their proper planning, design, construction, operation, monitoring, closure and postclosure maintenance in a manner which ensures against pollution of the waters of the state, prevents the harboring of vectors, prevents fire and explosion and minimizes the emission of objectionable odors, dust or other air pollutants so that the health, safety, and welfare of the people of the state shall be safeguarded and enhanced and the natural resources and environment of the state may be conserved, improved and protected.

The commissioner shall order the alteration, extension, limitation, closure or replacement of such facilities whenever necessary to ensure against pollution of the waters of the state, prevent the harboring of vectors, prevent fire and explosion hazards and minimize the creation of objectionable odors, dust or other air pollutants so that the health, safety and welfare of the people of the state shall be safeguarded and enhanced and the natural resources and environment of the state may be conserved, improved and protected provided, before ordering the closure of any solid waste facility, said commissioner shall determine that reasonable alternative facilities for the users of such facility exist.

In any such order, the commissioner may require the submission of and compliance with a plan for the design, construction, operation, monitoring, closure and postclosure maintenance of such facility in accordance with the provisions of this chapter. Notwithstanding the provisions of this section, the commissioner shall not issue 1 a permit for a solid waste land disposal facility on former railroad property until July 1, , unless the commissioner makes a written determination that such facility is necessary to meet the solid waste disposal needs of the state and will not result in a substantial excess capacity of solid waste land disposal areas or disrupt the orderly transportation of or disposal of solid waste in the area affected by the facility, or 2 an operational permit for a resources recovery facility unless the applicant has submitted a plan pursuant to section 22ag for the disposal or recycling of ash residue expected to be generated at the facility in the first five years of operation.

In making a decision to grant or deny a permit to construct a solid waste land disposal facility, including a vertical or horizontal landfill expansion, the commissioner shall consider the character of the neighborhood in which such facility is located and may impose requirements for hours and routes of truck traffic, security and fencing and for measures to prevent the blowing of dust and debris and to minimize insects, rodents and odors. In making a decision to grant or deny a permit to construct or operate a new transfer station, the commissioner shall consider whether such transfer station will result in disproportionately high adverse human health or environmental effects.

In making a decision to grant or deny a permit to construct an ash residue disposal area, the commissioner shall consider any provision which the applicant shall make for a double liner, a leachate collection or detection system and the cost of transportation and disposal of ash residue at the site under consideration.

An application for such permit shall be submitted on a form prescribed by the commissioner, include such information as the commissioner may require, including, but not limited to, a closure plan for such facility, and be accompanied by a fee prescribed in regulations adopted in accordance with chapter Notwithstanding any provision of the general statutes or any regulation adopted pursuant to said statutes, references to a permit to construct or a permit to operate in a regulation adopted pursuant to section 22a shall be deemed to mean a permit as required by this subsection.

The applicant shall send a written notification of any application for such permit to the chief elected official of each municipality in which the proposed facility is to be located, within five business days of the date on which any such application is filed. A fee of three thousand dollars shall accompany any closure plan submitted pursuant to this subsection.

The commissioner may require the owner of a solid waste disposal area to post sufficient performance bond or other security to ensure compliance with the approved closure plan. The commissioner may approve a modification to a closure plan for a solid waste disposal area. A fee of five hundred dollars shall accompany the request for such modification. The commissioner may reduce or waive the fees required by this subsection in cases of financial hardship and may modify such fees in regulations adopted in accordance with chapter The commissioner may require a person or municipality to provide public notice of a proposed modification of a closure plan if the modification involves any activity that would disrupt the solid waste or change the use of the solid waste disposal area.

Notwithstanding the provisions of this subsection, the commissioner may order a person or municipality that establishes or constructs a solid waste disposal area without first obtaining a permit as required by subsection b of this section to remove any solid waste disposed at such area, to remediate any pollution caused by such waste, and to properly dispose of such waste at a lawfully operated solid waste facility.

The owner or operator of any such facility shall, not later than thirty days after adding such recyclable items, submit a written notification to the commissioner describing such addition. The commissioner may approve, in writing, a modification of a closure plan for a closed permitted solid waste disposal area without modifying the permit for such area. The commissioner may require a person who, or a municipality that, requests such modification to provide public notice of a proposed modification of a closure plan if the modification involves any activity that would disrupt the solid waste or change the use of the solid waste disposal area.

A fee of five hundred dollars shall accompany any request for such modification of a closure plan. The commissioner may reduce or waive such fee in cases of financial hardship and may modify such fee in accordance with regulations adopted in accordance with chapter In addition, notwithstanding any provision of the general statutes or regulation adopted pursuant to said statutes, any such change shall not be considered a modification or new stationary source requiring a permit to construct or operate under chapter c or under any regulation adopted pursuant to chapter c, unless such change is a major modification or a major stationary source requiring a permit under the federal Clean Air Act Amendments of Any person making any such change to an odor control system at such a facility shall, not more than thirty days after making such change, submit a written report to the commissioner fully describing the changes made and the reason for such changes for the commissioner's review and comment.

Nothing in this subdivision shall affect the commissioner's authority to take any other action to enforce the requirements of this title. The commissioner may amend a permit to construct or to operate, without hearing, for minor changes in the facility design, practices or equipment that would not in his judgment significantly change the nature of the facility or its impact on the environment. Notwithstanding the provisions of this subsection, the commissioner shall conduct a public hearing on an application for a permit to construct a new solid waste disposal area. Such public hearing shall be commenced in the municipality in which the facility is to be located or a location in close proximity to said municipality.

Notwithstanding the provisions of this subsection, if a hearing has been held on and after July 1, , on an application for a permit to construct or alter a solid waste facility, the commissioner shall not hold a hearing on an application for a permit to operate such facility.

GEORGE GROTE,

The commissioner shall establish requirements for the presence of approved operators at solid waste facilities. The commissioner may develop, offer or sponsor training programs for operators of solid waste facilities and require participation therein. In adopting regulations pursuant to this section, the commissioner shall perform an evaluation of the actual costs necessary to process, review and render a decision on permit applications reflecting the time, resource commitments and expenses to the Department of Energy and Environmental Protection.

Lists with This Book. This book is not yet featured on Listopia. Community Reviews. Showing Rating details. All Languages. More filters. Sort order. There are no discussion topics on this book yet. About Kys Tillman. Kys Tillman. Books by Kys Tillman. The control group comprised data collected from simulated tourniquet use on the model with bone present. The study group comprised data from simulated tourniquet use on the model without bone.

Results: Comparing compression with and without bone, the mean volumes of compressed soft tissues alone were mL and mL, respectively. The bone had a volume of 41mL and pressed statically outward with an equal force oppositely directed to the inward compression of the overlying soft tissues.

With bone removed and compression applied, the mean residual void was 16mL, because 25mL i. The volume of the limb under the tourniquet with and without bone was mL and mL, respectively. The collapse volume, 25mL, was 3mL more than the difference of the mean volume of the limb under the tourniquet. More limb squeeze 22mL looked like better compression, but it was actually worse-an illusion created by collapse of the hidden void.

Conclusion: In simulated first aid, mechanical modeling demonstrated how tourniquet compression applied to a limb squeezed the soft tissues better when underlying bone was present. Bone loss altered the compression profile and may complicate control of bleeding in care.

This knowledge, its depiction, and its demonstration may inform first-aid instructors. Keywords: caregiver ; choice behavior ; public health ; medical device ; active learning ; tourniquet ; mechanics. Background: A tourniquet's readiness during emergencies depends on how it is configured. We investigated configuration so ways of improving readiness can be developed. Methods: This study was conducted at the Institute of Surgical Research in as sequential investigations by one user of Combat Application Tourniquets C-A-Ts in a band-and-rod design.

Results: Each tourniquet comes packaged with paper instructions for use, which include directions on how to configure it in preparation for caregiving. The paper and video instructions for use omit tensioning of the tourniquet in configuration, and the video misconfigured a time strap over the rod. In first-aid classrooms, we saw unwitting learners troubleshoot that misconfiguration. Problems with configuration were also seen in caregiving and with tourniquets stowed in kits. In deliberate practice, we self-applied a tourniquet to a thigh.

In configuration after each of uses, tourniquet elongation due to tensioning averaged 2. During configuration, if the C-A-T's stabilization plate slid along the band, out of position, the user slid the plate back into position. In various ways of testing other C-A-Ts, elongations averaged from 0. Elongation increments accrued as the tourniquet's band flattened. Configuration time averaged 22 seconds, and accrued experience improved the compactness of configuration. Conclusion: People are too often unreliable at putting C-A-Ts into the optimal configuration for use.

That ready-to-use configuration includes the tourniquet being at its full length, having the stabilization plate positioned correctly along the band, and having the strap fastened to its clip of origin. When used, tourniquets had normal, small elongations in part due to band flattening. This tourniquet study showed the importance of optimal configuration to first-aid readiness practices. Keywords: Combat Application Tourniquet ; tourniquet configuration ; limb tourniquet ; Stop the Bleed ; medical device ; combat injury first aid ; tourniquet band flattening ; tourniquet elongation ; use instruction ; resuscitation ; emergency.

The reasons for this remain unclear. This study expands on previous reports by evaluating a larger prehospital dataset for determinants of analgesia administration. Methods: This was part of an approved quality assurance project evaluating adherence to TCCC guidelines across multiple modalities. Data were from the Prehospital Trauma Registry, which existed from January through September , and comprises data from TCCC cards, Department of Defense forms, and after-action reports to provide real-time feedback to units on prehospital medical care.

Results: Of total patient encounters, there were documented administrations of analgesic medications given to patients. Of these events, Special Operations Command had the highest rate of overall adherence, but rates were still low Medical officers had the highest rates of overall administration. The low rates of administration and adherence persisted across all subgroups. Conclusion: Rates of analgesia administration remained low overall and in subgroup analyses. Medical officers appeared to have higher rates of compliance with TCCC guidelines for analgesia administration, but overall adherence to TCCC guidelines was low.

Future research will be aimed at finding methods to improve administration and adherence rates. Keywords: analgesia ; combat ; compliance ; military ; pain ; prehospital ; Tactical Combat Casualty Care. Background: To investigate questions about application of emergency tourniquets in very young children, we investigated practices of Combat Application Tourniquet C-A-T use on a simulated infant-sized limb to develop ways to improve readiness for caregiving. Methods: This study was conducted as investigations of C-A-Ts used by two individuals in deliberate practice.

The practice setup simulating a limb of infants aged months included a handrail circumference, 5. This setup needed a specific modification to the instructions for use to adhere the band between the clips. Each user performed practices. Results: With accrual of experience, application time was shorter for each user, on average in a power law of practice, and more ease was associated when less time was taken to apply the tourniquet. The ease of use was associated with accrued experience through deliberate practice of a tourniquet user while under coached learning.

A check of tourniquet fit on a 4. However, an additional modification of wrapping the band in a figure-8 pattern around the rod was needed because the rod and clip could not meet. The fit on a 3.

Spotlights

Tourniquet use was harder for smaller limbs i. A map of tourniquet fit was sketched of which sized limbs were too big, too small, within the fit zone, or at its borders. Conclusion: C-A-Ts mechanically fit the simulated limbs of infants aged months, and C-A-T use was practicably easy enough to allow experienced users to fit tourniquets to limbs well using a specific modification of the routine technique.

The findings and knowledge generated in this study are available to inform researches and developments in best preparation practices for instructing first aid. Keywords: Combat Application Tourniquet ; limb tourniquet ; Stop the Bleed ; medical device ; combat injury first aid ; use instruction ; resuscitation ; emergency. Background: The military is rapidly moving into a battlespace in which prolonged holding times in the field are probable. Ketamine provides hemodynamic support and has analgesic properties, but the safety of prolonged infusions is unclear.

In January , this ICU implemented a novel continuous ketamine infusions protocol. We performed a preintervention and postintervention cohort analysis. Results: We identified patients meeting our inclusion criteria in the ketamine group and in the control group. The median number of ventilator-free days within the first 30 days did not vary significantly between the ketamine group and the control group: 8. Subjects receiving ketamine had higher mortality rates: When controlling for TBSA category, ventilator days and vasopressor administration, there was no association between ketamine and in-hospital mortality 0.

Conclusions: When controlling for confounders, we found no difference in in-hospital mortality between the prolonged ketamine infusion recipients versus non-recipients. Keywords: ketamine ; prolonged ; military ; trauma ; analgesia. Background: The laryngeal handshake method LHM may be a reliable standardized method to quickly and accurately identify the cricothyroid membrane CTM when performing an emergency surgical airway ESA.

However, there is currently minimal available literature evaluating the method. Furthermore, no previous CTM localization studies have focused on success rates of military prehospital providers. This study was conducted with the goal of answering the question: Which method is superior, the LHM or the traditional method TM , for identifying anatomical landmarks in a timely manner when performed by US Army combat medic trainees? Two Army medic trainees with similar body habitus volunteered as subjects, and the upper and lower borders and midline of their CTMs were identified by ultrasound US.

The participants were also recruited from the medic trainee population. After receiving initial training on the LHM and refresher training on the TM, participants were asked to localize the CTMs of each subject with one method per subject.

Legion S03E04 "Chapter 23" - Review

Success was defined as a marking within the borders and 5mm of midline within 2 minutes. Conclusion: Findings of this study support that at present the TM is a superior method for successful localization of the CTM when performed by Army combat medic trainees. Keywords: laryngeal handshake method ; cricothyrotomy landmarks ; cricothyroidotomy palpation ; austere cricothyroidotomy.

Background: We sought opportunities to develop learning practices of individual first aid providers. In this study, we simulated deliberate practice in placing limb tourniquets. Methods: This study comprised tourniquet uses by two experienced persons. Their practice sessions focused on developing a motor skill with periodic coaching. The Combat Application Tourniquet is 1. Results: When represented as summary parameters, differences were small. For example, average ease of use was the same for both users, but such parameters only took a snapshot of performance, yielding a general assessment.

However, for a learning curve by use number, a surrogate of experience accrual, application time revealed spiral learning. Placement accuracy was classified relative to gap widths between the tourniquet and the wound, and of 60 performances, 55 were satisfactory and five were unsatisfactory i. When a tourniquet only overlaid the 2-inch edge of the placement zone i. These gauging errors led us to create a template for learners to see and to demonstrate what the meaning of inches is. Conclusion: Each metric had value in assessing first aid, but turning attention to gauging wound-tourniquet gaps revealed placement errors.

Analysis of such errors uncovered what inches meant in operation. Spiral learning may inform the development of best readiness practices such as coaching deliberate-practice sessions. Keywords: Combat Application Tourniquet ; tourniquet placement ; limb wound ; Stop the Bleed ; motor control and learning ; loop-passage technique. Background: Anterior shoulder dislocation is a common sports-related musculoskeletal injury. Various methods have been described for reduction of the dislocation.

A method that requires less sedation without compromising the success rate is likely to be highly useful in austere and prehospital settings. This study compares scapular manipulation with external rotation method for requirement of sedation and success rates. Methods: Forty-six patients with anterior shoulder dislocation were allocated alternatively to reduction using either scapular manipulation SMM or external rotation ERM techniques. The groups were compared for sedation requirements, pain scores, and success rates. The numeric rating score of pain during reduction procedures was less in SMM mean, 1.

Conclusion: The SMM required less sedation and had higher first-pass success rates than ERM for reduction of anterior shoulder dislocation. The SMM is thus likely to be of advantage in resource-limited austere settings. Keywords: shoulder reduction ; scapular manipulation ; external rotation.

Closed circuit underwater breathing apparatus UBA have gained popularity in recreational diving. Closed circuit UBAs carry a unique set of risks to the diver. We present the case of a diver who lost consciousness while diving and had pulmonary abnormalities. The case is illustrative of the diving related problems associated with closed circuit UBA that a physician may be faced with. Staphylococcus sciuri is an emerging gram-positive bacterial pathogen that is infrequently isolated from cases of human disease.

This organism is capable of rapid conversion from a state of methicillin sensitivity to a state of methicillin resistance and has been shown to express a set of highly effective virulence factors. The antibioticresistance breakpoints of S. Therefore, the rapid identification of S. Here, we present a brief literature review of S. In addition, we discuss potential implications for the distribution and evolution of antibiotic- resistant members of the genus Staphylococcus. Keywords: bacteriology ; entomology ; operating environment ; preventive medicine.

Throughout history, Soldiers in wartime have been especially vulnerable to infectious diseases, which have devastated and decimated entire armies, causing suspension and, in some cases, complete cancellation of military operations. Dr William Foege, a renowned Harvard epidemiologist, and his colleagues claim that throughout history, infectious diseases have killed more Soldiers than have weapons.

Reality shows that it does not matter if your Soldiers had the best training available with the best equipment and top of the world intelligence: if your personnel get sick, they become more of a liability than an asset for a combat operation. This article presents some of the key findings that continue to affect our Special Operations Forces SOF and how the use of specifically designed new products can help in controlling short- and long-term consequences of infectious diseases.

Keywords: preventive medicine ; diseases, infectious. Ahmed A , Peine S. The intents of this article are to share our experiences during a medical mission in the Dominican Republic and to provide the reader with a cross-sectional view of conditions seen and an overview of interesting and challenging cases encountered. We also discuss treatments and techniques used and share lessons learned.

Keywords: dermatology ; albinism ; chemdestruction ; chromoblastomycosis ; lesions ; skin dermatoses ; ecthyma ; intertrigo ; folliculitis ; fungal ; scabies ; eczematoid spectrum ; atopic dermatitis ; xerosis cutis ; polymorphous ; eruption ; mycetoma ; leprosy ; scarlatina ; genoderms.

Background: Uncontrolled hemorrhage remains one of the most challenging problems facing emergency medical professionals and a leading cause of traumatic death in both battlefield and civilian environments. Survival is determined by the ability to rapidly control hemorrhage. However, recent literature reviews have concluded that no ideal topical agent exists for all injuries and scenarios.

These dressings were selected for their commercial availability and design intended for control of massive hemorrhage. Methods: A complex penetrating femoral artery groin injury was made using a 5. The hemostatic dressings were randomized using a random sequence generator and then assigned to the animals. Three minutes of manual pressure was applied with each agent after the free bleed.

Hemodynamic parameters were recorded every 10 minutes and additionally at critical time points defined in the protocol. Primary end points included immediate hemostasis upon release of manual pressure T0 , hemostasis at 60 minutes, and rebleeding during the minute observation period. Results: NS was statistically superior to CG in a 5. NS and CG were statistically equivalent for hemostasis at 60 minutes, rebleeding during the study, and the additional secondary metrics, although the trend indicated that in a larger sample size, NS could prove statistical superiority in selected categories.

Conclusions: In this porcine model of uncontrolled hemorrhage, NS improved immediate hemorrhage control, stability, and use of fluid in a minute severe porcine hemorrhage model. In this study, NS demonstrated equivalence to CG at achieving long-term hemostasis and the prevention of rebleed after application. NS was shown to be an efficacious choice for hemorrhage control in combat and civilian emergency medical service environments.

Background: Junctional hemorrhage is a potentially preventable cause of death. In a human model, the AAJT was effective in stopping blood flow in the femoral arteries via compression of the distal aorta. Method: Six anesthetized swine were used. Carotid arterial catheters were placed for continuous mean arterial pressure MAP readings. A hemicorporectomy was accomplished with a blade lever device by cutting the animal through both femoral heads transecting the proximal iliac arteries and veins.

The primary outcome measure was survival at 60 minutes.

Ch. 33 - Transformation and Ch. 34 - Jason's Escape (The Warper)

During the minute monitoring period, only one CG animal achieved hemostasis. For the AAJT group, the mean time to hemostasis was 30 seconds. Keywords: junctional hemorrhage ; gauze ; tourniquet. Military personnel are at an increased risk for exposure to arthropod- borne and zoonotic pathogens. The prevalence of these pathogens has not been adequately described in the country of Georgia. As the Georgian military moves toward an increased level of capability and the adoption of European Union and North Atlantic Treaty Organization standards, international field exercises will become more frequent and will likely involve an increasing number of international partners.

This study was undertaken with the goal of defining the arthropod-borne and zoonotic pathogen threat in Georgia so force health protection planning can proceed in a rational and data-driven manner. To estimate disease burden, blood was taken from 1, Georgian military recruits between October and February and screened for previous exposure to a set of bacterial and viral pathogens using a antibody-based, serologic procedure.

The highest rate of exposure was to Salmonella enterica serovar Typhi, and the lowest rate of exposure was to Coxiella burnettii the causative agent of Q fever. These data provide insight into the prevalence of arthropod-borne infections in Georgia, fill a critical knowledge gap, will help guide future surveillance efforts, and will inform force health protection planning. Introduction: The usefulness of heart rate variability HRV and heart rate complexity HRC analysis as a potential triage tool has been limited by the inability to perform real-time analysis on a portable, handheld monitoring platform.

Through a multidisciplinary effort of academia and industry, we report on the development of a rugged, handheld and noninvasive device that provides HRV and HRC analysis in real-time in critically ill patients. Methods: After extensive re-engineering, real-time HRV and HRC analyses were incorporated into an existing, rugged, handheld monitoring platform.

Following IRB approval, the prototype device was used to monitor 20 critically ill patients and 20 healthy controls to demonstrate real-world discriminatory potential. Patients were compared to healthy controls using a Student's t test as well as repeated measures analysis. This prototype device successfully discriminates critically ill patients from healthy controls. This may open up possibilities for real-world use as a trauma triage tool, particularly on the battlefield. Keywords: heart rate complexity ; heart rate variability ; entropy ; triage ; combat. This article presents findings from a survey conducted to examine the availability of foreign language and culture training to Civil Affairs health personnel and the relevance of that training to the tasks they perform.

Civil Affairs forces recognize the value of cross-cultural communication competence because their missions involve a significant level of interaction with foreign governments' officials, military, and civilians. Members of the 95th Civil Affairs Brigade Airborne who had a health-related military occupational specialty code were invited to participate in the survey. Many also received predeployment language and culture training specific to the area of deployment.

Significantly more respondents reported receiving cultural training and training on how to work effectively with interpreters than having received foreign language training. Respondents perceived interpreters as important assets and were generally satisfied with their performance. Findings from the survey highlight a need to identify standard requirements for predeployment language training that focuses on medical and health terminology and to determine the best delivery platform s.

Civil Affairs health personnel would benefit from additional cultural training that focuses on health and healthcare in the country or region of deployment. Investing in the development of distance learning capabilities as a platform for delivering health-specific language and culture training may help ease the time and resources constraints that limit the ability of Civil Affairs health personnel to access the training they need.

Background: Soldiers serving in the Israel Defense Force Military Working Dogs MWD Unit spend many hours taming dogs' special skills, taking them on combat missions, and performing various dogkeeping activities. During this intensive work with the aggressive military dogs, bites are common, and some of them result in permanent disability. However, this phenomenon has not been quantified or reported as an occupational hazard.

Methods: This was a retrospective cohort study based on self-administered questionnaires. Information was collected about soldiers' baseline demographics, duration of the experience of working with dogs, total number of bites they had, circumstances of bite events, and complications and medical treatment of each bite. Bite risk was quantified by incidence, mean time to first bite, and a Cox proportional hazards model. Rates of complications and the medical burden of bites were compared between combat soldiers and noncombat dogkeepers.

Bite locations were presented graphically. Results: Seventy-eight soldiers participated and reported on bites. Overall bite incidence was 11 bites per person-months; the mean time to first bite event was 6. The Cox proportional hazards model showed that none of baseline characteristics significantly increased bite hazard.

Bite complications included fractures, need for intravenous antibiotic treatment and surgical repair, prominent scarring, diminished sensation, and stiffness of proximal joints. Bite complications were similar between combat soldiers and dogkeepers. Conclusion: MWD bites are an occupational hazard resulting in significant medical burden. Hands and arms were most common bite locations. Observance of safety precautions may be the most appropriate first-line preventive intervention. Barrier protection of upper extremities may reduce bite severity and complication rates.

Keywords: canine ; combat ; bites, dog ; dogs, military working ; Israeli Army ; dog keepers. Medical programs are valuable tools when they properly align with operational objectives. In counterinsurgency operations, the medical program should promote the capacity of the host nation government and lead to greater self-sufficiency. The Medical Civic Action Program MEDCAP often fails to fully integrate host nation providers and officials which may undermine local medical infrastructure and rarely provides sustainable improvement.

Furthermore, the MEDSEM forged relationships and promoted interoperability through collaboration between local medical providers, governmental leaders, host nation forces, and U. Special Operations Forces. Military partnering operations and military engagements with host nation civil infrastructure are fundamental missions for NATO Special Operations Forces SOF conducting military assistance operations.

Unit medical advisors are frequently called upon to support partnering operations and execute medical engagements with host nation health systems. The committee found no other venues offering the necessary training. Furthermore, a lack of a common operating language and inadequate outcome metrics were identified as sources of knowledge deficits that create confusion and inhibit process improvement. These findings provided the foundation of this committee's curricular recommendations. The committee constructed operational definitions to improve understanding and promote dialogue between medical advisors and commanders.

Active learning principles were used to construct a curriculum that engages learners and enhances retention of new material. To date, no published career resource exists to guide the careers of physicians interested in becoming a SOF surgeon. Using a survey tool, desirable characteristics and personal attributes were identified that can be used to inform candidate career decisions and better prepare them for a future position in Special Operations.

Methods: A descriptive, cross-sectional survey instrument was developed and distributed to current Army SOF Command Surgeons for further distribution to subordinate surgeons. Results were analyzed as a cohort and by subordinate command. Uniformly, the individual characteristics most strongly desired are professionalism, being a team player, and leadership.

Possessing or obtaining Airborne and Flight Surgeon qualifications prior to consideration for a surgeon position was highly desired. Residency training within Family Medicine or Emergency Medicine constituted the vast majority of specialty preference. Conclusions: Understanding which characteristics and attributes are desirable to current surgeons and commanders can aid physicians interested in SOF surgeon positions.

Using this study and future studies can guide career planning and foster the selection of ideally trained physicians who will operate at the tip of the spear. The views expressed are those of the author s and do not reflect the official policy of the Department of the Army, the Department of Defense or the U. Special Operations Forces medical providers are often deployed far beyond traditional military supply chains, forcing them to rely on alternative methods for field sterilization of medical equipment.

This literature review proposes several alternative methods for both sterilization and disinfection of medical instruments after use and cleaning of skin and wounds before procedures. Keywords: prolonged field care ; field sanitation ; instrument sterilization ; expedtionary medicine. Background: Based on the high tick-borne pathogen results from a surveillance study in three Colombian cities, an in-depth point prevalence survey was conducted to determine the seroprevalence of tick-borne pathogens at a specific point in time in 70 working dogs, shelter dogs, and 47 client-owned dogs in Barranquilla, Colombia.

Conclusion: Surveillance for exposure to tickborne pathogens provides vital information necessary to protect and conserve the health of local humans and animals, deployed military service members, and working dogs in various parts of the world. This study and resultant data demonstrate the value of following a broadbased surveillance study with a more specific, focused analysis in an area of concern. This area's high levels of exposure warrant emphasis by medical planners and advisors on precautionary measures for military dogs, Special Operations Forces personnel, and the local public.

Background: Excessive ventilation of sick and injured patients is associated with increased morbidity and mortality. Methods: This was a prospective, observational, semirandomized, crossover study using Army Medics. Subjects were observed during manikin simulation training in classroom and field environments, with total duration of manual ventilation and number of breaths given recorded for each device. Analysis was performed on overall ventilation rate in breaths per minute BPM and also by grouping the subjects by ventilation rates in low, correct, and high groups based on an ideal rate of BPM.

Results: A total of 89 Medics were enrolled and completed the classroom portion of the study, with a subset of 36 evaluated in the field. Conclusion: The study device effectively reduced rates of excessive ventilation in the classroom and the field. The military conflicts of the past 17 years have taught us many lessons, including the evolution of the tiered trauma system with en route resuscitation. The evolution of the conflict has begun to limit the reach of this standard trauma system. US Military Surgical Resuscitation Teams have been developed to shorten this time from injury to surgical care, as illustrated by this case report.

Keywords: en route surgery ; resuscitative thoracotomy ; HH ; surgical resuscitation team. There is some controversy about whether ballistic protective equipment body armor is required for medical responders who may be called to respond to active shooter mass casualty incidents.

In this article, we describe the ongoing evolution of recommendations to optimize medical care to injured victims at such an incident. We propose that body armor is not mandatory for medical responders participating in a rapid-response capacity, in keeping with the Hartford Consensus and Arlington Rescue Task Force models. However, we acknowledge that the development and implementation of these programs may benefit from the availability of such equipment as one component of risk mitigation.

Many police agencies regularly retire body armor on a defined time schedule before the end of its effective service life. Coordination with law enforcement may allow such retired body armor to be available to other public safety agencies, such as fire and emergency medical services, providing some degree of ballistic protection to medical responders at little or no cost during the rare mass casualty incident. To provide visual demonstration of this concept, we tested three "retired" ballistic vests with ages ranging from 6 to 27 years.

The vests were shot at close range using police-issue 9mm,. Photographs demonstrate that the vests maintained their ballistic protection and defeated all of these rounds. Keywords: body armor ; ballistics ; active shooter ; active assailant ; mass-casualty event. Background: One of the greatest conundrums with tourniquet TQ education is the use of an appropriate surrogate of hemorrhage in the training setting to determine whether a TQ has been successfully used.

At our facility, we currently use loss of audible Doppler signal or loss of palpable pulse to represent adequate occlusion of vasculature and thus successful TQ application. We set out to determine whether pain can be used to indicate successful TQ application in the training setting. Once successful placement of the TQ was noted, subjects rated their pain from 0 to 10 on the visual analog scale. Results: All 41 subjects had measurements at all anatomic sites with the pneumatic TQ, except one participant who was unable to complete the LUA.

For the C-A-T, data were collected from 40 participants. In total, pain was rated as 1 or less by Pain was rated 3 or 4 by Pain was rated 5 by Conclusion: The unexpected low pain values recorded when loss of signal was reached make the use of pain too sensitive as an indicator to confirm adequate occlusion of vasculature and, thus, successful TQ application. Keywords: tourniquet ; pain ; vasculature occlusion.

This information constitutes a robust dataset derived from real world operational medicine experiences. Methods: A retrospective analysis of deidentified entries from the MSP TMU operational response database was performed for the 5-year period of 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, tactical missions, of which there were total patient encounters during the study period. Conclusion: The 5-year analysis conducted in this study represents the largest known retrospective assessment of a state police tactical medical program. 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. Keywords: tactical emergency medical support ; tactical medicine. Excited delirium syndrome ExDS is a term used to describe patients experiencing a clinical condition characterized by bizarre and aggressive behavior, often in association with the use of chronic sympathomimetic drug abuse.

The agitated and disruptive behavior of persons with ExDS often results in a call to police resulting in an arrest for disorderly conduct. The suspect's inability to comply with police commands during the arrest frequently results in a struggle and the use of physical or chemical control measures, including the use of conductive energy weapons CEWs. Deaths from this hypermetabolic syndrome are infrequent but potentially preventable with early identification, a coordinated aggressive police intervention, and prompt medical care.

Preliminary experiences suggest that ExDS is a medical emergency treated most effectively using a coordinated response between police officers and emergency medical providers. Once the person suspected of experiencing ExDS is in custody, medical providers should rapidly sedate noncompliant patients with medications such as ketamine or an antipsychotic drug such as haloperidol in combination with a benzodiazepine drug such as midazolam or diazepam.

Once sedated, patients should undergo a screening medical assessment and undergo initial treatment for conditions such as hyperthermia and dehydration. All patients exhibiting signs of ExDS should be transported rapidly to a medical treatment facility for further evaluation and treatment.