{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,11]],"date-time":"2026-07-11T15:13:35Z","timestamp":1783782815712,"version":"3.55.0"},"reference-count":13,"publisher":"Oxford University Press (OUP)","license":[{"start":{"date-parts":[[2026,7,11]],"date-time":"2026-07-11T00:00:00Z","timestamp":1783728000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Military drill instructors are routinely exposed to extreme occupational demands, including high ambient temperatures, prolonged physical exertion, and repetitive forceful vocalization. We report the case of a 25-year-old active duty Marine drill instructor who presented with acute jaw swelling, chest tightness, and dark urine following prolonged yelling and physical exertion. Following a detailed work-up, he was found to have an acute kidney injury, clinically significant hyperkalemia, elevated creatine kinase, and a moderate pneumomediastinum with diffuse subcutaneous emphysema. The patient was treated emergently with targeted therapy for hyperkalemia and aggressive intravenous hydration. His pneumomediastinum was managed conservatively with close observation and did not require invasive intervention. Renal function and electrolyte abnormalities improved steadily throughout hospitalization, and follow-up imaging confirmed complete resolution of subcutaneous emphysema. The patient ultimately returned to full duty without complication. This case highlights that even young, physically fit service members may develop overlapping, potentially life-threatening pathology when under extreme occupational stress. Early recognition and prompt management are critical to preventing morbidity and ensuring rapid recovery and return to duty.<\/jats:p>","DOI":"10.1093\/milmed\/usag310","type":"journal-article","created":{"date-parts":[[2026,7,11]],"date-time":"2026-07-11T14:41:23Z","timestamp":1783780883000},"source":"Crossref","is-referenced-by-count":0,"title":["When Motivation Hurts: Barotrauma and Acute Kidney Injury in a Drill Instructor\u2014A Case Report"],"prefix":"10.1093","author":[{"ORCID":"https:\/\/orcid.org\/0009-0006-0074-2743","authenticated-orcid":false,"given":"Nicole A","family":"Nord","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine, NMRTC San Diego , San Diego, CA 92134,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-5871-1851","authenticated-orcid":false,"given":"Ryan M","family":"Kaylor","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, NMRTC San Diego , San Diego, CA 92134,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-7644-7689","authenticated-orcid":false,"given":"Tucker","family":"Brady","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, NMRTC San Diego , San Diego, CA 92134,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,7,11]]},"reference":[{"key":"2026071110411800000_usag310-B1","doi-asserted-by":"publisher","first-page":"157","DOI":"10.1186\/s13256-021-02701-z","article-title":"Spontaneous primary pneumomediastinum: is it always benign?","volume":"15","author":"Alemu","year":"2021","journal-title":"J Med Case Rep"},{"key":"2026071110411800000_usag310-B2","doi-asserted-by":"publisher","first-page":"1396","DOI":"10.7205\/milmed-d-12-00243","article-title":"Ooh-rah! an unusual cause of spontaneous pneumomediastinum","volume":"7","author":"Singla","year":"2012","journal-title":"Mil Med"},{"key":"2026071110411800000_usag310-B3","doi-asserted-by":"publisher","first-page":"364","DOI":"10.1016\/j.jadohealth.2025.10.022","article-title":"When screams turn into symptoms: Spontaneous pneumomediastinum in an adolescent after intense vocalization at a pop concert","volume":"78","author":"Wronkowska","year":"2026","journal-title":"J Adolesc Health"},{"key":"2026071110411800000_usag310-B4","doi-asserted-by":"publisher","first-page":"613","DOI":"10.1515\/reveh-2022-0038","article-title":"Analysis of physiological markers and risk factors for the development of rhabdomyolysis in military personnel: a systematic review","volume":"38","author":"Dantas","year":"2023","journal-title":"Rev Environ Health"},{"key":"2026071110411800000_usag310-B5","doi-asserted-by":"publisher","first-page":"e2046","DOI":"10.7205\/MILMED-D-17-00119","article-title":"Hyperkalemia in combat casualties: Implications for delayed evacuation","volume":"182","author":"Stewart","year":"2017","journal-title":"Mil Med"},{"key":"2026071110411800000_usag310-B6","doi-asserted-by":"publisher","first-page":"913","DOI":"10.1001\/archinte.1939.00190050019003","article-title":"Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum: Clinical implications","volume":"64","author":"Macklin","year":"1939","journal-title":"Arch Intern Med (Chic)"},{"key":"2026071110411800000_usag310-B7","doi-asserted-by":"publisher","first-page":"S44","DOI":"10.3978\/j.issn.2072-1439.2015.01.11","article-title":"Pneumomediastinum","volume":"7","author":"Kouritas","year":"2015","journal-title":"J Thorac Dis."},{"key":"2026071110411800000_usag310-B8","doi-asserted-by":"publisher","first-page":"997","DOI":"10.1177\/0218492313504091","article-title":"Systematic review of spontaneous pneumomediastinum: a survey of 22 years\u2019 data","volume":"22","author":"Dajer-Fadel","year":"2014","journal-title":"Asian Cardiovasc Thorac Ann"},{"key":"2026071110411800000_usag310-B9","doi-asserted-by":"publisher","first-page":"2463","DOI":"10.3390\/diagnostics15192463","article-title":"Boerhaave syndrome\u2014narrative review","volume":"15","author":"Predescu","year":"2025","journal-title":"Diagnostics"},{"key":"2026071110411800000_usag310-B10","author":"O\u2019Connor","year":"2025"},{"key":"2026071110411800000_usag310-B11","doi-asserted-by":"publisher","first-page":"117","DOI":"10.11124\/JBISRIR-2016-001879","article-title":"Treatment of exertional rhabdomyolysis in athletes","volume":"14","author":"Manspeaker","year":"2016","journal-title":"JBI Database System Rev Implement Rep"},{"key":"2026071110411800000_usag310-B12","doi-asserted-by":"publisher","first-page":"110489","DOI":"10.1016\/j.resuscitation.2025.110489","article-title":"Pharmacological interventions for the acute treatment of hyperkalaemia: a systematic review and meta-analysis","volume":"208","author":"Jessen","year":"2025","journal-title":"Resuscitation"},{"key":"2026071110411800000_usag310-B13","author":"Hyperkalemia and Dialysis in the Deployed Setting (CPG ID: 52)","year":"2017"}],"container-title":["Military Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/milmed\/advance-article-pdf\/doi\/10.1093\/milmed\/usag310\/68759306\/usag310.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/milmed\/advance-article-pdf\/doi\/10.1093\/milmed\/usag310\/68759306\/usag310.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,11]],"date-time":"2026-07-11T14:41:24Z","timestamp":1783780884000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/milmed\/advance-article\/doi\/10.1093\/milmed\/usag310\/8732554"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,11]]},"references-count":13,"URL":"https:\/\/doi.org\/10.1093\/milmed\/usag310","relation":{},"ISSN":["0026-4075","1930-613X"],"issn-type":[{"value":"0026-4075","type":"print"},{"value":"1930-613X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,11]]},"article-number":"usag310"}}