INCIDENT REPORT

https://www.nytimes.com/2019/10/11/world/africa/soldier-death-somalia.html

Why does it take the NY Times to identify and disseminate our medical lessons learned?!

How was this not immediately circulated to all medics internally the way parachute failure incidents and military vehicle accidents are?!

Why is there not an immediate safety stand down and retraining required?!

Don’t let Dunning-Kruger fool you. Any one of us could have been the initial medic, the receiving PJ or even the patient. Incidents like this can even occur here at hole in the firat world. Have you ever watched the Elain Bromily case?

Imagine if there were a proper incident report posted in every Command hallway, everytime there were a poor outcome experienced across the enterprise?

How much easier would it be to justify training and equipment needs with the penny pinchers, bean counters and check writers who were acutely aware of the actual risk to force?

If the article is accurate, this was a catastrophe for everyone involved. The lives of the patient, the family, the team and the medics are irreversibly altered.

Our last podcast was about High Reliability Organizations. A key hallmark of an High Reliability Organization involved in life and death operations is a preoccupation with failure. We cannot continue to bury our collective failures and must focus on identifying and fixing them all from an organizational level.

Here is a sample plan of action for organizational remedial training that I would do if I were a Senior Leader with medical personnel in my unit.

I personally challenge you to actually complete the following action items this week. If we do not learn from our collective failure we will repeat it until we do.

  • There should be immediate notification, reeducation and retraining for everyone followed by an improved initial and sustainment training plan. Battalion Surgeons, PAs Instructors and Senior Medics should ensure every single medic does the following:
  • Recieve(or Demand) the incident report and AAR from the Chain of Command the way other Saftey Stand Down incident reports are disseminated. -Post it for the entire unit to read next to the parachute failure incident.
  • As a small group, read and review the report and AAR.

  • Reread the guidelines and watch the videos freely available on the DeployedMedicine App

https://deployedmedicine.com/market/11/content/158

  • Ensure everyone immediately participates in hands-on table top training with whatever you currently have available or can easily construct.

https://emcrit.org/emcrit/ultimate-cricothyrotomy-trainer/

-Be sure to discuss shortfalls and inaccuracies of your trainer.-Dont just focus on the single skill, discuss other options that could have led to a better outcome:

-‘Could different patient positioning have helped the situation?’
-‘How could the outcome have been different with various pharmacological adjuncts?’

-‘One of the things I have seen in small group training was to inject a hematoma just over the cricothyroid membrane. This makes it super messy and hard to identify landmarks which is usually a slam dunk training scar.’

-Ask Medics how well their non-Medics are trained to take care of them if it were them on that table?

  • Submit a WRITTEN request through multiple channels for proper equipment citing the article, incident report and TCCC guidelines as justification to your MEDLOG, S4, XO and anyone else who can affect the situation.

-Imagine if 10,000 requests were simultaneously submitted for similar equipment…

  • Identify training deficiencies in your immediate organization and actually make a WRITTEN request to your Command for additional remedial training to be included in future non-medical training.

-Attach the article to the request.

  • Identify equipment deficiencies and again, submit a WRITTEN request through multiple channels for proper equipment citing the article, incident report and TCCC guidelines as justification to your MEDLOG, S4, XO and anyone else who can affect the situation.

-Do you have Super Glottic Airways in every aidbag and IFAK? An Emma Capnograph would have helped identify the false passage instantly.

These are just a few things an HRO can EASILY and IMMEDIATELY accomplish. What else can you do to ensure this death of our brother is not in vain?

Podcast Episode 55: JJ and Dennis on HROs. Part 1

The principles of High Reliability Organizations are necessary in those professions where mistakes can cost lives. The airline industry is the classic example and referenced many times in the articles below. Others included are those that could result in massive loss of life such as power plants, refineries, and many industrial chemical plants. Ideally, health care organizions including operational medical programs should also fall in this category. We have a long way to go but the more of us who underatand the principles of HROs, the closer we can get to truly defining our profession in this way.

Principle #1: Preoccupation with Failure

Principle #2: Reluctance to Simplify

Principle #3: Sensitivity to Operations

Principle #4: Commitment to Resilience

Principle #5: Deference to Expertise

Listen to the podcast and read more in the resources below to really understand what this all means…


Element Rescue Quick Reference Guide: Operational Reliability


The Purpose of High Reliability Organizations Daved Van Stralen, MD


High Reliability Organizing and Leadership
Daved van Stralen, MD


Organizing for Transient Reliability:
The Production of Dynamic
Non-Events
Karl E. Weick


Journal of Contingencies and Crisis Management


Managing the Unexpected

Jacksonville Florida
February 28, 2005
Presenters:
Karl Weick
Kathleen Sutcliffe


Download the episode here!

Podcast Episode 54: SOP for the Ideal SF Clinic?

While no single clinic setup will work for every situation, a common baseline and checklist can make it far easier in customizing a clinic in similar circumstances. This is not professed to be THE way but it is A way in which ONE experienced team has created, tested, revised and rehearsed a clinic with different casualties. Their pictures and diagrams are provided in the hopes that this audience will help refine and finalize a common baseline which any medic can use in he future. Please leave comments on your thoughts.

Continue reading Podcast Episode 54: SOP for the Ideal SF Clinic?

Podcast Episode 53: Ventilating in the Prone?!

What happens when your patient has been given a cric or intubated but continues to decline… SpO2 continues to slowly drop despite taking control of the airway. You have placed your patient on a ventilator and slowly adjusted the PEEP up to 20cmH20… which quickly leads to hypotension. Do you go lower? Higher? Change volume or rate? You are out of bottled O2 and your oxygen concentrator does not seem to have much effect. The SpO2 continues dropping. Telemedicine is not available. You try positioning the patient by sitting them up. You try a couple other recruitment maneuvers you heard about.

Nothing is working.

What would Doug do?

Prone the patient???

Continue reading Podcast Episode 53: Ventilating in the Prone?!

Version 22 of The Prolonged Field Care Card

We have been training teams in various settings over many years and have noticed that there are two categories of care that emerge during prolonged care: Those that react to stimuli and chase their tails and those that have a plan and follow it. Of course this happens on a spectrum Continue reading Version 22 of The Prolonged Field Care Card

Podcast Episode 52: Walking the Fence of Evidence, Environment and Experience with a word on Proning

After a few discussions with JJ who has also appeared in several Element Rescue podcasts, Doug and Dennis talk about using evidence based medicine whenever possible and what to do when no prospective randomized controlled trials exist

Continue reading Podcast Episode 52: Walking the Fence of Evidence, Environment and Experience with a word on Proning

Podcast Episode 51: Tropical Medicine Considerations with CAPT Ryan Maves

Not all PFC is trauma.  Malaria, Dengue, Chikungunya and others will take you out of the fight if given the chance.  In this episode CAPT Ryan Maves talks about some of the more concerning and prevalent diseases encountered by deployed military personnel and partner forces and what you can do about it before an infection becomes debilitating or life threatening.

A few things to remember from the episode:

  • History and assessment are key in identifying tropical diseases. Remember to consider both history of exposures as well as the accompanying syndromes in formulating a differential diagnoses.
  • Malaria treatment consists of Malerone, Coartem or both.
  • No one dies without Doxycycline!

Podcast Episode 50: Simple Sepsis Recognition and Intervention for Prolonged Field Care

Why do we care about sepsis in prolonged field care? What can we do about septic shock with what we are normally carrying on a deployment? How do you mix an epinephrine drip? Dr. Maves lays it all out in about 20 minutes.

Continue reading Podcast Episode 50: Simple Sepsis Recognition and Intervention for Prolonged Field Care

Podcast Episode 49: Set Up a Walking Blood Bank with Andy Fisher

When you can’t take Cold Stored whole blood with you and not all of your soldiers are titered, a walking blood bank can mean the difference between life and death for a patient in hemorrhagic shock.  With the mounting evidence suggesting early blood is essential and not just a good idea, you need to have a plan in order to hit the 30 minute target.  I have seen students struggle for hours trying to get access in both the patient and the donor.  An emphasis on early recognition and early access will save lives.

Damage_Control_Resuscitation_PFC_CPG 01_Oct_2018_ID73

Podcast Episode 48: Maximizing Hospital Rotations and Medical Proficiency Training

Hospital rotations for medical proficiency training give medics who operate in the field the opportunity to see what “right” looks like. Knowing this and understanding treatment principles can allow a flexible medic to adapt to unique situations in the absence of protocols, guidelines and evidence. If properly coordinated and supported, MPTs can be an invaluable and eye opening experience. When thrown together with a naive or indifferent staff or unmotivated medic, it can be a huge waste of time and money for everyone involved. In this episode Dennis and Dr. Mark Shapiro talk about several MPT programs, and strategies to maximize the effectiveness of an MPT.


Here are several elements necessary for a positive MPT experience:

  • An approved MOU
  • A motivated lead clinician
  • An administrative coordinator
  • A limited amount of competition with residents and fellows
  • Multiple capabilities and scope of practice briefs and videos to catch staff in all departments and shifts in which a medic will be working (Share this episode)
  • A synopsis of your scope of practice and goals emailed to the specific departments in the days prior
  • A list of procedures or experiences the medic is trying to complete may help the staff understand goals
  • If an MPT is meant to prep for prolonged field care the medic should strive to respond to the trauma bay and accompany the patient through the continuum of care including prep, surgery, post op and ICU

One last thing before the podcast;

Please dont show up to your first day to work at a world class level 1 trauma center and medical school wearing pink ranger panties when everyone else is in suit and tie. I wouldn’t say it if it hadn’t happened…

Here are some links from current and past Academis partners who have participated in Military/civilian MPT partnerships:

https://www.ajc.com/news/local/special-forces-trains-combat-medics-grady-hospital/rz58YOzyotj6L7N8ydc8lL


https://www.military.com/daily-news/2015/11/24/green-beret-medics-train-duke.html


https://www.army.mil/article-amp/133219/special_operations_combat_medic_students_take_lead_in_emergency_department_rotation


https://news.vcu.edu/article/VCU_Medical_Center_Trains_its_1000th_Special_Operations_Combat


https://www.military.com/military-fitness/general-fitness/who-attends-the-special-operations-combat-medics-socm-course




Improving Far Forward Contingency Care

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