PFC Scenario Script

This script is a customizable situation that any provider should be able to pick up and immediately understand.  I will post a link to download it in full as well as the text of it here.  This will allow you to download it to your eReader or tablet right now or read through it and make comments and suggestions at the end.  Please read it and please comment! What other scenarios do you want to see? Do you have any for us? Are yours different? How so? Are we missing something? Was this page easy enough to access?  If you are not able to answer questions with positive feedback we have failed in getting the proper information to the end user, the medic on the ground in the worst place in the world in the worst situation of his life.


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10th Special Forces Group Prolonged Field Care Exercise

Situation:  You are a SFODA operating at a Host Nation Army outpost in ###, ###.  Friendly forces include ### Army Commandos and local police forces.  You are operating under the request of the President and Government of ###, and have a well-established status of forces agreement with stipulation to not engage terrorist combatants unless in self-defense.

Mission: SFODA ####  trains, advises, and assists ### Army Commandos IVO of ###, ###,  to interrupt and interdict illegal transnational terrorist activities over a 5 month period, 2016, in order to improve ###’s sovereignty and deny local terrorist safe-havens.

Insert map imagery here

Execution:   Your ODA is at a Host Nation (HN) military base conducting range training. This training area is located 45-60 minutes (by truck, unimproved road) from the base where your team house is located. You have been training in small arms and explosives, with the intent of conducting live fire Immediate Action Drills (IADs). You are currently conducting a grenade familiarization range with live grenades. All training personnel are throwing from makeshift grenade pits. There is an explosion from the far right side of the range, in the area of a grenade pit. There is a dust cloud dispersing directly in the area of the pit, and yells and screams are coming from the area. Upon arrival, there are three apparently injured personnel on the ground, two USSF and one HN Soldier.

Sustainment:   Your HN outpost has a primitive FLS capable of supporting  STOL, twin engine aircraft (CASA, Cessna), and the ISOS and contract MEDEVAC takes approximately 8 hours from notification to reach your AO.  They will not fly at night.  They will not fly in the rainy season due to muddy runway. There is a local hospital 30 minutes away from your outpost, but it is considered “unsafe” by US standards, but there is a ### trained general surgeon and local blood supply there. There is an improved runway which can support anything up to C-130, just across the border in neighboring ###. This is the nearest place to get US Air Force Aircraft onto the ground. ### is a friendly country and the border crossing is usually open, but there is currently a Military Junta underway, and forces are divided in loyalty. Additionally, all ground and air transit into the sovereign territory of ### requires country clearances.

Command and Control:    Your commo PACE plan includes normal channels to higher HQs, including the TSOC at ###.  They will launch and C2 MEDEVAC.  You have DIRLAUTH to communicate with the 24 hour on-call Medical Consultation hotline at LRMC, Germany, for consultation and medical assistance during your scenario (CALL EARLY and as OFTEN!)

TRAINING INTENT: Dynamic, performance-based, and educational.  The scenario will pause at certain points to conduct “rolling” AARs and brief teaching points.   The patient(s) will respond appropriately to treatments, and your scenario will become more complicated if your interventions are inappropriate or inadequate.   Use the scenario to exercise team SOPs for C2, Comms, and transport as you see fit.

Training will proceed from this point with standard TCCC phases, moving into a prolonged casevac scenario, back of a van for 45 minutes transport back to your outpost, where most of your commo and medical equipment is located.

Consolidated Supply List for setup of exercise:

Personnel: 4-12 OpERATORS WITH AT LEAST 1 18d

1 X pATIENT (18d)

1-2 manikin operator

BN Surgeon/PA to serve as proctor

Medical Equipment:

1-2 mANIKINS WITH APPROPRIAte injuries or Moulage Kit

IFAKS for all personnel and patients

1 x AID BaG per 18D (stocked)

Trauma roll to set up Ambulance (optional)

1-2 litters

CLASS VIII: aid bags and ifaks stocked according to unit sop

Space Requirements: outdoor space with room for 3 patients and 12 operators

Vehicles: unit specific/mission specific organic vehicles (at least 1 to serve as casevac platform

Commo: handheld radios, cell phones, other unit commo as desired

External Support:

Manikin support/operator as needed

PFC Script and reference book

CRITICAL ACTIONS-Patient #2

1. Assess initial vitals – determine STABLE

2. Assess after conscious: full neuro exam

3. Secondary survey: identify injuries

4. Splint Arm

5. Treat pain

Phase 1 (TCCC, PT Transport and Arrival)

 

Duration: In actual exercise 1.5 Hours (here 45 min)

Equipment Required: 3 x patients, either moulaged or manikin, 3 x litters, IFAKs for each participant and patient, commo or cell phones, 1 x aid bag per medic, evacuation vehicles standing by, Casualty Cards and pens

Area Set up: patients displaced around a grenade pit (basically all strewn around in a 30 foot diameter circle) One uninjured team member calls the rest of the team to the scene by yelling.

Phase 1, Part A- TCCC:

 

Situation: You are at the range on the base of your partner force training Soldiers to throw hand grenades. The location is a 45 minute drive from your team house. Two personnel from the team are still at the house. You have Satcom and cell coverage to communicate with the team house.

Across the range there is a explosion close to a throwing  position. There are immediate yells and calls for help. Upon arrival there are three Soldiers on the ground. Two are moving, one is not.

Scene security

Performs appropriate Tactical Combat Casualty Care (TCCC) interventions in a timely manner

  • Achieves hemostasis
    • Yes- BP low, PT anxious. HR trends up to 130 and BP stays in high-80’s/high 40’s.  Lots of PAIN due to TQ’s.  IF treat pain then HR drops to 110-120, but BP drops to low 80’s/low 40’s
    • No- Weak, rapid radial pulse, PT HR 130, creeping up to 140 and higher as needed. and rising, PT becomes obtunded, and later unresponsive – BP: drops to 85/45 then 80/40, then 72/30, then can’t read it.
  • Airway-performs cricothyrotomy on patient #3
    • Yes – obtains definitive airway; pt still unresponsive
    • No – Pt immediately expires, ? performs CPR?
  • Respirations-recognizes chest wall injury
    • Yes – obtains definitive airway; pt still unresponsive
    • No – Pt immediately expires, ? performs CPR?
  • Circulation-recognizes shock, initiate IV
    • Yes – Pt remains stable with no change in Mental Status
    • No – Pt mental status worsens, HR increases
  • Hypothermia-patient are covered, blanketed
    • Yes – Pt remains stable with no change in Mental Status
    • No – Pt mental status worsens, HR increases
  • Obtain vital signs, complete casualty cards, appropriately triaged patient’s for transport
    • Team recognizes limitations of transport, may designate personnel to remain with the patient #3 on scene.
    • Patient #2 recognized as most critical, is continuously monitored.
  • Communicates with higher about casualty status; timeline for movement off OBJ
    • End forms of event, location, number and status of casualties, and intended plan/timeline for transport
  • Prepares patients for transport (CASEVAC – van/pickup/NSTV)
    • Proper use of litters, vehicle loading to allow ongoing care of patient #2
  • Prevents hypothermia, initiate active warming as available
  • Team communication-all team members are aware of the patient’s status and plan
Phase 1, Part B- Transportation:

 

Situation: Your teammates bring the team vehicles around (or helicopter arrives), and you load the patients onto the truck and begin movement to the team house. The ride will be at least 45 minutes along bumpy unimproved roads.

INITIAL CASEVAC
Advanced monitoring – patient connected to monitor, vital signs trending
§
§
ð       Communicates with higher about casualty status, timeline for movement to secure location/next level of care§  Yes – Resources available at next level without delay, MEDEVAC timeline stays on schedule§  No – Resources at drop-off limited, MEDEVAC delayed by up to 2 hours

ð       Perform/re-assesses interventions (airway adjuncts ,IV access, wound care) during tactical movement in vehicle/aircraft

§  Yes – Pt remains stable, no decompensation

§  No – TQ loosens, pt bleeding resumes, IV no longer patent

ð       Achieves Pain Control

§  Yes- Pt HR and BP decreases; PT LOC decreases as BP drops

§  No- PT HR remains High; PT verbalizes discomfort with bumps during transportation; PT anxiety High; PT BP is normotensive

ð       Administers TXA

§  Yes-

§  No-

ð       Airway – obtain definitive control as needed.  BVM/Cric/RSI

ð       Appropriately identifies emergency decompensation, changes in patient status during transport, stops movement if indicated

ð       Team communication-all team members are aware of patient’s status and plan

Phase 2 (Arrival, Stabilization and Urgent Care)

Duration: In actual exercise 2-3 Hours (here 45 min)

Equipment Required: Monitor, iSTAT (optional), Fake drug vials, Transfusion Kit, Foley and foley manikin.

Area Set up: Simulated Team house with litter stands and medical equipment ready for use, desks and chairs if possible, ODA organic communications equipment. Think about prepositioning commonly used charts and references which the team would have downrange.

Charts such as HITMAN, Normal Vitals, Normal Labs, Telemedicine Script, Ketamine drip sheet, Drug Cheat Sheet, Burns Formula, Standard Ventilator Settings, DOPE for airway tubes would be helpful.

Situation: You just arrived at your Team House and got your patient/s inside. The team should be aware that you are coming and how many patients and their severity. They will only know what they have received from the team during the previous phases. The patients will be moved in and treatment begins again.

INITIAL HAND OFF/RECEIPT OF CASUALTIESð       Patients prepared for off load and documentation completedð       Appropriate hand off reports to receiving medical authority

ð       Receiving medical team- previous interventions/IVs/02/monitor/secondary survey/patient warming in the first 2 minutes

ð       All injury/pathology correctly identified, advanced adjuncts/treatments initiated

ð       Flip (patient transferred to appropriate bed/padded later, pressure sore prophylaxis), Foley (empty bag, measure over 60 minutes to 10 mL accuracy), G-tube

ADVANCED SKILLS

ð       Ventilation

o   BVM with PEEP valve

o   Ventilator basics  (Set rate, volume, PEEP at 5, DOPE mnemonic)

o   Capnometry

ð       Pain control and sedation – Ketamine+midazolam (500mg+25 mg in 250 NS bag) cocktail, infuse at ½ body wt in kg = to ml/hr, titrate to effect

ð       Tourniquet conversion – pressure dressing applied, monitored for bleeding, prepared for toxic metabolite bolus upon takedown

ð       Labs– POCT – Istat basics, CLU update/calibration, critical values for CMP, CBC, VBG

ð       Fresh Whole Blood Transfusion – blood typing, Eldon cards, donation, filtered tubing, infusion, vitals monitoring, recognize transfusion reaction (tGVH disease) and treatment

§  After transfusion: HR 85, BP: 105/60, RR: 16-18, UOP 75mL/hr

ð       Nursing Care – Wound cleansing/washout, dressing revisions, head of bed elevation, G-tube feeds vs. decompression, patient re-positioned every 60 minutes (use sleeping pad, pillows, etc. to shift pt position)

ð       Vital signs trending and documentation, recognition of improvement/degradation of status

ð       Fluid resuscitation – choses appropriate fluids (LR, Plasmalyte) and can apply Rule of 10s formula for burns, and hypertonic saline (3%)  for head injury with evidence of increased ICP.  Titrates fluids to appropriate UOP.

Phase 3 (Extended Holding, Reassessment of supplies on hand, Work/Rest, Feeding)

Duration: In actual exercise 2-3 Hours (here 45 min)

Equipment Required: Team House Medical Equipment

Area Set up: Try to replicate a team house medical room. If possible include furniture, and desks to allow team to set up a commo station, and giving work spaces for team members to plan for future evac.

Situation: Your Team will be holding your patient/s at least 24 hours due to mission constraints or AC unavailability. During this period you will have to use the limited supplies and personnel you have to ensure the best possible outcome and do it in a way which does not put the Team or Mission at additional risk.

 

§  Medic Gives ODA members Nursing Orders and Rounding Instructions

§  Set Work and Rest Cycles

§  Manpower assignments

§  Medic wake up criteria

§  Patient positioning and movement

§  Ins and Outs logged

§  Feeding and Watering schedule

§  Class VIII Supply reassessment/inventory/resupply

§  Communication with higher for transport updates

§  Telemedicine

§  Trending/Charting

§  Blood Work

§  Move to Bed

§  Pad Litter

§  Roll/reposition Patient

§  Chapstick

§  Tube Care

§  IV Care

§  Brush Teeth

§  Labs

§  Teleconsult

§  Tetanus TX

§  Gastric Tube

§  UA Dipstick

§  Sedation

§  Analgesia

§  PEEP

Phase 4 (Prep for Transport, Logistics, Movement, Prep of Aircraft PRN)Duration: In actual exercise 1-2 Hours (here 45 min)

Equipment Required:

Area Set up:

 

Situation: Arrangement for evacuation has been made, however due to adverse weather the dirt airstrip nearby cannot be used. There is no rotary wing asset within range. After making arrangements with higher, you will need to drive to an improved airfield. It is a nine hour drive. It will involve crossing a border. You will need multiple vehicles due to the remote route, in case of vehicle breakdown. An Air Force C-130 will arrive at the airfield in 12 hours. There will be no medical capability on the C-130, so you will need to care for the patient for the next 12 hours until lift-off and also plan to provide care during the 7 hour flight to Germany.
ð       Full PACE communications plan for higher HQ and medical, LRMC SOF Hotline – 49-162-296-3962

ð       Telemedicine: patient presentation format (modified MIST)- clearly states:

o    Current diagnosis – “I have a 30 y/o male s/p vehicle accident with___________”

o    Condition, trends,   “Vitals currently____________, showing improvement/worsening over last ____hours, with drop/increase in _________

o   Treatments/Limitations- ““He has had 2 x TQs converted with pressure dressings, received 1 unit of FWB, splinting applied, oxygen, and Foley placed showing ongoing UOP of ______ml/hr.”

o   “I need_______” – “I’ve been speaking with Dr. X at  XXX HQs, and the patient needs immediate transport to higher level care for ____________”

ð       Addresses non-standard, non-attended medical evacuation and medically-supported MEDEVAC capabilities (who will pick-up the patient and what can they do during transport?)

ð       Consider stressors of flight:

o   G: G-Forces & Gases (brain, eye, sinus, chest, GI, cast? SCD’s?)

o   H: Humidity Decrease (mucous membranes)

o   O: Oxygen Partial Pressure Decreased

(pO2 60, Sat 90% at 8000 ft cabin pressure – chest/pulmonary issues)

o   S: “Shakes”/Vibration (fractures, pain)

o   T: Thermal Changes (coagulopathy)

o   B: Barometric Pressure Changes

o   A: Autograph – signed and complete documentation

o   N: Noise (can’t hear patients, or each other, so, game plan & signals)

ð       Plan Equipment Needed for Flight:

o   Oxygen (how much, what flow), Airway adjuncts, IV Fluids, Monitor (send yours, or MEDEVAC brings??), securing straps (floor load), padding

ð       Plan Medications Needed for Flight –

o   S – Sedation (Ketamine/midazolam, Fentanyl, Phenobarbital, Phenergan)

o   E – Emergency (Epinephrine, Adenosine, Lidocaine, nitroglycerine), Zofran (vomiting when restrained = emergency)

o   R – Reversal – Flumazenil, Naloxone, Glucagon

o   E – Epilepsy (Head Injury) – fosphenytoin(15-20mg PE/kg IV x1), phenobarbital, diazepam, hypertonic saline

o   A – Airway – RSI meds, consider succinylcholine, etomidate in addition to above.   Albuterol.

o   B – Bugs – Antibiotics (consider meropenem, levofloxacin, acyclovir, anti-malarials, and topical, eg bacitracin, silvadene

o   C – Circulation – (consider heparin/LMWH, furosemide)

ð       Patient packaging and preparation for flight – critical care transport: monitor, ventilator, oxygen, IV infusions, Foley all packaged per USAF CCATT standard (with available equipment), ET-tube air replaced with fluid, documentation complete

o   Avoid hypotension, hypoxia, hypothermia:

§  Maintain intravenous (IV) access with large bore peripheral IV’s

§  Consider taking blood products for continued resuscitation

§  Be prepared to perform needle thoracostomyand/or perform chest tube placement

§  Maintain adequate oxygenation and ventilation (FiO2 at least 40%) (Tidal volumes of 6-8 ml/kg); keep O2 Sats > 93%

o   Carefully evaluate/document neurologic status pre-flight

o   Potential for compartment syndrome (extremity wounds -consider pre-flight fasciotomies)

o   Moderate/Severe TBI – seizure prophylaxis, elevate head of bed and prevent jugular vein obstruction (C-collar?)

o   DVT prophylaxis

ð       Leverages advanced commo technology, sending images, video teleconference for telemedicine.

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