This post has been a long time coming. This is where it began and may be the most important tool we have to offer. This is the 10 Capabilities Position Paper revisited with the grid made easily available. If you have read the position paper you know that everything we recommend is in the “Minimum, Better and Best” format. Sometimes it’s equipment, others it’s training or experience. Most of us on the ground may never reach the “Best” level but we can always strive to attend another course or seek out a professional to teach us our shortcoming or at the very least, be aware of “right.” This is a huge step forward in anyone’s medical education, coming to the realization that you know what you don’t know. Your ignorance at any level is a detriment to your patient’s health.
This is how this all started, medics who care, seeking out smart guys to answer the burning questions tugging at their unconscious, knowing one day that they would be likely be called upon to answer it themselves in a time of crisis whether they had a solution or not.
or read it now below:
PROLONGED FIELD CARE WORKING GROUP POSITION PAPER
PROLONGED FIELD CARE CAPABILITIES
A newly formed Prolonged Field Care Working Group (PFC WG), comprised of medical‐specialty subject matter experts, has been tasked to evaluate the current training and preparedness of Special Operations Force (SOF) medics. The first formal position paper from the working group suggests that medical providers consider the below list of capabilities when preparing their medics to provide PFC in austere settings. It is presented in a “minimum, better, best” format. The intent is to demonstrate those basic skills, with adjunctive skills and equipment that may be employed when considering what to train for Prolonged Field Care (PFC). At first glance, the list may seem somewhat simple, but it emphasizes basic medical skills, that, when put together, allow for a more comprehensive approach to critical patient care in an austere setting. Of note, equipment is relatively de‐emphasized since medical skills and training should be the focus of preparing the Special Operations provider for providing this care. PFC requires the following capabilities in at least some capacity. If you can provide these 10 capabilities in at least the minimum requirements, you are on your way to being prepared for PFC. Here are the recommendations:
1. Monitor the patient in order to create a useful vital sign trend
Minimum – blood pressure cuff, stethoscope, pulse oximetry, Foley catheter (measure urine output) and an understanding of vital signs interpretation. Use a method to accurately document vital signs trends.
Better ‐ add capnometry
Best ‐ vital signs monitor in order to provide hands‐free vitals at regular intervals
2. Resuscitate the patient beyond crystalloid/colloid infusion
Minimum ‐ field Fresh Whole Blood transfusion kits
Better ‐ maintenance crystalloids also prepared for a major burn and/or closed head injury resuscitation (2‐3 cases of LR or PlasmaLyte A; hypertonic saline); consider adding Lyophilized Plasma as available; Fluid warmer
Best ‐ maintain a stock of PRBCs, FFP, and have type‐specific donors identified for immediate FWB draw.
3. Ventilate/oxygenate the patient
Minimum ‐ provide PEEP via BVM valve (you cannot ventilate a patient in the PFC setting (prolonged ventilation) without PEEP or they will be at risk for developing ARDS)
Better ‐ provide supplemental O2 via oxygen concentrator
Best – portable Ventilator (i.e. Eagle Impact ventilator or similar) with supplemental O2
4. Gain definitive control of the patient’s airway with an inflated cuff in the trachea (and be able to keep the patient comfortable)
Minimum ‐ Medic is prepared for a Ketamine cricothyrotomy
Better ‐ add ability to provide long‐duration sedation
Best ‐ add a responsible RSI capability with subsequent airway maintenance skills, in addition to providing long term sedation (to include suction and paralysis with adequate sedation)
5. Use sedation/pain control in order to accomplish the above tasks
Minimum ‐ provide opiate analgesics titrated IV
Better ‐ trained to sedate with ketamine (and adjunctive midazolam)
Best ‐ experienced with and maintains currency in long term sedation practice using IV morphine, ketamine, midazolam, Fentanyl, etc.
6. Use physical exam/diagnostic measures to gain awareness of potential problems
Minimum ‐ using physical exam without advanced diagnostics ‐ maintain awareness of potential unseen injuries (abdominal bleed, head injury, etc)
Better ‐ trained to use advanced diagnotics ‐ ultrasound, point‐of‐care lab testing, etc.
Best ‐ experienced in the above
7. Provide nursing/hygiene/comfort measures
Minimum – ensure the patient is clean, warm, dry, padded, catheterized and provides basic wound care
Better ‐ elevate head of bed, debride wounds, perform washouts, wet‐to‐dry dressings, decompress stomach
Best ‐ experienced in all the above
8. Perform advanced surgical interventions
Minimum ‐ chest tube, cricothyrotomy
Better ‐ fasciotomy, wound debridement, amputation, etc.
Best ‐ experienced with all the above
9. Perform telemedicine consult
Minimum – make reliable communications; present patient; pass trends of key vital signs
Better ‐ add labs and ultrasound images
Best ‐ video teleconference
10. Prepare the patient for flight
Minimum ‐ be familiar with physiologic stressors of flight
Better ‐ trained in critical care transport
Best ‐ experienced in critical care transport