A small team surrounded in a compound, active firefight, helicopter attempting MEDEVAC inside the walls but blades strike the building, TCCC, Prolonged Field Care, blood transfusions, 6 attempts at converting a tourniquet over 17 hours…
This 11B turned-RN and Flight Medic did so many things right… I originally recorded his 9-minute account of the incident from the JTS presentation and played it for our audience at SOMSA 2016. This video blows that audio clip out of the water. If you a serious practitioner of combat medicine I challenge you to take the time to watch the whole video. The video is about 52 minutes and worth every second. Take notes!
The video AAR was recorded and released by the U.S. Army Public Affairs Office and is now open source. The case was first identified earlier this year during one of the weekly Joint Trauma Service (JTS) Trauma Conferences which are hosted by the JTS and ISR staff in San Antonio. Everyone on the line immediately recognized the many lessons learned by SSG Decker’s account and it was obvious that his medical knowledge and experience saved not only his patient’s life but without a doubt his leg as well. The Committee on Tactical Combat Casualty Care (CoTCCC) invited him to go to the next committee meeting and give his account. The italicized lessons learned comments are my own and are by no means an attempt to armchair quarterback his performance in this situation. They are merely an attempt to capture some of the highlights as they relate to prolonged field care. Please leave comments below with additional lessons learned that you notice
Tragically not all patients lived that day despite heroic efforts by everyone involved. One of our brothers-in-arms Matthew Q. McClintock succumbed to his wounds before another MEDEVAC helicopter was able to extract the casualties. I have never asked for a dime in maintaining this site but after you watch the interview and read the lessons learned, please scroll to the bottom of the page and do what you can to help support the family Matt McClintock left behind, as we always take care of our own.
Please visit Matt’s GoFundMe page by clicking the link below
Marjah AAR Jan 2016 From SSG Decker (taken separately from the video)
Initial Patient Report and Handover
The MEDEVAC crew was alerted of Troops in Contact (TIC) at around 0900. “Dustoff was called for a Point-of-Injury (POI) 9‐Line MEDEVAC request at 0954. Upon landing inside the compound the helicopter sustained damage from a rotor strike and was unable to take off. Once on the ground, I made contact with the medic to receive a report. The patient was a 28 y/o male who had sustained a GSW to the right thigh. The 18D Special Forces Medical Sergeant on the ground stated that the tourniquet was placed at 0936 with a pressure dressing. He had established an 18g IV in left arm, administered 1g of TXA started and started a Ketamine drip at approx. 0945. The patient was in a Hypothermia Prevention and Management Kit (HPMK).” The 18D had to go back to the fight as the compound was still surrounded and under attack.
- A routine medevac that should have taken 30 minutes turned into a sustained firefight lasting over 17 hours.
- Fighting back in order to prevent more casualties takes precedence over medical treatment. Every gun in the fight counts.
- The initial tourniquet application could have been more timely in order to prevent shock in the first place.
- Visit DeployedMedicine.com/TCCC for official TCCC guidelines.
“Initial assessment of the patient showed the tourniquet in place with bleeding controlled and no signs of an exit wound or external bleeding elsewhere. The patient’s airway was patent with unlabored equal rise and fall of the chest. He had no radial pulse, appeared pale and felt cold to the touch. He was confused, combative and trying to get off the litter. We moved the patient from inside the building to an opening out in the compound for the second helicopter to land. While on the ground I reassessed the patient’s tourniquet; it was still effective. I started another 18g IV in the right arm. I gave 5mg of Versed (midazolam) to calm the patient then started Vampire blood administration protocols at 1015.”
- Very thorough head-to-toe assessment found all life threats
- Signs of shock were present but were initially mistaken for ketamine delirium. This was quickly corrected.
- SSG Decker quickly made a mental list of problems and developed a plan of care. Check out our post on Prioritizing a Care Plan
Resuscitation with Blood Products
“I started the first unit of type O positive pRBCs through an enFlow blood warmer. While the blood was being transfused I reassessed the patient’s interventions. The first round of blood was finished at 1025 the patient still had no radial pulse, was pale and still cold to the touch. I started the second unit of type O positive pRBCs at 1025.”
- The non-medical crew chief was able to help get the blood going because of prior training
- The timely transfusion of warm blood products likely saved the patient’s life.
- PFC Fluid Therapy Recommendations
Realization of Prolonged Field Care Situation and Continued Resuscitation
“After it was established that the second Medevac helicopter was unable to land, we decided to reposition back inside the compound into a building because we were taking effective small arms fire and mortar rounds. Once inside the building I reassessed that all interventions were still in place and working. After the second unit of PRBC’s ended at 1049 the pt’s status improved. A radial pulse was noted and the patient’s mental status improved. I started LR 500ml TKO hooked to the enFlow and stopped the Ketamine drip.”
- Continued, serial reassessments including interventions and vitals allowed the medic to mentally trend the patient’s condition
- Operational Context of PFC
Gathering Advanced Medical Equipment from the Downed Aircraft
“I then had the crew chief grab the Propaq[monitor] and O2 bottles from the helicopter to get an accurate set of vital signs on the patient. Vitals were BP 96/64, HR 95, O2 96%, RR 13. A detailed assessment showed the patient to be AOX3 with no other injuries present, pt stated that he felt warm. The pt was able to wiggle toes on the right foot and completed pedal push and pulls. The pt c/o severe pain 10/10. I gave 50mcg of Fentanyl at 1130. PT was placed on a nasal cannula at 2Lpm for supplemental O2. At 1200 hours I gave the patient the second dose of 1G TXA in 100mls of NS IV left AC and gave Invanz antibiotic IM, after learning that the third attempt to evacuate the patient had been aborted due to a crewmember being injured while trying to land.”
- While the patient stated that he felt warm, a core temperature could have been taken throughout the day in order to trend and prevent an important component of the lethal triad
- At this point, they really made an effort to improve their position by gathering and prioritizing use of, supplies
- The 10 Core PFC Capabilities Article
Continuing Pain Management and Urine Eval
“After pain reassessment, the patient stated that the pain medication helped take some of the pain away, but his pain was returning, I then gave another 50mcg of Fentanyl for a pain score of 9/10. The patient complained of needing to urinate, urine was observed as straw colored with no visual sediment or strong odors noted. 50mcg of Fentanyl was again given at 1300 for a pain of 9/10.”
- A foley catheter should be placed when possible in order to trend resuscitation efforts. Small portable kits are readily available which can fit in a PFC aid bag
- Listen to our podcast on Urine Output and Foley catheters in PFC
Tourniquet Conversion Attempt #1 – Failed
“At 1330 I made the decision to try to convert the TQ to a pressure dressing due to the unknown time until evacuation. I gave the patient 100mcg of Fentanyl and 2.5mg of Versed for pain and sedation. At 1340 I removed the current pressure dressing and packed the wound with combat gauze and applied pressure. After 5 mins of pressure, I placed a pressure dressing on top of the wound, gave the patient a fluid bolus of 200ml of LR, vital signs 110/63 HR 88, RR 14, O2 98%. I then slowly release the TQ and monitored pt’s vital signs AOX3, 106/64, HR 101, RR 16, O2 99% and watched the dressing for signs of bleeding. The patient was again able to perform pedal push and pulls, wiggle toes and had strong pedal pulses in right foot. At 1345 I noticed continued bleeding from the wound, marked the dressing, and retightened the TQ until pulse disappeared in right foot.”
- The patient was like acidotic, slightly hypothermic and coagulopathic at this point, perhaps another kind of hemostatic dressing could have been more effective
- Pedal pulses were noted in the foot despite continued bleeding. This was a sign to him that the limb had a better chance of salvage
- Tourniquet Conversion Recommendations
Tourniquet Conversion Attempt #2 ‐ Failed
“At 1430 the patient c/o severe pain 10/10, I gave 50mcg of Fentanyl. I gave 50 mcg of Fentanyl again for pain of 10/10 at 1515. At 1530 I gave the patient a bolus of LR 200ml vitals AOX3, BP 108/70, HR 89, RR 14, O2 98%. I then slowly released the TQ and observed for signs of bleeding. The patient was able to again perform pedal push and pulls, wiggle toes and had pedal pulsed in right foot. I then replaced the CAT with a SOF‐T Wide and cut away the remainder of the pants around the wound, again no exit wound was noticed on the back of the leg. Bleeding was observed, marked and TQ was retightened until pulses in right foot disappeared.”
- The patient was again in severe pain after multiple bolus doses of fentanyl. Changing analgesia strategies at this point, such as a ketamine drip would have been reasonable
- Analgesia and Sedation Recommendations
Tourniquet Conversion Attempt #3 ‐ Failed
“Pt vital signs were stable through the procedure. At 1615 the pt c/o of pain 10/10 once again and was given Fentanyl 50mcg, vitals were AOX3 BP 119/70, P 89, RR 14, O2 97%. The pt was given another 50mcg of Fentanyl at 1650 for pain of 9/10. At 1730 the patient was given a 150ml bolus of NS. Vitals were AOX3, 104/65, HR, 84, RR 16, O2 99%. The TQ was again slowly released. Patient was again able to perform pedal push and pulls, wiggle toes and had positive pedal pulses. Bleeding was observed spreading on the bandage, I marked it and reapplied the TQ until pulses disappeared.”
- You have read all of the vitals up until this point, is he getting better or worse? Trending vital signs on a visual graph can save you the headache of mentally calculating everything… you instantly see the trend going up, down or staying the same
- Print This Prolonged Field Care Card and Keep it Laminated in Your Aid Bag
Tourniquet Conversion Attempt #4 ‐ Failed
“50mcg of Fentanyl was given for pain of 10/10. Pt vital AOX3, 108/68, P 76, RR 16, O2 96%. Pt was c/o pain and nausea at 1830 pt was given 4mg of Zofran and 50mcg of Fentanyl. Pt was given bolus of 150ml of NS at 1930. TQ was released slowly and bandage was observed for bleeding. Pt was able to tell me which toe I was touching with his eyes closed, had pedal pulses and able to complete pedal push and pulls with right foot. Vital were AOX3, 110/66. HR 69, RR 14, O2 99%. Bleeding was observed, marked and TQ was reapplied.”
Tourniquet Conversion Attempt #5 ‐ Failed
“Pt c/o pain 9/10 and was given 50mcg of fentanyl. Upon pain reassessment pt c/o severe pain at 2030 and was given 50mcg of fentanyl for pain of 10/10. Pt was given Morphine 5mg at 2100 with no relief of pain, 5mg of morphine was given again at 2115 and again at 2130 with no relief. At 2245 I placed the patient on a ketamine drip 200mg in 100ml of NS, calculated the drip at 50ml an hour and continued that for the remainder of the night. At 2215 I gave the patient a 150ml bolus of NS and slowly released the TQ while observing for bleeding. I no longer had the ability to monitor BP, the batteries were dead on the equipment. Pt had radial pulse, HR 74, O2 98 via finger Pulse OX, RR 14. Pt again was able to wiggle toes, perform ROM exercises with right foot and had pedal pulses. Bleeding was observed, Marked and TQ reapplied.”
- A ketamine drip was initiated along with a bolus of opiates to get control of pain
- Have a plan for a telemedical consult, you don’t have to do this alone. The ODA likely had a sat phone that could have been used to call the Virtual Critical Care Consult line:
- Telemedical Consult Podcast
Tourniquet Conversion Attempt #6…
“Bolus of 150ml was given and TQ was slowly released at 0030, observed pt for signs of bleeding and vitals monitored. PT had strong radial and pedal pulsed and full ROM of foot. Pt was able to tell me which toe I was touching with eyes closed. No bleeding was noted and TQ was loosened and left in place. At approx. 0245 the word was given that we were going to reposition pt outside for evacuation. Pt was packaged, IV lines were secured. Once outside on the LZ pt was reassessed for bleeding, no additional bleeding was present. PT had Radial pulse present, P 77, O2 99%, RR 16. At approx. 0300 Helicopters landed, patient was loaded and secured to the floor.”
- Due to SSG Decker’s tenacity in converting the tourniquet he was finally able to save his patient’s leg! The patient made a full recovery and has already passed an APFT
- Training for a longer scenario will open your eyes to your shortcomings. Don’t just talk it through, do it live.
- PFC Training Recommendations/
MEDEVAC and Handover to Role 2
“Once inside the Helicopter the patient was reassessed for bleeding, none noted, all interventions were still in place. NS and Ketamine drip were hooked up to enflow fluid warmer to warm pt during flight and floor heater was requested through chinook crew. Pt maintained stable vital signs and showed no signs of bleeding throughout flight to FST. Once we arrived at FST report was given to CRNA.” [A Foley catheter was immediately placed with 1200cc urine collected before moving the patient to the next level of care.]
- During a 10 minute layover at a role 2 facility they prioritized one intervention; placing a foley catheter. 1200mLs of urine were collected!
- Make your life easier with these Pre-deployment Downloads and Printouts
My Other Observations
This was an interesting case for a few reasons and I’ll try and stay in my lane as I’m no vascular surgeon nor was I there.
First, the patient was already in shock by the time the tourniquet was placed, evidenced by absent radial pulse, altered mental status, etc. He was hypovolemic, likely hypothermic and coagulopathic, meaning his own ability to clot was greatly diminished. This situation has upward of a 90% mortality rate, or chance of dying already, but also would make conversion to a packed pressure dressing extremely difficult. Using Combat Gauze with kaolin may have made the conversion more difficult as the Kaolin works with the body’s natural clotting cascade. Perhaps Celox or Chitogauze would have worked better.
-Get tourniquets on early!
Once the coagulopathy was reversed after both, red blood cell transfusion and use of the HPMK to warm him, his body was able to form a clot with the help of the kaolin in the Combat Gauze. I think this was the biggest reason he couldn’t convert.
Since the injury did not involve the artery running along the bone like we normally train, it was likely harder to get enough pressure to stop the bleed. Our students are tested on packing a major arterial wound using only regular gauze. They have to make a wadded up “powerball,” press the artery directly onto the bone and maintain pressure until finally dressed. It might be harder without that backstop of the bone.
Second, the Femoral artery wasn’t the culprit causing the bleed, it was a superficial artery as stated by the surgeons on the JTS call from the role 3 in Afghanistan. This was also evidenced by the presence of a pedal pulse in his foot. Due to the circumstances he had to wait 4 hours to convert he was worried about rhabdomyolysis, or all the bad stuff that could damage the kidneys and heart, and gave crystalloid IV fluids each attempt. Probably not enough to blow a clot if there were one in the fist place. Tracking urine output, along with other vitals, could have given a more complete picture of resuscitation prior to converting the tourniquet.
Clamping and ligating the bleeder could have been an option if the situation and training level permitted. During our debridement surgeries we routinely find these superficial vessels that have been without a blood supply for 24 hours, some with clots in them and some without, that we cut out after we ligate higher and tie them off with absorbable suture. So relying on a clot for hemostasis in our surgeries is not an option. Even the small vessels that are tied off sometimes rebleed(usually at 0200 due to poor technique) and we have to go back in and re-tie it properly. This is one reason we are exploring the addition of TXA to our extremity surgery protocol. Another being a finite supply of blood available where TXA has shown to reduce intraoperative bleeding. There may however, be too big of a risk with unwanted clots not being broken down and causing other complications. More to follow… Some of our students are getting experiences doing arterial shunts where they suture in a piece of tubing to reconnect a torn or damaged artery. While not really applicable in this case, he could have clamped and tied. Better to try and save the limb than to amputate. His tenacity in converting this tourniquet definitely paid off.
Third, the patient’s pain was not controlled the majority of the time. It was 9 or 10/10 for an extended period of time. We are able to teach our students regional nerve blocks which are pretty effective and can last hours with the right agent. If you look up NYSORA sciatic or femoral block on YouTube, you can use landmarks, nerve stimulator or ultrasound. It’s another tool in the tool box which we believe worth while. Most of this casualty’s pain was likely due to the tourniquet. So much so that the pain meds were about depleted by the time they got out. An early bolus of ketamine or regional block and sedation on a stable patient in a stable environment could have allowed enough time to locate and ligate the bleeder thus drastically reducing his pain.
There are a multitude of learning points in this case. Every medic should be required to watch it.