After witnessing certain trends from participating in, and observing many training scenarios and AARs. These principals glare at me each time I watch a medic go through a PFC
scenario for the first time. The light bulbs then start clicking on and they begin working toward these same solutions while in the middle of the scenario, when it is too late. Learn from all of our hard-won lessons while you still have the luxury of doing so.
1. Planning for the event or deployment
I will always put planning first. Planning should be the bread and butter of the SOF medic just as running a TCCC clinic. It makes you aware of evac and treatment options that would otherwise remain hidden in the area of responsibility. You may have a surgical team a short 2 hour flight away. Conversely, that surgical team may not be operational or present even. If you have never methodically combed through all of the possibilities and verified every assumption you will find that the work and knowledge you gain is worth the time.
2. Resuscitating using blood products in order to achieve a predetermined goal
Replacing missing blood with warm fresh whole blood is likely the best option if it is available. Read the accompanying position paper below. Know how to draw and administer it. Know potential complications and treatments for those complications. Know how to administer a blood typing card and, if possible, have every member of your team pre-screened and tested. If you are going to have Freeze dried plasma or any other components, know how to reconstitute and administer them. If you have any questions read the documents below, especially the FAQs. Figure out what kind of patient you are dealing with and try and achieve a specific resuscitation goal such as a MAP (Mean Arterial Pressure), urine output or other value pertaining to your patient. If you are not sure, try a telemed consult. If not, just have some goals in mind as opposed to loading every patient with all you happened to bring with you.
3. Efficiently controlling pain and the side effects from the drugs
This is one of the biggest deficiencies we have seen over and over. Medics who don’t have the opportunity to work in clinics or hospitals regularly, to practice medicine, must take the time to know the drugs they will have, inside and out. Beside the podcasts, we have put the following resources together:
4. Monitoring and trending vital signs including serial physical exams and urine output
Visually and graphically trending vital signs makes recognizing changes much easier at 0400 when the rest plan fell apart. Another thing we have noticed lately is that medics who do serial physical exams also identify pathology earlier than those who don’t. It is a very simple concept that pays dividends. Get a Foley catheter in early, MEASURE AND DUMP THE INITIAL OUTPUT and start a timer. On the hour dump the contents of the bag into a container and use a 60cc syringe to get an accurate measurement down to the mL. Be sure to practice this and watch a YouTube video if you have to, just don’t mess it up and throw away one of the few valuable Foleys you may have.
5. Prioritizing procedures and create a care plan for each injury and intervention
This will really up your game if you step back and take the few short minutes to fill out and prioritize a plan before diving in and getting lost in your tasks. Check it out:
6. Performing surgical procedures, within scope of practice, in the absence of timely evacuation
This will have more to do with the training and proficiency of the practicing medic and his comfort level in doing the necessary procedures. Medics should take the MPT rotation opportunities very seriously and squeeze everything they can out of such a valuable learning experience. These procedures may include anything from a chest tube or cricothyroidotomy all the way up to amputation or debridement in order to prevent further deterioration of the patient. Don’t forget the possibilities of video telemedicine directed surgical procedures if you aren’t entirely comfortable or if it’s been a while.
7. Prevent iatrogenisis while providing aggressive nursing care
A ten dollar word meaning harm caused by one of our interventions. Everything we do as medics has the potential to cause harm to the patient. Each of these will be magnified in a PFC situation due to the limitations of the facilities, personnel and equipment. Putting a patient on a backboard or tactical litter may be the right answer at the time of the incident. This has the potential to cause serious ulcerative damage and unnecessary morbidity, complicating the case and, ultimately, the patient’s long term recovery. Think about every intervention and the potential complications that may arise if not properly addressed;
TXA- Deep Vein Thrombosis may occur without prophylactically massaging and performing passive ROM exercises for the the extremities. ICUs have pneumatic booties to take care of this, we don’t.
Intubation or other definitive airway adjunct- micro aspiration and pneumonia without washing out the mouth with oral chlorhexidine or performing oral hygiene with a toothbrush and suction every few hours
Keeping the head of the bed up could help manage ICP but also improve lung function compared to a patient lying flat on their back. They should be turned on their side every couple hours to 30 degrees! Much more than simply shoving an extra towel under one side at a time.
As the medic thinks through the list of all the interventions he may possibly provide, he should be thinking of the long term consequences as well as the short. Most of this is common knowledge in ICUs around the world and will certainly be done to your casualty once they arrive at definitive care, start early to save yourself and your patient unnecessary work and rehab later.
8. Perform a telemedicine consult early
There is much stigma surrounding this topic. What I can say about it is that after participating and observing in numerous scenarios, is that if you are able to call, just do it. Call early to be sure that you are on the right track or ask that nagging question that has been at the back of your mind. Write everything down including exactly what you are calling for. Use a prewritten script that includes vital signs and pertinent info such as the one prepared below:
As providers tire throughout a prolonged event they will begin to make questionable decisions that they otherwise wouldn’t have made. This happens to the best doctors and smartest residents in the world. One way they prevent this from causing harm to the patient is bouncing ideas off each other and making plans as a team with oversight from an experienced attending physician. In the absence of a well-trained medical team a telemedicine consult will likely do more good than harm. Which brings us to:
9. Manage the health and well-being of the team including the medic
Once a team runs a scenario that lasts longer than 24 hours there is an immediate recognition that a rest plan and duty roster is required in order to function at the high levels required by such a complex situation. Everyone will get tired, hungry, frustrated and need a break. Taking a step back and refreshing the perspective will allow the medic to regain the objective perspective that gets lost in the tunnel vision of medical tasks. This is the responsible, professional choice as opposed to driving on through the hours and days required by false bravado. Trust your team mates that you took the time to train. Take a break. Eat. Make sure your team is doing the same thing. Make the roster.
10. Plan and execute an effective non-standard evacuation and patient handover
There are several resources available and you always have the option of creating something from scratch. The homogenization of documentation across services may prove beneficial by providing vital information in a familiar format. If it doesn’t work for you, however, use something. We have included the information pertinent to us while the Air Force CCATT have developed a form over the course of the wars which has been honed over thousands of evacs. Even if you don’t have the ability to collect certain labs or values someone else in the chain of evacuation may find those sections useful. Add this to your folder and see what works for you::