A Re-Introduction to Prolonged Field Care After 5 Years of Work
PFC is doing the best you can to treat a sicker patient than you are prepared to handle for longer than you should be. It’s not a skillset, part of a plan or planned event, it is a bad situation that in which you find yourself due to extenuating circumstances.
The following documents and components have been published by the Prolonged Field Care Working Group over the last 5 years. We still have some in the works but they take time. I plan on adding those documents to the respective sections of this post as well as the Smart Book folder. This will allow anyone deploying to do so with a PDF version of almost everything we have published. All of our podcasts can be direct downloaded from libsyn.com.
Tactical Combat Casualty Care is the foundation of deployed trauma care. Without it, there is no opportunity to worry about prolonged field care. Despite this all care happens on a spectrum from TCCC to PFC and beyond into definitive care provided by a prehospital care provider. For this reason the current CoTCCC guidelines from the official Deployed Medicine website and app should be your first stop.
–DOD INSTRUCTION 1322.24
According to the Office of the Under Secretary of Defense for Personnel and Readiness and DOD INSTRUCTION 1322.24 MEDICAL READINESS TRAINING (MRT) it is instructed that “the Director of the DHA develops a standardized TCCC and prolonged field care curriculum.”
–ADVISSOR Telemedicine Info:
If you are a Medic, PA or Physician, you are encouraged to email the program manager at firstname.lastname@example.org in order to get the 1-833 number. E-Mails must be sent from an official military (i.e. “.mil”) account in order to recive a reply with the numbers.
The ADVISOR Physicians on the other line can only provide consults to deployed US Military Medics and providers but CAN be used for training purposes like we have been doing for over 2 years now with various prolonged field care exercises. If it will be a high call volume for multiple calls and lanes it is asked that coordinate prior. Onesies and twosies are fine.
IF IT IS A TRAINING CALL BE SURE TO BEGIN THE CALL WITH “Exercise, Exercise, Exercise.”
This is a direct result of the work of the Special Operations Medical Association’s Prolonged Field Care Working Group and efforts of those of concerned physicians in San Antonio, Madigan and TATRC.
They are great people who know our capabilities, limitations and concerns. They have even been out to our austere medical exercises as proctors to see first-hand what us guys on the ground have to deal with.
Continued support by SOMA Board and new SOMA President HR Montgomery in funding/hosting the podcast and www.Prolongedfieldcare.org website
COL Keenan’s PFC SOMSA18 Update and farewell address was livestreamed and still accessible on Prolonged Field Care Facebook Page with additional unique content available on Instagram and Facebook pages.
-Updates on Clinical Practice GuidelineDocumentation PublishedNursing Care CPG PublishedTelemedicine Position Paper PublishedPFC RDCR CPG Published New JTS CPG link:
–Needs and wants from the force:
-Continued call for all for AAR‘s, Case Reports and data submission! They don’t have to be new. These can be cases that you had in the past but never reported including cases involving host nation personnel and can include disease and non-trauma. These resulted in a data review and YouTube video that can be seen here: https://youtu.be/Y2XYTeu7YLA
Submit AARs: https://prolongedfieldcare.org/2017/09/22/new-jtspfc-aar-submission-form
Prolonged field care explained.
Joint Trauma System (JTS) Clinical Practice Guidelines (CPGs)
The Joint Trauma System (JTTS) Clinical Practice Guidelines(CPGs) are the standard of care for all US Military Medical Providers. They are backed by evidence and represent the current expectations of care. If you have a question as to where a specific recommendation came from the reference is usually included. Where no evidence exists, We have partnered with the JTS and have started slowly pumping out quality PFC CPGs on a variety of subjects. We take our time so that the recommendations are the most practical possible for medics in the field while being the most evidence based as possible. For instance, the TIB CPG took 18 months from inception to publication in the Journal of Special Operations Medicine where all of our CPGs are published. If you are not a member of the Special Operations Medical Association or don’t have access to the journal apart from SOMA, you can always access the CPGs on the JTS CPG page. Just Google it. Once on that page you can also check out the nearly 50 other CPGs for other issues.
The 3 pillars of prolonged field care are Planning, Evacuation and Medical Care. Here are a few resources for each…
Evacuation is always the goal but is not always possible due to enemy action, weather or even, poor planning.
Planning is always first and foremost when thinking about Prolonged Field Care. Planning should be the bread and butter of the SOF medic. 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.
Visually and graphically trending vital signs makes recognizing changes much easier at 0400 when the rest plan falls apart. It is a very simple concept that pays dividends. One such important way to monitor your patient besides the usual vital signs is to use a Foley catheter. 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 procedure 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.
2. Resuscitation using blood products and appropriate fluids
Replacing missing blood with warm fresh whole blood is likely the best option if it is available. Read the accompanying position paper and articles. 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. Ventilate and oxygenate
4. Control the airway
5. Sedation and Analgesia to efficiently control pain and manage 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:
6. Physical Exam and Diagnostics
Identifying all illnesses, injuries and problems through a thorough secondary physical exam is essential in prioritizing medical interventions and communicating when teleconsulting. Medics who do serial physical exams also identify pathology earlier than those who don’t. This can also be enhanced with equipment such as an ultrasound.
7. Nursing Care and Hygiene to prevent Iatrogenisis
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 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. Deep Vein Thrombosis may also occur in an immobilized without prophylactically massaging and performing passive ROM exercises for the the extremities. ICUs have pneumatic booties to take care of this along with Lovanox, 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. Surgical interventions, within scope of practice, in the absence of timely evacuation
Surgical procedures rely on 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.
9. Telemedicine and Teleconsultation
There used to be 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.
10. Package and Prep for flight
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 created our own single-sheet patient handover if you have nothing else. This quicly and effectively highlights the most critical patient information right up front. We have also 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.
Working Group Recommendations
Eye emergencies are one of the big 3 concerns; life, limb or eye sight. This will be the first of many installments on PFC specific eye recommendations, Open Globe Injuries. It is presented in a Power Point presentation for easy down load and printing for future reference. This was submitted out of the blue while we were at SOMSA 2014 by a PFCWG partner and a welcomed addition to our reference material. A CPG on Eye Injuries is nearing completion now…
One of the problems discussed during different conversations was engaging and educating medics, in Prolonged Field Care topics, who already have an overflowing plate or who may be deployed or busy with other training requirements. One thing we tried at our own unit was that of the working lunch discussion. Many medics voiced concern because they could not even make it to a quick weekly lunch session. Another idea was that of a weekly email quiz.
A periodic case study, real or hypothetical, with discussion questions may work as well. Video AARs with a link to a discussion thread might work if you had a decent internet connection. With all the junk in my inbox everyday, I feel it would be refreshing to see something relevant and useful. It would be great to see as much cross agency and unit participation as possible.
Training materials were the number 1 most requested item from our SOMSA AAR. We have put out other training recommendations in the past but wanted to also highlight some important skills that will help you identify gaps in your PFC training program, plan future training and measure progress. We will get more into this cycle in the future however, this should be a good place to start. Many thanks go out to Andrew who labored over many versions of the list over the past few months. One last thing, be sure that you are already at 100% T for Trained on your TCCC task list. There is no use in getting into PFC training prior to mastering TCCC. If you see something we may have overlooked and would like to see it on future versions, please comment below and let us know.
After witnessing certain trends from participating in, and observing many training scenarios and AARs I have noticed many trends that can be remedied. 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.
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.
Joint Trauma System After Action Review Submission Form
Stories and experiences can sometimes bring relevancy to a situation you are in or to a point you are trying to make while instructing. These singular stories are called anecdotes and while powerful and personal do not represent similar patient outcomes even in similar situations. They are not science. They do not take into account the vast number of variables that were present in that particular situation. Often these stories can mislead and misinform medical practice by inexperienced medics and practitioners due to that powerful personal experience clouding that person’s own judgment.
Experienced providers will take the sum of their experiences and add the most current and applicable science to make the most informed decision possible. If you don’t have much experience in a given situation and haven’t read the most current applicable literature, it is safe to fall back on protocols written by those who do, usually unit surgeons and medical directors who are influenced by specialty committees, working groups and task forces. In order to conduct relevant and timely research, gaps in practices and training must be identified. Evidence based medicine requires us to gather evidence. This is where this AAR form comes into play. This is a way to objectively look at the facts of a single case and the outcome of the patient. With enough of these AARs you can begin to pull patterns and data points to identify trends in care and outcomes. Some of these trends can result in questions and hypotheses that will then be researched. The core functions of the Joint Trauma System are to Sense, Aggregate, Evaluate and Disseminate practical medical information. This form is the sensing part of the cycle. Once enough of these AARs are collected the data points will be aggregated and evaluated through studies and research. This is where our clinical practice guidelines came from. Right now reporting is strongly recommended but not required by USSOCOM 350-29. The newest version proposes an AAR mandate for all medical cases. The JTS recognizes our this shortfall and has begun collecting cases in the interim. The last dissemination of the first version of this form resulted in an article in the JSOM where data points were taken from 54 PFC cases. We implore you to use this form and submit cases to the JTS for review.