Dennis had the honor of interviewing Dr. John Quinn who’s on the ground working Role 1 medical operations for an NGO somewhere in Ukraine.
The lessons being learned by John and others during the early days of this conflict and the past 8 years can be used to help those on the ground now and into the future. This is an amazing opportunity to stay informed of current events and prepare ourselves by narrowing expectations and tweaking training.
During the interview John stated that anything that can be done to further enable FWB availability and knowledge would be greatly appreciated. In particular, when asked what we could translate, he asked for: Damage Control Resuscitation guidelines to be translated, Prehospital Blood guidelines, anything on Damage Control Surgery for non-surgeons (they have a lot of OB/GYNs and others like OMFS functioning as DCS surgeons at Role 2s). He also stated that they’re seeing a TON of TBI “walking wounded” and anything on mild to moderate TBI management would be great.
When asked about a trauma registry, John stated that the Ministry of Health is attempting to catalogue all civilian casualty numbers. The Ministry of Defense is VERY close-hold with any info and it would be very hard to elicit the ground truth there for the time being.
John stated that many organizations are using the TCCC cards and all documentation is trying to be written in BOTH Ukranian and English, due to the large number of non-native providers helping in country. They LOVE DeployedMedicine, the translation of TCCC and Emergency War Surgery and absolutely look to US and NATO standards of care.
Dennis had the honor of interviewing Dr. John Quinn who’s on the ground working Role 1 medical operations for an NGO somewhere in Ukraine. The lessons being learned by John and others during the early days of this conflict and the past 8 years can be used to help those on the ground now and into the future.
The Society of Critical Care Medicine (SCCM) responds to disasters and emergencies by providing resources and updates to the critical care community. It is currently responding to the COVID-19 outbreak.
The Joint Trauma System and Defense Committees on Trauma are made up of several committees including the Committee on Tactical Combat Casualty Care (CoTCCC), the Committee on EnRoute Combat Casualty Care (CoERCCC) and the Committee on Surgical Combat Casualty Care (CoSCCC). These committees, along with the other branches of the JTS, strive to share lessons learned, data, research and form recommendations to DoD medical communities.
In particular, this newsletter:
-Explains the new position paper on small single-surgeon teams
-Illustrates the CCMD Dashboard and training
-Details the rebuilding of he DoD Trauma Registry
-Reviews data on search and rescue missions
-Provides links to studies based on DoDTR data
-Identifies a path to improve Highly Perishable Missions Essential Medical Skills(HPMEMS) Training
–Provides even more links to articles which impacted COMBAT CASUALTY CARE
From tourniquets to chest seals, our community has been at the forefront of innovating, problem solving and improvising when not able to get a commercially tested and manufactured medical device. A purpose-made, evidence-based solution should always be primary in the PACE plan. After the primary manufactured and evaluated product is exhausted, what then? What is your alternate, contingency or emergency? Do you and the people that may potentially be treating you, fully grasp the principles behind all the fancy, expensive equipment that you use for the environment in which you are operating? The easiest example is the tourniquet. A tourniquet provides the user a secure mechanical advantage to apply pressure to the vessels of a limb or junction over what they would normally be able to reliably apply without something such as a windlass or ratchet system. It also incorporates materials that will not break a wide enough strap to disperse the pressure over a wider area to reduce the chance of iatrogenic injury from a narrow strap or cord. Same with a pad under the mechanism to reduce the incidence of pinching. Once the principles of these devices are fully understood, trial and error testing can begin. You must test what ever it is that you are planning to use in place of a vetted product.
Does it work?
Is it reproducible?
By your less trained partner force?
In the conditions that you will be contending with?
Once you have a plan and begin testing. Make sure you record your results, including tips and pearls so that the next person can duplicate what you did. Here is our post on bleach powder for disinfection and Dakins solution as an example. If you have something that has worked for you, please detail it in the comments below and perhaps we can add it here as an addendum or as a separate post in the future.
Improvised Medical Supplies
What if you have to improvise more than a tourniquet or IFAK contents though? Here is a list put together in the case that you find yourself in a situation where traditional MEDLOG channels cannot keep up with, you have limited budget with which to purchase purpose made supplies, or have extremely limited space with which to travel and transport equipment. This list is not comprehensive and should not limit your imagination. It should, however, help organize your thoughts and jog your memory while on your shopping trip to Walmart or Maxima. Other outlets that have some of these supplies are agricultural stores and, of course, drug stores or apothecaries.
Once you do this locally, even just by taking pictures and comparing items with others. Try doing it while traveling or on deployment to a developing country where there is no Walmart.
Some of the testing and evaluation mentioned above, may have already been done with evidence published in peer reviewed resources. Check back issues of the Journal of Special Operations Medicine. Once you sign up for a membership, either directly with a digital subscription or though a membership with SOMA, you can download all past issues via PDF and search through them. Another resource that every austere clinician should check out is the book, “Improvised Medicine 2nd Edition,” by Kenneth Iserson. I cannot recommend this book enough. As a testament to its popularity, each time I have purchased a copy for a course, it gets reappropriated. The kindle edition is a little cheaper and can’t just walk away. We probably need an Amazon Smile account with all the book recommendations I’ve made but we don’t receive money from any purchases… yet.
The Role 1 Prolonged Casualty Care Guidelines for the entire DoD are now available here and on the Joint Trauma System website! This was a monumental undertaking from the beginning and required countless hours of research, writing, deliberations, and editing from subject matter experts, volunteering from each service and academia. The baseline for these guidelines were the previous clinical practice guidelines written by members of our legacy prolonged field care working group. Where those guidelines did not meet the requirements of one of the services, the members of this new Committee on Prolonged Casualty Care came together to ensure the verbiage met those unique needs while not taking away from the underlying principle. They ain’t perfect but fill a gap which has been hanging over our heads for years. They are version 1.0 with updates already being considered. In the future, concerned parties will be able to present evidence in the same change paper format used by the other official Defense Committees on Trauma such as CoTCCC and we can update it on the official JTS website quickly and efficiently. Aside from the work done by each of the listed authors an inordinate amount of work was done by MSG Mike Remley to edit and push them through the JTS process. It would have been another 6 months or more with him. COL Jamie Riesberg led this group from the beginning while juggling his day job which has almost nothing to do with the writing and editing of guidelines. He did this out of his never-satisfied sense of Service. They both certainly have my respect for embracing the challenge when I was much more skeptical. Another unsung hero stepped up in the final quarter was Dr. Dan Mosley. There is no question that all of us were spinning our wheels and hitting all the walls when he stepped up to do the hard, unenviable and tedious work, combing through each section and editing the minutia before handing it off to Mike and the JTS team for final approval and technical writing under COL Gurney and Col Shackleford.
Thank you to all involved in these guidelines and to those who paved the way from the beginning. Now back to work.
The PCC guidelines are a consolidated list of casualty-centric knowledge, skills, abilities, and best practices intended to serve as the DoD baseline clinical practice guidance (CPG) to direct casualty management over a prolonged period of time in austere, remote, or expeditionary settings, and/or during long-distance movements. These PCC guidelines build upon the DoD standard of care for non- medical and medical first responders as established by the Committee on Tactical Combat Casualty Care (CoTCCC), outlined in the Tactical Combat Casualty Care (TCCC) guidelines,1 and in accordance with (IAW) DoDI 1322.24. The guidelines were developed by the PCC Work Group (PCC WG). The PCC WG is chartered under the Defense Committee on Trauma (DCoT) to provide subject matter expertise supporting the Joint Trauma System (JTS) mission to improve trauma readiness and outcomes through evidence-driven performance improvement. The PCC WG is responsible for reviewing, assessing, and providing solutions forPCC-related shortfalls and requirements as outlined in DoD Instruction (DoDI) 1322.24, Medical Readiness Training, 16 Mar 2018, under the authority of the JTS as the DoD Center of Excellence pursuant to DoDI 6040.47, JTS, 05 Aug 2018. Operational and medical planning should seek to avoid categorizing PCC as a primary medical support capability or control factor during deliberate risk assessment; however, an effective medical plan always includes PCC as a contingency. Ideally, forward surgical and critical care should be provided as close to casualties as possible to optimize survivability. 2 DoD units must be prepared for medical capacity to be overwhelmed, or for medical evacuation to be delayed or compromised. When contingencies arise, commanders’ casualty response plans during PCC situations are likely to be complex and challenging. Therefore, PCC planning, training, equipping, and sustainment strategies must be completed prior to a PCC event. The following evidence-driven PCC guidelines are designed to establish a systematic framework to synchronize critical medical decisions points into an executable PCC strategy, regardless of the nature of injury or illness, to effectively manage a complex patient and to advise commanders of associated risks. The guidelines build upon the accepted TCCC categories framed in the novel MARC2 H3-PAWS-L treatment algorithm, (Massive Hemorrhage/MASCAL, Airway, Respirations, Circulation, Communications, Hypo/Hyperthermia and Head Injuries, Pain Control, Antibiotics, Wounds (including Nursing and Burns), Splinting, Logistics). The PCC guidelines prepare the Service Member for “what to consider next” after all TCCC interventions have been effectively performed and should only be trained after having mastering the principles and techniques of TCCC. The guidelines are a consolidated list of casualty-centric knowledge, skills, abilities, and best practices are the proposed standard of care for developing and sustaining DoD programs required to enhance confidence, interoperability, and common trust among all PCC-adept personal across the Joint force. The JTS CPGs are foundational to the PCC guidelines and will be referenced throughout this document in an effort to keep these guidelines concise. General information on the Joint Trauma System is available
on the JTS website (https://jts.amedd.army.mil) and links to all of the CPGs are also available by usingthe following link: https://jts.amedd.army.mil/index.cfm/PI_CPGs/cpgs. The TCCC guidelines are included in these guidelines as an attachment because they are foundational AND prerequisite to effective PCC.
Remember, the primary goal in PCC is to get out of PCC!!!
This article first appeared in the Jul-Sep 2019 Special Warfare Magazine which can be found open-source at soc.mil.
SURVIVABILITY
MEDICAL SUPPORT TO RESISTANCE
BY SERGEANT FIRST CLASS JAKE HICKMAN, U.S. ARMY; COLONEL JAY BAKER, U.S. ARMY; AND LIEUTENANT COLONEL ELIZABETH ERICKSON, U.S. AIR FORCE
Hope is a primary driver of resistance movements, and the best way to keep hope alive in a resistance movement is to keep people alive. There are many aspects to enhancing survivability of a resistance movement, and medical support is one critical part. Doctrinal military health service support constructs, such as combat support hospitals or forward surgical teams, will be wholly inadequate to support resistance movements in a peer conflict in Europe for the primary reasons that they are overmanned and under trained. This article will discuss a whole-of society approach to preparing military and civilian medical resources that will build readiness and resiliency of our allies or partners, improve casualty mortality rates and enable both resistance members and allied forces to sustain the fight to regain territorial sovereignty against an illegal occupation. Medical infrastructure is vastly different in peacetime Europe than in more austere areas frequented by U.S. Special Operations Forces. Medical evacuations begin with calling 112, the European 911 equivalent, ambulances arrive to provide pre-hospital care, sometimes with physicians onboard, the patient is transported to a trauma center, and medical care is generally comparable to U.S. standards. If peer conflict occurs again in Europe, medical infrastructure will be severely degraded and significant obstacles to medical support will immediately arise, especially regarding extremely prolonged evacuation times and scarce resource availability. The U.S. military has not faced as severe a challenge to provide medical support since World War II. The SOF medical community has been bracing for the regression of medical support in emerging conflicts since at least November 2017 when U.S Army COL (Ret.) Dr. Warner “Rocky” Farr published The Death of the Golden Hour and the Return of the Future Guerrilla Hospital; yet the existential threat facing Eastern Europe poses the worst case scenario for medical support to resistance. The restricted mobility for friendly forces in territory occupied by a peer adversary will severely limit external medical support to U.S. SOF and our allied partners, including the resistance. The isolation of U.S. and allied forces in a denied environment will by necessity convert the delivery of medical care from a linear progression of medical evacuations from point of injury to higher echelons of care outside the combat zone, to a cyclical progression of evacuation, treatment, convalescence and return to duty, all completely within occupied territory.
A resistance scenario in Europe presents a unique risk to U.S. SOF supporting resistance movements, as organic capabilities will not be able to provide required medical support in this tactical environment. Recent exercises have demonstrated that U.S. SOF surgical teams will be severely restrained and may not be survivable in a denied environment, and conventional medical forces will likewise be absent. U.S. SOF medics are highly capable within their scope of practice, but over-inflation of their ability results in commanders miscalculating risk; a medic’s ability to reduce serious risk is often predicated on access to definitive care. The Maquis in occupied France and Partisans of Yugoslavia faced similar challenges in World War II but were still able to provide medical support despite great odds. The relevance of these historical precedents might be limited, however, by exponential advances in technology over the last 75 years. Providing medical support to U.S. SOF and resistance forces will be immensely challenging, but there is one great advantage over historical precedence: there is time and space now to enable ourselves and our allies and partners to be prepared to provide medical support to resistance prior to conflict, instead of reacting after a violation of a country’s national sovereignty.
BACKGROUND
In early 2018, SOCEUR conducted a multinational SOF exercise focused on irregular warfare and resistance in the Baltic region of Eastern Europe. Key medical lessons learned from the exercise were that medical evacuation in restricted areas during peer conflict is incredibly challenging, and U.S. SOF surgical teams as currently configured and trained will have low, if any, chance of survival in occupied territory. It was evident that planning medical support solely using only a U.S. military doctrinal construct was impractical and ineffective; civilian medical resources were identified as, and will necessarily be, the center of gravity for medical support to resistance. Resistance doctrine was turned to as a possible solution to the way ahead, but existing doctrine was found to be largely inadequate for the range of potential operational environments in future conflicts against a peer adversary in Eastern Europe. The focus of U.S. resistance doctrine on unconventional warfare and resistance movements assumes that conflicts have already begun or are ongoing. Furthermore, reverse engineering resistance constructs prior to conflict is difficult because it is impossible to forecast who and what will survive the initial invasion. The whole-of-society approach advocated by the Resistance Operating Concept was embraced as a potential solution for addressing critical gaps in providing medical support to resistance.
WHOLE-OF-SOCIETY APPROACH TO MEDICAL SUPPORT FOR RESISTANCE
The SOCEUR Surgeon’s Office has developed a whole-of-society approach to enable medical support to resistance (Figure 01) as a tiered approach to improve trauma care from point of injury through surgical intervention, convalescence and return to duty. Additionally, it aims to increase medical interoperability with Allies and partners in preparation for a resistance scenario in Eastern Europe.
U.S. SOF MEDICINE
The core of this approach begins with increased readiness for U.S. SOF. If peer conflict in Eastern Europe occurs, U.S. SOF medics will be required to treat casualties on extended timelines with limited supplies. Proficiency in Prolonged Field Care improves the SOF medic’s ability to do this, but is dependent on the medic’s ability to transfer casualties to higher echelons of care for definitive treatment or required convalescence. SOF surgical teams may be part of the solution, but will require manning changes and additional training in order to improve survivability in peer-adversary occupied territory.
Previously, the SOCEUR Surgeon’s office developed and conducted a course in UW medicine for surgical teams. This training was conducted as a proof of concept in Fall 2017, and was subsequently turned over to U.S. Army Special Operations Command with a request to further develop UW training for SOF surgical teams. Currently, the SOCEUR Surgeon’s office is continuing to develop Trojan Footprint as an opportunity for U.S. SOF medical units to practice UW medical tactics and techniques in a major exercise. The command is developing training opportunities for U.S. SOF medics and surgical teams to work in partner-nation trauma centers in Eastern Europe. This aims to achieve multiple objectives including enhanced interoperability of U.S. medical personnel and potential partners, information sharing regarding medical materiel and techniques and potentially to raise standards of trauma care as best practices are shared between allies and partners. The strong relationships that would be created by this course of action would be mutually beneficial. These types of training opportunities may be expanded beyond U.S. SOF to other U.S. military medical personnel, further increasing interoperability and alliance building. SOCEUR is also assisting USSOCOM to define the Special Operations Forces Baseline Interoperability Standards for medics and surgical teams. These efforts attempt to link SOF medical requirements to National Defense Strategy priorities in order to develop the force for the future, and not simply to fight the last battle. Finally, current U.S. SOF doctrine on medical support to resistance appears to have gaps in Eastern Europe’s potential operational environment, especially with regard to preparing Allies and partners to conduct resistance prior to conflict. Working with USASOC’s medical teams will help develop future iterations of doctrine in order to prepare U.S. SOF for best success in an extremely challenging environment.
PARTNER MILITARY HEALTH SERVICE SUPPORT
A key focus area for the SOCEUR Surgeon’s office is supportive relationships with European partners. Effective relationships with partner SOF medical leaders builds shared vision and enables work toward common goals. The majority of partners’ SOF medical personnel are intertwined with their conventional military Health Service Support, similar to U.S. military medicine, and efforts with conventional HSS are required in addition to work with SOF medical leaders. Investments in relationships now with partner nations’ medical capabilities will pay dividends in a peer conflict and resistance scenario, even though partner’s military HSS will likely be diminished. Partner SOF medics, military medical personnel, and home guard units will serve as medical cadre in local resistance movements and save lives through application of their medical skills and knowledge. Special Operations Forces Institution Building is a primary line of effort that aims to improve interoperability. The near term plan is to promote Tactical Combat Casualty Care (as the base standard for all allied SOF medics and enable partners to conduct internal training without external support. An additional goal of this initiative is to assist North Atlantic Treaty Organization Special Operations Headquarters to develop doctrine for NATO and partner SOF medics and SOF surgical teams. This aims to make allied medical enablers similar, with improved interoperability. The SOCEUR Surgeon’s office is currently working with partners to develop a medical annex for the ROC to serve as a guide for medical support to resistance in Europe. The emerging medical annex is focused on key components of medical resistance networks, treatment and triage considerations and planning medical stay-behind capabilities. Major exercises like Trojan Footprint are opportunities to test the viability of potential medical resistance networks and competencies in a controlled setting, while identifying areas for improvement. SOCEUR aims to increase involvement of key European SOF medical enablers in order to further improve combined medical preparedness as an interoperable allied force.
CIVILIAN MEDICAL CAPABILITIES
Civilian personnel are anticipated to provide the majority of medical support to resistance, as most military medical capabilities are likely to be exhausted during an invasion. While there is no doubt our Eastern European allies have robust, capable trauma systems, a significant gap in our collective medical preparedness for resistance, however, is understanding the available civilian medical capabilities. Investing time and resources to better understand and cooperatively increase the trauma capabilities of civilian medical institutions will enhance our collective ability to provide medical support in a resistance scenario. Creating a medical common operating picture will identify where gaps exist and inform planning priorities for greater resilience in trauma care now, as well as prepare for medical support to resistance. First responders are the critical bridge from POI to higher levels of care. Sharing lessons learned from decades of combat with partner civilian first responder systems will improve initial survivability of resistance members and enable better chances of successful evacuation to higher levels of care. U.S. Allies in Eastern Europe are already preparing themselves. In Lithuania, for example, new regulations were recently passed to enhance the scope of paramedics in the event of disaster. The new training for these paramedics closely mirrors TCCC guidelines, which have saved many lives from combat trauma. In most resistance operations, bystanders will be the first on scene, just as they are in everyday life. Treatment of combat casualties at the POI by first responders improves the likelihood of survival until casualties can be treated by qualified medical personnel. Because it is impossible to predict who will be first on the scene in a resistance scenario, the potential target for training on POI care might be as large as a country’s entire population. There are precedents for whole-of-society programs for POI care in recent years due to terrorist acts against innocent civilians. In 2015, the U.S. Department of Homeland Security launched the STOP the Bleed campaign in order to cultivate a grass roots efforts to train, equip and empower bystanders to help in a bleeding emergency before professional help arrives. In the United Kingdom, London Ambulance provides life-saving first responder training to taxi drivers. Conducting large scale campaigns like these in Eastern Europe would undoubtedly save lives in future resistance scenarios. Finally, trauma systems and medical facilities are critical for definitive treatment of trauma casualties. Trauma center subject-matter expert exchanges would facilitate sharing of best practices and development of strong relationships. These relationships could be at a medical center or university level. Enduring institutional relationships would enable medical interoperability and could be expected to advance the efficiency and effectiveness of trauma systems bilaterally and multilaterally. A whole-of-society approach to enhancing trauma system capabilities is beneficial not only for resistance scenarios, but also to increase preparedness for, and improve response to, a host of contingencies. Trauma systems nest within broader emergency response systems, which must be prepared for natural disasters such as earthquakes, fires or floods, man-made disasters such as industrial accidents or chemical releases, disease outbreaks or terrorist attacks. Well-prepared, effective emergency response systems increase national resilience to adverse events and build hope.
PARTNERING WITH EUCOM
Observations from recent theater level exercises by the EUCOM Surgeon’s office closely parallel the SOCEUR Surgeon’s office’s lessons learned from focused exercises: modern conflict modeling and casualty estimates reveal that military medical resources may be rapidly depleted, such that civilian medical infrastructure, when present, will be critical for medical support to Allied operational forces in various Eastern European conflict scenarios. The EUCOM Surgeon and staff, along with Service Component Surgeons’ staffs, have begun efforts to address the identified need for a whole-of-society approach to preparing for the potential medical scenarios associated with contingencies in Europe. EUCOM is working with the Defense Health Agency’s Joint Trauma System to establish a Combatant Command Trauma System, which aims to set a common baseline across U.S. geographic combatant commands for standards of trauma training and components of trauma systems. This effort ensures that U.S. military HSS capabilities are optimally poised to be ready for response to contingencies, providing the best possible care from POI through surgical care. It also acknowledges the need to better integrate partner nation systems into a theater-wide trauma system. EUCOM has begun to develop a MEDCOP that will provide EUCOM and Component Commanders, Surgeons, and medical planners with increased awareness of military and civilian medical, and specifically trauma resources in Europe. Ideally, this MEDCOP will be developed corroboratively with partner nations, and shared for common operational benefit. EUCOM’s Global Health Engagement activities with Allied and partner nations over the last several years have focused primarily on military-to military activities that aim to support partner nations’ achievement of NATO standards for expeditionary medical capabilities. These have included cooperative training on TCCC and other trauma care standards, as noted above. Recognizing the importance of civilian medical capabilities in a variety of operational scenarios, EUCOM is updating its GHE strategy to increase U.S. engagement with partner nation civilian health systems, medical centers and personnel. This, of course, must be approached with a great deal of coordination: with U.S. Embassy country teams for synchronization with other U.S. government health efforts; with partner-nation military and civilian health leaders; and with multilateral organizations, such as NATO, as appropriate. One approach to enhancing understanding of partner nation trauma systems and developing institutional relationships is to capitalize on the State Partnership Program. This program, executed via the National Guard Bureau, pairs U.S. states with partner nations. There are 22 such partnerships in the EUCOM area of responsibility. Military-to-military activities, such as training and exercises, often lead to military-to-civilian and civilian to-civilian interactions with enduring personal and institutional relationships. CONCLUSION Medical support to U.S. SOF and partner resistance forces will be extremely challenged in the European theater in a resistance scenario. Specifically, medical evacuation will be severely restricted and U.S. SOF surgical teams, as currently designed, will have low survivability. The SOCEUR Surgeon’s office is targeting a whole-of society effort to enable medical support to resistance across multiple spheres of influence, including U.S. SOF medical forces, partner- nation military HSS and partner-nation civilian medical institutions. A whole-of-society approach is critical for uniting efforts of U.S. medical equities now in steady state operations, which will improve capabilities and increase options for medical support of U.S., allied and partner forces in the event of peer conflict in Eastern Europe. EUCOM recognizes the value of this approach and is developing a strategy toward end states of enhanced military and civilian trauma capabilities, and increased interoperability between civilian and military capabilities, both within and between nations. Embarking now on these collective steps will save lives and, should the worst case happen, enable better trauma care at every level, which will help keep hope alive.
SW ABOUT THE AUTHORS
Sgt. 1st Class Jake Hickman, U.S. Army, is a SOCEUR Medical Operations Sergeant.
Col. Jay Baker, U.S. Army, is the SOCEUR Command Surgeon.
Lt. Col. Elizabeth Erickson, U.S. Air Force is the EUCOM Chief of Global Health Engagement.
Acknowledgments: We extend a special thanks for review and comments to Col. (Ret.) Dr. Warner “Rocky” Farr, Col. (Ret.) Sean Keenan, Maj. Michael Weisman and Maj. Adrien Adams.
The RAVINES Mnemonic was created to help the medical provider on the ground in an austere environment with a very sick patient. Most medics will do a decent TCCC SMARCH survey and when they get to the end of that, get vital signs to begin trending and repeat the MARCH sequence while adding E-PAWS-B…
E for Eyes
P for Pain
A for Antibiotics
W for Wounds
S for Splinting
B for Burns round out the MARCH-E-PAWS-B mnemonic.
Doug and Dennis talk austere management of COVID19 patients with an emphasis on strategies for oxygenation and ventilatory support. The remainder of the post is an massive amalgamation of resources I have been collecting for over a year for my own respiratory refresher. Its alot to take in but if you are looking for something related to airway, oxygenation or ventilation, scroll down and you should have some great rabbit holes to dive down. Continue reading Podcast Episode 63: Oxygenation, Ventilation and COVID19→
Dennis and Paul talk with Dr. Ian Wedmore and discuss some interesting updates to the management of frostbite injury in the field and what to do when you get back to a hard stand shelter.
Why does it take the NY Times to identify and disseminate our medical lessons learned?!
How was this not immediately circulated to all medics internally the way parachute failure incidents and military vehicle accidents are?!
Why is there not an immediate safety stand down and retraining required?!
Don’t let Dunning-Kruger fool you. Any one of us could have been the initial medic, the receiving PJ or even the patient. Incidents like this can even occur here at hole in the firat world. Have you ever watched the Elain Bromily case?
Imagine if there were a proper incident report posted in every Command hallway, everytime there were a poor outcome experienced across the enterprise?
How much easier would it be to justify training and equipment needs with the penny pinchers, bean counters and check writers who were acutely aware of the actual risk to force?
If the article is accurate, this was a catastrophe for everyone involved. The lives of the patient, the family, the team and the medics are irreversibly altered.
Our last podcast was about High Reliability Organizations. A key hallmark of an High Reliability Organization involved in life and death operations is a preoccupation with failure. We cannot continue to bury our collective failures and must focus on identifying and fixing them all from an organizational level.
Here is a sample plan of action for organizational remedial training that I would do if I were a Senior Leader with medical personnel in my unit.
I personally challenge you to actually complete the following action items this week. If we do not learn from our collective failure we will repeat it until we do.
There should be immediate notification, reeducation and retraining for everyone followed by an improved initial and sustainment training plan. Battalion Surgeons, PAs Instructors and Senior Medics should ensure every single medic does the following:
Recieve(or Demand) the incident report and AAR from the Chain of Command the way other Saftey Stand Down incident reports are disseminated. -Post it for the entire unit to read next to the parachute failure incident.
As a small group, read and review the report and AAR.
Reread the guidelines and watch the videos freely available on the DeployedMedicine App
-Be sure to discuss shortfalls and inaccuracies of your trainer.-Dont just focus on the single skill, discuss other options that could have led to a better outcome:
-‘Could different patient positioning have helped the situation?’
-‘How could the outcome have been different with various pharmacological adjuncts?’
-‘One of the things I have seen in small group training was to inject a hematoma just over the cricothyroid membrane. This makes it super messy and hard to identify landmarks which is usually a slam dunk training scar.’
-Ask Medics how well their non-Medics are trained to take care of them if it were them on that table?
Submit a WRITTEN request through multiple channels for proper equipment citing the article, incident report and TCCC guidelines as justification to your MEDLOG, S4, XO and anyone else who can affect the situation.
-Imagine if 10,000 requests were simultaneously submitted for similar equipment…
Identify training deficiencies in your immediate organization and actually make a WRITTEN request to your Command for additional remedial training to be included in future non-medical training.
-Attach the article to the request.
Identify equipment deficiencies and again, submit a WRITTEN request through multiple channels for proper equipment citing the article, incident report and TCCC guidelines as justification to your MEDLOG, S4, XO and anyone else who can affect the situation.
-Do you have Super Glottic Airways in every aidbag and IFAK? An Emma Capnograph would have helped identify the false passage instantly.
These are just a few things an HRO can EASILY and IMMEDIATELY accomplish. What else can you do to ensure this death of our brother is not in vain?
The principles of High Reliability Organizations are necessary in those professions where mistakes can cost lives. The airline industry is the classic example and referenced many times in the articles below. Others included are those that could result in massive loss of life such as power plants, refineries, and many industrial chemical plants. Ideally, health care organizions including operational medical programs should also fall in this category. We have a long way to go but the more of us who underatand the principles of HROs, the closer we can get to truly defining our profession in this way.
Principle #1: Preoccupation with Failure
Principle #2: Reluctance to Simplify
Principle #3: Sensitivity to Operations
Principle #4: Commitment to Resilience
Principle #5: Deference to Expertise
Listen to the podcast and read more in the resources below to really understand what this all means…
While no single clinic setup will work for every situation, a common baseline and checklist can make it far easier in customizing a clinic in similar circumstances. This is not professed to be THE way but it is A way in which ONE experienced team has created, tested, revised and rehearsed a clinic with different casualties. Their pictures and diagrams are provided in the hopes that this audience will help refine and finalize a common baseline which any medic can use in he future. Please leave comments on your thoughts.
What happens when your patient has been given a cric or intubated but continues to decline… SpO2 continues to slowly drop despite taking control of the airway. You have placed your patient on a ventilator and slowly adjusted the PEEP up to 20cmH20… which quickly leads to hypotension. Do you go lower? Higher? Change volume or rate? You are out of bottled O2 and your oxygen concentrator does not seem to have much effect. The SpO2 continues dropping. Telemedicine is not available. You try positioning the patient by sitting them up. You try a couple other recruitment maneuvers you heard about.
After a few discussions with JJ who has also appeared in several Element Rescue podcasts, Doug and Dennis talk about using evidence based medicine whenever possible and what to do when no prospective randomized controlled trials exist
Not all PFC is trauma. Malaria, Dengue, Chikungunya and others will take you out of the fight if given the chance. In this episode CAPT Ryan Maves talks about some of the more concerning and prevalent diseases encountered by deployed military personnel and partner forces and what you can do about it before an infection becomes debilitating or life threatening. Continue reading Podcast Episode 51: Tropical Medicine Considerations with CAPT Ryan Maves→
Why do we care about sepsis in prolonged field care? What can we do about septic shock with what we are normally carrying on a deployment? How do you mix an epinephrine drip? Dr. Maves lays it all out in about 20 minutes.
When you can’t take cold stored whole blood with you and not all of your soldiers are titered, a walking blood bank can mean the difference between life and death for a patient in hemorrhagic shock. With the mounting evidence suggesting early blood is essential and not just a good idea, you need to have a plan in order to hit the 30 minute target. Continue reading Podcast Episode 49: Set Up a Walking Blood Bank with Andy Fisher→
Hospital rotations for medical proficiency training give medics who operate in the field the opportunity to see what “right” looks like. Knowing this and understanding treatment principles can allow a flexible medic to adapt to unique situations in the absence of protocols, guidelines and evidence. If properly coordinated and supported, MPTs can be an invaluable and eye opening experience. When thrown together with a naive or indifferent staff or unmotivated medic, it can be a huge waste of time and money for everyone involved. Continue reading Podcast Episode 48: Maximizing Hospital Rotations and Medical Proficiency Training→
So what is different than what we already have in the THOR recommendations, the JTS DCR clinical Practice Guideline and the Ranger Regiment TDCR? No hextend?! Calcium with the 1st unit of blood?! TXA slow push?! What if the patient is not responding to resuscitation efforts? This is a guideline truly written for the Medic working despite lack of help or resources in an austere environment…
Many efforts in the pre-hospital combat environment had been aimed at prolonging the viability of a patient until they are able to make it to a surgeon. The goal of military triage and evacuation is to have urgent surgical patients to a waiting surgical team within 2 hours. Despite our best efforts, this is not always possible. When it is not possible, Continue reading Podcast Episode 46: Bleeding in the Box: Non-Compressible Torso Hemorrhage with Dr. Mark Shapiro→
The Battle of Bentonville was fought 154 years ago just a short distance from Fort Bragg, NC. Each year the North Carolina Historic Site Staff and reenactors commemorate the battle with different types of reenactments. This year the focus is on Civil War Medicine and the originally preserved Union XIV Corps Field Hospital at the Harper house. This Event was called, “A Fighting Chance For Life.” It is important for us to look deep into the past and hold close the lessons learned which now benefit all mankind. Continue reading Video Recap of a Civil War Field Hospital Reenactment and PFC Display at Bentonville Battlefield in NC→
When properly and safely administered regional anesthesia can augment your limited supply of narcotics and ketamine in resource poor environments. It can also preserve your patient’s mental status while providing targeted pain relief. This can be accomplished using a nerve stimulator and the techniques found in the Military Advanced Regional Anesthesia and Analgesia Handbook as taught in the Special Forces Medical Sergeant course. If you have a portable ultrasound machine and a little practice you can also use the safe techniques found in the videos made available in by the New York School of Regional Anesthesia at NYSORA.com.
It has been our experience that high quality prolonged field care training takes time, resources and expertise by dedicated trainers well versed and experienced in critical care concepts. That being said we also believe that there are fundamental principles which can help
This project is an opportunity to collaborate and will attempt to use the wider working group audience to identify a standard list of drugs every Independant Duty Medic or Corpsman should have with him on every austere deployment. If put into practice properly across the force and coordinated with MEDLOGs, this will be one less chore for a medic and another place where we can help reduce mistakes and oversight. The following
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.
In this episode Dennis talks to PFC Wound Care CPG author Justin along with Surgery Instructors Jon and Rick about their experiences with austere wound care.
The essence of prolonged field care is now infused into many aspects of the austere and military medical lexicon. The response by the medical community to come together to help solve problems faced by medics and the warfighters they accompany has been nothing short of amazing.
After extensive cooperation and collaboration with operational medics and Docs at home and abroad, we continue to see that there is a clear desire to improve patient care by incorporating or improving
Powdered High Strength Calcium Hypochlorite (Ca(ClO)₂) is essential for a medic to keep in the team house or aid station in an austere environment. It can easily be bought, transported and reconstituted for many purposes…
Which burn fluid resuscitation formula is best? Does it really matter?
What can happen if you over resuscitate? Under?
What can cause an increase or decrease in the demand of fluids?
What can you do if you are running out of Lactated Ringers?
As a Lt. Cmmdr. with the U.S. Navy, Dr. Cairns was on duty and a principle responder to the KAL flight that crashed in 1997 in Guam. Dr. Cairns was instrumental in developing the level of preparedness at the Naval Hospital there which received and managed dozens of critical patients in the morning following the crash of the 747.
Telemedicine is a crucial capability that must be planned and practiced. The base of knowledge that a SOF medic’s knowledge encompasses includes many areas of medicine but generally lacks
Rick Hines has spent the last 20+ years in service to his country much of it deployed to combat zones and other unstable, austere environments and is dedicated to improving SOF Medicine. He made it a point to spend a fair amount of time with surgical teams when possible and has gained quite a bit of real world knowledge that we hope to pass on to a wider audience here. Continue reading Podcast Episode 33: TIVA: Another Look at Pre-Hospital Analgesia and Sedation→
When do you give a burn patient antibiotics? Which ones?
How do you calculate TBSA and the rule of 10s?
What do you use to guide fluid resuscitation? What fluid?
When is an escharotomy in the field appropriate?
Burns present another wound pattern that can be extremely difficult and time consuming for any level of provider to manage. So much so that there are dedicated burn teams that will often fly to where burn patients are being held in order to get them back to the burn center in San Antonio with the best chance of survival. We have taken the expert guidance of these critical care providers and packaged everything they Continue reading Podcast 32: Doug Explains the JTS Burn Care Clinical Practice Guideline For Medics→
In this live recording, guest lecturer COL Missy Givens shares the CBRNe knowledge she has learned while working as a clinical toxicologist, among many other positions, around the world including as the SOCAFRICA Command Surgeon where she personally helped prepare members of 10th SFG(A) to deal with some of the most venomous snakes in the world. Continue reading Podcast Episode 31: CBRN for Dummies By COL Missy Givens→
Colonel Warner “Rocky” Farr has made an important contribution to the body of SOF knowledge with this well-researched monograph. He advances the understanding of the many challenges and accomplishments related to guerrilla warfare medicine—care provided by predominantly indigenous medical personnel under austere conditions with limited evacuation capability— by providing a survey of the historical record in UW literature. Colonel Farr relates many historical experiences in the field, assesses their effectiveness, and lays a foundation for further in-depth study of the subject. The Joint Special Operations University is pleased to offer this monograph as a means of providing those scholars and operators, as well as policymakers and military leaders, a greater understanding of the complex and complicated field of guerrilla warfare medicine.
Here is a great video on PFC and the cases we helped collect from Air Force MAJ Eric DeSoucy, DO doing a Grand Rounds talk for the Department of Surgery at UC Davis.
Here is the study he referenced in the video which he also happened to head up for our working group and the Joint Trauma System.
You are in your Team House or BAS. You have given FDP, Whole blood, TXA calcium and don’t have much left despite the few units from the walking blood bank. Your patient continues to bleed internally. Nothing in the chest or upper abdomen. Probably pelvic. Damn. MEDEVAC is en route. They will have some blood too. You just need your patient to hold on for another hour before he gets to surgery… Continue reading Podcast Episode 30: REBOA?! with Joe DuBose→
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.
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.
