Category Archives: Principles

PFC and The Surgical Team Deficit

The vast majority of SOF deployments occur outside combat zones where the SOF Medic is expected to care for the entire team without a credentialed provider.  

Faced with a low level of risk, SOF Commanders opt to accept it.

The team also willingly accepts it due to the confidence that they have in the Medic.

Medics and Corpsmen bear the burden of the risk assumed by the Commander.

There is no Doc. 

No PA. 

No dentist or Vet. 

No surgical team or MEDEVAC standing by.  

What can be done? Hint… It’s training

In 2019 a US News investigation into the readiness of the military trauma system concluded with a series of articles to support what we already “knew” and were moving to address with the development of PFC Clinical Practice Guidelines, training events and tailoring hospital rotations.

A Crack in the Armor: Military Health System Isn’t Ready for Battlefield Injuries

Surgical readiness in the Military Health Service is fraying fast. A nine-month U.S. News investigation has uncovered mounting evidence that military medical leaders are squandering a valuable wartime asset: the surgeons and surgical teams that save lives on the battlefield and back home. The investigation is the latest chapter in a continuing U.S.

One of the PFC Truths is that If you think you need a surgical team or intensivist, you should bring one. If there already aren’t enough to go around to higher risk deployments, bringing one to the lower risk trips may not even be an option. Guys still get hurt on these trips.

Military Surgery in the Spotlight

SAN FRANCISCO – It took two surgeons 92 sponges and two towels to stop the soldier’s abdominal bleeding. To the surgeons’ horror, an otherwise routine exploratory surgery on a trauma patient had become life-threatening, within minutes. Retired Air Force Col.

“No one minds deploying, but it is too often, and since there’s usually not much to do [surgically], I know we lose our skills,” says an active-duty military surgeon.

Even the former Trauma Consultant to the former Army Surgeon General weighed in with a 13-page opinion on the topic summarized in the series:

“The Forgotten Surgeon Warriors.”

Top Army Surgeon Blasts Military’s Capability to Handle War Traumas

The Army’s top trauma surgeon has issued a powerful critique of military surgery, asserting that Army medicine is not “manned, trained or equipped” for the flood of complex battlefield casualties that would occur in even a limited war. “The failure of military medical leaders to acknowledge the critical requirement for trauma surgeons …

Once the surgeons openly (somewhat) established that bringing a whole surgical team, even a small one, to every deployment is just not a plausible solution, many attempts were made to increase the scope of practice of the enlisted clinician. This was a second order effect of the campaign to improve battlefield surgery along with the growing realization of this lack of support. 

What can be done? The first thing that should be implemented more widely is honesty. We need to be honest with ourselves first.  What are our capabilities and limitations relative to our training and experience overlaid onto caring for the complex casualties that we may expect to see? Once we come to terms with that, we need to accurately convey these limitations to Commanders who are charged with assuming the risk.  There should be a frank conversation about doctrinal evacuation timelines and policy compared to the pathophysiology with some of the more dangerous possibilities such as blunt trauma from a vehicle rollover, falls, envenomations, training accidents and other DNBI. “The stuff that keeps Medics up at night.” As stated by JB early on.

If the mission is to include higher risk activity, then a surgical team should rightly be requested.  At the end of the day though, as noted above, there may just not be enough to go around. If given the choice, we would probably all take a small surgical team with us so that we could focus on other aspects of the mission.  This is where honesty comes in again.  Just like the early days of the GWOT when every casualty was “Urgent Surgical” and over triage caused some misallocation of resources, an honest and critical assessment will bear out the actual risks and probability. That still leaves some risk to force that the Commander may assume.  That is the reason that additional training experience is crucial. That is why we are so adamant on being great at the basics but also going a little beyond.  No one is coming, not in time anyway. It is our job to recognize a bad situation early, use telemedicine when possible and temporize to the best of our ability, not to be a one man surgical team. This is instilled through rigorous and realistic training.

Training and Utilization.

Not Stuff.

Haven’t we always done PFC?

No.

Medics and Corpsmen have not always done Prolonged Field Care or Prolonged Casualty Care.

While it is true that combat medical providers have always taken care of patients for longer than anticipated, we did not have a set of dedicated principles on which to fall back and guidelines to follow. Since the dawn of battlefield medicine, Medics have always had to contend with the contingency of caring for patients for longer than they should be due to the negligence of commanders and planners or overwhelming enemy action. History is littered with accounts of litter bearers, Corpsmen and Medics caring for patients for extended periods of time trapped in shell holes, beach heads, ships, and urban settings such as Mogadishu. There are even detailed case reports and data from the modern GWOT when evacuation timelines were not adhered to despite mandates to the contrary.

If not using the MARCH algorithm for battlefield care, is it still considered TCCC? If you purposely disregard the CoTCCC guidelines, are you still doing TCCC? We may be stuck in a PFC situation but not be doing PFC just like it is possible to do medicine in combat without doing TCCC.

Just like Medics have only had the unique algorithms of TCCC for a few short decades, the modern principles of prolonged care aren’t even 10 years old and still being perfected for unique environments and patient challenges. PFC was a term coined by NATO in 2013/14 as the working group was first forming. Prior to that there were many terms such as extended care or simply austere care. Once agreeing on this term, our working group rapidly developed principles help organize allllll of the complex information being thrown at or hiding from a medic to help them figure out what is going on with a complicated illness or injury. It gives us a simple way to prioritize the immense amount of work required.

Some may consider the little bit of nursing care that they did as prolonged casualty care. While performing prolonged casualty care will likely involve some nursing care it also goes beyond that and involves forming differential diagnoses, creating problem lists and treatment plans, incorporating telemedicine, tailoring extended analgesia and sedation strategies just to start. Having a palliative care strategy is also an unfortunate part of failing to meet evacuation requirements. Simply moving an expectant patient around a corner is not a realistic strategy for managing a dignified death. Mastering these low-tech, analog principles requires reps on realistic (and real) patients and training scenarios in accurately austere environments. For more info on the principles, search this website or check out page 7 of the newest PCC clinical practice guidelines on the Joint Trauma System Website.