Let’s jump right in. No one wants to be in a prolonged care situation. It is a contingency like a MASCAL. Maybe even a subset of a MASCAL: Being overwhelmed with the complexity and severity of a single, critically ill or injured patient vs being overwhelmed by many patients. As discussed in yesterday’s post, Commanders assume the risk to force for this contingency. They do this more readily for SOF Medics than for conventional units. PFC was initially created to shore up some of the deficiencies that remained in the training and experience provided to SOF Medics and Corpsmen even after 9+ months of training and hospital rotations. Some of the PFC JTS guidelines and our other recommendations reflect this in the acknowledgment of the increased scope of practice and increased frequency in which SOF Medics are placed in these situations where evacuation timelines are extended beyond doctrine and policy.

The conventional military medical system, starting with the ground medic, is designed to treat and evac quicker and adhere to the doctrinal timeline. Yes. Commanders can still assume risk and push an element past this butikekly and rightfully so, with greater career and political consequences. As a prior 68w, I did this multiple times as a scout or infantry medic while deployed. Commanders were aware and informed. We mitigated risk as much as possible and kept the exposure to a minimum with several mitigation strategies.

Once the conventional Army planners and senior medical leaders contemplated potential contingencies and future conflict models and saw what we were doing they wanted in. Aside from some of the advanced skills, the scope of practice provided at Fort Sam covered the minimum category of the 10 essential PFC capabilities. Max Dodge wrote a great article on the topic in the Next Generation Combat Medic Blog:

https://nextgencombatmedic.com/2017/06/15/prolonged-field-care-for-the-combat-medic/

We did the same in 2016 based on training being done by the 82nd for 68Ws in 1st Brigade.

https://prolongedfieldcare.org/2016/07/09/prolonged-field-care-classes-for-68ws/

From this, the Prolonged Casualty Care working group was formed along with a parallel effort to create a Prolonged Field Care curriculum per DoDi 1322.24.

The Navy, realizing their vulnerabilities, also wanted in but felt that their sailors did not work in the field so we dropped “field” and replaced it with “casualty” to be more inclusive. You’re welcome Navy. The Navy does have different constraints and so some recommendations were shifted and included things like ventilators and other meds that fit easily on a ship with “endless” power that would be more prohibitive in a field setting. NATO and SOF still utilize the term PFC, for now.

The PCC working group is composed of members from all services and kept the tiered paradigm utilized by CoTCCC and the TCCC guidelines. Members from the original SOF working group and CoTCCC are represented to coordinate the recommendations as much as possible. As described by HR Montgomery at SOMSA last year, the PCC working group will likely get folded under the CoTCCC. We will remain here and n SOF to act as a hub for innovation and share lessons learned and emerging TTPs where they can then be better refined and studied for possible inclusion into official recommendations.

Some erroneously believe that PCC can somehow replace TCCC. That is ridiculous in that PCC/PFC are both built on the foundations of TCCC. Training should reflect this. Until mastery of TCCC, no one should be training PCC. That does not mean that no one should ever train on PCC though. Like training for a MASCAL response for a large number of patients, PCC training can help organize the chaos of a single complex patient until they can be evacuated to an appropriate facility and role of care.

The problem with PCC is that the breadth and depth are so wide and deep, training for PCC takes more time. Blunt trauma, burns, crush, TBI, tropical disease, envenomations, electrocutions, environmental injuries… The list goes on. Hitting the basics of each takes more than an afternoon like ironing out and rehearing a MASCAL response would. If time is very limited and TCCC is proficient, training should focus on the principles of PCC and ensure that references are readily available. Training can and should continue while deployed. Some of the best PFC podcasts that were never recorded were conversations had while deployed.

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.  

Listen Here

Prolonged Fieldcare Podcast 101: Ground truth in Ukraine by Prolonged Fieldcare Podcast

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.

Deployed Medicine

Deployed Medicine is part of a ongoing research and development activity sponsored by the Defense Health Agency in partnership with the Joint Trauma System and Committee on Tactical Combat Casualty Care. Copyright © 2017 – Deployed Medicine – All Rights Reserved.

SCCM | SCCM Ukraine Response

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.

Let’s start out with a scenario…

During a training mission to an extremely austere environment, one if your highly trained partner force Commandos takes a penetrating wound to the chest due to a negligent discharge by one of the new guys they are integrating into the longstanding unit. After initial treatment and getting him back to your team house for a secondary assessment, you determine that the patient has developed difficulty breathing, decreased breathing sounds and hyporesonance to the injured side. 

 You glove up and insert a chest tube. Upon entrance into the pleural space, you get a gush of hemothorax blood. As it flows out onto the ground, you are able to clamp the tube. Though breathing has improved, our patient begins to show signs of compensated hemorrhagic shock. You administer TXA and start actively warming your patient. You are far from any medical support, so you do not have any cold stored blood, but you do have your walking blood bank (WBB). Due to the limited supply of lyophilized plasma being prioritized to CENTCOM, you have no FDP. 

We’ll be optimistic and assume 4-5 people on your team are O low titer donors. You have 4-5 units of blood (1800-2250ml) that will take a little while to be drawn and transfused. Your evac time to his country’s nearest surgical facility is over 12 hours away by ground and you want to prepare for this long transport by ground convoy.  You could possibly go back to your own pre-screened teammates for a second unit of blood (Total: 3600-4500mls), and they would happily volunteer it, but you may be burning through these units and watching them come right out of your chest tube minutes later. You can also get some blood from your partner force squad(it’s “their guy” right?), but that will take significant effort and coordination, unless you have conducted thorough screening and rehearsals previously. There is always the risk of transmissible diseases without properly screening donors.

The process is discussed, but is deemed too labor intensive with the effort and time currently required.  We can also administer other substandard fluids or attempt hypotensive resuscitation and hope for a clot to form, but without the ability to ligate, shunt, or otherwise control hemorrhage in the thorax, we’re just praying at that point. A massive hemothorax can easily cost the patient 1500ml of blood initially and 200-250 ml per hour after that. For 18 hours, assuming a miracle clot does not form to save you, that is upwards of 5-6 liters. That is more than the average human total blood volume, and can easily eat through your entire walking blood bank and then some.

So, what can we do, except to try to fill a leaking bucket faster than it can empty? We can’t stop the bleed definitively. The bucket will keep leaking. We do not have a definitive solution in the austere or prolonged field care setting, but we may have something worth looking into if we are unwilling to concede our teammate’s life as expectant.

Reading the Joint Trauma System Clinical Practice Guideline (JTS CPG) on Wartime Thoracic Injury, you’ll find a small note in the middle of page 9. “Autotransfusion of shed pleural blood using a chest tube collection system and autotransfusion accessory can be considered”. It’s right at the end of the Hemothorax section and is a “blink and you’ll miss it” kind of note.

Autologous transfusion or autotransfusion is a technique in which a patient’s shed blood is collected and transfused back into the patient. The pleural space is an exceptionally clean compartment and can theoretically contain clean FWB that can be collected through a chest tube, and then transfused back into the patient. The risks of transfusion related issues are also lowered, as this is the patient’s own blood, not someone else’s. This is not a novel procedure. The first successful autotransfusion on record was conducted in 1818 by James Blundell on a patient suffering from postpartum hemorrhage. Through the end of the 1800s and into the early 1900s, surgeons utilized this technique with surprising success. Blood typing and banking improvements in the 30s and 40s made autotransfusion less popular, but advances in the washing process of blood in the late 60s brought about a resurgence. Since then, autotransfusion has been generally limited to the operating room to wash and return the patient’s blood lost during operations and to the austere setting where blood products are not readily available. The relative abundance of lab-tested blood products have undercut the interest in Western medicine for exploring autotransfusion further, but researchers have been looking into its possible role in the future of medicine.

One multi-institutional retrospective study₁ looked at 272 patients (136 receiving autotransfusion, and 136 receiving traditional allogeneic transfusions) and found that “the autologous transfusion of patient’s shed blood collected through chest tubes for hemothorax was found to be safe without complications”. Furthermore, this study found no adverse effects to 24hr post admission INR and patients required fewer allogeneic RBC and platelet transfusions. When you consider the broad support in our community for prehospital administration of blood products, autotransfusion seems to be a procedure worth looking into (at least based on this particular study).

So, why aren’t we doing this already? Several reasons; spent blood, through hemothorax, has a bit of a coagulopathy problem. When bleeding starts in the thorax, the clotting cascade is activated as the body tries to form a clot. The spent blood’s supply of clotting factors gets expended relatively quickly. It has been shown to have decreased fibrinogen, hematocrit and platelet content, as well as elevated fibrin degradation products (FDP). One study₂ found that hemothorax blood has longer activated partial thromboplastin times (aPTT), indicating decreased clotting capability. When this blood was mixed with the patient’s plasma samples, interestingly, the study found the mixture to be hypercoagulable. The authors of this study concluded that autotransfusion “should not be used in place of other blood products to resuscitate a trauma patient”. Though, in closing, they did concede that “autotransfusion of [hemothorax] may, however be of use in a resource limited environment where other blood products are not available.” Another study₃ found that shed pleural blood from hemothorax contained elevated levels of pro-inflammatory cytokines (IL-6, IL-8, TNFα, and GM-CSF). This study recommended further randomized trials to better assess the safety of autotransfusion.

There is also the possibility of contamination of the blood with various substances. Fat emboli may be present in the collected blood, if long bones have been compromised, which are difficult to detect and are not easily filtered out. Also, if there is diaphragmatic and gastric compromise the blood may be unsafe to administer, due to contaminants. Gastric compromise is likely to be detectable, either by visual inspection of collected blood, or by physical examination of the patient, but remains a potential complication.

All this might be a moot point though. Many of these instances utilized blood-cleaning devices, which remove fat emboli, clots and other debris from blood that could potentially cause harm to our patients. No medic in his or her right mind has the space in an aid bag for a bulky piece of very expensive equipment that has only one use. How feasible would this be outside of a hospital environment?

A retrospective study₄ out of India looked at 100 cases in which hemothorax and hemoperitoneum patients were autotransfused without the use of blood cleaning products. The study authors stated that “all patients had safe and unremarkable transfusions”. They used a ROMO- Abdominal Drain Kit (an Indian version of an Atrium collection bag, which is essentially a sterile bag with no anti-coagulants). They heparinized the blood collected (though stating that citrate could serve as an acceptable substitute). The autotransfusion was administered through a 40 µm micro-filter as “protection against potentially harmful micro-aggregates and non-blood component particulate matter”. They also discarded the last 100 MLs of blood as a further precaution against emboli. This study was borne out of necessity, as these facilities commonly lacked adequate allogeneic blood supply to treat these patients. This particular study lacked detail on the patient morbidity and mortality, but opens the door to the feasibility of autotransfusion in an austere setting. Theoretically, with the addition of collection bags, we could replicate this technique in an austere or prehospital environment with our existing WBB supplies.

A military case report₅ detailed the treatment of an Afghan soldier by US providers at a Role I Medical Treatment Facility in Afghanistan. They diagnosed severe hemothorax and autotransfused 1400mls of the patients spent pleural blood before evacuating to a Role III facility where he received emergency surgery. He was transferred to Afghan care after 5 days, but no long term details were discussed. In this case they utilized a Pleur-evac ATS system to collect and autotransfuse. Looking at this particular device, essentially, it consists of a water seal and a collection bag. This system could be streamlined for packing in an aid bag or, at the very least, set up in an aid station. SOF Medics are proficient in chest tubes and blood administration. The only skill needed to perform this procedure, that we do not already currently have, is transferring the blood from the collection system to the transfusion bag, which does not seem like a significant hurdle.

The International Committee of the Red Cross (ICRC) recommends the use of autotransfusion for patients who have lost roughly 1000mls of blood or more when supply of alternate blood products is limited. In the ICRC War Surgery Volume 2 (Chapter 34), they outline very clearly the potential risks and complications, but also state that, “autotransfusion has proven safe and effective. It causes only transient haematological abnormalities that disappear within 72 hours post-operatively. Furthermore, autotransfusion is not associated with increased mortality, or haematological, cardiopulmonary, and renal complications above what is considered normal for these severely injured patients”.

There is a solid precedent for the use of autotransfusion in the austere and resource limited environment. The ability to conjure up several units of blood for a hemodynamically unstable patient seems to be a capability that is too good to overlook dismissively. There are some definite drawbacks to autotransfusion. Coagulopathy can be an issue with shed pleural blood from hemothorax and various pro-inflammatory cytokines can definitely complicate a critical patient in an austere environment. These complications seem to be transient in nature, and have not been shown to have an adverse effect on patient outcomes. The possibility of contamination remains an ever-present risk in battlefield medicine, and this procedure would require strict aseptic execution. With a 200-year track record and the amount of study done so far, autotransfusion seems like a viable resuscitative strategy, but as with anything in medicine, more research can always be done to improve practice.

As medical practitioners in the austere and prolonged field care setting, we should be asking ourselves some questions:

-Are we, as medics, capable of performing this skill, not only aseptically, but also responsibly in the PFC or austere setting?

-Is the addition of oxygen carrying capacity through salvaged blood worth the potential drawbacks of coagulopathy?

-How many units of shed blood could potentially be autotransfused without adversely affecting coagulability?

-Could we figure out a ratio of shed blood to allogeneic blood that would enhance resuscitative efforts, while mitigating coagulopathic complications?

-Can the addition of this capability to our existing blood protocols save lives by increasing the medic’s organic blood supply and extending the time a medic can support a critical casualty before MEDEVAC arrives?

-Does autotransfusion deserve further consideration for a place in our Prolonged Field Care capabilities?

References

1. Rhee P, Inaba K, Pandit V, et al. Early autologous fresh whole blood transfusion leads to less allogeneic transfusions and is safe. J Trauma Acute Care Surg. 2015;78(4):729-734. doi:10.1097/TA.0000000000000599 https://pubmed.ncbi.nlm.nih.gov/25807402/
2. Harrison HB, Smith WZ, Salhanick MA, et al. An experimental model of hemothorax autotransfusion: impact on coagulation. Am J Surg. 2014;208(6):1078-1082. doi:10.1016/j.amjsurg.2014.09.012 https://pubmed.ncbi.nlm.nih.gov/25440491/
3. Salhanick MA, Sams VG, Pidcoke HF, et al. Shed Pleural Blood from Traumatic Hemothorax Contains Elevated Levels of Pro-Inflammatory Cytokines. Shock. 2016;46(2):144-148. doi:10.1097/SHK.0000000000000609 https://pubmed.ncbi.nlm.nih.gov/26974427/
4. Kothari R, Pandey N, Sharma D. A simple device for whole blood autotransfusion in cases of hemoperitoneum and hemothorax. Asian J Surg. 2019;42(4):586-587. doi:10.1016/j.asjsur.2019.01.018 https://pubmed.ncbi.nlm.nih.gov/30803766/
5. Hulsebos H, Bernard J. Consider Autotransfusion in the Field. Mil Med. 2016;181(8):e945-e947. doi:10.7205/MILMED-D-15-00046 https://pubmed.ncbi.nlm.nih.gov/27483539/
6. C. Giannou, M. Baldan, A. Molde. Chapter 34 Autotransfusion. War Surgery: Working with Limited Resources in Armed Conflict and other Situations of Violence Volume 2. Geneva, Switzerland, International Committee of the Red Cross. 11 JUNE 2020. https://www.icrc.org/en/doc/assets/files/publications/icrc-002-4105.pdf

Hot weather injuries are an issue medics have to account for even when not deployed. Proper planning, recognition and treatment can greatly reduce frequency and severity of these patients and their outcomes.

Before you listen to podcasts, let’s go over some talking points as a little pop quiz or a refresher to stay humble and check integrity. These are Socratic questions you can ask yourself, send to one of your other buddies to nerd out on, or bring into conversation with your fellow medics on the next workday. The podcast will cover these.

1.)  During a long physical event on a hot summer day you have an ataxic patient that is profusely sweating, and the core temperature reads 105+. There is another Medic there with you and they don’t think the patient needs evacuation since he is so profusely sweating that it cannot be heat stroke. Could he be wrong and are you willing to use or “waste” evacuation assets on this patient?

2.) When cooling down a patient such as the one above, your patient starts shivering. What does that mean and what can you do about it? Physically or with medication? 

3.) If you had a patient with heat stroke, are they fine once their body temperature reaches a more normal state, or are they going to have some follow on and longer-term systemic issues?

4.) On a heat exhaustion or heat stroke patient, should you get an IV first or start rapidly cooling first? How effective is an IV for these patients?  how much fluid can you consider versus what is the damage of giving too much? 

5.) How can we cool down patients without ice sheets or an ice bath? Perhaps this was a surprisingly warm days it wasn’t necessarily summer so the ice sheets were not planned, it is too austere of a situation for you to have ice with you at the moment, or even further down Murphy’s Law is that you have multiple heat casualties and are already using your ice for your more critical ones…

6.) If it’s a cold Winter where you are currently stationed, but in a few weeks you are deploying to a very hot country, What are some ways you can help acclimate yourself and recommend to your team that they do in order to prepare?  how long will it take? 

These are just some of the topics covered in this podcast. What are some of the myths, huge talking points you do not necessarily consider, or other comments you have about these patients? Drop them in the comments below, or join our discussion on the Facebook page. Thank you for listening to the PFC podcast. 

Click here to go to the podcast on iTunes

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.

Continue reading Podcast Eposode 60: Ian Wedmore on Frostbite and Cold Weather Injuries →

Dangerous snakes can be found both while training at home and far away while deployed. It may be a rare occurrence, but a catastrophic event when it does happen. Some austere providers may be aware of outdated treatments, and don’t know where to start when it comes to identification and management of a snake bite.

Feel free to ask yourselves these questions, or bring them up in a group discussion before listening to the podcast:

Continue reading Podcast Episode 57: Snake Envenomation in Austere Environments →

https://www.nytimes.com/2019/10/11/world/africa/soldier-death-somalia.html

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

https://deployedmedicine.com/market/11/content/158

• Ensure everyone immediately participates in hands-on table top training with whatever you currently have available or can easily construct.

https://emcrit.org/emcrit/ultimate-cricothyrotomy-trainer/

-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…

Element Rescue Quick Reference Guide: Operational Reliability

The Purpose of High Reliability Organizations Daved Van Stralen, MD

High Reliability Organizing and Leadership
Daved van Stralen, MD

Organizing for Transient Reliability:
The Production of Dynamic
Non-Events
Karl E. Weick

Journal of Contingencies and Crisis Management

Managing the Unexpected

Jacksonville Florida
February 28, 2005
Presenters:
Karl Weick
Kathleen Sutcliffe

Download the episode here!

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.

Nothing is working.

What would Doug do?

Prone the patient???

Continue reading Podcast Episode 53: Ventilating in the Prone?! →

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

Continue reading Podcast Episode 52: Walking the Fence of Evidence, Environment and Experience with a word on Proning →

Prep for flight is the 10th Core PFC Capability. Our working group had always deferred to subject matter experts

Continue reading Podcast Episode 44: Prep For Flight and En Route Care: The 10th Core PFC Capability →

All of us are smarter than one of us.

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

Continue reading Crowdsourcing a Standard PFC Deployment Med Box →

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.

Continue reading Podcast Episode 43: 5 years of Prolonged Field Care →

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.

Continue reading Podcast Episode 42: Wound Care Basics and Beyond →

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.

Continue reading Prolonged Field Care at MHSRS 2018 →

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 Continue reading Episode 41: The Death of the Golden Hour: SOMSA 2018 Talk, by COL (Ret.) Rocky Farr, MD →

Whether working on a casualty with a small team of medics or as a single medic with the help of other non-medic team members as helpers, someone has to be in charge of the situation in order to maintain a global view of priorities.  Continue reading Podcast Episode 40: Medic Team Dynamics with Dennis and Doug →

Continue reading Podcast Episode 38: Far Forward Surgical Support and Resources →

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 →