Tag Archives: PFC

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.

Podcast Episode 100 and SOMSA-22

In the 100th Episode of the Prolonged Field Care Podcast Dennis sits down with Jamie, Sean and Paul to talk about the last 100 episodes and how prolonged field care evolved over the past 7 years from when the working group was established at SOMA 2013 in Tampa, FL. Sean has since moved on and retired from the military and founded a non profit, Specialized Medical Standards, dedicated to developing, and distributing high quality education and training resources to the international medical community, much of it based on the lessons learned from his unique experiences and expertise.

Listen here on our Anchor FM page, YouTube Channel or on your favorite podcast app.

Come visit Sean and Dennis at the SMS booth in the SOMSA exhibition room and see the official Prolonged Field Care update from Paul on Friday morning on the main stage.

Improvised Field Medicine Shopping List for the Austere Clinician

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.

What would you add?

Podcast Episode 94: We are Back

The Prolonged Field Care Working Group is dead (actually, evolved…).

In its place, the new Prolonged Field Care Collective arises.


Be the first to get our newest episodes on our new Spotify Show by clicking here.

After some time to reorganize, restructure, and strategize, we will be continuing to update best practices, share ideas and raise the important questions faced by medics around the world. We have taken this step to lay the old prolonged field care working group construct to rest and form a new organization (with the same core people): the Prolonged Field Care Collective. Membership is based on participation and contribution. Dennis will continue to record podcasts, which will be posted on http://www.prolongedfieldcare.org, our new podcast feed (Search “Prolonged Fieldcare Podcast”) as well as the same old Special Operations Medical Association Libsyn feed. This will allow us to reach a wider audience, maintain complete control of our content, continue to “push the envelope,” nurture the unconventional Think Tank, and expand what we offer in the future.

Prolonged Casualty Care for all

The wait is over…

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.

Click to access Prolonged_Casualty_Care_Guidelines_21_Dec_2021_ID91.pdf

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!!!

Podcast Episode 61: TBI Update with Dr. VanWyck

 

Listen Now:

http://traffic.libsyn.com/specialoperationsmedicine/PFC_TBI_update_Final.mp3

Show Notes: Continue reading Podcast Episode 61: TBI Update with Dr. VanWyck

Podcast Episode 47: Andy Fisher and his Damage Control Resuscitation for Prolonged Field Care CPG

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…

Continue reading Podcast Episode 47: Andy Fisher and his Damage Control Resuscitation for Prolonged Field Care CPG

Video Recap of a Civil War Field Hospital Reenactment and PFC Display at Bentonville Battlefield in NC

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

Episode 37: PFC from the NGO Perspective With Alex Potter of GRM

Non-Governmental Organizations, Non-Profits and Volunteers have been providing critical services on the battlefield for millennia. Historically the traditional view of medical care in conflict zones was that the military focused on victory Continue reading Episode 37: PFC from the NGO Perspective With Alex Potter of GRM

Podcast Episode 35: Priorities of Burn Care With Dr. Cairns of The UNC Chapel Hill Jaycee Burn Center and the AMIT Program

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.

Continue reading Podcast Episode 35: Priorities of Burn Care With Dr. Cairns of The UNC Chapel Hill Jaycee Burn Center and the AMIT Program

New CPG! Traumatic Brain Injury Management in PFC

Traumatic Brain Injuries coupled with other injuries can be one of the most difficult wound patterns to manage in the field. Learn to manage TBI Continue reading New CPG! Traumatic Brain Injury Management in PFC

How to make labels to practice Medication administration:

Tactical Trauma Casualty Care(TCCC) and Prolonged Field Care can be heavy on the medication administration, but during training we can’t really give our real role player patients or even our mannequins a bunch of narcotics and other controlled substances, so it’s often verbalized in training. Not training on the medication they carry downrange, far from providers, can lead to improper Continue reading How to make labels to practice Medication administration:

Lessons Learned from a 2015 PFC Medical Exercise

ICU Doc, Doug Powell, was on staff for the recent Prolonged Field Care train-the-trainer exercise in June, and he observed Medics running through multiple scenarios, each 24 hours in length.

Continue reading Lessons Learned from a 2015 PFC Medical Exercise