LCDR Fermin S. Godinez
Naval Medical Center Portsmouth
Department of Emergency Medicine
Portsmouth, VA 23708

Course Overview
• Brief Introduction
• Course Schedule
• Navy Health Service Support of US
Marine Corps Forces
• Introduction of Guest Panel

Administrative remarks
• Contact information
• Logistics of work space
• Disclaimer
• Acknowledgements
• 3 rd Force Recon Combat Course
• TC3 SOCOM Recommendations
• Prior deployed HM’s, 18D’s,& MO’s

Course Schedule
Casualty Care Course Jan/Feb 2006
Monday-30 January
0730-0750 Check in Welcome/Admin remarks CDR CailteuxZevallos
LCDR Walters
0750-0800
0800-0850
0850-0900
0900-0950
0950-1000
1000-1050
1050-1100
1100-1200
1200-1700
BREAK
Course Introduction/Overview
BREAK
The Primary & Secondary Survey
BREAK
Airway/Breathing Management
BREAK
Working Lunch/Discussion Panel
AIRWAY SKILLS STATIONS
LCDR Godinez
LCDR Godinez
LCDR Godinez
Prior Deployed NMCP personnel
LCDR Godinez

Introduction
• The standards of care applied to the battlefield have always been based on civilian care principals.
• These principals while appropriate for the civilian community often do not apply to care on the battlefield .
• The 90% Solution

Introduction
Civilian medical trauma training is based on the following principles:
Emergency Medical Technicians
(EMT-B,I,P)
Basic Trauma Life Support (BTLS)
Advanced Trauma Life Support (ATLS)

Introduction
Guiding principles of this course
• 1. Treat the casualty safely
• 2. Complete the mission
"We must remember that one man is much the same as another, and that he is best who is trained in the severest school."--Thucydides, The History of the Peloponnesian War

Katrina/Rita
Disaster
Response
Somalia
Humanitarian
Assistance
Terrorist
Response
Peace
Keeping
Full Spectrum Operations
Iraqi/Enduring Freedom
Homeland
Defense
Major
Conflict
El Salvador HA
East Timor HA/PK Kosovo

Historical Route From Injury to Definitive Care
Evac Policy -
1 Hour
1 Day
–
Field Hospital
Forward Surgical
Capabilities
TACEVAC
Evac Policy -
7 Days
STRATEVAC
Evac Policy -
15 Days
Air Transportable
Definitive Care
Definitive Care
Forward Surgical Capability

LCDR Eric Timmens, MSC, USN
DEPMEDS Manager, Medical Resources,
Plans and Policy Division
Chief of Naval Operations
11-16 January 2004

Marine Expeditionary
Force (MEF)
20-90K Major Theater War
Marine Expeditionary
Brigade (MEB)
3-20K Smaller Scale Contingencies
Marine Expeditionary
Unit (MEU(SOC))
1.5-3K Promote Peace and Stability

Core Elements to the MEF
Marine Division
Marine
Expeditionary
Force (MEF)
Marine Air Wing
Force Service Support Group

• Marine Division (Battalion)
• Battalion Aid Stations
• 2 Medical Officers and 65 Hospital Corpsman
• FSSG (Medical Battalion)
• Shock Trauma Platoons (STP)
• Surgical/STP(S/STP)
• Forward Resuscitative Surgical System (FRSS)
• Surgical Company
• Expeditionary Medical Facility (EMF)

Health Service Support
Echelon I
Battalion
Aid
Station
Shock Trauma Platoon
Surgical STP
Forward Resuscitative
Surgical Suite (FRSS)
Surgical Company
Expeditionary Medical
Facility (EMF)
Echelon III

Ground Combat Element
Echelons of Care
FEBA
BAS
Level I
I
II
FRSS
+/-
STP
Level I
III
- 48 Hours -
Surgical Company
Level II
Fleet Hospital
Level III
LHD CRTS

MARINE DIVISION
INFANTRY
BATTALION
H&S
COMPANY
MEDICAL
PLATOON
WEAPONS
COMPANY
RIFLE
COMPANIES
2 MO'S/65 HM's
- 1 MO = Battalion Surgeon
- 1 MO = Battalion Aid Station (BAS)
- 21 HM's = Battalion Aid Station
- 11 HM's = Weapons Company
- 33 HM's = Rifle Companies (3)

MARINE DIVISION
MARDIV
INFANTRY
REGIMENTS
HEADQUARTERS
BATTALION
TANK
BATTALION
ARTILLERY
REGIMENT
LIGHT ARMORED
RECONNAISSANCE
BATTALION
ASSAULT
AMPHIBIOUS
BATTALION
COMBAT
ENGINEER
BATTALION
- Division Surgeon
- Medical Administrative Officer
- Environmental Health Officer
- Division Psychiatrist
- Enlisted Personnel Assistants

FORCE SERVICE
SUPPORT GROUP
FSSG
HEADQUARTERS
& SERVICE
BATTALION
ENGINEERING
SUPPORT
BATTALION
MOTOR
TRANSPORT
BATTALION
LANDING
SUPPORT
BATTALION
MAINTENANCE
BATTALION
SUPPLY
BATTALION
MEDICAL
BATTALION
DENTAL
BATTALION

FORCE SERVICE SUPPORT GROUP
FSSG
- S-1
- S-2/3
- S-4
- S-6
- Preventive Medicine
- Chaplain
- Shock/Trauma
Platoons (8)
HEADQUARTERS
& SERVICE
BATTALION
MAINTENANCE
BATTALION
ENGINEERING
SUPPORT
BATTALION
SUPPLY
BATTALION
H & S
COMPANY
MOTOR
TRANSPORT
BATTALION
MEDICAL
BATTALION
LANDING
SUPPORT
BATTALION
DENTAL
BATTALION
SURGICAL
COMPANIES

FORCE SERVICE SUPPORT GROUP
- STABILIZATION
SECTION
2 - MO 1 - NC
1 - PA 7 - HM's
- COLLECTING/EVAC
SECTION
1 - NC 7 - USMC
7 - HM's
0 OR's; 10 COTS
HEADQUARTERS
& SERVICE
BATTALION
ENGINEERING
SUPPORT
BATTALION
FSSG
MOTOR
TRANSPORT
BATTALION
LANDING
SUPPORT
BATTALION
MAINTENANCE
BATTALION
SUPPLY
BATTALION
H & S
COMPANY
SHOCK / TRAUMA
PLATOONS (8)
MEDICAL
BATTALION
DENTAL
BATTALION
SURGICAL
COMPANIES

FORCE SERVICE SUPPORT GROUP
HEADQUARTERS
& SERVICE
BATTALION
ENGINEERING
SUPPORT
BATTALION
FSSG
MOTOR
TRANSPORT
BATTALION
LANDING
SUPPORT
BATTALION
MAINTENANCE
BATTALION
SUPPLY
BATTALION
H & S
COMPANY
MEDICAL
BATTALION
DENTAL
BATTALION
SURGICAL
COMPANIES
- HQ Platoon
- Triage/Evacuation
Platoon
- Surgical Platoon
- Holding Platoon
- Combat Stress
Platoon
- Ancillary Service
Platoon
(Dental Detachment)

FORCE SERVICE SUPPORT GROUP
HEADQUARTERS
& SERVICE
BATTALION
ENGINEERING
SUPPORT
BATTALION
FSSG
MOTOR
TRANSPORT
BATTALION
LANDING
SUPPORT
BATTALION
MAINTENANCE
BATTALION
SUPPLY
BATTALION
H & S
COMPANY
MEDICAL
BATTALION
DENTAL
BATTALION
SURGICAL
COMPANIES
17 MC
7 MSC
23 NC
- 127 HM
19 USMC
- 3 OR's; 60 COTS

Forward Resuscitative Surgery System (FRSS)
Supporting Marine Corps Strategy 21
Joel Lees CAPT, MC, USN
I MEF Surgeon

FORWARD RESUSCITATIVE SURGERY SYSTEM
(FRSS)
• Where does FRSS apply in echelons of HSS support ?
STP+FRSS
ECHELON I
Buddy Aid
BAS
STP
ECHELON II ECHELON III ECHELON IV & V
Surgical Company
Casualty Receiving
Ships
Eg BHR, Iwo Jima
Fleet Hospitals
Hospital Ships
Out of theater
Medical Centers
Marine Health Service

FRSS Footprint - 1700 Sq ft
Post Op Beds
Operating Room
Pre Op Beds
Supplies
Litters on Stands

USMC
Casualty Receiving and Treatment Ships
OR’s
UNIT
FRSS
Shock Trauma Platoon
(STP)
1
N/A
Surgical Company
LHA
3 w/ 2 tables each
4+2
LHD
LHA R
MPF F
Medical capability on 2 ships of a 6 ship squadron
LPD-17
EMF-500
4+2
4+2
6
Fleet Hospitals-
1+1
6
EMF 116 2
EMF-10
TA-H
1
12 Hospital Ship
ICU/ICW
10
20/40
15/45
17/47
15/45
38/83
6/18
80/420
20/96
10
80/400

Combat Trauma Lectures
 Airway and Breathing
 Hemorrhage and Shock
 Extremity Trauma
 Thoracic Trauma
 Head Trauma
 Spine Trauma
 CASEVAC Procedures

Combat Trauma Skills Labs
 Airway Management
 Hemorrhage Control
 Splinting
 Intravenous Access
 Casualty Carries
 Chest Wounds
 Abdominal Wounds

Battlefield Care is

Introduction
Simple important principles –
• The correct intervention at the correct time.
• In combat, errors may lead to further casualties

Introduction
• Pre-hospital care continues to be critically important
• Up to 90% of all combat deaths occur before a casualty reaches a
Medical Treatment Facility (MTF)
• Penetrating vs. Blunt trauma

Factors influencing combat casualty care
• Enemy Fire
• Medical Equipment Limitations
• Widely Variable Evacuation Time

Factors influencing combat casualty care
• Tactical Considerations
• Casualty Transportation

Photo courtesy of HM3(FMF) McCLain

Photo courtesy of HM3(FMF) McCLain

Photo courtesy of HM3(FMF) McCLain

Photo courtesy of HM3(FMF) McCLain

Photo courtesy of HM3(FMF) McCLain

STAGES OF CARE
• Care Under Fire
• Over the barrier/berm
TCCC
• Tactical Field Care
• Combat Casualty Evacuation Care

Care Under Fire
• “Care under fire” is the care rendered by the medic at the scene of the injury while he and the casualty are still under effective hostile fire. Available medical equipment is limited to that carried by the soldier or the medic in his aid bag.

Tactical Field Care
• “Tactical Field Care” is the care rendered by the medic once he and the casualty are no longer under effective hostile fire. It also applies to situations in which an injury has occurred, but there has been no hostile fire.
Available medical equipment is still limited to that carried into the field by medical personnel. Time to evacuation to a MTF may vary considerably.

Combat Casualty Evacuation
Care
• “ Combat Casualty Evacuation
Care” is the care rendered once the casualty has been picked up by an aircraft, vehicle or boat. Additional medical personnel and equipment may have been pre-staged and available at this stage of casualty management.

Care Under Fire
• Attention to suppression of hostile fire may minimize the risk of injury to personnel
• Minimize additional injury to previously injured personnel.

Care Under Fire
Wounded personnel who are unable to fight should lay flat and motionless if no cover is available or move as quickly as possible to any nearby cover

Care Under Fire
• Medical personnel are limited and if your injured…….
• No other medical personnel will be available until the time of extraction during the CASEVAC phase

Care Under Fire
• Control of hemorrhage is important since injury to a major vessel can result in hypovolemic shock in a short time frame
• Over 2500 deaths occurred in Viet
Nam secondary to hemorrhage from extremity wounds

Care Under Fire
• Use of temporary tourniquets to stop the bleeding is essential in these types of casualties

Care Under Fire
The need for immediate access to a tourniquet in such situations makes it clear that all soldiers on combat missions have a suitable tourniquet readily available at a standard location on their battle gear and be trained in its use.

Care Under Fire
• Penetrating neck injuries do not require
C-spine immobilization.
• Other neck injuries, such as falls over
15 feet, fast-roping injuries, or MVAs may require C-spine control unless the danger of hostile fire constitutes a greater threat in the judgment of the medical personnel

Care Under Fire
• Litters may not be available for movement of casualties.
• Consider alternate methods to move casualties such as a SKED
® or Talon II
® litter. Smoke, CS, and vehicles may act as screens to assist in casualty movement.

KEY POINTS
• Try to keep yourself from being shot
• Try to keep the casualty from sustaining any additional wounds
• Stop any life threatening hemorrhage with a tourniquet
• Airway as required
• Reassure the casualty

Tactical Field Care
• The Tactical Field Care phase is distinguished from the Care Under
Fire phase by having more time available to provide care.
• A reduced level of hazard from hostile fire. The times available to render care may be quite variable.

Tactical Field Care
• In some cases, tactical field care may consist of rapid treatment of wounds with the expectation of a re-engagement of hostile fire at any moment.
• In some circumstances there may be ample time to render whatever care is available in the field.
• The time to evacuation may be quite variable from 30 minutes to several hours.

Tactical Field Care
• If a victim of a blast or penetrating injury is found without a pulse, respirations, or other signs of life,
• Do Not attempt CPR
• Casualties with altered mental status should be disarmed immediately, both weapons and grenades

Tactical Field Care
Initial assessment consists of:
Tactical Assessment
Airway
Breathing
Circulation

CASEVAC Care
• At some point in the operation the casualty will be scheduled for evacuation.
• Time to evacuation may be quite variable from minutes to hours.

CASEVAC

CASEVAC Care
• The Hospital Corpsman may be among the casualties
• The Hospital Corpsman may be dehydrated, hypothermic, or otherwise debilitated

CASEVAC Care
• There may be multiple casualties that exceed the capability of the medic to care for simultaneously.

CASEVAC Care
• Additional medical equipment can be brought in with the EVAC asset to augment the equipment of the
HM.
• This equipment may include:

Summary
• How people die in ground combat:
• 31% Penetrating Head Trauma
• 25% Surgically Uncorrectable Torso Trauma
• 10% Potentially Correctable Surgical Trauma

Summary
• 9% Exsanguination from Extremity
Wounds 1st
• 7% Mutilating Blast Trauma
• 5% Tension Pneumothorax 2nd
• 1% Airway Problems 3rd
• 12% Died of Wounds (Mostly infections and complications of shock)

Summary
• Three categories of casualties on the battlefield
• Injured personnel who will do well regardless of what we do for them
• Injured personnel who are going to die regardless of what we do for them
• Injured personnel who will die if we do not do something for them now (7-15%)

REMEMBER
• If during the next war you could do only two things,
• (1) put a tourniquet on and
• (2) relieve a tension pneumothorax then you can probably save between
70 and 90 percent of all the preventable deaths on the battlefield.
COL Ron Bellamy

Summary
• Medical care during combat differs significantly from the care provided in the civilian community.
Earl Wilson
Courage is the art of being the only one who knows you're scared to death!

Summary
We Serve So Others May Live

Earl Wilson
Courage is the art of being the only one who knows you're scared to death!

National Stock Numbers
• One handed tourniquet 6515-01-504-0827
• Hextend
®
Fluid 6505-01-498-8636
• FAST 1
®
6515-01-453-0960
• Emergency Trauma Dressing
®
6510-01-492-
2275
• HemCon Chitosan Dressing
®
6510-01-502-
6938
• Sked Litter
®
6530-01-260-1222
• Talon II Litter
®
6530-01-452-1651