Running a Prolonged Field Care Scenario
Testing the limits of the abilities of your teams and equipment prior to deploying
to a remote environment will allow for changes in SOP, load out and ordering that you
may not have anticipated prior to running the scenario.
If medics plan on using the Mountain Post Medical Simulation Training center
(MSTC), at the corner of Specker and Khe Sanh 526-2820
www.carson.army.mil/mstc/index.html, this should be done either many months in
advance or by actually going to the office and looking for white space on the calendar.
Scheduling training requires 3 different memorandums which are included at the bottom
of this doc. They have simulation rooms where you can request an operator for the
$70,000.00 mannequins as well as static, outdoor props including a helicopter, multiple
HMMWVs, guard tower, and multiple-story buildings.
Fort Carson's Training Support Center (TSC) has robust moulage kits available
for check out for up to 30 days at a time, CONUS only. It is required that the medic
signing out a kit be on the TSC specific signature card from the company.
Schedule a minimum of 2-3 days at the 10th SFG (A) Group PFC simulation room
through GroupMed: 526-2769. It is now located in the northwestern-most room of the
cold storage building in the Group Motorpool. It has multiple mannequins which can be
operated by GroupMed personnel if requested and available.
The first day or two will allow for pre-staging all medical gear to the room get
familiar with some of the equipment and most importantly train non-medical team
members in procedures. It is recommended that medics familiarize yourself prior to
training their teams. Some of the procedures commonly encountered over the course of
a PFC scenario and highly recommended for familiarization for medics and teammates
include;
Proper TQ placement and reduction
Packing an inguinal or axillary wound
Stopping bleeding and cleaning abdominal evisceration
Occlusive dressing or replacing bowels of evisceration
Occlusive Dressing
Assessing indications for needle D
Detailed head to toe assessment
Insertion of needle D
Preparation and placement of King LT
Using SSCOR and squid suction
Bagging with BVM
Oxygen tank prep including NRB and nasal cannula
Setting up the SAVent and Oxylator
Using the oxygen concentrator
Drawing blood for labs or iStat
Preparation and initiation of peripheral IV
Preparation of
foley catheter
Suprapubic bladder tap
Cricothyroidotomy
Glasgow coma scale from a cheat sheet
Taking a full set of vitals manually
Attaching Philips monitor or Tempus
Using the patient care flow sheet
Eldon blood typing card
Preparing the equipment for blood transfusion
Making comms and calling LRMC with the call sheet
Changing wet to dry dressings
Drawing and administering drugs
NG Tube prep
Irrigating wound
Suturing
Preparation and placement of Chest Tube including pleurevac and suction
Team leadership and Battalion PA and Surgeon should be involved as early as
possible to help in crafting a realistic scenario that corresponds to something teams
may encounter in an upcoming deployment. This will give them some ownership in the
training helping you to get maximum participation. When planning your scenario try and
use something that corresponds to the vehicle you will see in your AOR while deployed.
Privately owned trucks have been used successfully for TacEvac and the mock up used
for sustained airborne training has been used for STOL or rotary wing simulation away
from the simulation room.
Medics should try and use radios as much as possible to relay MIST reports and
vitals during TacEvac Care even if they are only off the shelf hunting radios. Another
mode of communication such as Iridium or cell phone can be used to call and ask for
offsite telemedical consulting support through either another provider or Lansthul
Regional Medical center's on-call number provided on the memo, +49 162 296 3962.
When calling have the necessary information available to relay and what exactly is
going on and what you are requesting. There is a recommended format for this as well,
also included at the bottom of this document.
If you have access to an iPad or iPhone the SimMon app makes vital signs
simulation much more convenient by allowing the Proctor to adjust the "monitor" on the
fly, remotely.
The medic may want to consider rotating non-medical personnel out of the
scenario as it progresses past the initial stages which will give you more time with the
proctor caring for the patient as opposed to teaching and re-teaching the other team
members. It may even be beneficial to rotate medics out to get lunch or dinner as it
would be necessary in real life anyhow.
It is highly recommended that the medics take the time in advance to review the
literature provided by the PFC working groups as well as practice using the nursing care
chart with the team. All of the PFC WG Position Papers are included for reference in
this document as well as packing lists.
DEPARTMENT OF THE ARMY
ALPHA COMPANY, 2nd BATTALION, 10th SPECIAL FORCES GROUP (AIRBORNE)
FORT CARSON, COLORADO 80913-7440
REPLY TO
ATTENTION OF:
AOSO-SFC-SNA
12 December 2013
MEMORANDUM FOR Medical Simulation Training Center (MSTC)
SUBJECT: MSTC Facility/ Training Request
1.
Request for training at the Mountain Post MSTC Facility for the following dates:
Dates of training:
5-6 Aug 2014
Number of Soldiers to train:
12
Unit:
0211 A Co 2nd Bn 10th SFG (A)
Type of Training:
CLS/ CTM (Unit Led)
2. I understand that the unit is responsible for providing a by-name list of Soldiers for training
one week prior to start of course.
3. I understand that the unit is responsible for providing a by-name list of Medical NCO’s if
planning to assist with CLS/ CTM validation.
4. POC for this memorandum is SSG Loos, Paul at 524-3289 or paul.loos@ahqb.soc.mil.
MATTHEW A. CHANEY
MAJ, SF
COMMANDING
FT CARSON MSTC:
APPROVED
DISAPPROVED
TIMOTHY D. OLSON
SITE LEAD
MOUNTAIN POST MSTC
DEPARTMENT OF THE ARMY
ALPHA COMPANY, 2nd BATTALION, 10th SPECIAL FORCES GROUP (AIRBORNE)
FORT CARSON, COLORADO 80913-7440
REPLY TO
ATTENTION OF:
AOSO-SFC-SNA
December 2013
12
MEMORANDUM FOR Medical Simulation Training Center (MSTC)
SUBJECT: MSTC Facility By-Name List of Medical NCO’s
1. The following is a list of Medical NCOs that will be conducting the CLS/ CTM training on the
5-6 Aug 2013:
NAME
Perry, John
Loos, Paul
Hewlett, Justin
RANK
MOS
SFC
SSG
SSG
18D/ 11B
18D/ 68W
18D
4. POC for this memorandum is SSG Loos, Paul at 524-3289 or paul.loos@ahqb.soc.mil.
MATTHEW A. CHANEY
MAJ, SF
COMMANDING
FT CARSON MSTC:
APPROVED
DISAPPROVED
TIMOTHY D. OLSON
SITE LEAD
MOUNTAIN POST MSTC
DEPARTMENT OF THE ARMY
ALPHA COMPANY, 2nd BATTALION, 10th SPECIAL FORCES GROUP (AIRBORNE)
FORT CARSON, COLORADO 80913-7440
REPLY TO
ATTENTION OF:
AOSO-SFC-SNA
12 December 2013
MEMORANDUM FOR Medical Simulation Training Center (MSTC)
SUBJECT: MSTC Facility By-Name List of Students
1.
The following is a list of students attending the CLS/ CTM training on the 5-6 Aug 2013:
NAME
RANK
Oakley, Joshua
Heydenberk, Drew
Brown, Christopher
Milan, Aaron
Braswell, Byron
Seizert, Sterling
Baumgardener, Jeremy
Overacre, Austin
Lemke, Joshua
Golinski, Karl
CPT
MSG
WO1
SFC
SFC
SSG
SSG
SGT
SGT
SGT
4. POC for this memorandum is SSG Loos, Paul at 524-3289 or paul.loos@ahqb.soc.mil.
MATTHEW A. CHANEY
MAJ, SF
COMMANDING
FT CARSON MSTC:
APPROVED
DISAPPROVED
TIMOTHY D. OLSON
SITE LEAD
MOUNTAIN POST MSTC
Draft 10 SFG(A) Medical Evacuation/Treatment Reference Card (modify as
needed)
Communications PACE Plan: (examples)
P: (SOCAFRICA SURGEON)
A: (SOCAFRICA JOC)
C: (LRMC ON-CALL NUMBER)
E: (GROUP OPERATIONS/GROUP OR BN SURGEON)
Call script:
“THIS IS _________________, (JOB/POSITION):___________________.
I HAVE A PATIENT WITH ___________ WHO I THINK HAS
___________,
AND I NEED _____________________________.”
CHIEF COMPLAINT: ______________________________
BRIEF HISTORY:__________________________________
PE: VITALS: HR:____________ BLOOD PRESSURE:
_______________
RESPIRATION RATE: _________ OXYGEN SATURATION:
___________
TEMPERATURE: _________ MENTAL STATUS (AVPU):
_____________
BRIEF EXAM: _______________________________________________
__________________________________________________________.
“I NEED _______________.” (CONSULTATION, HELP, ADVICE,
TRANSPO…)
Case Study: South Sudan Casualty Care
After Action Review
Mission Date: 21 December 2013
Situation: At approximately 0815Z (1015L) on 21 December 2013 while conducting a
Noncombatant Evacuation Operation (NEO) of the U.S. Embassy three CV-22 aircraft
carrying SOCCENT Crisis Response Element (CRE) came under small arms fire when
they attempted to land at the Bor civilian airport in South Sudan, East Africa. All three
aircraft suffered heavy damage during the small arms attack. Four U.S. personnel
sustained injuries on one of the aircraft.
Casualty Report: Patients will be referred to as Patients 1, 2, 3, and 4 for the duration
of this document.
Patient 1: Active Duty (AD) Service Member (SM) sustained a Gun Shot Wound (GSW)
to left buttock, above the gluteal crease, through to left thigh with profuse hemorrhage.
Patient 2: AD SM sustained a GSW to right mid-thigh.
Patient 3: AD SM sustained a GSW to left hip through to left thigh.
Patent 4: AD SM shrapnel wound to left lower back.
Care Under Fire included:
Onboard the CV-22, Patient 4 (Navy SEAL Corpsmen) treated Patients 1, 2, and
3 after receiving small arms fire during over-flight of the airstrip. Each had a GSW to a
lower extremity. Patient 4 applied tourniquets to Patients 2 and 3, and hemorrhage
control via manual pressure to Patient 1. Within 15 minutes of the attack, Patient 4
triaged the patients and immediately relayed injuries through the aircrew to the Special
Operations Forces Medical Element (SOFME) located at Entebbe International Airport
in Uganda. Patient 1 was the most critical due to wound proximity and sustained
bleeding. Patient 1 was initially triaged as expectant, but was re-triaged after bleeding
was controlled. The SOFME requested and received blood types for patients 1, 2, and
3, and collected donor fresh whole blood from a walking blood bank.
Patient 4 administered fentanyl lozenges to Patients 1, 2, and 3. Due to heavy
damage to the aircraft, the CV-22s were forced to land at Entebbe International Airport.
The Special Operations Resuscitation Team (SORT) was closer in N’zara, South
Sudan, but didn’t have the capability to evacuate the critical patients to a higher level of
care and was not resourced to perform surgery. The Combined Joint Task Force-Horn
of Africa (CJTF-HOA) liaison officer (LNO) in Nairobi was contacted and made
arrangements for ambulances to pick-up the patients at Nairobi Kenya Jomo Kenyatta
International Airport (HKJK). The SOFME plan was to trans-load the patients onto a C130 at Entebbe and fly directly to HKJK.
At approximately 1130L, the CV-22s carrying casualties arrived on the
commercial side of Entebbe International Airport and were met by United States Air
Force Para Rescue Jumpers (PJs). These PJs and accompanying C-130 were
prepositioned in Entebbe in support of this operation. The CV-22s then relocated to the
military side of the airport and were met by a team of six US Military providers. The
group included the SOFME Team of one USAF Flight Surgeon (FS) and one USAF
Independent Duty Medical Technician (IDMT) which was assisted by a United States
Army (USA) Special Forces Medical Sergeant (18D); all three personnel had regular
duty in Entebbe. Also present were a United States Navy (USN) Physician Assistant
(PA) with two medical technicians who were passing through Entebbe at the time. The
patients were offloaded from the CV-22s, and Patients 1 and 2 were loaded into a
converted van—three rows of seats were removed and replaced with two litters.
Treatment provided in Entebbe included:
Patient 1: Patient 1 was given one gram of Tranexamic Acid (TXA) via an
existing IV site initiated during the inbound CV-22 flight by Patient 4. A second IV site
was initiated by the USAF IDMT to enable the receipt of two units of whole blood—one
obtained from a donor using walking blood bank protocol in Entebbe and the second
was received from a PJ and administered by the USAF IDMT. Patient 1’s vital signs
indicated Class III hemorrhagic shock (low blood pressure, reduced pulse pressure, and
HR greater than 120 beats per minute).
Patient 2: Patient 2 had a tourniquet on the right thigh at arrival during handover
for further treatment. It was determined that the patient’s condition necessitated the
placement of a second tourniquet to control hemorrhaging. Patient was tachycardic but
normotensive, indicating a Class II hemorrhagic shock. He was in extreme pain from
GSW and tourniquet. During exposure of the patient and primary survey, the initial
bandage was removed, the wound packed with combat gauze and secured with ACE
wrap. The wound was oozing blood at the time of bandaging, but was found to be
controlled. At handover, Patient 4 stated that the wound was an arterial bleed and
tourniquet was placed at approximately 1000L.
Patient 3: Patient 3 was found to have palpable pedal pulses due to improperly
tightened tourniquet but was left as is since hemorrhage control seemed adequate.
Patient 4: Patient 4 (The Navy SEAL Corpsmen) was evaluated by the 18D and
deemed that treatment could wait until arrival at Nairobi General Hospital.
Time on the ground in Uganda was approximated 30 minutes.
A USAF C-17 was preparing for departure on an unrelated mission and was
redirected to transport the four patients to HKJK (instead of the pre-planned C-130) for
further treatment at Nairobi General Hospital. The aircraft departed at 1200L with all
four patients, along with the USAF FS, the IDMT, the 18D, and the Navy PA for an
approximately one hour flight to Nairobi. Patient 2 was floor-loaded first on the aircraft
and then Patients 1 and 3 were loaded onto litter stanchions.
Treatment en-route to HKJK included:
Patient 1: Patient 1’s left thigh was 1.5-2x the size of his right. He had a strong
pedal pulse and was given a femoral block with lidocaine for pain control, which
provided only minimal relief. Patient 1 remained stable throughout the flight though pain
was only partially controlled.
Patient 2: Patient 2 was administered 1 milliliter (ml) of Ketamine (500mg/5mL)
IM in the left thigh at the Entebbe airfield while waiting for departure. Patient descended
into delirium while on the C-17 and remained delirious during the course of the flight.
Sunglasses were put on the patient that reduced stimulus and allowed for the insertion
of two 18GA catheters: one on left hand, and one on right forearm. Both IVs required
splinting and extra taping to keep them in place. After the IVs were patent, one gram of
TXA was administered with the initiation of 500mL of normal saline.
Patient 3: During the flight Patient 3 became somnolent and then unconscious,
but breathing, likely secondary to the Versed given prior to administration of 100 mg of
Ketamine IM. An NPA was placed and oxygen was given via an emergency O2 tank
and aviator mask. Patient’s Sp02 and respirations continued to drop, so he was
ventilated via bag valve mask. Patient 3 awoke after administration of the reversal
agent Romazicon for Versed and did not require respiratory support the remainder of
the flight.
The C-17 arrived in HKJK at approximately 1315L. Ambulances took the
patients to Nairobi Hospital, where the team of surgeons and anesthesia personnel
were waiting. Transport time from aircraft to hospital was approximately 45 minutes.
Approximate time from initial injury to arrival at Nairobi emergency department was four
hours.
Treatment after arrival at Nairobi Hospital included:
Patient 1: Patient 1 was not bleeding, but deemed to be most critical and was
taken to the operating room. He was found to have no arterial injury; the hemorrhage
was venous and received additional transfusion of packed red blood cells (pRBCs). The
source of all blood products after leaving Entebbe was the Nairobi General Hospital.
After proximal fasciotomies, wound debridement, and hemostasis, he was taken to the
Intensive Care Unit (ICU). He had an uneventful post-operative course and was
transported to Landstuhl Regional Medical Center (LRMC) on 23 December by USAF
Aeromedical Evacuation (AE) crew (with Patients 3 and 4). At LRMC he was returned
to the OR for a washout and partial wound closure.
Patient 2: Patient 2 was sent to the Computed Tomography (CT) scanner for a
CT-angiogram. It was then discovered that his tourniquets were still in place. A UStrained African Cardiovascular Surgeon and staff arrived and took the patient to the OR,
where the tourniquets were removed. Total tourniquet time was approximated at 6-8
hrs without reassessment or conversion. No arterial injury was found, and proximal
fasciotomies (3 compartments) were performed. Bullet fragments were removed,
wound irrigated, and distal pulses were re-established. The morning of 22 December,
the wound was re-dressed and distal pulses were present. In the afternoon, distal
pulses were lost. In addition, throughout the course of the day, the patient developed
rhabdomyolysis, with reduced urine output, severe acidosis (bicarb (CO2) as low as 12)
and hyperkalemia (K=7.2) that was nonresponsive to aggressive medical management.
Continuous Veno-Venous Hemofiltration (CVVH) was initiated and the patient
returned to the OR for reevaluation. A superficial femoral artery thrombectomy was
performed along with fasciotomies of the four distal compartments. Pulses were reestablished. Heparin was initiated. The patient was taken to the ICU and became
hypotensive with significant bleeding from the surgical site. Reevaluation of the
thrombectomy site did not reveal any arterial disruption, but there was continued
significant hemorrhage requiring a massive transfusion of nine units of pRBCs and
crystalloid. He became coagulopathic, developed fluid overload, and required reintubation and ventilation. CVVH was continued. Early on 23 December, the patient’s
lower right extremity was deemed non-viable. Patient 2 returned to the OR for a right
above the knee amputation (AKA). Fresh frozen plasma, platelets, and CaCl2 were
administered along with additional six units of pRBCs. The coagulopathy was
corrected. Later on 23 December, the chest x-ray had improved, mechanical ventilation
was discontinued and the patient extubated. CVVH was continued, the stump dressing
changed, and the patient remained stable with a Glasgow Coma Scale (GCS) of 15. On
24 December at 1200L the patient was transported by International SOS (ISOS) to
LRMC.
Patient 3: Patient was taken to the OR at approximately 2100L on 21 December.
He was found to have no vascular injury and was transported to the ICU. Patient had an
uneventful post-operative course. A USAF AE crew transported him to LRMC on the 23
December (with Patients 1 and 4).
Patient 4: Patient had shrapnel to the left lower back above the gluteal crease.
He had been briefly evaluated by an 18D and was determined able to wait for treatment.
During the CASEVAC, he had continued treating Patients 1, 2, and 3. At approximately
2300L on 21 December, Patient 4 was taken to the OR for debridement, washout, and
removal of shrapnel. The USAF AE crew transported him to LRMC on 23 December
(with Patients 1 and 3). He had an uneventful post-operative recovery.
Lessons Learned:
Sustain:
1) Care Under Fire.
a. Initial tourniquet use in the care under fire phase was timely and effective.
b. Recommend continued Tactical Combat Casualty Care (TCCC) training
for all providers/medics deploying to the Continent of Africa.
2) Fresh Whole Blood transfusion on the battlefield.
a. Walking blood bank operations were utilized in an effective manner.
b. Recommend continued training and equipping for walking blood bank
operations in accordance with Journal of Special Operations Medicine
(JSOM) 2012 Training Supplement’s Tactical Trauma Protocol for Blood
Component Administration.
Improve:
1) Patient documentation/communication.
a. Insufficient patient documentation may have contributed to poor
communication during patient hand off. For instance, initial tourniquet
time was not recorded. No TCCC card was used for any casualty.
b. As part of pre-mission training, enforce routine use and rehearsals using
the TCCC Casualty Card.
2) Tourniquet use.
a. Prolonged tourniquet use likely contributed to rhabdomyolysis, renal
failure, and an AKA for one of these patients who ultimately was
determined not to have femoral artery damage. Clearly tourniquets save
lives; however, their role must be constantly assessed and reassessed in
this environment of prolonged field care. Of note, the times/distances of
Africa are significantly longer than Iraq or Afghanistan.
b. Reinforce proper tourniquet application in accordance with TCCC
guidelines. Stress the reassessment of tourniquet conversion after one
hour. If it is possible to maintain hemostasis without a tourniquet on, then
it should be converted to a field/pressure dressing and/or hemostatic
bandage as soon as tactically possible.
3) Pain Management.
a. Combination of pain medications may have led to an undesired decline in
patients’ mental status in this event. Two patients had issues with pain
management medications; one delirium, and the other over
sedation/respiratory failure.
b. Reinforce realistic pain management during training. Establish Pain
Management Protocols or Standing Operating Procedures for
administration of controlled narcotics and reversal agents in order to
prevent over sedation/medication in accordance with JSOM 2012 Training
Supplement Tactical Trauma Protocols and the TCCC Guidelines recently
updated in fall 2013, which provides a “triple option” for pain management.
Establish packing list of controlled medications in sufficient quantity to
ensure pain/mental status management is properly provided during the
long CASEVAC times required in this AOR.
USASOC Patient Scenarios:
Below are seven scenarios we identified that would not only strain the skills and
preparedness of any SOF medic, they may even be difficult for the SRT to manage for 24 hours.
These scenarios seem well within the initial pre-hospital management capability of a SOF
medic, but could also result in serious complications if improperly managed for 24 hours. It
should be recognized that some of the below injuries that are more serious than stated will likely result in the death
of a patient in an “extended pre-hospital management” environment. The goal is to take a patient who has selftriaged himself as a “survivor,” and optimize his medical care so that he has the best chance of recovery once he
arrives at a hospital. Any of the scenarios could present in any of the major AORs. These will be just as relevant for
the 7th Group guys in Bolivia, or the 1st Group guys in Papua New Guinea, as they are for the 10th and 3rd Group
guys in Africa.
Here are some “situational facts” that medics should keep in mind, and that these scenarios are
meant to reinforce:
1. In the world of Trauma, even within the best hospitals in the US, some patients die.
Trauma teams begin cases knowing that some patients are unlikely to survive certain
injury patterns. Shouldn’t medics be aware of those patterns, as well?
2. If you haven’t had “hands on” trauma experience, you cannot be expected to perform
exceptionally under the most stressful of circumstances. Shouldn’t there be more
emphasis on real patient contact? Live tissue is not a substitute for this.
3. If a US soldier in a remote site was sick or injured and required evacuation or 24 hours
of care, it would be a HUGE deal and would be visible all the way to the top, both
medically and tactically. Have we been provided all the necessary support to at least
have a chance of helping your mates? Does our chain of command know this is a
problem?
4. 72 hours is not a realistic time to “sit on a patient”. An FST only has a 72 hour “hold”
capability by doctrine. How are you expected to do as much as an FST with a fraction of
the people, equipment, and skill?
5. When your mate is seriously hurt or sick in front of you in a remote setting, that is not
the time to figure it all out by yourself. Why do we train to be a lone trauma solution,
when reality points to a mandatory team solution and if comms are ALWAYS available,
why isn’t this an option?
6. These situations would be difficult for any Doctor or Surgeon to handle if they were
presented with a patient in the remote site by themselves. Why don’t we plan to
engage every possible avenue of help available, especially when civilian systems are
available for teleconsultation?
7. There is a HUGE difference between doing your best with a local national and doing
your best for one of your mates. If you didn’t call for help, would you be able to look the
family in the eyes and say you did your best? You may be very experienced in indig
medicine, but when it comes to US soldiers, you owe it to them to call for help.
8. If this patient was in the best hospital in the US, there would be a team of experts
handling this. Did you train your non-medical guys to function as your trauma team?
Will their first scenario be a crisis?
Common Evacuation Timeline for all scenarios: While in Africa (or wherever), patient
evacuation requires the team to contract a CASA 212 from 3 hours away, to land at their
location, and then to move the patient to a runway capable of landing U.S. military aircraft (i.e.
C-130/C-17) in the nation’s capitol, 4 hours away. It is estimated that it would take 12-24 hours
for a US Air Force plane to land, and it will likely not have any medical assets onboard. The
team will need to initiate care at their camp, prepare the patient for a 4 hour flight on the CASA,
and then wait for the C-17, which will then have a 9 hour flight to LRMC once mobilized.
Scenario 1: A U.S. service member sustains a GSW to the calf when the host nation soldier fails
to clear his weapon properly. The soldier had no tourniquet on the range and bled for
approximately 5 minutes. With vascular injury to the popliteal artery, the SOF medic can only
gain complete hemorrhage control with a well-positioned tourniquet, although the patient has
already lost a significant amount of blood. This patient may appear to be an easy TCCC case,
but consider how this can spiral out of control. Will the medic just give him two bags of hextend
and hope for the best, or will he resus appropriately to a decent UOP? Was he even going to
measure UOP? Does he remember how to put in a Foley? How will he decide whether or not to
transfuse him with FWB? How will he manage his pain for 24 hours? Will he be too aggressive
and snow him with Ketamine, or will he keep him awake and coherent with Morphine? Will he
call for help? Will he attempt to remove the TQ, or convert it to a wide band? What are the
metabolic consequences of a TQ in place for 24 hours straight?
Scenario 2: A U.S. service member sustains a mild TBI /Closed Head Injury from an ATV crash (we have
had three of these patients in the past four months). The patient had a transient loss of consciousness, without any
other significant associated injuries. The patient complains of a severe headache, and the medic notices a decreasing
trend in GCS while waiting for evacuation. Does the medic have a strategy to secure his airway without RSI
medications? Does he know how to properly task his team to help? Will he devote one person to watch the airway
at all times? What is the plan to keep the patient comfortable with his ET tube for the next 24? Will he call for
help? Will he remember the CPGs for management of the head injury? Does he know how to properly trend a
GCS?
Scenario 3: A U.S. service member sustains a Blunt LUNG injury from a fall from height. The patient
complains of rib pain, but no obvious fractures. Other than tachycardia, the patient’s initial vital signs are within
normal parameters. Four hours into the situation, the patient has an obvious decrease in his pulmonary status (i.e.
increasing RR, decreasing SpO2, increase work of breathing, etc.). Will the medic opt to put in a chest tube? When
the chest tube does not help, what are his next actions? If he does put in a chest tube, is he prepared to put one in
properly with clean technique? Does he know how to troubleshoot the tube? Is he prepared to intubate, and what
medications will he use? What will his report sound like if he calls for help?
Scenario 4: A U.S. service member sustains pelvic trauma secondary to a motor vehicle collision. The
patient complains of a severe pain and the medic opts to control his pain with morphine, and now he is unaware of
the decrease in mental status. As the medic tries to check on his sleeping patient, the patient has a decreased loc,
and does not answer questions. Was the medic taught to treat pelvic trauma as a pelvic bleed until proven
otherwise? Taught to recognize the slight increases in diastolic BP and changes in pulse rate? Is he trending vitals
at all? If he would have put in a Foley, his UOP would have shown less than 30ccs for the last few hours. Is he
clear on the indications to initiate FWB? Did he give TXA early? Did he call anyone for help?
Scenario 5: A U.S. service member sustains deep partial thickness burns to both arms and the chest while
burning the trash. Does the medic recognize this as a life threatening burn requiring calculated fluid therapy?
Does he understand that LR is the fluid of choice? What is the pain control strategy for 24 hours? Is he ready to
place a Foley? Does he have a plan to measure UOP? Will he call for help?
Scenario 6: An ODA Team Sergeant complains of what seems like GERD but might be chest pain. Is the SOF
Medic aware of the red flags for Acute Coronary Syndrome? Does the medic realize the importance of an O2
generator? Is he prepared to use any sort of EKG and will he be able to transmit it via email? Does he have
someone to call who is a competent ACLS provider or will he attempt to manage this without help?
A-1.Scenario 7:
A Special Forces Engineer tried to take a crack at solving the Team house’s electrical problems
and received a massive electrical shock to his right hand. He presents visibly shaken, needing to
lie down, and breathing rapid and shallow. Does the medic understand electrical burn
pathology? Will he call for help? This patient will develop severe pain. Will the medic sedate
him and lose the ability to trend mental status, or choose to control his pain with opiates? Over
the course of 7 hours, the patient develops rhabdomyolysis. Will the medic monitor UOP and
does he know what rate to run fluids? The patient’s exit wound is in between his toes, will the
medic do a complete exam, and be suspicious of a developing compartment syndrome in his
lower leg? Will the medic be able to execute a fasciotomy?
A-2.Scenario 8:
Your senior medic presents with RLQ abdominal pain x 3 days, and is convinced that he does
not have appendicitis. You witness him sneeze while working at his computer and then wince in
pain and then guard his stomach. Has the medic been given clear guidelines for when to
consult? Will the medic defer to his senior medic? The next day, the patient feels the pain
completely subside and claims he is better. Four hours later the patient’s abdomen is tender to
palpation, although more generalized and the patient is not feeling well. What now?
These scenarios highlight how TCCC alone will not get a medic through a true extended prehospital management situation. If this occurred in a developed theatre, the above patients would
be quickly evacuated to a military treatment facility, and even a delay of up to four hours would
be manageable.
Rationale for including PEEP valves in extended care of critically ill
casualties
Under normal circumstances, the pressure in the lung at the end of expiration is equal
to the atmospheric pressure. PEEP refers to the application of additional pressure at the
end of expiration to maintain pressure in the lung slightly above atmospheric pressure.
Lung volume at end exhalation is determined by the interplay between the elastic recoil
of the lung (trying to collapse the lung) and the elastic recoil of the chest wall (acting to
pull the lung open). Under normal circumstances these forces are in balance and the
lung does not collapse completely when it reaches its smallest volume at end expiration.
Many disease processes make the lung stiffer (Physiologically this is known as
decreased compliance. Practically speaking it is analogous to a balloon that is very
difficult to inflate versus one that is very easy to inflate). This increased lung stiffness
makes the lung more prone to collapse completely at the end of expiration. The
tendency to collapse is worsened by the fact that the chest wall recoil is also adversely
impacted, meaning its ability to pull the lung open is impaired. Anything that increases
intra-abdominal pressure will also favor lung collapse at end expiration by pushing up
on the diaphragm. This may be gaseous distention of the G.I. tract, hemorrhage,
excessive edema of the abdominal wall/abdominal contents, etc. Spontaneously
breathing patients may be able to overcome this to some extent by closing the glottis
and trapping air inside the lung at end expiration and by engaging their muscles of
respiration. These compensatory mechanisms can only go so far, and they are
completely inoperable in patients receiving mechanical ventilation via an endotracheal
tube.
It is important to recall that the lung is composed of approximate 500 million individual
alveoli. When I say lung collapse, I do not necessarily mean that the entire lung
collapses. It does not behave as a single large balloon. Rather it behaves as 500 million
separate individual balloons interconnected by a complicated system of airways. So as
the forces favoring collapse become stronger, a larger percentage of the 500 million
individual units are collapsed.
PEEP improves oxygenation – In order for gas to change to occur, blood and fresh
inspired gas must be in close proximity to one another – the gas in the alveoli and the
blood in the alveolar capillaries, separated only by a very thin capillary wall that permits
gas exchange across it. As these alveoli begin to collapse oxygenation is obviously
impaired as there are fewer lung units taking part in gas exchange. The body does have
an intrinsic mechanism to direct blood preferentially to non-collapsed alveoli (known as
hypoxic pulmonary vasoconstriction). However, this is not a perfect system and cannot
overcome widespread alveolar collapse.
So we need a method to help prevent lung collapse at the end of expiration in critically
ill mechanically ventilated patients. This mechanism is PEEP, or positive end-expiratory
pressure. In its simplest terms this involves keeping a small amount of pressure in the
lung at the end of expiration rather than letting it return to atmospheric pressure. This
pressure trapped inside the lungs acts as a force pushing outward on the alveoli and
holding them open. It increases the volume of gas inside the lung at the end of
expiration- or increases Functional Residual Capacity (FRC) in physiological terms.
PEEP is a simple basic setting on most mechanical ventilators. When using a bag valve
ventilation device it can be accomplished by applying a small PEEP valve to the
expiratory port on the device. A PEEP valve is simply a spring loaded valve that the
patient exhales against.
PEEP prevents ventilator induced lung injury – The loss of lung units taking part in
gas exchange as a result of collapse at end expiration impairs oxygenation. Some of
these lung units remain collapsed during the next inspiration while others may collapse
in expiration only to be reopened again when the next breath is delivered. This is known
as recruitment-derecruitment of the lung. The repetitive collapse and re-expansion of
alveoli occurring with every breath is now widely recognized to contribute to the
development of ARDS. Prevention of collapse at the end expiration by the application of
PEEP is an effective method to counteract this process. The picture below shows two
rat lungs that were ventilated outside of the chest. The inspiratory pressure was the
same for both while one had PEEP applied and one did not. As you can see the lung
with zero PEEP is enlarged edematous and swollen while the other has a more normal
appearance. This is an old the very classic experiment demonstrating the harm of
repetitive collapse and re-expansion of lungs with mechanical ventilation (recruitmentderecruitment). The advantage of ventilating the lungs outside of the chest like this as
that they are able to swell and makes the point much clearer.
Adverse effects of PEEP – The predominant adverse effect of PEEP is a decrease in
venous return to the heart leader decreasing cardiac output. At low levels of PEEP (up
to 5, maybe 8) this effect is fairly minimal and can be largely ignored. Other adverse
effects of peep including over inflation and worsening barotrauma are less relevant
overall and are also negligible at the low levels of PEEP that will be applied in the field.
PEEP = 10
PIP = 45
PEEP = 0
PIP = 45
Additional resources for interested parties
The two links below will take you to some very interesting videos on YouTube that are
worth watching – it will only take a few minutes.
http://www.youtube.com/watch?v=hOa7zO1lImI
http://www.youtube.com/watch?v=iuUSDR4ocCY
They are both videos of animal lungs (rabbit and pig I believe) that are being ventilated
outside of the chest. In both videos the operator is steadily increasing PEEP while the
lungs are inflated and deflated. Note that in the video of the smaller lungs when the
when the narrator says ZEEP he is referring to zero PEEP- the pressure in the lung at
end exhalation is equal to atmospheric pressure. As you can see the lungs become very
collapsed at the end of exhalation on each breath when there is no PEEP applied. As
PEEP is gradually increased you notice that the lungs slowly begin to expand and they
do not completely collapse again at the end of expiration. It is interesting how this
happens bit by bit – you can see some areas that are collapsed and slowly inflate over
time. Once the lungs are exposed to ZEEP again (only shown in the first video), all of
this lung recruitment is lost almost immediately and the process must begin all over
again. This is what happens at the end of each and every breath in a mechanically
ventilated patient with no PEEP applied. To be fair, lungs that are ventilated outside the
chest behave slightly differently and are much more prone to collapse at end expiration
than lungs that are tethered within the chest as they no longer have the elastic recoil of
the chest wall to keep them open. However, this is not much different than diseased
lungs that are very stiff and highly prone to collapse. I think this is a good visual
depiction of how PEEP maintains lung recruitment which is critical to maintain
oxygenation. A very inexpensive PEEP valve goes a long way towards preventing this
when ventilating with an ambubag.
KEY POINTS
PEEP – prevents the lung from collapsing at end-exhalation.
PEEP makes oxygen saturation (SpO2) increase and reduces lung damage.
In early injury 5-10 cm H2O of PEEP is sufficient to prevent lung collapse.
If PEEP is too high it can cause blood pressure to fall.
PFC Working Group – Airway comments (Apr 14, 2014)
Summary comments:
-Airway management (and subsequent supplemental oxygen, ventilator support, gastric
decompression, and a suction device) is a core capability for Prolonged Field Care.
-Every medic should be trained and maintained with the following airway skills at a minimum:
opening and maintaining an airway (with adjunctive NP/OP), bag-valve-mask ventilation, placing
a supraglottic airway, and cricothyrotomy.
-Further training, to include RSI training and advanced ventilator management, can be
considered, but require maintenance training beyond current SOF medic training curriculums.
Much like ultrasound training, these skills are within the educational reach of most SOF medics,
but constant training and maintenance of the skill sets is required to ensure a medic is sustained
and able to safely practice them.
-It is not sufficient to state a SOF medic can safely practice rapid sequence intubation (RSI), to
include the administration of paralytic medications, from having initial training alone. Medical
Directors (unit medical officers) should establish a maintenance curriculum if they wish to have
their medics (or a certain select group of their medics) trained in this skill set. A proper
maintenance curriculum should have both recurrent classroom training and supervised
intubations on a regular basis.
-Cricothyrotomy training should be included in most medical training. It is considered a final
common definitive solution for securing an airway. It allows a cuffed tracheal tube to be placed,
and will allow adequate administration of PEEP, and use of a ventilator. Additionally, unlike
placing and maintaining an endotracheal tube placed from the oral route (standard orotracheal
intubation), maintaining a cric with sedation alone is much more feasible in an austere setting.
-In a patient who does not require an emergent cricothyrotomy, a reasonable approach might
incorporate a supraglottic airway, then controlled cricothyrotomy with both sedation and local
anesthesia.
-It is reasonable to use cricothyrotomy in a medical (non-trauma) patient that requires a cuffed
endotracheal tube placed for airway maintenance.
-Robert Mabry and Richard Levitan (among others) are developing an algorithm that
incorporates the recommended decision tree that incorporates the aforementioned techniques,
to include a surgical cricothyrotomy.
Supraglottic airways:
-Supraglottic airways (SGA) are a reasonable device to provide temporary airway support.
-Patients may have a hard time tolerating an SGA if they are maintaining any upper airway
reflexes. The SGA has been described as “a tennis ball on a stick” in the back of the
oropharynx.
-SGA’s required patent (not massively disrupted) anatomy to obtain an adequate seal. This may
not be the case with massive upper airway trauma, as taught in TC3.
-Characteristics of “ideal” SGA’s are: 1) low-pressure cuff, 2) gastric decompression ports, and
3) the ability to provide positive-pressure ventilation. Some available devices currently available
on the market, which include these features are, in no particular order: King LT-D, iGel, LMA
Supreme, and Cookgas ILA. The PFC Working Group does not endorse a particular product.
Sedation for airway maintenance:
-As previously stated in the PFC analgesia/sedation comments, ketamine is an excellent
medication for providing sedation for those patients with potential airway or ventilation
compromise. It has the unique characteristic of maintaining airway reflexes and not suppressing
ventilatory drive.
-The combination of medications used for standard RSI (as practiced in an emergency
department, or urban EMS systems) includes a paralytic agent. We cannot currently
recommend the routine use of paralytic agents in obtaining an initial airway for the SOF medic.
See comments above for RSI and advanced ventilator training above. Longer acting paralytics
MAY have use after a reasonable airway has been obtained (for instance, in a patient who has
had a cric successfully performed).
SOCOM PFC WG Analgesia/Sedation Comments (February, 2014)
The following comments are summarized from a sub-group expert panel of the SOCOM
PFC working group. They should be considered in the context of the South Sudan Case
Studies recently circulated.
Please use these comments when considering case discussions and training of medics.
All comments are directed at the level of the SOF medic, and their training.
GENERAL COMMENTS:
PFC pharmacology is a core concept to be discussed in any training session.
Any discussion of PFC pharmacology should include a discussion about the CONCEPTS of
analgesia, amnesia/anxiolysis, and sedation.
A reasonable formulary of “working drugs” for the SOF medic should include: morphine,
Fentanyl, ketamine, and midazolam (Versed). Adjunctive medications could include: narcan,
romazicon, antiemetics, antihistamines, atropine and others.
The first time a medic administers these drugs should NOT be on a sick (unstable or
complicated) patient. Practice with their use.
As with any medication, a medic should be able to demonstrate an active knowledge of the
pharmacology of any medication they are allowed to carry. This should include: indications,
therapeutic dosages, half-life, time for peak effect, contraindications, adverse effects, usual
concentrations, pitfalls, and your personal strategy for dilution and administration.
Any procedure that involves sedation should also include monitoring the patient, ideally with
end-tidal CO2 (with a waveform), and at a minimum, have oxygen saturation (pulse ox)
monitoring. Also, airway adjuncts, to include suction, BVM with oxygen source, and
advanced airway equipment, should be available.
If a patient is too unstable, pain control and sedation should be withheld until the patient can
be stabilized.
COMMENTS ABOUT THE AGENTS (in the context of the case study):
-There is a difference between analgesia (pain control) and sedation. Some patients who
appear to only need pain control MAY need sedation in order to perform prolonged
evacuations (travel over rough roads, for instance). Other examples of clinical scenarios
that may require sedation include: chest tube insertion, cricothyrotomy, reduction of
fractures or dislocations, large burn debridements, surgical procedures such as
fasciotomies, and rapid sequence induction for intubations.
-The reason opioids have been around for centuries is they work. This is in the case of the
need for analgesia. It is perfectly reasonable to treat >80% of patients with morphine.
Stable patients can get morphine.
-Hemodynamically unstable patients should get Fentanyl (or ketamine at pain control
doses). Remember, fentanyl and ketamine have very short half-lives and will need to be
dosed and re-dosed. A drip for analgesia can be very problematic and is NOT advised.
-Fentanyl lollipops are effective and easy to administer. 1 x 800mcg lollipop, in its entirety,
which has about 50% bioavailability, would be the equivalent of approximately 400mcg IV.
Do not discount this when adding drugs that are synergistic. A major side effect of the
lollipops is nausea.
-Get away from IM and go to IV meds as quickly as feasible. There is a time for
non-IV/IO administration, but that time ends with the establishment of IV's and
a couple of minutes to think through the process. In these cases (South Sudan case
studies), the patients received two different drugs through delivery mechanisms that make
them very difficult to titrate.
-Mantra should be “titrate to effect,” as there is a range for every patient and tolerance.
-Ketamine, in general, is an excellent medication if you understand its effects and pitfalls.
There are three ranges: effective pain range with little or no mental status effects (start with
10-20mg IV and titrate to effect), the mid-range where they’re still awake but agitated and
actively hallucinating (0.3-1.0 mg/kg; 30-80mg IV), and the dissociated range where they’re
sedated and dissociated: 1.0-2.0 mg/kg IV. Decide ahead of time if you’re going high or low,
but don’t get stuck in the middle. This is also an excellent medication to induce
unconsciousness prior to RSI (rapid sequence induction) prior to intubation (1.0 mg/kg IV
push). PLEASE NOTE: these are all IV/IO dosages, NOT IM. IM dose for initial
administration is 4X the IV/IO dose.
-Versed (and other benzodiazepines) is a great drug. Great for the correct indication, but
there can be some serious pitfalls with its use, especially when added to other potent drugs.
Understand the synergy of benzodiazepines and opioids (synergistic effect). Occasionally, it
can drop blood pressures or over-sedate your patient.
Below is a recommendation for a sedation (not pure analgesia) mix that can be used
to prepare and administer an infusion over time:
Basic principle: ketamine/versed drip with IV fentanyl bumps if needed.
Mix: 250ml bag of NS, filled with 750mg ketamine and 25mg Versed. The initial drip rate is
KG body weight/2 = cc/hr. For example a 100kg patient would be started at 50cc/hr drip
rate. At this rate, you can calculate the bag lasting about five hours. In practice, it is
observed that the majority of the time, the drip rate could be cut in half after 20-30min, and
the bag may last 8-9 hrs. (For reference, the initial doses are: ketamine: 1.5 mg/kg/hr, and
Versed: 0.05mg/kg/hr).
Remember, there is NO such thing as a cookbook. BE VIGILANT and titrate the drugs to
effect
Romazicon should be available with this drip combination in the event that the entire bag is
infused mistakenly as a bolus. There is a large safety margin with inadvertent high doses of
ketamine, but this dose of Versed would be problematic.
For reference, many sedation procedures in anesthesia are a combination of 2-3mg Versed
followed by 50-100mcg of fentanyl and then 20mg bumps of ketamine until the patient has
nystagmus (normally 60-80mg of ketamine).
For the sedation infusion combination above, some units package it and seal/band it to
distribute as a complete kit. This helps with both accountability of the various medications
and operational medical planning (one small package for the purpose of sedating one
critical casualty for approximately 8 hours).
PFC WG Tourniquet Conversion Recommendations
June, 2014
Background and General Notes:
Tourniquets (TQs) save lives. In care under fire, liberal use of tourniquets is
encouraged on all concerning extremity hemorrhage. In this phase, life-saving actions
take precedence over diagnostic maneuvers.
There are no documented cases of permanent tissue damage, permanent vascular
injury or permanent nerve injury from a properly applied TQ (arterial flow to extremity
stopped) in place for less than 2 hours.
TQ conversion is the deliberate process of trying to downgrade hemorrhage control to
hemostatic agents/pressure dressings.
Conversion has been advocated since World War II (Wolff and Adkins 1945) and at
each stage of TCC development but an up-to-date and formalized protocol has not been
completed
Conversion should be initiated as soon as the Care Under Fire Phase has stopped (or
sooner if tactically appropriate).
Conversion should be attempted with each progressive movement to the next level of
care, but not for TQs that have been in place for more than 6 hours unless at a definitive
care facility.
Recommended procedure for TQ conversion:
- Add 1 loose TQ to each extremity that already has a TQ applied (“Plus 1”). This
is done for two reasons:
1-If the TQ that is already in place breaks during the conversion process, there is
already a back up in place ready to be tightened. TQs carried exposed to the
environment are subject to degradation based on this exposure (references below)
2-It is difficult to determine where the patient is on the resuscitation curve.
Administration of fluids (crystalloids, colloids or blood) and/or ketamine has the potential
to raise blood pressure beyond your hypotensive target. A second TQ in place reduces
bleeding time if bleeding suddenly recurs.
- With “Plus 1” in place, loosen the first TQ. If no bleeding from the wound is
noted, then leave both TQs in place but not tightened and dress the wound.
- If bleeding is noted, apply a hemostatic agent and hold pressure for 3-5 minutes.
If no further bleeding is noted, leave the loose TQs in place and dress the wound.
- If hemostatic agents fail to control the bleeding, tighten the original TQ in as
distal a position as possible to control the bleeding. Leave the “Plus 1” TQ loose
and proximal to the tightened TQ.
FREQUENTLY ASKED QUESTIONS:
How long can TQs stay on before conversion should no longer be attempted?
The definitive answer to this is unknown. Most complications in the literature are a
result of improper application (venous occlusion without arterial occlusion is a major
concern). There is a case with documented total TQ time of up to 16 hours, but the
extremity was exposed to the cold environment and the TQ was placed distally. This
patient had residual motor and sensory deficits but no systemic complications of
reperfusion. (Kragh, J Orthop Trauma 2007)
<2 hours is considered safe (attempt conversion)
2-6 hours is likely safe (attempt conversion)
>6 hours requires caution (conversion not advised in PFC)
Should the TQ be loosened periodically to perfuse the distal tissues?
Absolutely not. This results in “incremental exsanguination.” The patient is bled to
death in short bursts. Conversion should be attempted as soon as possible and with
each movement to the next level of care.
References
TQ Failure:
Childers et al. Tourniquets exposed to the Afghanistan combat environment have
decreased efficacy and increased breakage compared to unexposed tourniquets. Mil
Med. 2011;176(12):1400-3.
Weppner et al. Efficacy of tourniquets exposed to the Afghanistan combat environment
stored in individual first aid kits versus on the exterior of plate carriers. Mil Med.
2013;178(3):334-7.
Prolonged TQ Use:
Kragh et al. Extended (16-hour) tourniquet application after combat wounds: a case
report and review of the current literature. J Orthop Trauma. 2007;21(4):274-8.
Dayan et al. Complications Associated with Prolonged Tourniquet Application on the
Battlefield. Mil Med. 2008;173(1):63-66.
Broad TQ Review including History/Complications/Conversion:
Wolff LH, Adkins TF. Tourniquet problems in war injuries. Bulletin of the U.S. Army
Medical Department 1945: 77-85.
Lakstein et al. Tourniquets for hemorrhage control on the battlefield: a 4-year
accumulated experience. J Trauma. 2003;54:S221-S225.
Walters TJ. Issues related to the use of tourniquets on the battlefield. Mil Med.
2005;170(9):770-5.
Richey SL. Tourniquets for the control of traumatic hemorrhage: a review of the
literature. World Journal of Emergency Surgery. 2007;2(28).
Lee et al. Tourniquet use in the civilian prehospital setting. Emerg Med J. 2007;24:584587.
MacIntyre A, Quick J, Barnes S. Hemostatic dressings reduce tourniquet time while
maintaining hemorrhage control. Am Surg 2011;77:152-165.
PROLONGED FIELD CARE WORKING GROUP POSITION PAPER:
OPERATIONAL CONTEXT FOR PROLONGED FIELD CARE
JUNE, 2014
We propose a universal approach to operational planning and logistical preparation for
Prolonged Field Care (PFC) missions, in the form of 4 stages. In the past, we have
been accustomed to view missions in terms of patient treatment stages, such as seen in
TCCC. This is less useful when planning for Prolonged Field Care, due to the more
comprehensive list of capabilities needed to consider across a wider spectrum of
operational realities. Instead of echelons of patient care, we propose to use a system of
mission or evacuation stages to simplify and standardize our language, utilizing the
following terminology: RUCK-TRUCK-HOUSE-PLANE (RTHP). We believe that the
RUCK-TRUCK-HOUSE-PLANE format is useful, being simple as well as easily
transferable and relatable, across all branches of service.
The stages are explained below:
RUCK - the gear carried to the furthest point on a mission, generally carried by medical
personnel dismounted.
TRUCK - whatever additional equipment will be carried in mission-specific
transportation, whether that is trucks, boats, ATVs, kayaks, etc.
HOUSE - gear available to the medic, but which is only feasible to be maintained at a
team house, firebase, or other mission support site. It represents the highest level of
care the operational element has organic to it.
PLANE - planning stage included to allow the medical providers to consider how they
will move patients on aircraft, whether MEDEVAC aircraft (those designated and
equipped to move casualties as a primary mission) or CASEVAC (pre-planned nonmedical mission support aircraft, opportunity or “slick”) aircraft.
These stages are conceptual, and not necessarily linear, but should be used as
guidelines only. An operational example could include:
A unit operating out of their vehicles on an extended desert mission may not have any
higher level of organic care than that which is contained on their trucks. They may not
operate out of a fixed facility or team house. The trucks would therefore represent the
highest level of capability the unit has organic to them, or HOUSE. However, when they
split up into patrols, the vehicles on each patrol will normally be stocked with resupply
bags, and perhaps heavier medical equipment, such as oxygen bottles. These patrol
vehicles now represent the TRUCK stage. The most specialized capabilities may only
be retained by the command and control element or mission support site (MSS),
representing HOUSE. The individual medic and the equipment on his person represent
RUCK.
In the above scenario, if the Special Operations team is engaged apart from their
vehicles they will only have the capabilities in their RUCK. If possible, they may move
back to the vehicles and evacuate the patient with the additional capabilities in TRUCK
to their command and control or MSS (HOUSE). Alternatively, if available, they may call
for air evacuation of a patient. Consequently they may go from the capabilities of RUCK
or TRUCK directly to PLANE.
The point of the above illustration is the flexibility of the language to describe
operational context of care. It should be noted these stages are always defined
according to assets available, mission and unit. There is no expectation that a TRUCK
or HOUSE is the same across the board.
A useful operational planning diagram would be to develop a matrix with 4 horizontal
rows labeled with the 4 operational stages, and the vertical columns labeled with the
PFC capabilities. This allows for easier visualization and decision-making with respect
to capabilities and equipment available throughout stages of the mission, with respect to
casualty treatment and transport. A partial example is below:
TRUCK
Monitor
Pulse ox,
BP Cuff,
Steth
Monitor
HOUSE
Monitor
PLANE
Monitor
RUCK
Airway
SGA/cric
…
…
SGA/cric
with
ketamine
drip
LR
O2
RSI
cases/hypertonic concentrator capability
saline/FWB
LR
BVM with
SGA/cric
PEEP
with
ketamine
drip
…
Resuscitate
NS/hespan
Vent/oxy
BVM with
PEEP
NS/hespan/FWB BVM with
kit
PEEP/O2
x2 bottles
…
…
There are several further advantages to considering this model. Most importantly, after
identifying stages in this manner, it is easy to identify which capabilities and which
specific equipment you will have at any point on a mission or during evacuation of a
patient. This then helps the medic to visualize gaps, and areas which lack important
capabilities along the proposed evacuation chain.
Space is a planning constraint on almost all SOF missions. From the moment a unit
loads out from their home station, decisions are made to prioritize the allocation of
space; in shipping containers, on vehicles, and on the person of the individual
combatants. The framework RTHP can be of utility by simplifying prioritization here as
well.
Using this verbiage, it is much easier for the medic to explain to his leadership what his
concerns are, and to pack an appropriate amount of equipment for a realistic
expectation of needs. A medic can use the operational context and stages to better
visualize the equipment needs, and communicate this to his team. For example, the
medic’s explanation would include the operational need to support a house, four trucks,
and possibly the capabilities to outfit an aircraft to some degree. Using this example, it
becomes easier to see that instead of one or two oxygen bottles, perhaps the team
needs two more, with another solution, such as an oxygen concentrator, at the HOUSE.
Finally, one of the strategic advantages of the community using this lexicon, is
homogenizing our research, development and procurement of equipment, and improve
our overall capabilities in the long run. Since part of the emphasis on PFC is to
effectively evaluate equipment to support capabilities, we can better evaluate equipment
in our numerous sets, kits and outfits, and objectively compare common equipment in
the standardized operational phases. It will also quickly identify capability gaps and
focus future research and development needs in the community.
To summarize, the application of a standardized operational context naming convention
system such as RTHP in the context of medical operational planning, and specifically in
PFC, provides several immediate benefits:
1. It provides a framework for planning your mission support and personal load out.
2. It provides a clear system to explain to leadership where your patient care and
holding capability shortfalls lie.
3. It is flexible language, applicable to any mission.
4. It gives the community common language, and allows all SOF medical providers and
planners to easily share best practices, or equipment suggestions.
5. It provides a simple lens through which to consider necessary research,
development, or acquisition.
PROLONGED FIELD CARE WORKING GROUP POSITION PAPER
PROLONGED FIELD CARE CAPABILITIES
JUNE, 2014
A newly formed Prolonged Field Care Working Group (PFC WG), comprised of medicalspecialty subject matter experts, has been tasked to evaluate the current training and
preparedness of Special Operations Force (SOF) medics. The first formal position
paper from the working group suggests that medical providers consider the below list of
capabilities when preparing their medics to provide PFC in austere settings. It is
presented in a “minimum, better, best” format. The intent is to demonstrate those basic
skills, with adjunctive skills and equipment that may be employed when considering
what to train for Prolonged Field Care (PFC).
At first glance, the list may seem somewhat simple, but it emphasizes basic medical
skills, that, when put together, allow for a more comprehensive approach to critical
patient care in an austere setting. Of note, equipment is relatively de-emphasized since
medical skills and training should be the focus of preparing the Special Operations
provider for providing this care.
PFC requires the following capabilities in at least some capacity. If you can provide these 10
capabilities in at least the minimum requirements, you are on your way to being prepared for
PFC. Here are the recommendations:
1. Monitor the patient in order to create a useful vital sign trend
a. Minimum – blood pressure cuff, stethoscope, pulse oximetry, Foley catheter
(measure urine output) and an understanding of vital signs interpretation. Use a method to
accurately document vital signs trends.
b. Better - add capnometry
c. Best - vital signs monitor in order to provide hands-free vitals at regular intervals
2. Resuscitate the patient beyond crystalloid/colloid infusion
a. Minimum - field Fresh Whole Blood transfusion kits
b. Better - maintenance crystalloids also prepared for a major burn and/or closed head
injury resuscitation (2-3 cases of LR or PlasmaLyte A; hypertonic saline); consider adding
Lyophilized Plasma as available; Fluid warmer
c. Best - maintain a stock of PRBCs, FFP, and have type-specific donors identified for
immediate FWB draw.
3. Ventilate/oxygenate the patient
a. Minimum - provide PEEP via BVM valve (you cannot ventilate a patient in the PFC
setting (prolonged ventilation) without PEEP or they will be at risk for developing ARDS)
b. Better - provide supplemental O2 via oxygen concentrator
c. Best – portable Ventilator (i.e. Eagle Impact ventilator or similar) with supplemental
O2
4. Gain definitive control of the patient's airway with an inflated cuff in the trachea (and be able
to keep the patient comfortable)
a. Minimum - Medic is prepared for a Ketamine cricothyrotomy
b. Better - add ability to provide long-duration sedation
c. Best - add a responsible RSI capability with subsequent airway maintenance
skills, in addition to providing long term sedation (to include suction and paralysis with
adequate sedation)
5. Use sedation/pain control in order to accomplish the above tasks
a. Minimum - provide opiate analgesics titrated IV
b. Better - trained to sedate with ketamine (and adjunctive midazolam)
c. Best - experienced with and maintains currency in long term sedation practice using
IV morphine, ketamine, midazolam, Fentanyl, etc.
6. Use physical exam/diagnostic measures to gain awareness of potential problems
a. Minimum - using physical exam without advanced diagnostics - maintain
awareness of potential unseen injuries (abdominal bleed, head injury, etc)
b. Better - trained to use advanced diagnotics - ultrasound, point-of-care lab testing,
etc.
c. Best - experienced in the above
7. Provide nursing/hygiene/comfort measures
a. Minimum – ensure the patient is clean, warm, dry, padded, catheterized and provides
basic wound care
b. Better - elevate head of bed, debride wounds, perform washouts, wet-to-dry
dressings, decompress stomach
c. Best - experienced in all the above
8. Perform advanced surgical interventions
a. Minimum - chest tube, cricothyrotomy
b. Better - fasciotomy, wound debridement, amputation, etc.
c. Best - experienced with all the above
9. Perform telemedicine consult
a. Minimum – make reliable communications; present patient; pass trends of key vital
signs
b. Better - add labs and ultrasound images
c. Best - video teleconference
10. Prepare the patient for flight
a. Minimum - be familiar with physiologic stressors of flight
b. Better - trained in critical care transport
c. Best - experienced in critical care transport
PROLONGED FIELD CARE DOCUMENTATION
AUGUST, 2014
The need for more robust patient care documentation while caring for a patient
over an extended period of time has been proven through exercises, scenarios and
incidents to be the most effective way to provide prolonged field care. Despite this,
many medics continue to fall short by attempting to improvise by using cardboard,
multiple strips of tape, or even writing on the wall or patient while in a crisis situation in
order to document. Any medic can greatly improve the morbidity, as well as mortality,
of their respective patients post-recovery through the use of an organized and efficient
flow-sheet. Through much trial and error, consulting, editing, and revising the local PFC
working group has agreed upon certain attributes that a single patient care document
should contain for the purpose of prolonged field care. While we have also made
available our product, we would like to emphasize that if you do not use ours, having
something ready and familiar pre-incident is better than neglecting this aspect of care
until a crisis arises.
Nowhere is the need for documentation more important than during the hand off
of patients between medical providers. In a remote, austere environment it is likely that
during a lengthy evacuation a patient will be transferred multiple times between medics
and providers. The sheer amount of information accumulated during a prolonged field
care event will not be manageable, recalled or relayed in the short time during hand-off.
Properly relaying injuries, treatments rendered and drugs administered to the next
echelon, team or lone medic can be the difference between a patient dying, living or
living with lifelong difficulties. We owe it to our patients to continue providing first world
care despite the circumstances and properly documenting that care is an easy way to
improve patient outcome which will make all the difference to our brothers-in-arms and
their families.
The first things mentioned and agreed upon is that the document should be a
single page utilizing both sides and able to cover as much time as safely possible. This
will prevent multiple pages from becoming separated during movement or transfer of the
patient. Several sizes and types of paper have been used but the most common and
easily accessible 8.5”x11” laminated page is being recommended and a much larger
version has also been used successfully in an aid station-like setting demonstrating its
utility. Having both and transferring data between the two is a viable option, using the
smaller size during the initial stages of care and transferring data to the larger once in a
more static position. Either can travel with the patient and be transferred to the
receiving medical treatment facility.
The first side of the flow sheet will be referred to as Side A and should contain all
necessary data pertinent to patient identification, safety, security and tracking by the
organization. The version 12 document we have available for use is in Excel format for
ease of editing and customization. Known patient allergies should be clearly visible,
along with tourniquet application time, which was proven crucial during the most recent
incident in South Sudan. The MIST report (Method of illness or injury, Injuries, Stable or
Unstable, and Treatments rendered) should be easily identifiable for anyone relaying
information to telemedical support as well as a current set of vitals is usually requested
and appropriate to relay here.
While most first rate medics may not be familiar with all labs and the
consequences of the values, it is worth adding them to the sheet for the purpose of
consulting and perhaps going a step further and adding the local conversion for the
country one is operating in. If one can run a couple vials of blood to the local host
nation clinic, or run it through an iStat, one should be able to relay that info, which will
greatly improve the clinical picture to another provider on the other side of the world.
Keeping the normal ranges for these labs can alert even an untrained team member
that the result is out of range and should be brought to the attention of the necessary
personnel.
Drugs and fluids administered, or Ins, will be important in the short term but also
very important when working with multiple providers, an unfamiliar team or anytime
there is a hand-off or transfer. If you are tracking Ins then tracking Outs nearby will be
as important. I cannot possibly go over all of the implications of properly recording and
trending urine output here, but of initial concern in shorter term patient management,
properly tracking urine output serves as a surrogate measure of adequate resuscitation
in many patient populations. Other Outs include chest tube drainage, stomach contents
via NG/OG tube and feces, which can all add pieces to the puzzle. An area for clinical
notes is usually useful for other info that does not fit into one of the other categories.
We have also adopted the pictogram from the TCCC card for another visual reference,
and will likely add the GCS criteria and possibly, a revised trauma score in a future
version in the notes section.
Side B started out with a visual trending chart that can be used for a multitude of
different vitals using different symbols and connecting those symbols like connect the
dots. This will make easier the instant recognition that a patient’s health is in decline or
if they are improving. In order to trend a patient throughout a PFC incident more
information will be needed over a longer period of time than is normally anticipated for.
Using a customizable grid with blanks for recording hours and minutes will give the user
the flexibility to take vitals as needed for either a stable or unstable patient without
skewing the trend line much at all. Our chart is easily used over a 10 hour period taking
vitals every 15 minutes before needing to move to a second sheet and can be used far
longer than this if time between vitals is increased. Other vital signs which are difficult
to trend due to the small change in number should still be recorded for comparison,
such as core temperature, pain scale or GCS and output of drains other than urine.
Due to the nature of small unit operations, taking even one or two casualties can
be extremely stressful as well as time and resource intensive for the medic and team as
a whole. A single medic caring for a casualty will likely experience an initial rush of
adrenaline as the patient is stabilized, and depending on the duration of the operation
and time to evacuation may also experience extreme fatigue. This fatigue, if not
managed properly can lead to mistakes by highly trained and experienced SOF medics.
Therefore, a chronological checklist of nursing care reminders is recommended in order
to remind the medic of procedures beneficial to the patient. Since not all patients
present with the same injury symptom, every effort should be made to anticipate as
many procedures and treatments common to the majority of patients seen due to both
trauma and illness. These reminders therefore, may appear to be random or generic
depending on the presentation of the patient but can easily be crossed out when not
applicable.
All team members should be educated on the use of this new flow sheet
prior to deployment or even a training scenario. Once demonstrated and explained it
becomes much easier for the non-medical person to understand what is going on with
the patient, making them an asset in care as opposed to a hindrance or worse, a
liability. The medic and non-medic alike will now be able to anticipate through trending,
the health of the patient in the near future. This will enable a proactive approach to
planning the procedures and care the patient receives as opposed to constantly
reacting to patient crises, possibly when it is too late.
PJ Extended Field Care Guidelines Paper
1. The unique nature of Pararescue missions may require tactical or remote/austere
field, safe house, or ship care lasting hours to days before evacuation can be achieved.
Identify the potential for prolonged tactical field care during mission planning in order to
prepare increased amounts of medical supplies (e.g.: carried on vehicles, bundled, etc.)
and/or resupply bundles.
Extended Tactical Field Care is presumed to exist when evacuation cannot be
performed within the 4 hour time frame doctrinally dictated for Priority patients. This
statement is a SOCOM recommendation. Judgment can be exercised on implementing
full on extended care if evac occurs by 6-8 hours.
General concepts with use of acronyms:
Use MARCH for patients who are unstable and for initial tactical field care.
Use MARCH PAWS to maintain acute care and tactical field care. Complete it fully at
least once prior to transitioning to HITMAN. Transition to HITMAN (extended field care)
after 4-6 hours, integrate it with MARCH as needed for unstable patients.
General considerations after patient is stable, or unstable patient and >8 hours
extraction/ exfiltration. Use HITMAN. Details below the specific guidelines.
H- Hydration- PO/ IV/ IO/ NG tube
Hypothermia- insulate from ground, keep warm and dry
Hygiene- prevent pressure sores/roll and pad patient, keep patient clean and dry
I- Infection- take temps, change wound dressings every 12-24 hours, confirm antibiotics
given on schedule, check IV/IO sites and sites of invasive procedures.
Increased compartment pressure - diagnose and treat compartment syndrome in
injured
extremities
T- Tubes & lines. Make sure all lines appear “neat and tidy” and are functioning
and draining properly. Intermittent or continuous suction applied if indicated (chest
tube, NG tube). Intermittent lavage PRN (cric, ET tube).
M- Medications- 6 rights-pt., med, dose, time, route, documentation.
Monitoring- as needed. If unstable q 2-4 h, record VS including AVPU/temp/
O2 sat, VS no less than q 12h
A- Analgesia. Document with pain scale. Add versed to ketamine or fentanyl as
needed to potentiate it, sedate patient, or manage anxiety. Add Duragesic
patches (72 hour fentanyl patches)-ideal for this setting.
N- Nutrition- extremely important for all patients, critical for severely injured
patients, important for the operator. Sports gel and high calorie protein bars
(>300 calories, or unsalted nuts instead of protein bars) are densely caloric and
supply
all 3 macronutrients- carbohydrates, protein and fat. Shoot for >1500 calories per
day
if they take PO. Can bring Gatorade (electrolyte) powder and protein/recovery
powders and give orally or rectally. In unconscious patients you can put small
amounts of GU in the buccal (cheek) pouch. Over 1-2 days critical patients may not
technically need calories, however there are many advantages to feeding patients
and
operators when possible. If not sure of feeding patient- give a gel q 3 hours and 1/3 to
½ a protein bar on the 90 minutes in between.
Hydration requirements: 4 ml/kg/hr for the first 10 kg, then 2 ml/kg/hr for the next 10, then 1
ml/kg/hr for any additional kg.
ie 60 kg person is 4(10) + 2(10) + 1(40) = 100 ml/hr. Maintain urine output at 30-60 cc/ hour.
DETAILED ASPECTS OF REASSESSMENTS
1. Airway Management:
a. Re-verify airway patency and security in a consistent manner.
b. Suction: Consider periodic low pressure suctioning of the oropharynx and
endotracheal tube.
c. Pulmonary toilet: Consider periodic gentle saline flushes (2 ml) to clear mucus/blood
from ET tube.
d. Local wound care at cricothyroidotomy site if applicable.
e. Drag partially inflated foley through ET tube to pull clots and mucus
2. Respiratory Management:
a. Place a small gauge thoracostomy device or chest tube if casualty required needle
decompression previously, or has chest trauma and respiratory distress/ low O2
saturation, etc.
b. Apply negative pressure to chest tube if available, not exceeding -20 cm water. Can
clamp and intermittently use suctions device gently, or set up one way valve to drainage
bag.
c. Consider rib blocks for pain management.
d. If available, administer oxygen to maintain O2 saturation > 90% (ideally>94% for
TBI).
e. If patient is being ventilated, maintain strict bagging cycles (1 breath every 5
seconds) and a tidal volume of approximately 500 ml (bag one handed, not a full bag of
volume) to allow for complete exhalation and avoid stacking breaths.
f. Consider the use of a ventilator/assist device if available. If the device permits, add
physiologic positive end-expiratory pressure PEEP (3-5 cm water). If using a SAVe or
Autovent, use the Bag for 4-8 breaths q 15minutes to provide positive pressure.
Patients on these devices need constant monitoring to make sure the device does not
fail. BVM always needs to be available.
g. Use the DOPE acronym to trouble shoot tube, vent or capnography problems:
Displacement: verify tube placement
Obstruction: use suction and flushes, replace tube if necessary
Pneumothorax: use your stethoscope, if prior needle decompressions, place chest
tube
Equipment: check all equipment, lines , connections, power sources, etc.
h.. Consider sedation with midazolam (Versed) 1-2 mg/hour IV/IO in casualties requiring
prolonged intubation/ventilation if no shock or hypotension.
3. Flail chest management:
a. Do not tape the chest.
b. Casualty may require positive pressure ventilation. RR>30, O2 sat <90%.
c. Ensure adequate analgesia. Consider rib blocks for pain management.
d. These casualties frequently fatigue and require intubation/definitive airway/
ventilation.
4. Fluid management:
a. Conscious: Instruct casualty to drink clear liquids up to 1 liter per hour; consider oral
electrolyte supplementation if available.
b. Unconscious: Insert Foley catheter and titrate IV/IO/NG/PR crystalloid fluids to
maintain urine output of 30-50 ml per hour.
i. Clean water may be utilized in lieu of crystalloid for NG infusion.
ii. Maximum NG fluid infusion rate for stable patients is 200 ml per hour.
c. Critical burn (> 20% TBSA of 2nd/3rd degree burns):
i. Insert Foley catheter.
ii. Continue fluid resuscitation according to “The Rule of Ten” for Burn patients.
(a) Initial rate is 10 ml per %TBSA per hour for a maximum casualty weight of 80 kg.
(b) Add 100 ml per hour to the rate for each 10 kg above 80 kg.
(c) Example: A 90 kg casualty with 50% TBSA burn would receive an initial rate of
(10 ml x 50) / hour + 100 ml / hour or 600 ml / hour.
iii. Adjust fluid rate q 2 hrs to maintain urine output of 30-50 ml per hour.
iv. Oral fluid administration may be acceptable in burns up to 40% TBSA if crystalloid
supplies are limited. Larger burns are associated with ileus and significantly decreased
bowel absorption. Use WHO oral rehydration packets if available.
5. Wound care management:
a. Irrigate with low pressure and redress wounds (any potable water can be used for
irrigation).
b. Debride only obviously devitalized tissue. Never cut what you are not sure of.
c. Change dressings every 24 hours. Consider converting to silver impregnated
dressings to reduce frequency of dressing changes.
d. Continue antibiotics. Repeat moxifloxacin (Avelox®) 400 mg PO or ertapenem
(Invanz®) 1 gm IV/IO/IM every 24 hours.
e. Know the signs of infection: redness, swelling, tenderness, pain, pus (purulence).
6. Analgesia:
a. See Procedural Analgesia Protocol for procedures.
b. Consider local blocks for pain management. Maximum lidocaine dose=
c. Use PJ 3 step approach to pain.
d. Get local Flight Surgeon approval to use Duragesic (Fentanyl) Patches with training.
Use 50 microgram patches incrementally to a max of 3 patches after 6 hours if
inadequate relief from first placement. Use OTFC or ketamine for breakthrough. Label
every patch with sharpie with date and time they have to be removed, 72 hours from
placement.
7. Orthopedic/ Compartment Syndrome management:
a. Apply traction or non-traction splints as required.
b. Reassess fractures and splint in position of function. Keep at height of the heart.
c. Check neurovascular status after any manipulation and during monitoring.
d. Be suspicious of compartment syndrome in the following conditions:
i. Fractures. ii. Crush injuries. iii. Vascular injuries. iv. Circumferential burns. v. Multiple
penetrating injuries (fragmentation).
e. Clinical signs of compartment syndrome:
These are the 2 findings that allow you to make the diagnosis in the presence of injury
to an extremity:
i. Pain out of proportion to injury.
ii. Pain with passive motion of muscles in the involved compartment.
The following are very late or usually not present:
iii. Pallor. iv. Paresthesias. vii. Pulselessness
f. Consider use of compartment pressure monitor if available and trained in its use.
g. Increasing swelling, decreasing motion, and increasing pain not responsive to
analgesics in the appropriate clinical setting should raise the possibility of a developing
compartment syndrome.
h. Compartment syndromes may take hours to develop. For patients with suspected
compartment syndrome, reevaluate every 30 minutes for 2 hours, then every hour for
12 hours, then every 2 hours for 24 hours, then every 4-6 hours for 48 hours..
i. Extremity compartment syndromes may occur in the thigh, lower leg/calf, foot,
forearm, and hand.
j. Compartment syndrome management:
i. Maintain extremity at level of heart. Do not elevate.
ii. Loosen encircling dressings. Use gentle splinting.
iii. Urgent evacuation.
k. Fasciotomy:
i. Only consider if evacuation is delayed 6 hours or longer and fasciotomy is within the
scope of the treating PJ.
ii. See Fasciotomy Protocol
8. Special blast injury considerations:
a. Tympanic membranes:
i. Inspect for perforation if possible.
ii. Presume perforation in the setting of post-blast hearing loss.
iii. Dexamethasone (Decadron) 10 mg IV/IO/IM/PO QD x 5 days for hearing loss if not
contraindicated by other injuries.
b. Lungs:
i. Pulmonary overpressure may result in delayed lung injury.
ii. Monitor patients closely for respiratory deterioration for at least 6 hours post-blast.
c. Abdomen:
i. Blast overpressure may result in bowel injury and delayed perforation.
ii. Acute abdominal pain, especially with evidence of peritoneal irritation, within 72
hours of blast exposure should be presumed to be a bowel perforation. If patient
develops severe pain, rigidity , rebound tenderness use Ertapenem, Fentanyl for pain,
and Zofran for nausea. Urgent evac.
d. Spine:
i. Patients involved in vehicular blasts or thrown by explosions are at high risk for spinal
injury. Immobilize as indicated. Use C-spine clearance protocol if appropriate. Pad back
boards and collars on boney prominences.
ii. Maintain a high index of suspicion for spinal injury: unconscious patients, blast,
rollovers, falls >10 feet, any midline neck or back pain. Document neurologic exam.
e. Soft tissue defects/ amputations:
i. Remove gross debris, irrigate, and debride.
ii. Cover and secure all soft tissue defects and amputations, even if not sterile:
e.g. cravats, chucks, T-shirts, space blanket, etc. and duct tape.
10. Comms: Pre-plan audio only vs. audio-visual vs. a-v + medical telemetry
a. ability to get Medical C2
b. ability to affect urgency of evacuation
11. Gear: if able to bring extra gear on vehicles or staged in shelters consider the
following for single patientsadjust quantity by mission specifications and ruck-truck-house- helo/plane logistics:
a. Chucks, 6-10 and 1 box of gloves
b. 6-10 L of NS, can use for initial burn care (do not duplicate NS and LR), need to
switch to LR after 4 L NS
c. Extra compressed gauze, syringes , needles, IV tubing, opsites, etc.
d. Nutrition as above – 10-15 gels, 5 bars, electrolyte powder, maybe protein powder
e. Warm items- wool blanket, extra change of fleece clothes/ hat, HPMK x 2
f. Duragesic patches for pain. 50 micrograms – box of 5
g. Extra Zofran, versed, fentanyl and ketamine
h. Full complement of PO meds
i. Water filtration system, iodine tablets
j. Baby wipes, 1-2 washcloths, small basin
k. Betadine
l. >2 foley catheters, urine collection bags
m. >2 NG tubes, 60 cc syringe that fits, plastic clamps for tubes
n. Baby wipes
o. Purell or other sanitizer
p. Flow sheets for vital signs, Is and Os and care provided
PFC Scenario AAR 18 July 2014
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This should be made into an annual, or bi-annual requirement. At the minimum, it
needs to be mandatory for all teams’ PMT schedule.
Teams that are savvy with the PFC routine should/need to roll it into part of a
larger exercise, whether it’s part of an UW exercise, or we integrate it with the
SFAUC committee.
PFC needs to be a 1 ½ or 2 day series, with the ½ or first day being a teaching
day with stations in the PFC room, as well as a “crawl” scenario which would
allow teammates to rotate through the various roles of scribe, airway, etc. The 2 nd
day needs to be a pure scenario with no teaching breaks letting the situation
develop for better or worse based on the team’s performance.
We need to use more realistic vehicles, such as SUVs and pickup trucks to better
simulate the kinds of vehicles that teams use in Africa.
Teaching stations need to include:
o Blood transfusion
o Eagle Vent
o Tempest
o FAST exam
o iStat
o Nursing/vitals chart
Night iterations need to be considered as a part of the PFC progression
We need better dummies.
o While the ones we have breathe, there’s still a lot of asking “What do I
have for vitals” while we’re working with the dummies.
o Also, they are already starting to show wear and tear with the inner
workings in regards to the blood tubes.
o The air tank fill line system is very poorly designed; there’s no way to
bleed the line going between the tanks.
The transition from dummies to live actors needs to happen when they get
loaded into the vehicles.
Allow the teams’ 18D to rearrange the PFC room work area as he would for his
own medshed down range, to include cheat-sheets and re-stocking the hanging
bag as he sees fit. Also, reminders for the 18D that they can pre-stage
equipment, to include bags and monitors, in the vehicles would be helpful.
The live patient needs to be given an acting time-line for things like pain
complaints, difficulty breathing, LOC, etc.
Allowing a “fish bowl” of other 18D’s or teams who will be conducting PFC next
will help prepare the next medics and teams for their planning.
A long-term goal of incorporating LTT, hybridized or pure LTT, will really drive
home that bad interventions in the field translate into bad times in PFC, whereas
good techniques and practices (aseptic techniques, proper bandaging/splinting,
etc.) will smooth out the PFC portion.
A clinical, rather than trauma based, scenario should be considered.
An outside observer should have a time-hack checklist for procedures so that the
teams can AAR time to conduct procedures and when various procedures took
place.
Have pre-made POIs for 2 day, 1 week, and 2 week training, similar to how the
SFAUC committee has their course set up for various companies’ needs.
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The nursing “checklist” on the vitals chart is random garbage with related items
(NG tube and upgraded airway for example) being spread very far apart. Rearranging this into like groupings will help que medics to related
procedures/nursing items that they may be forgetting
The truck-bag packing list is overly packed with unnecessary items, and missing
things, such as basic monitoring.
The way our PFC scenario is currently run is very expensive in terms of
personnel (Doc, MEDOPS staff).
AAR PFC Scenario 0211, 6 August 2014
On 5 August 2014 the members of ODA 0211 trained on the SMARCH algorithm
of Tactical Combat Casualty Care (TCCC) which consists of Security Massive Bleeding,
Airway, Respirations, Circulation and Hypothermia. This training was done in the team
room via lecture and hands-on instruction using the team members Individual First Aid
Kits (IFAK). This was the review and train-up for the training the next day at the
Mountain Post Medical Simulation Training Center (MSTC), at Khe San St. and Specker
St., with the medics of 0211.
Training at the MSTC was coordinated 8 months prior and was limited to training
at the outside area since the MSTC training area was being utilized by 4th ID. Several
short scenarios were run and team members of ODA 0211 took turns being the medic
and assistant while the rest of the team watched and medics proctored. A background
was given prior to each scenario and the team members responded to the scene of
each incident and provided care until relieved by a medic until the CASEVAC scenario
was initiated. Scenarios covered IED strikes, guard tower accident, accidental
discharge and MOUT operations using the 2-story building. CASEVAC platforms used
included UH-1 Helo, 113 tracked vehicle, Civilian Truck and HMMWV. At the end of
each scenario a short AAR was conducted.
Later that afternoon the ODA was taken to the Prolonged Field Care (PFC)
Medical Simulation Lab on the 10th SFG (A) compound in the old 2nd Bn Company area.
The tactical scenario for the next day was geared toward simulating a realistic casualty
scenario in the AFRICOM AOR. The Battalion Surgeon and PA oversaw the scenario
and gave their input as needed.
On 7 August 2014 the CULEX began at 0700 with a scenario brief. The ODA
used a POV during the scenario, which most closely resembled vehicles known to be
used in the AFRICOM AOR. ODA members responded to HN forces who struck a mine
in an unarmored vehicle during convoy operations (Realistic mannequins owned by
Group Med were used as patients and operated by Group Med support personnel).
Once all patients were stabilized and prepped for transport aboard the truck a quick
AAR was conducted, in order to keep what just happened fresh in the minds of the
participants. One patient was declared KIA and given back to the HN personnel for
processing. The live patient was loaded onto the truck with several ODA members,
including one of the medics. CASEVAC care was conducted as the truck was driven
around the compound slowly, with a chase vehicle to ensure safety while traveling.
The truck arrived at the HN airport (mock-up) and care was continued for a shorttime aboard the fixed wing aircraft. The patient was reassessed and placed on
monitors, using an iPad and patient sim app (Sim Mon) for fake vital signs, with an IV
started. The aircraft landed near the Team House (PFC Lab) and the patient was
transferred VIA POV into the Team House. The patient was stabilized and prolonged
field care was continued via protocols and SOPs.
To increase the complexity of the scenario a US soldier from a nearby FOB was
introduced as having symptoms of malaria, taxing the medical team who were already
in the process of treating two patients. During the scenario a multitude of complex
procedures were conducted as using live patients as much as possible; procedures
included IVs, Blood Draw, live blood transfusion, Malaria slide preparation as well as
microscopic examination and diagnoses. The scenario covered treating a casualty at
point of injury, mounted movement to the next level of care, and finally the sustained
care of a patient waiting for air transport to level I treatment facility; which help to
facilitate the teaching and further development of medically related skills in order to
prepare the ODA to treat, transport, and sustain a patient over an 8 hr period of time.
-Team leadership should be heavily involved in planning the scenario so that they have buy in
and participate more in the scenario.
-This should absolutely be a required PMT training evolution using the gear the team is actually
taking on deployment.
-The importance of bringing the microscope and lab supplies was apparent when trying to
definitively diagnose Malaria after using Binax.
-Need another bag to adequately organize and carry all of the requisite supplies needed for a PFC
scenario.
-Use the SimMon app with and iPad and iphone to accurately relay vitals from the provider to
the participants.
-Handheld radios to use during CASEVAC portion to prep the PFC room to receive a casualty
and MIST report should be available in the PFC room.
-Need silicone lube for airway dummies.
-PFC simulation room was much easier to use than going on post to the simulation center or off
post requiring TDY and per diem. We accomplished all of our training objectives during a
regular duty day.
-The Mountain post training simulation center was reserved 8 months in advance and we were
only able to get the outdoor area, not the actual indoor rooms with mannequins and operators.
-I would add a dummy that can take a Foley catheter.
-Some separated training for team vs just the medics would be useful. Maybe initially for the
morning using the entire team to run through the scenario, and once arriving to the PFC room,
letting the team go and working more specifically with the medics. It worked great as team
training, but the medics were never really taken out of their comfort zone.
-Team members should be taught skills the day prior to the scenario so that time is not taken
away training them how to do every little task.
OUTSIDE LARGEFLAT ZIPPER POUCH
Small Laminated Patient Care Flow Sheets
VS-17 Panel
Sterile Gloves
FOLDED INSIDE HANGING BAG
2-Large Laminated Patient Care Flowsheets
BLEEDING
Bag Gloves
1-Pr Trauma Shears
4-TQs
6-Combat Gauze
6-Compressed Gauze
2-Israeli Dressings
2-Lg Hemcon Dressings
1-Sm Hemcon Dressings
1-Skin Stapler
ASSESSMENT
HEENT
1-Monitor
1-Pulse Ox
1-Stethescope/ Sphygmomanometer
1-Small Digital Thermometer
1-Head Lamp
1-Otoscope/ Ophthalmoscope Set
1-Cobalt Light
Fluorescein Eye Stain Strips
BURN CARE
DRESSINGs
2- Sm Water Jel Burn Dressings
6-Sterile Burn Dressings
4-Silverlon Dressings
5-Silver Sulphadiazine Cream
Extra Kerlix
AIRWAY
1-Cric Kit
1-BVM w/ Mask
1-PEEP Valve for BVM
1-Squid Suction w/ suction catheter
King LT or other Supraglottic Airway
Laryngescope Set
1-ETD Detector Bulb
2-Easy Cap CO2 Detector
2-7.5 ET Tubes w/ stylets
1-20cc Syringe
3-NPAs
1-Scalpel
1-Bougie Introducer
1-ResQ Pod
BREATHING
RESPIRATORY
SAVent and Hoses
Small Boundtree Chest Tube Kit
Small Heimlich Valve
ET Tube securing device
4-10g Needle Catheters for Needle Ds
4-Halo chest seal kits
1-Chitogauze
SPLINTING
ORTHOPEDICS
4-SAM Splints
4-3in ACE Wraps
2-6in ACE Wraps
4-Cravats
INSIDE CENTER LONG ZIPPER POUCH
Large Trash Bags
Small Trash Bags
Red Bio Bags
Tape
550 Paracord
Gloves
IV/IO ADMIN
MEDICATION
1-FAST 1 IO Device
1-Bone Injection Gun
1-Sm Pelican Drug Case
2-IV Starter Kits
5-Oral Rehydration Salts
1-1000cc Bag NS Solution
1-500cc Bag Hextend or Hetastarch
1-250cc Bag NS Solution
1-250cc Bag NS with 400mg Avelox
1-100cc Bag NS Solution
3-Admin Sets with in-line Dial-a-flow
2-3-Way Stopcocks
1-Sm Sharps Shuttle
2-Preloaded 10cc syringes w/ NS
Extra Needles and syringes
Chinook Blood Whole Blood Kit
10 Eldon Cards
4x4s
2x2s
Extra Gauze
Extra Medical Tape
SURGICAL PREP
GI/GU
1-Sm Foley Kit
1-NG Tube w/ Toomey Syringe
1-Btl Lidocaine w/ Epi
4-Btl Lidocaine w/o Epi
1-60cc Syringe
3-Sterile Drapes
4-Chlorhexidine scrubbers
1-Soft Lac Kit
1-Disposable Scalpel
1-Lg Btl Eye Flush
DRESSINGS
WOUND CLOSURE
Minor Surgical Instrument Set
2 Laceration Kits
Skin Stapler
Staple Remover
Suture Removal Kit
Morgan Lens
Assorted Sized Sutures
Idioform Packing Strips
Bacitracin Packets
Non-Stick Telfa Pads
MACE Head Trauma Card
Extra Medical Tape
ASSESSMENT
GENERAL PURPOSE
Portaple Monitor Philips or Tempus
1-Pulse Ox
1-Stethescope/ Sphygmomanometer
1-Digital Thermometer
Portable Capnography
Digital Clock/ Timer
1-Head Lamp
1-Otoscope/ Ophthalmoscope Set
1-Cobalt Light
Fluorescein Eye Stain Strips
BURN CARE
2- Sm Water Jel Burn Dressings
6-Sterile Burn Dressings
4-Silverlon Dressings
5-Silver Sulphadiazine Cream
Extra Kerlix
IV/IO ADMIN
MEDICATION
1-FAST 1 IO Device
1-Bone Injection Gun
2-IV Starter Kits
5-Oral Rehydration Salts
1-1000cc Bag NS Solution
1-500cc Bag Hextend or Hetastarch
1-250cc Bag NS Solution
1-250cc Bag NS with 400mg Avelox
1-100cc Bag NS Solution
3-Admin Sets with in-line Dial-a-flow
2-3-Way Stopcocks
1-Sm Sharps Shuttle
2-Preloaded 10cc syringes w/ NS
Lots of Extra Needles and syringes
ABX Kit
AIRWAY
BREATHING
1-Cric Kit
1-PEEP Valve for BVM
1-Squid Suction w/ suction catheter
King LT or other Supraglottic Airway
Laryngescope Set
1-ETD Detector Bulb
2-Easy Cap CO2 Detector
2-7.5 ET Tubes w/ stylets
3-NPAs
1-Bougie Introducer
Box Scalpels
Chapstick
SURGICAL PREP
1-Sm Foley Kit
1-NG Tube w/ Toomey Syringe
1-Btl Lidocaine w/ Epi
4-Btl Lidocaine w/o Epi
1-60cc Syringe
3-Sterile Drapes
4-Chlorhexidine scrubbers
1-Soft Lac Kit
1-Disposable Scalpel
1-Lg Btl Eye Flush
MINOR SURGICAL
WOUND CLOSURE
Minor Surgical Instrument Set
Suture and ligature Set
2-Staplers
Portable Electrocautery
2-HemCon Dressings
1-Soft Lac Kit
1-Disposable Scalpel
1-Lg Btl Eye Flush
Suture and staple removal set
BOTTOM LARGE MAIN COMPARTMENT
2 Chinook Blood Whole Blood Kit
Extra Blood Y Tubing
20 Eldon Blood Type Cards
O2 Bottle or Saros Concentrator
Oxylator
BVM/ O2 Tubing
Nasal Cannula Tubing
SSCOR Suction
iStat or portable lab capability
Thor Drain
3-Chest Tubes with Heimlich valves
Syringes and Needles
Kerlix
4x4s
2x2s
Alcohol Pads
Iodine Pads/ Swabs
MACE Head Trauma Card
Extra Medical Tape
2-Extra IFAKs in Plastic Bags
Junctional Hemorrhage device
6-IV Starter Kits with dial a flow tubing
2-Sharps Shuttles
10-Liters Lactated Ringers
10-Liter Bags of .9% NS
3-500mL bags 3%Hypertonic Saline with red tape wrapped around
5-250mL bags .9% NS
5-100mL bags .9% NS
4-500mL bags Hespan or Hetastarch
1-Sm Pelican Drug Case w/ Narcs
Toothbrush with toothpaste
Large laminated Patient Care Flowsheets
Chest Tube kit
Occlusive Dressings with
10g Needles for Decompression
ICU Reference Book
SOF Med Handbook
TMEPS
Other reference sheets
BLEEDING
WOUND MANAGEMENT
Bag Gloves
1-Pr Trauma Shears
4-TQs
6-Combat Gauze
6-Compressed Gauze
2-Israeli Dressings
2-Lg Hemcon Dressings
1-Sm Hemcon Dressings
1-Skin Stapler
Hemostats and ligature
GI/GU
1-Sm Foley Kit
1-Bottle Urine Test Strips
Bladder Tap Kit
1-NG Tube w/ Toomey Syringe
ORTHOPEDICS
6-SAM Splints
6-3in ACE Wraps
4-6in ACE Wraps
4-Cravats
SAM Pelvic Sling
Finger Splints
Tape