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 reductionPacking an inguinal or axillary woundStopping bleeding and cleaning abdominal eviscerationOcclusive dressing or replacing bowels of eviscerationOcclusive DressingAssessing indications for needle DDetailed head to toe assessmentInsertion of needle DPreparation and placement of King LTUsing SSCOR and squid suctionBagging with BVMOxygen tank prep including NRB and nasal cannula Setting up the SAVent and OxylatorUsing the oxygen concentratorDrawing blood for labs or iStatPreparation and initiation of peripheral IVPreparation of foley catheterSuprapubic bladder tapCricothyroidotomyGlasgow coma scale from a cheat sheet

Taking a full set of vitals manuallyAttaching Philips monitor or TempusUsing the patient care flow sheetEldon blood typing cardPreparing the equipment for blood transfusionMaking comms and calling LRMC with the call sheetChanging wet to dry dressingsDrawing and administering drugsNG Tube prepIrrigating woundSuturingPreparation 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 ARMYALPHA COMPANY, 2nd BATTALION, 10th SPECIAL FORCES GROUP (AIRBORNE)

FORT CARSON, COLORADO 80913-7440

REPLY TOATTENTION 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. CHANEYMAJ, SFCOMMANDING

FT CARSON MSTC: APPROVED DISAPPROVED

TIMOTHY D. OLSONSITE LEADMOUNTAIN POST MSTC

DEPARTMENT OF THE ARMYALPHA COMPANY, 2nd BATTALION, 10th SPECIAL FORCES GROUP (AIRBORNE)

FORT CARSON, COLORADO 80913-7440

REPLY TOATTENTION OF:

AOSO-SFC-SNA 12 December 2013

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 RANK MOSPerry, John SFC 18D/ 11BLoos, Paul SSG 18D/ 68WHewlett, Justin SSG 18D

4. POC for this memorandum is SSG Loos, Paul at 524-3289 or paul.loos@ahqb.soc.mil.

MATTHEW A. CHANEYMAJ, SFCOMMANDING

FT CARSON MSTC: APPROVED DISAPPROVED

TIMOTHY D. OLSONSITE LEADMOUNTAIN POST MSTC

DEPARTMENT OF THE ARMYALPHA COMPANY, 2nd BATTALION, 10th SPECIAL FORCES GROUP (AIRBORNE)

FORT CARSON, COLORADO 80913-7440

REPLY TOATTENTION 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 CPTHeydenberk, Drew MSGBrown, Christopher WO1Milan, Aaron SFCBraswell, Byron SFCSeizert, Sterling SSGBaumgardener, Jeremy SSGOveracre, Austin SGTLemke, Joshua SGTGolinski, Karl SGT

4. POC for this memorandum is SSG Loos, Paul at 524-3289 or paul.loos@ahqb.soc.mil.

MATTHEW A. CHANEYMAJ, SFCOMMANDING

FT CARSON MSTC: APPROVED DISAPPROVED

TIMOTHY D. OLSONSITE LEADMOUNTAIN 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 C-130 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 US-trained 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 re-established. 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 re-intubation 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 self-triaged 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 pre-hospital 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 (recruitment-derecruitment). 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.

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

PEEP = 0PIP = 45

PEEP = 10PIP = 45

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 POINTSPEEP – 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;24:584-587.

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 non-medical 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:

Monitor Resuscitate Vent/oxy Airway …RUCK Pulse ox,

BP Cuff, Steth

NS/hespan BVM with PEEP

SGA/cric …

TRUCK Monitor NS/hespan/FWB kit

BVM with PEEP/O2 x2 bottles

SGA/cric with ketamine drip

…

HOUSE Monitor LR cases/hypertonic saline/FWB

O2 concentrator

RSI capability

…

PLANE Monitor LR BVM with PEEP

SGA/cric with ketamine drip

…

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 medical-specialty 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 trenda.  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 capnometryc.  Best - vital signs monitor in order to provide hands-free vitals at regular intervals 

2.  Resuscitate the patient beyond crystalloid/colloid infusiona. Minimum - field Fresh Whole Blood transfusion kitsb. 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 concentratorc. 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 cricothyrotomyb.  Better - add ability to provide long-duration sedationc.  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 tasksa.  Minimum - provide opiate analgesics titrated IVb.  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 problemsa.  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 careb.  Better - elevate head of bed, debride wounds, perform washouts, wet-to-dry

dressings, decompress stomachc.  Best - experienced in all the above

8.  Perform advanced surgical interventionsa.  Minimum - chest tube, cricothyrotomyb.  Better - fasciotomy, wound debridement, amputation, etc.c.  Best - experienced with all the above

9.  Perform telemedicine consulta.  Minimum – make reliable communications; present patient; pass trends of key vital

signsb.  Better - add labs and ultrasound imagesc.  Best - video teleconference

10.  Prepare the patient for flighta.  Minimum - be familiar with physiologic stressors of flightb.  Better - trained in critical care transportc.  Best - experienced in critical care transport

PROLONGED FIELD CARE DOCUMENTATIONAUGUST, 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 extremitiesT- 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 12hA- 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 telemetrya. ability to get Medical C2b. 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 patients- adjust quantity by mission specifications and ruck-truck-house- helo/plane logistics:a. Chucks, 6-10 and 1 box of glovesb. 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 NSc. Extra compressed gauze, syringes , needles, IV tubing, opsites, etc. d. Nutrition as above – 10-15 gels, 5 bars, electrolyte powder, maybe protein powdere. Warm items- wool blanket, extra change of fleece clothes/ hat, HPMK x 2f. Duragesic patches for pain. 50 micrograms – box of 5 g. Extra Zofran, versed, fentanyl and ketamineh. Full complement of PO medsi. Water filtration system, iodine tabletsj. Baby wipes, 1-2 washcloths, small basink. Betadinel. >2 foley catheters, urine collection bagsm. >2 NG tubes, 60 cc syringe that fits, plastic clamps for tubesn. Baby wipeso. Purell or other sanitizerp. Flow sheets for vital signs, Is and Os and care provided

PFC Scenario AAR 18 July 2014

- 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 2nd

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 transfusiono Eagle Vento Tempesto FAST examo iStato 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.

- 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. Re-arranging 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 4 th 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 short-time 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.

SURGICAL PREPGI/GU

1-Sm Foley Kit1-NG Tube w/ Toomey Syringe1-Btl Lidocaine w/ Epi4-Btl Lidocaine w/o Epi1-60cc Syringe3-Sterile Drapes4-Chlorhexidine scrubbers1-Soft Lac Kit1-Disposable Scalpel1-Lg Btl Eye Flush

Chinook Blood Whole Blood Kit10 Eldon Cards4x4s2x2sExtra GauzeExtra Medical Tape

Sterile Gloves

DRESSINGSWOUND CLOSUREMinor Surgical Instrument Set2 Laceration KitsSkin StaplerStaple RemoverSuture Removal KitMorgan Lens

Assorted Sized Sutures Idioform Packing StripsBacitracin PacketsNon-Stick Telfa PadsMACE Head Trauma CardExtra Medical Tape

AIRWAY1-Cric Kit1-BVM w/ Mask1-PEEP Valve for BVM1-Squid Suction w/ suction catheterKing LT or other Supraglottic AirwayLaryngescope Set1-ETD Detector Bulb2-Easy Cap CO2 Detector2-7.5 ET Tubes w/ stylets1-20cc Syringe3-NPAs1-Scalpel1-Bougie Introducer1-ResQ PodBREATHINGRESPIRATORYSAVent and HosesSmall Boundtree Chest Tube KitSmall Heimlich ValveET Tube securing device4-10g Needle Catheters for Needle Ds4-Halo chest seal kits1-Chitogauze

SPLINTINGORTHOPEDICS

4-SAM Splints4-3in ACE Wraps2-6in ACE Wraps4-Cravats

BURN CAREDRESSINGs

2- Sm Water Jel Burn Dressings6-Sterile Burn Dressings4-Silverlon Dressings5-Silver Sulphadiazine CreamExtra Kerlix

IV/IO ADMINMEDICATION

1-FAST 1 IO Device1-Bone Injection Gun1-Sm Pelican Drug Case2-IV Starter Kits5-Oral Rehydration Salts1-1000cc Bag NS Solution1-500cc Bag Hextend or Hetastarch1-250cc Bag NS Solution1-250cc Bag NS with 400mg Avelox1-100cc Bag NS Solution3-Admin Sets with in-line Dial-a-flow2-3-Way Stopcocks1-Sm Sharps Shuttle2-Preloaded 10cc syringes w/ NSExtra Needles and syringes

BLEEDINGBag Gloves1-Pr Trauma Shears4-TQs6-Combat Gauze6-Compressed Gauze2-Israeli Dressings2-Lg Hemcon Dressings1-Sm Hemcon Dressings1-Skin Stapler

INSIDE CENTER LONG ZIPPER POUCHLarge Trash BagsSmall Trash BagsRed Bio BagsTape550 ParacordGloves

ASSESSMENTHEENT

1-Monitor1-Pulse Ox1-Stethescope/ Sphygmomanometer1-Small Digital Thermometer1-Head Lamp1-Otoscope/ Ophthalmoscope Set1-Cobalt LightFluorescein Eye Stain Strips

FOLDED INSIDE HANGING BAG2-Large Laminated Patient Care Flowsheets

OUTSIDE LARGEFLAT ZIPPER POUCH Small Laminated Patient Care Flow SheetsVS-17 Panel