Prolonged Field Care Podcast

For more content: www.prolongedfieldcare.org

So what is different than what we already have in the THOR  recommendations, the JTS DCR clinical Practice Guideline and the Ranger  Regiment TDCR? No hextend?! Calcium with the 1st unit of blood?! TXA  slow push?! What if the patient is not responding to resuscitation  efforts? This is a guideline truly written for the Medic working despite  lack of help or resources in an austere environment…   When reviewing and editing this evidence-based consensus guideline there  were lengthy discussions about the realities of some of the issues  mentioned above. One of the biggest questions came when discussing TCCC  because there are slight differences with the CoTCCC guidelines which  were written specifically for a medic treating a patient sequentially in  the combat environment.   I will attempt to explain the thought process of the group of authors as  I understood the conversations and email chains in order to help you  make a better decision for your practice. That fact alone makes this  guideline different. It is specifically written for an independent duty  medic or corpsman who has the flexibility to make decisions about the  care based on available evidence for the patient which may or may not  yet exist in which case expert consensus was used.   Guidelines for medics must be written in a linear manner because they do  not merely manage the care of a patient as part of a large team working  together, they manage, prioritize, and physically complete each task  one after another. Training other team members to complete certain tasks  can greatly assist the medic. Gains in the quality of care and outcomes  can come from optimizing a dedicated trauma system. When that system is  a single person working problems in series, the variables must be  looked at in a sequential manner because that is how they are performed.  The administration of TXA comes to mind when talking about these minute  changes. TXA Slow Push:  TXA is not the cornerstone of austere resuscitation, administration of  blood is. Since the CRASH2 TXA trial results and per manufacturer  recommendations, it has been recommended that TXA be given slowly over  10 minutes so as to not cause transient hypotension. The provider should  absolutely be aware of this possibility no matter how small of a chance  it may have of occurring. Once aware and taken into account, a decision  can be made for the current situation. Do they have time to get out an  IV bag, reconstitute the TXA, Inject it into the bag, start a new IV/IO  site, hook up the line, count the drips, adjust the drip rate multiple  times and then check on the drip rate multiple times so as to make sure  that 10 minutes is vehemently adhered to? Does this bring the risk of  transient hypotension to absolute zero or does it merely reduce an  already small chance? This guideline gives the medic the same guidance  and recommendations from conclusions of the original study with the  caveat not to waste time they or the patient may not have due to the  situation or environment. If that IV line is already the second line, it  may be needed for other adjuncts including calcium, pain control,  sedation, antibiotics, antiemetics, etc. 10 minutes is a long time when  someone is writhing in pain, vomiting, mentally altered while bleeding  out. If on the other hand, a patient arrives to your aid station with 2  IVs, blood hanging, with appropriate sedation and analgesia, there is  likely time to adhere to the slow drip over 10 minute recommendation.  Again, it is the prerogative of the independent duty medic or corpsman  to weigh the risks versus gain.

Many efforts in the pre-hospital combat environment had been aimed at  prolonging the viability of a patient until they are able to make it to a  surgeon. The goal of military triage and evacuation is to have urgent  surgical patients to a waiting surgical team within 2 hours. Despite our  best efforts, this is not always possible. When it is not possible,it  is important to do the simple interventions which we know make a  difference for combat casualties such as tourniquets, wound packing,  needle decompression, airway adjuncts and pelvic binding. Wounds causing  non-compressible hemorrhage to the torso need additional strategies to  bridge the time and space gap to definitive treatment. A non-surgical  adjunct which has shown much promise has been the early transfusion of  whole blood and blood products until surgical care can be provided. Our  newest Clinical Practice Guideline on Remote Damage Control  Resuscitation details what should be done and why.  There is an entirely separate working group, The Tactical Hemostasis,  Oxygenation and Resuscitation (THOR) group dedicated to exactly those  principles which we partnered with early on to help identify solutions  dealing with hemorrhagic shock. Despite all that effort and brain power  however, blood remains a finite resource in the austere environment and  Medics have faced terrible situations where even blood administration is  not enough and surgery is too far away. It is in these times of  worst-case desperation that we want to do more for our patients. Some of  the adjuncts discussed in this episode are abdominal tourniquets, REBOA  and open surgical procedures. We don’t take any of this lightly and  realize that for the vast majority of our pre-hospital audience, many of  the procedures discussed are far outside the current scope of practice.   What is possible?   What is responsible?   What is sustainable?    Enjoy the talk.

When properly and safely administered regional anesthesia can augment  your limited supply of narcotics and ketamine in resource poor  environments. It can also preserve your patient’s mental status while  providing targeted pain relief. This can be accomplished using a nerve  stimulator and the techniques found in the Military Advanced Regional  Anesthesia and Analgesia Handbook as taught in the Special Forces  Medical Sergeant course.  If you have a portable ultrasound machine and a  little practice you can also use the safe techniques found in the  videos made available in by the New York School of Regional Anesthesia  at NYSORA.com.    For more content, visit www.prolongedfieldcare.org

For more content, visit www.prolongedfieldcare.org

For more content, visit www.prolongedfieldcare.org

For more content, visit www.prolongedfieldcare.org

Colonel Warner “Rocky” Farr has made an important contribution to the  body of SOF knowledge with this well-researched monograph. He advances  the understanding of the many challenges and accomplishments related to  guerrilla warfare medicine—care provided by predominantly indigenous  medical personnel under austere conditions with limited evacuation  capability— by providing a survey of the historical record in UW  literature. Colonel Farr relates many historical experiences in the  field, assesses their effectiveness, and lays a foundation for further  in-depth study of the subject. The Joint Special Operations University  is pleased to offer this monograph as a means of providing those  scholars and operators, as well as policymakers and military leaders, a  greater understanding of the complex and complicated field of guerrilla  warfare medicine.    For more content, visit www.prolongedfieldcare.org

Whether working on a casualty with a small team of medics or as a single  medic with the help of other non-medic team members as helpers, someone  has to be in charge of the situation in order to maintain a global view  of priorities.  The minute you get sucked in to do a specific task you  are losing situational awareness of the complete patient and  environment.  If you are working on your own as a lone medic with no  helper you have to fill both the technician and team leader role.  Treat  life threats through your TCCC/MARCH sequence and then mentally step  back and take in the whole picture.  When the situation permits and as  you begin a more detailed secondary exam, start writing down each  problem as you encounter it and then prioritize what is going to kill or  cause permanent damage first with.  Making a plan and being proactive  is what separates the great medics from less experienced medics who are  constantly chasing their tails reactively.  If you are not taking care  of patients on a daily basis training with the small team can help  delineate roles and responsibilities.  This is why if you are doing  medical training you should have your team or platoon leadership  involved along with anyone else who will be helping.    For more content, visit www.prolongedfieldcare.org

Upgrading your airway kit with a portable end tidal CO2 monitor can help  in a couple situations. While it has its limitations, it is essential  for  quickly determining if your tube is in the trachea during an intubation.  This can be accomplished most accurately via a device with a  quantitative waveform such as the Emma Capnograph. If you can’t get your  hands on an Emma, the qualitative colormetric device that changes color  when exposed to acid in the exhalations. False positives can occur due  to other acids in the airway such as vomitus or even if the patient has  recently had a carbonated beverage. While those are rare, you should be  aware of the possibility. Having a visual indication of tube placement  can be extremely helpful during loud transports such as on aircraft.   Another time that ETCO2 monitoring is very useful is during CPR. There  will likely be a very low reading despite high quality CPR. If the heart  begins to beat spontaneously, you should see an immediate increase of  the numbers on the display of your device. ETCO2 can also be used as a  prognostic indicator. If the ETCO2 remains below 10mmHg for 20 mins of  CPR this may indicate that the patient has a very poor prognosis. After  you listen to our podcast, Check out Scott Weingart’s EMCrit podcast on  the subjects to hear his thoughts on this.    ETCO2 is also useful the intubated TBI patient. Per our clinical  practice guideline, ETCO2 in a patient with moderate to severe TBI  should be kept between 35-40mmHg. In a patient with herniation, you can  temporarily increase ventilators rate in order to vasoconstrict the  blood vessels in the brain, thus reducing swelling. This can only be  done for a short time because hyperventilation worsens cerebral  ischemia. Also avoid hypoventilation (EtCO2 45mmHg or more) that will  increase ICP.    For more content, visit www.prolongedfieldcare.org