Prolonged Field Care Podcast

For more content, visit www.prolongedfieldcare.org

Non-Governmental Organizations, Non-Profits and Volunteers have been  providing critical services on the battlefield for millennia.  Historically the traditional view of medical care in conflict zones was  that the military focused on victory and everything else was ancillary,  even care of their own wounded. Only in the last few centuries has there  been an evolution of care as another focus after completing the  mission. Through all of this it was often family members, clergy and  Volunteers providing aid to those left to rot on historic battlefields.   These NGOs and Volunteers have recognized this gap and organized  themselves into powerful coalitions that are able to go where  traditional militaries cannot or will not due to political pressures.  Sometimes however, there exists an overlap of traditional military  presence and NGO response as the situation matures or devolves.   Alex Potter and Global Response Management positioned themselves far  forward on the front lines of the battles for Mosul when times were  tough and the International military and humanitarian response to ISIS  was in its infancy. Thank you GRM for your hard work and dedication. We  are extremely proud of what your team accomplished and maybe even a  little jealous in the bittersweet way that only those who have  experienced the horrors of armed conflict can comprehend.   www.prolongedfieldcare.org

The Trauma Hemostasis and Oxygenation Research (THOR) Network including  the 75th Ranger Regiment, NORNAVSOF, and others have led the way in  re-implementing type-O, low titer fresh whole blood far forward with the  Ranger type-O Low titer(ROLO) program. In 2015 the Ranger medical  leadership along with founders of the ROLO program published the paper,  “Tactical Damage Control Resuscitation” outlining in detail why they  chose to bring back fresh whole blood at the point of injury. Since that  time further studies have strongly suggested that the earlier fresh  whole blood was transfused, the greater the benefit to the patient.  Shackleford et al. demonstrated that the greatest benefit to a patient  receiving fresh whole blood occurred within 36 minutes of injury. After  36 minutes no decrease in 24-hour mortality was found.    Blood must be replaced as soon as possible. The Committee on Tactical  Combat Casualty Care also recommends FWB as the first line intervention  for patients in hemorrhagic shock with blood products in both second and  third place. We cannot ignore whole blood any longer if we wish to  deliver the best possible battlefield care possible. Excuses citing  logistical difficulty, concerns about safety or lack of information are  unfounded. There are multiple ways to ensure our casualties are  receiving fresh whole blood. The first is through the Armed Services  Blood Program (ASBP) delivering cold stored O-Low titer blood to a Role 2  facility where it is picked up and pushed forward from there.  Refrigeration is necessary in order to keep it below 4°C. If going out  on mission insulated containers such as the Golden Hour or Golden Minute  containers can be used to keep the blood within temperature specs for  24 hours, 72 hours or longer. If dismounted, a transfusion can occur at  or near the point of injury with pre-typed, screened and titered  ROLO/SOLO donors. Other non-Ranger Special Operations units have since  followed suit and have tweaked the name to suit them, hence the new SOLO  (Special Operations Low-O) acronym.    www.prolongedfieldcare.org

Which burn fluid resuscitation formula is best? Does it really matter?   What can happen if you over resuscitate? Under?   What can cause an increase or decrease in the demand of fluids?   What can you do if you are running out of Lactated Ringers?   As a Lt. CMMDR. with the U.S. Navy, Dr. Cairns was on duty and a  principle responder to the KAL flight that crashed in 1997 in Guam. Dr.  Cairns was instrumental in developing the level of preparedness at the  Naval Hospital there which received and managed dozens of critical  patients in the morning following the crash of the 747.   Dr. Cairns has served North Carolina as a Burn Trauma Surgeon at the  state’s Burn Center at UNC. In 2006, Dr. Cairns was named as the  Director of the North Carolina Jaycee Burn Center and is nationally  known as a leader in Burn Trauma Care. He is a John Stackhouse  Distinguished Professor of Surgery, an Associate Professor of Surgery,  Microbiology and Immunology at the University of North Carolina at  Chapel Hill School of Medicine.   Be sure to read the Clinical Practice Guideline discussed in this and a  prior episode with Dr. Doug Powell. In this episode we will take another  look at the CPG from another perspective.

Telemedicine is a crucial capability that must be planned and practiced.  The base of knowledge that a SOF medic’s knowledge encompasses includes  many areas of medicine but generally lacks  the depth of knowledge and experience of specialists available to  consult. This depth of knowledge is almost universally available when  making a simple telephone call to any number of docs willing to take a  call at all times of the day and night. Don’t let pride or hubris  prevent you from seeking advice from someone more experienced than you  in taking care of critically injured, complex patients. Telemedical  consult is one of the most important core capabilities in a prolonged  field care situation.  BOTH the medic making the call as well as the Provider receiving the  call must practice and rehearse a telemedical consult placed from a  field environment. The medic will gain confidence and be able to relay  vital information efficiently in a timely manner. The provider on the  other end will have to anticipate problems that the medic may not have  thought of and help create a prioritized treatment care plan from  incomplete information.   Trust must be built prior to an actual call being made under stressful  conditions; trust in the receiving physician and, more importantly,  trust in the process. Medics may be apprehensive in calling a complete  stranger if they haven’t made a test call or even better, a face to face  meeting. If you build the rapport before the crisis, this won’t be an  issue. You may even have the time to prep a draft email who you are and  your equipment, training level and usually a region where you will be if  you think it will be pertinent.   For more content, visit www.prolongedfieldcare.org

Rick Hines has spent the last 20+ years in service to his country much  of it deployed to combat zones and other unstable, austere environments  and is dedicated to improving SOF Medicine.  He made it a point to spend  a fair amount of time with surgical teams when possible and has gained  quite a bit of real world knowledge that we hope to pass on to a wider  audience here. He was formerly an SF Medical Sergeant turned Team  Sergeant before going on to work as the 3rd SFG(A) Senior Enlisted  Medical Advisor, the Unites States Army Special Forces Command (USAFC)  SEMA and within the USASOC Surgeon’s Office.      For more content, visit www.prolongedfieldcare.org

When do you give a burn patient antibiotics? Which ones?   How do you calculate TBSA and the rule of 10s?   What do you use to guide fluid resuscitation? What fluid?   When is an escharotomy in the field appropriate?    Burns present another wound pattern that can be extremely difficult and  time consuming for any level of provider to manage.  So much so that  there are dedicated burn teams that will often fly to where burn  patients are being held in order to get them back to the burn center in  San Antonio with the best chance of survival.  We have taken the expert  guidance of these critical care providers and packaged everything they  have learned into a single clinical practice guideline targeted at the  medic and other Role 1 Providers who might find themselves sitting on a  patient at a Battalion Aid Station or team house before evacuation is  available.  Initial priorities such as estimating percentage of body  surface area burned, starting fluid resuscitation with the rule of 10s, Foley placement along with many others may determine the mortality and  morbidity of your patient.   For more content, visit www.prolongedfieldcare.org

In this live recording, guest lecturer COL Missy Givens shares the CBRNe  knowledge she has learned while working as a clinical toxicologist,  among many other positions, around the world including as the SOCAFRICA  Command Surgeon.  For more content, visit www.prolongedfieldcare.org

You are in your Team House or BAS. You have given FDP, Whole blood, TXA  calcium and don’t have much left despite the few units from the walking  blood bank. Your patient continues to bleed internally. Nothing in the  chest or upper abdomen. Probably pelvic. Damn. MEDEVAC is en route. They  will have some blood too. You just need your patient to hold on for  another hour before he gets to surgery…   Dr. Joe DuBose is an Air Force Trauma Surgeon who recognized early in  his career that hemorrhage was the number one killer of potentially  survivable patients. This led him to a fellowship in vascular surgery  and, as Dennis put it made him a guru in the emerging technology that  allows a catheter to be placed in the femoral artery and snaked up past a  bleed in the pelvis, abdomen and even chest where a balloon is then  inflated cutting off all blood flow below that point. Dr. DuBose was the  first to do This in the ED using a newer version that had a small  enough diameter that a vascular repair would not be required after use.  It is simply placed through a central line and removed as such later on.  This is called REBOA or Resuscitative Endovascular Balloon Occlusion of  the Aorta. As you can imagine this is not without limits and  complications if done improperly.    You are in your Team House or BAS. You have given FDP, Whole blood, TXA  calcium and don’t have much left despite the few units from the walking  blood bank. Your patient continues to bleed internally. Nothing in the  chest or upper abdomen. Probably pelvic. Damn. MEDEVAC is en route. They  will have some blood too. You just need your patient to hold on for  another hour before he gets to surgery…  Dr. Joe DuBose is an Air Force Trauma Surgeon who recognized early in  his career that hemorrhage was the number one killer of potentially  survivable patients. This led him to a fellowship in vascular surgery  and, as Dennis put it made him a guru in the emerging technology that  allows a catheter to be placed in the femoral artery and snaked up past a  bleed in the pelvis, abdomen and even chest where a balloon is then  inflated cutting off all blood flow below that point. Dr. DuBose was the  first to do This in the ED using a newer version that had a small  enough diameter that a vascular repair would not be required after use.  It is simply placed through a central line and removed as such later on.  This is called REBOA or Resuscitative Endovascular Balloon Occlusion of  the Aorta. As you can imagine this is not without limits and  complications if done improperly. REBOA   In this episode we explore the usefulness and limitations of this  strategy in deployed settings and discuss the use of REBOA by  non-physician providers in austere situations. He has written several  articles on use of the REBOA and it is now one of the most promising and  controversial adjuncts available for hemorrhage control of bleeding  inside the box of the thorax, abdomen and pelvis. In order to do this o e  would likely have to be within an hour of a facility that can repair  the retired vessel as the lactic acid and other toxins would quickly  build up causing a massive repercussion injury. To this end he discusses  his strategy for partial REBOA during resuscitation that would leave  the balloon partially inflated allowing a clot to strengthen and  circulation distal to the balloon.  For more content, visit www.prolongedfieldcare.org

Dr. Cap has been leading the way here in the US with the Armed Services  Blood Program on fresh whole blood transfusion research in conjunction  with the THOR Network and answering tough questions that different  Special Operations Units come up with when analyzing how best to  implement a fresh whole blood resuscitation protocol. In this episode  Dennis presses him on the important resuscitation questions medics  everywhere seem to be asking :       I don’t have blood yet; Crystalloid isn’t really that bad, is it?      Can’t I just resuscitate to a normal BP with hetastarch or hextend?      Where does FDP fit in with resuscitation?      What do you mean by, “dose of shock?”      Do I really have to give TXA over 10 minutes?      What comes first TXA, Calcium or Blood?      Why should patients get calcium as soon as possible once you  identify they need blood?      What’s this about pre-hospital albumin?     For more content, visit www.prolongedfieldcare.org