Prolonged Field Care Podcast

Training materials were the number 1 most requested item from our SOMSA  AAR.  We have put out other training recommendations in the past but  wanted to also highlight some important skills that will help you  identify gaps in your PFC training program, plan future training and  measure progress.  We will get more into this cycle in the future  however, this should be a good place to start.  Many thanks go out to  Andrew who labored over many versions of the list over the past few  months.  One last thing, be sure that you are already at 100% T for  Trained on your TCCC task list.  There is no use in getting into PFC  training prior to mastering TCCC.  If you see something we may have  overlooked and would like to see it on future versions, please comment  below and let us know.   For more content, visit www.prolongedfieldcare.org

For more content, visit www.prolongedfieldcare.org

This Clinical Practice Guideline was written by a fellow 18D with input  from around the surgical community.  It reconciles the differences  between wound care done in a role 2 or 3 facility, such as serial  debridements, with what is taught in the 18D Special Forces Medical  Sergeant Course with regards to delayed primary closure.  One way is not  “right” while the other wrong, it has more to do with the amount of  time and resources available to the medic or other provider.  The  remainder of the blog post and podcast is meant to be a refresher for  those who have already been taught these procedures.  It is also meant  to be informational for those medical directors who may not be exactly  certain of what has been taught as far as wound care and surgery.  If  you haven’t been trained to do these procedures before going ahead with  them, it is very likely that you may do more harm to the patient than  good. That being said…  The following are recommendations made by the International Committee of  the Red Cross (ICRC) concerning the surgical management of war wounds  in austere conditions and with limited resources. This is when the  provider has some or all of the following considerations which would  prohibit him from performing serial (follow-on) debridement with  associated post-operative care.      Dirty environment      Limited supplies      Limited manpower      Limited time (mission dictated)      Wounds greater than 24 hours    The considerations above, accompanied with the position that the  provider will be managing that patient for more than a couple days or  become the definitive provider, should warrant ICRC recommendations for  surgical management.   For more content, visit www.prolongedfieldcare.org

You have probably treated someone with an infection and likely even with  someone with SIRS criteria at some point in your career.  At what point  does a simple infection become concerning to the point that you should  call for a teleconsult?  When does it become emergent or life threatening, demanding intervention  and treatment?  How can you prevent an infection from getting to that point?  Once it becomes systemic how can you best manage a patient that meets  SIRS criteria?  When can you send a guy back to his room and when should you keep a  close eye on him so that he doesn’t suddenly crash and die after  discharge?  At what point does sepsis turn into septic shock and become a life  threatening emergency?   In this episode Dennis moderates an interesting discussion on  recognition and management of sepsis in Prolonged Field Care.  We have  Doug and Jaybon from the ICU, Jay from the ER perspective along with  Paul providing some questions and insight on prehospital and evacuation  considerations.  This is a followup to Doc Jabon Ellis’ previous sepsis  video podcast so if you want to “pre-read” listen to that first.  If you  just want to listen to this one and still have some questions, go back  and watch that one… a coupe times.  I feel like these 2 episodes will  help make you a better medic who will be able to accurately place a  patient on the SIRS/SEPSIS spectrum and apply appropriate treatments  before we get to life threatening septic shock or death.   www.prolongedfieldcare.org

What is the process that the CPGs go through before publication?       Medics identify what guidelines are needed.      A team consisting of a medic, unit surgeon and specialist in the  field begin a draft.     Additional authors, specialists and SMEs are added as identified      Progress is monitored by the Prolonged Field Care Working Group  Steering Committee and advisors from the Joint Trauma System.     Final draft sent out to interested parties, other specialists and  PFC working group members for review      Published in the Journal of Special Operations Medicine(JSOM) with  proprietary format      Formatted for public release via the JTS website      Presented as a Thursday morning JTS CME Conference Talk.      Posted on prolongedfieldcare.org          Interviews with authors are published as podcasts.          Primary and Co-Authors may write additional thoughts as a blog  post.      Polldaddy quizzes may be included in the posts or separately.          Released and promoted through social media such as our Facebook  Pages, Instagram and Twitter feeds.   Why not just update the Tactical Medical Emergency Protocols?      We wanted peer reviewed guidelines that could be updated  individually as needed.  Independent medical providers can now see what  studies were referenced per recommendation.  We have partnered with  USSOCOM and advised several changes and additions to the TMEPs.  The  CPGs will help guide the CEB as they update future additions of the  TMEPS as a reference.  What are the origins of the CPGs?      Sharing lessons learned and best practices accross the theaters of  war  Why are there CPGs specific to Prolonged Field Care and Critical Care  Evacuation Teams(CCAT) in addition to the main JTS CPGs?      There are large enough differences in levels of training, equipment  and medications available and general logistics involved that make  providing an identical care in all environments impossible. The CPGs  take into consideration the unique challenges of the operational  environment so the the provider is presented with several best options  for the unique issues presented with each etiology and environment.  What CPGs are in the works and when can we expect to see them published?

Are you familiar with the concept of oxygen debt or oxygen deficit?   What constitutes a “dose” of shock?  What systolic BP constitutes  hypotension on the battlefield?  Where did the concept of permissive  hypotension come from?  Is it still valid? How long can fresh whole  blood last?   Blood Transfusions were a huge topic at this year’s meeting in Charlotte  with no less than 3 major speakers giving multiple talks on the  subject.  This talk was recorded during the Prolonged Field Care  Pre-Conference Lab during the Special Operations Medicine and Scientific  Assembly (SOMSA).   Dr. Geir Strandenes   is a founding member of the THOR (Tactical Hemostasis, Oxygenation, and  Resuscitation) Group, the Senior Medical Officer of the Norwegian Naval  Special Operations, and a Researcher in the Department of Immunology and  Transfusion Medicine at Haukeland University Hospital in Bergen,  Norway.  He has worked hand-in-hand with the U.S. Army Institute of  Surgical Research and the US Armed Forces Blood Program.  You can read  more about his research and other articles at www.RDCR.org.  Our PFC  working group has always gone to the THOR network with any blood  questions that we have, as they usually have an answer or best practice  already established.  I have included a link to the THOR/RDCR.org  publication page below along with other notable publications which he  helped to author such as the recently published JTS ISR Clinical  Practice Guideline on Damage Control Resuscitation and the Frequently  Asked Questions we sent to Geir and the THOR network over the last  couple years.   www.prolongedfieldcare.org

Prolonged Field Care is back with a new episode on a long awaited topic,  traumatic ventilation.  We were finally able to corner a real, live  anesthesiologist who was actually more than happy to sit down and talk  about ventilation after his years of experience working at the heads of  thousands of patients.  This episode starts right off with a difficult  scenario discussion that includes a hypovolemic patient with a GSW to  the pelvis, RR 35  As they work to get the patient stabilized, Dr. Kopp recommends an end  tidal CO2 Capnograph as the single best patient monitor for this  situation.  A SAVE2 vent is discussed along with the ARDSnet recommendations for a  lung protective vent strategy including the preferred tidal volume of  6-8ml/kg of ideal bodyweight based on patient height.  This is to reduce  barotrauma and over-ventilation that can lead to other problems.  This  begins with attempting to match the patients physiologic respiratory  rate to prevent acidosis by giving too few breaths.  The beginning Positive End Expiration Pressure (PEEP) recommendation  should start somewhere around 5 to keep alveoli open and recruited,  prior to increasing oxygen levels if available.  PIP or Peak Inspiratory Pressure or the maximum pressure of each breath  which has a default setting of 30 corresponding with the ARDSnet  protocol.  For an uninjured patient in the Operating Room, Dr. Kopp  would start at 20-22 and then titrate from there.  While we are working on an Airway Clinical Practice Guideline with the  Joint Trauma System and Army Institute of Surgical Research, this will  go along with our earlier posted PFC WG Airway recommendations (April,  14) until we can get a consensus on the CPG and get it published.     www.prolongedfieldcare.org

This podcast is a follow up from our last post on managing traumatic brain injuries in austere environments. We included a scenario  discussion with David, Jamie, Daryl, Jay, Doug and I with much needed  answers to some frequently asked questions.  What are your priorities?  How do you assess in the field without labs and imagery? Do you include severe TBI injuries in your trauma training?  What if he also has a pelvis injury or internal bleeding? When do you take the airway, if at all? When do you provide positive pressure ventilation in these patients?  Can it be dangerous?    www.prolongedfieldcare.org

If you sit on a patient long enough, infection has a greater chance of  taking hold and progressing to sepsis, or you may receive a patient who  has already been sick for days. Doc Jabon Ellis walks us through the  full spectrum from infection and SIRS to sepsis, shock and death.  Despite firm CoTCCC and ICRC recommendations for early antibiotics, in  the past we may have foregone that luxury because of lighting fast  evacuation times, maybe even thinking, ‘they’ll take care of it at the  next echelon.’  A great medic should not only treat their patient but  set them up for success at the next echelon, as sepsis is a testament to  how poor care during the TCCC phases of care can cost our patients days  and weeks in a hospital later.  But what if you are your own next echelon?  Point of injury to Role 1+  could be your own team house or single litter aid station.  Go down the  checklist on the right side of the PFC trending chart and make sure you  are taking care of anything that could result in an infection.  Have you  given those antibiotics?  How is your airway and respiratory care?    Did you replace any dirty IV or IO sites you placed in the field?  Are  you doing all your procedures an as aseptic manner as much as possible?   When will you debride?  Are you doing everything you can to prevent  pressure ulcers?  When will you call for a telemedical consult?  When your patient  develops a fever?  Blood pressure falling?  Altered mental status?   Do you know how to dilute your 1:1000 epinephrine to use as a push dose  pressor?  (It’s in the Tactical Medical Emergency Protocols) Is an Epi  drip approriate, why or why not?  How much fluid will you give to help  prop up that BP? All questions that the medic prepared for PFC should be  looking to answer.   For more content, visit www.prolongedfieldcare.org

We want you to be able to have more knowledge on this topic and more  confidently be able to answer these questions and plan for it, as well  as implement this into your training for hands on and trauma patient  assessment skills.   Traumatic Brain Injury (TBI) is physical damage to the brain caused by a  blow to the head, penetrating objects, motor vehicles crashes and  explosions, or a combination of these, which are all familiar scenarios  we encounter in our community. This is especially true for Motor Vehicle  Crash, the number one cause of death of our Operators on peacetime  deployments, and still 5% of deaths even in warzones. To make matters  worse, the force that caused the TBI also created other injuries such as  a hemothorax, making it even more of an animal to treat. It’s more  difficult to understand what is going on because there isn’t an artery  spurting blood we can address, so we have to put on our thinking caps  and understand what is going on at the cellular level.    For more content, visit www.prolongedfieldcare.org