Prolonged Field Care Podcast

Dennis and Ian discuss spinal trauma in the austere environment.    For more content, visit www.prolongedfieldcare.org

Dennis and JJ discuss Highly Reliable Organizations.    For more content, visit www.prolongedfieldcare.org

While no single clinic setup will work for every situation, a common  baseline and checklist can make it far easier in customizing a clinic in  similar circumstances. This is not professed to be THE way but it is A  way in which ONE experienced team has created, tested, revised and  rehearsed a clinic with different casualties. Their pictures and  diagrams are provided in the hopes that this audience will help refine  and finalize a common baseline which any medic can use in he future.  Please leave comments on your thoughts.   This builds upon clinic setups in SOCM, SFMS and other courses such as  SOFACC and combines all into a single, ergonomic clinic in which all  members of a team can easily assist the primary medic or in the worst  case, effectively treat the wounded medic.    For more content, visit www.prolongedfieldcare.org

What happens when your patient has been given a cric or intubated but  continues to decline… SpO2 continues to slowly drop despite taking  control of the airway. You have placed your patient on a ventilator and  slowly adjusted the PEEP up to 20cmH20… which quickly leads to  hypotension. Do you go lower? Higher? Change volume or rate? You are out  of bottled O2 and your oxygen concentrator does not seem to have much  effect. The SpO2 continues dropping. Telemedicine is not available. You  try positioning the patient by sitting them up. You try a couple other  recruitment maneuvers you heard about.  Nothing is working.   What would Doug do?   Prone the patient???   Your patient may be suffering from ARDS, Acute Respiratory Distress  Syndrome caused by a number of etiologies such as pneumonia or other  lung injury. Carefully turning your patinet on their stomach may improve  oxygenation by recruiting alveoli formerly compressed and “drowned” as  demonstrated in the picture below. Positioning your patient on their  stomach in the prone position must be practiced with anyone who will be  helping you. Put someone else in a similar position and have the team  with which you plan to help move the real patient do a couple  rehearsals. You don’t want to flip them over only to lose your IVs, IOs  and yank the airway out. Check out this Brazilian article which includes  a proning checklist and some informative pictures and tips.  You also don’t get an automatic win by flipping them on their belly and  calling it a day. You will have to be even more vigilant about any  potential complications with a dedicated airway person as is is a little  harder to recognize a patient in distress if you are not used to it.   You will also have to do more nursing care on the delicate skin of the  face and other surfaces not normally on the down side: Shoulders, hips,  knees tops of the feet. Put yourself in this position for a few minutes  on a litter and you can quickly tell where the major pressure points  will be. All of these complications increased along with the benefits of  the study. While no prolonged field care patient should be on a bare  litter, there is even more reason to move them to a mattress or other  more comfortable padded surface.    For more content, visit www.prolongedfieldcare.org

After a few discussions with JJ who has also appeared in several Element  Rescue podcasts, Doug and Dennis talk about using evidence based  medicine whenever possible and what to do when no prospective randomized  controlled trials exist for a specific problem you face. What do you do  when no evidence exists for a specific problem you face? With such a  wide scope of practice while deployed and a lack of protocols SF medics  are often faced with unique situations in which they must actually weigh  the evidence, best practice, guidelines and expert consensus against  the given situation. This is a great responsibility not entrusted to  many other combat arms troops. In order to weigh the evidence you must  first be aware it exists and how to interpret what you are reading. This  will help get you on the right path in making informed decisions. Check out the Discussion:  https://oembed.libsyn.com/embed?item_id=10109669   Prolonged Prone Positioning Article NEJM 2013   Protocols and algorithms likely drive the majority of decisions a medic  will ever make. If you find yourself in a situation, such as a prolonged  field care situation, that outlasts all of those you should know some  of the current best practices and data to back up your decisions you may  be forced to make. Dogma is believing something to be true without  knowing if it actually is, or why. Don’t rely on dogma, question things  and have your own opinions. Know why you believe what you believe. When  you make a telemedicine consult call you should have a fairly good idea  of the decision you are leaning toward and why. You will sound much more  like the medical professional you claim to be and less like the knuckle  dragger they may be expecting. Medicine is a separate language and you  are expected to be somewhat fluent. Data and research are intellectual  and professional currency and which can add to your credibility. Read an  article, understand who the authors are, their specialty, where they  work and who funded or sponsored it as well as the references at the  end. You will run across words you aren’t familiar with. Put them in the  Google machine and expand your medical vocabulary. You may even want to  read those references and the references to those in order to really  dig deeper. (Three deep, right Scott?) Podcasts are a great way to hear  opinions on some of these studies and how others have incorporated them  into their practice. Podcasts and blogs (even this one) are not journal  articles and studies. They are meant to raise discussions and spark  debate and make you aware of new techniques or practices. If a study is  mentioned find the article and read it yourself. Does it apply to your  environment, experience and training? Don’t be the guy quoting a podcast  or Facebook post in a scholarly discussion, at that point it will just  be entertainment, for the other guy. Know where it originated.

Not all PFC is trauma.  Malaria, Dengue, Chikungunya and others will  take you out of the fight if given the chance.  In this episode CAPT  Ryan Maves talks about some of the more concerning and prevalent  diseases encountered by deployed military personnel and partner forces  and what you can do about it before an infection becomes debilitating or  life threatening.  A few things to remember from the episode:    - History and assessment are key in identifying tropical diseases.  Remember to consider both history of exposures as well as the  accompanying syndromes in formulating a differential diagnoses.  -  Malaria treatment consists of Malerone, Coartem or both.  -  No one dies without Doxycycline!    For more content, visit www.prolongedfieldcare.org

Why do we care about sepsis in prolonged field care? What can we do  about septic shock with what we are normally carrying on a deployment?  How do you mix an epinephrine drip? Dr. Maves lays it all out in about  20 minutes.   Here are some of the resources and pearls he mentioned in the episode:       Infection plus organ dysfunction is sepsis      Infection plus hypotension is septic shock      Q-SOFA positive with 2 of the three and suggestive of sepsis:          Systolic BP less than 100          RR greater than 22 breaths per minute          Presence of delirium     Earlier intervention is better than later      Higher mortality rate than poly trauma or myocardial infarction     Something is better than nothing      Septic shock is not purely distributive. You will also see  myocardial depression loss of contractility, capillary leakage,  microvascular obstruction from small thrombi and concomitant  hypovolemia. Some fluids are good but more fluids mat be dangerous. If 2 or 3 liters does not work it is unlikely that 5 or 6 fix  hypovolemia. At some point it will start increasing mortality. The best vasopressor is the one you have. Delaying proper antibiotics increases risk of death by 8% every  hour.    For more content, visit www.prolongedfieldcare.org

When you can’t take cold stored whole blood with you and not all of your  soldiers are titered, a walking blood bank can mean the difference  between life and death for a patient in hemorrhagic shock.  With the  mounting evidence suggesting early blood is essential and not just a  good idea, you need to have a plan in order to hit the 30 minute target.   I have seen students struggle for hours trying to get access in both  the patient and the donor.  An emphasis on early recognition and early  access will save lives.  This episode expands upon our latest JTS  Clinical Practice Guideline on Remote Damage Control Resuscitation with  Dennis interviewing the primary author Andy Fisher.  For more content, visit www.prolongedfieldcare.org

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.