Prolonged Field Care Podcast

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

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