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. 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.
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 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!
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.
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 properly and safely administered regional anesthesia can augment your limited supply of narcotics and ketamine. 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. If you have a portable ultrasound machine and a little practice you can also use the techniques found in the videos made available in by the New York School of Regional Anesthesia.
The Tactical Hemostasis, Oxygenation and Resuscitation(THOR) Group 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 of 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 Forces Blood program 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, 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.
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 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.
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.
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.
COL Missy Givens shares the CBRNe knowledge she has learned working , among other positions, as a Clinical Toxicologist around the world including as the SOCAFRICA Command Surgeon where she personally helped prepare members of 10th SFG(A) to deal with some of the most venomous snakes in the world.
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.
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.
Version:1.0 StartHTML:000000313 EndHTML:000022696 StartFragment:000021664 EndFragment:000022613 StartSelection:000021664 EndSelection:000022613 SourceURL:https://prolongedfieldcare.org/2017/08/11/podcast-episode-25-advanced-icrc-wound-care-and-the-acute-wound-care-management-clinical-practice-guideline/ Podcast Episode 25: ICRC Style Wound Care and the NEW Acute Wound Care Management Clinical Practice Guideline â€“ ProlongedFieldCare.org This Clinical Practice Guideline was written by a fellow 18D with input from around the surgical community. Â 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. Â One way is not â€œrightâ€ while the other wrong, it has more to do with the amount of time and resources available to the medic or other provider. Â The remainder of the blog post and podcast is meant to be a refresher for those who have already been taught these procedures. Â 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.Â Â If you havenâ€™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.
In this episode Dennis moderates a 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.
While at the 2017 Remote Damage Control Resuscitation(RDCR) conference put on by the Tactical Hemostasis, Oxygenation and Resuscitation(THOR) network in Norway, Sean took the time to corner Dr. Shackleford to get her thoughts on the Joint Trauma System Clinical Practice Guidelines. Be sure to check out the new JTS Facebook, LinkedIn Pages, Instagram and Twitter feeds and YouTube Channel for more updates.
This talk was recorded live 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 wit the US Army Institute of Surgical Research and the US Armed Forces Blood Program.
Dennis was finally able to corner an anesthesiologist who was actually more than happy to sit down and talk about his years if experience working from the head of thousands of patients. While we are working on an Airway Clinical Practice Guideline with the Army Institute of Surgical Research, this will go along with our earlier posted airway recommendations until we can get a consensus and get it published.
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? When is that dangerous?
If you sit on a patient long enough, infection has a greater chance of taking hold and progressing to sepsis, or may receive a patient who has already been sick for days. Doc Jaybon walks us through the full spectrum from infection and SIRS to sepsis, shock and death. Despite firm CoTCCC 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? Listen in...
Be sure to visit www.prolongedfieldcare.org for the associated quiz and show notes! Dr. David Van Wyck an Intensivist and Neurointensivist Fellow at Duke Medical Center in North Carolina explains the evolving management of TBI in the field for medics in austere environments. Go to www.prolongedfieldcare.org for the accompanying blog post, shownotes and quiz.
Despite our best efforts, endless training, and reading, some of our patients will die. This has been a taboo subject that is difficult to broach in the best of times. We aim to start a conversation here with the hope thatit continues with your Medical Director, PA, Surgeon and fellow Medics before you are ever faced with this difficult situation out on your own. Often prolonged field care involves treating the most critically sick or injured patients longer than you expect to. Inevitably some of these "sickest-of-the-sick" will not make it in time to see definitive care and you will be left to ease the suffering during end of life care alone. While you may have to deliver end of life care by yourself, you may not have to make all the decisions alone. In this episode Dennis and Doc Powell discuss how to treat expectant patients. This could be as part of a multi-patient MASCAL or a happen to a single patient who is critically ill or injured. If it happens during a MASCAL, once you are done treating your urgent patients, what do you do when you go back to your expectant patients? It's common to skip over discussing and training on losing patients... Taboo even. The fact is that it will eventually happen; No matter how good of medics we are, patients may die. Doc Powell has spent innumerable hours in Intensive Care Units with the best and brightest medical teams a patient could hope for. Often in this setting the top notch care, medicines and interventions are not enough and patients code and die. This is part of medicine whether we talk about it openly or not.
Just snow your patient with ketamine and versed to prevent PTSD right? Maybe not. While talking through some more analgesia and sedation strategies, Doc Powell shares his thoughts on what he has read recently and it might blow your mind. It did mine andI'll definitely have to dig in and do more research of my own. We also go through some of the answers to our survey we put out on our last post. For the most part we did pretty good as a whole. There were, however, some dangerous answers such as using propofol or benzodiazepines for pain control, and we will discuss why that's not necessarily such a great idea.
In this episode we gathered around a microphone to discuss the management of crush injury in austere environments including a scenario and the answers to our poll. Go to www.prolongedfieldcare.org to take the follow-up, 3-question quiz to make sure you understand the principles of the latest evidence based recommendations.
Crush injuries are difficult to manage in the best of circumstances. In an austere environment by a practitioner with little to no experience they can be overwhelming. In deciding which problem to address in depth first crush syndrome seemed to be a great choice. The Clinical Practice Guideline is well on it's way to being released very soon. As discussed in the podcast, our recommendations are an amalgamation of best practices adapted for our difficult environment. It is an injury that can happen anywhere to anyone and the correct initial management can make all the difference in patient outcome. Enough out of me, I'll let Doc Riesberg explain it via his talk he gave earlier this year to the Joint Trauma System Teleconference.
The following video podcast was recorded live at the JSOMTC during the July 21 2016 weekly Joint Trauma System Teleconference. Dr. Doug Powell talks about providing critical care in austere environments. He has been answering tough questions that medics have been asking the Prolonged Field Care Working Group for over 2 years as he simultaneously provided intensive care to sick patients in his ICU. He has proctored and instructed more prolonged field care and other austere medical exercises than anyone I know. He is now a Battalion Surgeon for a Special Forces Group and has a very good idea of what is required of a Special Operations Medic. All of the downloads from the talk can be found at our website: www.prolongedfieldcare.org
Justin and Sean review the basic concepts with telemedicine. Often confused with the technology used, telemedicine, at its most basic form, is calling for remote consultation to help manage a patient. It's a basic concept in civilian medicine, but will require a cultural shift and training to incorporate into SOF and austere medicine. Luckily, the PFC WG, in conjunction with partners at SOCOM and the medical facilities, are jumping into the problem set to bring you the concepts and solutions to some of your operational challenges.
In this great podcast Justin introduces the principals of pharmacology that have served him well over the years and have done far more for him than simply keeping him out of trouble. He also introduces Brad Morgans CRNA who is a wealth of knowledge and experience in not only combat and austere theaters but also in working with and relating to, SOF medics and the challenges we face. This is the first with more episodes in the series to come. So listen, download, read and understand the principals that, if heeded, can make the lives of you and your patients’ safer and more comfortable. These principals should challenge you and spur you along to learn more about the drugs in the magic, locked narc box and the effects they will have on your patient. If you have questions or comments add them to the comments section of this post at www.prolongedfieldcare.org
Now it’s time to bust out some clinical content and talk resuscitation. You can start today! You don’t need fancy equipment or tools. Just reach down and grab something, use a Foley and you’re there…and as a special bonus, you get a little intro on hypotensive resuscitation and why it may not be all that for the long haul…Drs. Phil Mason and Chris Burns are interviewed by Justin.
This podcast was originally recorded in May, 2014. Some of the information and discussion about the direction of the Prolonged Field Care Working Group (PFC WG) is a little dated, but this will give the listener some idea of what this PFC thing is all about and how the US SOF PFC WG started out. Dr. Sean Keenan is interviewed about the initial development and concept. Enjoy!