Prolonged Field Care Podcast

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

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.