Prolonged Field Care Podcast

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 of knowledge 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.   For more content, visit www.prolongedfieldcare.org

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. He was formerly an SF Medical Sergeant turned Team  Sergeant before going on to work as the 3rd SFG(A) Senior Enlisted  Medical Advisor, the Unites States Army Special Forces Command (USAFC)  SEMA and within the USASOC Surgeon’s Office.      For more content, visit www.prolongedfieldcare.org

When do you give a burn patient antibiotics? Which ones?   How do you calculate TBSA and the rule of 10s?   What do you use to guide fluid resuscitation? What fluid?   When is an escharotomy in the field appropriate?    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.   For more content, visit www.prolongedfieldcare.org

In this live recording, guest lecturer COL Missy Givens shares the CBRNe  knowledge she has learned while working as a clinical toxicologist,  among many other positions, around the world including as the SOCAFRICA  Command Surgeon.  For more content, visit www.prolongedfieldcare.org

You are in your Team House or BAS. You have given FDP, Whole blood, TXA  calcium and don’t have much left despite the few units from the walking  blood bank. Your patient continues to bleed internally. Nothing in the  chest or upper abdomen. Probably pelvic. Damn. MEDEVAC is en route. They  will have some blood too. You just need your patient to hold on for  another hour before he gets to surgery…   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.    You are in your Team House or BAS. You have given FDP, Whole blood, TXA  calcium and don’t have much left despite the few units from the walking  blood bank. Your patient continues to bleed internally. Nothing in the  chest or upper abdomen. Probably pelvic. Damn. MEDEVAC is en route. They  will have some blood too. You just need your patient to hold on for  another hour before he gets to surgery…  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. REBOA   In this episode we explore the usefulness and limitations of this  strategy in deployed settings and discuss the use of REBOA by  non-physician providers in austere situations. He has written several  articles on use of the REBOA and it is now one of the most promising and  controversial adjuncts available for hemorrhage control of bleeding  inside the box of the thorax, abdomen and pelvis. In order to do this o e  would likely have to be within an hour of a facility that can repair  the retired vessel as the lactic acid and other toxins would quickly  build up causing a massive repercussion injury. To this end he discusses  his strategy for partial REBOA during resuscitation that would leave  the balloon partially inflated allowing a clot to strengthen and  circulation distal to the balloon.  For more content, visit www.prolongedfieldcare.org

Dr. Cap has been leading the way here in the US with the Armed Services  Blood Program on fresh whole blood transfusion research in conjunction  with the THOR Network and answering tough questions that different  Special Operations Units come up with when analyzing how best to  implement a fresh whole blood resuscitation protocol. In this episode  Dennis presses him on the important resuscitation questions medics  everywhere seem to be asking :       I don’t have blood yet; Crystalloid isn’t really that bad, is it?      Can’t I just resuscitate to a normal BP with hetastarch or hextend?      Where does FDP fit in with resuscitation?      What do you mean by, “dose of shock?”      Do I really have to give TXA over 10 minutes?      What comes first TXA, Calcium or Blood?      Why should patients get calcium as soon as possible once you  identify they need blood?      What’s this about pre-hospital albumin?     For more content, visit www.prolongedfieldcare.org

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