BringingCombat Medicine

to the Wilderness

MAJ Will Smith MD, EMT-P

US Army www.wildernessdoc.com

Washington, DCSeptember 29, 2012

Disclaimers

• No financial conflicts to disclose

• Board of Advisors for Chinook Med

• Volunteer Position - sample products

• This presentation is NOT an official position or endorsement from the United States Department of Defense/US Army

Objectives

• Briefly describe military casualty care

• How to apply what we learn between austere environments

• What military lessons learned should be adopted into Wilderness Medicine

My Perspective

• EMT - Basic 1990

• EMT- Intermediate 1992

• EMT - Paramedic 1995

• MD - 2001

• Emergency Medicine - 2004

My Perspective

• Joined Army Reserve - Sept, 27 2001

• Deployments

• Iraq - Dec 2005 to Mar 2006

• Egypt - Oct 2007 to Nov 2007

• Iraq - Oct 2008 to Jan 2009

• El Salvador - Sept 2009

• Panama - April 2010

Instead of ‘Don’t Feed the Bears’

• Before: ‘Streets of EMS’ to Combat• Now: Combat to ‘Streets of EMS’

TCCC

Butler, et. al. Military Medicine 2006

• Tactical Combat Casualty Care - 1996

“Conventional civilian medicine was not appropriate for optimizing casualty care within the tactical environment.”

Two Important Principles

1. To perform the correct intervention at the correct time in the continuum of Tactical Care.

2. A medically correct procedure performed at the wrong time may lead to further casualties.

TCCC• American College of Surgeons (PHTLS)

TCCC/TEMS Recognized• DOD - All branches

• DOI - National Park Service

• Dept Homeland Security (Boarder Patrol)

• Civilian Law Enforcement/EMS

• National Tactical Officers Assn (NTOA)

• Others

Levels of Combat Care

• Self Aid

• Buddy Aid

First Aid Kit - All Soldiers

Personal Responsibility?

Levels of Combat Care

• Combat Life Saver

WFR/EMR

Levels of Combat Care

• Combat Lifesaver Skills (CLS)

• Rapid casualty assessment (Triage)

• Control hemorrhage

• Treat penetrating chest trauma

• Maintain BLS airway

• Initiate saline lock and IVF (Removing?)

• Package casualty for transport

Permissive Hypotension

• ‘Death by Salt Water Drowning’

• Haut et al. - Ann Surg 2011 - 2 L NS/LR standard = increased mortality

• Civilian trauma studies - Don’t Delay Transport!

• Surgical cure needed to stop bleeding!

Levels of Combat Care

• Combat Medic

(91 W)

• SF Medic

(18 D)

WEMT or Paramedic

Levels of Combat Care

• Medical Treatment Facilities (MTF)

• Level 1 - BAS

• Level 5 - CONUS

Rural Clinic to Trauma Center

TCCC

• 3 Phases

• Care under fire

• Direct Threat Care

• Tactical field care

• Indirect Threat Care

• Tactical Evacuation Care

• TEMS Transport

Tactical EMS terms

Care Under Fire

• Return fire

• Provide basic care

• Stop bleeding (TQ)

• Move patient to CCP (if safe)

Stabilize the Scene

Tactical Field Care

• No longer under direct fire

• AVPU

• Airway, Breathing

• NPA

• Recovery position (on side)

• Rescue breaths

3 Categories of patients in Tactical Environment

1. Patients who will live regardless

2. Patients who will die regardless

3. Patients who will die from preventable deaths unless proper life-saving steps are taken immediately

Goal of TCCC/TEMS #3

OIF$–$Opera*on$Iraqi$Freedom;$OEF$–$Opera*on$Enduring$Freedom$(Afghanistan)$

CNS$–$Central$Nervous$System$MSOF$–$Mul*CSystem$Organ$Failure$FST$–$Forward$Surgical$Team$CSH$–$Combat$Support$Hospital$Most%Preventable%

Tactical Field Care• “Tourniquet First” for

extremity bleeding

• Use other methods as needed

• Direct pressure

• Pressure bandages

• Hemostatic agents

• Forget Pressure Points and Elevation!

Last Resort or First Choice?

Tactical Field Care

• Chest injuries

• Cover sucking chest wounds

• Needle decompression

Chest Seals

• 3 vs. 4 Sides

• Vented (1-way valve)

• Multiple Products

• Expired AED pads are adequate

Needle Decompression

• At least 3” needle/catheter - 10-14 gu

• Chest Walls >2”

• Combat Life Saver level

• EMR (not ALS)

Tactical Field Care

• Additional Skills

• Surgical Criocthyroidotomy

Tracheal Hook

Cuffed Tube

King Airway

Tactical Field Care

• IV Fluids

• Radial pulse - Saline Lock

• No Radial - 500 ml Hextend

• 30 min - No Radial - 500 ml Hextend

Limited Resources

Tactical Field Care

• Splint obvious fractures

• Combat Pill Pack• Acetaminophen (Tylenol)

• Meloxicam (Mobic - NSAID)

• Gatafloxacin

Early Field Antibiotics

Combat TACEVAC

• TACEVAC - Tactical Evacuation

• CASEVAC - Casualty Evacuation

• MEDEVAC - Medical Evacuation

Combat Medic

• Narcotics

• Morphine Auto-Injectors (5-10 mg)

• ACTIQ - ‘Fentanyl Pop’

• Intranasal Ketamine

• Narcan, Fentanyl

• Versed, Glucagon

Combat Medic

• Intraosseous (IO)

Bleeding Control

• Direct Pressure

• Elevation (above heart)

• Pressure Points

• Tourniquet (LAST RESORT)

NEW Old Algorithm

Tourniquets

• Risk vs. Benefit

• Appropriately applied

• Limited application time

Tourniquets

C-A-T Tourniquet

What makes a good TQ?

• Width >1”, Mechanical arm (cam)

• Easily application (<60 sec)

• Self-applied, adjustable, non-slip

Ideal Pneumatic Cuff

Delphi Tourniquet

Compression Bandages

• Direct Pressure = Stop Bleeding

Compression Bandages

Hemostatic Agents

Hemostatic Agents

• Stop bleeding in areas where TQ don’t work

• TCCC Top agent:

• Combat Guaze

Other Agents

Harmful effects of Granular Clotting Agents

• Kheirabadi, J Trauma 2009

• Exothermic local effect of complete vessel occlusions (injured and surrounding)

• Embolic events (PE/Stroke)

PPE

Traditional Wilderness PPE

Hypothermia Kills

• Even in Iraq, 18% of pts arrived T<36C (96.8F)

• Temps in critical trauma pts < 34C (93F) = near 100% mortality

Arthurs 2006 Am J Surg

Warmed Fluid (blood)

Wilderness Hypothermia Treatment

Wilderness Hypothermia Treatment

Calories (food and drink)

Exposure to other things

Exposure to other things

Summary

• “Tourniquet First” for severe extremity bleeding

• Adapted protocols for Tactical EMS and Wilderness Settings

• Care Under Fire

• Use of many other Specialized Skills and Products for the Wilderness

Questions?

www.wildernessdoc.com

References

• The War on Trauma, Lessons Learned from a Decade of Conflict. Supplement to JEMS October 2008, sponsored by North American Rescue, Inc. Download at: www.NARescue.com

• War Surgery in Afghanistan and Iraq. A series of cases, 2003-2007. Ed. Nessen, et. al. 2008. Office of the Surgeon General.

References

• Combat Lifesaver Course: Student Self-Study Guide. Subcourse IS0871, Edition B. Army Institute for Professional Development. Ft. Sam Houston, TX.

• PHTLS - Military Edition. 6th Ed. Elsevier/Mosby JEMS. 2007