BringingCombat Medicine

to the “Streets of EMS”

MAJ Will Smith MD, EMT-P

US Army www.wildernessdoc.com

June 11, 2010CSEC

Telluride, CO

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 tactical combat casualty care (TCCC)

• How to apply what we learn between austere environments (EMS?)

• Discuss products and protocols that should be adopted into EMS patient care

My Experience

• EMT - Basic 1990

• EMT- Intermediate 1992

• EMT - Paramedic 2005

• MD - 2001

• Emergency Medicine - 2004

My Experience

• 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

• 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.”

TCCC• American College of Surgeons (PHTLS)

Levels of Combat Care

• Self Aid

• Buddy Aid

First Aid Kit - All Soldiers

Levels of Combat Care

• Combat Life Saver

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

Levels of Combat Care

• Combat Medic

• 91 Whisky

• Special Forces Medic

• 18 Delta

EMT 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

• Tactical field care

• Tactical Evacuation Care

Care Under Fire

• Return fire

• Provide basic care

• Stop bleeding (TQ)

• Move patient to CCP (if safe)

Scene Safety

Tactical Field Care

• No longer under direct fire

• AVPU

• Airway, Breathing

• NPA

• Recovery position (on side)

• Rescue breaths

http://www.narescue.com/TacticalCombatCasualtyCare.aspx

LTC McManus, USAISR

LTC McManus, USAISR

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

Combat Medic

• 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)

Old Algorithm

“Hemorrhage due to penetrating trauma is the leading cause of preventable death during military operations” Butler, JEMS 2008

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

PPE

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)

Hypothermia Prevention

Hypothermia Kills

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

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

HPMK - Hypothermia Kit

Warmed Fluid (blood)

Exposure to other things

Summary

• “Tourniquet First” for severe extremity bleeding

• Adapted protocols for EMS and Tactical Settings

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.

Questions?

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