operational casualty care course 2006 introduction lcdr fermin s. godinez naval medical center...

Operational Casualty Care Course Operational Casualty Care Course 20062006

IntroductionIntroductionLCDR Fermin S. GodinezLCDR Fermin S. Godinez

Naval Medical Center PortsmouthNaval Medical Center Portsmouth

Department of Emergency MedicineDepartment of Emergency Medicine

Portsmouth, VA 23708Portsmouth, VA 23708

Course OverviewCourse Overview

• Brief IntroductionBrief Introduction

• Course ScheduleCourse Schedule

• Navy Health Service Support of US Navy Health Service Support of US Marine Corps ForcesMarine Corps Forces

• Introduction of Guest PanelIntroduction of Guest Panel

Administrative remarksAdministrative remarks

• Contact informationContact information

• Logistics of work spaceLogistics of work space

• DisclaimerDisclaimer

• AcknowledgementsAcknowledgements• 33rdrd Force Recon Combat Course Force Recon Combat Course• TC3 SOCOM RecommendationsTC3 SOCOM Recommendations• Prior deployed HM’s, 18D’s,& MO’sPrior deployed HM’s, 18D’s,& MO’s

Course ScheduleCourse ScheduleCasualty Care Course Jan/Feb 2006

Monday-30 January

0730-0750 Check in Welcome/Admin remarks CDR CailteuxZevallosLCDR Walters

0750-0800 BREAK

0800-0850 Course Introduction/Overview LCDR Godinez

0850-0900 BREAK

0900-0950 The Primary & Secondary Survey LCDR Godinez

0950-1000 BREAK

1000-1050 Airway/Breathing Management LCDR Godinez

1050-1100 BREAK

1100-1200 Working Lunch/Discussion Panel Prior Deployed NMCP personnel

1200-1700 AIRWAY SKILLS STATIONS LCDR Godinez

IntroductionIntroduction

• The standards of care applied to the The standards of care applied to the battlefield have always been based on battlefield have always been based on civilian care principals. civilian care principals.

• These principals while appropriate for These principals while appropriate for the civilian community often the civilian community often do not do not apply to care on the battlefieldapply to care on the battlefield..

• The 90% SolutionThe 90% Solution


Civilian medical trauma training is based Civilian medical trauma training is based on the following principles:on the following principles:

Emergency Medical Technicians Emergency Medical Technicians

(EMT-B,I,P)(EMT-B,I,P)

Basic Trauma Life Support (BTLS)Basic Trauma Life Support (BTLS)

Advanced Trauma Life Support (ATLS)Advanced Trauma Life Support (ATLS)


Guiding principles of this courseGuiding principles of this course

• 1. Treat the casualty safely1. Treat the casualty safely

• 2. Complete the mission2. Complete the mission

"We must remember that one man is much the same as another, and that he is best "We must remember that one man is much the same as another, and that he is best who is trained in the severest school."--Thucydides, who is trained in the severest school."--Thucydides, The History of the Peloponnesian WarThe History of the Peloponnesian War

Katrina/Rita

HumanitarianHumanitarianAssistanceAssistance

MajorMajorConflictConflict

Iraqi/Enduring FreedomIraqi/Enduring Freedom

Terrorist Terrorist ResponseResponse

East Timor HA/PKEast Timor HA/PK

SomaliaSomalia

PeacePeaceKeepingKeeping

KosovoKosovo

Full Spectrum Operations Full Spectrum Operations

El Salvador HA

HomelandHomelandDefenseDefense

Disaster Disaster ResponseResponse

Full Spectrum of Medical Support

http://www.af.mil/photos/images/people_0105.jpg

http://www.af.mil/photos/images/001838a.jpg

Air Transportable Hospital (ATH)

TACEVAC- Evac Policy -

7 Days

STRATEVAC- Evac Policy -

15 Days

Field HospitalBattalion AidStation

Definitive Care

CASEVAC- Evac Policy -

1 Day

Critical Care GapCritical Care Gap

Historical Route From Injury to Definitive Care

Forward Surgical Capability

- 24 Hours -

Field Hospital Definitive Care

- 48 Hours -

Self Aid / Buddy Care

Forward Surgical Capabilities

Casualty Evacuation-1 Hour –

Marine Corps Structure & Health Marine Corps Structure & Health Service Support CapabilitiesService Support Capabilities

LCDR Eric Timmens, MSC, USNDEPMEDS Manager, Medical Resources, Plans and Policy DivisionChief of Naval Operations11-16 January 2004

Marine Air Ground Task ForceMarine Air Ground Task Force(MAGTF)(MAGTF)

Marine Expeditionary Marine Expeditionary ForceForce (MEF)(MEF)

20-90K20-90K20-90K20-90K Major Theater WarMajor Theater War

Marine Expeditionary Marine Expeditionary BrigadeBrigade (MEB)(MEB)

3-20K3-20K3-20K3-20K Smaller Scale Contingencies Smaller Scale Contingencies

Marine Expeditionary Marine Expeditionary UnitUnit (MEU(SOC))(MEU(SOC))

1.5-3K1.5-3K1.5-3K1.5-3K Promote Peace and StabilityPromote Peace and Stability

Core Elements to the MEFCore Elements to the MEF

Marine Marine Expeditionary Expeditionary

ForceForce (MEF)(MEF)

Marine DivisionMarine Division

Marine Air WingMarine Air Wing

Force Service Support GroupForce Service Support Group

Health Service SupportHealth Service Support(Deployable Capability Sets)(Deployable Capability Sets)

• Marine Division (Battalion)Marine Division (Battalion)• Battalion Aid StationsBattalion Aid Stations• 2 Medical Officers and 65 Hospital Corpsman2 Medical Officers and 65 Hospital Corpsman

• FSSG (Medical Battalion)FSSG (Medical Battalion)• Shock Trauma Platoons (STP)Shock Trauma Platoons (STP)• Surgical/STP(S/STP)Surgical/STP(S/STP)• Forward Resuscitative Surgical System (FRSS)Forward Resuscitative Surgical System (FRSS)• Surgical CompanySurgical Company

• Expeditionary Medical Facility (EMF) Expeditionary Medical Facility (EMF)

Health Service SupportHealth Service Support

BattalionBattalionAid Aid

StationStation

Shock Trauma PlatoonShock Trauma PlatoonSurgical STPSurgical STP

Forward Resuscitative Forward Resuscitative Surgical Suite (FRSS)Surgical Suite (FRSS)

Surgical CompanySurgical Company

Expeditionary Medical Expeditionary Medical Facility (EMF)Facility (EMF) Echelon IIIEchelon III

Echelon IEchelon ILa

rger

Foo

tprin

t

Fleet HospitalLevel III

BASLevel I

STPLevel I

FEBA

Surgical CompanyLevel II

LHD CRTS

FRSS

+/-

Ground Combat ElementEchelons of Care

I

II

III - 48 Hours -

MARINE DIVISION

INFANTRYBATTALION

H&SCOMPANY

WEAPONSCOMPANY

RIFLECOMPANIES

MEDICALPLATOON

- 1 MO = Battalion Surgeon- 1 MO = Battalion Aid Station (BAS)- 21 HM's = Battalion Aid Station- 11 HM's = Weapons Company- 33 HM's = Rifle Companies (3)

2 MO'S/65 HM's

MARINE DIVISION

MARDIV

TANKBATTALION

HEADQUARTERSBATTALION

ARTILLERYREGIMENT

ASSAULTAMPHIBIOUSBATTALION

LIGHT ARMOREDRECONNAISSANCE

BATTALION

COMBATENGINEER

BATTALION

INFANTRYREGIMENTS

- Division Surgeon- Medical Administrative Officer- Environmental Health Officer- Division Psychiatrist- Enlisted Personnel Assistants

FORCE SERVICESUPPORT GROUP

FSSG

HEADQUARTERS& SERVICE

BATTALION

MOTORTRANSPORTBATTALION

ENGINEERINGSUPPORT

BATTALION

LANDINGSUPPORT

BATTALION

MEDICALBATTALION

MAINTENANCEBATTALION

SUPPLYBATTALION

DENTALBATTALION

FORCE SERVICE SUPPORT GROUP

- S-1- S-2/3- S-4- S-6- Preventive Medicine- Chaplain- Shock/Trauma Platoons (8)

FSSG


BATTALION


ENGINEERINGSUPPORT

BATTALION

LANDINGSUPPORT

BATTALION

MEDICALBATTALION


SUPPLYBATTALION

DENTALBATTALION

H & SCOMPANY

SURGICALCOMPANIES


SHOCK/TRAUMAPLATOONS (8)

- STABILIZATION SECTION 2 - MO 1 - NC 1 - PA 7 - HM's

- COLLECTING/EVAC SECTION 1 - NC 7 - USMC 7 - HM's

0 OR's; 10 COTS

FSSG


BATTALION


ENGINEERINGSUPPORT

BATTALION

LANDINGSUPPORT

BATTALION

MEDICALBATTALION


SUPPLYBATTALION

DENTALBATTALION

H & SCOMPANY

SURGICALCOMPANIES


H & SCOMPANY

SURGICALCOMPANIES

FSSG


BATTALION


ENGINEERINGSUPPORT

BATTALION

LANDINGSUPPORT

BATTALION

MEDICALBATTALION


SUPPLYBATTALION

DENTALBATTALION

- HQ Platoon- Triage/Evacuation Platoon- Surgical Platoon- Holding Platoon- Combat Stress Platoon- Ancillary Service Platoon (Dental Detachment)


H & SCOMPANY

SURGICALCOMPANIES

FSSG


BATTALION


ENGINEERINGSUPPORT

BATTALION

LANDINGSUPPORT

BATTALION

MEDICALBATTALION


SUPPLYBATTALION

DENTALBATTALION

- 17 MC- 7 MSC- 23 NC- 127 HM- 19 USMC

- 3 OR's; 60 COTS

Forward Resuscitative Surgery System Forward Resuscitative Surgery System (FRSS)(FRSS)

Supporting Marine Corps Strategy 21

Joel Lees CAPT, MC, USNI MEF Surgeon

FORWARD RESUSCITATIVE SURGERY FORWARD RESUSCITATIVE SURGERY SYSTEM (FRSS)SYSTEM (FRSS)

• Where does FRSS apply in echelons of HSS supportWhere does FRSS apply in echelons of HSS support??

STP+FRSS

ECHELON I ECHELON II ECHELON III ECHELON IV & V

Marine Health ServiceMarine Health Service

Fleet HospitalsHospital Ships

Out of theater Medical Centers

Surgical CompanyCasualty Receiving

ShipsEg BHR, Iwo Jima

Buddy Aid BASSTP

FRSS Footprint - 1700 Sq ft

Post Op Beds

Pre Op Beds

Operating Room

Supplies

Litters on Stands

CapabilitiesUNITUNIT OR’sOR’s ICU/ICWICU/ICW

USMCUSMC FRSSFRSS 11

Shock Trauma Platoon Shock Trauma Platoon (STP)(STP)

N/AN/A 1010

Surgical CompanySurgical Company 3 w/ 2 tables each3 w/ 2 tables each 20/4020/40

Casualty Receiving Casualty Receiving and Treatment Shipsand Treatment Ships

LHALHA 4+24+2 15/4515/45

LHDLHD 4+24+2 17/4717/47

LHA RLHA R 4+24+2 15/4515/45

MPF FMPF F

Medical capability on 2 Medical capability on 2 ships of a 6 ship ships of a 6 ship squadronsquadron

66 38/8338/83

LPD-17LPD-17 1+11+1 6/186/18

Fleet Hospitals-Fleet Hospitals- EMF-500EMF-500 66 80/42080/420

EMF 116EMF 116 22 20/9620/96

EMF-10EMF-10 11 1010

Hospital ShipHospital Ship TA-HTA-H 1212 80/40080/400

Combat Trauma LecturesCombat Trauma Lectures

Airway and BreathingAirway and Breathing Hemorrhage and ShockHemorrhage and Shock Extremity TraumaExtremity Trauma Thoracic TraumaThoracic Trauma Head TraumaHead Trauma Spine TraumaSpine Trauma CASEVAC ProceduresCASEVAC Procedures

Combat Trauma Skills LabsCombat Trauma Skills Labs

Airway ManagementAirway Management Hemorrhage ControlHemorrhage Control SplintingSplinting Intravenous AccessIntravenous Access Casualty CarriesCasualty Carries Chest WoundsChest Wounds Abdominal WoundsAbdominal Wounds

Battlefield Care is Battlefield Care is Improvised Improvised CareCare


Simple important principles – Simple important principles –

• The correct intervention at the correct The correct intervention at the correct time. time.

• In combat, errors may lead to further In combat, errors may lead to further casualtiescasualties


• Pre-hospital care continues to be Pre-hospital care continues to be critically importantcritically important

• Up to 90% of all combat deaths Up to 90% of all combat deaths occur before a casualty reaches a occur before a casualty reaches a Medical Treatment Facility (MTF)Medical Treatment Facility (MTF)

• Penetrating vs. Blunt traumaPenetrating vs. Blunt trauma

Factors influencing Factors influencing combat casualty care combat casualty care

• Enemy FireEnemy Fire

• Medical Equipment LimitationsMedical Equipment Limitations

• Widely Variable Evacuation TimeWidely Variable Evacuation Time

Factors influencing Factors influencing combat casualty carecombat casualty care

• Tactical ConsiderationsTactical Considerations

• Casualty TransportationCasualty Transportation

Photo courtesy of HM3(FMF) McCLain

STAGES OF CARESTAGES OF CARE

• Care Under FireCare Under Fire• Over the barrier/bermOver the barrier/berm

• Tactical Field CareTactical Field Care

• Combat Casualty Evacuation CareCombat Casualty Evacuation Care

TCCC

Care Under FireCare Under Fire

• ““Care under fire” is the care rendered Care under fire” is the care rendered by the medic at the scene of the by the medic at the scene of the injury while he and the casualty are injury while he and the casualty are still under effective hostile fire. still under effective hostile fire. Available medical equipment is Available medical equipment is limited to that carried by the soldier limited to that carried by the soldier or the medic in his aid bag.or the medic in his aid bag.

Tactical Field CareTactical Field Care

• ““Tactical Field Care” is the care rendered by Tactical Field Care” is the care rendered by the medic once he and the casualty are no the medic once he and the casualty are no longer under effective hostile fire. It also longer under effective hostile fire. It also applies to situations in which an injury has applies to situations in which an injury has occurred, but there has been no hostile fire. occurred, but there has been no hostile fire. Available medical equipment is still limited to Available medical equipment is still limited to that carried into the field by medical that carried into the field by medical personnel. Time to evacuation to a MTF may personnel. Time to evacuation to a MTF may vary considerably.vary considerably.

Combat Casualty Combat Casualty Evacuation CareEvacuation Care

• ““Combat Casualty Evacuation Care” Combat Casualty Evacuation Care” is the care rendered once the is the care rendered once the casualty has been picked up by an casualty has been picked up by an aircraft, vehicle or boat. Additional aircraft, vehicle or boat. Additional medical personnel and equipment medical personnel and equipment may have been pre-staged and may have been pre-staged and available at this stage of casualty available at this stage of casualty management. management.


• Attention to suppression of hostile Attention to suppression of hostile fire may minimize the risk of injury fire may minimize the risk of injury to personnelto personnel

• Minimize additional injury to Minimize additional injury to previously injured personnel.previously injured personnel.


Wounded personnel who are Wounded personnel who are unable to fight should lay flat and unable to fight should lay flat and motionless if no cover is available motionless if no cover is available or move as quickly as possible to or move as quickly as possible to any nearby coverany nearby cover


• Medical personnel are limited and if Medical personnel are limited and if your injured…….your injured…….

• No other medical personnel will be No other medical personnel will be available until the time of extraction available until the time of extraction during the CASEVAC phaseduring the CASEVAC phase


• Control of hemorrhage is important Control of hemorrhage is important since injury to a major vessel can since injury to a major vessel can result in hypovolemic shock in a result in hypovolemic shock in a short time frameshort time frame

• Over 2500 deaths occurred in Viet Over 2500 deaths occurred in Viet Nam secondary to hemorrhage from Nam secondary to hemorrhage from extremity woundsextremity wounds


• Use of temporary tourniquets to Use of temporary tourniquets to stop the bleedingstop the bleeding is essential in is essential in these types of casualtiesthese types of casualties


The need for immediate access to a The need for immediate access to a tourniquet in such situations makes tourniquet in such situations makes it clear that all soldiers on combat it clear that all soldiers on combat missions have a suitable missions have a suitable tourniquet readily available at a tourniquet readily available at a standard location on their battle standard location on their battle gear and be trained in its use.gear and be trained in its use.


• Penetrating neck injuries do not require Penetrating neck injuries do not require C-spine immobilization. C-spine immobilization.

• Other neck injuries, such as falls over Other neck injuries, such as falls over 15 feet, fast-roping injuries, or MVAs 15 feet, fast-roping injuries, or MVAs may require C-spine control may require C-spine control unlessunless the the danger of hostile fire constitutes a danger of hostile fire constitutes a greater threat in the judgment of the greater threat in the judgment of the medical personnelmedical personnel

Care Under Fire Care Under Fire

• Litters may not be available for Litters may not be available for movement of casualties. movement of casualties.

• Consider alternate methods to Consider alternate methods to move casualties such as a SKEDmove casualties such as a SKED®® or Talon IIor Talon II®® litter. Smoke, CS, and litter. Smoke, CS, and vehicles may act as screens to vehicles may act as screens to assist in casualty movement.assist in casualty movement.

KEY POINTSKEY POINTS• Try to keep yourself from being shotTry to keep yourself from being shot• Try to keep the casualty from sustaining any Try to keep the casualty from sustaining any

additional woundsadditional wounds• Stop any life threatening hemorrhage with a Stop any life threatening hemorrhage with a

tourniquettourniquet• Airway as requiredAirway as required• Reassure the casualtyReassure the casualty


• The Tactical Field Care phase is The Tactical Field Care phase is distinguished from the Care Under distinguished from the Care Under Fire phase by having more time Fire phase by having more time available to provide care.available to provide care.

• A reduced level of hazard from A reduced level of hazard from hostile fire. The times available to hostile fire. The times available to render care may be quite variable. render care may be quite variable.

Tactical Field CareTactical Field Care• In some cases, tactical field care may consist In some cases, tactical field care may consist

of rapid treatment of wounds with the of rapid treatment of wounds with the expectation of a re-engagement of hostile fire expectation of a re-engagement of hostile fire at any moment. at any moment.

• In some circumstances there may be ample In some circumstances there may be ample time to render whatever care is available in time to render whatever care is available in the field. the field.

• The time to evacuation may be quite variable The time to evacuation may be quite variable from 30 minutes to several hours.from 30 minutes to several hours.


• If a victim of a blast or penetrating injury If a victim of a blast or penetrating injury is found without a pulse, respirations, or is found without a pulse, respirations, or other signs of life,other signs of life,

• DoDo NotNot attempt CPR attempt CPR

• Casualties with altered mental status Casualties with altered mental status should be disarmed immediately, both should be disarmed immediately, both weapons and grenadesweapons and grenades


Initial assessment consists of:Initial assessment consists of:Tactical AssessmentTactical Assessment AirwayAirway

BreathingBreathing

CirculationCirculation

CASEVAC CareCASEVAC Care


• At some point in the operation the At some point in the operation the casualty will be scheduled for casualty will be scheduled for evacuation. evacuation.

• Time to evacuation may be quite Time to evacuation may be quite variable from minutes to hours.variable from minutes to hours.

CASEVACCASEVAC


• The Hospital Corpsman may be The Hospital Corpsman may be among the casualtiesamong the casualties

• The Hospital Corpsman may be The Hospital Corpsman may be dehydrated, hypothermic, or dehydrated, hypothermic, or otherwise debilitatedotherwise debilitated


• There may be multiple casualties There may be multiple casualties that exceed the capability of the that exceed the capability of the medic to care for simultaneously.medic to care for simultaneously.


• Additional medical equipment can Additional medical equipment can be brought in with the EVAC asset be brought in with the EVAC asset to augment the equipment of the to augment the equipment of the HM.HM.

• This equipment may include:This equipment may include:

SummarySummary

• How people die in ground combat:How people die in ground combat:• 31% Penetrating Head Trauma31% Penetrating Head Trauma• 25% Surgically Uncorrectable Torso 25% Surgically Uncorrectable Torso TraumaTrauma

• 10% Potentially Correctable Surgical Trauma10% Potentially Correctable Surgical Trauma

SummarySummary

• 9% Exsanguination from Extremity 9% Exsanguination from Extremity Wounds Wounds 1st1st

• 7% Mutilating Blast Trauma7% Mutilating Blast Trauma

• 5% Tension Pneumothorax 5% Tension Pneumothorax 2nd2nd

• 1% Airway Problems 1% Airway Problems 3rd3rd

• 12% Died of Wounds (Mostly infections 12% Died of Wounds (Mostly infections and complications of shock)and complications of shock)

SummarySummary

• Three categories of casualties on the Three categories of casualties on the battlefieldbattlefield• Injured personnel who will do well Injured personnel who will do well

regardless of what we do for themregardless of what we do for them• Injured personnel who are going to die Injured personnel who are going to die

regardless of what we do for themregardless of what we do for them• Injured personnel who will die if we do not Injured personnel who will die if we do not

do something for them now (7-15%)do something for them now (7-15%)

REMEMBERREMEMBER

• If during the next war you could do If during the next war you could do only two things, only two things, • (1) put a tourniquet on and (1) put a tourniquet on and • (2) relieve a tension pneumothorax (2) relieve a tension pneumothorax

then you can probably save between then you can probably save between 70 and 90 percent of all the 70 and 90 percent of all the preventable deaths on the battlefield. preventable deaths on the battlefield. COL Ron BellamyCOL Ron Bellamy

SummarySummary

• Medical care during combat differs Medical care during combat differs significantly from the care provided significantly from the care provided in the civilian community. in the civilian community.

Earl WilsonCourage is the art of being the only one who knows you're scared to death!

SummarySummary

• These timely interventions will These timely interventions will be the mainstay in decreasing be the mainstay in decreasing the number of combat fatalities the number of combat fatalities on the battlefield.on the battlefield.

We Serve So Others May LiveWe Serve So Others May Live

QUESTIONS ??QUESTIONS ??

Earl WilsonCourage is the art of being the only one who knows you're scared to death!

National Stock NumbersNational Stock Numbers

• One handed tourniquet 6515-01-504-0827One handed tourniquet 6515-01-504-0827• HextendHextend® ® Fluid 6505-01-498-8636Fluid 6505-01-498-8636• FAST 1FAST 1®® 6515-01-453-0960 6515-01-453-0960• Emergency Trauma DressingEmergency Trauma Dressing®® 6510-01-492- 6510-01-492-

22752275• HemCon Chitosan DressingHemCon Chitosan Dressing®® 6510-01-502- 6510-01-502-

69386938• Sked LitterSked Litter®® 6530-01-260-1222 6530-01-260-1222• Talon II LitterTalon II Litter®® 6530-01-452-1651 6530-01-452-1651

operational casualty care course 2006 introduction lcdr fermin s. godinez naval medical center...

Documents

medical resources

echelons of hss support

civilian care principals

following principles

civilian community

casualty safely2

joel lees capt

introductionlcdr fermin