Bringing Combat Medicine September 29, 2012 to the … ExpedMed... · Principles 1.To perform the...
Transcript of Bringing Combat Medicine September 29, 2012 to the … ExpedMed... · Principles 1.To perform the...
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
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/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
• 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
• 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?
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
• 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
Bleeding Control
• Direct Pressure
• Elevation (above heart)
• Pressure Points
• Tourniquet (LAST RESORT)
NEW Old Algorithm
What makes a good TQ?
• Width >1”, Mechanical arm (cam)
• Easily application (<60 sec)
• Self-applied, adjustable, non-slip
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 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
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
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.