Bringing Combat Medicine to the Streets of EMS. MAJ Will Smith MD, EMT-P US Army

Transcription

1 Bringing Combat Medicine to the Streets of EMS MAJ Will Smith MD, EMT-P US Army

2 Disclaimers No financial or other conflicts to disclose This presentation is NOT an official position or endorsement from the United States Department of Defense/ US Army

3 Objectives Briefly describe military casualty care What should be adopted into EMS

4 My Experience EMT - Basic 1990 EMT- Intermediate 1992 EMT - Paramedic 2005 MD Emergency Medicine

5 My Expereince Joined Army Reserve - Sept, Deployments Iraq - Dec 2005 to Mar 2006 Egypt - Oct 2007 to Nov 2007 Iraq - Oct 2008 to Jan 2009 El Salvador - Sept 2009

6 Before: Streets of EMS to Combat Now: Combat to Streets of EMS

7 TCCC Conventional civilian medicine was not appropriate for optimizing casualty care within the tactical environment. Butler, et. al. Military Medicine 2006 Tactical Combat Casualty Care American College of Surgeons (PHTLS)

8 Levels of Combat Care Self Aid Buddy Aid First Aid Kit - All Soldiers

9 Levels of Combat Care Combat Life Saver

10 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 Package casualty for transport

11 Levels of Combat Care Combat Medic 91 W

12 Levels of Combat Care Medical Treatment Facilities (MTF)

13 TCCC 3 Phases Care under fire Tactical field care Combat casualty evacuation care

14 Care Under Fire Return fire Provide basic care Stop bleeding (TQ) Move patient to CCP (if safe)

15 Tactical Field Care No longer under direct fire AVPU Airway, Breathing NPA Recovery position (on side) Rescue breaths

16 Tactical Field Care Chest injuries Cover sucking chest wounds Needle decompression

17 Tactical Field Care Tourniquet First for extremity bleeding Use other methods as needed Direct pressure Pressure bandages Hemostatic agents

18 Tactical Field Care IV Fluids Radial pulse - Saline Lock No Radial ml Hextend 30 min - No Radial ml Hextend

19 Tactical Field Care Splint obvious fractures Combat Pill Pack Acetaminophen (Tylenol) Meloxicam (Mobic - NSAID) Gatafloxacin

20 Combat CASEVAC CASEVAC - Casualty Evacuation to MEDEVAC (medical evacuation) or MTF (Medical Treatment Facility)

21 Combat Medic Additional Skills Surgical Criocthyroidotomy Cuffed Tube Tracheal Hook

22 Combat Medic Narcotics Morphine Auto-Injectors (5-10 mg) Fentanyl Transmucosal Lozenge Intranasal Ketamine

23 Combat Medic Intraosseous (IO)

24 LTC McManus, USAISR

25 LTC McManus, USAISR

26

27 Bleeding Control Direct Pressure Elevation (above heart) Pressure Points Tourniquet (LAST RESORT)

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

29 PPE

30 Exposed Extremities

31 Tourniquets Risk vs. Benefit Appropriately applied Limited application time

32 Tourniquets C-A-T Tourniquet

33

34 What makes a good TQ? Width >1, Mechanical arm (cam) Easily application (<60 sec) Self-applied, adjustable, non-slip

35 Ideal Pneumatic Cuff Delphi Tourniquet

36

37 Compression Bandages Direct Pressure = Stop Bleeding

38 Compression Bandages

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40 Combined Use

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42 Hemostatic Agents

43 Hemostatic Agents Stop bleeding in areas where TQ don t work TCCC Top agent: Combat Guaze

44 Other Agents

45 Hypothermia Prevention

46 Hypothermia Kills Even in Iraq, 18% of pts arrived T<36C (96.8F) Temps in critical trauma pts < 34C (93F) = near 100% mortality

47 HPMK - Hypothermia Kit

48 Warmed Fluid (blood)

49 Summary Tourniquet First for severe extremity bleeding Adapted protocols for Tactical EMS Settings

50 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: War Surgery in Afghanistan and Iraq. A series of cases, Ed. Nessen, et. al Office of the Surgeon General.

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

52 Questions?