Bringing Combat Medicine to the Streets of EMS MAJ Will Smith MD, EMT-P US Army
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
Objectives Briefly describe military casualty care What should be adopted into EMS
My Experience EMT - Basic 1990 EMT- Intermediate 1992 EMT - Paramedic 2005 MD - 2001 Emergency Medicine - 2003
My Expereince 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
Before: Streets of EMS to Combat Now: Combat to Streets of EMS
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 - 1996 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
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
Levels of Combat Care Combat Medic 91 W
Levels of Combat Care Medical Treatment Facilities (MTF)
TCCC 3 Phases Care under fire Tactical field care Combat casualty evacuation care
Care Under Fire Return fire Provide basic care Stop bleeding (TQ) Move patient to CCP (if safe)
Tactical Field Care No longer under direct fire AVPU Airway, Breathing NPA Recovery position (on side) Rescue breaths
Tactical Field Care Chest injuries Cover sucking chest wounds Needle decompression
Tactical Field Care Tourniquet First for extremity bleeding Use other methods as needed Direct pressure Pressure bandages Hemostatic agents
Tactical Field Care IV Fluids Radial pulse - Saline Lock No Radial - 500 ml Hextend 30 min - No Radial - 500 ml Hextend
Tactical Field Care Splint obvious fractures Combat Pill Pack Acetaminophen (Tylenol) Meloxicam (Mobic - NSAID) Gatafloxacin
Combat CASEVAC CASEVAC - Casualty Evacuation to MEDEVAC (medical evacuation) or MTF (Medical Treatment Facility)
Combat Medic Additional Skills Surgical Criocthyroidotomy Cuffed Tube Tracheal Hook
Combat Medic Narcotics Morphine Auto-Injectors (5-10 mg) Fentanyl Transmucosal Lozenge Intranasal Ketamine
Combat Medic Intraosseous (IO)
LTC McManus, USAISR
LTC McManus, USAISR
http://www.narescue.com/tacticalcombatcasualtycare.aspx
Bleeding Control Direct Pressure Elevation (above heart) Pressure Points Tourniquet (LAST RESORT)
Hemorrhage due to penetrating trauma is the leading cause of preventable death during military operations Butler, JEMS 2008
PPE
Exposed Extremities
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
Combined Use
Hemostatic Agents
Hemostatic Agents Stop bleeding in areas where TQ don t work TCCC Top agent: Combat Guaze
Other Agents
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)
Summary Tourniquet First for severe extremity bleeding Adapted protocols for Tactical EMS 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?