Matt and Dennis go over the basics in pediatric trauma.

Dennis and Collin discuss the new Prolonged Fieldcare Airway CPG

Dennis nerds out with Justin and Ricky on the importance of calcium during fresh whole blood transfusion.

For more content, visit www.prolongedfieldcare.org

For more content, visit www.prolongedfieldcare.org

For more content, visit www.prolongedfieldcare.org

Dennis talks with Doug about the difficulty with oxygenating COVID 19 patients.

Dennis chats with Sean on the approach to confined space rescue.

For more content visit www.prolongedfieldcare.org

Ian schools us up on some updates for treating cold weather injury.

Dennis and Mark discuss assessment of a modern medical facility.

Dennis and Justin discuss medical planning.  For more content, visit www.prolongedfieldcare.org

Dangerous snakes can be found both while training at home and far away  while deployed. It may be a rare occurrence, but a catastrophic event  when it does happen. Some austere providers may be aware of outdated  treatments, and don’t know where to start when it comes to  identification and management of a snake bite.  Feel free to ask yourselves these questions, or bring them up in a group  discussion before listening to the podcast:   1.) Which type(s) of snakes would you put a tourniquet on?   2.) Under what conditions would you apply ice, cut into, or use an  extractor on the wound?   3.) Before you deploy to “country x”, how can you find out dangerous  fauna and flora? How can I prepare, equipment wise?   4.) How important is it to identify the snake? What if it cannot be  found?   5.) How do I assess a snake bite patient and tell a difference between  the various types of venom?   6.) How can you tell if it’s a “dry bite”?   7.) You receive a patient with a Tourniquet already applied by a  non-medic or junior medic… what now?   8.) When do I give anti-venom, of what type and quantity? What are the  side effects?   9.) When would you take the airway in a patient with snake envenomation?  When would you have MSMAID ready?   10) How do you handle a patient with venom sprayed into their eyes?   11) What are concerns with compartment syndrome in these patients?   12) How do you administer a push dose pressor or dirty epi drip for  anaphylactic reaction?   13) If you have a confirmed snake bite but NO antivenom… how can you  manage a patient, if at all?   14) What are your pain management considerations for these patients? Do you know the onset and durations for the medications you push or TIVA?  What happens if the patient has breakthrough pain before the expected  time?

Dennis and Ian discuss spinal trauma in the austere environment.    For more content, visit www.prolongedfieldcare.org

Dennis and JJ discuss Highly Reliable Organizations.    For more content, visit www.prolongedfieldcare.org

While no single clinic setup will work for every situation, a common  baseline and checklist can make it far easier in customizing a clinic in  similar circumstances. This is not professed to be THE way but it is A  way in which ONE experienced team has created, tested, revised and  rehearsed a clinic with different casualties. Their pictures and  diagrams are provided in the hopes that this audience will help refine  and finalize a common baseline which any medic can use in he future.  Please leave comments on your thoughts.   This builds upon clinic setups in SOCM, SFMS and other courses such as  SOFACC and combines all into a single, ergonomic clinic in which all  members of a team can easily assist the primary medic or in the worst  case, effectively treat the wounded medic.    For more content, visit www.prolongedfieldcare.org

What happens when your patient has been given a cric or intubated but  continues to decline… SpO2 continues to slowly drop despite taking  control of the airway. You have placed your patient on a ventilator and  slowly adjusted the PEEP up to 20cmH20… which quickly leads to  hypotension. Do you go lower? Higher? Change volume or rate? You are out  of bottled O2 and your oxygen concentrator does not seem to have much  effect. The SpO2 continues dropping. Telemedicine is not available. You  try positioning the patient by sitting them up. You try a couple other  recruitment maneuvers you heard about.  Nothing is working.   What would Doug do?   Prone the patient???   Your patient may be suffering from ARDS, Acute Respiratory Distress  Syndrome caused by a number of etiologies such as pneumonia or other  lung injury. Carefully turning your patinet on their stomach may improve  oxygenation by recruiting alveoli formerly compressed and “drowned” as  demonstrated in the picture below. Positioning your patient on their  stomach in the prone position must be practiced with anyone who will be  helping you. Put someone else in a similar position and have the team  with which you plan to help move the real patient do a couple  rehearsals. You don’t want to flip them over only to lose your IVs, IOs  and yank the airway out. Check out this Brazilian article which includes  a proning checklist and some informative pictures and tips.  You also don’t get an automatic win by flipping them on their belly and  calling it a day. You will have to be even more vigilant about any  potential complications with a dedicated airway person as is is a little  harder to recognize a patient in distress if you are not used to it.   You will also have to do more nursing care on the delicate skin of the  face and other surfaces not normally on the down side: Shoulders, hips,  knees tops of the feet. Put yourself in this position for a few minutes  on a litter and you can quickly tell where the major pressure points  will be. All of these complications increased along with the benefits of  the study. While no prolonged field care patient should be on a bare  litter, there is even more reason to move them to a mattress or other  more comfortable padded surface.    For more content, visit www.prolongedfieldcare.org

After a few discussions with JJ who has also appeared in several Element  Rescue podcasts, Doug and Dennis talk about using evidence based  medicine whenever possible and what to do when no prospective randomized  controlled trials exist for a specific problem you face. What do you do  when no evidence exists for a specific problem you face? With such a  wide scope of practice while deployed and a lack of protocols SF medics  are often faced with unique situations in which they must actually weigh  the evidence, best practice, guidelines and expert consensus against  the given situation. This is a great responsibility not entrusted to  many other combat arms troops. In order to weigh the evidence you must  first be aware it exists and how to interpret what you are reading. This  will help get you on the right path in making informed decisions. Check out the Discussion:  https://oembed.libsyn.com/embed?item_id=10109669   Prolonged Prone Positioning Article NEJM 2013   Protocols and algorithms likely drive the majority of decisions a medic  will ever make. If you find yourself in a situation, such as a prolonged  field care situation, that outlasts all of those you should know some  of the current best practices and data to back up your decisions you may  be forced to make. Dogma is believing something to be true without  knowing if it actually is, or why. Don’t rely on dogma, question things  and have your own opinions. Know why you believe what you believe. When  you make a telemedicine consult call you should have a fairly good idea  of the decision you are leaning toward and why. You will sound much more  like the medical professional you claim to be and less like the knuckle  dragger they may be expecting. Medicine is a separate language and you  are expected to be somewhat fluent. Data and research are intellectual  and professional currency and which can add to your credibility. Read an  article, understand who the authors are, their specialty, where they  work and who funded or sponsored it as well as the references at the  end. You will run across words you aren’t familiar with. Put them in the  Google machine and expand your medical vocabulary. You may even want to  read those references and the references to those in order to really  dig deeper. (Three deep, right Scott?) Podcasts are a great way to hear  opinions on some of these studies and how others have incorporated them  into their practice. Podcasts and blogs (even this one) are not journal  articles and studies. They are meant to raise discussions and spark  debate and make you aware of new techniques or practices. If a study is  mentioned find the article and read it yourself. Does it apply to your  environment, experience and training? Don’t be the guy quoting a podcast  or Facebook post in a scholarly discussion, at that point it will just  be entertainment, for the other guy. Know where it originated.

Not all PFC is trauma.  Malaria, Dengue, Chikungunya and others will  take you out of the fight if given the chance.  In this episode CAPT  Ryan Maves talks about some of the more concerning and prevalent  diseases encountered by deployed military personnel and partner forces  and what you can do about it before an infection becomes debilitating or  life threatening.  A few things to remember from the episode:    - History and assessment are key in identifying tropical diseases.  Remember to consider both history of exposures as well as the  accompanying syndromes in formulating a differential diagnoses.  -  Malaria treatment consists of Malerone, Coartem or both.  -  No one dies without Doxycycline!    For more content, visit www.prolongedfieldcare.org

Why do we care about sepsis in prolonged field care? What can we do  about septic shock with what we are normally carrying on a deployment?  How do you mix an epinephrine drip? Dr. Maves lays it all out in about  20 minutes.   Here are some of the resources and pearls he mentioned in the episode:       Infection plus organ dysfunction is sepsis      Infection plus hypotension is septic shock      Q-SOFA positive with 2 of the three and suggestive of sepsis:          Systolic BP less than 100          RR greater than 22 breaths per minute          Presence of delirium     Earlier intervention is better than later      Higher mortality rate than poly trauma or myocardial infarction     Something is better than nothing      Septic shock is not purely distributive. You will also see  myocardial depression loss of contractility, capillary leakage,  microvascular obstruction from small thrombi and concomitant  hypovolemia. Some fluids are good but more fluids mat be dangerous. If 2 or 3 liters does not work it is unlikely that 5 or 6 fix  hypovolemia. At some point it will start increasing mortality. The best vasopressor is the one you have. Delaying proper antibiotics increases risk of death by 8% every  hour.    For more content, visit www.prolongedfieldcare.org

When you can’t take cold stored whole blood with you and not all of your  soldiers are titered, a walking blood bank can mean the difference  between life and death for a patient in hemorrhagic shock.  With the  mounting evidence suggesting early blood is essential and not just a  good idea, you need to have a plan in order to hit the 30 minute target.   I have seen students struggle for hours trying to get access in both  the patient and the donor.  An emphasis on early recognition and early  access will save lives.  This episode expands upon our latest JTS  Clinical Practice Guideline on Remote Damage Control Resuscitation with  Dennis interviewing the primary author Andy Fisher.  For more content, visit www.prolongedfieldcare.org

For more content: www.prolongedfieldcare.org

So what is different than what we already have in the THOR  recommendations, the JTS DCR clinical Practice Guideline and the Ranger  Regiment TDCR? No hextend?! Calcium with the 1st unit of blood?! TXA  slow push?! What if the patient is not responding to resuscitation  efforts? This is a guideline truly written for the Medic working despite  lack of help or resources in an austere environment…   When reviewing and editing this evidence-based consensus guideline there  were lengthy discussions about the realities of some of the issues  mentioned above. One of the biggest questions came when discussing TCCC  because there are slight differences with the CoTCCC guidelines which  were written specifically for a medic treating a patient sequentially in  the combat environment.   I will attempt to explain the thought process of the group of authors as  I understood the conversations and email chains in order to help you  make a better decision for your practice. That fact alone makes this  guideline different. It is specifically written for an independent duty  medic or corpsman who has the flexibility to make decisions about the  care based on available evidence for the patient which may or may not  yet exist in which case expert consensus was used.   Guidelines for medics must be written in a linear manner because they do  not merely manage the care of a patient as part of a large team working  together, they manage, prioritize, and physically complete each task  one after another. Training other team members to complete certain tasks  can greatly assist the medic. Gains in the quality of care and outcomes  can come from optimizing a dedicated trauma system. When that system is  a single person working problems in series, the variables must be  looked at in a sequential manner because that is how they are performed.  The administration of TXA comes to mind when talking about these minute  changes. TXA Slow Push:  TXA is not the cornerstone of austere resuscitation, administration of  blood is. Since the CRASH2 TXA trial results and per manufacturer  recommendations, it has been recommended that TXA be given slowly over  10 minutes so as to not cause transient hypotension. The provider should  absolutely be aware of this possibility no matter how small of a chance  it may have of occurring. Once aware and taken into account, a decision  can be made for the current situation. Do they have time to get out an  IV bag, reconstitute the TXA, Inject it into the bag, start a new IV/IO  site, hook up the line, count the drips, adjust the drip rate multiple  times and then check on the drip rate multiple times so as to make sure  that 10 minutes is vehemently adhered to? Does this bring the risk of  transient hypotension to absolute zero or does it merely reduce an  already small chance? This guideline gives the medic the same guidance  and recommendations from conclusions of the original study with the  caveat not to waste time they or the patient may not have due to the  situation or environment. If that IV line is already the second line, it  may be needed for other adjuncts including calcium, pain control,  sedation, antibiotics, antiemetics, etc. 10 minutes is a long time when  someone is writhing in pain, vomiting, mentally altered while bleeding  out. If on the other hand, a patient arrives to your aid station with 2  IVs, blood hanging, with appropriate sedation and analgesia, there is  likely time to adhere to the slow drip over 10 minute recommendation.  Again, it is the prerogative of the independent duty medic or corpsman  to weigh the risks versus gain.

Many efforts in the pre-hospital combat environment had been aimed at  prolonging the viability of a patient until they are able to make it to a  surgeon. The goal of military triage and evacuation is to have urgent  surgical patients to a waiting surgical team within 2 hours. Despite our  best efforts, this is not always possible. When it is not possible,it  is important to do the simple interventions which we know make a  difference for combat casualties such as tourniquets, wound packing,  needle decompression, airway adjuncts and pelvic binding. Wounds causing  non-compressible hemorrhage to the torso need additional strategies to  bridge the time and space gap to definitive treatment. A non-surgical  adjunct which has shown much promise has been the early transfusion of  whole blood and blood products until surgical care can be provided. Our  newest Clinical Practice Guideline on Remote Damage Control  Resuscitation details what should be done and why.  There is an entirely separate working group, The Tactical Hemostasis,  Oxygenation and Resuscitation (THOR) group dedicated to exactly those  principles which we partnered with early on to help identify solutions  dealing with hemorrhagic shock. Despite all that effort and brain power  however, blood remains a finite resource in the austere environment and  Medics have faced terrible situations where even blood administration is  not enough and surgery is too far away. It is in these times of  worst-case desperation that we want to do more for our patients. Some of  the adjuncts discussed in this episode are abdominal tourniquets, REBOA  and open surgical procedures. We don’t take any of this lightly and  realize that for the vast majority of our pre-hospital audience, many of  the procedures discussed are far outside the current scope of practice.   What is possible?   What is responsible?   What is sustainable?    Enjoy the talk.

When properly and safely administered regional anesthesia can augment  your limited supply of narcotics and ketamine in resource poor  environments. It can also preserve your patient’s mental status while  providing targeted pain relief. This can be accomplished using a nerve  stimulator and the techniques found in the Military Advanced Regional  Anesthesia and Analgesia Handbook as taught in the Special Forces  Medical Sergeant course.  If you have a portable ultrasound machine and a  little practice you can also use the safe techniques found in the  videos made available in by the New York School of Regional Anesthesia  at NYSORA.com.    For more content, visit www.prolongedfieldcare.org

For more content, visit www.prolongedfieldcare.org

For more content, visit www.prolongedfieldcare.org

For more content, visit www.prolongedfieldcare.org

Colonel Warner “Rocky” Farr has made an important contribution to the  body of SOF knowledge with this well-researched monograph. He advances  the understanding of the many challenges and accomplishments related to  guerrilla warfare medicine—care provided by predominantly indigenous  medical personnel under austere conditions with limited evacuation  capability— by providing a survey of the historical record in UW  literature. Colonel Farr relates many historical experiences in the  field, assesses their effectiveness, and lays a foundation for further  in-depth study of the subject. The Joint Special Operations University  is pleased to offer this monograph as a means of providing those  scholars and operators, as well as policymakers and military leaders, a  greater understanding of the complex and complicated field of guerrilla  warfare medicine.    For more content, visit www.prolongedfieldcare.org

Whether working on a casualty with a small team of medics or as a single  medic with the help of other non-medic team members as helpers, someone  has to be in charge of the situation in order to maintain a global view  of priorities.  The minute you get sucked in to do a specific task you  are losing situational awareness of the complete patient and  environment.  If you are working on your own as a lone medic with no  helper you have to fill both the technician and team leader role.  Treat  life threats through your TCCC/MARCH sequence and then mentally step  back and take in the whole picture.  When the situation permits and as  you begin a more detailed secondary exam, start writing down each  problem as you encounter it and then prioritize what is going to kill or  cause permanent damage first with.  Making a plan and being proactive  is what separates the great medics from less experienced medics who are  constantly chasing their tails reactively.  If you are not taking care  of patients on a daily basis training with the small team can help  delineate roles and responsibilities.  This is why if you are doing  medical training you should have your team or platoon leadership  involved along with anyone else who will be helping.    For more content, visit www.prolongedfieldcare.org

Upgrading your airway kit with a portable end tidal CO2 monitor can help  in a couple situations. While it has its limitations, it is essential  for  quickly determining if your tube is in the trachea during an intubation.  This can be accomplished most accurately via a device with a  quantitative waveform such as the Emma Capnograph. If you can’t get your  hands on an Emma, the qualitative colormetric device that changes color  when exposed to acid in the exhalations. False positives can occur due  to other acids in the airway such as vomitus or even if the patient has  recently had a carbonated beverage. While those are rare, you should be  aware of the possibility. Having a visual indication of tube placement  can be extremely helpful during loud transports such as on aircraft.   Another time that ETCO2 monitoring is very useful is during CPR. There  will likely be a very low reading despite high quality CPR. If the heart  begins to beat spontaneously, you should see an immediate increase of  the numbers on the display of your device. ETCO2 can also be used as a  prognostic indicator. If the ETCO2 remains below 10mmHg for 20 mins of  CPR this may indicate that the patient has a very poor prognosis. After  you listen to our podcast, Check out Scott Weingart’s EMCrit podcast on  the subjects to hear his thoughts on this.    ETCO2 is also useful the intubated TBI patient. Per our clinical  practice guideline, ETCO2 in a patient with moderate to severe TBI  should be kept between 35-40mmHg. In a patient with herniation, you can  temporarily increase ventilators rate in order to vasoconstrict the  blood vessels in the brain, thus reducing swelling. This can only be  done for a short time because hyperventilation worsens cerebral  ischemia. Also avoid hypoventilation (EtCO2 45mmHg or more) that will  increase ICP.    For more content, visit www.prolongedfieldcare.org

For more content, visit www.prolongedfieldcare.org

Non-Governmental Organizations, Non-Profits and Volunteers have been  providing critical services on the battlefield for millennia.  Historically the traditional view of medical care in conflict zones was  that the military focused on victory and everything else was ancillary,  even care of their own wounded. Only in the last few centuries has there  been an evolution of care as another focus after completing the  mission. Through all of this it was often family members, clergy and  Volunteers providing aid to those left to rot on historic battlefields.   These NGOs and Volunteers have recognized this gap and organized  themselves into powerful coalitions that are able to go where  traditional militaries cannot or will not due to political pressures.  Sometimes however, there exists an overlap of traditional military  presence and NGO response as the situation matures or devolves.   Alex Potter and Global Response Management positioned themselves far  forward on the front lines of the battles for Mosul when times were  tough and the International military and humanitarian response to ISIS  was in its infancy. Thank you GRM for your hard work and dedication. We  are extremely proud of what your team accomplished and maybe even a  little jealous in the bittersweet way that only those who have  experienced the horrors of armed conflict can comprehend.   www.prolongedfieldcare.org

The Trauma Hemostasis and Oxygenation Research (THOR) Network including  the 75th Ranger Regiment, NORNAVSOF, and others have led the way in  re-implementing type-O, low titer fresh whole blood far forward with the  Ranger type-O Low titer(ROLO) program. In 2015 the Ranger medical  leadership along with founders of the ROLO program published the paper,  “Tactical Damage Control Resuscitation” outlining in detail why they  chose to bring back fresh whole blood at the point of injury. Since that  time further studies have strongly suggested that the earlier fresh  whole blood was transfused, the greater the benefit to the patient.  Shackleford et al. demonstrated that the greatest benefit to a patient  receiving fresh whole blood occurred within 36 minutes of injury. After  36 minutes no decrease in 24-hour mortality was found.    Blood must be replaced as soon as possible. The Committee on Tactical  Combat Casualty Care also recommends FWB as the first line intervention  for patients in hemorrhagic shock with blood products in both second and  third place. We cannot ignore whole blood any longer if we wish to  deliver the best possible battlefield care possible. Excuses citing  logistical difficulty, concerns about safety or lack of information are  unfounded. There are multiple ways to ensure our casualties are  receiving fresh whole blood. The first is through the Armed Services  Blood Program (ASBP) delivering cold stored O-Low titer blood to a Role 2  facility where it is picked up and pushed forward from there.  Refrigeration is necessary in order to keep it below 4°C. If going out  on mission insulated containers such as the Golden Hour or Golden Minute  containers can be used to keep the blood within temperature specs for  24 hours, 72 hours or longer. If dismounted, a transfusion can occur at  or near the point of injury with pre-typed, screened and titered  ROLO/SOLO donors. Other non-Ranger Special Operations units have since  followed suit and have tweaked the name to suit them, hence the new SOLO  (Special Operations Low-O) acronym.    www.prolongedfieldcare.org

Which burn fluid resuscitation formula is best? Does it really matter?   What can happen if you over resuscitate? Under?   What can cause an increase or decrease in the demand of fluids?   What can you do if you are running out of Lactated Ringers?   As a Lt. CMMDR. with the U.S. Navy, Dr. Cairns was on duty and a  principle responder to the KAL flight that crashed in 1997 in Guam. Dr.  Cairns was instrumental in developing the level of preparedness at the  Naval Hospital there which received and managed dozens of critical  patients in the morning following the crash of the 747.   Dr. Cairns has served North Carolina as a Burn Trauma Surgeon at the  state’s Burn Center at UNC. In 2006, Dr. Cairns was named as the  Director of the North Carolina Jaycee Burn Center and is nationally  known as a leader in Burn Trauma Care. He is a John Stackhouse  Distinguished Professor of Surgery, an Associate Professor of Surgery,  Microbiology and Immunology at the University of North Carolina at  Chapel Hill School of Medicine.   Be sure to read the Clinical Practice Guideline discussed in this and a  prior episode with Dr. Doug Powell. In this episode we will take another  look at the CPG from another perspective.

Telemedicine is a crucial capability that must be planned and practiced.  The base of knowledge that a SOF medic’s knowledge encompasses includes  many areas of medicine but generally lacks  the depth of knowledge and experience of specialists available to  consult. This depth of knowledge is almost universally available when  making a simple telephone call to any number of docs willing to take a  call at all times of the day and night. Don’t let pride or hubris  prevent you from seeking advice from someone more experienced than you  in taking care of critically injured, complex patients. Telemedical  consult is one of the most important core capabilities in a prolonged  field care situation.  BOTH the medic making the call as well as the Provider receiving the  call must practice and rehearse a telemedical consult placed from a  field environment. The medic will gain confidence and be able to relay  vital information efficiently in a timely manner. The provider on the  other end will have to anticipate problems that the medic may not have  thought of and help create a prioritized treatment care plan from  incomplete information.   Trust must be built prior to an actual call being made under stressful  conditions; trust in the receiving physician and, more importantly,  trust in the process. Medics may be apprehensive in calling a complete  stranger if they haven’t made a test call or even better, a face to face  meeting. If you build the rapport before the crisis, this won’t be an  issue. You may even have the time to prep a draft email who you are and  your equipment, training level and usually a region where you will be if  you think it will be pertinent.   For more content, visit www.prolongedfieldcare.org

Rick Hines has spent the last 20+ years in service to his country much  of it deployed to combat zones and other unstable, austere environments  and is dedicated to improving SOF Medicine.  He made it a point to spend  a fair amount of time with surgical teams when possible and has gained  quite a bit of real world knowledge that we hope to pass on to a wider  audience here. He was formerly an SF Medical Sergeant turned Team  Sergeant before going on to work as the 3rd SFG(A) Senior Enlisted  Medical Advisor, the Unites States Army Special Forces Command (USAFC)  SEMA and within the USASOC Surgeon’s Office.      For more content, visit www.prolongedfieldcare.org

When do you give a burn patient antibiotics? Which ones?   How do you calculate TBSA and the rule of 10s?   What do you use to guide fluid resuscitation? What fluid?   When is an escharotomy in the field appropriate?    Burns present another wound pattern that can be extremely difficult and  time consuming for any level of provider to manage.  So much so that  there are dedicated burn teams that will often fly to where burn  patients are being held in order to get them back to the burn center in  San Antonio with the best chance of survival.  We have taken the expert  guidance of these critical care providers and packaged everything they  have learned into a single clinical practice guideline targeted at the  medic and other Role 1 Providers who might find themselves sitting on a  patient at a Battalion Aid Station or team house before evacuation is  available.  Initial priorities such as estimating percentage of body  surface area burned, starting fluid resuscitation with the rule of 10s, Foley placement along with many others may determine the mortality and  morbidity of your patient.   For more content, visit www.prolongedfieldcare.org

In this live recording, guest lecturer COL Missy Givens shares the CBRNe  knowledge she has learned while working as a clinical toxicologist,  among many other positions, around the world including as the SOCAFRICA  Command Surgeon.  For more content, visit www.prolongedfieldcare.org

You are in your Team House or BAS. You have given FDP, Whole blood, TXA  calcium and don’t have much left despite the few units from the walking  blood bank. Your patient continues to bleed internally. Nothing in the  chest or upper abdomen. Probably pelvic. Damn. MEDEVAC is en route. They  will have some blood too. You just need your patient to hold on for  another hour before he gets to surgery…   Dr. Joe DuBose is an Air Force Trauma Surgeon who recognized early in  his career that hemorrhage was the number one killer of potentially  survivable patients. This led him to a fellowship in vascular surgery  and, as Dennis put it made him a guru in the emerging technology that  allows a catheter to be placed in the femoral artery and snaked up past a  bleed in the pelvis, abdomen and even chest where a balloon is then  inflated cutting off all blood flow below that point. Dr. DuBose was the  first to do This in the ED using a newer version that had a small  enough diameter that a vascular repair would not be required after use.  It is simply placed through a central line and removed as such later on.  This is called REBOA or Resuscitative Endovascular Balloon Occlusion of  the Aorta. As you can imagine this is not without limits and  complications if done improperly.    You are in your Team House or BAS. You have given FDP, Whole blood, TXA  calcium and don’t have much left despite the few units from the walking  blood bank. Your patient continues to bleed internally. Nothing in the  chest or upper abdomen. Probably pelvic. Damn. MEDEVAC is en route. They  will have some blood too. You just need your patient to hold on for  another hour before he gets to surgery…  Dr. Joe DuBose is an Air Force Trauma Surgeon who recognized early in  his career that hemorrhage was the number one killer of potentially  survivable patients. This led him to a fellowship in vascular surgery  and, as Dennis put it made him a guru in the emerging technology that  allows a catheter to be placed in the femoral artery and snaked up past a  bleed in the pelvis, abdomen and even chest where a balloon is then  inflated cutting off all blood flow below that point. Dr. DuBose was the  first to do This in the ED using a newer version that had a small  enough diameter that a vascular repair would not be required after use.  It is simply placed through a central line and removed as such later on.  This is called REBOA or Resuscitative Endovascular Balloon Occlusion of  the Aorta. As you can imagine this is not without limits and  complications if done improperly. REBOA   In this episode we explore the usefulness and limitations of this  strategy in deployed settings and discuss the use of REBOA by  non-physician providers in austere situations. He has written several  articles on use of the REBOA and it is now one of the most promising and  controversial adjuncts available for hemorrhage control of bleeding  inside the box of the thorax, abdomen and pelvis. In order to do this o e  would likely have to be within an hour of a facility that can repair  the retired vessel as the lactic acid and other toxins would quickly  build up causing a massive repercussion injury. To this end he discusses  his strategy for partial REBOA during resuscitation that would leave  the balloon partially inflated allowing a clot to strengthen and  circulation distal to the balloon.  For more content, visit www.prolongedfieldcare.org

Dr. Cap has been leading the way here in the US with the Armed Services  Blood Program on fresh whole blood transfusion research in conjunction  with the THOR Network and answering tough questions that different  Special Operations Units come up with when analyzing how best to  implement a fresh whole blood resuscitation protocol. In this episode  Dennis presses him on the important resuscitation questions medics  everywhere seem to be asking :       I don’t have blood yet; Crystalloid isn’t really that bad, is it?      Can’t I just resuscitate to a normal BP with hetastarch or hextend?      Where does FDP fit in with resuscitation?      What do you mean by, “dose of shock?”      Do I really have to give TXA over 10 minutes?      What comes first TXA, Calcium or Blood?      Why should patients get calcium as soon as possible once you  identify they need blood?      What’s this about pre-hospital albumin?     For more content, visit www.prolongedfieldcare.org

Training materials were the number 1 most requested item from our SOMSA  AAR.  We have put out other training recommendations in the past but  wanted to also highlight some important skills that will help you  identify gaps in your PFC training program, plan future training and  measure progress.  We will get more into this cycle in the future  however, this should be a good place to start.  Many thanks go out to  Andrew who labored over many versions of the list over the past few  months.  One last thing, be sure that you are already at 100% T for  Trained on your TCCC task list.  There is no use in getting into PFC  training prior to mastering TCCC.  If you see something we may have  overlooked and would like to see it on future versions, please comment  below and let us know.   For more content, visit www.prolongedfieldcare.org

For more content, visit www.prolongedfieldcare.org

This Clinical Practice Guideline was written by a fellow 18D with input  from around the surgical community.  It reconciles the differences  between wound care done in a role 2 or 3 facility, such as serial  debridements, with what is taught in the 18D Special Forces Medical  Sergeant Course with regards to delayed primary closure.  One way is not  “right” while the other wrong, it has more to do with the amount of  time and resources available to the medic or other provider.  The  remainder of the blog post and podcast is meant to be a refresher for  those who have already been taught these procedures.  It is also meant  to be informational for those medical directors who may not be exactly  certain of what has been taught as far as wound care and surgery.  If  you haven’t been trained to do these procedures before going ahead with  them, it is very likely that you may do more harm to the patient than  good. That being said…  The following are recommendations made by the International Committee of  the Red Cross (ICRC) concerning the surgical management of war wounds  in austere conditions and with limited resources. This is when the  provider has some or all of the following considerations which would  prohibit him from performing serial (follow-on) debridement with  associated post-operative care.      Dirty environment      Limited supplies      Limited manpower      Limited time (mission dictated)      Wounds greater than 24 hours    The considerations above, accompanied with the position that the  provider will be managing that patient for more than a couple days or  become the definitive provider, should warrant ICRC recommendations for  surgical management.   For more content, visit www.prolongedfieldcare.org

You have probably treated someone with an infection and likely even with  someone with SIRS criteria at some point in your career.  At what point  does a simple infection become concerning to the point that you should  call for a teleconsult?  When does it become emergent or life threatening, demanding intervention  and treatment?  How can you prevent an infection from getting to that point?  Once it becomes systemic how can you best manage a patient that meets  SIRS criteria?  When can you send a guy back to his room and when should you keep a  close eye on him so that he doesn’t suddenly crash and die after  discharge?  At what point does sepsis turn into septic shock and become a life  threatening emergency?   In this episode Dennis moderates an interesting discussion on  recognition and management of sepsis in Prolonged Field Care.  We have  Doug and Jaybon from the ICU, Jay from the ER perspective along with  Paul providing some questions and insight on prehospital and evacuation  considerations.  This is a followup to Doc Jabon Ellis’ previous sepsis  video podcast so if you want to “pre-read” listen to that first.  If you  just want to listen to this one and still have some questions, go back  and watch that one… a coupe times.  I feel like these 2 episodes will  help make you a better medic who will be able to accurately place a  patient on the SIRS/SEPSIS spectrum and apply appropriate treatments  before we get to life threatening septic shock or death.   www.prolongedfieldcare.org

What is the process that the CPGs go through before publication?       Medics identify what guidelines are needed.      A team consisting of a medic, unit surgeon and specialist in the  field begin a draft.     Additional authors, specialists and SMEs are added as identified      Progress is monitored by the Prolonged Field Care Working Group  Steering Committee and advisors from the Joint Trauma System.     Final draft sent out to interested parties, other specialists and  PFC working group members for review      Published in the Journal of Special Operations Medicine(JSOM) with  proprietary format      Formatted for public release via the JTS website      Presented as a Thursday morning JTS CME Conference Talk.      Posted on prolongedfieldcare.org          Interviews with authors are published as podcasts.          Primary and Co-Authors may write additional thoughts as a blog  post.      Polldaddy quizzes may be included in the posts or separately.          Released and promoted through social media such as our Facebook  Pages, Instagram and Twitter feeds.   Why not just update the Tactical Medical Emergency Protocols?      We wanted peer reviewed guidelines that could be updated  individually as needed.  Independent medical providers can now see what  studies were referenced per recommendation.  We have partnered with  USSOCOM and advised several changes and additions to the TMEPs.  The  CPGs will help guide the CEB as they update future additions of the  TMEPS as a reference.  What are the origins of the CPGs?      Sharing lessons learned and best practices accross the theaters of  war  Why are there CPGs specific to Prolonged Field Care and Critical Care  Evacuation Teams(CCAT) in addition to the main JTS CPGs?      There are large enough differences in levels of training, equipment  and medications available and general logistics involved that make  providing an identical care in all environments impossible. The CPGs  take into consideration the unique challenges of the operational  environment so the the provider is presented with several best options  for the unique issues presented with each etiology and environment.  What CPGs are in the works and when can we expect to see them published?

Are you familiar with the concept of oxygen debt or oxygen deficit?   What constitutes a “dose” of shock?  What systolic BP constitutes  hypotension on the battlefield?  Where did the concept of permissive  hypotension come from?  Is it still valid? How long can fresh whole  blood last?   Blood Transfusions were a huge topic at this year’s meeting in Charlotte  with no less than 3 major speakers giving multiple talks on the  subject.  This talk was recorded during the Prolonged Field Care  Pre-Conference Lab during the Special Operations Medicine and Scientific  Assembly (SOMSA).   Dr. Geir Strandenes   is a founding member of the THOR (Tactical Hemostasis, Oxygenation, and  Resuscitation) Group, the Senior Medical Officer of the Norwegian Naval  Special Operations, and a Researcher in the Department of Immunology and  Transfusion Medicine at Haukeland University Hospital in Bergen,  Norway.  He has worked hand-in-hand with the U.S. Army Institute of  Surgical Research and the US Armed Forces Blood Program.  You can read  more about his research and other articles at www.RDCR.org.  Our PFC  working group has always gone to the THOR network with any blood  questions that we have, as they usually have an answer or best practice  already established.  I have included a link to the THOR/RDCR.org  publication page below along with other notable publications which he  helped to author such as the recently published JTS ISR Clinical  Practice Guideline on Damage Control Resuscitation and the Frequently  Asked Questions we sent to Geir and the THOR network over the last  couple years.   www.prolongedfieldcare.org

Prolonged Field Care is back with a new episode on a long awaited topic,  traumatic ventilation.  We were finally able to corner a real, live  anesthesiologist who was actually more than happy to sit down and talk  about ventilation after his years of experience working at the heads of  thousands of patients.  This episode starts right off with a difficult  scenario discussion that includes a hypovolemic patient with a GSW to  the pelvis, RR 35  As they work to get the patient stabilized, Dr. Kopp recommends an end  tidal CO2 Capnograph as the single best patient monitor for this  situation.  A SAVE2 vent is discussed along with the ARDSnet recommendations for a  lung protective vent strategy including the preferred tidal volume of  6-8ml/kg of ideal bodyweight based on patient height.  This is to reduce  barotrauma and over-ventilation that can lead to other problems.  This  begins with attempting to match the patients physiologic respiratory  rate to prevent acidosis by giving too few breaths.  The beginning Positive End Expiration Pressure (PEEP) recommendation  should start somewhere around 5 to keep alveoli open and recruited,  prior to increasing oxygen levels if available.  PIP or Peak Inspiratory Pressure or the maximum pressure of each breath  which has a default setting of 30 corresponding with the ARDSnet  protocol.  For an uninjured patient in the Operating Room, Dr. Kopp  would start at 20-22 and then titrate from there.  While we are working on an Airway Clinical Practice Guideline with the  Joint Trauma System and Army Institute of Surgical Research, this will  go along with our earlier posted PFC WG Airway recommendations (April,  14) until we can get a consensus on the CPG and get it published.     www.prolongedfieldcare.org