ProlongedFieldCare.org: Recent Episodes
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In this episode, Dennis and Doug discuss acute liver injury, its causes, recognition, and management. They explore the liver’s vital functions, the implications of liver injury in shock situations, and the importance of early recognition and treatment. The conversation also touches on the role of supplements and heat injury in exacerbating liver issues, emphasizing the liver’s resilience and the need for vigilant care in critical situations.
Takeaways:
The liver plays a crucial role in toxin clearance and blood metabolism.
Acute liver injury can result from hypoxia, heat stroke, and toxins like acetaminophen.
Recognizing signs of liver injury early can significantly impact patient outcomes.
Supportive care for liver injury includes maintaining glucose levels and managing coagulopathy.
The timeline for liver injury can vary, often showing signs later than other organ failures.
Preventing acute liver injury involves early recognition and treatment of shock.
Supplements can increase the risk of liver injury, especially in heat-related cases.
The liver’s resilience allows it to withstand significant damage before showing dysfunction.
Monitoring lactate and glucose levels can help in diagnosing liver injury.
Effective resuscitation is key to preventing progression to severe liver injury.
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In this gripping conversation, trauma surgeon Max Sirkin MD shares his harrowing experience of being a patient in a mass casualty situation following a helicopter crash. He recounts the chaos of the event, the physical and emotional trauma he endured, and the profound lessons learned about resilience, brotherhood, and the importance of being present for others in crisis. Sirkin’s narrative highlights the stark realities of military medicine and the bonds formed in the face of adversity. In this conversation, Max shares his harrowing experience in the trauma bay after a serious injury, reflecting on feelings of inadequacy and failure in the face of trauma. He discusses the psychological impact of moral injury and the importance of behavioral health in recovery. The conversation emphasizes the principle of ‘less is more’ in trauma care, highlighting the need for careful decision-making in chaotic situations. Max also recounts his experience with ketamine during treatment, illustrating the limited situational awareness of patients in trauma. Finally, he underscores the significance of camaraderie and support among peers in the recovery process. In this conversation, Max Sirkin shares his harrowing experiences in a life-threatening situation, emphasizing the importance of training and preparation in chaotic medical environments. He discusses the critical role of behavioral health in recovery from trauma and the necessity of learning from failures in medical practice. The dialogue highlights the need for teamwork, effective communication, and continuous training to ensure readiness in emergency situations.
Takeaways:
He shares his unique perspective as a patient in a mass casualty situation.
The chaos of a mass casualty requires quick and effective decision-making.
Surviving a helicopter crash was a life-altering experience for Sirkin.
The importance of brotherhood and support in crisis situations is paramount.
Sirkin emphasizes the need for medical professionals to be present for their patients.
He reflects on the emotional toll of being unable to help others in distress.
The narrative illustrates the unpredictability of trauma care in combat zones.
Sirkin’s story serves as a reminder of the resilience of the human spirit.
The conversation sheds light on the realities faced by military medical personnel.
It’s hard to face the reality of failure in trauma situations.
Moral injury can be as impactful as physical injuries.
Behavioral health is crucial for recovery after trauma.
Less intervention can sometimes lead to better outcomes.
Situational awareness is limited when you’re a patient.
Keeping injured individuals together can aid in recovery.
The importance of communication in chaotic medical situations.
Ketamine can provide pain relief but also alter perception.
Understanding the dynamics of trauma care is essential for providers.
Camaraderie among peers is vital for emotional support.
Training is essential for managing chaos in medical emergencies.
Behavioral health is crucial for recovery from trauma.
Surgeons should not consider themselves special; everyone is vulnerable.
Daily medical practice is necessary for readiness.
Teaching non-medical personnel basic medical skills saves lives.
Failure in medicine is inevitable; learning from it is essential.
Hope alone is not a strategy in critical care.
Understanding trauma can lead to better coping mechanisms.
Team dynamics and communication are vital in emergency situations.
Every medical provider should be prepared for the unexpected.
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In this episode of the PFC Podcast, Dennis and John discuss the ongoing updates and changes within the Tactical Combat Casualty Care (TCCC) guidelines. They delve into the role of the TTC Committee, the importance of literature reviews in developing algorithms for trauma care, and the proposed changes to the March algorithm, emphasizing the need for resuscitation before decompression. The conversation also covers the overhaul of the analgesic section, the recommendations for antibiotics, and the role of TXA in treating hemorrhagic shock. Additionally, they touch on the significance of triage in mass casualty situations and the future directions of the committee’s work.
Takeaways:
TCCC is continuously updated to reflect new research.
Resuscitation should be prioritized over decompression in trauma care.
The March algorithm may undergo significant changes to improve outcomes.
Analgesic options are being re-evaluated due to supply issues.
Rocephin is being recommended as a primary antibiotic.
TXA is crucial for managing hemorrhagic shock in trauma patients.
Triage protocols are essential for effective mass casualty management.
The committee is open to innovative ideas and solutions.
Training and education are vital for implementing new guidelines.
Future meetings will focus on finalizing and voting on proposed changes.
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In this podcast episode, Dennis, Stacy Shackelford, and Doc Rush discuss the critical topic of triage in emergency medical situations, particularly in military contexts. They explore the current challenges in triage practices, emphasizing the need for a shift in thinking towards large-scale events and the importance of adapting strategies based on the number of casualties. The conversation highlights the significance of immediate actions in the first hour post-injury and the necessity of training medics to handle chaotic situations effectively. The episode concludes with a call for a more standardized approach to triage that prioritizes population health over individual patient categorization. This conversation delves into the complexities of tactical medicine in combat situations, emphasizing the importance of prioritizing tactics over medicine, the necessity of clinical experience for medics, and the psychological challenges faced in high-stress environments. The discussion also covers the decision-making process in evacuation scenarios, the identification of surgical needs, and the training required for mass casualty incidents. The speakers advocate for a simplified approach to triage and the need for ongoing training to prepare medics for the realities of their roles.
Takeaways:
Triage practices need to evolve with changing conflict scenarios.
Current triage systems are not standardized and often ineffective.
Immediate actions in the first hour post-injury are crucial.
Training should focus on large-scale event responses, not just individual cases.
The first pass actions should prioritize stopping bleeding and ensuring airway clearance.
Medics should be prepared for chaotic situations and make quick decisions.
Understanding the scale of an event is essential for effective triage.
The concept of treating the population rather than individuals is vital.
Preparation and rehearsal are key to effective triage in emergencies.
Triage decisions should be offloaded to allow for rapid response.
Tactics often take precedence over medical interventions in combat.
Medics should have regular clinical rotations to enhance their skills.
Risk management in evacuation decisions is crucial for team leaders.
Psychological preparation is essential for medics facing trauma.
Identifying surgical needs should focus on unstable patients.
Basic principles of triage should guide decision-making in emergencies.
Training for mass casualty scenarios is vital for operational readiness.
Medics must be prepared for the reality of not saving every patient.
Experience and pattern recognition are key to effective triage.
Simplicity in approach can lead to better outcomes in chaotic situations.
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In this episode of the PFC Podcast, Dennis speaks with John McClellan, a military trauma surgeon, about the use of Tranexamic Acid (TXA) in trauma care. They discuss the mechanism of TXA, its applications in pre-hospital settings, potential complications, and evolving dosing strategies. John emphasizes the importance of TXA in managing hemorrhage and the need for standardized protocols in trauma care, especially for medics in the field.
Takeaways:
TXA is a lysine analog that helps stabilize clots.
The ideal patient for TXA is anyone suspected of needing massive transfusion.
TXA is considered a low-risk drug for trauma patients.
Pre-hospital administration of TXA is crucial for patient outcomes.
Complications from TXA are not increasing significantly.
Current dosing strategies for TXA are evolving towards higher initial doses.
Preloading TXA can save time in emergency situations.
TXA has solidified its role in trauma care over the years.
Understanding the pharmacokinetics of TXA is essential for effective use.
Standardized protocols are vital for medics in the field.
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In this conversation, Dennis and John discuss the current state of medical training, particularly in military contexts. They explore the shortcomings of existing training methodologies, emphasizing the need for a foundational knowledge base and a structured approach to skill acquisition. John introduces the concept of cognitive load theory and advocates for a gradual progression in training stressors to enhance learning outcomes. The discussion also touches on cultural challenges within training environments and the importance of engaging experienced learners effectively. In this conversation, Dennis discusses the intricacies of training in operational medicine, emphasizing the importance of establishing a solid training framework, the need for skill development, and the role of effective instructors. He highlights the significance of providing immediate and actionable feedback to build confidence in trainees while avoiding no-win scenarios that can negatively impact learning. The discussion also touches on the cultural aspects of training and the necessity for instructors to adapt their methods based on the audience’s experience and needs.
Takeaways:
Training needs a refocus on foundational knowledge.
Skill atrophy occurs quickly without regular practice.
Repetition is crucial for skill mastery in medical training.
Cognitive load theory helps optimize training effectiveness.
Gradual progression in stress is essential for learning.
Cultural issues can hinder effective training.
Experienced learners require different engagement strategies.
Training should have clear objectives and outcomes.
Effective training must balance quality and quantity of practice.
Understanding the audience is key to successful instruction. Establish a clear training framework to guide instruction.
Skill development should be prioritized over complex scenarios.
Instructors must adapt their teaching methods based on audience experience.
Immediate feedback is crucial for effective learning.
Avoid no-win scenarios that can demoralize trainees.
Confidence building is a key goal of training.
Cultural issues can impact training effectiveness.
Deliberate practice is essential for instructor improvement.
Training scenarios should be relevant and realistic.
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In this episode of the PFC podcast, Dennis and Doug delve into the practical aspects of lab values in trauma care. They discuss when to draw labs, the significance of pH, the role of bicarbonate and calcium in resuscitation, and the interpretation of blood gas values. The conversation also covers the limitations of hemoglobin measurements, the management of potassium levels in crush injuries, and the use of hypertonic saline in head injury cases. The episode emphasizes the importance of understanding lab values in the context of patient care and the need for timely interventions.
Takeaways:
The pH level is crucial for assessing trauma patients.
Resuscitation strategies should be based on lab values.
Calcium and bicarbonate play significant roles in trauma care.
Blood gas values are essential for ventilator management.
Hemoglobin levels may not accurately reflect bleeding severity.
Lactate levels can be misleading in trauma situations.
Frequent lab draws are not always necessary in stable patients.
Hypertonic saline can be beneficial in head injuries.
Potassium management is critical in crush injuries.
Understanding lab values helps in making informed clinical decisions.
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Hemodynamic Deterioration StudyIn this episode of the PFC Podcast, Dennis and Alex delve into a recent study on hemodynamic deterioration in trauma patients during inter-hospital transfers. They discuss the implications of the study’s findings, the challenges posed by the tyranny of distance in trauma care, and the importance of effective communication in medical transfers. The conversation also covers the study’s methodology, the significance of injury severity scores, and the need for stringent monitoring parameters in trauma patient management. In this conversation, Dennis and Alex delve into the complexities of trauma data, particularly focusing on civilian versus military contexts. They discuss the prevalence of ground-level falls in geriatric patients, the challenges of translating civilian trauma data to military settings, and the importance of diagnostic imaging and clinical experience in making informed decisions about patient transfers. The conversation emphasizes the need for better methodologies in trauma research to identify reversible outcomes and improve patient care.
Takeaways:
The tyranny of distance significantly impacts trauma care delivery.
Retrospective studies have limitations that can affect their reliability.
Effective communication is crucial in medical transfers between facilities.
Monitoring parameters like heart rate and blood pressure may not always indicate true patient stability.
Understanding injury severity scores is essential for assessing trauma patients.
The shock index can be a valuable tool in trauma assessment.
There is a need for more stringent criteria in determining patient deterioration.
The study’s findings highlight the importance of optimizing pre-hospital care.
Collaboration between military and civilian medical communities is vital for improving outcomes.
Evidence-based practice should guide trauma care protocols.
The most common injury mechanism in civilian trauma is ground-level falls.
Geriatric patients are particularly vulnerable to lethal injuries from falls.
Civilian trauma data may not apply to military settings due to different injury patterns.
Diagnostic imaging plays a crucial role in assessing trauma patients.
Clinical experience is essential for making transfer decisions.
Understanding the limitations of diagnostic tools is vital for accurate assessments.
Identifying reversible outcomes can improve trauma care.
There is a need for better trauma research methodologies.
Noise in data can obscure meaningful insights in trauma studies.
Engaging with recent articles can enhance the quality of trauma discussions.
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In this episode of the PFC Podcast, Dennis and Rich discuss the intricacies of preparing for evacuation in various environments, focusing on rotary wing and ground operations. Rich, a soft medic with extensive experience in flight medicine, shares insights on the challenges faced during patient transport, common mistakes made during handovers, and the importance of accurate MIST reports. The conversation emphasizes the need for thorough preparation, effective communication, and the critical nature of documentation in ensuring optimal patient care during transport.
Takeaways:
The environment significantly impacts patient care in rotary wing medicine.
Common mistakes during handover can jeopardize patient safety.
Accurate MIST reports are crucial for effective triage and resource management.
Documentation should be legible and concise to facilitate smooth handovers.
Patient care should not cease during evacuation preparations.
Understanding the capabilities of the receiving team is essential for effective handover.
Optimizing patient condition before transport is vital for successful outcomes.
Communication between ground and air medics is key to effective patient management.
Planning ahead for equipment needs can prevent last-minute complications.
Maintaining a focus on life-saving interventions is critical during transport.
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It is difficult to begin to know how to begin to honor a man who has given so much to the community that he helped to build and guide for more than half a century. A Distinguished Member of the Special Forces Regiment, Rocky Farr was one of those larger-than-life legends whose exploits are almost too numerous and astounding to believe. As a prior 18D with an Army Career spanning almost 5 decades, Rocky was a dedicated mentor and friend to many in our community across multiple generations. He played no small part in shaping modern SOF and SOF Medicine. I wish we had a 5-hour podcast with the giant of a man but this short bootleg snippet of his talk and his JSOU monograph will have to do. Before going to med school and working his way up to the position of USSOCOM Command Surgeon during the height of the GWOT, he reportedly hunted the Jackal with Billy Waugh, and served in BOTH MACVSOG AND Det-A Berlin…
Rocky was “on the ground” and part of the fast paced innovations when his generation of Vietnam Combat Vets pivoted to face the spread of Cold War communism in a Europe divided, and then yet again to build the world’s most capable counterterrorism force in history. After an already storied SOF career he decided to go to Med school and since that wasn’t hard enough apparently, he also got rated to solo-fly helicopters while at flight surgeon School. Every time I look into his history, I find more unbelievable tales. You would never know it when talking to him on-on-one until a random and unbelievable anecdote was pulled from the depths of his mind to add unneeded weight to his words. Rocky’s wisdom gained from his experience and education always provided us with insight and a perspective that couldn’t be found anywhere else on earth. He has 38 Articles and Book reviews chronicled in the Journal of Special Operations Medicine and many, many more ‘Letters from the SOCOM Surgeon,’ where is words will live on for generations of future Special Forces Medical Sergeants and those interested in SOF and IW Medicine. Rocky will be missed by many.
Gone but never forgotten.
-De Oppresso Liber
Our Recording of Rocky from a talk that he gave at SOMSA 2018:Slides from the SOMSA talk:Farr SOMSA ppt European Guerrilla HospitalsDownload
From the Joint Special Operations University: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.
Download the Free PDF: The Death of the Golden Hour and the Return of the Guerilla Hospital -COL (RET) Warner D. “Rocky” Farr MD
From the Special Forces Taps Facebook Group:Dr. Rocky Farr passed away on November 20, 2024 while under hospice care in Tampa, FL. Awaiting obituary. Rocky Farr enlisted in Airborne in 1967. He was the distinguished honor graduate of his Special Forces medic class, and served as a team medic with 7th SFG(F). In Vietnam, he served as a medic and recon team member with MACV-SOG, CCS. He served with SGM Billy Waugh in Cambodia in an operation written about in the book “Chasing the Jackal. In 1971 he joined Det. A, Berlin. He became the SF instructor at Northeast Louisiana University. As an SFC, he taught in the SF Medical Course and was selected for promotion to MSG. He was then commissioned 2LT.While a medical student, he was the medical platoon leader for the 11th SFG(A). Receiving his M.D. in 1983, he served as commander, Co. F (Abn), running the Special Operations Medical Sergeants Course. He was the Division surgeon of the 10th Mountain Division and deputy commander of the Aeromedical Center, Fort Rucker. He attended Air War College before becoming deputy chief of staff, Surgeon, USASOC, and Surgeon, Special Forces Command and Civil Affairs and Psychological Operations Command. He served in Vietnam, Cambodia, Berlin, Bosnia, Kosovo, Kuwait and Afghanistan.
Rocky Farr in MACVSOGCOL (Ret.) Warner “Rocky” Farr while he was part of Detachment A in Berlin
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In this episode of the PFC Podcast, Dennis and JP Kolcun, a neurosurgery resident, delve into the complexities of spinal trauma. They discuss the differences between spinal shock and neurogenic shock, the assessment and management of penetrating and blunt spinal injuries, and the critical importance of addressing secondary injuries. The conversation emphasizes the need for timely intervention and the nuances of trauma care in both field and hospital settings. This conversation delves into the complexities of spinal cord injury treatment, emphasizing the importance of timely surgical decompression, understanding spinal cord perfusion, and the role of intrathecal pressure. The discussion highlights the need for optimizing spinal cord perfusion pressure and the implications of using vasopressors. Innovations in treatment, including the potential for intrathecal medication delivery and advancements in brain-computer interfaces, are explored as future avenues for improving patient outcomes.
Takeaways:
Spinal shock is a neurologic phenomenon, while neurogenic shock is hemodynamic.
Penetrating spinal cord injuries are often more severe than blunt injuries. Immediate stabilization and ABCs are crucial in trauma care.
Understanding the difference between spinal shock and spinal cord injury is vital.
Secondary injury can worsen outcomes if not addressed promptly.
Timely decompression of the spinal cord can improve recovery chances.
Assessment of spinal stability is essential in blunt trauma cases.
The presence of a bulbocavernous reflex can indicate spinal cord injury.
Norepinephrine is preferred for treating neurogenic shock.
Avoid hypotension to prevent further complications in spinal injuries.
The timing of surgical decompression can significantly impact recovery.
Surgical decisions must consider the overall health of the patient, not just the injury.
Spinal cord perfusion is critical for recovery post-injury. Intrathecal pressure varies and can affect spinal cord perfusion.
Targeting spinal cord perfusion pressure may improve outcomes over traditional MAP goals.
Vasopressors can constrict blood vessels, potentially reducing perfusion to the spinal cord.
Innovative treatments, such as lumbar drains, can enhance spinal cord perfusion.
Research is ongoing into the use of intrathecal medications for spinal cord injury.
The ultimate goal is to improve quality of life for spinal cord injury patients.
Advancements in technology may lead to breakthroughs in treating chronic spinal cord injuries.
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In this episode of the PFC Podcast, Dennis and ICU doctor Doug discuss the intricacies of resuscitation techniques, focusing on the use of freeze-dried plasma (FDP) and its benefits in trauma care. They explore the physiological aspects of trauma, the role of endotheliopathy, and practical applications of FDP in emergency situations. The conversation also touches on the comparison between FDP, whole blood, and albumin, highlighting the challenges and considerations in using these fluids for resuscitation. The episode concludes with a discussion on the future of blood products in trauma care and the importance of making FDP more accessible.
Takeaways:
FDP is a viable alternative to whole blood in trauma resuscitation.
Endotheliopathy of trauma can lead to widespread coagulation issues.
FDP helps stabilize the vascular endothelium during resuscitation.
Whole blood is preferred when available, especially in early resuscitation.
Albumin has limited benefits and can dilute clotting factors.
FDP has a longer shelf life and is easier to store than whole blood.
The physiological effects of trauma require careful consideration in resuscitation.
Resuscitation goals should focus on patient stability rather than strict numerical targets.
Acidosis can complicate trauma resuscitation and should be monitored closely.
Increased access to FDP could improve outcomes in trauma care.
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In this episode of the PFC Podcast, Dennis Price discusses the efforts of Heroes for Humanity in response to Hurricane Helene’s devastation in Western North Carolina. He shares insights on the immediate activation of volunteers, the assessment of needs, and the challenges faced during search and rescue operations. The conversation highlights the importance of community knowledge, the integration of various organizations, and the human behavior observed during crises. As winter approaches, the focus shifts to recovery efforts and the ongoing need for support and resources.
Takeaways:
Heroes for Humanity activated volunteers immediately after Hurricane Helene.
Community knowledge is crucial in identifying vulnerable individuals.
The initial response focused on delivering medical supplies and aid. Search and rescue operations were prioritized in the aftermath of the hurricane.
Integration with government and other organizations improved coordination.
Survival mode affects human behavior during crises, leading to security issues.
The transition to recovery involves addressing winter preparedness.
Hope and faith play a significant role in recovery efforts.
Safety concerns, such as carbon monoxide poisoning, are critical during winter.
Support can be provided through donations and volunteering efforts by clicking the logo below.
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In this podcast episode, Dennis and Chris discuss the essentials of starting a podcast, including overcoming initial fears, the importance of authentic conversations, essential gear, post-production techniques, and the significance of media hosting. They also address common pitfalls like podfading, the need for quality content, and the importance of energy and authenticity in podcasting. The conversation provides valuable insights for aspiring podcasters looking to create engaging and successful shows.
Takeaways:
Podcasting can be for fun or a serious endeavor.
Authentic conversations resonate more with listeners.
Audio quality is more important than video quality.
Starting with a clear purpose helps guide your podcast.
Longer conversations can feel more natural than short, scripted ones.
Invest in good audio equipment for better sound quality.
Post-production is crucial for a polished final product.
Media hosting is essential for distributing your podcast.
Maintaining passion is key to avoiding podfading.
Quality content will keep listeners engaged, regardless of length.
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In this episode of the PFC podcast, Dennis and Kevin delve into the critical aspects of patient care, particularly focusing on hypothermia management. They explore the mechanisms of heat loss in patients, strategies to prevent it, and the challenges faced in austere environments. The conversation emphasizes the importance of maintaining patient warmth during trauma care and the implications of blood resuscitation on body temperature. They also discuss practical approaches for managing hypothermia in deployed settings and the significance of team coordination in patient care. The episode concludes with insights on temperature monitoring techniques and the necessity of understanding heat loss to improve patient outcomes.
Takeaways:
Hypothermia management is crucial in patient care.
Heat loss occurs through radiation, convection, conduction, and evaporation. Keeping the ambient temperature warm is essential for patient care.
Covering the head can significantly reduce heat loss.
Fluid warming is a key strategy in managing hypothermia.
Team coordination is vital to prevent unnecessary patient exposure.
Active cooling can complicate patient management in trauma cases.
Blood resuscitation can lead to further cooling of the patient.
Innovative solutions like inflatable tents can help maintain warmth.
Understanding heat loss mechanisms is critical for effective patient care.
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In this episode of the PFC Podcast, Dennis interviews Mark Little, a recently retired Navy medic with extensive maritime experience. They discuss the unique challenges faced in maritime operations, including planning for casualties, the importance of waterproof gear, and the need for thorough preparation. Mark emphasizes the significance of mastering basic skills and being an asset to the team, while also navigating the complexities of medical facilities at sea. The conversation provides valuable insights for medics operating in maritime environments.
Takeaways:
Planning is crucial in maritime operations due to unique environmental challenges.
Waterproofing gear is essential for effective medical care at sea.
Basic medical skills should never be neglected, even in advanced training.
Understanding the maritime environment can significantly impact casualty management.
Coordination with air and sea assets is vital for patient evacuation. Medics should be proactive in seeking knowledge and mentorship.
Communication is key in ensuring effective patient care and logistics. Pre-planning for contingencies can save lives in critical situations.
Being an asset to the team requires both technical and tactical proficiency. The environment dictates the approach to medical care, whether on land or at sea.
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In this episode, Dennis interviews Justin, a second-year medical student and co-founder of Special Operations Forces to School of Medicine (SOFtoSOM), a nonprofit organization that helps Special Operations Forces service members and veterans in their journey to become physicians. Justin explains that SOFTSOM provides mentorship, guidance, and support to individuals from the SOF community who are interested in pursuing a career in medicine. The organization helps with the application process, offers scholarships for MCAT prep, conducts research on veterans in medicine, and partners with universities to increase soft representation in medical school classes. Justin also emphasizes the importance of tailoring application essays and preparing for interviews to highlight the unique experiences and skills of SOF applicants.
Takeaways:
SOFtoSOM is a non-profit organization that helps Special Operations Forces service members and veterans in their journey to become physicians.
The organization provides mentorship, guidance, and support throughout the application process for medical school. SOFTSOM offers scholarships for MCAT prep and conducts research on veterans in medicine.
The organization partners with universities to increase soft representation in medical school classes.
Applicants from the SOF community should tailor their application essays and prepare for interviews to highlight their unique experiences and skills.
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Mikola, a combat medic from the Ukrainian Special Operations Task Forces, shares his experience and challenges in providing medical care in the war-torn region of Ukraine during SOMSA 24. He discusses the difficulties of operating in a large and constantly changing frontline, with different terrain and medical systems in each administrative region. Mikola explains the concept of medical evacuation and the various facilities and modes of transportation used. He also highlights the dangers faced by medics, including attacks from Russian forces and the use of drones with payloads. Mikola emphasizes the importance of training, supply management, and improvisation in overcoming these challenges. If you would like to see the slides, sign up for our Patreon (link below) and get early access to presentations and more.
Takeaways:
Operating as a combat medic in the war-torn region of Ukraine presents numerous challenges, including a large and constantly changing frontline.
Medical evacuation involves coordinating with different facilities and modes of transportation, taking into account the specific terrain and enemy patterns in each administrative region.
Medics face significant dangers, including attacks from Russian forces and the use of drones with payloads.
Training, supply management, and improvisation are crucial in overcoming the challenges faced by combat medics in Ukraine.
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In this episode, Dennis and Alex discuss the importance of reading research papers and critically analyzing their applicability to the operational environment. They review a paper on the role of red blood cells in thrombosis and post-transfusion hypercoagulability. The study found that red blood cell aggregation increased in the presence of tissue factor and calcium. While the study had limitations in terms of sample size and external validity, it raised questions about the use of calcium and tranexamic acid (TXA) in trauma patients. Dennis emphasizes the need to critically assess the need for these interventions based on individual patient factors. The conversation explores the complexity of blood clotting and the challenges of managing critically ill trauma patients. The hosts discuss the activation of blood components, the role of red blood cells in clot formation, and the use of thrombin matrix. They also touch on the age of blood and its impact on clotting, as well as the importance of trauma surgeons in managing these patients. The conversation emphasizes the need for continuous learning and clinical decision-making based on individual patient scenarios.
Takeaways:
Reading research papers and critically analyzing their applicability is important in the operational environment.
The study discussed the role of red blood cells in thrombosis and post-transfusion hypercoagulability.
Red blood cell aggregation increased in the presence of tissue factor and calcium.
The study raised questions about the use of calcium and tranexamic acid (TXA) in trauma patients.
It is important to critically assess the need for interventions based on individual patient factors.
Blood clotting is a complex process involving the activation of various blood components.
Red blood cells play a role in clot formation and can drift to the site of injury.
The age of blood does not significantly affect clotting ability. Trauma surgeons are crucial in managing critically ill trauma patients.
Clinical decision-making should consider individual patient scenarios and the nuances of clotting.
Continuous learning is essential in the field of trauma medicine.
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Mike and Brad discuss the benefits and drawbacks of using ether as an anesthetic. They highlight its historical significance, safety profile, availability in developing countries, and field expediency. They also mention the flammability and pungent smell of ether, as well as its slower uptake and potential for post-op nausea and vomiting. The conversation emphasizes the importance of understanding ether anesthesia and maintaining high clinical standards in austere settings. In this conversation, Brad, Mike, and Dennis discuss the use of ether as an anesthetic in prolonged field care scenarios. They emphasize the importance of understanding the different stages of anesthesia and how ether can be used for conscious sedation. They also highlight the significance of logistics and problem-solving in austere environments, where medical supplies may be limited. The conversation encourages listeners to do their own research and learn from historical medicine.
Takeaways:
Ether is the foundation for all gas anesthesia inhalation and has been used in surgery since 1846.
Ether is simple, safe, and easy to manufacture, making it a viable option in austere settings and developing countries.
Ether has a unique safety profile, making it suitable for high-risk patients and trauma cases.
Ether is field expedient and can be administered using simple techniques and equipment.
Ether is highly flammable and has a pungent smell, but its availability and low cost make it a valuable option in certain situations.
Understanding the stages of anesthesia and maintaining high clinical standards are crucial when using ether in surgery.
Understanding the stages of anesthesia is crucial for using ether effectively in prolonged field care scenarios.
Ether can be used for conscious sedation and is a versatile option for various medical procedures.
Logistics and problem-solving skills are essential in austere environments where medical supplies may be limited.
Learning from historical medicine and conducting research can enhance medical knowledge and preparedness in resource-limited settings
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In this podcast episode, Dennis interviews Tom Avery, a surgeon who worked in Myanmar with the Free Burma Rangers. Tom shares his experience providing critical care in a war-torn area and the challenges he faced. He discusses the importance of stabilizing patients and bridging the gap between the frontline and higher echelons of care. Tom emphasizes the need for flexibility and creativity in an austere environment and the importance of communication and cooperation with local forces. He also highlights the lessons learned, including the need for in-field sterilization, the value of a mobile ultrasound device, and the importance of a standardized trauma kit.
Takeaways:
Stabilizing patients and bridging the gap between the frontline and higher echelons of care is crucial in a war-torn area.
Flexibility and creativity are essential in an austere environment.
Communication and cooperation with local forces are key to success.
In-field sterilization and cleaning of medical instruments are important considerations.
Having a mobile ultrasound device and a standardized trauma kit can greatly enhance patient care.
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In Part 2 of this conversation, Dennis and Andy discuss common health issues and injuries that can occur in the jungle. They specifically focus on heat illnesses, musculoskeletal conditions, dermatological conditions, and tropical diseases. They provide tips on how to manage exertional heat illness, such as stopping activity, finding shade, and using water to cool down. They also discuss the importance of proper hydration, nutrition, and hygiene in the jungle. Additionally, they talk about the wet and dry routine for clothing, managing blisters and cuts, and dealing with insect bites and envenomation. In this conversation, Andy discusses various hazards and challenges faced in the jungle, including snake bites, tarantulas and spiders, toxic plants, and scorpion stings. He emphasizes the importance of pre-planning and education to mitigate risks. Andy also highlights the need for specialized equipment and techniques for evacuations in the jungle, such as technical rope rescues and securing stretchers in different modes of transportation. He recommends the Oxford Handbook of Expedition and Wilderness Medicine as a valuable resource for healthcare providers in jungle environments.
In Part 1, they discuss the challenges and skills required to operate in the jungle, such as personal administration, environmental health, and communication. Andy emphasizes the importance of being physically fit and mentally prepared for the jungle environment. He also provides tips for preparing and packing essential medical equipment. The conversation highlights common mistakes made by rookies and offers advice for those interested in venturing into the jungle.
Takeaways from both Episodes:
Working in the jungle requires specific skills and preparation, including personal administration, environmental health, and communication.
Being physically fit and mentally prepared is crucial for surviving and thriving in the jungle.
Proper packing and preparation of medical equipment is essential for providing medical care in the jungle.
Rookies often make mistakes in setting up their hammocks, personal administration, and being prepared for the jungle environment.
Taking a course or participating in an expedition with experienced guides can provide valuable knowledge and experience for working in the jungle.
Common health issues in the jungle include heat illnesses, musculoskeletal conditions, dermatological conditions, and tropical diseases.
Proper management of exertional heat illness involves stopping activity, finding shade, and using water to cool down.
Hydration, nutrition, and hygiene are crucial in the jungle to prevent health issues.
The wet and dry routine for clothing helps maintain personal hygiene and prevent skin problems.
Proper management of blisters, cuts, and insect bites is important to prevent infections and complications. Educate yourself on the risks and hazards specific to the jungle environment you will be operating in.
Pre-plan and practice different evacuation scenarios, considering the challenges of the jungle terrain.
Have specialized equipment and techniques for technical rope rescues and securing stretchers in different modes of transportation.
Laminate important documents and resources to protect them from the jungle environment.
The Oxford Handbook of Expedition and Wilderness Medicine is a valuable resource for healthcare providers in jungle environments.
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In this podcast episode, Dennis interviews Andy, a former UK Special Forces paramedic, about working in the jungle. They discuss the challenges and skills required to operate in the jungle, such as personal administration, environmental health, and communication. Andy emphasizes the importance of being physically fit and mentally prepared for the jungle environment. He also provides tips for preparing and packing essential medical equipment. The conversation highlights common mistakes made by rookies and offers advice for those interested in venturing into the jungle.
Takeaways:
Working in the jungle requires specific skills and preparation, including personal administration, environmental health, and communication.
Being physically fit and mentally prepared is crucial for surviving and thriving in the jungle.
Proper packing and preparation of medical equipment is essential for providing medical care in the jungle.
Rookies often make mistakes in setting up their hammocks, personal administration, and being prepared for the jungle environment.
Taking a course or participating in an expedition with experienced guides can provide valuable knowledge and experience for working in the jungle.
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Phil Gonzalez shares his experiences from Vietnam to Central/South America, and the GWOT to the current conflict in Ukraine. He discusses the intense situations he faced in Vietnam, including being in dangerous situations and witnessing the horrors of war. He also talks about the importance of medics in Special Forces and the impact they have on the people they treat. After Vietnam, Phil pursued a career in medicine and worked in various locations, including Panama and Salvador, providing medical care to those in need. Dennis shares his experiences working as a medic in remote areas, including his time in Panama and Colombia. He recounts the challenges he faced and the impact he made on the communities he served. Dennis emphasizes the importance of empathy, communication, and adaptability in providing effective medical care. He also highlights the power of mentorship and the need to pass on knowledge and skills to future generations. Dennis concludes by encouraging aspiring medics to never stop learning and to always seek out those in need.
Takeaways:
The role of medics in Special Forces is crucial, as they provide medical care to those in need in intense and dangerous situations.
Phil’s experiences in Vietnam shaped his desire to become a medic and make a difference in people’s lives.
His journey took him to various locations, including Panama and Salvador, where he provided medical care to those in need.
The importance of compassion and bedside manner in being a medic and building trust with patients. Empathy and caring for fellow human beings are essential qualities for a medic working in remote areas.
Effective communication and adaptability are crucial in providing medical care in challenging environments.
Mentorship and passing on knowledge and skills are important for the future of healthcare in underserved communities.
Continuous learning and seeking out those in need are key to making a lasting impact as a medic.
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Dennis Price discusses his experiences in organizing rescues in Afghanistan and Ukraine. He attributes his success to the blessings of God and his strong faith. In Afghanistan, he formed a company called Polaris to legally protect himself and his team. They were able to save 55 Americans and SIV interpreters in two weeks. Later, he joined a committee called Save Our Allies and worked with the government to rescue and vet interpreters. In Ukraine, he formed a nonprofit called Heroes for Humanity and led a team to provide medical aid and assistance to special needs orphans. He describes the devastation of the war in Ukraine and the innovation of the local people in defending their towns. Dennis Price shares his experiences in Ukraine and his work in rescuing sexually trafficked children. He emphasizes the importance of doing the right thing for the right reasons and helping those in need. He also discusses the challenges of rescuing victims of human trafficking, including the influence of Stockholm syndrome and the need for a compassionate and nurturing approach. Dennis encourages listeners to get involved in organizations that are well-vetted and work closely with law enforcement. He also highlights the need to focus on the rescue mission and not engage in illegal activities. Dennis concludes by urging people to follow Heroes for Humanity on Instagram and support their efforts to make a difference.
Takeaways:
In Afghanistan, Dennis formed a company called Polaris to legally protect himself and his team, allowing them to focus on rescuing families. In Ukraine, Dennis formed a nonprofit called Heroes for Humanity and led a team to provide medical aid and assistance to special needs orphans.
The war in Ukraine was described as peer-to-peer modern warfare with devastating consequences. The local people in Ukraine showed incredible innovation in defending their towns.
Do the right thing for the right reasons and help those in need Rescuing victims of human trafficking requires a compassionate and nurturing approach. Get involved in well-vetted organizations that work closely with law enforcement Focus on the rescue mission and avoid engaging in illegal activities.
Click the link to support Heroes for Humanity https://www.zeffy.com/en-US/fundraising/a5925aa7-6994-4247-9271-527face51842
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In this podcast episode, Dennis interviews Dr. Jim DuCanto, an anesthesiologist with a special interest in airway management. They discuss the decision-making process in emergency airway management, particularly in challenging situations such as facial trauma. Dr. DuCanto emphasizes the importance of assessing the patient’s neurologic status and respiratory efforts, as well as considering the safety of the scene. He also highlights the need for clear communication with the patient and the use of appropriate techniques and tools for airway management. In this conversation, Dr. Jim DuCanto and Dennis discuss various aspects of airway management. They cover topics such as the importance of recognizing the signs of airway compromise, the stages of anesthesia, the role of the spinal cord and reflexes in anesthesia, and the use of different techniques and tools in emergency airway management. They also touch on the potential risks and complications of airway management procedures and the importance of thorough physical examinations. Overall, the conversation emphasizes the need for preparedness, clinical judgment, and the ability to adapt to different situations in airway management.
Takeaways:
Assess the patient’s neurologic status and respiratory efforts in emergency airway management
Consider the safety of the scene and the need for patient mobility
Communicate clearly with the patient and explain the procedure
Use appropriate techniques and tools for airway management The patient’s ability to hear may persist even when they are unconscious under anesthesia.
Emergency airway management requires an understanding of the patient’s reflexes and potential resistance.
Clinical judgment and the ability to adapt to different situations are crucial in airway management.
Thorough physical examinations can provide valuable information in assessing the patient’s condition.
Preparedness and having the necessary tools and equipment readily available are essential in airway management.
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In this episode we discuss the controversial topics of expectant care and end-of-life care in a role one setting. The panel of experienced medics and docs share their personal experiences and concerns regarding training and implementation of these types of care. We highlight the need for clear guidance and training for medics and corpsmen to make difficult decisions in the field. The panel also discusses the potential obstacles and unintended consequences of implementing clinical practice guidelines for expectant and end-of-life care. The conversation focuses on the need for guidance and training in making difficult medical decisions on the battlefield, particularly in the context of end-of-life care. The speakers discuss the importance of identifying patients who would most benefit from direct care and the potential moral injury that can occur when undertrained individuals are put in positions of medical directorship. They also explore the challenges of decision-making in mass casualty situations and the need for clear guidelines and policies. The conversation emphasizes the importance of having conversations about death and dying early in training and the need for realistic expectations and shared decision-making. To hear more of these talks recorded at SOMA become a SOMA member and check out their recorded content from past events. Special Operations Medical Association: Home (specialoperationsmedicine.org)
Takeaways:
Expectant care and end-of-life care are important topics that need to be discussed and addressed in the role one setting.
Training for medics and corpsmen in expectant and end-of-life care is currently inadequate and needs improvement.
Clear guidance and clinical practice guidelines are necessary to help medics and corpsmen make difficult decisions in the field.
Implementing expectant and end-of-life care guidelines may have unintended consequences and require careful consideration.
Empowering medical directors to make decisions based on their unit’s needs and training is important for effective implementation. The need for guidance and training in making difficult medical decisions on the battlefield, particularly in the context of end-of-life care
The potential moral injury that can occur when undertrained individuals are put in positions of medical directorship
The challenges of decision-making in mass casualty situations and the need for clear guidelines and policies
The importance of having conversations about death and dying early in training and the need for realistic expectations and shared decision-making
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In this conversation, Dennis and Ian Wedmore discuss the new high altitude Clinical Practice Guideline (CPG) in the Joint Trauma System. They cover topics such as acute mountain sickness (AMS), high altitude cerebral edema (HACE), and high altitude pulmonary edema (HAPE). They discuss the pathophysiology, symptoms, diagnosis, and treatment options for these conditions. They also touch on pre-treatment strategies and the use of portable hyperbaric chambers. Overall, the conversation provides a comprehensive overview of altitude-related illnesses and their management. In this conversation, Dennis and Ian discuss the treatment options for altitude illness, specifically AMS, HAPE, and HACE. They cover the use of pharmacologic therapy, oxygen, and portable hyperbaric chambers to stabilize and bring down patients with altitude illness. They also discuss the use of dexamethasone as the primary treatment for HACE and the potential use of hypertonic saline for extreme cases. They touch on the side effects of dexamethasone and the importance of protecting the airway. They also mention the use of acetazolamide for prophylaxis and the benefits of intermittent hypoxic exposure. Finally, they discuss the importance of good nutrition and hydration and the new medic encounter form for recording data on altitude illness.
Takeaways
- Acute mountain sickness (AMS) occurs when the body does not have enough time to acclimatize to the physiological stress of altitude.
- High altitude cerebral edema (HACE) is characterized by ataxia and can occur even without AMS symptoms.
- High altitude pulmonary edema (HAPE) is characterized by decreased exercise tolerance and tachypnea.
- Assessment of vital signs, such as heart rate and respiratory rate, can help differentiate between altitude illnesses.
- Portable hyperbaric chambers can be used to stabilize patients with altitude illnesses until they can be brought down to lower altitudes.
- Pharmacologic treatments, such as acetazolamide and dexamethasone, can be used for prophylaxis and treatment of altitude illnesses.
- Improvement in symptoms of HAPE can be rapid with oxygen therapy.
- Pre-treatment strategies, such as using acetazolamide, can help acclimatize the body to altitude before ascent. Pharmacologic therapy, oxygen, and portable hyperbaric chambers can be used to stabilize and bring down patients with altitude illness.
- Dexamethasone is the primary treatment for HACE, and hypertonic saline may be considered for extreme cases.
- Side effects of dexamethasone include increased sugar, gastric erosions, gastric bleeding, and adrenal suppression.
- Acetazolamide can be used for prophylaxis, and intermittent hypoxic exposure may help with acclimatization
- Good nutrition, hydration, and iron status are important for preventing altitude illness.
- The new medic encounter form is a valuable tool for recording data on altitude illness.
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In this podcast episode, Dennis interviews Pete, a former Navy Special Warfare medic with experience in maritime operations. They discuss the unique challenges of providing medical care in a maritime environment, including the need for self-extraction and the difficulties of working on an unstable platform. Pete emphasizes the importance of realistic training and self-reliance in maritime medicine. They also touch on the training of Ukrainian forces and the misconceptions surrounding tourniquet use. Overall, the conversation highlights the need for constant adaptation and a focus on patient survivability in maritime medical operations.
Takeaways:
Providing medical care in a maritime environment presents unique challenges, including the need for self-extraction and working on an unstable platform.
Realistic training and self-reliance are crucial in maritime medicine, as medical professionals must be prepared to adapt to the dynamic nature of the environment.
Training Ukrainian forces in medical skills requires expectation management and prioritizing the most essential knowledge and skills within a limited timeframe.
Misconceptions surrounding tourniquet use in Ukraine highlight the importance of proper training and understanding of when and how to apply tourniquets.
In maritime medical operations, constant adaptation and a focus on patient survivability are key to providing effective care.
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In this conversation, Dennis interviews Victor about his experiences in Burma and his work with Free Burma Rangers. Victor discusses the changing dynamics of the conflict in Burma and the progress made by ethnic forces. He also talks about his role as a medic and the challenges of teaching combat medicine to indigenous groups. Victor emphasizes the importance of focusing on the basics and tailoring training to the specific needs of the students. He shares his experiences with teaching pressure points, tourniquets, casualty drags, and blood collection. Victor also reflects on the challenges of triage and decision-making in a mass casualty situation. During the conversation, Victor shares several lessons learned from his trip to Burma. He discusses the importance of going back to the basics and relying on ground reconnaissance when operating without ISR capabilities. He also highlights the need for movement and noise discipline to avoid detection by the enemy’s reconnaissance planes and jets. Victor emphasizes the significance of good topside cover and concealment to protect against airstrikes and mortar attacks. He also talks about the challenges of providing prolonged field care and the importance of being mentally sharp and prepared for the continuous cycle of problems that arise during operations. Victor mentions the disbursement of medical equipment and the need for contingency plans in case of CCP destruction. Overall, the conversation provides valuable insights into the realities and complexities of operating in a hostile environment with limited resources.
Takeaways:
The ethnic forces in Burma have been gaining ground and achieving significant victories in the conflict.
Teaching combat medicine to indigenous groups requires focusing on the basics and tailoring training to their specific needs.
Training on pressure points, tourniquets, casualty drags, and blood collection were essential for the indigenous groups in Burma.
Triage and decision-making in a mass casualty situation can be challenging, but it is important to prioritize casualties based on their chances of survival. Rely on ground reconnaissance and basic skills when operating without ISR capabilities
Maintain movement and noise discipline to avoid detection by enemy aircraft
Seek good topside cover and concealment to protect against airstrikes and mortar attacks
Be mentally sharp and prepared for the continuous cycle of problems during operations
Disburse medical equipment strategically and have contingency plans in case of CCP destruction
Here are some clips from Victor’s experiences:
https://youtu.be/dBkTziMluyk?si=DIwvc-SAHCJ81hSM
https://youtu.be/wNKHL_OJ4TMsi=vC1WoJWH_hhKme1h
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In this episode of the PFC Podcast, Dennis recorded a plenary presentation by the cadre of the JSOMTC Refresher courses, Dan, Ben and Rick. They discuss the state of medics in Special Operations Medicine and offer recommendations for improvement and highlight the importance of regular and realistic medical training at the unit level, as well as the need for feedback and accountability. The speakers also address specific issues such as lack of familiarity with protocols, equipment shortfalls, and training scars. They emphasize the need for critical thinking and individualized patient care rather than relying on algorithms. Overall, the podcast aims to improve the quality of medical training and performance among medics in Special Operations. To hear more of these talks recorded at SOMA become a SOMA member and check out their recorded content from past events. Special Operations Medical Association: Home (specialoperationsmedicine.org)
Takeaways:
Regular and realistic medical training at the unit level is crucial for improving the skills and performance of medics in Special Operations.
Feedback and accountability are essential for medics to identify and address their shortcomings.
Familiarity with protocols, equipment, and drug administration is crucial for effective medical care.
Training should focus on critical thinking and individualized patient care rather than relying on algorithms.
Unit leaders and commanders should prioritize and support medical training to ensure the readiness of their medics.
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In this episode, Doug and Dennis discuss the appropriate use of vasopressors, specifically epinephrine and norepinephrine, in the management of shock. They highlight the importance of fluids in sepsis resuscitation and the potential dangers of using high concentrations of epinephrine. They also discuss the different effects of epinephrine and norepinephrine on heart rate and blood pressure, and the potential side effects of epinephrine, such as arrhythmias and lactic acidosis. The conversation concludes with a discussion on the use of epinephrine in anaphylaxis and the importance of individualizing treatment based on the patient’s response.
Takeaways:
Epinephrine is commonly used as a vasopressor in the management of shock, but it should be used with caution due to its potential side effects.
Norepinephrine is often preferred over epinephrine in sepsis resuscitation due to its more selective vasoconstrictive effects and lower risk of arrhythmias.
Fluid resuscitation is an important component of sepsis management and should be prioritized before initiating vasopressor therapy.
Monitoring the patient’s response to vasopressor therapy, including blood pressure, heart rate, and organ perfusion, is crucial in determining the effectiveness and safety of the treatment.
Individualizing treatment based on the patient’s specific needs and response is essential in optimizing outcomes in shock management.
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In this conversation, Dennis and Doug discuss crush syndrome and the challenges it presents in dynamic environments such as natural disasters or man-made incidents. They emphasize the importance of scene safety and the need to assess and stabilize any other traumatic injuries before addressing crush syndrome. They also discuss the use of tourniquets and the potential risks and benefits associated with their application. The conversation covers the management of crush syndrome, including fluid resuscitation, monitoring for cardiac complications, and the use of calcium and sodium bicarbonate. They highlight the need for a comprehensive approach to diagnosis and treatment, considering factors such as time of response and the presence of other injuries. In this conversation, Dennis and Doug discuss the management of crush syndrome in a resource-limited setting. They cover topics such as tourniquet use, fluid resuscitation, potassium management, and the use of sodium bicarbonate. They also touch on wound management and the importance of antibiotics. The conversation concludes with a discussion on the use of insulin and dextrose, as well as albuterol, in managing cardiac instability. Overall, the conversation provides a comprehensive overview of the management of crush syndrome in a challenging environment.
Takeaways:
Scene safety is paramount in crush syndrome situations, and rescuers should be aware of potential hazards such as secondary devices, unstable structures, and chemical releases.
Assessing and stabilizing any other traumatic injuries is crucial before addressing crush syndrome.
The use of tourniquets in crush syndrome is a topic of debate, and a protocol should be in place to reassess their necessity and remove them as soon as possible.
Fluid resuscitation is important in managing crush syndrome, and the amount and rate of fluid administration should be based on the patient’s condition and available resources.
Monitoring for cardiac complications, such as arrhythmias and acidosis, is essential, and interventions such as calcium and sodium bicarbonate may be necessary.
A comprehensive approach to diagnosis and treatment is necessary, considering factors such as time of response and the presence of other injuries. Tourniquets can be used to manage crush syndrome in the lower extremities, but there is a risk of unnecessary amputations.
Fluid resuscitation is important in stabilizing the patient and increasing urine output.
Sodium bicarbonate can be used to manage metabolic acidosis and improve the effectiveness of vasopressors.
Calcium can be given to stabilize cardiac rhythm, and insulin and dextrose can be used to manage high potassium levels.
Albuterol can be used to treat respiratory acidosis, but it may be challenging to administer in a resource-limited setting.
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In this podcast episode, Dennis interviews Alex McDonald, a medical student and member of Tactical Medicine New Zealand, about the republishing of the book ‘Guerilla Surgeon.’ The book tells the story of Dr. Lindsay Rogers, a New Zealand-born surgeon who served with the Special Operations Executive in Yugoslavia during World War II. The conversation covers topics such as the challenges of providing medical care in resource-limited environments, building trust with local forces, and the importance of cultural competency. Alex also discusses the mission of Tactical Medicine New Zealand and their partnership with the Special Operations Medical Association (SOMA) to republish the book.
Takeaways
- The book ‘Guerilla Surgeon’ tells the story of Dr. Lindsay Rogers, a New Zealand-born surgeon who served with the Special Operations Executive in Yugoslavia during World War II.
- Providing medical care in resource-limited environments requires improvisation and making the most of available resources.
- Building trust with local forces is crucial for successful medical operations in foreign nations.
- Cultural competency is important for effective communication and collaboration with partner forces.
- Tactical Medicine New Zealand aims to promote and advance tactical medicine in New Zealand and has partnered with SOMA to republish ‘Guerilla Surgeon.’
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This is not just another wilderness medical course, though wilderness medical providers would certainly benefit. It’s also not just a different take on TECC, but those who are charged with performing TECC would also greatly gain much from the instruction.
In certain subsets of EMS and Law Enforcement, patient evacuation times are expected to exceed those that are optimal and contribute to patient morbidity and mortality. This 4-day course is for any non-military responder, clinician or provider who may have manage the care of patients in austere and resource limited environments for longer than desired. It is ideal for teams operating in any remote locale where quick medevacs are not readily available such as Humanitarian Assistance/Disaster Relief (HA/DR), Search and Rescue (SAR), Expedition, Arctic, Maritime, Topical, Off-Shore, or even Rural EMS crews who have long transport times due to distance or weather.
The Austere Emergency Care Course is a prolonged field care course based on 10 years of knowledge gained from our original Prolonged Field Care Working Group and Ragged Edge Solutions’ experience and background in training military special operations to operate around the world without traditional medical Support. Over time, and after many inquiries by civilian/non-military clinicians it was realized that the need and demand signal is robust outside of the military. Just like PFC was developed as an adjunct for military medics once they reached the end of Tactical Combat Casualty Care (TCCC,) AEC was created with the civilian provider in mind once they reached the end of Tactical Emergency Casualty Care algorithms. From this Specialized Medical Standards and the Austere Emergency Care Course were born.
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There are courses coming up with seats still available!
| Course Dates | Event Title | Location | Affiliate | Registration Info | | --- | --- | --- | --- | --- |
| April 23 – April 26, 2024 | Austere Emergency Care | Lillington, North Carolina | Ragged Edge Solutions | Contact | | May 7 – May 10, 2024 | Austere Emergency Care | Coronet Peak, New Zealand | Ragged Edge Solutions | Contact | | May 7 – May 10, 2024 | Austere Emergency Care | Colorado Springs, CO | Anyone Not Ready | Register | | May 27 – May 30, 2024 | Austere Emergency Care | Pretty Bay, Malta | College of Remote and Offshore Medicine | Register | | Summer 2024 (Dates TBD) | Austere Emergency Care | Horton, Norway | Norwegian Society for Sea Rescue – Academy | Register |
What to Expect at an AEC Course:
Courses are be broken up into 2 concurrent tracks: BLS for minimally-trained, non-credentialed first responders, and ALS for credentialed/certified Paramedics, Nurses, PAs, and Doctors who have not had to operate outside of a clinic setting. If your agency/organization wants to host a course and only has ALS level providers, a single track, without BLS/first responders. The first three days are didactic in nature but rely heavily upon interaction between the participants and instructors. There is a heavy emphasis on getting out of your seats to put theory into practice with hands-on skills. With the option to choose electives, participants can intentionally explore those areas that they want to know more about. Classes are not purely canned lectures and with the reliance on participant interaction, instructors work within the protocols, resources, and drugs available to maximize relevance. The last day is a customized culminating exercise that will take place in an environment that matches that of the target operating environment.
More From the SMS website:Prolonged Field Care
The term prolonged field care was first coined in 2013 by the US Special Operations Forces (SOF) medical providers, following a lead from NATO SOF developers. Prolonged Field Care (PFC) describes a situation where a critical patient needs to be managed in a remote setting (i.e. your “worst day”). The original working group members tapped into the experience of over one hundred providers, representing decades of direct medical support to military forces in some of the most harsh and remote conditions on earth.
With an interest in sharing these best practices with a wider audience, the PFC Working Group, now the Prolonged Field Care Collective, was formed in December 2013, led by Dr. Sean Keenan. In 2014, this group launched the infamous Prolonged Field Care Podcast and website, prolongedfieldcare.org. These two platforms have resources and interviews, which today are downloaded by people in more than 100 countries on a monthly basis.
Military Best Practices
Between the years of 2014 and 2018, active duty US Army Special Forces medical teams from the 10thSpecial Forces Group (SFG) in Colorado, and the 3rd Special Forces Group in North Carolina began developing robust training platforms to prepare small teams to deploy regularly to Africa. The conditions in Africa, characterized by huge distances and harsh conditions, were particularly austere, being resource-limited and logistically challenging. For example, evacuation of patients was routinely challenging, with some being held on small bases for over a day before flying out to a hospital. Many medics required additional knowledge and skills to handle these situations –unlike their previous experiences in Iraq and Afghanistan. And so, due to the remote and austere conditions of this problem set, the Mountain Path medical exercise was created, based on the principals of Prolonged Field Care.
Ragged Edge Solutions
The Mountain Path exercise was successful and held up as an example of PFC best practices, but soon proved to be unstainable as a program within the military. Consequently, a privately owned training company was founded to continue the important work of training medics to work within austere conditions. In 2018, the original founder, Roger Dail, combined forces with Special Operations and PFC experts, Sean Keenan, Bill Vasios, and Rich Salve. They founded what is now Ragged Edge Solutions.
Today, Ragged Edge Solutions trains military and government personnel using the Dark+Woods course, derived and designed through best practices from the original Mountain Path program. This course combines classroom instruction with live action scenerios, which immerses students in a hyper-realistic training environment. Known as the gold standard in prolonged field care training, this course is highly sought after by both US and international special operations medics and their teams.
After a few years of running these military trainings, the team at Ragged Edge Solutions learned that there is a strong need for PFC training for civilian emergency medical responders (EMS). In the US alone, 18% of the population is considered to be living in rural areas. Access to hospitals can sometimes be hours, if not days, away from the patient’s home. Because most EMS training focuses on urban environments, many of these EMS professionals are lacking the skills and knowledge to handle emergency situations in remote or austere conditions.
Specialized Medical Standards
With Dr. Sean Keenan at the helm as CEO, Specialized Medical Standards was formed in 2020 as a non-profit company. The mission of SMS is to develop and maintain education and training resources, and our flagship program is a robust curriculum based upon PFC best practices for EMS practitioners. The curriculum for our Austere Emergency Care (AEC) courses is derived from the Ragged Edge Solutions’ Dark+Woods course, utilizing scenarios and educational materials that are directly relevant to a much wider audience of professional prehospital providers.
The AEC Basic Life Support and AEC-Advanced courses, designed as stand-alone robust continuing education (CE) curricula, were validated in 2022 and have since been adopted by a handful of SMS-licensed training partners. We rely on critical care thought leaders, our partners, and course participants to continually enhance the material. Initial feedback also confirms that this is industry-leading medical education and training.
Today, SMS operates with a small team, volunteers, and subject-matter expert contractors. In addition to our Board of Trustees, SMS hosts the International Committee for Austere Emergency Care, an advisory board of medical education leaders who advise the AEC curriculum. Additionally, SMS also directly supports the Prolonged Field Care Collective and the PFC podcast.
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Maggot therapy, also known as maggot debridement therapy (MDT), is a treatment that uses live maggots to clean and heal wounds. The therapy has a long history, dating back thousands of years, and has been used in various settings, including war zones and modern hospitals. Maggots are effective in wound healing because they eat necrotic tissue, have antimicrobial properties, and promote the growth of new tissue. The therapy is cost-effective and can be used in low-resource settings. It can be applied directly to the wound or placed in a mesh bag. Maggot therapy is often used as an adjunct to antibiotics and other wound treatments.
Takeaways
Maggot therapy is a cost-effective and efficient treatment for wound healing.
Maggots eat necrotic tissue, have antimicrobial properties, and promote the growth of new tissue.
The therapy can be used in various settings, including war zones and low-resource environments.
Maggot therapy can be used as an adjunct to antibiotics and other wound treatments.
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In this episode, Dennis interviews John and Paul about the Abdominal Aortic and Junctional Tourniquet (AAJT). They discuss the background and reasons for inventing the AAJT, including the need to control bleeding in the pelvis. They also talk about the first application of the AAJT and the positive results seen in combat situations. The conversation then moves on to study data and research on the device, including some negative studies that have been conducted. They also discuss the pressure levels used with the AAJT and the potential for extending the application time. Finally, they address the negative consequences of high pressure and the comfort level of wearing the device. The conversation explores the application and function of the Abdominal Aortic Junctional Tourniquet (AAJT) and its potential use in pre-hospital care. It discusses the challenges of prolonged application and the risks associated with it. The conversation also delves into alternative techniques and future developments in the field. The importance of reperfusion and monitoring is highlighted, along with the impact of the AAJT on breathing and inspiratory pressure. The discussion touches on the considerations for reducing pressure during reperfusion and the duration of application. The risk-benefit analysis of heroic interventions is examined, emphasizing the need for rapid hemorrhage control. The limitations and risks of REBOA are discussed, and a cadaveric study on the AHAT is presented. The conversation concludes with the role of the AHAT in preparing for future wars and its potential use in traumatic cardiac arrest.
Takeaways
-The AAJT was invented to control bleeding in the pelvis and junctional areas.
-The device has been successfully used in combat situations and has saved lives.
-There have been several studies conducted on the AAJT, with mixed results.
-The device applies pressure to occlude blood flow, but the pressure levels are safe and well-tolerated. The –Abdominal Aortic Junctional Tourniquet (AAJT) is a fielded device that can be used for rapid hemorrhage control in non-compressible torso hemorrhage.
-Prolonged application of the AAJT should be avoided, and it is important to consider the risks and benefits of its use.
-Alternative techniques and future developments, such as foams, are being explored for the treatment of non-compressible torso hemorrhage.
-Reperfusion and monitoring are crucial considerations when using the AAJT, and the pressure can be reduced during transfusion to mitigate ischemic change.
-The AAJT has shown promising results in traumatic cardiac arrest and can be a valuable tool in pre-hospital care
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In this episode, Dennis and Alex discuss the truth about pelvic binders and their relevance in trauma care. They explore the background and experience of Alex, who has extensive knowledge in trauma surgery. They delve into the anatomy and injury patterns of pelvic fractures, as well as the different phases of damage control surgery. They also discuss the importance of understanding research and the levels of evidence. The conversation highlights the contradictory evidence surrounding the use of pelvic binders and emphasizes the need to critically evaluate citations and research findings. This conversation covers blast injuries, types of pelvic fractures, mortality rates, considerations for prolonged field care (PFC), the flow of care in PFC, normalization and observation, initial stabilization, massive transfusion protocol, futile transfusions, clinical decision making, pelvic binder design, imaging challenges, ultrasound for pelvic fracture assessment, duration of pelvic binder use, preventing pressure sores, consulting with medical professionals, proper application of pelvic binder, retroperitoneal hemorrhage, the role of telemedicine, critical care and decision making, and resources for further learning.
Takeaways
-Understanding the anatomy and injury patterns of pelvic fractures is crucial in trauma care.
-The levels of evidence in research range from high-quality studies to expert opinions.
-The use of pelvic binders in trauma care is a topic of debate, with conflicting evidence and opinions.
-It is important to critically evaluate citations and research findings to make informed decisions in patient care. Understanding blast injuries and the different types of pelvic fractures is crucial in providing effective care in PFC.
-Mortality rates for pelvic fractures vary depending on the severity of the injury and associated injuries.
Clinical decision making in PFC requires a thorough understanding of the patient’s condition and available resources.
-Proper application and duration of pelvic binder use are important considerations in PFC.
-Consulting with medical professionals and seeking skeptics’ opinions can help in making informed decisions in PFC.
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This conversation explores the topic of gas anesthesia, its historical background, and its use in various environments. The conversation covers the shift to the TIVA technique, the importance of the anesthesia machine and equipment, and the training required to administer gas anesthesia. It also discusses the combined techniques used in the operating room and the stages of anesthesia. The conversation highlights the advantages and disadvantages of ether and chloroform as anesthetics. It emphasizes the need for vigilant monitoring and the use of IV induction agents for safety. The conversation concludes by discussing the duration of gas anesthesia and the importance of witnessing wakeups.
Takeaways
Gas anesthesia has a long history and is still used today in various environments.
The TIVA technique is a popular approach to gas anesthesia, especially in field environments.
The anesthesia machine and equipment play a crucial role in administering gas anesthesia.
Vigilant monitoring is essential during gas anesthesia to ensure patient safety.
Witnessing the stages of anesthesia, including wakeups, is important for understanding the process.
Ether and chloroform were popular anesthetics in the past but have been replaced by safer alternatives.
IV induction agents are used to quickly transition patients through the stages of anesthesia.
The duration of gas anesthesia depends on the amount and length of use.
Observing gas anesthesia in the operating room provides valuable insights into its application.
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In this conversation, Dennis and John discuss chest trauma management, specifically the use of chest seals and the sequence of interventions. They explore the overuse of chest seals and the potential complications they can cause. They also discuss the importance of assessing the patient and determining if a chest seal is necessary. John shares his insights on the use of finger thoracostomy and the technique for performing it. They also touch on the revision of the TCCC algorithm and the need to prioritize hemorrhage control. The conversation explores the challenges and approaches in operational medicine, emphasizing the need to align policy and guidelines with the experiences of field practitioners. It highlights the importance of preserving the rich experience and lessons learned by experienced personnel. The discussion also delves into the management of chest trauma, specifically focusing on emergent situations and the challenges in current practices. The conversation concludes with the anticipation of future discussions and the potential for further exploration of the topics.
Takeaways
Chest seals should be used specifically for sucking chest wounds or open pneumothorax.
Chest seals can cause tension pneumothorax if used inappropriately.
The decision to use a chest seal should be based on the patient’s breathing status and the nature of the injury.
Negative suction can be beneficial in re-inflating the lung and improving oxygenation in patients with chest trauma.
The TCCC algorithm may need revision to prioritize hemorrhage control. Operational medicine requires a balance between algorithmic approaches and the practical experiences of field practitioners.
Preserving the experience and lessons learned by experienced personnel is crucial for the development of effective policies and guidelines.
Chest trauma management involves various emergent situations, including tension pneumothorax, hemothorax, and pneumothorax.
Challenges in chest trauma management include the use of occlusive dressings and the need for surgical interventions.
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Imagine sitting there on a nice lazy Sunday morning drinking a nice warm cup of coffee as you plan prolonged field care training for the upcoming week. Now imagine doing exactly the same thing PLUS the added bonus of supporting a veteran owned coffee company that is donating a significant portion of the proceeds to fund Dennis’ insatiable appetite for new video equipment and my addiction to fumbling through Adobe to bring you better content. Lobo Coffee is owned and operated by Erik Herr, formerly of 7th SFG(A,) and has partnered with us to continue providing the Medics on the ground with the most up to date knowledge, techniques and ideas in our field.
Click here to order and help us help you!
If you don’t drink coffee but still want to support the podcast and website, we always welcome Patreon support by clicking here. We are also working with Ragged Edge Solutions to add some PFC merch like Hats and hoodies to their store in the very near future.
For 10 years the members of our working group have endeavored to deliver the most relevant content such as our PFC Podcast, Deployment Downloads, and Documentation at no cost to those on the ground doing the real work. We are currently aligned with the Non-Profit, Specialized Medical Standards for administrative support and to accept donations, sponsors and advertising in addition to the other options above. If you have anything else that you can contribute and add to the community and body of knowledge let me know below.
DOL, -Paul
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In this conversation, Dennis and Mike discuss the process of providing medical care and education in austere environments. They emphasize the importance of understanding the requirements and asking the right questions to ensure success. They also discuss the significance of analyzing the environment, finding reliable sources of information, and building relationships with partners and friends. Planning and preparation are highlighted as crucial steps, along with effective teaching methods and the use of the Learning to Listen, Listening to Teach technique. The conversation concludes with a discussion on measuring performance and effectiveness, and the importance of flexibility and focusing on the student.
Takeaways:
Understand the requirements and ask the right questions to ensure success in providing medical care and education in austere environments.
-Analyze the environment and find reliable sources of information to make informed decisions.
-Build relationships with partners and friends to enhance understanding and collaboration.
-Plan and prepare thoroughly, focusing on the basics and acquiring the necessary knowledge.
-Use effective teaching methods and the Learning to Listen, Listening to Teach technique to engage and educate students.
-Measure performance and effectiveness to assess the impact of the medical care and education provided.
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In this conversation, Aaron Epstein from GSMSG discusses the background and formation of GSMSG, their focus on training partners rather than providing services, and their work with military and security forces around the world. He shares lessons learned in surgical resuscitation, dealing with mass casualties, and planning for different phases of war. Aaron emphasizes the importance of tourniquet use and the need for more surgeons in combat situations. He also discusses the challenges in the training pipeline and the need for more medical training. The conversation concludes with a discussion on transportation challenges and lessons learned, as well as how to get in contact with GSMSG.
Takeaways:
GSMSG focuses on training partners rather than providing services.
Tourniquet use is vital in combat situations and should not be removed from the treatment algorithm.
Planning for different phases of war, including defensive, static, and offensive actions, is crucial for effective medical support.
There is a need for more surgeons and better medical training in combat situations.
Transportation challenges in combat zones require innovative solutions.
GSMSG can be contacted through their website, http://www.gsmsg.org or at the link below.
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Dennis had the honor of interviewing Dr. John Quinn who’s on the ground working Role 1 medical operations for an NGO somewhere in Ukraine. The lessons being learned by John […]
In the 100th Episode of the Prolonged Field Care Podcast Dennis sits down with Jamie, Sean and Paul to talk about the last 100 episodes and how prolonged field care evolved over the past 7 years from when the working group was established at SOMA 2013 in Tampa, FL.
The Joint Trauma System and Defense Committees on Trauma are made up of several committees including the Committee on Tactical Combat Casualty Care (CoTCCC), the Committee on EnRoute Combat Casualty Care (CoERCCC) and the Committee on Surgical Combat Casualty Care (CoSCCC). These committees, along with the other branches of the JTS, strive to share lessons learned, data, research and form recommendations to DoD medical communities.
From tourniquets to chest seals, our community has been at the forefront of innovating, problem solving and improvising when not able to get a commercially tested and manufactured device. A purpose-made, evidence-based solution should always be primary in the PACE plan. After the primary manufactured and evaluated product is exhausted, what then?
After some time to reorganize, restructure, and strategize, we will be continuing to update best practices, share ideas and raise the important questions faced by medics around the world. We have taken this step to lay the old prolonged field care working group construct to rest and form a new organization (with the same core people): the Prolonged Field Care Collective.
The wait is over... The Role 1 Prolonged Casualty Care Guidelines for the entire DoD are now available here and on the Joint Trauma System website! This was a monumental undertaking from the beginning
This article first appeared in the Jul-Sep 2019 Special Warfare Magazine which can be found open-source at soc.mil. SURVIVABILITY MEDICAL SUPPORT TO RESISTANCE BY SERGEANT FIRST CLASS JAKE HICKMAN, U.S. […]
The RAVINES Mnemonic was created to help the medical provider on the ground in an austere environment with a very sick patient. Most medics will do a decent TCCC SMARCH […]
This is not a novel procedure. The first successful autotransfusion on record was conducted in 1818 by James Blundell on a patient suffering from postpartum hemorrhage. Through the end of the 1800s and into the early 1900s, surgeons utilized this technique with surprising success
Hot weather injuries are an issue medics have to account for even when not deployed. Proper planning, recognition and treatment can greatly reduce frequency and severity of these patients and […]
Doug and Dennis talk austere management of COVID19 patients with an emphasis on strategies for oxygenation and ventilatory support. The remainder of the post is an massive amalgamation of resources I have been collecting for over a year for my own respiratory refresher. Its alot to take in but if you are looking for something related to airway, oxygenation or ventilation, scroll down and you should have some great rabbit holes to dive down.
On to the Podcast!
http://traffic.libsyn.com/specialoperationsmedicine/PFC_COVID.mp3
We have been trying to get more vent training with the Advanced Special Operations Medical Sergeant Course, Regional Support Medic program and prolonged field care training for a while recognizing that this is a universal weakness for the majority of us SOF Medics. We just don’t do it enough. I had the 6 students go through over 7 hours of vent training in 4 blocks over the course of 9 weeks and we were just getting comfortable with the basics. Most go back to their day jobs and won’t likely touch it again for a long time.
While getting ready for an upcoming class I was invited to take, I wanted to review everything I had found useful for airway and ventilation. There is a lot here but contains all the resources I found most useful…
Prolonged Field Care Principles you can use for any patient
COVID19 Airway and Vent
Disclaimer: I am not currently taking caring for any COVID19 patients,or any others for that matter, but these resources seem to be helpful to those who are. Recommendations are evolving daily so be sure to check the date on everything in this section…
Infection Control
Use an exhalation filter no matter what airway or vent you are using!
https://vimeo.com/403343413
Walter Reed COVID19 Toolbox
JTS COVID for Deployed Providers
10th SFG(A) SOCRATES Training:
SOCRATES Syllabus v 1.5
SOCRATES Practical lab v.1
EMCrit always has some great resources like this 4 Apr webinar…
https://emcrit.org/emcrit/avoiding-intubation-and-initial-ventilation-of-covid19-patients/
This deals with other, non-invasive positive pressure solutions such as COVID19 CPAP: https://emcrit.org/pulmcrit/cpap-covid/
This is the comprehensive PulmCrit/EMCrit Internet Book of Critical Care post if you have the time: https://emcrit.org/ibcc/COVID19/
Bill Cantrell also has some great resources on ResusMed: http://www.resusmed.com/2020/03/30/protected-airway-management/
You could try awake proning
CPAP machines (and some kind of viral exhaust filter) could buy time or prevent getting them on a vent. Most of the stuff I have read says that COVID19 Patients on vents have anywhere from a 50% to 90% mortality even with properly trained and equipped ICU teams. A SOF medic probably shouldn’t intentionally be trying to do any of this without very close oversight or in extremis. Like I said, it would be a bad day for the best of us.
PEEP valve with viral exhalation filter for COVID19 patients from Bob Hesse
BVM with PEEP valve with viral exhalation filter for crashing COVID19 Patients from Bob Hesse
Visit the Society of Critical Care Medicine for some great resources
including this
FREE Critical Care Training
COVID19 Ultrasound
Use Telemedicine!
Current Airway Guidelines
Current Role 2/3 JTS Clinical Practice Guideline on Airway Management
Original PFC WG Airway recommendations (April, 14)
Original PFC Airway Video:
https://prolongedfieldcare.org/wp-content/uploads/2015/03/airway-class-with-post-lecture-edits-and-narration.mp4PFC Airway Presentation Slides
SPO2
Next Generation Combat Medic Embrace the Full Power of your SPO2
PulmCrit-Top 10 Reasons Pulse Oximetry Beats ABG for Assessing Oxygenation
Airway Prep
MSMAID Handout
MSMAID Acronym with Minimum, Better, Best Packing List
EMCrit Preintubation POO
EMCRit Airway Positioning and Bougie
Manual Bag Valve Mask
ProlongedFieldCare.org Optimizing Manual Ventilation
https://youtu.be/wMFpg665ZWo
PEEP Valves
ProlongedFieldCar.org PEEP Valves
EMCrit Awake Proning
https://emcrit.org/wp-content/uploads/2020/04/COVID-CARP-Protocol-postable.pdf
Cric
Cricothyroidotomy Checklist
Intubation
RSI technique and checklist 2016
EMCrit-Dissociated Awake Intubation
EMCrit Ketamine Facilitated Intubation
ETCO2
ProlongedFieldCare.org ETCO2
EMCrit Episode 2 ETCO2
Capnography.com
Post Intubation
Post Cric/ET Tube Checklist
Tube Depth
PulmCrit ET Tube Depth
Cuff Pressure
ProlongedFieldCare.org Cuff manometer
PulmCrit-Liberating the Patient with no Cuff Leak Extubation
SAVent
No.
It has no PEEP or adjustability. If you do end up using it, do it for no more than 20 minutes at a time and then take them off in order to use a BVM with a PEEP valve.
The only time I would use this is for the extreme emergency where you need to bag a patient but must also do something else like drive and really need more hands.
SAVeII
The SAVE2 is underpowered for most situations. Patients would almost certainly need to be paralyzed (especially if ketamine were used which would maintain the patient’s own drive) as it is not a smart vent and they would constantly be breathing over it causing dyssynchrony, stacked breaths, agitation, pop-offs and more. It may work for the initial managemwnt of compliant COVID19 patients but as they descend into classic ARDS, they would need to be switched over to a fully capable vent.
SAVeII Operator Manual
SAVe2-vent-study
SAVeWhitePaper
Ragged Edge Blog Post by RT Wayne Trainer: SAVEII Save Who?
MOVE Vent Patient Assessment Tool
SAVe II Ventilator Easy Set Up Guide
Quote from a well respected intensivist..“I spoke with the SAVE folks themselves at MHSRS. They said it was never designed to provide mechanical ventilation support and never intended as a ventilator for SOF. “If you need a ventilator,” their guy said, “buy a ventilator.” Both SAVE 1 and 2 are mechanical bagging devices. They do not supply enough flow to generate meaningful tidal volumes for adult trauma patients. This results in a) under ventilating and under oxygenating a sedated, PARALYZED patient (because, as you’ll see, spontaneous breaths on the SAVE are bad) or b) when the patient breathes spontaneously, their natural tidal volume exceeds the flow the machine can provide, triggering a pop-off valve that entraps ROOM AIR, to provide the missing flow/volume demanded by the patient. So, if you are lucky enough to have supplemental O2, a spontaneously breathing patient on a SAVE 1 or 2 will regularly dilute that with 21 % FIO2… A bag mask with a PEEP valve provides FAR greater respiratory therapy than any SAVE machine.”
We eventually need a better vent.
Zoll/Impact Eagle 731 Vent
Great YouTube Playlist for 731 training: https://www.youtube.com/playlist?list=PL6mgSPXJ-4is0NRTMC5ecXvUKdjEMvwYK
Zoll Impact Eagle 731 Vent Easy Set Up Guide
Zoll/Impact 731 ventilator Cheat Sheet
Old Impact Eagle 752 Vent
Old Eagle Impact 752 Ventilator Cheat Sheet (Rule of 5s
Next Generation Combat Medic 5 part Ventilator Series
Next Generation Combat Medic Intro to Vents
Next Generation Combat Medic Applied Ventilator Theory
Next Generation Combat Medic Ventilatory and Respiratory Control
Next Generation Combat Medic Ventilator Theory
Next Generation Combat Medic Vent Practicalities
Even More Vent Stuff!
Doug’s Vent 101 – 1 Page
ARDSNet Protocol for ideal bodyweight calculation
Scott Weingart,s EMCrit Dominating the Ventilator Handout
EMCrit Vent Alarms=Code Blue
EMCrit-RACC Vent And PREVENT Episodes
Analgesia and Sedation
Blood Gas
PulmCrit-Converting a VBG into an ABG
Misc Airway
EMCrit How do you know you are actually good at airway management
PulmCrit-Mastering the Dark Arts of BiPAP & HFNC
PulmCrit-Fighting Refractory ARDS with Physiologic Jiu Jitsu
Proning
Our PFC Proning Podcast Episode 53
https://youtu.be/FS4t5w1eCYw
Early Prolonged Patient Proning nejmoa1214103
Splitting Vents Between Patients?!
Ventilator-Sharing-Protocol-Dual-Patient-Ventilation-with-a-Single-Mechanical-Ventilator-for-Use-during-Critical-Ventilator-Shortages
Shared vent for mult pts_2006.05.009
Joint-Statement-Patients-Single-Ventilator
https:/emcrit.org/pulmcrit/pulmcrit-wee-why-the-sccm-aarc-asa-apsf-aacn-chest-joint-statement-on-split-ventilators-is-wrong/
Don’t try and split a SAVE2. Here is my SAVE2 Math if thinking about splitting it between 2 patients:
Let’s pretend we have a 60y/o 5’9″ 230lb male as our first patient.
Push the button corresponding with the height of our height of our imaginary patient of 5’9″ which calculates the ideal body weight and gives us a tidal volume of 420mL if we use the lower 6mL/Kg of the ARDSNet recommendations.
Now we have to set rate. Our patient presumably needed the ventilator due to COVID19 and his inability to satisfy his oxygenation and ventilation and is now in respiratory distress on the verge of failure. He is breathing fast and shallow with fits of coughing so we pick a slightly higher rate of 16 to begin with.
420Vt x 16RR = 6,720Ve
The max minute minute ventilation for a SAVE2 is 8000mL. No more. Patient number 2 would have less than 1300 minute volume left at the lowest settings for the first.
If you are having issues with oxygenation and low sats we traditionally can adjust PEEP and/or oxygen if we have it. COVID Patients seem to be hypoxemic need more O2.
For issues with high ETCO2 we can adjust volume and rate.
Increasing any of those variables would use even more of the limited minute volume.
It just wouldn’t work.
Documentation
PFC Card v22.2 1Dec2020
MOVE Vent Patient Assessment Tool
What would you add???
Vasopressors
https://emcrit.org/emcrit/push-dose-pressor-update/
https://rebelem.com/one-more-update-on-using-peripheral-intravenous-piv-vasopressors/
Responding as a Medical Volunteer?
Advice on Integrating SOF Medics Into Existing or Developing Civilian Medical Systems During Disasters
Here are some thing I learned during Hurricane Katrina and have refined over the last 15 years of being a Medic…
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Remember that it is not about you. You are there to provide support, in a supporting role, as a support guy, volunteering to do support things. Defer to expertise. Read about HROs while you’re thinking about it.
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Watch out for yourself and know when to tap out. It is easy to get sucked in to working 24 hours straight… and then be worthless for the next 2 days. This is a marathon. Pick a predetermined stopping point and stick to it.
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Watch out for those around you. If you notice a fellow volunteer trying to muscle through a triple shift making bad decisions, take them with you when you get a break and talk to them. They will get really tired and crash. Night night. Soft power win.
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Constantly ask yourself if you are making it better. The situation, the patient, the family, the process…
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There are laws and protocols but often there is an unofficial process hindering everyone in the background. What can you fix right now? Tomorrow? Next disaster? Step back and observe when you can. Write down what you observe and make sure the right decision maker gets it.
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Don’t bang your head against an immovable object. Go around it. If you can’t do something because of legal ramifications or logistical constraints, what can you do?
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Nothing is beneath you. Everything needs to get done so look for work, especially that which no one else wants to do. Bottlenecks can be caused by the most mundane things so clean up, move things and do the dirty jobs.
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No one wins an argument in public in the heat of the moment. Pick your battles and the ground which fought on. Do you really want to influence a change in behavior or just prove to everyone you are an asshole?
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Know what you can do, what you can’t and what you shouldn’t. Your scope of practice changed the minute you left the gates of a military installation. Who is your medical director? Who’s license you are working under? What protocols are they using? Who is liable? Are you willing to lose your house over it?
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Know when to take charge. Is a patient crashing or in imminent danger? How can you temporize the situation and get them out of the weeds?
-Paul Loos, 18D
Listen Now:
http://traffic.libsyn.com/specialoperationsmedicine/PFC_TBI_update_Final.mp3
Show Notes:
Positioning
- Keep head at 30° or higher
Seizure Prophylaxis
- Keppra 1.5g initial dose 500mg every 12 hours
- Barbituates by telemedical consult
Seizure treatment
- Midazolam
Monitoring
- Compare serial measurements of Optic Nerve Disc Sheath Diameter
Impending Herniation Treatment
- Hypertonic Saline 23.4% vial or 3% 250mL
- Sodium Bicarbonate also acceptable
Palliative Care for Expectant Patients
- Have a plan or Call Telemedicine
Check out our previous TBI content:
Traumatic Brain Injuries coupled with other injuries can be one of the most difficult wound patterns to manage in the field. Learn to manage TBI on its own and when other complications arrive you will be in better condition to handle an even more difficult situation.
This Clinical Practice Guideline was initially drafted after our meeting in December of 2015. We wanted to make sure that we had a majority consensus from operational Medics and Docs along with the Researchers and clinicians in each recommendation we made, making this a 2-year endeavor. It was a long hard road to reconcile all the “Best” recommendations possible in a “House” phase with what a Medic should be expected to handle out of his ruck near the point of injury. There are a few interventions that some medics may not be famiar with, or drugs that are not commonly carried out side of a larger treatment facility. In these instances we realize that situations and even budgets may dictate what you have available. This still doesn’t change what is best for the patient. If it is physically possible and backed by evidence we included it as a “Best” recommendation with options for alternate therapies below them. This could also be a catalyst for change and improvement by giving the medical planner (usually the Medic) justification to make a request out of the ordinary.
This was the case 4 years ago with some of our MEDLOGs when we would request 10 vials of Ketamine for a 4 month Africa Deployment and they would respond by issuing 3 vials, saying that we don’t really need that much. In fact when we layed out the math it was evident that three was woefully inadequate.
Sometimes it is not so straightforward with hard math to back you. Sometimes you need a consensus guideline to help push naysayers in the right direction. We hope these recommendations by our Working Group and the Joint Trauma System have the clout you need to increase your medical capabilities and ultimately the care you provide.
If you are not a SOMA Member and missed the article in the Journal of Special Operations Medicine you can download the guidelines from the JTS CPG webpage or via the link below. Since it is now considered a scholarly article this is also archived in the NIH PubMed Database for future reference.
JTS/PFC_CPG Final 15_Aug_2017
Check out our previous posts and podcasts on TBI management:
Podcast Episode 20: TBI Round Table and Case Discussion
Podcast Episode 18: Traumatic Brain Injury
Dennis and Paul talk with Dr. Ian Wedmore and discuss some interesting updates to the management of frostbite injury in the field and what to do when you get back to a hard stand shelter.
2019 WMS Guidelines on Frostbite Management
Alaska Cold Weather Guidelines
Click here to download the episode
Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2019 Update The Wilderness Medical Society convened an expert panel to develop a set of evidence-based guidelines for prevention and treatment of frostbite. We present a review of pertinent pathophysiology. We then discuss primary and secondary prevention measures and therapeutic management. Recommendations are made regarding each treatment and its role in management.
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?
Now on to the podcast:
http://traffic.libsyn.com/specialoperationsmedicine/Snake_envenomation_.mp3
Here are just some materials you can find from The Asclepius Snake Bite Foundation website: (Under “Resources”)
https://www.nytimes.com/2019/10/11/world/africa/soldier-death-somalia.html
Why does it take the NY Times to identify and disseminate our medical lessons learned?!
How was this not immediately circulated to all medics internally the way parachute failure incidents and military vehicle accidents are?!
Why is there not an immediate safety stand down and retraining required?!
Don’t let Dunning-Kruger fool you. Any one of us could have been the initial medic, the receiving PJ or even the patient. Incidents like this can even occur here at hole in the firat world. Have you ever watched the Elain Bromily case?
Imagine if there were a proper incident report posted in every Command hallway, everytime there were a poor outcome experienced across the enterprise?
How much easier would it be to justify training and equipment needs with the penny pinchers, bean counters and check writers who were acutely aware of the actual risk to force?
If the article is accurate, this was a catastrophe for everyone involved. The lives of the patient, the family, the team and the medics are irreversibly altered.
Our last podcast was about High Reliability Organizations. A key hallmark of an High Reliability Organization involved in life and death operations is a preoccupation with failure. We cannot continue to bury our collective failures and must focus on identifying and fixing them all from an organizational level.
Here is a sample plan of action for organizational remedial training that I would do if I were a Senior Leader with medical personnel in my unit.
I personally challenge you to actually complete the following action items this week. If we do not learn from our collective failure we will repeat it until we do.
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There should be immediate notification, reeducation and retraining for everyone followed by an improved initial and sustainment training plan. Battalion Surgeons, PAs Instructors and Senior Medics should ensure every single medic does the following:
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Recieve(or Demand) the incident report and AAR from the Chain of Command the way other Saftey Stand Down incident reports are disseminated. -Post it for the entire unit to read next to the parachute failure incident.
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As a small group, read and review the report and AAR.
Botched Medical Procedures May Have Led to Death of U.S. Soldier Staff Sgt. Alex Conrad, 26, died from wounds he received during a militant attack on a small outpost in Somalia. A complex and difficult medical procedure that ultimately failed might have contributed to the death of an American Special Forces soldier killed last year in a firefight in Somalia, according to an investigation into the episode obtained by The New York Times.
- Reread the guidelines and watch the videos freely available on the DeployedMedicine App
https://deployedmedicine.com/market/11/content/158
- Ensure everyone immediately participates in hands-on table top training with whatever you currently have available or can easily construct.
https://emcrit.org/emcrit/ultimate-cricothyrotomy-trainer/
-Be sure to discuss shortfalls and inaccuracies of your trainer.-Dont just focus on the single skill, discuss other options that could have led to a better outcome:
-‘Could different patient positioning have helped the situation?’
-‘How could the outcome have been different with various pharmacological adjuncts?’
-‘One of the things I have seen in small group training was to inject a hematoma just over the cricothyroid membrane. This makes it super messy and hard to identify landmarks which is usually a slam dunk training scar.’
-Ask Medics how well their non-Medics are trained to take care of them if it were them on that table?
- Submit a WRITTEN request through multiple channels for proper equipment citing the article, incident report and TCCC guidelines as justification to your MEDLOG, S4, XO and anyone else who can affect the situation.
-Imagine if 10,000 requests were simultaneously submitted for similar equipment…
- Identify training deficiencies in your immediate organization and actually make a WRITTEN request to your Command for additional remedial training to be included in future non-medical training.
-Attach the article to the request.
- Identify equipment deficiencies and again, submit a WRITTEN request through multiple channels for proper equipment citing the article, incident report and TCCC guidelines as justification to your MEDLOG, S4, XO and anyone else who can affect the situation.
-Do you have Super Glottic Airways in every aidbag and IFAK? An Emma Capnograph would have helped identify the false passage instantly.
These are just a few things an HRO can EASILY and IMMEDIATELY accomplish. What else can you do to ensure this death of our brother is not in vain?