TACTICAL COMBAT CASULATY CARE

Tactical Combat Casualty Care in Special Operations CAPT Butler/LTC Hagmann Military Medicine Supplement August 96

“90% of combat deaths occur on the battlefield before the casualty ever reaches a medical treatment facility.” COL Ron Bellamy

Tactical Context Incoming fire Darkness Environmental factors Casualty transportation problems Delays to definitive care Command decisions

“Two of the obvious differences (in combat casualty care) are the adverse conditions of war and the fact that under certain tactical conditions, the care of the patient is secondary to the mission at hand.” CAPT Byron Holley

Cocaine Lab Raid 32 man Ranger team Planned raid on a cocaine lab in dense jungle Estimated hostile strength is 8 men with automatic weapons Insertion from HELO 8 Kilometer movement to target

Cocaine Lab Raid As patrol reaches the objective area, a booby trap is tripped resulting in a point man without pulse or respirations and a squad leader with massive trauma to the leg and femoral bleeding Heavy incoming fire as hostiles respond Planned extraction by boat at point on river 1/2 mile from target

Tactical Combat Casualty Care Good medicine can sometimes be bad tactics!

Tactical Combat Casualty Care Bad tactics can get everyone killed and/or cause the mission to fail!

Tactical Combat Casualty Care Casualty scenarios in Ranger operations usually entail both a medical problem and a tactical problem. We want the best possible outcome for both the man and the mission.

Combat Casualty Care Objectives Treat the casualty Prevent additional casualties Complete the mission

Editorial The most important aspect of caring for trauma victims on the battlefield is well thought out planning for that environment and appropriate training of Ranger First Responders and Combat Medical Personnel.

Phases of Care Care under Fire Tactical Field Care Casualty Evacuation (CASEVAC)

"Care under Fire" The care rendered by the RFR/NREMT-B/ Ranger Medic at the scene of the injury, while he and the casualty are still under effective hostile fire. Available medical equipment is limited to that carried by the individual Ranger or medic in his gear.

"Tactical Field Care" Care rendered by the RFR/NREMT-B/ Ranger Medic when no longer under effective hostile fire. Applies to situations in which an injury has occurred on a mission, but there has been no hostile fire. Available medical equipment limited to that carried into the field by mission personnel.

”CASEVAC" Care rendered once the casualty (and usually the rest of the mission personnel) have been extracted by aircraft, vehicle, or boat. Personnel and medical equipment previously staged in these assets are now available. Use "CASEVAC" to describe this phase vs the commonly used term "MEDEVAC".

Basic Tactical Combat Casualty Care Plan Key Point: The plan described is presented as a generic sequence of steps that will probably require modification in some way for almost any casualty scenario encountered in Ranger Operations.

Care under Fire Return fire as directed or required Try to keep yourself from getting shot Try to keep the casualty from sustaining additional wounds Stop any life-threatening external hemorrhage with an Emergency Trauma Dressing and/or tourniquet

What does returning fire have to do with medical care? Care under Fire What does returning fire have to do with medical care?

The best medicine on the battlefield is Care under Fire The best medicine on the battlefield is Fire Superiority! Fire superiority and control of the tactical situation is a must. The Tactical Commander (TM LDR, SQD LDR, PLT SGT) must have control of the situation to effectively manage casualties.

Care under Fire No immediate management of the airway should be anticipated at this point because of the need to move the casualty to cover as quickly as possible.

Care under Fire Exsanguination from extremity wounds is the #1 cause of preventable death on the battlefield. Control of hemorrhage is the top priority! Hemorrhage from extremity wounds was the cause of death in more than 2500 casualties in Vietnam who had no other injuries.

Tourniquets Most reasonable initial choice to stop major bleeding in the Care Under Fire Phase Direct pressure is hard to maintain during casualty transport under fire

Tourniquets Tissue damage to the limb is rare if the tourniquet is left in place less than an hour. Tourniquets often left in place for several hours during surgical procedures. In the face of massive extremity hemorrhage, in any event, it is better to accept the small risk of tissue damage to the limb than to lose a casualty to bleeding to death.

Tourniquets The need for immediate access to a tourniquet in such situations makes it clear that all Rangers on combat missions should have a suitable tourniquet readily available at a standard location on their battle gear and be trained in its use.

Questions?

Tactical Field Care Reduced level of hazard from hostile fire Amount of time available extremely variable Time prior to extraction may range from less than a half hour to many hours. Limited visibility Nonsterile field conditions

Airway Management: Conscious Patient No attempt at airway intervention is required if the patient is conscious and breathing without difficulty on his own.

Airway Management: Unconscious Patient Without airway obstruction Usual cause is hemorrhagic shock or penetrating head trauma Chin lift or jaw thrust maneuver No need for cervical spine immobilization Nasopharyngeal airway if no obstruction

Nasopharyngeal Airway Better tolerated than an oropharyngeal airway should the patient subsequently regain consciousness Less likely to be dislodged during patient transport.

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Suction If blood or other obstructions are present in the mouth, they should be removed by hand.

Breathing Tension pneumothorax is the second leading cause of preventable death on the battlefield. Consider progressive, severe respiratory distress resulting from unilateral chest trauma to represent a tension pneumothorax and decompress.

Tension pneumothorax Signs/Symptoms Decreased breath sounds Tracheal shift Hyperresonance to percussion Difficult to appreciate on the battlefield!

Needle Thoracostomy Decompress affected side with a 14 gauge needle inserted at 2nd ICS at MCL. A patient with penetrating chest trauma will generally have some degree of hemothorax or pneumothorax as a result of the primary wound. Additional trauma from needle thoracostomy will not significantly worsen patient’s condition if no tension pneumo.

Needle Thoracostomy RFR’s, Squad EMT’s, and Medics are trained in this technique Technically easy to perform May be lifesaving if the patient does in fact have a tension pneumothorax.

Open Pneumothorax Asherman Chest Seal is the standard Occlusive dressing Not necessary to vent one side of the wound dressing: difficult to do reliably in a combat setting Watch for development of a tension pneumothorax Asherman Chest Seal is the standard

Bleeding Ranger survivability on the battlefield is measured by immediate control of hemorrhage. When tactically feasible consider standard bleeding control procedures. Don’t hesitate to use a tourniquet under more severe battlefield conditions (Care Under Fire). Application of a tourniquet is only acceptable under extreme circumstances.

Bleeding Tourniquets are only used to control serious extremity bleeding by RFR’s under real world combat conditions.

Bleeding Ranger Rescue Wrap Remove minimum clothing required to expose and treat injuries Emergency Trauma Dressing Ranger Rescue Wrap Need to protect the patient against the environment

Ranger Rescue Wrap

IV Therapy Large IV catheters are needed to administer large volumes of blood products rapidly Not a factor in the tactical setting since blood products will not be available 18 gauge catheter preferred in the field setting because of increased success rate

IV Therapy Larger gauge IVs may have to be started at MTF Common practice to discontinue prehospital IVs upon arrival at MTF because of concern about contamination of the IV site

IV Therapy Don't start on an extremity distal to a significant wound Saline locks are used (Eliminates the logistical difficulties of managing the IV bag during transport)

IV Therapy Extremity (Upper > Lower) vein first choice External jugular vein next option Sternal Intraosseous is last option

Fluid Resuscitation 1. Controlled bleeding/ no shock: Saline lock, NO IV fluids required 2. Controlled bleeding/shock: Saline lock, IV Hespan 500 - 1000cc 3. Uncontrolled bleeding: Saline lock, NO IV fluids

Fluid Resuscitation Despite its widespread use, the benefit of prehospital fluid resuscitation in trauma patients has not been established.

Fluid Resuscitation: Uncontrolled Bleeding Several studies noted that only after previously uncontrolled hemorrhage was stopped did fluid resuscitation prove to be of benefit.

Fluid Resuscitation: Uncontrolled Bleeding (Human) World War I combat trauma patients Concluded that initiating IV fluid replacement without first obtaining surgical hemostasis promoted further hemorrhage. Cannon

Fluid Resuscitation: Uncontrolled Bleeding Weight of evidence at this time favors withholding aggressive IV fluid resuscitation in patients with uncontrolled hemorrhage from penetrating thoracic or abdominal trauma until the time of surgical intervention.

Fluid Resuscitation: Controlled Bleeding Immediate fluid resuscitation is still recommended for casualties on the battlefield whose hypovolemic shock is the result of bleeding from an extremity wound which has been controlled.

Comments/Questions?

Inspect and Dress Wound Minimize further contamination Promote hemostasis

Check for Additional Wounds A careful check for additional wounds should be made, since high velocity projectiles from assault rifles will tumble and take erratic courses when travelling through tissue. Exit sites are often remote from the entry wound.

Splint Fractures and Recheck Pulse Check distal pulses both before and after splinting Remedy any decrease in the pulse caused by splinting by adjusting the position of the splint

Cardiopulmonary Resuscitation (CPR) Battlefield CPR for victims of blast or penetrating trauma who have no pulse, no respirations, and no other signs of life, will not be successful and should not be attempted. Attempts to resuscitate trauma patients in arrest have been futile even in the urban setting where the victim is in close proximity to a trauma center.

Cardiopulmonary Resuscitation The battlefield cost of attempting to perform CPR on casualties with what are inevitably fatal injuries will be measured in additional lives lost as care is withheld from patients with less severe injuries and as Rangers are exposed to additional hazard from hostile fire because of their attempts.

Cardiopulmonary Resuscitation Only in the case of nontraumatic disorders such as hypothermia, near drowning, or electrocution should CPR be considered prior to the CASEVAC phase.

CASEVAC Care Two significant differences will be present in progressing from the Tactical Field Care phase to the CASEVAC phase: Additional medical personnel may accompany the evacuating asset. Additional medical equipment may be pre-staged on the evacuating asset.

CASEVAC Care: Monitoring Helicopter transport impairs or precludes the provider's ability to auscultate the lungs or even to palpate the carotid pulse Electronic monitoring systems capable of providing blood pressure, heart rate, pulse oximetry, and capnography are commercially available and needed for air medical transport

Recommendations 1. Base planning for Ranger combat casualties should be incorporated into specific mission scenarios to aid in identifying the unique medical and tactical requirements that will have to be addressed in that scenario.

Recommendations 2. On combat missions, all Rangers should have a suitable tourniquet readily available at a standard location on their battle gear. 3. All Rangers should be trained to use a tourniquet.

Recommendations 4. Designate and train Combat Casualty Transport Teams. 5. In the event of a conflict, assign these teams to the JSOTF commander.

Vision Statement how to think, not just what to think.” “We must also have the intellectual agility to conceptualize creative, useful solutions to ambiguous problems.…this means training and educating people on how to think, not just what to think.” Gen Peter Schoomaker Commander-in-Chief

Questions?