Part One - The Major Trauma Kit. 09(4). - Journal of Special ...

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Carrying locations include the following: • Combat jacket main pocket. Often, this is not an option in hot environments, as lightweight desert or jungle shirts normally don’t have large-capacity pockets. • Trousers cargo pocket. Depending on size and shape, this could interfere with leg movement if not carefully packed and is often not possible if a dropdown pouch with leg straps is worn on the same leg. • Combat shirt/jacket sleeve pocket. This is only possible if the kit is rather small and when not wearing ballistic protection over the deltoid muscle area. While not being practical for self-aid if wounded in the arm opposite the one carrying the kit. • Dedicated medical pouch with multiple compartments, attached to the trousers belt (at waist level or on the thigh, using a drop-down extension strap), on the body armor system or load-carrying vest/rig. The quality of any elastic straps is an important consideration, as they may wear out over time. If replacement cost is an issue, mesh compartments closed with a drawstring may be a better alternative. Compartments shouldn’t be too item-specific, so as to allow some flexibility to repack the kit when new products or different-sized replacement items become available. • Many individual medical pouches are quite large (four PALS/MOLLE bars wide), 80 although more compact versions (only two PALS/MOLLE bars wide) are now commercially available. Some medical pouches are designed to be rapidly pulled from a panel that itself can be attached to the PALS loops on a load-carrying system. • Canteen, ammunition, or utility pouch carried on the body armor system or load-carrying vest/rig. While usually being cheaper and more readily available than dedicated medical pouches, care should be taken that the pouch can be closed properly, so as not to lose a kit. The simple addition of a strong wide elastic strap, sewn on the inside under the lid, may be useful to secure a dressing while allowing instant access. • Split among several locations, including any of the above. While in theory, the kit could be split in different parts and carried in different locations based on criteria such as the need for immediate or delayed use, the ability to use items for self-aid or not, or a combination of those. In practice, this may hamper rapid retrieval. Possibly, only items that more than one of is carried, should be considered to be carried in different locations and even different layers of equipment, as a precaution against potential partial equipment loss. This can be tricky, especially if no clear and rigidly enforced unit standing operating procedures (SOPs) for this exist. While being a common practice in many units for a long time, care should be taken when modern field dressings are being taped to weapons or load-bearing equipment, as their thin packaging materials may be more prone to damage than many older standard issue field dressings. When adhesive tape is used, the tape ends should be folded back so as to have a quick access point. MARKING In order to facilitate identification, the trauma kit could be appropriately marked. Different options exist, such as an embroidered text (“IFAK”, for “individual first aid kit”), a patch containing a cross (red, subdued, or reflecting visible or infrared light), or by using two sewn-on crossed webbing tapes. Due to cultural sensitivities, the use of a cross may be ill-advised during overt missions in some areas. TRAINING IMPLICATIONS Having an excellent trauma kit doesn’t provide the capability to deal with injuries on the battlefield. The “train as you fight” principle applies to the use of medical kit. This implies the following: • Individual trauma kits should be issued on a permanent basis. Most components are single-use-items, some may deteriorate with repeated use and/or be rapidly perishable, and still others may be controlled items or be too expensive to be issued when not on operations, so using a training kit containing mock items with similar size, shape, and weight, should be considered. Expired items can be used to fill this training kit. • Individual trauma kits should be carried during all field exercises, as per unit SOPs. This not only accustoms Operators to the fact that they carry a trauma kit, it also forces them to think about how to pack it, and more importantly, to identify those items not to pack in the space to be used for this medical kit. 50 Journal of Special Operations Medicine Volume 9, Edition 4 / Fall 09
• Operators must be able to effectively use all items carried in their trauma kit. While not all items can be used for self-aid, any item from a casualty’s kit may have to be used for the administration of buddy-aid in the absence of a medic. • Combat gear should be worn during routine medical training, even during classroom training. This article tried to give some insights on what might be included and why, when building a major trauma kit for SOF. It should be remembered that kit contents should always be adapted to the mission, the environment, and the adversary situation, while only a properly packed and configured kit, carried in a suitable location, will make it truly useful, provided adequate training has been conducted prior to mission execution. REFERENCES 1. Butler FK, Holcomb JB, Giebner SD, et al. (2007). Tactical Combat Casualty Care 2007: Evolving concepts and battlefield experience, U.S. Army Institute of Surgical Research technical report; March 30. 2. Grossman D, Christensen LW. (2004). On combat: The psychology and physiology of deadly conflict in war and peace, PPCT Research Publications, pp. 30-32. 3. Butler FK, Hagmann J, eds. (2000). Tactical management of urban warfare casualties in Special Operations, Mil Med; 165(Suppl):1–48. 4. McPherson JJ, Feigin DS, Bellamy RF, (2006). Prevalence of tension pneumothorax in fatally wounded combat casualties, J Trauma; 60:573–578. 5. Holcomb JB, McMullin NR, Pearse L, et al. (2007). Causes of death in U.S. Special Operations Forces in the Global War on Terrorism: 2001–2004, Ann Surg; 245:986–991. 6. This is defined as care rendered at the point of injury, while still under effective hostile fire. 7. This is defined as care rendered once the casualty and his/her unit is no longer under effective hostile fire, or during situations in which injury has occurred without hostile fire. 8. Lakstein D, Blumenfeld A, Sokolov T, et al. (2003). Tourniquets for hemorrhage control on the battlefield: A 4-year accumulated experience, J Trauma; 54:S221–S225. 9. Walters TJ, Mabry RL. (2005). Issues related to the use of tourniquets on the battlefield, Mil Med; 170:770–775. 10. Calkins MD, Snow C, Costello M, et al. (2000). Evaluation of possible battlefield tourniquet systems for the far-forward setting, Mil Med; 165(5):379-84. 11. Lakstein et al., p. 222. 12. Brodie S, Hodgetts TJ, Ollerton J, et al. (2007). Tourniquet use in combat trauma: UK military experience, JR Army Med Corps; 153:310-313. 13. TCCC Guidelines July 2008. 14. Personal communication, former U.S. Navy Naval Special Warfare Development Group physician’s assistant. 15. The 2003 and 2006 TCCC guidelines recommended the use of hemostatic agents as of the care under fire phase. This recommendation changed, due to the fact that it was realized that applying a hemostatic agent during the care under fire phase is time consuming and increases the risk to both the casualty and the responder. 16. Grimes M, Rocheleau DN. (2007). Analysis of the Pressure distribution of army bandages, University of South Carolina Department of Mechanical Engineering report for North American Rescue, Inc., August 8. 17. “Battle pack” is used both as a synonym for field dressing and to describe a package containing a field dressing packed together with other bleeding control items (personal communication, USAF PJs, Jan 2006). “First field dressing” and its acronym “FFD” are common British terms. Large FFDs are sometimes called “shell dressings”. 18. Cloonan CC, Immediate care of the wounded. 19. Bellamy RF. (1991). The nature of combat injuries and the role of ATLS in their management. in: Zajtchuk R, Jenkins DP, Bellamy RF, et al., eds., Combat Casualty Care guidelines, Operation Desert Storm, Washington DC, Office of the Surgeon General. 20. Szul AC, Davis LB, eds. (2004). Emergency war surgery - 3rd U.S. revision, p. 1-2. 21. Champion HR, Bellamy RF, Roberts P, Leppaniemi. (2003). A profile of combat injury. J Trauma; 54: S13-S19. 22. Mabry RL, Holcomb JB, Baker AM, et al. (2000). United States Army Rangers in Somalia: An analysis of combat casualties on an urban battlefield. J Trauma; 49:515–529. 23. Personal notes, 2nd International Medical Technologies Symposium, Tampa, December 2007. 24. Hetzler MR, Ball JA. (2008). Thoughts on aid bags, Part one. JSOM; Summer 8(3):47-53. 25. Waydhas C, Sauerland S. (2007). Pre-hospital pleural decompression and chest tube placement after blunt trauma: A systematic review, Resuscitation; 72:11-25. 26. Butler et al., Tactical management of urban warfare casualties in Special Operations, p. 26. 27. Ranger Medic Handbook 2007, p. 2-12. 28. Britten S, Palmer SH, Snow TM. (1996). Needle thoracocentesis in tension pneumothorax: Insufficient cannula length and potential failure. Injury; 27:321–322. 29. Zengerink I, Brink PR, Laupland KB, et al. (2008). Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: What size needle? J Trauma; 64(1):111-114. 30. Harke HT, Pearse LA, Levy AD, et al.(2007). Chest wall thickness in military personnel: Implications for thoracentesis in tension pneumothorax. Mil Med; 172:12:1260–1263. 31. Department of the Army, Office of the Surgeon-General, Management of Soldiers with Tension Pneumothorax, 25 August 2006 (Memorandum). 32. Personal notes, 2nd international medical technologies symposium, Tampa, December 2007. 33. Personal notes, Operational and Emergency Medical Skills course, January 2006, and 2nd international medical technologies symposium, December 2007. 34. Netto FA, Shulman H, Rizoli SB, et al.(2008). Are needle decompressions for tension pneumothoraces being performed appropriately for appropriate indications? Am J Emerg Med; 26(5):597-602. 35. Director General Army Medical Services, Battlefield Advanced Trauma Life Support, 2nd Edition (2000), [British] Army Code No 63726, p. 4-19. 36. McSwain NE, Salome JP, (2006). eds: PHTLS - Prehospital Trauma Life Support : Military version. Sixth Edition, Akron, OH, Mosby, p. 516. Special Operations Individual Medical Equipment Part I – The Major Trauma Kit 51
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