Summer - United States Special Operations Command

Figure 4 : A Special Forces medic conducts an I & Dprocedure in Bolivia in 1967.(Courtesy USASOC Historian’s Office)ital or manual pressure is paramount and almost alwaysassures immediate effectiveness. Remember, the goalis not just to limit the amount of blood loss, but to saveevery single drop possible. Paramount towards this endis the expectation that each Soldier, if able, performsself-care. This requires mental preparation, musclememory, and psychological hardening to perform underphysical pain, stress, and challenging conditions. Pressurepoints are next, or act as an adjunct to minimizeblood loss and always attempt to use other Soldiers todeal with pressure points even under the best circumstances.The benefit is reduced time to hemostasis andpreserved blood volume, while maintaining combatpower during the fight. Other essential multipliers includethe medic placing pressure with his own kneewhile he works, or effective support from his teammatesfrom prior cross-training or on-scene instruction.Tourniquets are extremely effective in the treatment ofextremity wounds and their success since 9/11 is inarguable.There have been no reports of amputations duringthe conflict directly attributable to tourniquet usage.Remember that bleeding control is a graded response,so if a limb is mangled enough a tourniquet will likelybe the first step in hemorrhage control. 9 Tourniquet effectivenessis based on the principles of ensuring theyare placed proximal to the wound, active bleeding stops,the distal pulse is absent, and that reassessment is frequentand continuous. Keep in mind that the durationa tourniquet is applied will bring new concerns in prolongedcare. Present standards call for removal withintwo hours and, if conscious, the patient will remind themedic of this with the pain that normally accompaniesprolonged tourniquet use. Application over two hourscan also predispose the patient to increased morbiditysuch as fasciotomies and amputations, all of which maylater be the medic’s responsibility in this scenario. 10Converting a tourniquet to an effective pressure dressingas soon as possible while leaving the tourniquet looseand in place, for use if reapplication is necessary, willlikely prevent issues later in prolonged care.Packing wounds is a science in itself, requiringeffective technique, proper supplies, and completed witha pressure dressing to optimize the medic’s work. Makingthe decision to pack early is important too; packingis dependent on the patient’s ability to form good clotsand if too many factors are lost, then packing will notbe effective. Bowl-type wounds must be addressed immediatelyby packing with a maximum of two fingersusing unrolled Kerlix® and working from the bottom ofthe wound up, left to right or circumferentially, as if fillinga bucket. Finding and addressing all potential spacein the wound to ensure that there is no opportunity forany leakage of blood is a difficult task, especially whilepacking blindly, in the dark, and under stress at speed.An effective packing job can provide hemostasis with aminimum amount of supplies. Packing should not onlybe reserved for bowl-type wounds but also used inanatomical girdle areas such as the groin or shoulder.Hemostatic agents provide additional tools for more difficultwounds but they require thorough training, ideallyduring predeployment trauma training, to utilize effectively.The same rule applies for hemostatics as withpacking: hemostatics + packing + pressure = success.Future technologies that are presently being developedfor advanced hemostatics such as vessel closure andpressurized viscotic hemostatics may offer additional adjunctsin time.PREVENTION OF HYPOTHERMIAWithin the lethal triad itself, the prevention ofhypothermia is probably the simplest and most practicedeffort for SOF medics. Hypothermia has significant effectsand yields 100% mortality to severely traumatizedpatients with core temperatures less than 90ºF (32ºC). 11The goal is to maintain the casualty’s core temperature togreater than 95ºF (35ºC). Preventing hypothermia takesfar less effort and time than attempting to treat it undercombat conditions.Temperature monitoring should be as continuousas possible. Use every tool in sequence from skincolor and extremity warmth, patient feedback, and mentation.Objective findings can be obtained from toolsDamage Control Resuscitation for the Special Forces Medic:Simplifying and Improving Prolonged Trauma Care: Part One17