Summer - United States Special Operations Command

SHOULD WE TEACH EVERY SOLDIER HOW TO START AN IV?MAJ Robert L. Mabry, MC USA *; MAJ Peter J. Cuenca, MC USA tPreviously published in Military Medicine,. 2009 Jun;174(6):iii-v. Permission granted to republish in the JSOM.The recent mandate by the U.S. Army Training andDoctrine Command (TRADOC) requiring all soldiers enteringbasic combat training (BCT) after October 1, 2007 to be combatlifesaver (CLS) certified is an outstanding step to improvetraining across the Army in lifesaving first-aid skills. 1 However,requiring all Soldiers to be competent in placing an intravenousline and initiating treatment with IV fluids, per thecurrent CLS standards, may not be the best use of precioustraining resources in light of the most recent medical researchand battlefield experience.The outcome of a battle casualty will often be determinedby whomever provides initial care. In most cases thiswill be a fellow Soldier, not the medic. The CLS course wasdeveloped to bridge the gap between self-aid or buddy aid untilcare could be provided by the platoon 68W combat medic. 2The CLS concept has been further refined over the last decadeto reflect the concepts of TC3. Tactical combat casualty carefocuses on treating the leading causes of preventable battlefielddeath while minimizing the risk to first-aid providers andthe tactical mission. 3 The TC3 concept is possibly the mostsignificant advance in point of injury care since the distributionof the individual field dressing in the late 1800s. 4The most important battlefield first-aid skill is controllinghemorrhage, by far the leading and most preventablecause of battlefield death in modern warfare. Bellamy showed9% of those killed in action during the Vietnam conflict diedof potentially preventable extremity hemorrhage. 5 A similarfatality rate from compressible extremity hemorrhage in Iraqwas demonstrated by Cuadrado et al. 6 Proper tourniquet applicationis the most important method in controlling severehemorrhage in the tactical setting.Other lifesaving skills emphasized in the TC3 includeneedle decompression of a tension pneumothorax and airwaymanagement, the second and third leading causes of preventablebattlefield deaths, causing 4% and 1% of all fatal injuresrespectively 5,7The main purpose of performing IV catheterization inthe setting of trauma is to administer fluids or blood productsto treat hemorrhagic shock. Seven percent of patients on thebattlefield require aggressive resuscitation. 8 Current transfusionprotocols emphasize fresh whole blood and procoagulantsrather than crystalloids to restore organ perfusion, prevent thedilution of clotting factors, and avoid hypothermia. 8 For patientsin significant hemorrhagic shock, aggressive hemorrhagecontrol at the point of wounding, followed by expeditioustransport to surgical care is most important. Evacuation andsubsequent surgical management of noncompressible truncalhemorrhage should not be delayed by attempts to place an IV.In the management of shock, the traditional strategyof early fluid resuscitation beginning in the field and continuinginto the operating room has been challenged, specificallyin the context of penetrating thoracic trauma. In 1994, aprospective trial by Bickell et al. compared immediate versusdelayed fluid resuscitation in hypotensive patients with pene-trating torso injuries. They reported that patients in whom fluidswere restricted until arrival in the operating room hadlower mortality, fewer postoperative complications, andshorter hospital length of stay. 9 In a follow-up prospectivetrial, patients were divided into either restrictive resuscitation(goal systolic blood pressure (SBP) greater than 80mmHg)versus liberal resuscitation (goal SBP greater than 100mmHg).There was not a significant difference in mortality betweengroups but hemorrhage did take longer to control in the groupwith the liberal fluid strategy. 10These studies were largely responsible for significantchanges in the management of injured soldiers on the battlefieldand were adopted by American Military and Israeli DefenseForces. 11-15 In 2003, the term “hypotensiveresuscitation” was introduced in a article entitled, “Fluid Resuscitationin Modern Combat Casualty Care: LessonsLearned from Somalia.” 15 Current military prehospital doctrinenow emphasizes restricting IV fluids in casualties whohave controlled hemorrhage, normal mental status, and stablevital signs or even mild hypotension (systolic blood pressuregreater than 90). A relatively small percentage of all combatcasualties are likely to benefit from IV fluid resuscitation onthe battlefield.These include patients with significant hypotensionresulting from severe hemorrhage that has been controlled;and, those with hypotension or severe hemorrhage and a headinjury. All other casualties with uncontrolled hemorrhage andsigns of shock may be challenged with a very limited amountof IV fluid (l,000mL of Hextend). Further fluid administrationis likely to be detrimental. The practice of permissive hypotensionis designed to prevent “popping the clot” off an injuredvessels as well as diluting clotting factors with massiveamounts of crystalloid fluid.Intravenous placement is a skill that requires significanttime to acquire. In the current CLS course, the IV portionis the longest, most resource and instructor intensive block oftraining. This is precious training time that could be used fortactical casualty scenarios and practicing sustainable, lifesavingskills such as hemorrhage control techniques. In the civiliansector, basic emergency medical technicians (EMT-B) arenot taught IV insertion. The first level of civilian EMT to haveIV placement in their scope of practice is EMT-Intermediates.The national standard curriculum for EMT-I requires 300-400hours of classroom and field instruction after EMT -8 certification.EMT-I students are required to place a minimum of25 IVs on live patients of various age groups under instructorsupervision to be considered competent in this skill. 16 Thecurrent 2006 CLS Course Instructor Guide (Edition B, Subcourse IS00873) does not specify the number of successful IVcatheterizations required to certify a CLS in this skill. It is leftto the unit’s medical officer. Certification as a CLS will notmean these Soldiers are competent at placing IVs. At best itwill mean they are familiar with the procedure.64Journal of Special Operations Medicine Volume 9, Edition 3 / Summer 09