Summer - United States Special Operations Command

Casualties presenting in overt shock typically have difficultintravenous access. They are often extremely diaphoreticand their peripheral vasculature is constricted. Placement ofan IV in a trauma patient in a moving ambulance by an experiencedEMT-I or higher level provider takes 10 to 12 minutesand has a 10% to 40%, failure rate. 17 Paradoxically, starting anIV in those patients who would most benefit from limited fluidresuscitation will be extremely difficult for even the mostskilled medical provider. During a hostile tactical situationcombined with darkness, fatigue, and fear it will be very unlikelythat a Soldier without significant medical experience willbe able to place an IV under battlefield conditions. For thisreason, TC3 guidelines emphasize sternal intraosseous catheterplacement for fluid resuscitation. 18Insertion of an IV catheter is not without risks. Complicationsinclude local and systemic infections, deep venousthrombosis, thrombophlibits, catheter embolism, and injury toassociated nerves, tendons, and arteries. 19-21 Complications areinversely related to skill and experience of the medicalprovider.On the basis of the available literature and the lessonsbeing learned from both Iraq and Afghanistan, it is clear that IVplacement is not a critical lifesaving skill, while hemorrhagecontrol is. Training all Soldiers to start IVs without the requisiteunderstanding of the indications, contraindications, risks,and benefits of who would benefit from IV fluids and whocould be harmed, could result in many receiving unneeded ordetrimental care on the battlefield. If Soldiers spend the vastmajority of their first-aid training time learning IV placement,the most time-consuming skill in the CLS course, yet one thatdoes not save lives, which tool will they reach for under thestress of combat? Will Soldiers be killed by snipers as theywaste precious minute starting IVs? Will evacuation to lifesavingsurgical care be delayed while attempts to “get the IV”are made? Will proper tourniquet and dressing application beneglected while focusing on the more “technical” and “highspeed”IV insertion?While most Soldiers will not benefit from IV training,it may have a place in some units. Units operating far forwardwith little or no organic medical support such as Special OperationsForces (SOF) may benefit from this training. These unitsare often small and have the time and resources to train to ahigh standard in advanced first-aid skills.Many line commanders likely participated in “IV training”led by their unit medical officers during their formativeyears. Insertion of an IV on the “first stick” is considered bymany as the quintessential battlefield medical skill. It is not.Rapid hemorrhage control is. Additional medical training forall Soldiers is much needed. TRADOC has taken an excellentfirst step. Our battlefield commanders want robust first-aidtraining for our warriors. We must continue to synthesize thetactical and medical lessons from the present conflicts to guideour training. It is the duty of the AMEDD and military healthcareproviders to develop best practices of battlefield care andadvise our combat commanders how to implement them so togetherwe can save lives on the battlefield and accomplish theArmy mission.REFERENCES1. Glasch MA: IV injections added to BCT requirement The Leader,TRADOC News Service. Available at www.tradoc.army.mil/pao/TNSarchives/September%2007/091407-1.html: Accessed September 14,2007.2. FM 4-02.4. APPENDIX C Role of the Combat Lifesaver.3. Butler F: Tactical Combat Casualty Care: Combining good medicinewith good tactics. Editorial J Trauma Inj Infect Crit Care 2001;54(Suppl 5) S2-3.4. Mabry RL. McManus JG. Prehospital advances in the management ofsevere penetrating trauma. 2009 (in press)5. Bellamy RF: The causes of death in conventional land warfare: Implicationsfor combat casualty care research. Mil Med 1984; 149(2):55-62.6. Cuadrado D. Arthurs Z. Sebesta J, et al: Cause of death analysis at the31st Combat Support Hospital during Operation Iraqi Freedom. Presentedat the 28th Annual Gary P. Wratten Army Surgical Symposium.Silver Spring, Maryland. Walter Reed Army Institute of Research. May2006.7. McPherson JJ, Feigin DS, Bellamy RF: Prevalence of tension pneumothoraxin fatally wounded combat casualties. J Trauma 2006;60:573-8.8. Beekley A. Starnes B, Sebesta J: Lessons Learned from modern militarysurgery. Surgical Clinics of North America, Volume 87, Issue 1,February 2007.9. Bickell W, Wall M. Pepe P, et al: Immediate versus delayed fluid resuscitationfor hypotensive patients with penetrating torso injuries. N EnglJ Med 1994; 331(17): 1105-9.10. Dutton R. Mackenzie C, Scalea T: Hypotensive resuscitation during activehemorrhage: Impact on in-hospital mortality. J Trauma 2002: 52(6):1141-6.11. Holcomb J: Fluid resuscitation in modern combat casualty care: Lessonslearned from Somalia. J Trauma 2003: 54(Suppl 5): S46-51.12. Champion H: Combat fluid resuscitation: Introduction and overview ofconferences. J Trauma 2003; 54(Suppl 5): S7-12.13. Butler F. Hagmann J. Richards D: Tactical management of urban warfarecasualties in Special Operations. Mil Med 2000: 165(Supp14): 1-48.14. Krausz M: Fluid resuscitation strategies in the Israeli army. J Trauma2003; 54(Suppl 5): S39-42.15 Rhee P, Koustova E, Alam H: Searching for the optimal resuscitationmethod: Recommendations for the initial fluid resuscitation of combatcasualties. J Trauma 2003: 54(Suppl 5): S52-62.16. NREMT National Standard Curriculum for NREMT EMT-Intermediate:1998. Available at http://www.nh!sa.dot.gov/peoplc/injury/ems/EMT-Uindex.html.17. Lewis F: Prehospital intravenous fluid therapy: Physiologic computermodeling. J Trauma 1986: 26(9): 804-11.18. Butler FK, Holcomb JB. Giebner SD, et al: Tactical Combat CasualtyCare 2007: Evolving Concepts and Battlefield Experience. U.S. Armyinstitute of Surgical Research Technical Report. March .10. 2007.19. Bregenzer T. Conen D, Sakmann P, Widmer A: Is routine replacementof peripheral intravenous catheters necessary? Arch Intern Med 1998:158: 151-6.20. Levine R, Spaite D, Valenzuela T. Criss E, Wright A., Meislin H:Comparison of clinically significant infection rates among prehospitalversus in-hospital-initiated IV lines. Ann Emerg Med 1995: 25:502-6.21. Elliot T, Faroqui M: Infection and intravascular devices, Br J HospMed 1992: 48: 496-503.Previously Published 65