Spring 07 front cover - United States Special Operations Command

CRNATasked to support the objective as a member ofground force element. With knowledge that other medicalproviders (two assault Medics, battalion surgeon,and FST ER) were equipped with hemostatic dressings,tourniquets, and other “bleeding stoppers.” I chose tobring two units PRBC, IV start kit, ETT and laryngoscope,blood tubing, two bags of Hespan®, the EnflowFluid Warmer with one battery, three 2.4mg vials of FactorVII, and an HPMK. I felt the outside temperature ofless than 40 degrees would aid in keeping blood and FactorrVIIa cold.ER and CRNA informed of PT #2, but decisionwas made by Medic to take the patient who was stablefor move to exfiltration HLZ due to proximity to HLZ.The ER physician initially saw and assumed care for patient#2 at the exfiltration HLZ.PT #1 was brought to ER and CRNA by the battalionsurgeon and senior Medic for purpose of “bloodand Factor VII.” Patient was responsive and alert, hada palpable radial pulse, demonstrated tolerable pain, andwas wrapped in two blankets with patent IV. The patientwas given oral fentanyl and IV Invanz by the AssaultMedic. An initial head to toe assessment showedRUE and left lower extremity (LLE) wounds with cleandressings. The most significant injury was a penetratingwound to the right lower back. The abdomen wasrigid and the HR was noted to be in the 130s. A decisionwas made to take the patient out of the blankets and intoan HPMK. Also, due to the torso injury, the patient wasgiven 4.8mg of Factor VII (approximate wt 50kg). Oneunit of PRBCs was started and administered through theEnflow fluid warmer. The tactical situation did notallow for further medical treatment.PT #1 then carried over 1 kilometer to exfilHLZ. This took over an hour due to terrain and enemycontact. This patient was assessed frequently over thisperiod, and remained alert with palpable radial pulse. Attime of exfil, HR was in the 100s; there was no otherchange in status.On CH-47, able to get oxygen saturation of 98to 99, with HR in the 100s. Approximately 1½ hourafter started, PRBC completed. Started Hespan® at100ml/hr. Patient continued to verbalize tolerable pain;time of flight one hour; patient remained stable.At arrival airfield the patient was escorted bythe CRNA from the CH-47 to the ambulance to traumabay. The patient was turned over to FST surgeon, physicianassistant, and hospital staff. Patient remained responsive,vital signs were; temp - 36.1C, BP - 110/70,HR - 90s, SpO2 - 98, respirations - 20s. The HGB was12; no other labs recalled. Patient was taken to OR forexploratory lap.Keeping this patient warm after penetratingtrauma in sub 40 degree temps was a definite factor in thestatus of patient upon arrival to CSH. The ground forcemedical team did this with use of an HPMK and givingfluids via Enflow warmer. The simplicity of the warmerallowed the CRNA to deliver an adequate amount of fluids(PRBC) to keep the patient from shock without worryof re-bleeding. The decision to use Factor VII wasproven excellent as reported by the FST surgeon, whostated the patient had a liver laceration.LESSONS LEARNEDKEY NOTES1. PT#1 stabilized and improved with care given duringcare under fire phase; actually resuscitated adequatelyin field. Able to give warm blood and Factor VII dueto its presence forward, especially given tenuous tacticalsituation. A CRNA should always be consideredas a member of a resuscitation team on ground whenFST not first surgical option.2. HPMK proved extremely effective in patient warmingin this case.3. Do not hesitate to restrain violent patients during transportto protect force and facilitate care, even youngones.4. Provide lots of pain medications after tourniquet application,if patient tolerates and is stable.5. Do what you can, as fast as you can and allowed byground situation, but be ready to move with patientand kit on moment’s notice; not as easy as it sounds.6. Practice with red or blue light.AUTHORS COMMENTS: This AAR emphasizes the benefitsof thorough mission analysis by the ground forcemedical element and the medical augmentees. The augmenteesare being brought on target to do just that, “augment”the ground force. The personnel in this scenariodid that! Had the ER physician and CRNA not broughtthe tools to allow them to utilize their skill set, they wouldhave been no value added to this mission and quite possibly,a detriment. Hypothermia has been shown in recentliterature to be a major independent variable inmortality, blood products required, etc. The forward useof blood and Recombinant Factor VIIa is a very sensitivetopic with the conventional medical community. ThisAAR clearly demonstrates that there is a place for themon the battlefield. It appears as if the appropriate indicationswere met in this case and the products were successfullyused. We don’t have any issues with this, but ILessons Learned 31