Lessons Learned from a Decade of Conflict - Boekje Pienter

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Evacuation & TransportationTraditional manual carries and drags of non-ambulatory casualtiesdepicted in numerous texts simply aren’t effective when rescuer andcasualty alike are outfitted in full combat gear. Additionally, a tacticalunit carrying evacuation platforms/stretchers into live combat cannegatively impact maneuverability if the selected platform is too bulkyor heavy for a single person to carry effectively.Talon II® 90CCollapsibleHandle LitterThe Talon II by NARprovides the material solutionfor this issue. Unlike non-rigid litters,the Talon provides a measure of patient safetyby preventing excessive body movement, securingthe casualty to the device via the integrated safetystraps. In addition, over most terrain, moving a rigid litter requiresmuch less effort than other types of platforms. The litter can then besecured directly to a vehicle or to a traditional movement gurney. Collapsiblerigid litters are also easily stored in vehicles and occupy relativelylittle space.Until fairly recently, hypothermia was a major source of morbidityamong combat casualties. Even though ambient temperatures in combatareas often exceeded 100º F during daytime hours, casualties whohad been previously exposed during evaluation and treatment werearriving at Combat Support Hospitals and Forward Surgical Teamsprofoundly hypothermic.One retrospective review revealed that 18% ofcasualties evacuated to one hospital arrived with coretemperatures of less than 36ºC. 23 This study showedthat the presence of hypothermia was an independentpredictor of operative management,surgical procedures, Factor VIIa use and mortality,with temperatures of less than 34ºC associatedwith a near 100% mortality rate.Acknowledging that active re-warming capabilityat the point of injury during tactical operationsis not logistically feasible, military medical researchersturned their efforts toward hypothermia prevention.Traditional “space blankets” were found not to be effective enough;soldiers needed a small, lightweight product that could be easily carriedin a medic’s aid bag, preferably without an external power source.The result was a system that incorporates a heat source with an improvedinsulator. 24NAR’s Hypothermia Prevention Management Kit (HPMK) is avacuum-sealed compact kit that has proven very effective in preventinghypothermia. It was selected as one of the hot products at the 2008EMS Today Conference.Educating military rescuers on the importanceof hypothermia and employing an effective kitvirtually eliminated the incidence of hypothermiarelatedcomplications and mortality. The HPMK’scompact size and proven performance makes it anideal candidate for consideration as a contingencyitem in civilian emergency vehicles and an importantasset to have on hand in large quantities foruse at MCIs.MedicinesAnother challenge encountered during tacticaloperations: adequately medicating casualtiesin a timely manner. When casualty evacuationdelays occur, the timely administration of antibioticsis crucial for the prevention of subsequentwound infections.One product that addresses both moderatepain control and antibiotic prophylaxis is theCombat Wound Pill Pack, a “homemade” packetthat Special Operations Forces use consistingof acetaminophen, meloxicam and a flouroquinolone.The combination of acetaminophen andmeloxicam provides analgesia for mild to moderatepain without altering the sensorium, thusallowing the operator to continue participating inthe tactical mission.Military medical providers have also successfullyused oral trans-mucosal fentanyl devicesfor pain management during combat operations.These devices have the advantage of rapidonset of action, significant pain-control properties,not requiring IV/IO access and the ability tobe self-administered and titrated. 25 Although notrequired for every trauma patient, such devicescertainly bear consideration for use as a viableoption in civilian prehospital and emergencydepartment pain-control protocols.VacuumSealedPackageSelf-HeatingShell LinerHPMKHypothermia Prevention& Management Kit22 War on TraumaJournal of Emergency Medical Services
ConclusionMilitary medicine has contributed to manyadvances in prehospital trauma care by applyingsound medical principles to account for thechallenging tactical environment. These advanceswere achieved due to the requirement to optimizecasualty care while simultaneously minimizing theimpact on ongoing combat operations. Althoughall these applications may not be appropriatefor the contemporary civilian environment, weshould examine current military tactical medicaltechniques and procedures for possible crossoverbenefit to our civilian trauma patients, or as areasthat may require further study.Dr. Jeffrey Cain is an emergency medicine physicianpracticing in McKinney, Texas. He is a graduate ofWest Point and the Uniformed Services Universityof the Health Sciences, with service in the 75thRanger Regiment as an infantry officer and lateras a battalion physician. Other active-duty Armyassignments included academic director for theArmy Combat Medic Course and research physicianwith the U.S. Army Institute of Surgical Research.He has conducted extensive TCCC training forthe Department of Defense and other governmentorganizations, and is currently serving as the vicechairman for the Committee on TCCC. Cainhas reported receiving honoraria and/or researchsupport, either directly or indirectly, from the sponsorof this supplement, North American Rescue.Dr. Jeff Cain will be a featured speakerat the EMS Today Conference inBaltimore, Maryland, March 26–29, 2009.References1. Butler FK, Hagmann JH, Richards DT: “Tacticalmanagement of urban warfare casualties in specialoperations.” Military Medicine. 165(4 Suppl):1–48,2000.2. Butler FK Jr, Hagmann J, Butler EG: “Tacticalcombat casualty care in special operations.” MilitaryMedicine. 161(Suppl):3–16, 1996.3. McSwain NE, Salomone JP (eds): PreHospitalTrauma Life Support Manual, 6th edition. Mosby:Akron, Ohio, 2006.4. Butler FK Jr, Holcomb JB, Giebner SD: “Tacticalcombat casualty care 2007: Evolving concepts andbattlefield experience.” Military Medicine. 172(11Suppl):1–19, 2007.5. Beekley AC, Sebesta JA, Blackborne LH, etal: “Prehospital tourniquet use in Operation IraqiFreedom: Effect on hemorrhage control andoutcomes.” Journal of Trauma. 64(2Suppl):S28–S37, 2008.6. Kragh JF Jr, Walters TJ, Baer D, et al: “Practical use of emergencytourniquets to stop bleeding in major limb trauma.” Journal of Trauma.64(2 Suppl):S38–S50, 2008.7. Walters TJ, Wenke JC, Kauvar DS, et al: “Effectiveness of self-appliedtourniquets in human volunteers.” Prehospital Emergency Care. 9(4):416–422, 2005.8. Grimes M, Rocheleau DN: Analysis of pressure distribution of armybandages. University of South Carolina Department of MechanicalEngineering Technical Report; September 21, 2007.9. Wedmore I, McManus JG, Pusateri AE: “A special report on the chitosanbasedhemostatic dressing: Experience in current combat operations.”Journal of Trauma. 60(3):655–658, 2006.10. Ward KR, Tiba MH, Holbert WH: “Comparison of a new hemostatic agentto current combat hemostatic agents in a Swine model of lethal extremityarterial hemorrhage.” Journal of Trauma. 63(2):276–284, 2007.11. Rhee P, Brown C, Martin M: “QuikClot use in trauma for hemorrhagecontrol: Case series of 103 documented uses.” Journal of Trauma.64(4):1093–1099, 2008.12. Schwartz R, McManus J, Hill G: “Supraglottic devices in tactical airwaymanagement: A comparison of the King Laryngeal Tracheal device and theCombitube in Army combat medic students.” Paper presentation, AnnualMeeting of the National Association of EMS Physicians, 2008.13. Russi CS, Miller L, Hartley MJ: “A comparison of the King-LT toendotracheal intubation and CombiTube in a simulated difficult airway.”Prehospital Emergency Care. 12(1):35–41, 2008.14. Bellamy RF: “The causes of death in conventional land warfare:Implications for combat casualty care research.” Military Medicine.149(2):55–62, 1984.15. Holcomb JB, McMullin NR, Pearse L: “Causes of death in U.S. SpecialOperations Forces in the global war on terrorism 2001–2004.” Annals ofSurgery. 245(6):986–991, 2007.16. Zengerink I, Brink PR, Laupland KB: “Needle thoracostomy in thetreatment of pneumothorax in trauma patients: What size needle?” Journalof Trauma. 64(1):111–114, 2008.17. Harcke HT, Pearse LA, Levy AD: “Chest wall thickness in militarypersonnel: Implications for needle thoracentesis in tensionpneumothorax.” Military Medicine. 172(12):1260–1263, 2007.18. Givens ML, Ayotte K, Manifold C: “Needle thoracostomy: Implicationsof computed tomography chest wall thickness.” Academic EmergencyMedicine. 11(2):211–213, 2004.19. Beekley AC, Starnes BW, Sebesta JA: “Lessons learned from modernmilitary surgery.” Surgical Clinics of North America. 87(1):157–184, 2007.20. Dubick MA, Holcomb JB: “A review of intraosseous vascular access:Current status and military application.” Military Medicine. 165(7):552–559, 2000.21. Calkins MD, Fitzgerald G, Bentley TB, et al: “Intraosseous infusiondevices: A comparison for potential use in special operations.” Journal ofTrauma. 48(6):1068–1074, 2000.22. Frascone RJ, Jensen JP, Kaye K: “Consecutive field trials using two differentintraosseous devices.” Prehospital Emergency Care. 11(2):164-171, 2007.23. Arthurs Z, Cuadrado D, Beekley A, et al: “The impact of hypothermiaon trauma care at the 31st combat support hospital” American Journal ofSurgery. 191(5):610–614, 2006.24. Winkenwerder W: “ASDHA Policy Letter on Hypothermia Prevention andTreatment.” Feb. 16, 2006.25. Kotwal RS, O’Connor KC, Johnson TR, et al: “A novel pain managementstrategy for combat casualty care.” Annals of Emergency Medicine.44(2):121–127, 2004.Elsevier Public Safety War on Trauma 23
Page 1 and 2: Lessons Learned from a Decade of Co
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Lessons Learned from a Decade of Conflict - Boekje Pienter

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