Prolonged Field Care (PFC): Lessons Learned from SOF

Prolonged Field Care (PFC): Lessons Learned from SOF
COL Sean Keenan, MD FAAEM FAWM Financial disclosures: The presenter has nothing to disclose.
DISCLAIMER The opinions and/or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the view of USSOCOM, the Department of the Army or the Department of Defense . Financial disclosures: The presenter has nothing to disclose. PART 1: THE PROBLEM Case Study South Sudan Cases (compiled by SOCAFRICA Surgeons Cell), December, 2013: Situation: At approximately 0815Z (1015L) while conducting a Noncombatant Evacuation Operation (NEO) of the U.S. Embassy three CV-22 aircraft carrying SOCCENT Crisis Response Element (CRE) came under small arms fire when they attempted to land at the Bor civilian airport in South Sudan, East Africa.All three aircraft suffered heavy damage during the small arms attack.Four U.S. personnel sustained injuries on one of the aircraft. Casualty Report: Patients will be referred to as Patients 1, 2, 3, and 4 for the duration of this document. Patient 1: Active Duty (AD) Service Member (SM) sustained a Gun Shot Wound (GSW) to left buttock, above the gluteal crease, through to left thigh with profuse hemorrhage. Patient 2: AD SM sustained a GSW to right mid-thigh. Patient 3: AD SM sustained a GSW to left hip through to left thigh. Patent 4: AD SM shrapnel wound to left lower back. Case Study (cont.) Onboard the CV-22, Patient 4 (Navy SEAL E-5 Corpsmen) treated Patients 1, 2, and 3 after receiving small arms fire during over-flight of the airstrip.Each had a GSW to a lower extremity.Patient 4 applied tourniquets to Patients 2 and 3, and hemorrhage control via manual pressure to Patient 1.Within 15 minutes of the attack, Patient 4 triaged the patients and immediately relayed injuries through the aircrew to the Special Operations Forces Medical Element (SOFME) located at Entebbe International Airport in Uganda (2 hours south of incident). Patient 1 was the most critical due to wound proximity and sustained bleeding. The SOFME requested and received blood types for patients 1, 2, and 3, and collected donor fresh whole blood from a walking blood bank. Patient 4 administered fentanyl lozenges to Patients 1, 2, and 3.Due to heavy damage to the aircraft, the CV-22s were forced to land at Entebbe International Airport (not the planned airfield at Djibouti). Case Study (cont.) At approximately 1130L (H+75 minutes), the CV-22s carrying casualties arrived on the commercial side of Entebbe International Airport and were met by United States Air Force Para Rescue Jumpers (PJs). The CV-22s then relocated to the military side of the airport and were met by a team of six US Military providers.The group included the SOFME Team of one USAF Flight Surgeon (FS) and one USAF Independent Duty Medical Technician (IDMT) which was assisted by a United States Army (USA) Special Forces Medical Sergeant (18D); Also present were a United States Navy (USN) Physician Assistant (PA) with two medical technicians who were passing through Entebbe at the time.The patients were offloaded from the CV-22s, and Patients 1 and 2 were loaded into a converted vanthree rows of seats were removed and replaced with two litters. Case Study (cont.) Treatment provided in Entebbe included:
Patient 1: Patient 1 was given one gram of Tranexamic Acid (TXA) (and) two units of whole bloodone obtained from a donor using walking blood bank protocol in Entebbe and the second was received from a PJ and administered by the USAF IDMT.Vital signs indicated Class III hemorrhagic shock (low blood pressure, reduced pulse pressure, and HR greater than 120 beats per minute). Patient 2: Patient 2 had a tourniquet on the right thigh at arrival (and) it was determined that the patients condition necessitated the placement of a second tourniquet to control hemorrhaging.Patient was tachycardic but normotensive, indicating a Class II hemorrhagic shock.He was in extreme pain from GSW and tourniquet.the wound packed with combat gauze and secured with ACE wrap. Patient 3:Patient 3 was found to have palpable pedal pulses due to improperly tightened tourniquet but was left as is since hemorrhage control seemed adequate. Patient 4: Patient 4 (The Navy SEAL Corpsmen) was evaluated by the 18D and deemed that treatment could wait until arrival at Nairobi General Hospital. Case Study (cont.) A USAF C-17 was preparing for departure on an unrelated mission and was redirected to transport the four patients to HKJK (instead of the pre-planned C-130) for further treatment at Nairobi General Hospital (Kenya).The aircraft departed at 1200L (H+1:45) with all four patients, along with the USAF FS, the IDMT, the 18D, and the Navy PA for an approximately one hour flight to Nairobi.Patient 2 was floor-loaded first on the aircraft and then Patients 1 and 3 were loaded onto litter stanchions. Treatment en-route to Kenya included: Patient 1: Patient 1 was given a femoral block with lidocaine for pain control, which provided only minimal relief.Patient 1 remained stable (after 2x units FWB) throughout the flight though pain was only partially controlled. Patient 2: Patient 2 was administered 1 ml of Ketamine (500mg/5mL) = 100mg IM in the left thigh at the Entebbe airfield while waiting for departure.Patient descended into delirium while on the C-17 and remained delirious during the course of the flightafter the IVs were patent, one gram of TXA was administered with the initiation of 500mL of normal saline. Case Study (cont.) Treatment enroute (cont.):
Patient 3: During the flight Patient 3 became somnolent and then unconscious, but breathing, likely secondary to the Versed (midazolam) given prior to administration of 100 mg of Ketamine IM.An NPA was placed and oxygen was given via an emergency O2 tank and aviator mask.Patients Sp02 and respirations continued to drop, so he was ventilated via bag valve mask.Patient 3 awoke after administration of the benzodiazepine reversal agent, Romazicon, and did not require respiratory support the remainder of the flight. The C-17 arrived in Kenya at approximately 1315L (H + 3 hours).Ambulances took the patients to Nairobi Hospital, where the team of surgeons and anesthesia personnel were waiting.Transport time from aircraft to hospital was approximately 45 minutes.Approximate time from initial injury to arrival at the Nairobi Hospital emergency department was four hours. Case Study (cont.) Kinda makes you pause Realistic? Probable?
Textbook PFC scenario Fog of War Planes, trains, and automobiles Multiple patients Ad hoc CASEVAC TCCC executed flawlesslybut then what??? OBJECTIVES Define Prolonged Field Care Introduce SOCOM PFC Working Group Discuss Lessons Learned in analysis and training of PFC in SOF Iraq Afghanistan Memphis Raleigh Atlanta New Orleans Africa: Tyranny of Distance Current Paradigm WHY? Non-TCCC Events Those things which keep medics awake at night.
Examples include: Accidental GSW ATV rollover with suspected TBI Fall from roof with blunt lung injury MVA with Pelvic fracture House-fire with smoke inhalation 40% TBSA burn Electrocution ACS Near drowning Envenomation What should we focus on? Scope of Practice TCCC vs. PFC
TCCC: combat trauma Practitioner (lowest level): Combat Life Saver, Combat Medic WITHIN doctrinal planning guidelines PFC: all-causes mortality or significant morbidity in austere environments (Opens the aperture on medical and traumatic conditions) Practitioner (lowest level): Independent SOF practitioner (SOCM, 18D, IDMT, IDC); Physician/PA deployed for FID or Humanitarian Assistance (non-combat roles) BEYOND doctrinal planning guidelines DEFINITION Field medical care, applied beyond doctrinal planning time-lines, by a SOCM or higher, in order to decrease patient mortality and morbidity. Utilizes limited resources, and is sustained until the patient arrives at an appropriate level of care. The SOF Truths Humans are more important than Hardware.
Quality is better than Quantity. Special Operations Forces cannot be mass produced. Competent Special Operations Forces cannot be created after emergencies occur. Most Special Operations require non-SOF assistance The PFC Truths If you think you need a surgeon or intensivist in the Field, put one there. No magic piece of kit will give you the capability. PFC is not a qualification or skill set, it is an operational problem or situation that you find yourself in. Competent (PFC medical) Forces cannot be created after emergencies occur. Most Special Operations require non-SOF assistance (especially if you have a smaller deployed force). PFC Working Group and Lessons Learned SOCOM PFC Working Group
Started at SOMSA, December, 2013 with the Extended Care Working Group Interested individuals met over two lunchtime sessions From this meeting a list of priorities emerged, as well as WG memberlist OVER THE PAST 24 MONTHS: Established Steering Committee: 2 docs, 3 medics list grew to over 150 names Representatives from all major Commands in SOF, partner agencies, civilian and military academic faculty and international representation Established websites (SOMA and independent site) and multimedia education and discussion tools SOCOM PFC Working Group
Mission: develops a forum for discussion, education and training, and suggests medical efforts to better prepare Special Operations Forces for medical and operational planning, and execution of medical evaluation, treatment and evacuation, of critical and serious casualties, managed in an austere environment. PFC WG Products and Projects
Position Papers, Guidelines, PFC-specific References, Podcasts Website/discussion forums Established Journal of Special Operations Medicine (JSOM) Ongoing Series Collaboration with JTS/ISR Case series for epidemiologic analysis Pre-hospital Clinical Practice Guidelines (CPGs) Burn, Crush Injury, Pain Control, TBI Lessons Learned TCCC is the foundation of care for PFC
Master the Basics TCCC absolutely decreases mortality TCCC is the what (to do), PFC is the why (we do it) What = technician(EMT-B, CLS) Why = clinician (independent practitioner) If you dont know TCCC, dont even bother trying to learn PFC Prioritize your medical training Lessons Learned (cont.)
PFC scenarios require a higher level of care => independent practitioner Medical Planners, Operations Personnel and Commanders must be informed of the risk of operating in austere environments Basic medics (68W) should not be expected to succeed in PFC scenarios without significant back-up PFC core skills include secondary survey and problem list development TCCC training has de-emphasized the history/physical exam/problem list You must identify your targets before you can engage them Lessons Learned (cont.)
By definition, the provider on the ground will be overwhelmed.We must develop systems which model current medical practice, to include: Decision aides Update references: TMEPs, SOF Med Handbook, Ranger Handbook Clinical Practice Guidelines (CPGs) Using existing technology Tele-consultation How do you call Training Technology Who do you call?(VC3, TSOCs, unit docs) Lessons Learned (cont.)
Mission planning by the medics must be much more comprehensive than previous experiences Evac chain Referral facilities Logistics Multiple references in blogs and posts on website Continuous evaluation and re-evaluation Trending of vital signs is essential in any serious or critical patient Blogs, decision aids, patient care flowsheets available on website Lessons Learned Summary
Many of the products on the website address previous requirements PFC is a new operational reality for many of our deployed forces both SOF and conventional Many of the PFC Capabilities are not new or unique, but require a shift in focus of training once you have Mastered the Basics (TCCC) Ref: PFC Position Papers (Capabilities and Operational Context of PFC) Questions? PFCare.org