# After Action Review



## MedCorps (20 Apr 2008)

This is from a discussion on another means.  I reckoned it might be of interest to some of the CFMS pers here to talk about.  Good lessons learned from it.  

Mods:  No fear it is all open-source.  

Situation: 

Special Operations Task Force (TF) conducts an assault to kill or capture a high value target (HVT). The objective (OBJ) was a small single story house located within a forested area with single road access. TF elements inserted via Special Operations aviation (SOA) aircraft. The casualty evacuation (CASEVAC) plan was a single MH-60 that would be located in a field approximately 500 meters south of the OBJ. Due to the increased risk and concerns with landing zone (LZ) and fast rope points, an additional TF Medic accompanied the assault.

ACTION ON THE OBJ:

Immediately upon commencement, two previously unidentified fences surrounding the OBJ delayed the assault. A driveway channelized the ground element on approach and a parked vehicle further channelized the troop into what became the primary cone of fire. Upon entry the TF was engaged with AK fire and immediately sustained 4 x friendly wounded in action (FWIAs). Two of the three enemies were killed immediately, while a short fifteen second firefight killed the remaining shooter.

ASSESSMENT & TREATMENT (FIRST MEDIC’S PERSPECTIVE):

On the call of wounded, the other Medic and I moved to the target building. FWIA #1 Sustained a GSW that entered under the left armpit in the mid-axillary line that appeared to have severed some axillary vasculature. The entrance wound was approx 1 to 2cm wide with a large racquetball-size cavity behind
it. I managed to clamp one of the bleeding vessels by palpation with a set of large hemostats. I continued to work on obtaining control of the axillary wound while the second Medic started exposing the chest. A third Soldier exposed the arm and found a GSW to the left bicep. There was significant bleeding from the wound and I told another Soldier to put a combat application tourniquet (CAT) on that arm, and he did an excellent job of getting the CAT in proper position and stopping the bleeding. *I was wounded while entering the building and at this point was unable to continue helping due to blood loss and some shock-like symptoms and told my fellow Medic that he had to manage the bleeder.*

ASSESSMENT & TREATMENT (SECOND MEDIC’S PERSPECTIVE)

On the call of wounded, Medic One and I moved to the target building. Medic One was the first to arrive
and began treatment. He had removed the body armor and was trying to gain hemostasis on the left axillary wound with a pair of hemostats. The injuries and treatments were as follows:

FWIA #1 (everything is the same up to the point when the first Medic could not continue)
Just prior to taking over for Medic One I performed a cricothyroidotomy to gain control of the airway. I used a 6.0 cut down endotracheal tube and secured it with 550 cord. Medic 1 told me to take over the bleeder because he had been shot. I moved over to FWIA #1’s right side and started trying to palpate the bleeder to get a clamp on anything pulsing. After finding a large area that I could palpate a flow of blood, I decided I needed to open up the wound to the cavity and try to get eyes on the bleeders. I did a three-pointed star pattern from the initial bullet hole. After this, a large cavity opened up and I visualized no independent bleeders; however, what was exposed was a large area of severely devitalized tissue along the chest wall and upper axillary area that was bleeding severely. With the help of another Soldier, I wiped away as much blood as possible and applied two Hemcon dressings that we tore in half and started to line the chest wall and axillary area. We then started to pack the hole cavity with Kerlix trying
to build a “ball” putting pressure on the chest wall and upper axillary area, and rotated the arm down using the shoulder to put pressure on the “ball” of Kerlix. We secured the arm with a cravat looped around FWIA #1’s wrist and then tied around his thigh trying to keep the shoulder over the ball and maintaining traction. I was able to visualize some of the white Kerlix and this seemed to tamponade the bleeding. I then rolled FWIA #1 to check the down side and found an exit wound 1 to 2cm in diameter in the mid-thoracic area of the left chest just lateral of the spine. I applied an Asherman chest seal to the exit wound and it was effective. Another Soldier opened the litter and we then placed FWIA #1 on to the litter and strapped him in. We moved to the LZ where Medic One, FWIA #1, and I were loaded onto a MH-60 and took off for the CSH. Immediately on loading we began to bag FWIA #1 with a bag valve mask (BVM) and O2. The flight ATP tried several times to get his oxylator working properly; however,
it was not functioning. I continued to bag FWIA #1 and the flight ATP conducted a therapeutic decompression to the left chest. The packing in the axillary was holding and there was no hemorrhaging. When reassessing the pulse in the aircraft it seemed to fade in and out; at one point chest compressions were started and when reassessed the pulse was back and we continued to monitor FWIA #1 for the flight.

FWIA#2 received a non-debilitating ricochet to the left forearm. The intact bullet was buried within the dermis and later removed with secondary closure upon return to base. Post wound prophylaxis included Gatiflaxacin 400mg qd x 7d.

FWIA #3 received minor shrapnel to the face when his weapon was hit while returning fire. The shrapnel
was removed, and the area irrigated and debrided accordingly, and followed up daily for s/s of infection.
Medic One was hit in the medial aspect of the right forearm by an AK round which tracked up the length of the arm and left only ulnar innervations to the right hand. He had an estimated 500cc estimated blood loss before requiring treatment. Another Soldier placed an effective tourniquet that held until arrival at the CSH.

PROGNOSIS

Upon arrival at the CSH, the ER team immediately obtained hemostasis surgically on FWIA #1. Six units of PRBCs where used in regaining what the doctors considered a stable enough condition to move to surgery. While in surgery FWIA#1 went through another seven units of PRBCs, but the wounds were so catastrophic that he died while  on the operating room table.

Medic One underwent surgical debridement of his wound and was able to return to duty after a period of convalescence and rehabilitation.

LESSONS LEARNED (MEDIC ONE’S PERSPECTIVE)

1. You MUST treat yourself first! My wound and my blood loss severely affected my abilities on target to the point where I had lost and regained consciousness twice. You are no good to anyone and you are not losing any time or showing any weakness to ensure you are treated first so that you are ABLE to be an asset to your casualties and your unit.

2. When we needed to pack this wound there was no question as to the speed and large amount of Kerlix we would need, and the crinkle Kerlix did not provide either. Crinkle Kerlix is great for nice compact bleeder kits but it did not provide the same volume and speed as a noncompressed Kerlix would have. It is also very difficult to unroll in a single handed scenario.

3. Don’t attempt to clamp a bleeder you can’t clearly identify. I initially located the primary axillary bleeder on FWIA #1 and attempted to clamp it with minimal success; we then decided to pack that area for more effective hemostasis. It was a bowl-like wound and that should have been the initial treatment in the first place; blind clamping in a field environment does not work.

4. Don’t be proud; consider the two Medic option. Initial planning called for all personnel to be fast roped into separate and very undesirable landing points and I knew that if anything happened it would probably be significant. But as target analysis progressed we realized that we would not have the speed and surprise normally enjoyed, thereby increasing the threat level. Additionally, this was an upper level terrorist leader, which we have found not only to be more prone to a fight, but a likely body bomb wearer – which he was.

5. Brevity codes: We use CPR (critical, priority, and routine) for our evacuation calls. They worked! After infiltration, the air package was moving to a lager site but before arriving they heard over the radio that a critical casualty had been sustained. The CASEVAC pilots immediately returned to the CASEVAC LZ, saving everyone time and coordination. Upon review of the Tactical Operations Center (TOC) log it was 26 minutes from the report of the injury to touchdown at the CSH, a very respectable achievement considering the distance and situation.

6. The present chest plates work. Counting the fatality, four friendlies sustained hits to the chest or side plates, with all rounds being effectively stopped and no detriment to shooter effectiveness in the fight.

7. The absolute minimum size of a cricothyroidotomy should be a 7.0. In this instance, a 6.0 was not sufficient. The oxillator is set to stop respirations when a tidal resistance pressure is met; in this case it was the diameter of the tube that prevented the oxillator from working.

ATP Comments: Medics do get wounded! You must be ready for every contingency. Knowing what assets for evacuation you have and where they are is key. Rehearsing and everyone knowing the plan was instrumental in the success of this mission. If you find something works like the medics did here with the critical/priority/routine (CPR) designation of casualties, and everyone is on board with it, go for it. MAKE SURE EVERYONE IS ON THE SAME SHEET OF MUSIC before undertaking a change in well known military designation. This is relatively easy with a small task force and people who are trained to think outside of the box. Look at some of the medical procedure and equipment lessons learned. Armed with these types of lessons learned you should be able to develop great and meaningful training. Lessons like this can also help you pack your aid bag.

Enjoy, 

MC


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## Armymedic (20 Apr 2008)

I would just like to add to the lessons learned above that attempting to "clamp" a bleeder is inefficient given the homeostatic dressing that are currently in production and to come out in the near future. Just like he said:


> It was a bowl-like wound and that should have been the initial treatment in the first place; blind clamping in a field environment does not work.



Have a bullet entry wound bleeding profusely and can't pack it? Take the small wound and make it bigger, that way all the bleeding treatments that you have learned will definitely work. (medics only...NOT recommended for TCCCs)

Further, Kerlix is not designed to be balled up. Take control of the free end, throw the rest over your shoulder and finger it into the wound. Then continue to finger jam it all into the wound until you can not fill it up anymore...then put HARD pressure on the wound for 3-5 mins. That will work to control the vast majority of bleeds.


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## MedCorps (21 Apr 2008)

Here is a good little video on packing a bleed: 

http://www.tacmedsolutions.com/blog/?p=26


It provides an alternate solution to the "throw the rest over your shoulder" method described above (although I am sure that works also). 

Enjoy, 

MC


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## Armymedic (21 Apr 2008)

A viable solution, although it lacks the agressiveness of having a provider using both hands to jam in as much guaze into a wound as fast a possible.


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## ArmyGuy99 (22 Apr 2008)

MedCorps said:
			
		

> ASSESSMENT & TREATMENT (SECOND MEDIC’S PERSPECTIVE)
> 
> One I performed a cricothyroidotomy to gain control of the airway.



I was just wondering why the cricothyroidotomy??  FWIA #1 didn't appear to need it.  Would not an OPA/NPA or Combi-Tube have been a more efficient use of time?  It was also noted that the Patient wasn't Bagged until after he was on board the MH-60. ( Or just not mentioned earlier).


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## Armymedic (22 Apr 2008)

Instead of thinking time, think "effective" and "definitive" in a tactical scenario where the cas is going to be moved aggressively across complex terrain at night. There are only 2 ways you can secure a tube below the vocal cords: ET or cric. Cric can be done much more rapidly (slice, stick, twist, hook, insert, inflate, secure) and with greater success than ET. Not to mention it is much harder to dislodge a cric.

BTW, as opposed to what JIBC/PCP trained medics are taught, the combitube is one big piece of crap and has little or no use in the tactical/battlefield environment. There are slicker and smaller blind insertion devices avail.


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## kj_gully (23 Apr 2008)

American (Canadian too I hope...?) TC Medics use crics as their advanced airway of choice. It is quick and effective. Also use prophylactic chest decompression in any thoracic injury, the thinking being that the risk of inducing injury is much less than the potential benefit. Excellent post, I am impressed by the speed and decisiveness in the treatmen, as well, as usual, with their candid assesment. Lessons learned is a concept our American brothers take very seriously, and we should strive to do as well to pass on our experiences.


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## ArmyGuy99 (23 Apr 2008)

kj_gully, agreed all of us in the trade should take the time and learn from the experiences and lessons being learned.  

SMMT, thanks for answer, makes sense when I think about it that way.  Too bad it isn't taught from the start, although I understand we have to crawl before we run.  It would be nice though to streamline some of the skill sets we get.  Especially at the 3's level.  When we're still trying to digest the several text books and skills that were crammed into our heads during training.  Each of course is different ie. clinical/field/civilian.  But that's a rant for a separate post and I digress.


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