# Tactical combat casualty care ( TCCC )



## starlight_745

Who will be eligible to teach this course?  Does anyone have links to the training plans and how do we get it up and running in our area?


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## MedCorps

Where is your area? 

Have you done the course before?  Have they run one in your area before?  

Cheers, 

MC


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## starlight_745

LFWA.  I haven't taken the course but I'd love too.  As far as I know there was one pilot course run by 1 CMBG other than that I'm not sure.


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## Yard Ape

I'm interested to hear what is taught on this course.  Can soemone break it down by PO?


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## MedCorps

Unfortunately at this time there is not standardized course.  I have seen presented in two ways.  

The first way is for medical personnel as part of a larger course that deals with Combat Casualty Care in general (just not tactical combat casualty care).  When I first took it, I did it this way as part of the Combat Casualty Care Course run by the Defense Medical Readiness Training Institute in Fort Sam Houston.  I have also seen it run by the UK RAMC as part of the Battlefield Advanced Trauma Life Support Course.  We have run it in Canada as part of larger OP ATHENA medical pers work-up training for ROTO 0 and ROTO 0A (Medical Augmentation).  We also ran it as part of a clinical training week called "Combat Medicine 2004".   

The second way is for the warfighter, whom it really is intended for.  It was run as a 1 or 2 day course.  If I had to put PO's to it... it would look like this.  

PO 001  -  The Casualty Treatment and Evacuation Process  (CUF vs TFC vs CCEC)
PO 002  -  How Casualties Die (the big 3 and Tri-model death distribution) 
PO 003 -   Care Under Fire
PO 004  - Airway Problems and Management  (with Lab [open airway, bulb suction, NPA, OPA])
P0 005 -   Tension and Open Pnumothorax and Management (with Lab [needle decompression and Chest   
                    sealing techniques x2]) 
PO 006  - Stop Bleeding and Treat Shock (with lab [shell dressing and one handed tourniquet, and improv. 
                  tourniquet]) 
PO 007  - Triage 
PO 008  - Morphine Autoinjectors (if issued) 
PO 010  - Scenario Based Training (Exercise) 

Here is more information:   
http://www.google.ca/search?q=cache:X5nV_O9BVUAJ:www.nomi.med.navy.mil/Text/Tactical%2520Combat%2520Casualty%2520Care%2520Guidelines.pdf+%22Tactical+Combat+Casualty+Care%22&hl=en&ie=UTF-8

I suspect sooner or later that it will be standardized for the CF in a course.  It is the waiting game, as mentioned in another thread.  It is good to hear that 1 CMBG ran a course.  

Cheers, 

MC


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## Donut

The US 91W web page had a link to a very long (150+) powerpoint presentation that seems to sum up the TCCC   (see link in this thread for the ppt) .   The program is also supposed to be covered in the latest edition of Prehospital Emergency Care and Crisis Intervention, but I haven't seen it yet.


It is a standardized course, in that a syllabus has been approved by the American College of Surgeons, so if you're going to call it the TCCC, it probably needs to be run along their syllabus.   I haven't heard of it being offered anywhere outside of the military, but I suspect some of the ATLS chapters would have the resources and expertise to run an excellent one.

DF

Addendum:

here's the link to the actual powerpoint, fromt he US Army 91W site:

http://www.cs.amedd.army.mil/91w/index.html

As well, thinking of the training of non-medical people in this as a standard of care, it would need to be divided into an advanced and basic provider course.  While IV initiation, needle decompression, and crychoidthyrotomy are all very good procedures to have available, the possible complications, especially on the battlefield, are catastrophic.  WRT Needle cothoracocentesis, go to trauma.org and read the archived discussion by thoracic surgeons as to the efficacy and usefullness of prehospital decompression by paramedics and EMT's, much less Combat Life Savers


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## MedCorps

The non-Med Tech TCCC Crses did not include IVs nor crics.  The MO(s) running the program did not  feel that you could teach, with any confidence or real practice a non clinician how to do a cric.  It is a complex procedure... we opted for the, head tilt chin lift, NPA / OPA instruction in lieu of cric.  

IVs again.  In the early / mid 1990 we opted to start teaching warfighter how to do IVs.  It turned out that while some of them could gain ability in the classroom, in almost none of the "real life" (then Bosnia) situations where IVs attempted to be started could they get it.  Lets face it, someone in hypovolemic shock who may be already dehydrated to start with is hard to get a IV on.  There were other issues... 

1)  "Well, if we cannot get it into the vein we will sent it per rectum like the Brits did in the Falklands" (2 attempts then go rectal).   DCIEM did a study (with UofT) and it turned out that fluid really could not be absorbed at any useful rate to be helpful to the shocky casualty.  Bad idea. 

2) "Gee... IV solution is heavy... maybe I don't want to carry a 1L (=1 kg) bag round in my asspack / tac vest". 

3) How much of a 1 L bag of Lactated Ringers stays in the vascular space after 1 hour of being dumped in?  Around 300 mL worth.  In order to replace real losses (even for hypovolemic resus), you really need to put in more than one or two bags (especially in a long evac).  The real answer would be to go to Pentaspan or the like.  We are not quite there yet (did you know a 500 cc bag of Pentaspan is like $600.00 cdn?).  A month or so ago DCIEM ran a really good conference on fluid resuscitation in combat.  Neat stuff.  They are still hard at work on an artificial blood expander.  When that happens we have had a revolution in battlefield medicine.  

4) What is the best treatment for hypovolemic shock?  Stop the bleeding.  Quick.  Thus the one handed tourniquet being procured and taught.  We also taught improvised tourniquets too.  

Needle decompression is taught.  Pneumothorax is the #2 killer of the preventable combat deaths (21%).  Needs to be treated quick, quick especially if it of any real size.  It is felt that you can teach a non-clinician to recognize (and then test them with SimMan / METI) a tension pneumothorax.  I would rather they decompress someone (with proper technique) who did not need it than miss someone who needed it.  We can deal with someone a few hours down the road who has a 14 ga angiocath in their chest and an Asherman Chest Seal over it, much easier than treating someone a few hours down the road who has had a massive pneumothorax. 

Cheers, 

MC


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## starlight_745

Med Corps, 
Great info in your post above.  I heartily agree with your above post.  I attended some con ed in my civi job last year where a trauma surgeon was talking about the vicious triad of hemodilution, coagulopathy, and hypothermia in regards to zealous fluid resuscitation.  Made for some interesting thinking.  We cannot over emphasize the importance of doing the basics properly and quickly.  Do you know if there is any trialing of things like the chitosan/fibrin impregnated bandages nad/or quickclot?  What we really need is a well stocked and useful individual and section level first aid kit for the troops to use and then give them the training on how to use it properly.


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## Donut

I agree, judging from the presentation, entirely about the fluid resuscitation and airway management, and the need for a CLS-type course for our cbt arms team, but I still have reservations about the over-zealous application of 14g angiocaths to chest walls.  

Most 14g needles ( and the standard CF one) are too short to penetrate the parietal pleura, anyway, 2" or 5cm is needed, and most are 1 1/4 to 1 1/2" long.

I'd again recommend reading the 5yr+ debate on decompression on the trauma archives discussion group.  An interesting section on permissive hypotension, too.

Doug


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## MedCorps

A few thoughts.... 

Section medical kit.  For OP ATHENA Roto 0 we issued the following "leg bag"" medical kit to the sections with a "CF TCCC Crse".  

CPR Mask x 1 
NPA x 1 set 
Small KY Jelly for NPA x 6 pk 
OPA x 2 
Bulb suction x 1 
Asherman chest seals x 2 
Alcohol Swabs x 4 
14 ga angiocatheters x 2 
Tourniquets x 2 
Field dressing x 2 
Triangular bandages x 2 
OpSite x 2 
EMT Sissors x 2 
Latex Gloves x 2 pr 
Roll of tape x 1 
Skin marker x 1 

Because 3 RCR is keen, they took First Aid prep quite seriously, and upped the holding of medical supplies in in the tac vest and in all vehicles, purchased lightweight folding stretchers for troops to carry in the rucksack.  

14 ga Angiocath... yep 2" is what you need.   That is what is in the kit.  They are in the CAMMS (CMED) catalog for order.  I am not sure if they are matched to a SMN yet, but if they are not I can get that done easy enough for everyone.   The UK have a piece of kit I am quite smitten with.  When I worked with them, it is what was issued to all of the RMAs and CMTs for needle decompression.  It is by Tyco Health Care and called the Kendall Meicut Intravenous Cannula (p/n 8888-100206).  It is a 12 ga, 2" sheathed needle attached on a 2.5 cc syringe.  The whole thing comes in a hard plastic container, which survives much better in a jump bag than the normal angio-cath package.  Good for needle decompression.   I could not link the page, but if you go here:

http://www.kendallhq.com/catalog/searchtype.asp

and type Medicut in the word search you will return the ARGYLE MEDICUT Intravenous Cannulas.  Click this and ou have a picture.  

Clotting Dressings.  When I was with the Americans on the Comabt Casualty Care Course in Texas they spoke about the Quik-Clot dressing they were using in Iraq (http://www.z-medica.com/).  They were having some problems with it at the time (the biggest problem being that the pouch contained a powder to place on the wound [like old Sulpha powder] before putting the dressing on.  In people with heavy bleeding, in the panic, the soldier would pour the powder on the bleeding wound.  By the time then opened the dressing an placed it on the wound, all of the clotting powder was washed away by the bleeding before it could work.  

Then came the bad news message....  Quick Clot creates an exothermic reaction in the clotting process bringing the wound temperature up to 100 + degrees.  Oh... that is not good.  Stop using it, the message came out.  If you want to see the message let me know.  It is at work, and I need to send it to my home account.  

Here is some talk about it though...  interesting read.  The USASOC message they talk about is the one I have:

http://www.warriortalk.com/showthread.php?t=1183&page=1&pp=10

I am not sure what the status of the product is.  Pre OP ATHENA Roto 0 CFMGHQ / G4 was not comfortable with going with the quick-clot dressing.  Thus we opted for the 2 normals field dressings in the kit vice the planned 2 x Quick-clot.  Looking at the z-medica website it looks like they may have sorted things out.... then again these are the people who make it, so can you really trust them? 

The US DoD and the CF are working on new clotting dressings.  We will see them in out lifetime I am sure.  Another tool.   The other product the US Army was looking at was the Chitosan Hemostatic Dressing (Hemcon?).  Here is some information on it: 

http://www.dcmilitary.com/army/standard/8_04/national_news/21677-1.html

At the time they were more impressed with the QuikClot, but I am not sure what the deal is. 

Cheers, 

MC


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## Donut

Good to hear that the CF has the longer angiocaths in the system now, and, again, I agree about the British 12g caths, I managed to scoop 3 or 4 while in the UK with 75 ER, great "jump-bag friendly" packaging (speaking of which, most of their kit is much better packaged then ours).  I'd heard about the exothermic problem with the clotting dressings, kinda funny, isn't the center of a burn the "zone of coagulation" ?  what are we trying to achieve anyway?  ;D

Army Lesson Learned Center put out a suggested list of the section medical kits from one of the Roto to Bosnia, again I seem to recall it being an RCR initiative.  Seemed to be a good idea, lots of dressings, little bit of fluids, good for a well trained First Responder with IV potential.

Folding strethers, great idea.  I like the SKED, used it a couple of times, but it's very bulky to pack around, even if it does give you that golfing LCF.  I've never used the Talon or Talon II, any comments on them out there?

NPA/OPA, sure, whatever holds the tongue out of the way.  Bulb suction is of limited value, but better then nothing.  There's a new product out that combines a reservoir bag with a "turkey baster" style suction, same size benfits of the bulb with a capacity that probably exceeds a Res-Q-Vac, which puts the V-Vac to shame.

Speaking of the RAMC CMT's they don't seem to have the same concerns on CME or MCSP that we have, it would be interesting to see how they've worked out on deployment.  I also really admired their Patient Care Regimes, which set out "standard" treatments, including abx and analgesics, at various level of evac.

Doug


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## starlight_745

I have used the talon folding litters berfore and they are great.  Fold out and look very similar to our regular litters but just fold up into a nice compact package for storage.  There are also poleless litters out there than are nylon and can be basically rolled up and stashed in a pack, ideal for an infantry section.


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## Armymedic

I instructed on the course that was taught to 3 RCR prior to going to OP Athena. The Doctor who rammed it thru the planning was in contact with the team from LFWA who organized the courses out there. These courses have been reconized as filling a gap within the military between the normal first aid training, and what we need in the true basic combat lifesaving skills. Med Corps already talked about some of the course content and kit used...

Coming shortly is a confrence about the course in Edmonton, and CFHS discussion on course content and to whom the course/skills should be taught. IMO it should be taught to 1 in 10 cbt arms pers, 1 in 20 CSS and all QL 3 med techs on completion of thier PCP course to give them a military knowledge base they all currently lack.

As for instructors, It wasn't a stretch for the experienced BTLS instructors on the above course to teach, as it is still good basic medicine taught with a diffrent mind set.

So we should hear more about in the Reg forces circles in the next couple months...


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## MedCorps

SPECOPS IDC HM 8491/HM 8403 JSOMTC: USE OF THE HEMOSTASIS PRODUCT QUIKCLOT MADE BY Z-MEDICA

1. UNTIL FURTHER NOTICE ALL USSOCOM PERSONNEL ARE PROHIBITED FROM
USING THE HEMOSTASIS PRODUCT QUIKCLOT (TM) MADE BY Z-MEDICA.

2. QUIKCLOT (TM) IS A COMMERCIAL OFF-THE-SHELF PRODUCT WITH FDA
APPROVAL FOR EXTERNAL USE TO ACHIEVE HEMOSTASIS (CONTROL
HEMORRHAGE). THIS PRODUCT WAS PURCHASED IN QUANTITY BY THE ARMY AND
USMC MEDICAL AGENCIES BECAUSE OF THE EARLY FDA APPROVAL AND THE
BLOOD CLOTTING POTENTIAL OF THE PRODUCT. SMALL QUANTITIES OF THE
QUIKCLOT (TM) HAVE FOUND THEIR WAY TO USSOCOM MEDICS THROUGH
SERVICE CONTACTS AND DIRECT FROM THE VENDOR FOR THE SAME REASON
SERVICES ORIGINALLY PROCURED THE PRODUCT

3. WHEN QUIKCLOT (TM) GRANULES ARE POURED INTO A HEMORRHAGING WOUND
A REACTION BEGINS HEATING THE BLOOD TO TEMPERATURES FROM 90-100
DEGREE CENTIGRADE (194-212 DEGREE FAHRENHEIT). THIS TEMPERATURE
COAGULATES (CLOTS) THE BLOOD, BUT ALSO HEATS LOCAL SKIN, MUSCLE,
AND NERVE TISSUE TO BOILING TEMPERATURES.

4. ARMY AND AIR FORCE MEDICAL RESEARCH LABS HAVE REVIEWED QUIKCLOT
(TM) AND RECOMMEND NOT USING THE PRODUCT.

5. UNTIL APPROVAL BY SERVICE MEDICAL RESEARCH LABS, DEVELOPMENT OF
POST USE PROCEDURES, AND CONCURRENCE OF USSOCOM COMMAND SURGEON;
QUIKCLOT (TM) IS PROHIBITED FROM USE BY USSOCOM PERSONNEL.

6. POC IS LT COL J. R. LORRAINE, USSOCOM:SOCS-SG, DSN
299-5051/5442. Submitted by: HMCM Gary E. Welt, USN SEA, JSOMTC,
FT. Bragg, NC Comm: (910) 396 - 0089 Ext. 145 DSN: 236 Fax: 396 -5395

 ----------------------------------------------------------

Field Report Marine Corps Systems Command Liaison Team
Central Iraq 20 April to 25 April 2003

QuikClot by Z-Medica ~ 2D Tank Battalion Surgeon LT Bruce Webb
(USN) stated that Quik-Clot was ineffective (specifically, it was
ineffective on arterial bleeding). Battalion Corpsman attempted to
use Quik- Clot in three separate occasions:

Wounded Iraqi civilian. Shot near brachial artery. Quik Clot was
applied >per the instructions. The substance dried but was
flaking off. Standard direct pressure applied by corpsman proved
more effective on the patient.

Iraqi civilian shot in back with punctured spine. Quik-Clot
applied to severe bleeding. Pressure from bleeding sprayed
Quik-Clot away. According to LT Webb, "Quik-Clot was everywhere
but the wound".

Iraqi civilian, female, shot in femoral artery. She suffered
severe arterial bleeding. Patient bled out. Quik-clot unable to be
applied effectively due to pressure of blood >flow from wound.
Patient died.

An LAR Marine was shot in the femoral artery. Quick Clot was
applied to >the heavily bleeding wound. The pressure from the
blood soon caused the quick clot to be pushed >out of the wound and
rendered ineffective. A tourniquet was applied instead. The patient
died. Quik Clot may work if applied in a "buddy system" manner. One
individual applies the Quik Clot substance while another individual
 quickly applies the sterile gauze to the wound. However, applying
the Quik-Clot as directed proved ineffective. Direct pressure and
tourniquets were used instead. (note: different opinion from the
MEU MO interviewed. Recommend further study on this item).

Cheers, 

MC


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## brin11

Quick question...was the QuickClot intended for arterial bleeding in the first place?


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## MedCorps

The company markets it to "speed coagulation of blood, even in large wound", and for "Traumatic Bleeding".  They make no direct claim (that I am aware of) about  in being used for the control of bleeding from an artery.  

That being said in real life medicine traumatic bleeding, does not exclude arterial bleeds,  in fact "good trauma (tm)" often has the person pouring out blood from a arterial bleed.  Large wounds also are more likely to have an arterial bleed (location on body dependant).... 

With all the hype of this product (from both z-medica, and the US DoD) orginally, you would guess that it would stop any bleeding, drive the amublance and bill the casualty on it's own. <smile>.   

Cheers, 

MC


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## Armymedic

And the best some of the best medicine was practiced 2000 yrs ago. Sometimes new and hi tech just doesn't mean good.


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## starlight_745

I agree with Armymedic.  After working EMS for several years in a major Canadian city and attending numerous beatings/shootings/stabbings, I have yet to see life threatening bleeding that could not be controlled by direct pressure, pressure points, tourniquets or a combination of the previous (not including internal bleeding of course).  I would be very leary of anything causing an exothermic reaction as well.  Also how difficult is it to get this stuff out of a wound?  Are there any surgeons here with experience removing this stuff from a gaping wound?  We can never emphasize the basics enough.  I think armymedics earlier post about applying good basic medicine in a hostile environment is bang on and should really guide our training at all levels.


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## Grunt_031

Here is a list from the Interim TP of the CF TCCC

PO 401 Tactical Combat Casuality Care Concept

401.01 Intoduction/Legal Considerations
401.02 Review of TCCC/Crse Objectives
401.03 TCCC Part 1,2,3
401.04 Scenario Homework (Presentations and Discussions)

PO 402 Perform Intial Assesment

402.01 Airway
402.02 Breathing
402.03 Circulation
402.04 Shock/IV Conterversy

PO 403 Perforn Rapid Tramua Survey

403.01 Head Injuries
403.02 HEENT
403.03 Chest Injuries
403.04 Abdominal Injuries
403.05 Pelvic and Extremity Fractures
403.06 C Spine/Back Trauma

PO 404 Combat Related Injuries/Treatment

404.01 Burns and Blast Injuries
404.02 Soft Tissue Injuries
404.03 NBCW
404.04 Analgesia in the Field

PO 405 Casevac

405.01 Prepare the causalty for Tpt
405.02 Carries, Lifts, Improvised Stretchers
405.03 Improvised rescue techniques
405.04 Veh and Medical Equipment Famil

PO 406 Mass Causualty/Triage

406.01 Mass Causualty/Triage

PO 407 FTX/Scenarios 


LFWA ran 3 Serials from time period of Jun 03-Mar 04. The last two serials all candidates (all cbt arms) were qualified to PHTLS. Revision is now in the hands of CFMG. The course was 5 weeks in duration. 

Week 1/2 Prestudy Package (under supervision of Medical staff)
Week 3/4 Course Content including Low/high speed scearios
Week 5 FTX

FTX was 24/7 5 days (Dismounted Platoon tasks) 
Infantry Platoon dismounted org (32 pers/ 8 per section).   
assesed medicall and cbt tactics
Fully equiped Light Infantry Equipment and full Cbt loads 
(Body Armour/Wpns/NVG's/NBC/Radios/Ammo/Rations etc)
Veh platforms included LSVW Amb, Bision Amb, LAV 3, Coyote, BV206, CH 146


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## Armymedic

Looks good so far for course content.

It says your qualified to PHTLS, and not BTLS (they are really two in the same).  Did they issue cards for qualification or just say that was the standard?

Most Med Techs are trained BTLS so that medical standard is more widely accepted amongst CFHS.


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## Grunt_031

The Medical Pers (Med Techs) were sent on a PHTLS Instructor course proir to the TCCC being run and then instructed to the Candidates. The PHTLS was intergrated into the course content. All the candidates where given certifcation by Canadian College of Emergency Medical Services. 

This was a trial run using this civilian qualification and probably will not be run this way in the future. Once the Militray version of PHTLS being developed in the US becomes available they may revist the idea.


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## Armymedic

We are improvising with intergrating BTLS with military medicine...PHTLS just has a chapter in its manual, whereas BTLS does not. 

I think the CFMG version will teach based on BTLS, but final decisions on the matter are well above my pay grade.


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## ModlrMike

Grunt_031 said:
			
		

> All the candidates where given certifcation by Canadian College of Emergency Medical Services.


Which is a private civilian school, not to be confused with an National oversight agency.


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## MedCorps

Grunt_031, 

Did you do the course?  How did you like it?  What would you add / delete?  Do you feel more comfortable at responding to a trauma in your section now, without a Med Tech? 

Interested to know.  

Army Medic... there has been some throught at CFMGHQ / Med Trg to go with the PHTLS as opposed to the BTLS.  Why... the only reason anyone can give is that PHLTS in the 5th edition (2003) put a chapter (16) on military medicine.  In the last version of BTLS (5th Ed 2004) they did not.  We will have to see what the giant head comes up with on this one. 

Cheers, 

MC


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## Armymedic

There is simple reasons for no military chapter in the BTLS book. 1. No military contributors, dispite having military chapters(branches) in the BTLS community. 2. Also, John Campbell wants the medical knowledge to be widespread, not how to apply the knowledge. There are still military based senarios in BTLS testing, but its left to the instructors to instruct. 

The PHTLS just took concepts from US Army pams and put it into a civilian book (why? I don't know). I have both texts and with the exception of a few chapters (the military chapter being one), the concepts and skills are very similar. BTLS, IMHO, has better assessment "drills" then PHTLS.


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## MedCorps

Army Medic, 

Having done both courses in the last little while (and getting IP on both :smile  I agree that the BTLS has better drills.  I will give you that for sure.  I also think that much of the stuff from the military chapter was taken from other stuff (the scenarios are from Military Medicine in around 2000).  

I also think that PHTLS has a military chapter because of the active involvement of the US military to assist in authoring the text.  The US military kicked up a team of 8 people to assist in writting the text.  In terms of man-hours / cost of labour that is big bucks for a publisher.  They did not kick up bottom feeder either.  I know three of the people who were on the writing team.  All three are ER docs and two are Capt(N) (read: full Col) and one is from USASOC and is a doc who is a LCol (although he was expecting to get promoted soon, and might be a Col now).

Cheers, 

MC


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## Armymedic

I think if you would have had highly trained free instructors from across the street,   ;D

there would be a MCpl who would have loved to give you the gears to see you earn that IP    >

Anyway, pulling back to topic.

If CFMG were to start this course in Petawawa, I believe some of the first instructors should be BTLS instructors with much Cbt arms/fd experience. When 2 Fd ran the short course for ISAF roto 0, the brigade surg went to the BTLS cadre and pulled all the senior ones to teach.


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## Donut

One other consideration for PHTLS vs BTLS, is that BTLS requires a medical director, while PHTLS doesn't need to be run with physician oversight.  Given the shortage of MO in the CF, and cost associated with hiring Medical Directors, this is a valid concern.

The flip side is that, especially when our instructors may not be all that current on trauma, do we want to do away with the oversight that provides?  I know that running our courses, with our Bde Surg as the med director, helps him get a feel for the various skill levels of his medics.  The first question he or the HCC ask when he's reading a medic emerg report is "how'd he do on the last BTLS?"

Now, out here we pay $800 a day for a civi med director, and $400 a day for the civi instructors. Big bucks, and if we can save that and keep the standards high enough, we clearly should.


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## Armymedic

But the TCCCS is meant for Army soldiers in a reg force brigade. In which case you have a Fd Amb, which has more then one or two MO's and I have yet to meet a young Capt who wasn't interested in assisting in instruction of their Med Techs.

Also the $ issue for instructors. A certain large CFMG organization has lots of $ to hire instructors from Toronto to come up and teach...A smaller unit has instructors, coordinators, and instructor trainers avail who travel to places like Trenton and Ottawa to teach for the cost of TD. 

My point is if there is a will there is a way. But BTLS should be the basis of the medical standard.


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## Donut

Quick note to add to this thread:

Just last week I was asked (yet again) to submit my civi quals up the chain.   Included in the latest spreadsheet of quals was TCCC Instructor, right next to the ACLS and BTLS instructor columns.

As well, with instructors who teach for the cost of TD, there'd be a lot more of them if the CF would fund some instructor courses, and maybe establish regional instructor cadres.  When I pay out of pocket for membership in a professional organization, licensing fees, instructor qualifications, instructor updates, etc, and then the army assumes I will lower my fees by over 70% to teach the course to a class that's twice the size it should be, my GAFF drops precipitously.


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## Fraser.g

Doug,

There is a fine line between use of civi qualifications and abuse of same. If the army wants to use you as a BTLS instructor then they should pay your dues. They do mine! I suspect that the regular force members of this forum and BTLS Instructors have DND pay their memberships.

I believe that this should go for CPR, SFA, BTLS, ACLS, ATLS and TCCC if it is licenced from an external agency other than DND.

As you said, they ask us to teach classes that are larger than recommended, get paid less for doing it, and expect us to maintain the certifications on our own time and nickle. Not on bro! 

I have my unit pay for my instructor papers and they have never questioned them. I simply pay my dues and then submit a CF 52 for the expenditure.

Grant


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## Armymedic

RN PRN said:
			
		

> Doug,
> 
> There is a fine line between use of civi qualifications and abuse of same. If the army wants to use you as a BTLS instructor then they should pay your dues. They do mine! I suspect that the regular force members of this forum and BTLS Instructors have DND pay their memberships.
> 
> I believe that this should go for CPR, SFA, BTLS, ACLS, ATLS and TCCC if it is licenced from an external agency other than DND.
> 
> As you said, they ask us to teach classes that are larger than recommended, get paid less for doing it, and expect us to maintain the certifications on our own time and nickle. Not on bro!
> 
> I have my unit pay for my instructor papers and they have never questioned them. I simply pay my dues and then submit a CF 52 for the expenditure.
> 
> Grant



Oh heck YEAH, I got my BTLS Intructors for free, as do all the students I teach...We only charge $20 per person for BTLS ontario so every student gets the appropriate card. Books are bought and held by the 2 Fd Amb...




			
				ParaMedTech said:
			
		

> Quick note to add to this thread:
> As well, with instructors who teach for the cost of TD, there'd be a lot more of them if the CF would fund some instructor courses, and maybe establish regional instructor cadres. When I pay out of pocket for membership in a professional organization, licensing fees, instructor qualifications, instructor updates, etc, and then the army assumes I will lower my fees by over 70% to teach the course to a class that's twice the size it should be, my GAFF drops precipitously.



This is exactly what has happened in Petawawa for the last 5-8 yrs....We have a system in place where every yr or two we certify new BTLS instructors from the courses we ran, currently roughly 20. The military paid for us to be qualified and we don't earn any $ by teaching....BTLS Ontario allows us to have this group because of all the potential students in Pet, Ottawa, Kingston, Trenton, and Borden.

If I were you I'd get the CF to pay (reimburse) for any future courses you take if they want you to teach.

Anyway, this is pulling off track....more to the MCSP thread then TCCCS....

If there is no "Official" TCCC course yet in CFMG's eyes...how can anyone become an instructor yet?


----------



## MedicMW

The use of free instructors is not appropriate. Units should be reimbursing instructors who maintain instructor qualifications and use them within the military environment.

The PHTLS course is similar to BTLS. I found that PHTLS expected the Care Provider to be immediate in treatment and determination of injuries. I found the scenarios to be much more appropriate with the military module (in place since 1974). The PHTLS course assumes the knowledge of Anatomy and Physiology is already in place and there has been experience.

The TCCC course is a PHTLS specialization, (PHTLS does require a medical director for program to run) and was originally proposed by Major (ret.) Dan Voriout (mis-spelled) and Capt. (ret.) Roger King from 1 CMBG. Dr. King still fills in at the Base Hospital and is usually fairly even tempered and helpful. Major Barry Ellis is the current Medical Director for the program and seeking ways to effectively implement it CF wide.


----------



## Armymedic

MedicMW said:
			
		

> The use of free instructors is not appropriate. Units should be reimbursing instructors who maintain instructor qualifications and use them within the military environment.



How? 

They pay for me to become qualified, why do I require reimbursement to teach?

If I pay for the course, I get 80% reimbursement thru BPSO....military still pays me....(rules on course reimbursement currently changing, see PEP thread in current events)

What more can they do?





			
				MedicMW said:
			
		

> The PHTLS course is similar to BTLS. I found that PHTLS expected the Care Provider to be immediate in treatment and determination of injuries. I found the scenarios to be much more appropriate with the military module (in place since 1974). The PHTLS course assumes the knowledge of Anatomy and Physiology is already in place and there has been experience.
> 
> The TCCC course is a PHTLS specialization, (PHTLS does require a medical director for program to run) and was originally proposed by Major (ret.) Dan Voriout (mis-spelled) and Capt. (ret.) Roger King from 1 CMBG. Dr. King still fills in at the Base Hospital and is usually fairly even tempered and helpful. Major Barry Ellis is the current Medical Director for the program and seeking ways to effectively implement it CF wide.



Thanks for the background,
That being said...TCCC could easily be adapted with BTLS medical protocols and extra expense and time would not have to be wasted re qualifying your SMEs in another prehosp technique so that they can teach TCCC to nonmedical pers. In Petawawa, where the largest concentration of MA's are there are 0 (I say again none) PHTLS instructors here that I am currently aware of. If they want to implement it CF wide, then standardizing the medical protocols with what the current standards are is the next most appropriate action.

When I see Maj Ellis at the OP Med at the end of the month , I am sure this topic will come up.


----------



## Donut

PHTLS and BTLS have a reciprocity agreement in place, so converting BTLS instructors to PHTLS Instructors shouldn't be too difficult.

As for PHTLS being the creator of TCCC, I've seen documents and powerpoints written by a Capt Frank Butler of USN Spec Ops Command, I think, that may or may not predate the PHTLS program.  I'm not saying PHTLS doesn't have a TCCC, just as BTLS has an Access and Pediatrics courses, but I'm fairly certain the original TCCC came from the US.

As for instructor reimbursement, DND hasn't bought me a BTLS qual since 1997.  I'm out of pocket $1400, including travel and upgrades, for a qualification I took to further my CIVI career. PEP isn't available because I have a degree, nowhere in my job description does it say BTLS Instructor, Coordinator, or Paramedic, yet because I have these I'm expected to provide these services within my salary.


----------



## MedCorps

Some light reading from Iraq.  CLS is like TCCC providers are for the CF, more or less (some delta in skill set, but same idea). 

Enjoy 

MC

Operation Iraqi Freedom (OIF)
CAAT II Initial Impressions Report (IIR)

Chapter 4: Combat Service Support 
Topic F: Health Service Support

Subtopic 3: Combat Lifesavers (CLS)


Observation Synopsis

Ensure unit's combat lifesavers (CLS) are fully trained and understand their role in the medical treatment process. Once-yearly training is insufficient to ensure they can perform necessary duties in a critical situation. There was at least one incident on the road where the targeted unit was rendered ineffective in terms of medical treatment by an improvised explosive device (IED) attack that resulted in several casualties. Another unit passing by stopped and took control of the situation, including providing medical care to the wounded. Specifically, CLS need extensive training in starting intravenous (IV) lines and providing appropriate first responder aid. Starting IVs is a skill that is difficult to do in controlled settings for the inexperienced (like the vast majority of combat lifesavers), and almost impossible to do in an emergency without prior proficiency. All vehicles traveling in a convoy should have at least one combat lifesaver with their bag. Vehicle first aid kits, though useful for minor injuries, are not sufficient for major traumas associated with IED, small arms, or rocket-propelled grenade (RPG) attacks on convoys. On more than one occasion, combat lifesavers did not have their bags available or in their possession because they were kept locked up or in storage to keep from losing them or to maintain accountability. 

Lessons Learned

*	Convoy commanders need to ensure a sufficient number of CLS providers are included in the personnel of each convoy. 
*	Prior to deployment, all combat lifesavers need to be trained and certified, have possession of their CLS bags, and exhibit confidence in using the enclosed medical supplies. 

DOTMLPF Implications

Training: Recommend at least quarterly hands-on training, especially an IV starting workshop, and not just a paper or lecture review of basics to â Å“check the block


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## Donut

I found the section on the movement of casualties in a non-linear battlespace interesting, as well as the description of equipment shortfalls, both with the jump bags and with the stretchers.

Has anything like this been reported from Op Athena?  I don't suppose we're having to decontaminate our stretchers with nearly the regularity that the US is having to, but still...

I did like the M577 CP amb conversion.  Can you say headspace! (and, I suppose, big @#^$%*  profile, too for a tactical environment)


----------



## MedicMW

Re: BPSO reimbursement of Instructor fees.

As a reservist I am not eligible for those same reimbursements (16 days short of four years cumulative class B service). My unit does reimburse under the MCSP requirments for maintenance of my registration. Initially they did pay for me to become qualified and I instructed frequently for the first three years. After my re-certification (not reimbursed) my RSS staff ensured I was rewarded within the unit alternatively.

I suppose it comes down to the consistency and competence of leadership to make me happy. Their occasional benevolence doesn't hurt either.

Re: PHTLS may be a US thing.
PHTLS *is* a US thing. The physician that developed PHTLS and the TCCC module is American and can be socialised with every year at the PHTLS world conferences in The US. I believe this year it is in Phoenix. It is an excellent opportunity to meet military medical personnel from around the world (last year there were Israeli, French, German, American and Italian medics all over the place). Dr. Houston in Edmonton will have more information on the conference this year.

Williams, M.


----------



## Donut

MW, what I said was that a variant of Tactical Combat Casualty Care was developed by the US Spec Ops Command which predates the PHTLS course of the same name(can't find the course on the PHTLS website, though).  Similarly, CONTOMS, the US Counter Narcotics Tactical Operations Medical Support could make a claim to be the originator, through their EMT-T program.

I have found, at the US AMedd site (www.amsc.amedd.army.mil/Doc/ PA/TACTICAL%20COMBAT%20CASUALTY%20CARE.doc ), a paper which cites both PHTLS 4th&5th edition texts (use of Hetastarch blood expanders and fluid resuscitation) and the paper by Dr FK Butler et al entitled Tactical Combat Casualty Care in Special Operations, published in Military Medicine in 1996.

Further, according to Specialoperations.com, the first TCCC protocols were included in PHTLS in 1999, from existing US Naval Spec Ops directives, approved in 1997, and based on a requirement identified in 1993.

Last I heard, TCCC had been endorsed by the American College of Surgeons, the source of ATLS and the program that both BTLS and PHTLS try to keep in line with.  

St John Ambulance teaches CPR and to elevate the legs of the shocked patient; I'm pretty sure they never invented external chest compressions or had Trendelenburg working for them, either.

BTW, is this Dr Houston an anaesthesiologist?  I suspect I worked with him a decade or so ago in Edmonton.


----------



## MedicMW

Doc Houston is Emergency Spec. and Anaesth. So you might have worked with him. As an aside I just participated in an Edmonton Police Services Tac EMS course and it has some nice components to it as well. They really stress the immediate threat factor.


----------



## Fraser.g

While at Op Med there were several presentations covering both PHTLS, BTLS and TCCC. The big thing that was stressed was that the TCCC course was for non-medical trades. They received the TCCC, PHTLS, an orientation to lines of evac (Ambulances like the LSVW, Bison and Griffin) and a final tactical field ex. According to the presenter this took a total of 2 weeks and he was surprised that the TCCCs trainees at the end were talking like medics.

In my opinion and that of several others at the conference there is no need to teach the PHTLS course to teach the TCCC portion. What do you get out of the TCCC?

IA= Win the fire fight

A= Get your Ass down
B= Get your Butt out of the line of fire
C= Check for deadly bleeds

     -if there is a change in LOC dissarm the casualty   
     -if there is a bleed in an extremity put on a tourniquet
     -if there is a change in airway then put in a nasal trumpet (NPA)
     - if there is a chest wound with resp distress and possible tracheal shift land mark and decompress with the 14 G provided.


Why do these personnel need the anatomy and physiology of a PHTLS and/ or BTLS for this...they don't.

Why don't they get IV cannulization on this course...because fluid resuscitation with high volume cristaloid does more damage then good and by the way they can not possibly Cary enough to make a difference (3 L of crystaloid for 1 L of blood loss). and if they transfuse that amount they will destroy any chances of the casualty clotting or transporting Oxygen to the tissues any way due to dilution. One day our jump bags will carry Pentaspan but we are not there yet.

So what?

The TCCC course is great for the non medical trained, it teaches a couple of quick interventions that should be propagated within each combat arms section. The recomentation from the pilot project team is 2 TCCC per section. These two should not be jnr Pte and Cpl. It should be the Snr Cpls but not the 2IC or section commander.

It would also be an increase in skill set for the reserves. Easily and cheaply taught. 

1. Reduce the course to one day of skills lab and lecture. Use the new Sim mans to teach the skills.
2. one day of orientation to the emergency veh.
3. A three day FTX where they are bombarded with casualties in different situations, and degrees of urgency.

Heck with that time line both regular and reserve combat arms pers could take the same course at the same time. Standardization, what a concept.

OK the idea is out so 

comments please

GF


----------



## Armymedic

You must have fell asleep during portions of the 3 presentations of the subject...

The idea being pursued is the Combat Casualty Care will teach the cbt arms cbt medicine techniques and skills, and teach the Med tech how to think tactically while performing their skills.

So why not teach basic BTLS or PHTLS to the cbt arms? A good dose of theory and background knowledge will definitely lead to better understanding of why and when the techniques being learned are to be used. Not to mention their ability to help us when the deficat hits the ventilation and we are the only Med tech on the ground. Cbt arms are , contrary to popular belief, extremely motivated to learn the skills that will keep their buddies alive. We have taught numerous cbt arms who were applying to SAR basic BTLS, and all did well.

Nothing they talked about was new or controversial to us from the Reg force who are pushing to get this tng directed by the CF H Svc Gp.

Heck as a Bc Sn Nur you should understand you can't do anything with a whole bunch of classroom work first...

BTW, we have been carrying Pentaspan overseas for 3 yrs.


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## Fraser.g

Nope, I was wide awake during all three lectures as I am sure were you.

My statements about reducing the length of the course was two fold.

1. They do not need the theory and A&P to do the intereventions taught on the course.
2. By reducing the length to one week from two it will make the course more available to and possible for more combat arms to take it. 

They are quite pressed for time especially when about to deploy. I can see this being treated as a nice to have rather than the need to have you and I both know it to be.
 It is all about saving lives on the battle field I would like to see the day that this is a simple extention of the SFA taught on basic but that is way down the road.

As for Pentaspan, you are carrying it in your jump bag or in the amb? If it is in your bag of tricks then how much do you carry and what are your directions on indication. I am not trying to test you or sound arrogant but I have not seen it on any of my load lists and if it is there then we should have it as well.
On the same line, do you have an updated kit list for the jump bag? the ones that I have are sadly outdated and archaic.

Thanks

G


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## Armymedic

Sure, we could teach it all in a day, but really how good would that be? Remember, unlike many who sat in on the three lectures, we have been exposed to this topic for a number of yrs. I purchased the PHTLS text and read the military chapter in it way back in 99 when it first came out. Former Airborne medics (like both my CSM and RSM who were in the sessions) quickly jumped on it (like the pun) and taught the newer medics like me the "way". Combining those "tactics" to a high BTLS skill, make for a pretty impressive package. We have never done it in a formal course, and have met stiff Resistance from "higher" anytime time it was attempted.

I do have to agree that the length is a bit much though. For the med techs a week in class and field combined would be sufficient (5 tng days). The cbt arms need longer for skills labs, and scenarios. I prefer 5 didactic/skill days and 3 field days (8 tng days). If your working on a standard Reg force tng day, add in 1 hr of pt (0700 - 0900) because after all it is physically taxing....and you might as well have a full 10 training days.

Ref Pentaspan: I carried 1x 500 ml bag plus a 500 ml bag of NS, with 2 starter sets. To properly administer it, you start the NS line then go to corn starch. I didn't leave any in the Bison because it is temperature sensitive (between 10-25 C). In Canada, we can get it but only by pulling teeth because it isn't on the UMS set of panniers. Here at home,  all my medics at the UMS are told to carry no less then 1x 500 ml of NS (dismounted role). 

Any of the jump bag lists we have are those used by Amb Coy of 2 fd Amb. They will probably be as ancient. After all, budget conscious Pharmacists are the ones who decide what we are allowed to use. Hence the UMS set of panniers still carries 50 1L bags of R/L. And we heard time and again last week that R/L isn't worth the bags its in.

Personally, I change what I carry for whatever role I am in: dismounted, LSVW, Bison.

Too bad Hypertonic Saline is 10 yrs away. 

Goodies I carry:
1  500 ml pentaspan,
2 Asherman seals,
2 14 gauge 3 inch long angiocaths,
1 normal sized combitube (using 100 ml syringe only)
foil blanket

to name a few...


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## Fraser.g

I am aware that the pentaspan is temp sensitive and it was one reason why I was enquiring. I would not want to try and start pentaspan as the primary but as a piggyback it works great. This way you will have the line after the Pentaspan is in and you don't have to mess with the ONC. I have done this on many occasions but none of them pre-hospital. Scope of practice and all that. We do use them in the Air amb quite a bit. Also if you can get a nice stable IV before they get to the Treatment facility or FSU (I wish) it makes things flow nicely. I would go for two 250 NS bags instead of one 500 and another infusion set because then you can at least get IV access and TKO for analgesic, Atropine etc. The other option is just use a saline lock. This way it is lighter and access is portable. No lines to get messed up if the patient is hemodynamicly stable.
As for the RL debate, I know many anesthesiologists that use it extensively and even order it for re hydration instead of NS. The only time they change is because of medication infusion conflict.

Now on to the time line:
You can teach the BTLS in two days but it is with a fire hose if the students are not medical providers already. I am a BTLS instructor and admit that I have not seen the PHTLS course. One decision that came out of Op med was to standardize the training for reserves from BTLS to PHTLS gradually. Once the medics have to to their re-cert they will get the PHTLS.
If the PHTLS can be taught in two days, then the skills for TCCC in one we could then do the field portion in two. This still fits into under a week. It would be a full one but once again more troops through the door. 
The re cert could then be two -three days. One day class room and two days in the field.

Goodies:

I have about all the same stuff with the following extra

2x 250 cc bag NS instead of one 500 cc bag
2x Morgan lenses
3 IV start sets


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## Armymedic

Ack on the 250's, but we don't carry them as part of the panniers, hence not easy to get....but 100 mil NS would be the other option.

From the branch chief, BTLS WILL remain the prehosp trauma standard for Med Techs. So we'll see how the recommendations turn out on the new course.

Difference between Btls and Phtls is that the laters exam is too simple (A,B,C, D,E) and BTLS is more precise (akin a drill). The remainder medical knowledge is almost exactly the same.

Its late, more tomorrow...


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## JANES

And what is 500ml of NS going to do for anybody?


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## Armymedic

It gets the IV started and give you the greatest versitility to switch that particular line to any other IV solution currently used by the CF, i.e. Pentaspan, blood products, etc.


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## Fraser.g

At Op Med we saw video evidence of it used on a Pig Femoral Artery successfully. That being said I still do not like the idea of cooking the flesh around the wound to a depth of 5 mm. This would require a large vein graft at the least to correct the damage caused by the product.


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## JANES

But wait, wouldn't a saline lock do the same thing, and lighten the medics load????


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## Armymedic

No. because what good is sticking a hole in someone without anything to put in it?

Second to trauma, heat illness/dehydration is the next likely use for a solution, and 500 ml is a real good start in solving those problems


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## JANES

Its a shame what the JI is teaching our medics!


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## Armymedic

Couldn't really comment on that due to the fact I have yet to have the "privilege" of their tutelage.

But its still a medical course, and no matter the type, its still what we do. Nobody is really in a position to judge the merits of a particular technique or procedure. It is always good to have 2 or 3 different ways to deal with any situation, and then its up to the particular person in that situation to judge which would be the most effective/appropriate at the time. End result should be in every case a favourable outcome of our patients.


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## Donut

Uhmmm, JANES, could you be a little more specific?

Neither of the other posters in this thread have anything to do with the JIBC, so if this is about the saline lock/500 ml NS issue, please leave them out, they have their own problems.

I'm not a card-carrying member of the JIBC fan club, but I've been a student in their Paramedic Academy and taught for their Professional Health Programs, as well as knowing many of the Chilliwack staff professionaly, and some personally, too. They try to give students three or four ways to deal with a situation, and try to teach some decision making, and then it's up to the MedTechs.

I will say that the PCP scope of practice, with some intelligent interpretation of the situation and a little experience, is effective for the vast majority of EMS calls.  I look around and see two other JI grads, and a current student, I don't think we've killed anyone in weeks  .  

So maybe you think there's something wrong with the scope of practice, or treatments, or the appropriateness of teaching civilian EMS to med techs, 



			
				JANES said:
			
		

> Its a shame what the JI is teaching our medics!



is a great third post.

Welcome to the board.


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## JANES

So what is this tactical combat casualty care?  Whats wrong with the what we have?


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## Fraser.g

JANES said:
			
		

> So what is this tactical combat casualty care? Whats wrong with the what we have?



OK, 

Let me get this strait, you wade into a discussion with out reading the previous postings, make disparaging comments and then when you get scolded by one of the members you then ask for clarification? Not a great way to start off in this forum son.

By the way the other members in this thread I would trust with my life. Some of which are trained by the JI and some by other military and civi schools across this country. Each has the ability to think around a situation, size up what is required and then act in the most favorable way for the patint. What you have so far revealed is linear thinking. You see one line of action and then go ahead with out getting all the facts. Scary!

Many of the other posters have years of experience with pre hospital and Emergent training and experience, it would serve you well to listen, read and then ask questions not only on this forum but in your civi and military life as well.


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## JANES

Easy there cowboy, I was just asking a couple questions.  Lets watch our hippocriticism.


----------



## R22eRKodiak

I am very excited by what I am reading in this thread.

Being a proud infantryman, I cannot stress enough the importance of what Armymedic stated:

 '' Cbt arms are , contrary to popular belief, extremely motivated to learn the skills that will keep their buddies alive. We have taught numerous cbt arms who were applying to SAR basic BTLS, and all did well. ''  (I'm afraid I haven't figured out how to quote yet! :)

We all need to know how to keep our soldiers alive in a state that they can be helped when the professional caretakers arrive.   Unfortunately, the little section first aid kits and the St Johns first aid course, although nice for dealing with minor scrapes and sprains of daily life, are insufficient for the type of trauma that are usually caused by weaponry whose sole purpose is to maim and kill.   Although it is nice to believe that one of our fine and dedicated medical personnel will be immediately on hand to treat critically injured personnel, it is simply not a realistic assessment of the actual threat that we face.   

This sort of instruction would be invaluable to us because:

A.   I am afraid that there simply aren't enough of you around to ship out with every patrol that goes out (particularly the longer duration ones)

B.   A critical incident (artillery, mine, IED strike, ambush, etc,) may cause more critical casualties than a single medic can handle.   That's the whole reason the bad guys are trying to do this, after all.

C.   What happens if the medic is one of the casualties?   Do we simply condemn everyone because of this, or do we increase our chances of making it through by giving ourselves the best chances possible and most redundancy possible.

I am not advocating making cbt arms pers medics by any means, but we must give them the training that is sufficient to actually make a difference.   I am glad to hear that there is support for such initiatives as the TCCC program.   I will be deploying soon, and as such have run many medical/trauma scenarios integrated into our standard operations, using troopers that we have managed to train on TCCC or other qualifications (e.g. those that are interested in becoming SARTECHs; I have a few of those, and they can't get onto enough medical courses!!)   Unfortunately, operational schedule has prevented us from having the experts out with us as counsel, as they are scattered to   the four winds to cope with tasking demands (reminiscent of point A above). 

We have come to the conclusion that the current training and kit available to cbt arms sections(TCCC notwithstanding -- I'll get to that in a bit), is insufficient to the real demands of a critical incident.   I am particularly concerned, as my troops may be operating quite some time away from medevac due to terrain and distance factors and in some occasions, medical personnel may not be able to be attached to them (again, A above).

We tried to get a TCCC setup for the troops.   After much deliberation, the course was allowed, but because of the time constraints, it was limited to a one day course (20 candidates for the bde), and there appears to be no occasion to run it again until we get in theatre.   As I understand, the main issue was one of liability.   On this level, I believe it may be more one of interpretation of the code of law, as you all appear to be very supportive of training cbt arms pers in this critical skillset.

I understand that there are limitations governing the employment of such skills in Canada, but what concerns can we have overseas?   Is it better to have someone that is trained trying to save someone's life in an incident (and possibly facing legal ramifications) rather than someone who has no idea what to do other than putting a shell dressing and cepacol on a traumatic amputation of a lower extremity (which is just about what any infanteer would try to do with the knowledge and kit they have right now at their disposal   ;D)

We've been relatively lucky so far with casualties.  We have been unconsciously counting on our luck up to now to get us through.  However, all it would take is one event for us to come to the same painful conclusions that the US currently are.  Luck shouldn't be a doctrine (even an unwritten one).  Commanders have the responsibility of minimizing risk by taking the steps they can to control as many factors of the battle/operation that they can all while accomplishing the mission.  This is one that we can control.  Let's keep as many of our troops alive as possible so that we can keep on giving the bad guys a hard time and keep on doing the good job we have been.  More Canadians alive after ambush = more Canadians around to make life hard on the bad guys.  

My kind of math.


In conclusion:

1.  Keep up the good *GREAT* work
2.  Help us by giving us the means to keep our buddies alive until you can get to them
3.  Glad to hear that the mindset is evolving
4.  Sure love for someone to clarify liability issues so that I can continue to develop things on my side in a more informed fashion

Thanks!


----------



## Armymedic

Thank guy...we serve so you survive


----------



## Fraser.g

R22eRKodiak said:
			
		

> As I understand, the main issue was one of liability.   On this level, I believe it may be more one of interpretation of the code of law, as you all appear to be very supportive of training cbt arms pers in this critical skillset.
> 
> I understand that there are limitations governing the employment of such skills in Canada, but what concerns can we have overseas?



The Liability issue was brought up at a medical conference in September. The way that the pilot course navigaed it by keeping the TCCC kits in theater and only issue them on arrival. With keeping the equiptment concontrolled and stressing that this was for battle field use only the MO for the course seemed confident that he was not releasing a bunch of infanteers with the overwhelming desire to drive 14g cathlons into every civi they met at West Edmonton Mall  .

If you BN was to to the same they might have a more favorable outlook on the training.

Good luck and keep us posted as to your progression with this fight.

GF


----------



## medicineman

I caught a note someone wrote about saline locks - TCCCs guidlelines do advocate there use.  They serve the TKVO role well without having tubing and such taking up space in your ambulance (not to mention getting hooked up on everything).  If the person needs a bolus, it's easy to hook up a line and drop in the fluid they need.  I seem to recall reading something to that effect as well in the "Tactical Emergency Care" manual put out by our friends at Brady. 

MM


----------



## JANES

It's inspiring to see such interest in the topic, especially from the Combat Arms.  It's also very scary to see all these self proclaimed experts on the topic.  It's important to realize, just because you're a medic or nurse or whatever in the Army, doesn't mean you're a TCCC SME.  Half the reason TCCC was presented to the CF was because of the lack of tactical knowledge and skill in our medics.  Not their fault, it's a training failure.  And the fact that civilian based approaches that the medics are taught, such as all your favorite acronyms (B/PH/ATLS) are the wrong approaches in a tactical and combat environments.  You're friendly neighborhood JI instructor, who teaches our medics pre-hospital care doesn't know TCCC.  Two sandbags on the head, two large bore IV's, call Rampart and Bobs your uncle.  If only that worked!  And what part of the medic course is patrolling taught on?  How many trauma casualties does a medic see in a year?  Unless they work for a civilian service, not enough.
Seems we can't even master the basics.  We have a militia platoon commander here who's so confident in his knowledge and abilities, yet makes accusations based on false assumptions.  He claims to have the ability to think around a situation, size up what is required and then act in the most favorable way for the patient.  Yet a couple benign questions and he gets completely bent out of shape and defensive.  Is that a good way to practice medicine?  Or TCCC?
For TCCC to work, it has to be a joint effort.  And the Vandoo makes some brilliant statements.  But its not the Cbt Arms that has to learn from the medics, the medics need to learn from the Cbt Arms, and both need to learn what's missing in the middle.  Now it's just a matter of filling that gap and if the CF wants to dedicate time, effort and money to filling it.  

And one more thing, sometimes modesty can go a long way!


----------



## Donut

Seems to me you've answered a lot of your own questions here.

The JI teaches a course designed around stated CF requirements, which, for whatever reason, doesn't include patrolling.  If we wanted them to hire some tactics guru to teach parts of it, they probably would have.  We didn't.  There's another entire thread about tactical skills for medics, too.

In one line you say that medics don't see enough trauma in a year unless they work for a civi organization, then in the next you denigrate the medical skills of a full time ER Nurse who serves in the primary reserve at, no doubt, significant sacrifice for 19 years, as well as all other medically employed reservists. That's right, we're just the Mo, and those civi patients out there that we scrape up off the road or stitch up or heal every time we go to work have an entirely different physiology of those in the real army, so we can't possibly have any insight into how to look after soldiers when they're broken.

Your benign questions displayed a pretty high level of ignorance of the original thread, seeing as how the discussion was about the need for tactical training of medics and the medical tng of cbt arms to bridge that "middle ground", a discussion by actual, real, SME's, ie people who had taken and/or taught the course, or clinicians with a genuine interest in improving tactical patient care, and turned into a technical discussion about fluid resuscitation in the field.  

Apparantly, you need NS or another solution to piggy-back Pentaspan with.  Pentaspan, I'm told, even in relatively small amounts, provides a benefit to the hypovelemic patient.  I didn't know that, and now I do, thanks to reading a discussion between two other experienced health care providers.  Seeing as how I didn't make it to Op Med, and the info hasn't been distributed here, it's nice to find this stuff out.

Thanks to them, I'm one learning point closer to providing better tactical patient care.  That's kind of the point of this discussion, to improve tactical patient care, which is something even you seem to find agreeable.

So, have you any points of professional interest to add? Know a super-ninja-tactics type who can tell us how to do it better ( a new system), or is it just a matter of more tactical training for medics (more field time and the same drills)? 

DF


----------



## Armymedic

Janes, 
I hide nothing of my ability and background to discuss matters on this thread as a SME in this area. I play, teach and practice the skills mentioned and put forth what I have personally found, or heard from my peers experience, works. 



> It's important to realize, just because you're a medic or nurse or whatever in the Army, doesn't mean you're a TCCC SME.  Half the reason TCCC was presented to the CF was because of the lack of tactical knowledge and skill in our medics.  Not their fault, it's a training failure.  And the fact that civilian based approaches that the medics are taught, such as all your favorite acronyms (B/PH/ATLS) are the wrong approaches in a tactical and combat environments.



Well, yeah... Why do you think I like this, want this and encourage it to be taught to all medics and a good portion of the cbt arms. 

I also learned my tactical skills as a cbt arms soldier and combined those skills with good BTLS/civilian medical skills while employed with soldiers with a similar thought pattern like those in 3 RCR. We professional military medics take all those skills we learn and attempt to employ them in the most effective manner regardless of the situation. 

Before you take another shot over my bow, please bring some substantiation to your position.


----------



## JANES

This is the whole problem TCCC implimentation is trying to address.  You can't be the medic with a recce course and do BTLS in a tactical environment.  If you think thats what TCCC is, quite obvious you dont have a clue what you are talking about.  

This is a bad medium to learn in gents, I dont recommend it.  You cant verify any info as being true.  

For the record, you do Not need to piggyback a colloid (Pentaspan) on NS, it's a nicety that they do in a clinical setting. And this is the whole point.  The tactical environment is not the clinic.  Clinical practitioners take note.  Again, this is hardly the place to discuss Tx specifics.  If you want to learn about these things then talk to your MO.  Dont take discussion on a chat site as medical gospel.

I'm gone boys, nice chatting, but no one would give me the right answer to my questions, Whats 500ml of NS going to do for anyone?

Good luck!


----------



## Fraser.g

Who was talking about doing BTLS in a tactical environment?
If JANES read the whole thread instead of picking up on the conversation in the middle we would not be having this discussion. 

Who was he anyways? Reg? Res? or Civi who just wants to play army medic? his profile says zip.

GF


----------



## Armymedic

Janes, now you are annoying me. 

Being a good medic is taking any and all medical knowledge, and taking and and all fd/tactical knowledge and combining it all into a successful outcome for you patients.

Ref the 500 NS,
If you are a medical pers then this answer should come as no surprise, and if you had to carry any more fluid then that on long dismounted patrols you'd understand why I'd limit my load to 500 ml.

NS will increase the circulating volume by 500 ml in the short term. Due to osmosis and other natural forces, the circulating volume increase from the NS will decrease to 1/3 of that volume in 4 hrs. But as something is better then nothing, getting IV access and having something to put in is better then sitting with your thumb up your rectum. It is an effective increase if amb support is close by (less then 1 hour).

BTW, I have been given a job for the next roto which reaffirms to me the thougths of my chain of command about my abilities and knowledge. Needless to say, the MWO, WO and three Sgts would trade me positions in a sec.

So Janes...just piss off.


----------



## 2Charlie

Well, 

This has finally come into fruition, or at least the machinations to implement it in some framework.

After finishing my ICP in 1989, I completed my Advanced FA and then challenged the EMR program.

15 Years ago I was part of a five member group of MCpl's who got sent to the UK to participate in the UK Combat Medic Course.   It had a funky proper title, however it was ref'd as such as it was designed for grunts and most of it was done in conjunction with patrolling ops.   

Upon completion we submitted a Course Critique, recommendations etc for CFMSS, DND Special Centre and the Standards Gods.

In essence, implement the UK program in Canada or send Canucks there for qual.   As an alternative, train certain members of units to an advanced level and if time allowed, certify to the EMR level.   

There was no response or further contact.   

After remustering in 1991, with approval, I attempted to get most of the folks in my Section   to an Advanced level and   outfitted vehicles with para-med packs.   Essentially I was demonstrating how easy it was to get pers up to an Advance Level and the benefits thereof.   Especially in first response situations and as an augmentation in support of med perss.   

As a result, I was marched into the G-4's office, addressed in a rather unpleasant manner and told to cease and desist.   The overriding attitude was that CFMSS would be the only provider of any form of advanced first aid or higher forms of med intervention.   No consideration or training would be given to commoner lay people.   Ironically, some of it was dusted off for deployments after 1994, but quickly dissuaded or stopped by concerns of CFMSS.     

And to counter the IV comments above.   When appropriate instruction and time is allocated to IV's, a grunt can stick a cas effectively.   Some of the training I saw prior to deployments was essentially a JOKE.


----------



## Armymedic

> And to counter the IV comments above.  When appropriate instruction and time is allocated to IV's, a grunt can stick a cas effectively.  Some of the training I saw prior to deployments was essentially a JOKE.



Indeed the skill is easy to learn. As mentioned, 031 are usually well motivated to learn. And thinking that I am a competant instructor, I believe I can teach anyone any skill I am proficient at doing. The concern is the ability to maintain those skills without adequate practice and supervision, and the relevence of a cbt arms soldier maintaining a skill they may only use once or twice in a career.

Also IV's is a poor example of a skill for all mbrs to learn as there is a growing concern amongst trauma specialist as to the proper application of the fluids applyed. There is too many cases of a) wrong type of fluids, b) too much fluid, and c) steps such as controlling bleeding not being done, causing a negitive outcome for our patients. 

As such these concerns have caused us (medical pers) to avoid teaching IV skills, but instead emphise skills such as airway management and tourniquet application as taught with the TCCC.


----------



## 2Charlie

Yes,

I have heard all the empire related CONCERNS.

My Ex was a medic and no doubt one of your cohorts in this process.

I spent many an afternoon in Gagetown contributing my veins for medics to poke, why, I had a LOW BP with good veins.  Game on.

Try this on for size.  When the Canadian Forces was preping troops for Gulf War Part 1, it wasn't a Medic, Doc etc of CFMSS ilk who did the casualty side, it was a combat arms first aid instructor.

This instructor also was an NBCD Op.

The emph was the treatment of open wounds in a contaminated environment, AKA Kuwait.

Training was well received and is now part of the US TC program and a lesson on hot arid ops for the UK.  Input from a Canuck.  Moi.

So don't give me the knuckle dragging 031 adage.

Most of the civvie amb drivers I know are ex GRUNTS.  Ask anyone working in the South-Southern Ontario region (Win-Sarn), especially the air amb...


----------



## Fraser.g

There is no "knuckle dragging 031 adage to be seen here. The thought is that there is a profound change in thinking when it comes to fluid replacement therapy underway. Now what was the preferred fluid for traumatic resuscitation (Ringers Lactate) is going by the way side. One anesthesiologist I know is quoted as saying that it would not even be listed for human use if it was suggested today.
What is being offered is a new modality in Trauma Care on the battle field and that is reflected in the TCCC program.
People are fascinated by the concept of IV therapy, giving someone fluid is had become the symbol of assistance. The fact is that the whole idea of large volume fluid replacement is being questioned in the most learned halls of trauma care. So the question is not whether we trust the "knuckle dragging 031" or that we teach the combat arms what research says is the best way to keep their friends alive until they get to higher medical assistance.

By the way now the thought is that only three fluids should be bolused in a trauma environment. 1. Packed Red Blood Cells (preferably cross matched),2.  Pentaspan, 3. Platelets.The risk of doing any other with out the proper backup is that you will dilute the blood and therefore the clotting factor to the point that they will only bleed out pink instead of red blood.

GF


----------



## Armymedic

Correct nomiclature for the course in Canada is now the "Combat First Responder"...or so it seems.


----------



## vr

Question to the more enlightened:

How amenable are the Pentaspan/packed cells/platelets to the rigors of field life.  How would they hold up bouncing in a Med A bag or the back of an LSVW ambulance.  I'm sure there must be some sort of temperature restrictions esp. for the platelets/RBC.

Thx


----------



## Fraser.g

Pentaspan is kept at room temperature, like any other IV fluid you have to protect it from freezing. This is the most viable for the field environment.
http://www.rxmed.com/b.main/b2.pharmaceutical/b2.1.monographs/CPS-%20Monographs/CPS-%20(General%20Monographs-%20P)/PENTASPAN.html

Platelets are also stored at room temp but break down after 5 days.
The up side is that they do not have to be cross matched.
 (http://www.newenglandblood.org/medical/plateletlife.htm
This would limit the amount available by the supply train and therefore IMO be used at the UMS or higher but not with the field medic.

PRBC (Packed Red Blood Cells) 
The best replacement for blood loss
Need crossmatching and therefore the requirement for all blood types would need to be kept on hand.
Required to be refrigerated and agitated until used. The formed bodies start to break down in less than two hours at room temp.

I hope this helps

GF


----------



## Donut

From Dr K Mattox's editorial on Fluid Resuscitation on trauma.org

" No IV lines should be started if the patient cerebrates normally or if a line is started, the rate of fluid administration should be to keep open only. Some clinicians would desire an intravenous portal just to be available in case the patient "crashes." In the absence of cerebration, the examiner looks for the presence of a radial or pedal pulse. If present, no lines are started and transport or treatment is determined on the basis of diagnosed injury. Should the peripheral pulse be absent, a solution of an acceptably standard fluid is given in aliquots of 25 ml. until a pulse returns. At that point, NO ADDITIONAL FLUID is administered. This approach has been recently used with success in some international military campaigns."

The whole article can be found at http://www.trauma.org/resus/permhypoeditorial.html

I urge you to read it.

So, we don't need a whole lot of WHATEVER we're infusing, unless it's packed cells, which, even then, probably should be used judiciously until after operative control of the bleed is achieved.

So, bring back the Buretrol chambers for fluids?


The British Medical Journal published (BMJ 1998;316:961-4 ) a meta-analysis of fluid resuscitation trials involving both crystalloids and colloids found virtually no difference between the two; in fact one study I came across suggested colloids were associated with a 4% higher fatality rate (one of the few REAL indicators of trauma resuscitation success or failure). Granted this was conducted in 1998, and the methodology may be somewhat suspect, I haven't found any newer studies then this, not in Essentials of Paramedic Care (published 2003), not in the new BTLS text, not on Trauma.org, the ACS, CAEP or other websites I visited.  A google of "colloid resuscitation" turned up lots of journal articles, all pointing to the same study, or a similar, older meta-analysis of other trials, a 1989 study by Velanovich, which found a 12 % benefit to colloid in traumatic shock patients.

We have two meta-analysis of older trials.  One shows worse outcomes with colloids, one show benefits to colloids.

Beyond the hypothesis that colloidal osmotic pressure will bring additional fluid into the vascular spaces and therefore be of benefit, do we have a EBM reason to put colloids into service, or is it "just common sense" this will work?  Can someone point me to a peer reviewed study, please?


Primum non nocere.  Let's keep that in mind when we go to work every day.

DF


----------



## Armymedic

This is good stuff..bring on more.

I haven't seen anything published later then what you found either. Some of my info is from talking to people and presentations I received during OP MED. Much of the debate about which type of solution is better goes as much towards weight issues (how much you have to carry and how much needs to be put in to get the same effect)  as it does the effect on the outcome of the patient.


----------



## Fraser.g

I think the topic of fluid Resuscitation deserves its own thread and will allow this one to continue with the TCCC topic.For that reason I have started one specifically for the Crystaloid/colloid/bolus debate.


GF


----------



## Fraser.g

Armymedic said:
			
		

> Correct nomenclature for the course in Canada is now the "Combat First Responder"...or so it seems.



Do they have different TPs?
 Who is running this new Combat First Responder? 
Is it through CFMG or is it a brigade or area initiative?
Does anyone have any more info? 

It is great that someone has taken the ball and gone for a run, now it has to get to as many troops as possible.

What would be the best route to go about this? Through the field ambs? 

Yeah I know alot of questions and not alot of answers but the iron is hot so lets get this thing in gear!

GF


----------



## medicineman

I have heard through my grapevine here that TCCC or whatever it's new nom de jour is might be coming here to Gagetown and run through CTC.  That would almost (I emphaisze almost) make some sense - bigger budget, more resources, etc, though there might be some fun trying to get some specialist physicians to teach some of the classes.

On another note about the course, it's great that something is coming back to replace the old Combat Medical Techniques course - we've been straying a bit (well, alot) in our training of the newer folks and refreshing some of us old farts as well in battlefield medicine and survival.  I remember vividly one year in Calgary when our CO's competition went off and the guys/gals were being graded upon applying BTLS "protocols" (verbatim from the book I might add) while under simulated mortar attack and machine gun fire.  Most of us know how hard it is to use a stethescope in an ambulance, forget if someone is blowing stuff up all around us (and as if you would in real life - please tell me you wouldn't!!).  The judging sheets didn't take that into account and everyone was expected to apply everything according to the book.  In fact, after my platoon went through first, I noticed the "battle" took on a shorter and quieter tone ...

Unfortunately, you have to think and act a somewhat differently under fire and that includes patient assessment.  Tactical EMS courses in the US dedicate a fair amount of time to patient assessment in sensory deprived conditions and adapting the assessment to the situation and to a point that was taught on the CMT.  I know this might sound a little heretical (especially from a BTLS Instructor), but we really ought to be using Dr Campbell's assessment methodology exactly as it was intended to be - a recipe - and not the Gospel according to him.

My rant for the day.

MM


----------



## Donut

I agree wholeheartedly, I don't think it's heresy to say we need to adapt Dr Campbell's vision to the situations at hand.

I think it would be grossly negiligent to not provide a perfect survey of the patient when doing so doesn't delay evac, doesn't expose responders to risk, and the resources are there, but you're absolutely correct, it's a recipe for care, not the only way to do deliver it.

I'm wondering if Pet would have been a better place to run the course?  Between 1 CFH and 2 Fd Amb they've probably got one of the highest concentrations of our doctors, plus the CFH's simulators, or even Valcartier with the multi-media simulator?  

Anyone have a good CD of battlefield sounds?  Maybe we'll need to record the next BatSim out this way...then you put them in a bunny suit...turn out the lights, start a strobe light...

If it's run in Gagetown, could they syncnronize the course with some other cbt arms tng, get the mech inf out with an inf QL3, the armoured out with an armoured 3's, etc?

How do the American's control their CLS programs?


----------



## starlight_745

My understanding of the CLS in the US is that any medic can teach the course. All the LP's and checklists are available it just requires some initiative at the unit level to get time and stores set aside to run the course.  I also believe it requires around one day per year of refresher training.


----------



## Armymedic

Not any medic can teach CLS, as there is a specific qualification for that, but most above E-5 (straight up Sgt) get it as I recollect (its been 4 yrs since I worked with the yanks). There is material avail on line, try to Google it and see what you get.

I have heard such rumour as well about it being taught in Gagetown (tactics school), and in Borden (CFHSA)....either way its coming out. Personally, it should be taught by the brigade Fd Ambs as that is where the medics and the infantry work the closest.

The TCCC/cbt first responder I teach is more mission specific then what the new courses will be when they come out ot everyone. With the team I will be deploying with, I will be teaching the following skills:

Tactical Assessment,
Airway management and suctioning, NPA
Tourniquet application and removal,
asherman chest seals & chest decompresion

and skills so they can assist me:
C-spine and collar,
initiate (read prime) IV's


----------



## medicineman

The CLS has been a bit of a pet peeve of mine for several years now - ie trying to implement it here.  I have the courseware CD from the US Army - to be an instructor (unless it's changed) you need to be a Senior NCO and an "experienced" CLS.  Instructor is a bit of a misnomer - more like facilitator, becasue alot can be done by distance ed.  I managed to get hold of the CD after much nashing of teeth - took an officer to get it for me (Tech Adj at 2 RCR).  The idea was to try it out with 2RCR - in the end, all the while waiting for some blessings from above, I designed a combat first aid package that seemed to be well received by the unit (they're still using it I mean) - did some real world bleeding control and TK use, rapid surveys and blast/ballistics/burns.  Prior to deploying on Op Athena for the TAT, I did a little IV and morphine famil session as well (hey, my ass could get nailed too).

I couldn't tell how they plan on integrating the TCCC course into the CTC program - it's all still in the word of mouth/pencil stage. Watch and shoot for now.  But, on the bright side, if we're hearing these rumours, the Army wants the training so it's just a matter of when and where it'll be delivered - of course how and by who as well.

MM


----------



## Armymedic

The Army lessons learned center's latest edition of "Dispatches" (Vol 10 no. 2) is about the Tactical Combat Casualty course, written By Cpl Kopp of 3 PPCLI.

It is a good read (as per most ALLC Dispatches) that covers all the good, bad and misunderstood points of current military tactical medicine...even though he is a Infantryman (albiet a civ qual paramedic).

If anyone out there knows Cpl Kopp, pass on a BZ for me.


----------



## PRL ER NO

Can you forward the link for that article.  Sounds like a good read.

Thanks


----------



## Fraser.g

It's not up yet but when it is you will find it at:
http://armyapp.forces.gc.ca/ALLC/Downloads/dispatches.asp?tree=downloads

GF


----------



## Navydoc

Gents-

I came across this chat while at the SOMA meeting 2004.  I represent the USMC on the Committee for TCCC.  I noticed a lot of valid questions about the program and some issues on what is taught.  If I could provide a brief outline, you can fire any questions, concerns, requests my way in the future.

1.  TCCC was born out of the SOF experience in Mogadishu
2.  SOCOM currently endorses TCCC and trains all departing SOF units in TCCC principles.  SOCOM also provides essential supplies.
3.  TCCC is spreading to the USMC and beyond.  TCCC is a mindset, not a rigid set of rules.  It attempts to train medics, corpsmen, and warfighters on how to save lives during the battle.  Obviously, there is more to it.
4.  The Committee on TCCC is composed of trauma surgeons, ER physicians, Delta medics, SOF medics, PJs, and a few good ole Navy docs.  Almost all have seen combat.  All have seen death.  They know their stuff.
5.  TCCC guidelines and ppt presentations can be found on the NOMI (Naval Opeational Medical Institute) website- just google search.
6.  TCCC is being used in Afghanistan and Iraq and is saving lives.

Feel free to contact me for more specifics.  Thanks for the service and thanks for pressing the important issues.

LT David Callaway
Third Radio Battalion
US Marine Forces Pacific


----------



## Armymedic

Sir,
Welcome to the board, any insights and opinions you have are welcome. As we are all a creature of our experience and instruction of others, I look forward to any real time experience you can bring to the site.


----------



## medicineman

I got hold of said powerpoint slides -alot good stuff and some rather intrigung stuff in there too, such as personal non-narcotic analgesia - they have 1G Tylenol with 50mg of Vioxx in a pain pouch as it were - something to get the morphine monkey off our backs for people that can tolerate PO meds.

MM


----------



## Fraser.g

The US troops in theater carry the above mentioned Pain pack along with a broad spectrum antibiotic that they are to take immediately on being injured. 

I don't know what a couple of plain Tylenol will do for the pain and now that Vioxx is pulled from the shelf I assume they will be dispensing another anti-inflammatory in its place.

Morphine is still the gold standard for pain control. As long as it is being used in appropriate doses for analgesia there should be no problems with addiction. Where we were hitting the snag is that it was being given IM. Hmmmm Pt loosing blood, going into shock, shunting remaining supply to heart, lungs and brain... away from voluntary muscle...minimal analgesic getting into systemic circulation...Analgesic not effective....given another shot IM.... Pt gets to treatment facility...fluid resuscitation started...blood returns to muscle flushes out all the morphine...Narcan required!

GF


----------



## medicineman

I was rather bemused myself about the Vioxx issue.   I did work with some docs previously who had no greif giving out high doses of Tylenol with or without an NSAID for pain relief.  I still see and read form some medical texts as well that high end NSAID's should be first line for some pain.  A good dose of an NSAID coupled with a high dose of acetaminophen can produce a decent level of analgesia without the narcotic side effects that could inhibit someone who is not terribly injured from putting rounds down range.  The NSAID is also there to try and settle some immuno-inflammatory reactions to trauma.

As for the morphine issue, you're preaching to the choir.  As a pharmacist told me one day - as long as they are in pain, they won't stop breathing on you, so top them up just enough.  You can only do that by IV.

MM


----------



## Fraser.g

With the majority of battle field wounds (80 %) being penetrating I would be hesitant to give anything by mouth as they probably are surgical candidates. The analgesic  aspects of Tylenol are well established and I am not calling it down by any stretch of the imagination however I think it would be the analgesic equivalent of hitting an elephant with a fly swatter. If there is going to be a delay in getting that soldier to care then go for it. The only cautionary thing would be if they are injured in the abd of course. On the side of narcotic effect, if a person is in that much pain to require analgesic they are not going to be in any shape to fight. If you have the time to start an IV or lock then I suspect that the fire fight is over in most cases. 
Remember that in battle field aid the first thing you have to do is make the scene safe and that means winning the fire fight. I don't think St Johns had that in mind when they started teaching the scene survey LOL.

As one of the docs said at OP Med..."Remember your ABC's...A Get your ass down, B  Get you butt out of the line of fire, C Circulation (Deadly bleeds only)"



I suspect that they will replace the Vioxx with Baxtra in the near future. 

GF


----------



## Fraser.g

It is on line now

GF


----------



## MJP

> If anyone out there knows Cpl Kopp,



I was in the same section as him in Bosnia.  He is a SAR tech now.


----------



## Infanteer

Very cool.  The mentality behind this publication is the one we need.  I'll second the BZ.


----------



## Armymedic

The first time I read the credits, I was thinking "what the f#$%? Why is an infanteer writing this?"

Then I thought, if you want to get this message to the masses, its better to use an infantry Cpl, then a trauma surgeon Major. 

I ensured every mbr of the team I am going overseas with has a copy. All mbrs want the skill while we are in Afghan. The RCR Major, upon return from tour is going to push for this training for the Bn upon his return.

Too bad it takes people to die to realize what it is we need.


----------



## Fraser.g

here is the link for the PPT for the TCCC course overview.

http://ppt.armystudyguide.com/first-aid/12.htm

There is allot of good stuff on this site. 

Merry x-mas

GF


----------



## Laps

I started reading the new Army Lessons Learn - Dispatches today, one that talks about Casualty evacuation.  I really like the fact that the army realizes that the good 'ol standard first aid and CPR from St John Ambulance isn't quite enough.  I hope the airforce (or at least my part of the airforce - the kind that plays with the army quite a lot) gets into it as well.

That booklet talks about the new TCCC course as a pilot program(? meaning of TCCC).  I have not finished reading the whole booklet yet, but I was interested in finding if such a course is offered at large, and what it consists of.

Thanks for any info...


----------



## Blakey

TCCCS "Tactical Command and Control Communications System" I hope I got that in the right order.


----------



## PPCLI MCpl

I believe it is the Tactical Casualty Care Course


----------



## Blakey

:rocket: Blakey


----------



## old medic

Us medic types have a long thread about TCCC going. 
It is located at:

http://army.ca/forums/threads/17775.0.html

Cheers


----------



## Armymedic

This topic has been discussed in depth in the Combat Service Support Site.

Boys, you are both right:
TCCCS


			
				Blakey said:
			
		

> TCCCS "Tactical Command and Control Communications System" I hope I got that in the right order.


TCCC


			
				PPCLI MCpl said:
			
		

> I believe it is the Tactical Casualty Care Course



the new nomiclature in the CF will be "Combat First Responder"

Mods: please move to CSS...


----------



## Laps

Sorry guys for jumping in at the end of a (very well) established thread...

I started reading the Army Lessons Learned on the TCCC today and I was quite thrilled about the whole thing, since I didn't know that such thing was around.  As a St. John Instructor (don't shoot me!!!) teaching in the military, I have been fighting for a while for something more military-like.  However, despite working for the army, the tachel's airforce's origines remain just that: Airforce.  There seems to be a fair bit of apprehension into jumping towards such a great idea.

Can you guys let me know where the course's devolpment is at, and when should we expect to see people taking the course at large?  From what you guys seem to talk about (yes, I did read the whole thing), the course appears more geared towards the already Med-A qualified guy.  Asside from the PHTLS / BTLS dillema and issue (BTW, we are having a hard time getting a medical director for a PHTLS course, so they DO require medical direction), will there be a difference between a course taught to combat or CS / CSS guy than for a medic?

Again, sorry for jumping in late in the "chat"!!!

Laps

PS.: I guess you guys will have to forget the Vioxx now...  good 'ol Motrin anyone???


----------



## Armymedic

Laps said:
			
		

> Can you guys let me know where the course's devolpment is at, and when should we expect to see people taking the course at large? From what you guys seem to talk about (yes, I did read the whole thing), the course appears more geared towards the already Med-A qualified guy. Asside from the PHTLS / BTLS dillema and issue (BTW, we are having a hard time getting a medical director for a PHTLS course, so they DO require medical direction), will there be a difference between a course taught to combat or CS / CSS guy than for a medic?



No problem Laps welcome aboad. (Not ANOTHER chopper pilot on the site   :)

A proper course is being developed as we speak. The course is directed at both the cbt soldier to teach them medical skills, and the med techs to teach them a bit of tactics. Medical skills (no matter the name) are the basics.

Where are you at, maybe I can suggest course of action to help you hitch onto the course.


----------



## Laps

I'm out of Edmonton.  I thought that while it would be next to impossible to get our members on such course, we could probably have a couple of FA instr TCCC qual'd, and we can maybe modify our FA course accordingly.  We do spend a fair bit of time in the field, and have extremely limited med ressources, so some more advanced medical training would definitely be an asset.


----------



## Armymedic

give 1 Fd Amb tng a call, they may be able to set you up.

Just remember, the course is not meant to replace medics, but to supplement them.


----------



## Laps

I'll try to give them a buzz and see if we can get some support.



> Just remember, the course is not meant to replace medics, but to supplement them



You're right, but until the time where we will get more than 2 medics per Sqn, we will have to make sure evrybody knows what to do when someone gets a bullet...  (Something the Airforce could never imagine happening) :warstory:


----------



## Armymedic

or the time between crash and SAR arrival...

oh yeah, you guys don't crash, but land with more than normal force... :


----------



## Laps

My seat will stand the crash... uhmmm hard impact...  bu the troppies' one in the back is a different story.   

On a different note, I would be really interested in this course, so if anyone's got some good info, please let me know!


----------



## Armymedic

Heck, my ideal "flight" is where I depart the aircraft before it lands.


----------



## medicineman

When we run a BTLS course here in Gagetown, we usually have spots available on it for non-medics.  These people still have to do the same pre-reads and skills stations, just that the learning curve is different as alot of them have to make up for lack of prior medical training and we only test them on Basic Provider skills.

MM


----------



## Fraser.g

TCCC seems to be more of a mind set than a course in its self. It seems that the TCCC is one lecture of many in the Combat First Responder Program and T-FIT programs offered by the US Military.

Ref:
http://www.drum.army.mil/sites/tenants/division/CMDGRP/SURGEON/91W%20slide.htm

GF


----------



## Armymedic

One difference of thought is that the new 91W program teaches TCCC skills as part of the US Armys medic training. Its somewhere we need to go soon for our medic as well.


----------



## Fraser.g

Absolutely. 
It has to be part of both Medic training and Combat First Responder/Combat Life Saver. We have to get away from the SFA mentality. Yes it has its place but that place is not in combat operations or a field environment. We have to teach both the 0 trades and our medics how to function and save lives in a military context.


----------



## JANES

Has anyone heard anything concrete about national standardization or implimentation?  What is the means and the end?  And who knows enough about it to make sure it is done right?


----------



## Fraser.g

JANES,

Good questions both. The answers are that any BTLS Advanced Instructor can teach the skills involved in the TCCC. TCCC is only a mind set to a greater treatment course. IMO what needs to happen is to run a BTLS Advanced Course with the TCCC priority listing of skills. Please see the skill set attachment to the thread "restructuring the reserve" as an example. As of now it has only been run at the area level for deploying combat arms types as an adjunct to their regular training. They did not get the kits until in theater and then had to turn them in on repatriation. 
What is needed is a re righting of CFAO 9-5 has to be re written to the TCCC standard or at least a SFA standard.http://www.admfincs.forces.gc.ca/admfincs/subjects/cfao/009-05_e.asp. 
Another thing is that each of the areas and/ or regiments should start requesting the training for their troops. 
This is how it is going to be for the next while and it is a damn good standard to be teaching a select few of the combat arms troops to. 
It is up to CFMG, and the area commanders to elevate the standard of medical preparedness within their commands.

IMHO


----------



## JANES

You see, this is where you're wrong.  The whole problem that TCCC was designed to solve was to get out of the BTLS mentality casualty approach.  The BTLS instructor (alone) has no tactical background, and if they do then is it standardized TCCC?  It seems to me like it is the delicate balance between tactics and medicine, not civi medicine in a fancy green uniform.  To teach someone to stop bleeding and crack a chest is not enough, you need to teach them how and when to do these skills in a tactical and combat environment, hence its name.  You can read all the slideshows and books you want, but to truely understand it you need the experience.  So I'll ask again, who will develope the standards and who will teach it?


----------



## Fraser.g

Ahhh,

If you read my last post I stated that "any BTLS Advanced Instructor can teach the skills involved in the TCCC". The skills can be taught like needling the chest, applying a tourniquet etc. What has to be taught is the skills and then how apply them to the tactical environment. There are some things that BTLS and TCCC do not mesh on and that is dictated by the environment. 
As I stated before TCCC is a mind set and a read of the environment. It is a theory, based on practice, that the individual receiving the course can then use as a guideline for application in the field. The BTLS course is the basis of Prue-hospital care in North America. This way the Combat First Aider and the Medic are all on the same sheet of music and if there is a deviation then there can be a rational for the deviation. The problem with BTLS is that it is too rigid and why we are now looking and liking the TCCC guide to amend the course for military use.


True any monkey can stand up and click a PPT slide show with out knowing the material. The idea here is to teach First Aid that can be applied in a combat environment.


----------



## Armymedic

JANES said:
			
		

> You see, this is where you're wrong.   The whole problem that TCCC was designed to solve was to get out of the BTLS mentality casualty approach.   The BTLS instructor (alone) has no tactical background, and if they do then is it standardized TCCC?   It seems to me like it is the delicate balance between tactics and medicine, not civi medicine in a fancy green uniform.   To teach someone to stop bleeding and crack a chest is not enough, you need to teach them how and when to do these skills in a tactical and combat environment, hence its name.   You can read all the slideshows and books you want, but to truely understand it you need the experience.   So I'll ask again, who will develope the standards and who will teach it?



CF H Svc Gp will, eventually.

BTW, you are also wrong. TCCC was designed to get out of the (ST Johns, Red Cross) Standard First Aid mentality casualty approach. Actual medical skills being added to tactically adept soldiers to alleviate the requirement to have medical specialists along with every special mission.



> The problem with BTLS is that it is too rigid and why we are now looking and liking the TCCC guide to amend the course for military use.


Newest versions of BTLS is not as rigid. Its the instructors who are too rigid. In my BTLS courses, we give example in military medicine, and actually look at options when you don't have the perfect 3:1 ratio of providers to casualties.

And what would be so wrong with an Adv BTLS instructor/Coordinator like myself teaching 30 infanteers TCCC?


----------



## JANES

Everybody sure does a good job of letting everybody else know how smart they think they are.  But does anyone really know how this is going to be implimented and standardized nationally?


----------



## Fraser.g

For someone who has ZERO info in their bio you are certainly pontificating allot. The answer is that it is still in the developmental stage. We have offered as much info as there is at this time. If this does not satisfy you then I am sorry but that is all there is.

In the future I would suggest reading all the posts in all related columns before demanding information on a subject.

Have a great day.


----------



## JANES

Who's developing it?


----------



## Fraser.g

Once again

From Armymedic "CF H Svc Gp will, eventually"


----------



## excoelis

JANES said:
			
		

> To teach someone to stop bleeding and crack a chest is not enough, you need to teach them how and when to do these skills in a tactical and combat environment, hence its name.   You can read all the slideshows and books you want, but to truely understand it you need the experience.   So I'll ask again, who will develope the standards and who will teach it?



Sorry to wade in on a discussion that is outside my area of expertise, but this latest from Janes strikes me as a sophism or 'circular logic'.   I would like to see some of you fine folks teach me and the boys some of this new shit before heading back over to the sandbox.   So if we all sit around arguing that if you don't have operational experience in a tactical environment then you can't teach it - then we will deploy with the same old shit - while the argument continues and the wealth of knowledge remains untapped.   So if no one makes the call, teaches it, and tries it out operationally then it is relegated to another great idea that never came to fruition.   Shit or get of the pot I say.   Personally, I'm impressed by the positive forward thinking research and discussion going on here.   Conversely, I see no benefit to me and the boys from negativity without advice or solutions.   I don't plan on recruiting my troops from the local penitentiary before going down range just because I know they have 'trigger time'.


----------



## JANES

I like this guy!


----------



## Armymedic

excoelis said:
			
		

> I would like to see some of you fine folks teach me and the boys some of this new crap before heading back over to the sandbox.
> 
> So if no one makes the call, teaches it, and tries it out operationally then it is relegated to another great idea that never came to fruition.   crap or get of the pot I say.



We are pushing it. Edm is did courses 2-3 weeks long, and cont to instruct thier guys before going over. After the well recieved courses that were run in Pet for Roto 0, we've got 20+ cbt arms taught prior to deployment training for roto 3, and plans to teach about 50 more. The team I am with (14 Snr NCO and Officers), I spent a day teaching the lectures and introducing the skills so in one day upon arrival to theatre we can test them, and they will be able to do the skills. 

But we are at the bottom pushing up....nothing goes quick that way.

As for standards, Pet and Edm are doing thier own courses, with thier own style and content. There is no standard. A working group in Health Services HQ has been developing the standarization and implementation of a CF Cbt first responder course for about a yr now, and it is one of several areas for improvement that is being developed. The closest standard we have is Cpl Kopp's article in the Lessons Learned Pub, and a great standard it is.

Who will teach?  In Edmonton they used BTLS and PHTLS inst qualified Medics and infanteers. In Pet, because we only teach the medicine, we use BTLS instructors with PA's and MO's for evaluators.


----------



## Fraser.g

Excoelis

This is where we are as far as I know.

There was a pilot course taught by 1 Fd Amb to selected members of 3 VP before their deployment. From what I understand the course was quite expensive to run. It was 2 weeks long with the first week being dedicated to the medical interventions taught and methods of evacuation so that the candidiates were familiar with the kit like Bison Amb and Helos kited out with litters etc.

The second week was an FTX where the candidates rotated through the part of the Combat First aider on fighting patrols and other tasks. They got bumped and moulaged casuaties were introduced. The First Aider had to act accordingly to prioritize and evac the cas when apropreate in the tactical scenario.

It was expensive because of the Helo support and the insane ammount of blank ammo and pyro used. 

IMHO it could be done in less time for money. Yes the pilot was a great course and I would have loved to teach on it but I believe the cost will make the bean counters balk.

So this brings us back to the main question. "How do we get this product from the medical side of the house to the pointy end where it is needed?"

I believe the answer is a two pronged approach. 
1. there has to be a will from within the medical comunity to pass the infromation down and provide a course that is both cost and time effective while simultaniously provide an end product that will save lives on the battle field. The US has proven in the past two years that this avanue of treatment works.

2. There has to be an increased pressure from the combat arms units to CFMG to provide this course. The "Dispatches" on the topic is a great step in increasing the awairness of the course to the "Zero" trades.

We as the end providers and users must keep up the pressure or this innitiative will fall by the wayside as so many other great ideas that loose steam. 

So what can the individual do?

1. Request the course up the chain of   command.
2. Request it again
3. and again
4. repeat steps 1-3 until the desired result is attained.

GF


----------



## excoelis

Yessss........the beancounters and their self-aggrandizing, self-perpetuating beauracracy.  I love how they sit on shit like this and Light Forces doctrine so they can feel impotent........oops Freudian slip......important.  Fact is the troops at the coal face are quite adept at identifying needs and persuing results with a vengeance, particularily when it is of grave consequence to do nothing.  We have had Docs from 'certain communities' teaching TCCC on the Patrol Pathfinder course for a few years now.  How is it that as a student or Instructor on a COURSE you can get that, and actually deploying operationally in that role you have to wait until some pompous ass makes it all HIS idea?  I suppose that question is rhetorical :

Good luck with the push boys...........don't worry the pull is already there!

I'll let you guys get back to your blah-blah-50ml-plomywhateverstuff discussion and I'll go back to beasting the cadets in one of their threads ;D


----------



## Radop

RN PRN said:
			
		

> Excoelis
> 
> There was a pilot course taught by 1 Fd Amb to selected members of 3 VP before their deployment. From what I understand the course was quite expensive to run. It was 2 weeks long with the first week being dedicated to the medical interventions taught and methods of evacuation so that the candidiates were familiar with the kit like Bison Amb and Helos kited out with litters etc.
> 
> 2. There has to be an increased pressure from the combat arms units to CFMG to provide this course. The "Dispatches" on the topic is a great step in increasing the awairness of the course to the "Zero" trades.


I am reading that right now, very interesting as I am a First Aid instructor.  I thought that what you discribed was like MCM in St Johns Ambulance's first aid with a  combat perspective.  I do see wholes in SFA and CPR trg but for all soldiers in Garrison, I think it is evective and appropriate.  I would like to see all instructors qualified to this level to teach all field trades not just combat arms.


What is the plan for the future of this course, as an instructor for St Johns first aid, I would love this course.


----------



## Radop

Armymedic said:
			
		

> The first time I read the credits, I was thinking "what the f#$%? Why is an infanteer writing this?"
> 
> Then I thought, if you want to get this message to the masses, its better to use an infantry Cpl, then a trauma surgeon Major.


I think that it coming from him was definitely an eye opener.  Let some of our snr people know what would happen it they were to listen to their men.  I recommend the read as I am half way through the book now.  I would like to take the course and am a First aid instructor. :


----------



## JANES

St Johns ambulance first aid goes against the majority of what is taught in TCCC.  Everything from casualty approach to the use of tourniquets and the non use of CPR, removing dressings if the bleeding is not controled and even pushing bowel back into the gut, all goes against St. Johns teachings.  TCCC is as much tactics as it is medicine.  There is no tactical scope in St Johns, and an advanced first aid instructor won't have the knowledge on anatomy physiology and skills to properly teach it.  The new dispatches explains this all well.  It is what TCCC is trying to get away from.  It is great for the Gari-trooper that wants to get their CDS commendation for doing CPR on some fat civi who had a heart attack at McDonalds, but I see no scope for for the cross over.  It would be going backwards.


----------



## Fraser.g

Radop

The Combat First Aid course utilizing the TCCC approach is not for garrison life nor exercises. It is for a tactical environment where the mission comes before the immediate concerns of the individual while simultaneously trying to preserve as much of your own manpower as possible while trying to deny the same to the enemy. It is not for any scenario where you have the luxury of calling End Ex or No duff and shutting things down while your get your wounded out. I see from your bio that you have many tours under your belt. Should select members of every section have access to this information... Yes, and it should not matter what trade you are. Should the combat arms trades have first crack? Yes, because they have a greater chance of using the skills. It is much more advanced than anything that St Johns teaches or would want to take liability for. The bare minimum level of instructor for the course is an ALS Medic.

GF


----------



## Radop

JANES said:
			
		

> St Johns ambulance first aid goes against the majority of what is taught in TCCC.   Everything from casualty approach to the use of tourniquets and the non use of CPR, removing dressings if the bleeding is not controled and even pushing bowel back into the gut, all goes against St. Johns teachings.   TCCC is as much tactics as it is medicine.


I thought you were a medic.  If you look at MCM again, cardiac arrest casualties are lowest priority.  Tourniquets are discouraged in St Johns ambulance not disreguarded.  As for the bowels back into the gut et al, the reasoning as you should know if you read Lessons Learned, is due to availability of medical aid.  Leaving organs out for 72 hrs would definitely cause complications.  St Johns Ambulance teaches similar techniques in wilderness first aid as what is proposed in TCCC except for tactical considerations.  Tactics is the biggest difference I see between TCCC and St Johns Ambulance.



			
				JANES said:
			
		

> There is no tactical scope in St Johns, and an advanced first aid instructor won't have the knowledge on anatomy physiology and skills to properly teach it.   The new dispatches explains this all well.   It is what TCCC is trying to get away from.   It is great for the Gari-trooper that wants to get their CDS commendation for doing CPR on some fat civi who had a heart attack at McDonalds, but I see no scope for for the cross over.   It would be going backwards.


So what you are saying is that medics know tactics and medicine well enough to teach this course!  I have seen few medics that can teach anything about tactics and even fewer that are attached to Coys in the infantry.  As for knowledge about anatomy, I took physiology in university and somehow passed yet me is just a sig op.  You expect to teach infanteers this knowledge yet you say they could not teach it once they were qualified?

As for Gari-troopers, tell that to MCpl Hamilton and Cpl Matthews who crawled through minefields to reach Sgt Short, Cpl Beerenfinger and Cpl Stirling (who they were able to treat and enabled him to survive possibly) and have been announced as being awarded the Star of Courage.  Yet they did this with only the St. Johns Ambulance course.

I think that first aid instructors would be able to get the anatomy knowledge down.  I know what a presure point is, what a flailed chest is, and other injuries are and building on what we already know would be better for us all.  Things like standards should and must be controlled by medics as they should be the ones that are the best trained for combat first aid.  We would be the ones who would have to carry out the first aid in combat situations.  In our trade, we are often sent out on RRBs where we are left on our own accord.  We ussually have no medics and if the vehicle is downed, we may have to defend our location until reinforcements and casevac arrive.  Can the medics train 1 in 8 to be a TCCC soldier especially if a Battle Group of 2500 is departing to lets say, Afghanistan?  I know a lot of first aid instructors that are more trained in medical care than medics.  Plse don't downplay the role this training provides.

Further to that, most of my time in the military has been spent in Canada.  TCCC would not be the best method of treating wounds in this case as medical aid would be brought in within one hour.  The procedures outline in St Johns first aid would be the best steps to follow.  As for saving someone at McDs, should we not try to preserve life of all Cnd people?  Do we only protect people who meet our fitness criteria?  If you are a medic, do you only treat people who get injured while you are on duty?  I enjoyed learning Children CPR as it was something I could do if my child ever suffered an injury that caused their hearts to stop such as electrocution.


----------



## Radop

RN PRN said:
			
		

> Should select members of every section have access to this information... Yes, and it should not matter what trade you are. Should the combat arms trades have first crack? Yes, because they have a greater chance of using the skills. It is much more advanced than anything that St Johns teaches or would want to take liability for. The bare minimum level of instructor for the course is an ALS Medic.



I see but as I stated above, I feel you would get swamped with the numbers if what was proposed in the Lesson Learned dispatch comes to fruition.  I believe that Combat Support units are almost as high for casualties especially Eng who are exposed to land mine clearances under tactical settings.  Artillery on the other hand are 7 Km or further from the enemy at most points in battle.  One of the people developing the plan was an infanteer (although a paramedic trained one) so I think that having others trained as instructors and standards being a medic responsibility would be best and most cost effective (as this is the most important point for COs).


----------



## Armymedic

Ok lets sum up this argument as to who will teach the TCCC/ Cbt First responder/ or whatever....

All medical services and treatments provided to the members of the CF fall under the legal responsibilities of the Surg Gen. Those responsibilities are delegated down thru the med chain to the lowest level at the MO, PA, NP level. Med Techs are authorized to provide medical services with a specific scope of practice that is allowed thru that chain, but ultimately its the supervising MO, PA or NP who is responsible for maintenance of the standard.

So for an TCCC/Cbt first responder trained nonmedical person to be able to practice and use the medical skills (and hence teach them as well...) they must first gain approval of their command (brigade, wing, fleet) Surgeon.

These Majors, who are no different then any other officer, trust in their Snr NCOs and troops. They trust in their skills as medics and as instructors. 

For this reason, all medical training on these courses will be conducted by Medical capbadge wearing personnel. 

Radop does bring up a good point, as FAI could possibly teach this. Not wrong as a good instructor with a sound knowledge of the subject matter will be a capable instructor regardless of the subject. But the skills taught and tested on the course are outside the acceptable "scope of practice" for a FA qualified CF member. But a Cbt Arms Snr NCO or MCpl FAI would be a good skill set to teach the tactics portion of the course.

Anyway we are all arguing the definition of fruit here. Apples are the best fruit. No oranges are the best fruit. No pears are the best fruit.....

It really doesn't matter as long as we get to eat good fruit.


----------



## excoelis

Armymedic said:
			
		

> It really doesn't matter as long as we get to eat good fruit.



.......and you are what you eat, you.......  ;D


----------



## Radop

RN RPN and Armymedic thanks for your imput.   

Armymedic, what I can assume is the main reason is that the procedures are more of a 'medical' procedure than a 'first aid procedure' and as such you must be taught by medical personnel approved/under the direction of a doctor.   This would be similar to the use of AEDs which needs you to be certified by a medical doctor.   Is this correct or am I missing something?   At least your not telling me I wouldn't be able to figuar out anatomy.

RN RPN, I understand that you would not use this on exercise, domestic ops or even probably on peacekeeping missions.   On deployments such as OP APOLLO or ATHENA, the use of both SFA or TCCC would be required depending on the situation both tactical and availability of Casevac.

Unlike what Jane said about SFA only being good if you want to treat someone having a cardiac arrest at McD, first aid is a way of assisting people in need of help.   I have assisted many people with the knowledge I have and most of the time all I have had to do is "steady and support until medical aid arrives".   I am not a doctor nor do I profess to be.   I do believe to be knowedgeable in tactics (former infanteer, signals operator) and am getting comfortable in instructing first aid.   All the IT say that the best course to teach is wilderness first aid as it covers a lot of care outside the scope of 'steady and support' and goes into improvised methods of treating until you can get to medical aid or medical aid gets to you.   She also states that SFA goes against what is taught in TCCC.   I disagree with this assessment as they talk about quite a bit of the similar priorities as MCM in SFA.   The amount of stuff you can do with TCCC is greater than SFA and takes into account the tactical environment.   In SFA this would fall under step 3 of ESM, assess the hazards.   If you cannot do first aid 'cause your receiving fire, you must first supress the fire and win the firefight.   I don't really see how they are opposites?

My last question (at least for now, lol) is would we be able to use this in garrison or like Wilderness first aid, is only used when medical help is unavailable for a long period of time?


----------



## Armymedic

excoelis said:
			
		

> .......and you are what you eat, you.......  ;D



WO, 

thats bad... :


----------



## Armymedic

> My last question (at least for now, lol) is would we be able to use this in garrison or like Wilderness first aid, is only used when medical help is unavailable for a long period of time?



As it stands now, the "qualification" only lasts as long as you are on overseas deployment.

But this question is one of the many being worked out as the development of the recognized course continues.


----------



## Bruce Monkhouse

Quote from Armymedic,
WO, 

thats bad...  

...sorry to jump in here my friend, but I think it should read,

WO,
thats priceless...


----------



## Armymedic

Same thought, diffrent words.


----------



## Radop

Armymedic, I love your second line of your signature, isn't it the truth! lol.


----------



## PRL ER NO

This would be similar to the use of AEDs which needs you to be certified by a medical doctor.   Is this correct or am I missing something?   

The use of AED's in Ontario, at least, are taught under the direction of a MD.   The programs must reviewed and the program signed off.


----------



## JANES

Its funny how you talk about first aid being only support.  If you look at what is going to save someone in a tactical environment its Tactics(prophylaxis), tourniquets, chest decompressions, and airway management.  So if we look at standard first aid - there is no tactics taught, tourniquets are discouraged (as opposed to the first adjuct used in TCCC), chest decompression is well beyond scope of practice, and airway, only 1% of preventable death, can only be basically managed - no definative adjucts within scope.  So yes, the first aider can provide reassurance to the casualty, that is true, but so can everyone else.  What I get from the data explained in the Dispatches is that if the casualty is alive then youll have to work hard to kill them, and if theyre dead theres not much you can do.  There is only a tiny percentage that you will be able to do anything for, ie, tourniquet and needle thoracostomy.  So where does the first aid instructor feel they have the position to teach this?  I'm not trying to be difficult, just realistic.  It is the medical community that needs to teach the medical skills, that has already been clearly stated.  The tactics side of this is where the confusion is from.  An infanteer (who specialized in tactics) with no medical experience, isnt going to be able to figure out what is the most important medical prodecdure to do and when to do it tactically.  That is why TCCC became to existance.  It is why 1 CMBG put medics and combat arms on the same course.  They both need to learn something from it.  It is that bridge that everyone is missing.  So to me it makes perfect sense why an Infanteer with a pre-hospital medical background wrote the Dispatches on the subject.  Everybody wants to be part of this new idea, but they have to realize thier position and limitations.


----------



## Bruce Monkhouse

Quote from JANES,

_ Everybody wants to be part of this new idea, but they have to realize their position and limitations._

...well I just read through this entire thread and realized that you sound like a pompous wannabe who didn't quite make it, you tear everyone apart and talk about their "limitations" but offer nothing of ANY substance in return.   Half your sentences seem to be taken right out of articles as your next one's info doesn't "line" up, please show me I'm wrong  as I am beginning to believe that your here only to troll,....prove me wrong, add something of significance or at least, some of your background...........awaiting.....


----------



## JANES

Trolling?  No!  Something to add?  Not yet!  What I see, is everybody wants a piece of this TCCC pie.  It's the newest coolest thing.  I'm not claiming I know everything about the topic as some are.  There are not too many people that know everything about any topic.  I'm just trying to put it into perspective for everyone.  I don't read a book on how to blow up a bridge and then go into the engineer forum and start telling them how it's done.  So why in this forum are people telling how it is with regards to TCCC, when they are only â Å“expertsâ ? on one side of the topic, yet claim to be experts on the whole topic.  Everyone is writing what they know, what they think they know, their opinions.  I guess I just have a different perspective.  I thought that's what this forum was for; to discuss and debate topics of interest.  And because I challenge peoples opinions, I'm questioned on intensions?  My only intension is to keep it real.


----------



## Fraser.g

Janes

No Bio, No opinion as we do not know from what experience or training you are putting forth your opinion from.

Ta

By the way "Trolling?  No!  Something to add?  Not yet!" You seem to post allot for someone who has nothing to add.

I do not profess to know all there is to know about a topic but what I do know is that I know more than you.

Prove me wrong.


----------



## Armymedic

JANES said:
			
		

> What I see, is everybody wants a piece of this TCCC pie. It's the newest coolest thing. I'm not claiming I know everything about the topic as some are. There are not too many people that know everything about any topic. I'm just trying to put it into perspective for everyone.



It might be a new cool thing to you but where I have been working, its been around. The CAR, LIB, 3 RCR (UMS), Patrol Pathfinders, and JTF have been using this knowledge shortly after Frank Butler first proposed it. Just because 1 CMBG was the first one to run a "course" doesn't mean the knowledge wasn't out there. Whats new is that we have people with the right frame of mind in the right places to make this happen.



			
				JANES said:
			
		

> I don't read a book on how to blow up a bridge and then go into the engineer forum and start telling them how it's done.   So why in this forum are people telling how it is with regards to TCCC, when they are only â Å“expertsâ ? on one side of the topic, yet claim to be experts on the whole topic.   Everyone is writing what they know, what they think they know, their opinions.   I guess I just have a different perspective.   I thought that's what this forum was for; to discuss and debate topics of interest.   And because I challenge peoples opinions, I'm questioned on intensions?   My only intension is to keep it real.



Get bent.

I will endeavour to do my best keeping it real in Afghanistan next week. First by instructing my team (all cbt arms, I am the only medical pers) in the ways of TCCC, then by living it for the next 6 months where my medevac resource is a Turkish or American Blackhawk on 30 min NTM and the teams LUVW, and all the medical gear I have is carried on my back or in teams med packs....

And if you doubt my understanding of tactics, I am sure a quick review of my profile will reveal the wide range of army experience I have accumulated.

So go back and read your copy of Dispatches which apparently is you only reference, and quit bothering those who are constantly learning and teaching in an endevour to bring this knowledge to as many as we can.


----------



## Radop

JANES said:
			
		

> There is only a tiny percentage that you will be able to do anything for, ie, tourniquet and needle thoracostomy.   So where does the first aid instructor feel they have the position to teach this?



I know I can teach and according to my students, quite well.  I am an intellegent person with the ability to learn and instruct others on what I have learned including anatomy.  If no one takes the time to learn, then no one will get taught.  Either you have never taken a SFA course or have not read the complete dispatch.  The outline the CPL INFANTEER outlines is very similar to MCM with some obvious tactical differences.



			
				JANES said:
			
		

> I'm not trying to be difficult, just realistic.   It is the medical community that needs to teach the medical skills, that has already been clearly stated.   The tactics side of this is where the confusion is from.   An infanteer (who specialized in tactics) with no medical experience, isnt going to be able to figure out what is the most important medical prodecdure to do and when to do it tactically.   That is why TCCC became to existance.   It is why 1 CMBG put medics and combat arms on the same course.   They both need to learn something from it.   It is that bridge that everyone is missing.   So to me it makes perfect sense why an Infanteer with a pre-hospital medical background wrote the Dispatches on the subject.   Everybody wants to be part of this new idea, but they have to realize thier position and limitations.


That Bridge as you mention is exactly what we are talking about.  It is the arrogance that you are portraying that no one but the medical world would understand the subject matter that gets my goat.  As I stated before, we have been using SFA up until now and keeping people alive.  If it could be done more efficient and could be done under fire, then I am all for it.  The wilderness first aid course teaches a lot of what you talk as being difficault medical skills.  As some of the other people have pointed out in this forum, I realise that the medical issues must be taught by medical personnel but the application of these priciples under fire would be best taught by the infantry as I see it.


----------



## Fraser.g

For the last time,

JANES RadOp

Quote from Armymedic:

"All medical services and treatments provided to the members of the CF fall under the legal responsibilities of the Surg Gen. Those responsibilities are delegated down thru the med chain to the lowest level at the MO, PA, NP level. Med Techs are authorized to provide medical services with a specific scope of practice that is allowed thru that chain, but ultimately its the supervising MO, PA or NP who is responsible for maintenance of the standard.

So for an TCCC/Cbt first responder trained nonmedical person to be able to practice and use the medical skills (and hence teach them as well...) they must first gain approval of their command (brigade, wing, fleet) Surgeon.

These Majors, who are no different then any other officer, trust in their Snr NCOs and troops. They trust in their skills as medics and as instructors. 

For this reason, all medical training on these courses will be conducted by Medical capbadge wearing personnel."  

ArmyMedic is closest to the planners and is the only one that seems to be in the loop on the progression of things. It is my hope that he keeps us informed as to the progression as I believe, as do many others in the group, that the Combat First Aid course must be taught to as many deploying troops as possible. At least Two per section for the Combat Arms and one per section for the rest of the support arms. IMHO

RadOp, the difference is who is capable and who can teach the course. I am sure that you are capable of teaching the course, I am also sure that many Infantry are capable of theaching the course. The rub here is that that is not your job in the CF. You are paid to maintain Comms, the infantry is here to seek out and close with the enemy, the medics hare here to preserve manpower. One of the ways we do our job is to teach first aid. That First aid could be SFA, it could be BTLS (PHTLS) and yes it could also be Combat First Aid.

The Medical Group is working on a standardized course and when it is done and signed off by the Surgeon General then and only then will it be taught on a wide scale. 

That being said, Am I teaching the basic principals for the treatment of casualties in a tactical environment to my medics...yes. Am I teaching them the TCCC...NO because it is not an authorized course yet and I would only have to re-teach it once the official lesson plan comes out.

I hope this clarifies matters.

Edited for gramar and punctuation


----------



## Radop

What you said RN PRN makes sense to me and does sound like what others have said.  The only thing that gets me is how it was said by others.  I cannot nor do I disagree with yours  and armymedics assessments of the plans for TCCC training.  I was wondering what soldiers trained in the system would be able to use it here in Canada.  Your explaination makes sense to me.  As for it being your job, noted.  I wouldn't expect you to teach TCCCS WAS to your people when I run you through the system or to set up a satallite dish.  I just got focused on the statement that I couldn't understand anatomy and wouldn't be able to instruct it.  (got too focused on the slam rather than what the rest of you were all saying).  

Moving on to another question for you guys reference this topic.  Will this now be a requirement for medics who are attached to coys when they are deployed overseas?  (asking for a projection here as I know it is not adopted as of yet)  Secondly, how long is the training?


----------



## JANES

Let me clarify.  What was meant was that the average First Aid Instructor does not have the in depth knowledge of A & P.  It is not taught at any depth in the 1st aid instructor course.  I'm sure you are well versed in A&P.


----------



## Fraser.g

Radop said:
			
		

> Moving on to another question for you guys reference this topic. Will this now be a requirement for medics who are attached to coys when they are deployed overseas? (asking for a projection here as I know it is not adopted as of yet) Secondly, how long is the training?



1. From what I gather there will be (or should be) two tiers of training. the first for the Combat first aider within the combat arms sections. These being combat arms troops who are trained in first aid. Second are the medics assigned to combat arms units. These members will be trained to a higher level of intervention within the protocol. ArmyMedic perhaps you can help us out on this phase?
There may not be a necessity to train regular force med As to this level as they will function at the UMS level and rearward. therefore will not be in contact and not have to depend on the TCCC protocol. This if from my read of 1 Fd Amb SOP where the first involvement of Med tecs is at the Triage and CCP after the casualty sweep and before the Amb shuttle back to the treatment fac.

2. The training on the pilot course from 1 Fd Amb to 3 VP was two weeks long. This is ideal as it give plenty of time for repetition and a long FTX. IMHO it could be shortened by several days and several thousand dollars and still get the same result. We have had this discussion earlier in the thread.

GF


----------



## Armymedic

Two directly answer your questions.

a. no,
b. unkown, at this time, but courses run by 1 CMBG were 10 tng days long. The two courses run by 2 Fd Amb were 1 training day to qualify and some hours of refresher and skill maintenance training while overseas.


----------



## Radop

Armymedic said:
			
		

> Two directly answer your questions.
> 
> a. no,
> b. unkown, at this time, but courses run by 1 CMBG were 10 tng days long. The two courses run by 2 Fd Amb were 1 training day to qualify and some hours of refresher and skill maintenance training while overseas.



One day, wow.  Did they have any other training before that?  Like an advance first aide course?  What I read in dispatches seams like it would take at least a week!


----------



## Armymedic

Yep 1 day. Students were to be intrested, well motivated, with a current SFA and CPR cert.

All that is taught is 4 "major" subjects, a. Concepts/tactics of TCCC, b. airway management, c. Tourniquet, and d. needle thoracotomy. The day consists of 4 classes, three skill stations, written test, practical skills confirmation and a oral test.

The course for roto 0, 39 of 40 passed, last course we ran in Nov 40% failed (IMHO because the right instructors were not avail, had a couple less experienced people teaching).

To requalify my earlier statement, it probably won't ever become a medical "qualification" for medics, as they are already allowed to do the medical skills in the course. Its more likely to be a common qualification for all members of the army (like comms, mountain ops, etc...)


----------



## Radop

Was the roto 0 training only given to the RCR guys as it was not even offered to us at HQ & Sigs?  We had the det on TV Hill and I don't think anyone was trained there even as a first aid instructor.  We had the guys also traveling all over Kabul on SDS runs (4 pers in 2 Veh) and my det and my cohorts was in bisons and went out alone to support combat teams doing things like raiding houses to catch bad guys.  Was this just because it was the initial training, lack of time or lack of interest by the snr staff?


----------



## docrogerking

I've taken some time tonight to review a few pages of the TCCC discussion, and I thought I would weigh in.  I was unaware of this site until one of my friends e-mailed me about it today.  Otherwise, I would have been here sooner. 

First, let me say that I was the Course Director for the 1 CMBG pilot course that was held in July '03, so the comments I make are from first hand experience.

Second, I am delighted that there has been a lot of seemingly excited discussion here regarding TCCC.  That is exactly what I had hoped to achieve when we started course planning over three years ago.

Third, I am again pleased that the dispatches article that Chris Kopp wrote and I edited seems to have made its way around for general reading.

Overall, I am confident the use of TCCC principles will eventually find their neiche.  However, even after a lot of experience with the first pilot course, and moderate contact with the two subsequent courses within 1 CMBG, I can tell you that the optimal implementation of TCCC within the CF is going to be very difficult to sort out.  The reason is that it is a combined medical and tactical course.  Much of the discussion you folks have had has centred on who should be teaching the course, who should be trained, what the medical SOP's are and how TCCC should be integrated into them, optimal course duration, and the list goes on.  We had similar questions when we did the pilot and the solutions are not easy to come by.

The issue of medical SOP's is an interesting one.  First, let me say that the entire structure of medical SOP's are from the WWII / Korea era.  They simply do not work in the 360 degree threat environment that our soldiers face on many deployments.  Nor do they work with the ever more common scenario of small party tasks that occur on deployments like Afghanistan.  The medical branch simply does not have enough medics to go around to support all the activities that occur during an operation like we did in Kandahar or like is occurring in Kabul.  Recognizing the new ways the army was being employed was paramount in pushing for a new way to support the soldiers on the pointy end, and short of hiring and training enough medics so that you had one for every section of soldiers, the TCCC approach seemed a logical and necessary alternative.  Secondly, the St. John Amb FA course is woefully inadequate for the needs of today's soldiers.  I'm not telling you all anything you don't already know.

So,..... who should teach the course?  In my opinion, the course should lay the foundation for cooperation between the combat arms and their medical support.  This course is best implemented with the medical reps maintaining overwatch of the quality control ref medical aspects.  The tactical aspects need to be spearheaded by a rep of the audience you are teaching i.e. teaching tankers... you need someone who can help to insert the medical scenario into a realistic tactical scenario.  The same is true when teaching infanteers, engineers, etc.  So in many ways, each course should be different.  This is going to be difficult for the CF because of the layers of coordination and cooperation this involves.  On our pilot I was course director and an infantry officer served as course officer, and it worked well because he knew he drove the scenarios, I just supplied the medical input and oversight.  If we make this just a course about providing soldiers with intermediate medical skills, we've missed the boat entirely.  And I'll go one better,..... TCCC should be an integral part of every field exercise, large or small.  You can practice your infantry or engineer skills all you want, but when someone gets hit, you better know how to react or chaos ensues.  The experience of many militaries has shown us that.

I'm preaching here a little but I'll continue.  Should medics be required to take TCCC?  Absolutely.  Anyone who thinks medics only work at the CCP, UMS, Fd Amb levels hasn't been on a deployment in a while.  In fact I would argue that the school in Borden should have a battle school component (which suprisingly they do not).  So they may have decent medical skills but haven't once been asked to deliver those skills under realistic combat conditions  Soldier first, medic second.  Fire superiority is the best medicine.  Keep yourself from getting shot!!  Need I say more.  And furthermore, I think every medic going to a UMS with a front line combat arms unit should first have to have a TCCC course as a prerequisite.  I think the ratio of TCCC trained soldiers to non trained should probably be 1:10.  Pretty high expectations, huh?  Again, train how you fight so you will fight how you were trained.  If we deliver this training in the all too common abbreviated, just in time, typically canadian format prior to a mission, we're already behind the 8 ball.  

How long should the course be?  There are some significant interventions taught in TCCC.  Too short a course risks producing grads who are simply dangerous.  Too long if fiscially unacheivable.  IF TCCC was integrated into the regular training routine, a TCCC course could be done in 7-10 training days with the right staff.  Again, it is essential that there be an FTX component.  Otherwise, we are simply teaching a medical course.  The tactical component is just as important, if not more important to producing competent grads.

Resource issues.  They're numerous and I'm not even going to go there.

Mentality.  The biggest obstacle we face in making TCCC a success or just another painful course that you need to go on is the way in which it is delivered..... not simply the course content.  I always get very concerned when I hear people say, "I read about the components of the course, it's not that complicated".  They're right, the content is relatively straightforward medically.  The crux of the issue is developing a dynamic and realistic course that mimics the operational environment.

I could go on, but I'm sure some of you are tired of my philosophizing.  Sufficie it to say that I have concerns over the ability of the medical branch to ensure a quality product is delivered.  It is one of the many reasons I released in 2003. 
When we started the TCCC initiative in 1 CMBG our ultimate goal was to get the info out to the front line soldiers.  In large part, I think that's happening.  My concern now is whether or not all of the issues above, and more, will be overcome.  My reasons for posting this e-mail are mainly to encourage you all to look closely at the end product and demand that it meet the need.  Anything else is just glorified advanced first aid.

Dr. Roger King
Ex-MO now a civi


----------



## Bruce Monkhouse

Thank you for that info, Dr. , and welcome to Army.ca. I[we] hope you stick around, it can be a great source of info and stimulating "conversation".


----------



## Donut

Kudos for starting this, Dr King.

Welcome to the board.

DF


----------



## docrogerking

Thanks for the welcome.  I look forward to your comments and, as you say, stimulating conversation.  Fire away with any questions if you think I might have an answer.  Cheers

Roger


----------



## Armymedic

Welcome Dr King. Nice to see you on board.


----------



## Fraser.g

Roger,

You seem to have created quite a snowball in the medical world at least. Now we just have to roll it down hill and see if stuff sticks to it.

Granted it will be hard to get the integration of zero trades and medical in one course but all those hurdles can be overcome if the leadership wants the best training for their troops. Your integration of the Course O as the Target Combat arms branch and then a MO being the adviser seems to be the best way to go. What about the training cadre? Are the medics predominately in the classroom for your model and then as DS assessors in the field with the combat arms instructors?

I the reserve world we have infanteers with their PCP and even MD and RNs. We then have medics who are SWAT. How would you see the integration. 

IMHO I would like to see the medics take charge of the theoretical portion until the application phase. Then during the field phase have the medics take an advisory stance and let the tactics direct the care. I know you touched on the way it was implemented in your earlier post but I would ask you to go more into detail so that we could start to have an idea of the way this will actually work in the future in the nitty gritty. 

Who is the Crs WO Med or Cbt Arms
Who are the Secton/syndicate commanders Med Or Cbt Arms
etc.

GF


----------



## Spr.Earl

I have taken combat first aid i.e how too hook up intrevenous and a shot of Sister Morphine if needed and we carried all on my tour.
Don't go  changing things now!
So what is the standered for now?


----------



## Fraser.g

Sorry Spr.

That is not Combat first aid. What you learned for your tour was a stop gap measure. The literature now says that an IM injection of Morphine will not do much good, and High volumes of Crystaloids pre-facility may do more harm than good. 

Neither of these measures are taught on the TCCC course. What is taught is how to deal with the big life threatening ABC until you can get to a medic.

Please see the thread on fluid resuscitation for more info or better yet talk to DF (ParaMedTec) he is quite current on latest trauma theory from a pre-hospital POV.

GF


----------



## locdawg

I work for the Canadian distributor of QuikClot and other wound care I couldn't help but noticing that our product seems to be somewhat of a topic in this forum.  I would be happy to address any questions or comments (positive or negative) on the product and its usefullness in the battlefield and training ground. 
Thank You 
Andy


----------



## Fraser.g

MedCorps said:
			
		

> SPECOPS IDC HM 8491/HM 8403 JSOMTC: USE OF THE HEMOSTASIS PRODUCT QUIKCLOT MADE BY Z-MEDICA
> 
> 1. UNTIL FURTHER NOTICE ALL USSOCOM PERSONNEL ARE PROHIBITED FROM
> USING THE HEMOSTASIS PRODUCT QUIKCLOT (TM) MADE BY Z-MEDICA.
> 
> 2. QUIKCLOT (TM) IS A COMMERCIAL OFF-THE-SHELF PRODUCT WITH FDA
> APPROVAL FOR EXTERNAL USE TO ACHIEVE HEMOSTASIS (CONTROL
> HEMORRHAGE). THIS PRODUCT WAS PURCHASED IN QUANTITY BY THE ARMY AND
> USMC MEDICAL AGENCIES BECAUSE OF THE EARLY FDA APPROVAL AND THE
> BLOOD CLOTTING POTENTIAL OF THE PRODUCT. SMALL QUANTITIES OF THE
> QUIKCLOT (TM) HAVE FOUND THEIR WAY TO USSOCOM MEDICS THROUGH
> SERVICE CONTACTS AND DIRECT FROM THE VENDOR FOR THE SAME REASON
> SERVICES ORIGINALLY PROCURED THE PRODUCT
> 
> 3. WHEN QUIKCLOT (TM) GRANULES ARE POURED INTO A HEMORRHAGING WOUND
> A REACTION BEGINS HEATING THE BLOOD TO TEMPERATURES FROM 90-100
> DEGREE CENTIGRADE (194-212 DEGREE FAHRENHEIT). THIS TEMPERATURE
> COAGULATES (CLOTS) THE BLOOD, BUT ALSO HEATS LOCAL SKIN, MUSCLE,
> AND NERVE TISSUE TO BOILING TEMPERATURES.
> 
> 4. ARMY AND AIR FORCE MEDICAL RESEARCH LABS HAVE REVIEWED QUIKCLOT
> (TM) AND RECOMMEND NOT USING THE PRODUCT.
> 
> 5. UNTIL APPROVAL BY SERVICE MEDICAL RESEARCH LABS, DEVELOPMENT OF
> POST USE PROCEDURES, AND CONCURRENCE OF USSOCOM COMMAND SURGEON;
> QUIKCLOT (TM) IS PROHIBITED FROM USE BY USSOCOM PERSONNEL.
> 
> 6. POC IS LT COL J. R. LORRAINE, USSOCOM:SOCS-SG, DSN
> 299-5051/5442. Submitted by: HMCM Gary E. Welt, USN SEA, JSOMTC,
> FT. Bragg, NC Comm: (910) 396 - 0089 Ext. 145 DSN: 236 Fax: 396 -5395
> 
> ----------------------------------------------------------
> 
> Field Report Marine Corps Systems Command Liaison Team
> Central Iraq 20 April to 25 April 2003
> 
> QuikClot by Z-Medica ~ 2D Tank Battalion Surgeon LT Bruce Webb
> (USN) stated that Quik-Clot was ineffective (specifically, it was
> ineffective on arterial bleeding). Battalion Corpsman attempted to
> use Quik- Clot in three separate occasions:
> 
> Wounded Iraqi civilian. Shot near brachial artery. Quik Clot was
> applied >per the instructions. The substance dried but was
> flaking off. Standard direct pressure applied by corpsman proved
> more effective on the patient.
> 
> Iraqi civilian shot in back with punctured spine. Quik-Clot
> applied to severe bleeding. Pressure from bleeding sprayed
> Quik-Clot away. According to LT Webb, "Quik-Clot was everywhere
> but the wound".
> 
> Iraqi civilian, female, shot in femoral artery. She suffered
> severe arterial bleeding. Patient bled out. Quik-clot unable to be
> applied effectively due to pressure of blood >flow from wound.
> Patient died.
> 
> An LAR Marine was shot in the femoral artery. Quick Clot was
> applied to >the heavily bleeding wound. The pressure from the
> blood soon caused the quick clot to be pushed >out of the wound and
> rendered ineffective. A tourniquet was applied instead. The patient
> died. Quik Clot may work if applied in a "buddy system" manner. One
> individual applies the Quik Clot substance while another individual
> quickly applies the sterile gauze to the wound. However, applying
> the Quik-Clot as directed proved ineffective. Direct pressure and
> tourniquets were used instead. (note: different opinion from the
> MEU MO interviewed. Recommend further study on this item).
> 
> Cheers,
> 
> MC



Yes there was conciderable interest in the product as with the US until field trials found that if used in instances like above there can be dire repercussions.

More study and increased attention to protocol must be in place before we start issuing this to members.

I would much rather have the TCCC pers use direct pressure and tourniquets and then evac were medical professionals can deal with the issue.

IMHO


----------



## docrogerking

RN PRN,
Your comments on QuikClot I second.  Having reviewed extensive data on the subject and having had the input from experts in the field (Both US and Canadian) there is no doubt that using QuikClot is potentially dangerous.  The issue of users not following the correct procedures is true (see field report) but even so, there are other products that seem more efficacous and don't have the exothermic reaction associated with it.

Also, thanks for clearing up the misconception that TCCC and Combat First Aid are the same.  Nothing could be further from the truth as you know.  IM morphine is dangerous and should be considered for discontinuation due to the slow onset of action and the propensity for users to give a second dose due to the slow onset, thus causing side effects.  Also, the contraindications to morphine use frequently prohibit its use on the battlefield (altered Level of consciousness, difficulty breathing, uncontrolled hemorrhage and hypotension).  Unlike what we see from Hollywood, using morphine for combat casualties should be the exception rather than the rule.  Likewise, data from many surgical studies has shown that there may be a propensity to a higher mortality rate if liberal fluid rescuscitation is given to victims with uncontrolled hemorrhage.  Permissive hypotension is the rule of thumb, i.e. in a patient with uncontrolled hemorrhage, if they can perfuse their brain enough to stay awake, who cares what their blood pressure is.  You treat the patient not the monitor.  Those are two  good examples of how medical treatment has evolved in the last two decades wrt combat casulaties.  TCCC takes into account thes issues and more, such as: medical rescue under fire, medical interventions under fire, CPR in the trauma victim, C-spine immobilization in the penetrating trauma victim, battlefield antibiotics, tourniquets, carries, lifts, and mobilization techniques, and the list goes on.  The point is, TCCC is, in no way, combat first aid and confusing the two is the first misconception that needs to be cleared up in the military community.
I'm not telling you anything you don't already know.  I'm merely posting these comments for the wider audience. 

Now, to answer your earlier questions.  The training cadre for our pilot consisted of 031 and 711 MOC's.  All were put through a week of trianing and lecture standarization prior to the course commencing.  That way, the entire course staff was working off the same page.  So, in a way, the 031 staff had taken the academic part of the course prior to the course commencing.  The Crse O wasn't the only zero trade.  There was also the course warrant O and there were two 031 MCpl/Sgt's.  The MCpl/Sgt's were the tactical advisors / Tactical assessors but also attended all lectures, again so we were all on the same page.  Also, they gave comments and a "tactical face" to the classroom discussions.  The medics were classroom instructors and were medical assessors in the field.  So after every scenario, candidates got debriefed on both their medical and tactical approach to the scenario.  The section commanders and sections were candidates themselves.  They were asked to go into a scenario with a candidate section commander and a candidate "acting as TCCC medic".  That way two people got assessed in different areas for each scenario.  The overriding concern is obviously the medical stuff, but if their tactics were such that they were getting members of their section "killed" then that was also addressed.  Unlikely we would fail someone off the course for their tactics unless they were grossly incompetent.  That's what I mean by integrated, and that's why I think it's going to be so hard for the CF to standardize a course like this.  I've done briefings in Ottawa on this course, and I can tell you, in my opinion, it's not going to be an easy sell to acheive the type of course that is required. 

I believe that was all your questions.

Obviously, I have been through the buildup phase of this initiative and I can tell you that it worked very well when there was that level of intimate cooperation.  However, what I've seen since has amounted to a bit of a turf battle between zero trades and med branch about who's responsible for what.  In the end, that just results in a suboptimal product for the soldiers on the pointy end.

Just my thoughts.

Roger


----------



## locdawg

Interview with
Captain Frank K. Butler, M.D.
Command Surgeon United States Special Operations Command

Q: What are some of the promising technology solutions currently emerging that might enhance emergency medical care on the battlefield in the near future?

A: Penetrating head trauma or other wounds that are inevitably fatal cause many of our deaths on the battlefield. The battlefield trauma care that holds the most promise is that aimed at effectively addressing preventable causes of death. We are making some real progress here. The most common cause of preventable death on the battlefield is bleeding to death from extremity wounds. The Institute of Surgical Research has just completed testing of commercially available tourniquets and recommended two: the Combat Application Tourniquet System for all combatants and the EMT tourniquet for combat medics. We are moving forward with field-testing on both of these items. Using the TCCC Transition Initiative, the elapsed time between ISR identifying the best tourniquet for SOF operators and the time when we began fielding it for deploying SOF units was less than a month. 

Bleeding to death from torso wounds where the source of bleeding is accessible by the first responder is another cause of preventable death. The MRMC has tested the HemCon dressing and found it to be effective in stopping this type of bleeding. We have been fielding this dressing for several years. The Committee on Tactical Combat Casualty Care has recently conducted a review of hemostatic agents and updated guidelines, to be published next year, to incorporate the use of QuikClot into the hemostasis algorithm as well. The anticipated guidelines will call for HemCon to be used first in situations where hemostatic agents are appropriate and QuikClot to be used as the second option if HemCon is not effective. 

Other promising technologies that might help first responders save lives on the battlefield are hemoglobin-based oxygen carriers, better prevention and treatment of hypothermia in casualties, better airway devices, an injectable hemostatic agent for internal bleeding and adding improved casualty evacuation equipment to the vehicles currently being used for combat operations. 

Perhaps most important of all is for us to continue to work to ensure our deploying forces have today's technology and the best training possible. 



Thanks for getting back to me so quickly:
It seems that the USSOCOM is starting to think a bit differently now.  Every US Marine in the United States is also carrying a pouch of QuikClot and some are using it with amazing results.  It is true that the product should not be used in all major trauma, but in some cases it can save lives. 

Andy


----------



## locdawg

Here are some frequently asked questions on QuikClot:

Q. How Does QuikClot Work?

A. It works by providing a hemo-concentration effect in the blodd that is exiting a wound.  The body's natural clotting process is accelerated by the increased concentration of platelets and clotting factors at the wound site.

Q. What Causes the Hemo-Concentration?

A.QuikClot's main component material is called an adsorbent, it is actually a synthetic derivative of volcanic rock.  It has many pores, internal and external, which capture and hold the water molecules that make up the majority of the blood.  The ability to attract and hold the water molecules is due to the electrostatic forces that are present in the pores of QuikClot material when it is dry and are liberated when the QuikClot is saturated.  These are the same types of forces that cause static cling, but in the formulation of QuikClot, they are much stronger.  Water molecules are held very strongly.

The clotting factors, protiens in the blood, and the cellular components of the blood are not attracted nor held by the QuikClot, because they are simply too big to fit in the pore structure of the QuikClot material.  This leaves them free to do their work at the wound site.

Q. Is there a chemical reaction involved?

A. No, the interaction of the QuikClot and the water in the blood (called adsorption) is purely physical in nature.   Upon application, QuikClot rapidly attracts water molecules, and almost instantly the internal pores are filled.  There are no chemical changes to the blood, the water, or the QuikClot.  Since the reaction is physical, and not biological or chemical, there is almost no chance for an allergic reaction to occur.

Q.  Are there any side effects?

A. The adsorption of water into the QuikClot granules can cause an instantaneous release of heat, called an exothermic reaction.  The release of heat stops when the pores of QuikClot become filled, when due to QuikClot's strong attraction for water, is only a second or two.

Q. What Causes the Heat?

A. The heat is generated by a phenomenon called the Heat of Absorbtion.  The electrostatic charge in each pore of the QuikClot, which attracts the water molecules, is released when the pore is filled. The liberated enegy is in the form of heat.

If you have any more questions on QuikClot would be happy to answer them for you.

Thanks Andy


----------



## Fraser.g

Once again I will stress,

The CF does not, I say again, NOT advocate the use of quickclot in any documentation that I have found.
Until such time as they do I would not encourage any CF pers from carrying this product while in uniform only because of the temptation of its use. 

If this product is used incorrectly it has the potential to cause serious circulatory and nerve damage distal to the application site. 

Please only use those procedures that you have been taught in CF sanctioned courses and training for first aid purposes.

GF


----------



## Radop

This is excellent.  The info is great and will give everyone something to think of.  I would like to know why all deploying pers are not getting this training in some form.  My unit (CFJSR) sends people out the door every few months and only require them to have SFA.  I wish we would have had this course for Kabul Roto 0 and in my det, myself and my partner in crime are ussually deploying by ourselves with limited security in some of the hottest places in the world.  Although not a combat arms unit, we do deploy frequently.


----------



## docrogerking

Radop,
For what's it's worth, and having  seen you guys work in '02 in Kandahar, I completely agree with you.  You guys are a good example of a unit who, although not combat arms, could definitely use this training.  All I can say is keep pushing for it and raising awareness at your level.  The only reason we got the course off the ground within 1 CMBG in the first place was that we went straight to the operators and sold them on the idea.  If we had left it to the med branch, well......., I fear we'd still be no further ahead.  Not bitter, just realistic.  Hope you've gotten something from my posts to date.  Feel free to e-mail any questions.  Cheers.

Roger


----------



## Radop

Sorry but I lost the name of the cpl who wrote the Dispatches article but I was amazed that he was able to put that togeather and that his chain of command accepted to try it especially when it included coordination with the medical branch.  I had heard that he is now a sar tech.  I hope it is true as he seamed like a very knowledgeable person when it came to medical treatment in a field environment.

A question I have for you has to go with this scenerio in a field environment within Canada.  We were on ex in Sept this year when a Sgt fell and struck his head on a rock and knocked himself out.  We had no medical support but there were several of us who were First aid instructors.  We wanted to immobilize him but a capt ordered us to put him on a stretcher and put him in the back of an LSVW to transport him to a hospital because they were concearned an ambulance would not be able to get to our location.  The first aider on the scene advised them that this procedure was incorrect but they insisted.  The first aider then log rolled him onto a litter and secured him in place.

Now my question.  What type of training is given to officers in regards to safe practices for first aid (anything other than SFA)?  Which would you have done, transport him yourself or wait for an ambulance?  I actually got my first aid instructors course after this ex and have been mauling this over ever since.  Thanks.


----------



## old medic

I'll let someone else answer the first part about officer training.

A fall from a standing position may not seem like a big deal to some, but a blow to the head causing a loss of consciousness should immediately fall into the "high index of suspicion" category for head or spinal injury. This Sgt. should have had spinal precautions taken (collar and board), and then brought to a hospital for examination.    The officer(s) should have waited for an ambulance to come out from the base. This was training, and there is no training important enough to risk a spinal injury to a member.  If an LSVW was at the location, It could not have been that remote a spot. If it was remote, then a stretcher team could have been formed on direction of the medics to carry this man to the closest ambulance access point.

those are my 2 cents.


----------



## Radop

Thanks for confirming what I thought should have been done.  As it turned out, he spent 10 days in hospital with his 7th concussion and was still having headaches up until the end of Nov.  Our base is strange in that we have no medics on call after hours.  The civis do this for the base.  For some reason, they feel it is cheaper to do it this way.  The accident was less than 20 meters from a "MSR" and I too believe an ambulance would have made it in.  The powers that be desided that they could posibly be delayed so they sent him in a back of an LSVW because "it was only a bump on the head".


----------



## Armymedic

In liue of the amb showing up, C-spine control can be improvised using a CF issued stretcher (more imp later) with tape, towel/blanket roles and manual stabilization in this case. Also in addition to the stretcher straps, tape the body to the stretcher (2 inch wide gun tape, packing tape etc) to ensure min movement is you have to rotate the patient for airway. As a dismounted medic in the fd we might not alwys have the luxury of a back board, so the goal then would be to min movement and ensuring airway patency as best you can in your scope.

So in this case, plywood, a 6 foot table, or even a large piece of cardboard that can fit into the back of the truck with manual stabilization would suffice.



			
				old medic said:
			
		

> A fall from a standing position may not seem like a big deal to some, but a blow to the head causing a loss of consciousness should immediately fall into the "high index of suspicion" category for head or spinal injury.



With the LOC, this case is an urgent case and by right should be at care (Hospital, not just a UMS) within the hour (not condoning the descision).
A fall from above your body height in feet (ie, for me above 5 ft as I am 5'8") would be an absolute indication for c-spine precautions to be used. ref BTLS 5th ed.


----------



## old medic

For those of you reading these posts down the road, I'm going to re-emphasis my saying "brought to a hospital" in the above posts,
and what Armymedic said about "Hospital, not just a UMS".

The only way to clear someone off a backboard is to take an x-ray or scan of the spinal column and look for injury.
Your not going to find that equipment in the UMS.

that said, I still run into the odd nurse who immediately pulls the collar and straps off a patient in a ED after asking the patient if
their neck is sore, or maybe feels along the cervical spine once...........  :-X


----------



## Fraser.g

old medic said:
			
		

> that said, I still run into the odd nurse who immediately pulls the collar and straps off a patient in a ED after asking the patient if
> their neck is sore, or maybe feels along the cervical spine once........... :-X



Not on my shift and not if you value your license. 

Usually we will get the person of the back board ASAP once they are in the ED. Before we log roll them to assess the back we will do a full neurological exam including CSM. Once the patient is rolled and the spine is examined and palpated along with assessing rectal tone will we do away with the board. The collar will remain in place and the patient supine until the X-Ray / CT clears the spine. Then and only then will the collar be removed.


----------



## old medic

True enough .. most are excellent.  Most of the scary stuff I see at small remote clinics and certain small town hospitals.
I should also emphasis it's not common.


----------



## Radop

RN PRN said:
			
		

> Not on my shift and not if you value your license.
> 
> Usually we will get the person of the back board ASAP once they are in the ED. Before we log roll them to assess the back we will do a full neurological exam including CSM. Once the patient is rolled and the spine is examined and palpated along with assessing rectal tone will we do away with the board. The collar will remain in place and the patient supine until the X-Ray / CT clears the spine. Then and only then will the collar be removed.


In '93, I was in an accident in Dundurn where I suffered a head injury.  I was a driver instructor on a FMC Dvr Wh crse when we went around a blind corner and right there was a MLVW bearing down on us.  We were in an iltis.  We had no time to get out of the way but we could get the front end off the dirt trail and up onto the field.  I leaned between the front seats and yelled hard right at the driver and he did just that.  The ML hit us in the left quarter panel and through us back before it hitting us again this time in the drivers compartment slamming the light switch into the drivers leg and pushing the seat into my face breaking my cheek bone and depositing it into my jaw.  I was placed in the ambulance on a spine board and sent into Saskatoon's Royal University Hospital.  I was in there for 4 hrs before they could get the portable x-ray machine down there to check out my neck and head.  I required plastic surgery and it was successful (I am still my homely self).  My head was soar for two days as I was stuck on that spine board for 4 hrs.


----------



## old medic

Radop said:
			
		

> I leaned between the front seats and yelled hard right at the driver and he did just that.




Getting a bit off topic here, but you were driver instructing from the back seat ??

How was the ride in, did you get the crestliner (civy base amb) or an SMP amb ride?
I always prefered using the crestliner myself, the traffic moves pretty quick on that highway.


----------



## Radop

old medic said:
			
		

> Getting a bit off topic here, but you were driver instructing from the back seat ??


Yes, we were doing a map and compus road rally type thing.  The instructors were told to sit in the rear passenger seat and let the co-drivers give directions to the rally point.



			
				old medic said:
			
		

> How was the ride in, did you get the crestliner (civy base amb) or an SMP amb ride?
> I always prefered using the crestliner myself, the traffic moves pretty quick on that highway.


I guess it was the crestliner in to Saskatoon and the SMP veh into camp.  (I feel sorry for the two medics as I was a bossy infantree MCpl back then and wouldn't let them look at me until they had treated and taken care of the two drivers.  The doctor gave them sh** when we got into camp as I had obvious head injury and was just riding with the injured driver -just required stiches to his leg)


----------



## 043

MedCorps said:
			
		

> Unfortunately at this time there is not standardized course.   I have seen presented in two ways.
> 
> The first way is for medical personnel as part of a larger course that deals with Combat Casualty Care in general (just not tactical combat casualty care).   When I first took it, I did it this way as part of the Combat Casualty Care Course run by the Defense Medical Readiness Training Institute in Fort Sam Houston.   I have also seen it run by the UK RAMC as part of the Battlefield Advanced Trauma Life Support Course.   We have run it in Canada as part of larger OP ATHENA medical pers work-up training for ROTO 0 and ROTO 0A (Medical Augmentation).   We also ran it as part of a clinical training week called "Combat Medicine 2004".
> 
> The second way is for the warfighter, whom it really is intended for.   It was run as a 1 or 2 day course.   If I had to put PO's to it... it would look like this.
> 
> PO 001   -   The Casualty Treatment and Evacuation Process   (CUF vs TFC vs CCEC)
> PO 002   -   How Casualties Die (the big 3 and Tri-model death distribution)
> PO 003 -     Care Under Fire
> PO 004   - Airway Problems and Management   (with Lab [open airway, bulb suction, NPA, OPA])
> P0 005 -     Tension and Open Pnumothorax and Management (with Lab [needle decompression and Chest
> sealing techniques x2])
> PO 006   - Stop Bleeding and Treat Shock (with lab [shell dressing and one handed tourniquet, and improv.
> tourniquet])
> PO 007   - Triage
> PO 008   - Morphine Autoinjectors (if issued)
> PO 010   - Scenario Based Training (Exercise)
> 
> Here is more information:
> http://www.google.ca/search?q=cache:X5nV_O9BVUAJ:www.nomi.med.navy.mil/Text/Tactical%2520Combat%2520Casualty%2520Care%2520Guidelines.pdf+%22Tactical+Combat+Casualty+Care%22&hl=en&ie=UTF-8
> 
> I suspect sooner or later that it will be standardized for the CF in a course.   It is the waiting game, as mentioned in another thread.   It is good to hear that 1 CMBG ran a course.
> 
> Cheers,
> 
> MC



Hey there,

Petawawa is running a 3 wk TCCC's course next month. It should be alot better than the 4 day one they taught before.


----------



## Armymedic

CHIMO!!!!! said:
			
		

> Hey there,
> 
> Petawawa is running a 3 wk TCCC's course next month. It should be alot better than the 4 day one they taught before.



Say what?

Are you sure...cause those who would make that happen are all just back from Sri Lanka. And the all the previous course taught in Pet were 1 day (I should know I taught on all of them).


----------



## 043

4-22 April.

And just so you know, the last flight from the DART returns this weekend.


----------



## Armymedic

more info pls...whose running it, where, etc. Because usually the course it tied to a deployment, and it would be interesting to see whos running it.


----------



## 043

Ash,

The Brigade or Base Surgeon is the Opi. It is for Roto 4 pers. Steve O, told me that the call came out for instructors this week. I think there are 20 spots throughout the Bde for the course.

Say Hi to Perry would you? And Big E!


----------



## Fraser.g

this stuff is exactly why CFMSG must quickly come up with a standard package in both official languages.

 We have LFWA operating in one quasi standard while LFCA, LFQA, and LFAA are all about to or are already designing adn executing their own package. Each are calling it the TCCC.

We have to prepare our troops going overseas so that they are ready to aid their comrads in a conflict situation but we also have to have one standard for all forces not what the individual commands want or can afford at the time.

GF


----------



## medicineman

We have to prepare our troops going overseas so that they are ready to aid their comrads in a conflict situation but we also have to have one standard for all forces not what the individual commands want or can afford at the time

GF

Add to that one standard one training establishment.

MM


----------



## MedTech 711

Anybody have more current information on this course?  Any idea who might have a MTP, MLPs or a contact name for the TCCC course?


----------



## Armymedic

I developed a step by step protocol for care under fire and tactical cas care for my team here in Afghanistan. I used Cpl Kopps Lesson learned pub, and all the other pubs since 96 to make a step by step sequence of events to asssist the Cbt arms members of the team to have a standardised  approach to conduct a cbt cas assessment. And steps and protocols to follow for the three skills they learn: NPA insertion, Chest needle decompression, and tourniquet application. I'll put the outline on here as a new thread once I get it completed on an electronic version.


----------



## Fraser.g

Here is a doc from the US DoD on TCCC and an assessment that I have modified slightly from the 10th Mountain Div.

Has anyone herd about the CF progress on this?

GF


----------



## Armymedic

In another string in this topic, I have posted a draft copy of a tactical assessment for nonmedical pers. It will become the SOP for TFK once it gets the TF surgeons approval. It may also be adopted for the course as its assessment for all students.


----------



## 043

Hopefully R4 gets the info as there is nothing worse than learning one thing and doing something a totally different way


----------



## Armymedic

The Brigade surg has been emailed a copy and I will also talk to him when I come home on leave, so hopefully they are doing that as well.

He liked it and told me he may use it. 

The next roto ANTC det (ETT) will definately get it as it is part of our SOPs.


----------



## McG

There is a TCCC Crse being ramped-up for the Strat Res BG right after its validation trg.   It sounds like about 200 pers will be getting pumped through it.


----------



## 043

Hopefully it is squared away!

2 Fd Amb is running one right now. They took a 4 day course, made it 3 wks, added another week to it and let the students go home in the afternoons. Now the troops that are on this course will get screwed out of leave because instead of being on leave prior to the tour, they will have to do 1 - 2 weeks of MLOC trg to catch up with the rest of the Bn Gp.

Good Call!!!!!!!!!!!!


----------



## COBRA-6

I'm anxiously awaiting a formal TCCCC to be finalized... I've tried to get on a PHTLS the local medics were running but had a scheduling conflict. I'm involved with the CIMIC world and we frequently work out of camp, by ourselves (2-4 pers) in one soft-skin veh... something tells me just having the SFA crse leaves us lacking... maybe they'll include something in the roto 4 workup training starting in May...


----------



## Armymedic

Generally, they run the course in theater, as CIMIC I think you will get it, the ones on this tour definately should have...


----------



## Fraser.g

Mike_R23A said:
			
		

> I'm anxiously awaiting a formal TCCCC to be finalized... I've tried to get on a PHTLS the local medics were running but had a scheduling conflict. I'm involved with the CIMIC world and we frequently work out of camp, by ourselves (2-4 pers) in one soft-skin veh... something tells me just having the SFA crse leaves us lacking... maybe they'll include something in the roto 4 workup training starting in May...



Some members of CIMIC have approached me to instruct them on a BTLS advanced course this summer before their deployment. I will inclued the TCCC PPT lecture as one of the add ons.

GF


----------



## COBRA-6

That would be outstanding!


----------



## Fraser.g

Mike_R23A said:
			
		

> That would be outstanding!



perhaps I will see you in Dundurn then

GF


----------



## COBRA-6

Arrgh! If it's in Dundurn then I don't think it's our CIMIC crew from LFCA doing workup training for roto 4 that contacted you  ???


----------



## Fraser.g

Since every one and their dog seem to be offering the course (RCR, PPCLI, etc battle groups) but as of yet we have no standard I am seriously considering adding my own spin on things. 

My line of thinking is to put togeather a course for reservist combat arms and support trades but building into it a Delta for the conversion from a MLOC type standard to a DELOC standard.

Such things that I would add into the Delta would be needle chest decompression to name but one.

What do the rest of you think?

GF


----------



## Armymedic

I think a course for getting the concept out in your area would be good. 

The national course should be out by next summer (what I hear) and we should have further direction as to its content then.


----------



## Dale Turner

RN RPN,

    What do you mean when you say that you may put together a TCCCC but put it in a "Delta"? I'm not familiar with that term. 

    It's nice to see that you think reservists should have access to a course like this. We appreciate it.




     DT


----------



## Fraser.g

A Training Delta is a term for change or upgrading of a skill set.

There is a Delta for all reservists who want to go on tour for example. This is what the pre-deployment training is all about.

What I am proposing is a TCCC with a delta portion that will be taught only when a member is going to deploy. These are the skills that would be hard to maintain in a reserve fd amb or possibly out of scope in peace time but would be beneficial in a theater of ops. A great example is needle chest decompression for tension pnumothorax.

To maintain that skill indefinitely would be very time an labour intensive over the long haul. Therefore we teach it before they deploy as part of the DELTA and then only maintain it over the six months that they are overseas.

I hope this answers your question.

GF


----------



## Dale Turner

RN RPN,

     Thanks, that does answer my question.  Just a tid bit of info for you to think about is that as a civy ACP I'm taught and certified to perform needle decompressions for hemo/pneumothorax.  However in my four years as an ACP I've only had the opportunity to exercise this skill once.  My co-workers also have only performed it once or twice each in their careers.  The skill itself is not all that hard to learn.  I will always suggest refresher training for any medical skill.  Maybe attached MCSP training?  The hardest part about the skill is to correctly assess a pneumo/hemothorax.  So I can see the reluctance to with hold such training until a reservist is on a Delta but I dont think that this is necessary.  It's a juicy bit of training that reservists would eat up.  

     Just a thought.

     Thanks again.




     DT


----------



## Dale Turner

RN RPN,

     Just an add on to my last.  ACPs dont recert on any specific skill.  We recert each year on protocols and exams and they throw in the odd case study and scenerio station, but we dont specifically have to perform all our skills during a recert.  


    (At least ay my Base Hosp)



    DT


----------



## Fraser.g

The big difference between you as an ACP and the reservist is that the TCCC is designed for non-medics.  The course will be taught to the Combat arms types who will not have the exposure to trauma that you or I have on a regular basis.

It is for this reason that the DELTA is so important.

GF


----------



## Dale Turner

Sorry, I was under the assumption that TCCCC was for medics as well as for combat arms trades.  And you're right reservists dont see the same amount or type of trauma we see. But do you not think that a TCCCC for medics is a good idea?  I read the Despatches article about TCCCC and I learned a lot about operating in a hostile environment and how certain priorities change when you're actually engaged in combat.  

And speaking of TCCCC is there any plans for CFMG to start using hetastarch/hetaspan to fully implement TCCC?


----------



## Fraser.g

The concept as I read it is for non-medics to have a basic interventional skill set to start the stabilization process before a medic arrives on scene.

Should the reserve medics learn the skills?...Absolutely. 
IMHO it should be part of the PHTLS/BTLS re-certs.

The medics must know what can and has been done prior to their arrival as well as knowing how to react in the tactical environment. The difference is that the TCCC is designed as a secondary skill set where with medics it is primary.

All that said, it would be far better to train all the reserve medics to the TCCC level than have them stay at the AMFR2 level they are at now.

I don't know if it will become protocol but I Carry a bag in my jumpbag.

GF


----------



## Radop

I am amazed that this topic is still near the top.  It is great to see and I hope to someday take the course.


----------



## Dale Turner

So in your opinion is TCCC more or less advanced than AMFR2 and PHTLS. Because if it is more advanced how can CFMG let medics take the back seat of medical training?

DT


----------



## Fraser.g

TCCC is the last chapter of Military version PHTLS. The skills are in the advanced package just like the BTLS Advanced.

Is it more advanced than AMFR2? YES!

Is it more advanced then the basic training for reserve medics? YES!

Do I intend to orient my medics to the theory of TCCC? YES!

Do I intend to teach the PHTLS Advanced package to my medics? YES!

Is TCCC the standard for the reserves? NO!

Do I believe we should train our medics to the PHTLS Advanced standard AND allow them the scope to practice to that level? YES!

Vent Ends.


----------



## Dale Turner

Makes you wonder why the infantry would yell "MEDIC!!!!!!!!!!!!" any more. Hell they'll be more trained in caring for the cas. than we will be.

But I suppose the casualty will need a ride to the UMS. We can do that.


----------



## Armymedic

Coy medic, get out of the mindset that TCCC is more or less advanced skill set. Its not...its just a different approach to giving care to the patient.

It involves both the shooters and the medics (regardless of the tactical situation) to know and understand certain protocols that will aid in the rapid treatment of life threatening injuries. In particular three life threatening injuries that cause preventable deaths on the field, extremity hemorrhaging, compromised airway, and tension pneumothorax.

It is not designed for non medical pers to become medics, nor gives them any ability to replace them. Its just a different level of training.


----------



## Fraser.g

Army Medic,

The big frustratoin that Coy medic has is in the training that the reserves are getting now, not the mind set IMHO.
The reserves are trained to the AMFR2 level while simultaniously staiting that the TCCC level is maintainable at the regular force level. 
I beleve this is flawed logic. If the regular force can maintain the TCCC set then the reserves can maintain a higher level then TCCC as a basic level.

To say no would indicate that it would take more than three days a month to maintain the skill set and I have not herd of a single combat arms unit that is willing to donate that time to any member whether they are in theater or not.


----------



## Dale Turner

Right on!!


----------



## Bruce Monkhouse

Highlights of an incident in which several American soldiers won a silver star.
http://forums.army.ca/forums/threads/31767.new/boardseen.html#new

Quotes,

The squad's medic dismounts from that third vehicle, and joined by the first vehicle's driver (CLS trained [combat lifesaving] who sprinted back to join him, begins combat life-saving techniques to treat the three wounded MPs.

Meanwhile, the two treating the three wounded on the ground at the rear vehicle come under sniper fire from the farmer's house. Each of them, remember one is a medic, pull out AT-4 rocket launchers from the HMMWV and nearly-simultaneously fire the rockets into the house to neutralize the shooter

The medic who fired the AT-4, said he remembered how from the week before when his squad leader forced him to train on it, though he didn't think as a medic he would ever use one. He said he chose to use it in that moment to protect the three wounded on the ground in front of him, once they came under fire from the building

Their only complaints in the AAR were: the lack of stopping power in the 9-mm; the .50 cal incendiary rounds they are issued in lieu of ball ammo (shortage of ball in the inventory) didn't have the penetrating power needed to pierce the walls of the building; and that everyone in the squad was not CLS trained.


----------



## Dale Turner

It's always good to hear about medics actually" supporting " the troops they are tasked to support. I think this example illustrates the need for combat troops to have some semblance of advanced first aid or TCCC and that medics need to have some practice on combat and weapons skills.


----------



## Radop

Bruce, 

Strong words and very encouraging.  I am currently on tour (although very comfortable one), I wish we would have this training before we go overseas.  This tour came up so fast we didn't have time to do any training of any type.  I think this is training that should be done annually or at the very least, before deployment if time permits.


----------



## JANES

Seems this thread has gone dead,
kinda like the topic in the CF - no implimentation, no standardization, everyone teaching their own version.  Brass doesnt know what or how to address it, so they ignore it.  Seems like TCCC is a swear word to cbt arms cmdrs.  First Aid all the way!!!!  DCDS directive!!!  No staffing, no money no time, no subject matter experts.  To proud to look south for advice?  Gonna bite the CF in the bum.  Hows that First Aid workin out for ya?


----------



## Armymedic

JANES said:
			
		

> Seems this thread has gone dead,
> kinda like the topic in the CF - no implimentation, no standardization, everyone teaching their own version.   Brass doesnt know what or how to address it, so they ignore it.   Seems like TCCC is a swear word to cbt arms cmdrs.   First Aid all the way!!!!   DCDS directive!!!   No staffing, no money no time, no subject matter experts.   To proud to look south for advice?   Gonna bite the CF in the bum.   Hows that First Aid workin out for ya?



Gee nice to see your head pop out once again, and as per normal, with nothing of value to add....

BTW, Roto 3 trained up approx 20% of troops. So it is getting out.


----------



## Fraser.g

JANES said:
			
		

> Seems this thread has gone dead,
> kinda like the topic in the CF - no implimentation, no standardization, everyone teaching their own version.   Brass doesnt know what or how to address it, so they ignore it.   Seems like TCCC is a swear word to cbt arms cmdrs.   First Aid all the way!!!!   DCDS directive!!!   No staffing, no money no time, no subject matter experts.   To proud to look south for advice?   Gonna bite the CF in the bum.   Hows that First Aid workin out for ya?



Not quite accurate, 

OK not accurate at all. There is progress being made and TCCC is not a "swear word" as a matter of fact several commanders have approached me to get a brief on what it is and how they can implement it.

TCCC is, as I have stated again and again, TCCC is covered in chapter 16 of the PHTLS text book. 

The reserve component of H Svc Gp are starting to use PHTLS as the standard for care of casualties. Note that they are not using TCCC as the stadard for obvious reasons.

JANES

1. Get you facts strait;
2. Post when you have something of value to say.

GF


----------



## Dale Turner

RN RPN,

     Just a quick question. I understand that TCCC is for non-medical pers, and that it is utilized by troops prior to a medic arriving on the scene. So asside from the standard fd dressing who will carry the medical kit needed for TCCC. Will everyone have to carry med supplies during their patrols and attacks?

Thanks.



DT


----------



## Fraser.g

The American system is that one or two members of a squad "Section" are designated as the Combat First aiders. Each of them caries a small leg or arm pack that contains airway supplies, chest seals, 14g Cathlons, Scalene Locks and a couple of one handed tourniquets to use above and beyond what the individual members have on themselves like field dressings. The point of TCCC is to do the quick life saving procedures until a medic arrives on scene or you can evac the Pt to a medical team.

GF


----------



## KevinB

TCCC bag







FWIW most of it can be in a day bag - for you are not going to be using it until the Fire Fight is over/Scene is safe.


----------



## Fraser.g

Thanks KevinB

Which version of the kit bag is that?

Is it the first gen that came out of the orrigional course taught in Edmonton or a later one from LFCA or LFQA?

GF


----------



## KevinB

Version 1 Mod 1  
Second Gen of the LFWA bag.


----------



## Fraser.g

Thanks,

I can see most of it but what was/ is the pack list.

A couple of OPAs
an NPA,
2 x 14 G cathlons,
a couple of field dressings,
a tourniquet,
Gloves, 
Micro shield

What else?


I am curious about the evolution of the kit.

GF


----------



## medicineman

The kit itself is a mod of the "Battlepacks" carried by USAF PJ's - the kit was designed by them so that they could have immediate access to the "bare bones" essentials for care under fire.  The fill is what the LFWA SME's felt was required to cover those bones.

MM


----------



## Armymedic

RN PRN said:
			
		

> Thanks,
> 
> I can see most of it but what was/ is the pack list.
> 
> A couple of OPAs
> an NPA,
> 2 x 14 G cathlons,
> a couple of field dressings,
> a tourniquet,
> Gloves,
> Micro shield
> 
> What else?
> 
> 
> I am curious about the evolution of the kit.
> 
> GF



no OPAs (medics only)
packet of lub gel
alcohol swabs.
Asherman chest seal,
cas tags, 
and a red fine tip marker.

The ones we pack in Pet are similar to the LFWA kit list.


----------



## Donut

AM,  is everyone carrying the 14g's, too?  Seems kinda odd to restrict OPA's but permit TPN needling.

DF


----------



## Armymedic

Those qualified the course do. 14 g, 3 inch, angiocath, I believe.



			
				ParaMedTech said:
			
		

> Seems kinda odd to restrict OPA's but permit TPN needling.



Restriction from theater is due to the short and simple nature of the course. They are taught NPA in addition to the FA airway techniques beacuse it is a simple and quick technique. It also goes to not having to carry 3 or 4 OPAs and that in reality one airway is not much better then the other (NPA vs OPA) for thier use.


----------



## Donut

Makes sense.  Thanks.

DF


----------



## KevinB

We have OPA's.  The picture was my kit as issued.

 FWIW In theory we can also do emergency tracheotomy with Bic pen...  (we got about 30min on that)

 Realistically the Torniquet's, and pressure dressings is what we where concerned about.  Although I spent the entire time hopign for a tension pnuemothoracs (sp) to needle decompress  ;D.  My GF is a medic, she was horrified to find out what we could do 'underfire'.  Heck I had some quik clot I got from US guys in theatre -- worse case scenario and we had no evac ability and one of our guys was still bleeding out - I would have used it.


----------



## Armymedic

You did the long course. The kit I speak of was for the people who did the one day course.



			
				KevinB said:
			
		

> My GF is a medic, she was horrified to find out what we could do 'underfire'.   Heck I had some quik clot I got from US guys in theatre -- worse case scenario and we had no evac ability and one of our guys was still bleeding out - I would have used it.



Use quickclot only after direct pressure and tourniquets are applied. Lift bandage, pour and recover the wound immediately. This stops the arterial blood for shooting the granules out.

Horrified is the usual response from medical personnel when they find out what is taught. Not to mention the TOTAL reversal of protocol by ignoring airway to immediately treat life threatening bleeds, before securing the A and B. 

A nurse asked me if there a difference in civie and military protocols. Well no, but there is a big difference between those and tactical protocols.


----------



## KevinB

Ack,

 I dont think the Combat First Responder 1 and 2 days courses actually got any gear afterwards.

We where lucky in our deployment as we had about 10 TCCC pers  in our Platoon.


----------



## Donut

In the past, we've debated the best way to achieve a high standard of medical care under tactical conditions. 

We've debated the deltas to be covered from a civilian paramedic to a deployable medical technician, we've covered topics to be taught to bring a cbt arms member up to a Cbt FR level; we've debated fluid resuscitation methodology, techniques and procedures, pre-MTF analgesia, training plans and techniques.

We've discussed reserve HS medic employment, and we've discussed limitation on skills and their maintenance.  We've seen several different skill sets presented as "the solution," and progress seems to be proceeding apace at developing a national-level course to give our "sharp end" more ability to look after their wounded prior to contact with HS staff.

In the "CSS Less Deserving" thread, Infanteer summarized four attributes of a combat-ready CSS member: Physical preparedness for the rigors of combat; Mental preparedness for the psychology of combat (will to combat?-Author); Skill at arms (and a willingness to use them-Author); and tactical awareness.  I won't dispute Infanteers analysis of this.

These leads me to consider which medical personnel have these attributes, fairly consistently, across a spectrum of the CF units, and are best able to provide medical support.  Then it hit me.  The pers who best embody these qualities aren't CF medical pers at all. In fact, most that I've encountered are extremely opposed to joining the CFHS. They're the Res Cbt Arms members who are also EMS.  As Armymedic pointed out, tactical medicine is best achieved when 

"both the shooters and the medics (regardless of the tactical situation) ...know and understand certain protocols that will aid in the rapid treatment of life threatening injuries."     http://forums.army.ca/forums/threads/26415.210.html

Currently, these people are being told specifically that, unless employed as a 737, they are not authorized to provide treatment as a 737.  This is due to the fact that:

"All medical services and treatments provided to the members of the CF fall under the legal responsibilities of the Surg Gen. Those responsibilities are delegated down thru (sic) the med chain to the lowest level at the MO, PA, NP level. Med Techs are authorized to provide medical services with a specific scope of practice that is allowed thru that chain, but ultimately its the supervising MO, PA or NP who is responsible for maintenance of the standard."  Armymedic http://forums.army.ca/forums/threads/26415.135.html

Several posters have pointed out that, not only must we improve the medical skills of our cbt arms mbrs, but we must improve the tactical capabilities of our medics, and equip them with a skill set that embodies Infanteer's Four Points, and gives them the approach to provide only the necessary care required, as dictated by the tenets of TCCC.

Dr King expressed his concerns as to the advanced nature of the skill sets required to intervene in life-threatening battlefield wounds.

"There are some significant interventions taught in TCCC.  Too short a course risks producing grads who are simply dangerous.  ...  Again, it is essential that there be an FTX component.  Otherwise, we are simply teaching a medical course.  The tactical component is just as important, if not more important to producing competent grads."

Dr Roger King 

http://forums.army.ca/forums/threads/26415.150.html

The shooters have shown a remarkable interest in this topic.  They want to look after their own, and they want medics who can look after themselves, put rounds on target when required, and provide the care needed without compromising the mission.  But, we're handcuffing the people best able to provide this.  One of the principle reasons these people are opposed to remustering is the reorganization of the HS and the "calling home" of the medics to the Fd Ambs, which is understandable.  In the Res world, loyalty tends to lie with the Regiment, not the trade.

Acknowledging that there is a delta to be crossed to bring any res force member up to a deployable standard, is this delta perhaps not best crossed by someone who's clinically current and tactically aware?  By someone who's used to working with both an infantry/ armoured/ eng/ arty  unit AND taking care of sick and broken people?  We need to embrace these paramedic/infanteers, not tell them they can't take care of their own because the CF won't cover them.

I'm not advocating a return to reserve trained med-a's on their own in UMS, or even to Reg F medics spending years in UMS. WRT the Reservists, they have neither the skills nor the experience to be working as we did in the past (fun as it was), and the Reg F are too few in number to dole out as they were, but these people who hold a civi license can be bridged to a working knowledge of CFHS procedures much more quickly then we can bridge a medic to be a integral member of an LIB, and provide a level of experience you will not see in a typical Reg F med tech.

Obviously there are exceptions.  The medics who spent years in 2 Cdo, or was a crewman in the LdSH, or a Diver or Bos'n are clearly going to have a better understanding as to what's what in their old unit's operations.

Sqn Medic, Old Ranger, I'm especially interested in your views on this, 

DF


----------



## Dale Turner

WOW! Your synopsis is bang on. You're absolutely right that detached medics to cbt arms units tend to consider themselves members of that unit as opposed to the Fd Amb that pays them. Why? I feel, at least in my case, that medics are a valued commodity to that unit. And the unit we support make us feel that we are one of them. We are invited to train along side them in their trade and likewise they learn from us a few tricks of our trade. We compliment each other like some sort of symbiotic relationship. 

When we are at our Fd ambs though we as individuals disappear. We become just another medic in a medical unit and whose skill is not unique to the unit. It may be a vain way to think about it but it's true.

I like you stated feel that cbt arms soldiers are very interested in the medical/trauma field. Whenever I'm on ex's I always answering very good and well thought out questions from infanteers and gunners etc. who are genuinely keen about casulty care. So why not train them up to a higher standard of casualty care? TCCC is a fantasic start. 

I think that as a medic in a cbt arms unit you automatically get a sense that there is a sort of "tactical" aire about the training. Something you dont get while in a medical unit. And as a member of that cbt unit you are expected to be as proficient as they are in weapons drills etc. Hell the other day I learned how to saftey precaution the C7 with M203 for the first time. But it was expected of me. So why would it not be expected of me to be able to look after myself in a fire fight? I know that I have a lot to learn about cbt tactics but I'm sure I'm going to get taught this as a member of this unit.

Being civy trained as an ACP my skills are relied upon by the medical unit and the cbt arms unit. I have been "told" that I can practice up to my scope of practice. Which is great as long as I have my CO and CFMG baking me up. Are they? I dont know. I think my CO will but not so sure about CFMG. And what of civy trained PCP's are they able to practice up to their scope of practice? Also are they not able to learn and practice the skills that TCCC teaches to non medical pers? ie; needle decompression etc.

It's very frustrating time being a medic in the army today. In my perfect world you'd be able to have medics attaced to cbt arms units instructing TCCC to the troops but also returning to the Fd ambs for contiuation and upgrade training all the while becoming more proficient in their personal battle skills making them indeed a very integral part of the combat unit and not just a liability.

Thats all for now. I'll have to read your post again to think of more points to add.


DT

CHIMO


----------



## Dale Turner

Duh! : I just got the jist of your post. Infanteers, gunners, sappers, and armoured troops that have civy paramedic quals should be able to provide cas care to their own in a tacitcal situation, by all means. Like you said they already have the tactical awareness and the combat experience. However I think you can also train medical pers to have the same tactical skills a cbt arms soldier has. They too had to learn these skills so why cant we? In the civy world some people believe that as a paramedic I work for the fire dept therefore must be a firefighter. Or they say whats the difference? between a firefighter and a paramedic. We have a saying ... "you can train a paramedic to be a firefigher but you cant teach a firefighter to be a paramedic". I would'nt sell medical pers short on learning battle skills.

There are some medics who dont want to be in a cbt situation. They would prefer to be in a stable clinical environment. Which is cool and very important. But I feel you also need medics at ground zero if you will. They need to be on the scene. 

Now I understand the fact that the civy trained infanteer/paramedic would be there also but his job is to be an infanteer. His sect. comd would be without a member of his sect. because he/she is providing cas care. If a tactical medic was there you would have just had an extra weapon at the fire fight. So no big deal when it's not there during the consolidation phase.

That's one reason medics should not have been pulled out of cbt arms units. If medics could stay in an inf. reg for example they would learn all the battle skills. So if a infanteer did have medic quals thats great, he/she can give the medic a hand when theres time for him/her to do so.


DT  

CHIMO


----------



## old medic

I'm going to take counter point on this one gentlemen.



> We need to embrace these paramedic/infanteers, not tell them they can't take care of their own because the CF won't cover them.



This summed it up. If your a paramedic, and your not at work, then your probably not a paramedic.  
Paramedics can only perform delegated acts under the medical licence of their medical director or base hospital 
physician while on duty.  They can not walk around on their time off practicing medicine or doing invasive procedure.

A medic should only be performing what their trade quals and their MO allows them to perform (standing orders). Civy paramedic quals 
(myself included) are no good without green quals and the medical chain allowing me to perform skill sets.



> Being civy trained as an ACP my skills are relied upon by the medical unit and the cbt arms unit. I have been "told" that I can practice up to my scope of practice. Which is great as long as I have my CO and CFMG baking me up. Are they? I dont know. I think my CO will but not so sure about CFMG. And what of civy trained PCP's are they able to practice up to their scope of practice?



Check with one of the MO's at your Field Ambulance.  It's the medical chain of command you will wind up answering too.

Cheers.


----------



## Dale Turner

Hey Old Medic. as it pertains to me it was actually my CO who is an MO who said I can practice as an ACP while wearing green, so did my DCO who is a NO and my RSM is a PA. I hope this is enough to allow me to practice. What do you think? Obviously I have to prove my quals yearly. I would like something in writing though.


DT  

CHIMO


----------



## old medic

PM on the way.

You should pursue it in writing. "He said it was ok" is shaky ground in the medical world.
Just think back to "not documented, not done".


----------



## Dale Turner

Amen  ;D

In regards to ParaMedtech's suggestion of combat arms troops that happen to be paramedics provide cas care, what if they had some affliliation to the closest Fd Ambs that would recognize their individual quals. If they recognize med tech's quals as ACP or PCP why not Bombardier Bloggins civy paramedic quals? On the same idea the Good Samaratan Act allows an individual to apply aid up to the level of care that the individual has been trained. So they in essence can care for the casualties as a good samaratan could'nt they?



DT


CHIMO


----------



## KevinB

What is missing in the above is a lot of those civy qualifiaction or protocals are irrelevant in a combat trauma scenario.
Where we jump to deadly bleeding some paramedic is busying pissing around with an airway.

We are using Tourniquets and that makes a lot of people cringe.

 The fact that the CF keeps trying to shove USELESS (For COmbat Trauma) St John's First Aid down our throats does not help either.

IF the CF medical world wants to hang onto trauma medicine - it had best come up with a plan to either split the medic stream into tectical medicine and clinical -- or be VERY upfront and explain to the medics they are shooters first, and the namby pamby crap of I dotn want to carry a gun today is not going to cut it.


----------



## Dale Turner

I know that uncontrolled bleeding was the leading cause of death of soldiers during the Vietnam War, thus TCCC states that the bleed should be controlled prior to anything else. I'm not intending to insult your common sense but we're not going to piss around with an airway if dosent need to be dealt with. But I have a hard time understanding the theory of putting a fd dressing on someone who isn't breathing or has an airway. If you dont deal with the obstructed airway or lack of breathing the bleed will quickly be controlled on it's own. Then again if the cas isn't breathing chances are they're not going to make it anyway.

I appreciate the fact that you have been on tours and you have taken TCCC. So you know the difference's between non medical pers TCCC and our medical training. And your right. Civy protocols dont always apply to the military or a tactical situation. What we need is to return medics to combat arms units and not only have coy medics but platoon medics or even section medics. The medics you speak of that dont want to carry a weapon are the personnel that want to be in a clinical setting and tactical medicine is not for them. Fair enough. They fill an important role in its own right. But there are medics out there that prefer to be in the bush or in the urban ops working the tactical side of things (ooh pick me! pick me!   ;D).

I think the point is though that if you already have fully trained medics whether civy or military trained they need to be taught battle skills and not shuffled away from the lines so they can provide the care that TCCC is geared to supplement.

Also I'm pretty sure the CF isn't expecting you to perform St. John's FA duing a fire fight. I think its more for when we're in garrison etc.

DT

CHIMO


----------



## KevinB

Well considering we had to do St John's as our Afghan medialcal refresher check in the box...

  WE HAD ZERO other medical famils...


I'm not saying ignore civy courses - but I am cautioning -- we have had problems in the past with some 031 trade EMT's and St John's Amb instructors...
 CPR being a case in point - Trying to explain there is no point in trying to revive a GSW who's heart has stopped...


----------



## Dale Turner

I hear ya. I'm a St. John's FA instuctor as well but trust me I'm not a slave to it's policy, or the CF's regarding the absolute need to have it in theatre.

I'm not sure about your experiences with medics or medic trained infanteers but not all of us think you can save the world by pushing on someones chest. Some of us are realistic. Thats another reason to have military medics ride out on civy ambs to expose them to the death's of patients, and again keep those medics with combat units.



DT


CHIMO


----------



## Donut

Kevin, Ack on the utility of standard treatments in a cbt environment, I am saying that someone with time treating sick and injured is better then someone without it.  I'm advocating that we take these pers and train them in tactical care, and then authorize them to use it.  That, if you had someone like Kopp in your section, that they, with appropriate training, would be the best bet for a high level of field care under fire.

I've said before, and I'll say it again, that having people run around punching needles into peoples chests is something we may regret.  I'd much rather have someone who has seen respiratory distress go from bad to worse to life threatening make that call then someone whose exposure to it is "cyanosis is bad, mmmkay?  Your next class is ..."

TCCC isn't the end-all and be-all of care--surgery is, it's trauma!

With regards to trauma-induced cardiac arrest, the civi world is realizing that prehospital penetrating trauma arrests are almost uniformly irretrievable in the field, even with a short transport to a facility that can crack the chest. Even worse outcomes for blunt trauma.

Sqn Medic, that's exactly what I'm advocating, that Med Gp take these cbt arms members with medical training, and embrace them, familiarize them to our equipment, run them through a Cbt FR, and employ them as such.

OM, what I'm advocating is that we provide these people with the medical direction they need to operate at their standard of care, that we 'bring them into the fold' so to speak, in the same way you were cautioning Sqn Medic about his oversight.

DF


----------



## Armymedic

KevinB said:
			
		

> Trying to explain there is no point in trying to revive a GSW who's heart has stopped...



Especially when the second round of the three round burst hits a little north of center of mass.

Actually its not so much the cause of cardiac arrest that will determine the worth of doing CPR, but the time until you can hook up that little shocky making machine to the patient...10% decrease in survivability/minute...so after 10 mins, they are FUBAR'ed


----------



## Fraser.g

Yes, and we all carry an AED in our jump bags. NB when we are doing dismounted support.
Lets not forget that CPR is very time consuming. The time you take on a casualty thats heart has actually stopped in a mass casualty environment will cause more pers to deteriorate from lack of care.

The needs of the many out weigh the needs of the one.

GF


----------



## JANES

"Actually its not so much the cause of cardiac arrest that will determine the worth of doing CPR, but the time until you can hook up that little shocky making machine to the patient"

This is interesting!  So when the cause of cardiac arrest is a a big hole in the heart, or maybe the aorta and theres no blood left for preload so the heart stops beating - asystole - then how does an AED work?  What will CPR do?  And when you've got a guy shot throught the arm hole in his vest and he's got a nasty tension with delayed care, so he arrests with PEA, how does this AED work again?  The cause of cardiac arrest IS actually very relivent to determine whether CPR will be effective.  AED's may be usefull in certain environmental injuries and certain illnesses, but how many drownings, electrocutions, hypothermia's, MI's occur in theatre?  Potentially, but is it worth humpin that piece of kit for the few that may or may not happen, or should emphasis be on prevention of those injuries and illness?


----------



## Fraser.g

janes, 
Once again your observations are astute to the point of the mundane. If you were to actually READ what was posted instead of jumping on the last post made you would see that the majority are saying that CPR has virtually no place in phase I or II of TCCC.

I also note that you are still resistant to filling out your profile.


----------



## medicineman

As an ER doc so aptly put it on grand rounds one day - PEA with no blood still equals DEAD - so I'd say the cause of arrest has alot to do with whether or not you should do CPR.  In combat, bad idea - ties up resources and makes you a very intriguing target.

MM


----------



## Armymedic

medicineman said:
			
		

> As an ER doc so aptly put it on grand rounds one day - PEA with no blood still equals DEAD - so I'd say the cause of arrest has alto to do with whether or not you should do CPR.


yeah yeah...first step of PEA algorithm is to attempt to correct the cause

And, yes, Cardiac arrest caused by penetrating chest trauma has less then a 1% survival rate.

My point was for the nonmedical troops, in response to KevB:
the cause of pulselessness is not what should prevent you from doing CPR, but it should be determined by time and resources.


----------



## KevinB

I appreciate I am preaching to the choir in here.

 But there are a bunch of CFMS pers that need to be dragged kicking and screaming into the 21st Century.  Of course I dont think that ratio is any different from other trades that are out to lunch.

 Medics have to get more combat oriented -- We had one Cpl show up with a weapon, and then I lost a pissing match with a incredibly obstanate and obtuse MWO (Medic) when I made her go back and get her weapon. 

 I'd like to see TCCC courses become more wide spread and Advanced TCCC as well. 




 FWIW with needle decompressions I had a SF medic explain to me with the holes in the chest that you will already have, then one itty bitty needle hole is not going to make any changes for the worse...




Armymedic - time and resources - something I am unlikely to have in the field...  But I agree if they are available - the casualty with get the best standard of care that we can afford to provide.


----------



## Dale Turner

I agree whole heartedly, the TCCCC should be a CF standard course just like FA is or SHARP is. 

The problem in the reserve world is that we're so busy keeping ourselves qualified with MCSP and trying to fit some ex's in there as well that there is no time to a) take the course/instructor course, b) there is no time to teach it to anybody else.

And I've said in some other medical threads needle decompression is not that hard of a skill to learn. I think land marking and assessment of a pneumo. would be the toughest part to learn. 

I agree and have stated that some CFMG people dont have the heart for the combat stuff but what do you suggest would remedy that?





DT


----------



## Armymedic

sqn_medic said:
			
		

> And I've said in some other medical threads needle decompression is not that hard of a skill to learn. I think land marking and assessment of a pneumo. would be the toughest part to learn



Yes, but not nearly as simple as the two other skills which are more likely to save lives, AND not nearly as invasive:

Tourniquets and,
Nasal Pharyngeal Airways.

Given the choice, I'd have every member of the CF instructed on tourniquet techniques and issued one with their fd dressings.


----------



## KevinB

Good point.

 As far as the NPA goes -- I always wanted to do a emergency tracheostomy/tracheotomy  ;D

Some rubbing alchol on a bic pen (ink section removed) and voila intanct trach tube - and trusty knife cut for a stoma.
 This was actually touched on by the CF MO teaching OPA/NPA's as well...

* I got a copy of a buddies SF Med book - watchout here come Dr. Death


----------



## Armymedic

Kev, using a bic pen cylinder to do a emergency trach would be the equivilent of you using the normal service C7A1 vs your own rifle in a shooting competion. As it, it would work, but why when much better kit is avail?

Way cool to try, no doubt, but that is not a "tactical" medical procedure.


----------



## KevinB

No - but as you said "cool to try..."

  ;D


----------



## Dale Turner

Armymedic, Good point re; tourniquets however some medics dont even have a good working knowledge of tourniquet use.

Do you know of any plans of aquiring proper tourniquets. I'm sure our regular IV tourniquets will work in a pinch but like you said why not use the best kit available.


----------



## Fraser.g

sqn_medic said:
			
		

> Armymedic, Good point re; tourniquets however some medics don't even have a good working knowledge of tourniquet use.
> 
> Do you know of any plans of acquiring proper tourniquets. I'm sure our regular IV tourniquets will work in a pinch but like you said why not use the best kit available.



Although I do not have any knowlage on the CF purcurment of new equipment I do know that a regular IV tourniquet is not sufficient. They are designed to arrest venous flow not arterial. 

You would be better off with a 1 inch cargo strap and a winlass then using a penrose drain or other IV tourniquet in a situation where direct pressure or pulse pressure points will not arrest the flow.

GF


----------



## Dale Turner

See what I mean? ;D 

Maybe tourniquet usage SHOULD be taught during QL3 or PHTLS.

Thanks RN RPN




DT


----------



## Fraser.g

Here is a site with the best explination in laymans terms the indications and contraindications as well as the usage and maintainance of a tourniquet once it is applied.

By the way the VNH is a fantastic resouce for anyone who is interested in military medicine. IMHO.

http://www.vnh.org/StandardFirstAid/chapter3.html

GF


----------



## medicineman

I was doing a search on CMED's site and found that there is a CF NSN for the CAT - Combat Application Tourniquet - which is on issue with the US Army.  Apparently a bunch were procured for ROTO 4.  It looks like a decent device - quick application with a windlass built into it.  NSN is 6515-CF-001-9812, Tourniqet Combat Application, Hemorrhage Control.

Someone brought up using an IV TK - you'd need alot of bulk underneath it to get the pressure you'd need to get good arterial bleeding control - better off using a BP cuff.

MM


----------



## Armymedic

medicineman said:
			
		

> I was doing a search on CMED's site and found that there is a CF NSN for the CAT - Combat Application Tourniquet - which is on issue with the US Army.   Apparently a bunch were procured for ROTO 4.   It looks like a decent device - quick application with a windlass built into it.   NSN is 6515-CF-001-9812, Tourniqet Combat Application, Hemorrhage Control.



In fact it was for Roto 3. In practice they're slick and easy to use.

2 Fd Amb is teaching another course in Jan.

RN PRN,
I used same reference cut and pasted into a PP lecture I did a while back...simple and direct.


----------



## Old Ranger

Any chance there available in CIVI land?


----------



## Old Ranger

Old Ranger said:
			
		

> Any chance there available in CIVI land?



Disregard, found in Medical Forum, under U.S. First aid Kits.


----------



## Armymedic

From website:
http://www.phildurango.com/index.htm

Combat Application Tourniquetââ€žÂ¢
(C-A-T)ââ€žÂ¢ 
    
The C-A-Tââ€žÂ¢ is the 1st choice of the U.S. Army, the Army Surgeon General, and the Army Institute of Surgical Research. 

The Combat Application Tourniquetââ€žÂ¢ (C-A-Tââ€žÂ¢) (Patent Pending) is a small and lightweight one-handed tourniquet that completely occludes arterial blood flow in an extremity. The C-A-Tââ€žÂ¢ uses a Self-Adhering Band and a Friction Adaptor Buckle to fit a wide range of extremities combined with a one-handed windlass system. The windlass uses a free moving internal band to provide true circumferential pressure to an extremity. The windlass is then locked in place; this requires only one hand, with the Windlass Clipââ€žÂ¢. The C-A-Tââ€žÂ¢ also has a Hook-and-Loop Windlass Strapââ€žÂ¢ for further securing of the windlass during patient transport.


Combat Application Tourniquetââ€žÂ¢
(C-A-T)ââ€žÂ¢ 
    
      
Product   Tourniquet Combat Application One-Handed
NSN: 6515-01-521-7976
Part Number: NAR-CAT  
  
      
Distributor   North American Rescue Products, Inc. is now the exclusive U.S. distributor for the Combat Application Tourniquetââ€žÂ¢. 

www.NARescue.com
info@NARescue.com
888.689.6277


----------



## 2Charlie

I am in a place where the Tq is a must have piece of kit.

Most of the guys I am with ditched the CAT and went with a very simple design that pulls through a buckle and then you pull a lanyard that snaps a ratchet closed.  One handed, and fast.

The CAT is good, but you better not be on the down side of fading on a bleed out reading the freakin directions.


----------



## Fraser.g

2Charlie said:
			
		

> I am in a place where the Tq is a must have piece of kit.
> 
> Most of the guys I am with ditched the CAT and went with a very simple design that pulls through a buckle and then you pull a lanyard that snaps a ratchet closed.   One handed, and fast.
> 
> The CAT is good, but you better not be on the down side of fading on a bleed out reading the freakin directions.



2C

Do you know the name of the TQ you and your friends have? I would be interested to get your feedback.

Also, no piece of kit shuld have its instructions read in the instant you need to use it.

Hmmm "in case of miss fire cant the weapon to the left and note the position of the bolt (Ref A)"...

GF


----------



## JANES

You need to be careful.  Look at the data.  Theres been alot of testing done (the the US and CDN Militaries) that says the only effective ones are the CAT and the SOF-T.  Hence why they are the ones that are issued now (US).  The one you have may be easier to use, but unfortunately thats not the only criteria for an effective tourniquet.  It needs to stop arterial bleeding completely, or you could be doing more harm than good (lets blood out, but none back in - better to let none out or in).  And you need a doppler to test this, not simply a loss of distal pulse.  All I'm saying is be carefull - check the data before you decide something is "better" - it may be a relative term.


----------



## JANES

2Charlie said:
			
		

> I am in a place where the Tq is a must have piece of kit.
> 
> Most of the guys I am with ditched the CAT and went with a very simple design that pulls through a buckle and then you pull a lanyard that snaps a ratchet closed.   One handed, and fast.
> 
> The CAT is good, but you better not be on the down side of fading on a bleed out reading the freakin directions.



The tourniquet described here is the SATS - Self Applied Tourniquet System.  It was one of the ones the the US SF initially started using, as well as one of the ones trialed on the TCCC pilot course.  Since the testing has been done on it, as well as many others, it was proven to be ineffective.  Very ineffective actually.  If you go by the data from the studies - the ones recognized as effective by the Canadian and the US studies (Military) are simple surgical tubing (not penrose drains) (also, one handed application problems and securing problems) the CATS, EMT which is the same idea as the CATS in a bulkier heavier design, and the SOFT-T recommended for medics because it's bulkier and heavier but better tolerated by the casualty as it is pneumatic.  The idea being that self/buddy aider applies the CATS then when the Medic gets to them may apply a SOFT-T.  There are tons of other ones out there, but the cooler looking one, or the easier to put on one might bight you in the bum in the end.  Stay safe!


----------



## JANES

A correction to my previous post.  I mixed the SOFT-T and the EMT up.  The EMT is the pneumatic tourniquet that the medics should carry, and the SOFT-T is the one that is similiar to the CATS only heavier and bulkier.  Again though, these were the only three found to be effective.


----------



## rhino18

LDTFS has completed the QS for this course and it looks very similar to the courses run by 1CMBG.  This will include not only theory, A&P, Dx, and Rx.  But most importantly the field time to produce the stress imoculation required to be effective under tactical conditions....


----------



## Fraser.g

Are the QS published anywhere on the DIN?
When are the rest of us able to see it and then the logical end point is when can we start actually start training pers to the new standard?


----------



## rhino18

Like all things in the military----This will take some time.  Once the QS is approved it will go to CTC for a TP writing board and them, only to an implemantation phase.......In short, don't hold your breath, unless you can do it for about a year.

That said, there are many references on the DIN to this topic.  And there is nothing stopping you from running this training locally.  It will give troops, specifically predeployment, valuable skillsets.  This, however, will not result in any type of qualification.


----------



## Fraser.g

I think you are being quite optimistic in saying that it will only be a year until the official TP is out. 
Heck, the powers that be can not even decide which course will be our standard of trauma care let alone which TP will be the standard for Combat First Aiders. 

I know it is a hard decision to make...being that the US TP has been out for years, it tried and true, battle tested and is founded on hard resarch based practice.

Yet another example of not adopting another nations doctrine because it is not the "Canadian Solution."
In the mean time more and more pers are being trained up with a hodge podge of courses with a wide assortment of skills and knowledge to prepare them for deployment only so that when the official one comes out some time in the next decade, they can say "sorry, all your qualifications don't count" Please take the next two weeks or so to re-do the course to the "Canadian Standard" By the way, here is the US Text, modified US PPT lectures and US stats to back up our decision.

OK, cynical I know, but I have herd it before and am becoming more and more jaded.

Happy new year and may the next one be more prosperous then the last.

GF


----------



## Grunt_031

Writing boards were held in Kingston the week of 12-16 Dec.


----------



## rhino18

OK, cynical I know, but I have herd it before and am becoming more and more jaded.


I think you summed it up......

As a military we all have to push for an "I can attitude"  And I know it's hard but nothing will get down if we're all jaded and cynical....


----------



## ab00013

Okay I'm sure this is going to sound kind of out of the ordinary but here goes. I'm a reserve infantry soldier who has finished BMQ,SQ,DP1,DP2A and this summer (sometime between May - August) I'd like to go away for more courses. However, I'm really interested in taking a medic course, but I don't want to change trades. I just feel that it would be very useful for me, considering infantry is always out in the field, to take a medic course. I have searched the forums and all I could find was one topic mentioning a tactical combat casualty care course, but I don't know if its avaliable to reservists, if its still being run, or any details. If anyone is out there that can tell me about this course or any other course I may be able to take, along with when and where it might be run, I'd greatly appreciate it. If there is such a course, I'd like to submit my memo as soon as possible requesting to be on it but without knowing if there is such a thing I can't really request it.  


Thanks


----------



## Cansky

You can see if your gaining unit will give you time off to take a local ambulance course.  In Edmonton some of the troops took EMR/EMT a (emergency medical responder/ambulance).  Emr is also advanced first medical responder which is also provided by the military.  If you come to gagetown we running amfr course frequently.  Other units offer a new military accessable course only called TCCC (there is a thread here about that course).  My best advice to you is to go and see your unit ops and trg pers to find out what exactly your unit will provide for you and may even pay for.
Kirsten


----------



## medicineman

The TP board for the TCCC is being sat here in Gagetown in the near future, so it will be an actual course finally.

You'd likely have to put a memo up through your chain after finding out when and where one is being run.  Having said that, email traffic I've read suggests that this course will only be offered as pre-deployment training for units visting far away lands, not to mention the fact that you will have to partake in refresher training about roughly every 90 days and the certification has a 2 year best before date on it before youhave to take it again.

On another note, we used to cross train an awful lot when I was a reservist - perhaps they still do that.  Stuff we have done here in GTown is keep a few non-medical spots on BTLS courses and such, plus there is an active First Responder training cell as well with the Base First Aid Cell.  Check around your area and see what there is.

Hope that helps some.

MM


----------



## medic31

The TCCC ( Tactical Combat Casualty Care ) course is up and running in Petawawa. Don't think there are any reserve PERS on it though. Again staff it up through your COC.


----------



## Armymedic

medic31 said:
			
		

> The TCCC ( Tactical Combat Casualty Care ) course is up and running in Petawawa. Don't think there are any reserve PERS on it though.



There isn't. The majority are going on tour in Aug.


----------



## kj_gully

hello again from an Airforce cousin. After beating up casevac for awhile I have turned my attention to this thread. forgive me if this was prev discusse in the 19 pages of this thread, but I am interested in thoughts on inter ossious fluid replacement. Having recently returned from a SF med conference in the US, it seems that their overworked medics are using inter ossious fluid replacement preferentially to IV in major trauma. makes good sense to me. in my practice, the folks most deseving of fluid are cold and peripherally shut down, and starting a line in a chopper (probably worse in a Bison, I know) is always excellent sport, and worthy of a beer reward for success. Rumour is we are getting fast1 system for interossious fluids, along with a 'new' fluid to supplement saline that will remain within the vasculature better than NS. What is happening in the "real" medic world? BTW, fast1 is a sternal placement.


----------



## Fraser.g

IO starts are relatively easy to initiate. One of the major drawbacks is post procedure complications such as fat emboli and infection. In the ER where I work we have a pediatric policy that states that you go peripheral for two attempts. If no line is achieved then you go for the IO in the leg just distal to the knee as the preferred site.

I can not see there being any difference or contra indications to having the same policy for pre-hospital Trauma esp with longer evacuation times.

As for the fluid replacement are you talking about pentaspan or pentastarch? These items are great for fluid  recitation when you do not have PRBC available. 

Pentaspan is talked about at length in earlier in this thread http://forums.army.ca/forums/threads/26415/post-126875.html#msg126875.

GF


----------



## Armymedic

IO is not in the CF med tech scope of practice. But we are aware and have used them on children while deployed with DART.

Fast1 kit for adults would be what we used if we were allowed to do them on adults, and we do discuss them as part of continual training. If you are being allowed to start sternal IO, then it won't be long before we are too.

As for fluids, we have colliods (penta/hepa/span/starch or combination of the above) avail for overseas, but because of its sensitivity to heat/light and expense are not carried often here at home.

IO and colloids are out of the TCCC arcs here in the CF and better spoken about in other threads.


----------



## kj_gully

Groovy, thanks for the posts, i will delve deeper....


----------



## Journeyman

kj_gully said:
			
		

> Groovy, thanks for the posts, i will delve deeper....



Why do I feel uncomfortable with someone discussing inter-ossious fluid replacement .....who ends his post with "groovy"?


----------



## Donut

Ya ever seen the marks the FAST1 leaves?  It's the sternum that becomes "Groovy"   8)


----------



## JANES

WRT IO's, the B.I.G. or Bone Injection Gun is the weapon of choice and proved easier to use in tests done by the US.  And the fluid in question is not Hextend (current fluid used by the US) or Pentaspan (only CDN available semi-equivalent), but is in fact HSD or Hypertonic saline Dextran, also known as Rescueflow.  Currently being tested in Canada and the US, the tests are almost complete.  250ml of fluid is approximately equivalent to 500 of Hextend/Pentaspan and about 4000ml of NS or RL in the body over time, which is the importance for delayed and extended CASEVAC times.  Which would you rather carry/jump in? 8L or 500ml of fluid?  As for IO's not have any place in Canadian TCCC, I would have to disagree whole heartedly as R&D continues and the CF evolves on the topic.  The skill is definetely a requirement.


----------



## Fraser.g

Janes,

Once again you are making allot of grand statements. Is there any research that backs up some of your claims or is this all "personal Experience".
I also notice that despite repeated request you have not filled out your profile.


----------



## medicineman

http://www.forces.gc.ca/site/community/mapleleaf/html_files/html_view_e.asp?page=vol9-03_16#e1

Here is a link to the Maple Leaf about a Canadian surgeon involved in the HSD research - doesn't look like he was pulling everything out of his backside.

MM


----------



## Armymedic

JANES said:
			
		

> Currently being tested in Canada and the US, the tests are almost complete.  250ml of fluid is approximately equivalent to 500 of Hextend/Pentaspan and about 4000ml of NS or RL in the body over time,
> 
> As for IO's not have any place in Canadian TCCC, I would have to disagree whole heartedly as R&D continues and the CF evolves on the topic.  The skill is definitely a requirement.


Good post JANES.

I thought it was a 1-4 ratio, or 250 ml of Hyertonic Saline Dextran = 2000 ml. Either way, carrying 500ml of fluids for trauma beats 2-4 kgs of extra fluids. We medics will still need to carry (or have access to) isotonic solutions, but far less then before.

This solution was first licenced for use in Sweden and now used in many European countries. Its use has definite promise. I am unsure about its environmental hardiness (temperature ranges), but its got to be better then the 15-25 C that Petaspan needs to be kept at.

About IO, new knowledge and technologies are constantly coming out. I wouldn't be surprised if in 5 yrs we may be teaching a new IO skill to TCCC students, with Rescueflow the fluid of choice.


----------



## Gunner98

medicineman said:
			
		

> http://www.forces.gc.ca/site/community/mapleleaf/html_files/html_view_e.asp?page=vol9-03_16#e1
> 
> Here is a link to the Maple Leaf about a Canadian surgeon involved in the HSD research - doesn't look like he was pulling everything out of his backside.
> 
> MM



This particular fellow spent several years (prior to his current posting) doing residency at the US Naval Medical Centre/Hospital in San Diego and saw things that most mil doctors only dream of.  He is indeed one of the good guys.


----------



## kj_gully

great posts, I had heard some murmurs about hypertonics, hope to see itb4 I retire ;D, as for JANES posts re BIG, I think, for our practice, that the fast1 may be a better option, only because the placement lends itself to easy monitoring. Having the line in the Tibial epiphysis while "out of the way", is out of sight, out of mind. I am sure there will those who will scoff @ that line of reasoning, and if we go to the BIG, I will be satisfied, but I'll also be writing "IO" on my pts forehead! LOL


----------



## Armymedic

Gunner98 said:
			
		

> This particular fellow spent several years (prior to his current posting) doing residency at the US Naval Medical Centre/Hospital in San Diego and saw things that most mil doctors only dream of.  He is indeed one of the good guys.



I think you are confusing LCol J. Doucet who spent 5 yrs in San Diego with LCdr Filips who worked out of Sunnybrook.


----------



## Journeyman

Gunner98 said:
			
		

> ...doing residency...in San Diego and saw things that most mil doctors only dream of.



I saw things in San Diego that I had never, ever dreamt of!!   

Oh sorry, completely wrong thread   ;D


----------



## JANES

FAST 1 will due for SAR, but in a tactical combat environment, the BIG is better.  Less screwing around for insertion (pun intended), and less peices to lose in the dirt.  The BIG is one peice, the FAST 1 has many different parts.  The BIG you just pull the pin, palm it, landmark, point and shoot instead of drilling for marrow.  Don't hold it backward or you'll have to dig the needle out of your metacarpal.  They are also very compact.


----------



## kj_gully

A close quarter combat weapon of last resort! ;D


----------



## JANES

WRT the ratio of fluid; after infusing 1L of NS, only about 200ml is left in the vasculature at the end of that hour.  The rest goes interstitial.  The same amount of colloid, 1L of say hetastarch will increase the vascular volume to about 1600ml.  Now don't go and give someone 1L of colloid at once, this is just for ease of understanding the ratios here.  After 8 hours, you have about the same amount of fluid in the vasculature from the colloid.  If you have infused 1L of NS every hour for 8 hours (Lets hope that the casuatly is catheterized if you're giving that much fluid) at 200ml remaining intravascular per hour, then you've got about 1600ml in the vascualture in that 8 hours.  We don't give 1L boluses of hetastartch or pentastarch, we give them 500ml, then if that doesn't work we try 500ml more, then stop it for a couple reasons.  Higher amounts can have adverse effects and if he needs more then he is probably bleeding internally and anymore fluid will make him bleed more.  Better to use it on someone else that is salvageable.  The colloid molecule is too big to diffuse into the interstitium.  So you come out with a ratio of 4L NS to about 500ml of Hextend/Pentaspan.  The equivalent of HSD to Hextend/Pentaspan is about half, so 250ml.  I hope this is an understandable explaination.  Maybe it should be in the fluid resus thread. 

The days of following the ATLS guideline in a tactical environment should be forgotten.  We are not in a hospital, we are far from it, thats why this research is being done.  Treating a number of say 90mm Hg is not a good practice.  Filler up and blow the clot.  Especially if the hemorrhage is internal.  Theraputic hypovolemia can be benificial.  The AMMED fluid resus algorhythm is pretty good all things considered.

The other problem with filling somone full of 8L of NS is that someone who is hypovolemic is probably acidotic.  The periferi is shut down, acid is being produced from anerobic cellular metabolism.  Lets say hypovolemic shock assumes slight acidosis.  The pH of NS is about 5.5, so you are filling someone who is acidotic with alot (8L) of acid, as opposed to a little bit (250ml) of acid.  Another reason that it may be more benificial.

With the hypertonic solutions, cellular dehydration is an obvious problem, the hypertonicity of the fluid pulls body fluids from the interstitial and then intracellular spaces into the vasculature.  This is why it is called a "volume expander" but the celular dehydration is secondary of concern to vascular volume expansion and oxygen tranport to the cells.  Anemia isn't usually a problem as fairly low hematocrit levels are generally tolerated.  Perfusion is priority #1.  You're right, medics will still have to carry NS to rehydrate hyperthemics and other conditions, but these fluids allow much more sustained care - read longer CASEVACs and CASEVAC delays, as well, can carry fluid to treat more casulties.  Yes, this fluid would also be benificial in a non-combat SAR environment when the SAR-Tech has to treat casualties in isolated locations with CASEVAC delays.  

Cost shouldn't be that big of an issue.  We're not drinking the stuff for breakfast.  We don't hang 10 bags a day like you're average city ambulance.  And as to the temperature durability, I will see what I can find.  

On another note, when is the CF going to issue eveyone in theatre a manufactured tourniquet?  Is this not negligence on their part to not provide this item to everyone?  They know what they number one preventable casue of battlefield death is, yet they are painfully slow in doing anything about it.  Is this not called negligence?


----------



## kj_gully

Holy! I thought everyone was issued a CAT or SOFFT in theater! I was pissed off becuse I thought that SAR was last to get them, especially once I heard that Mcpl Franklin had TK'ed himself. i asumed, that he had used a manufactured windlass., and that they were on everyone's load bearing vest, like the WWII shell dressing (any move to get the israeli dressing?). It is in my opinion negligent to not provide these, especially with the documentation coming out of Iraq with regards to how they are saving lives. Thanks for the post on fluid resus, good review. I  was in the CAR with a Sgt Janes... good medic, taught me how to give an IV to my buddy... my first TCCC training. I can't imagine trying it in the field  but it improved my confidence and morale going overseas.


----------



## Armymedic

JANES said:
			
		

> On another note, when is the CF going to issue eveyone in theatre a manufactured tourniquet?  Is this not negligence on their part to not provide this item to everyone?  They know what they number one preventable casue of battlefield death is, yet they are painfully slow in doing anything about it.  Is this not called negligence?



If the CDS' interest is any indication, very soon. I'd hazard to guess by the end of this tour. Everyone on the next roto is getting taught how to use one.


----------



## JANES

What tk's is the CF looking at?  CAT or SOFT-T, both?  Are the Medics going to get the EMT?  Which one is being taught?


----------



## Armymedic

CAT,

Word is that medics are to get EMS, but I have yet to see one.


----------



## JANES

What kind of tk was put on MCpl Franklin anyway?



			
				kj_gully said:
			
		

> I  was in the CAR with a Sgt Janes... good medic, taught me how to give an IV to my buddy... my first TCCC training. I can't imagine trying it in the field  but it improved my confidence and morale going overseas.



Its funny how people think that an IV is the end all be all saviour of all.  When in fact all the studies done haven't proven it to be benificial at all, and can potentialy cause more harm than good if you dilute their clotting factors or raise their BP and blow any clotting.  The old pre-deployment training would teach troops how to give morphine and IV's.  They would give them the skills, but how many would retain the knowledge of when NOT to use it, or exactly how much to give or not give.  In Mogadishu (and in general everywhere) it was documented that soldiers considered an IV so important that there were cases of attempts to start one before doing BLS proceedures like stopping hemorrhage.  I'm going to preface my next statement by saying it isn't a hidden desire of trying to protect a skill or scope of practice, I could care less about that, but I truely believe that soldiers should not be taught how to administer an IV.  They should be taught why not to start an IV.  They should also be taught to oral rehydrate every casulaty that is conscious.  I realize the Combat Life Saver Course teaches this skill.  I also realize that the CF TCCC non-standardized training has generally not taught this skill to soldiers.  There are cases where soldiers should be taught it.  Sub units that operate isolated and distant from operations bases, i.e. recce.  Give those poor boys some HSD so they don't have to hump so much weight.  Medics, of course should retain this skill, and in my opinion be taught the topic more in depth than a PCP level.  Perhaps the future standardized TCCC course for Medics shall address this issue.

I do believe however that soldiers should be taught to decompress a tension pneumo, with the only criteria being penetrating chest trauma and respiratory distress.


----------



## medicineman

JANES said:
			
		

> In Mogadishu (and in general everywhere) it was documented that soldiers considered an IV so important that there were cases of attempts to start one before doing BLS proceedures like stopping hemorrhage.



Funny, I`ve seen video from the Falklands War of just that - some poor soul looking like he`s about to pack it in and a couple of Paras so worried about that IV that they seemed to fail to notice him drifting off - there didn`t appear to be much else done to him.  It`s also amazing that the Canadian Army is still trying to refight that war 24 years after the fact and using that as the reason that they want their soldiers taught IV`s.  Strange, medical science has (oddly enough) advanced in the last 24 years and people just don`t seem to get that...

MM


----------



## starlight_cdn

If you are willing to pay for a course check out     www.tacticalelement.com

They teach a Warfighter's Medical course to the current USSOCOM standard. They are one of the few private training establishments that regularly teaches the Combat Lifesaver Course (CLS) to the US Army. The American military is using private companies to teach some course like Tacmed, CQB and tactical driving. These companies have the knowledge base and experience plus using them frees up good NCO's for deployment.

Don't be afraid to go outside the military. My private course are all on my PERS file and UER. Get out of the box 

Tell Don I sent you.....


----------



## JANES

How are these guys running courses on CF bases?  Are they contracted by DND, a US company???, or are they just renting the training area?


----------



## starlight_cdn

JANES said:
			
		

> How are these guys running courses on CF bases?  Are they contracted by DND, a US company???, or are they just renting the training area?



They primarily rent the facilities. The CF has not expanded into using private companies to teach mil medical. They are still inside the box.

American companies train a lot of CF members. We are on the same team....Why not? 

The medical corp will use privat instructor to bring a skillset into the military but after that a military member will teach the subject. Big problem with that is the level that the subject is taught at never evolves as the private practioner who constantly train, deploys and gets trained by other companies and armies.....


----------



## JANES

Are there any CDN Coy's?


----------



## Armymedic

For Roto 3-6 TSMT training, the troops are doing a shortened, 1.5 day version of TCCC. They will learn the theory and tactics. They will learn about tourniquets, Quick clot and the new Israeli style compression dressings. There will be scenario practice. 

They will all be issued CAT tourniquets (when, I am not sure).

A little more then your Dad's redeployment first aid training.


----------



## JANES

Sounds like an improvement from when daddy did work-up training.  No more morphine autoinjectors without Narcan, and fillin people full of Ringers cause IV's save everybodies life.  It's just a shame that they are still getting gyped training and the tools they need.  Everybody should have a CAT.


----------



## starlight_cdn

JANES said:
			
		

> Are there any CDN Coy's?



Yes, but they don't have the experience that is required. 

Experience is the best teacher. Or an experienced teacher is best. The instructor are all 18D, SEAL Corpsman, or SWAT tasked medics. Nothing beats BTDTs for realistic training. This is not a First Aid course that can be taught in the basement of the local church. It is a tactical course......your instructor should have dropped brass and/or gotten his hands bloody a few times.

I'm hoping your preference for CDN companies is not Anti-USA bias? If so, get over it.....


----------



## JANES

starlight_cdn said:
			
		

> I'm hoping your preference for CDN companies is not Anti-USA bias? If so, get over it.....



How about that for an assumptive attack?

I'm just curious what Canadian companies offer tactical medical training.  There's a lot of experienced Canadians out there too!


----------



## starlight_cdn

JANES said:
			
		

> How about that for an assumptive attack?
> 
> I'm just curious what Canadian companies offer tactical medical training.  There's a lot of experienced Canadians out there too!



We have to be honest with ourselves when comparing experience. British and American militaries have a lot (re:tons of) combat experience. Canada has good troops, an excellent training system but only a few have any combat experience. The majority of those are not involved in training companies.'nuff said.

That was not an assumptive attack.....it was a preemptive strike. I'm very tired of the anti-USA bias that permeates our country.


----------



## JANES

starlight_cdn said:
			
		

> We have to be honest with ourselves when comparing experience. British and American militaries have a lot (re:tons of) combat experience. Canada has good troops, an excellent training system but only a few have any combat experience. The majority of those are not involved in training companies.'nuff said.
> 
> That was not an assumptive attack.....it was a preemptive strike. I'm very tired of the anti-USA bias that permeates our country.



Well your preemptive strike was friendly fire.  Good job.  Noted!  

For the record, I have nothing against the US.  I believe the CF should seriously look at the way the US does business on numerous topics and consider it for ourselves.  Adopting it blindly would be niave, but consideration, especially from all their operations and lessons learn would be behoove us.  Its a shame, sometimes it almost seems like the CF will purposely NOT adopt a tactic or peice of equipment because they feel they need something "Canadian", so instead they try to re-invent the wheel in the shape of a mapleleaf.  Doesnt really role that well, but the troops sure look patriotic!  or was it the politicians?  

WRT experience,  there are a lot more Americans, and they have a much more agressive foreign policy shall we say, so yes there will be more of them with "real" experience.  But, maybe you should take your own advice and think outside the box.  Not all the experience has to come from the conventional CDN Army.  There are a lot of Canadians who have served in the US and British Forces with "real experience", CDN Ex-SOF, CDN's with overseas security experience for Brit security Coys, some even made it over with Blackwater and Triple Canopy before the State Dept shut down the hiring of Foreign Nationals, lets see who else?...Loads of Police officers with tons of good "real" experience including SWAT, a few TEMS paramedics, the list goes on, quite a few of which I personally know have loads of "real" experience and are or at least were involved in training.  Its to bad they have to fly red white and blue before YOU will consider them "experienced".  I don't have to prove that I'm not anti American, but I'm starting to think you should tell us how you're not anti-Canadian.

Back to the topic of the thread, and my original question, what are the Canadian Companies that exist, regardless of your opinion of their experience?


----------



## MG34

The simple fact is that the US Military does have a hell of a lot more experience,therefore thier military/ex-military trainers have a alot more experience. I have seen our Canadian medics in action while under fire and after a mass cas event,for the most part they performed adequately for the most part but are lacking in many of the skills required to operate beyond a clinical enviroment,on the other hand there is the St. John's Amb., and Red Cross to name a couple,that offer excellent training.
  We can't even count on our own system to train the soldier in what is needed,as all the qualified MCpls and Sgts are too busy re-arranging bed pans or some damn thing than bother to conduct the training as needed. (Yes I know there is alot of admin in an 8 man/woman med section or UMS : ). Once we break our own medics from their hospital and civilian equavalency mindset and start thinking tactically maybe we will actually get the training we need, but as of now there are no Canadian companies that offer REAL and revalant TCCC training because none have been there or done that.
  StarlightCDN, is not anti Canadian in his comments but is simple stating a fact,there are very small amounts of Canadians that have any operational experience in this field (no a tour cleaning bedpans in T-SG is not an operational experience). He has realized there is no option for training in canada and has gone out of the box so to speak,at least he was willing to make the leap and put quality training as a priority as opposed to some minimal  "required' standard BS training provided in Canada.

 BTW Blackwater does not hire foriegn nationals..that is done by other orgs working under the BW umbrella,SWAT or TRU,or ERT or what ever are not combat medics,different roles and mission parameters. 

So there you have it,of course the short version is that there are no credible schools or organizations in Canada yet that teach TCCC or anything close to it that can back their experiences in combat, or have "dropped brass and gotten their hands bloody".


----------



## Armymedic

MG34 said:
			
		

> We can't even count on our own system to train the soldier in what is needed,as all the qualified MCpls and Sgts are too busy re-arranging bed pans or some damn thing than bother to conduct the training as needed.


Yeah, right...see you in the next couple of weeks, when we are teaching you TCCC concepts as part of TSMT.
And for the record, it is NOT the NCOs who are unwilling or stopping this training, it is at a much higher pay grade level then us. If it takes the CDS and a Brigade Commander to push to get it...
I can't even get tourniquets for my UMS rifle company medics.  :rage:



> So there you have it,of course the short version is that there are no credible schools or organizations in Canada yet that teach TCCC or anything close to it that can back their experiences in combat, or have "dropped brass and gotten their hands bloody".



I agree its just that sufficent numbers have yet to be exposed those situations, whether real or simulated.


----------



## JANES

MG34 said:
			
		

> on the other hand there is the St. John's Amb., and Red Cross to name a couple,that offer excellent training.
> 
> BTW Blackwater does not hire foriegn nationals..that is done by other orgs working under the BW umbrella,SWAT or TRU,or ERT or what ever are not combat medics,different roles and mission parameters.



Are you kidding?  St.John's Amb and Red Cross offer excellent training?  Is this sarcasm?  Maybe for garritrooping, but these companies have no business teaching soldiers how to treat combat casualties.  They do a good job teaching them how to put a bandaid on a boo-boo or giving granny CPR.  When a first aid course tells me that if the dressing is bleeding through to just place a dressings overtop until you can't see blood soaking through, it tells me that they really dont have a clue what they are doing. 

Did you even read my post?  If you did you would have seen that I said that the hiring of foreign nationals by US companies, Blackwater, Triple Canopy, was shut down by the State Department (for OpSec reasons), but a few CDN's made it in before that came down.  They will hire foreign nationals for non-security positions.


----------



## MG34

Yes that was in fact sarcasm (can't get nothing past you eh?). Blackwater has never hired foriegn nationals,if you had bothered to read *MY* post you would have seen that they use other corporations under contract to them.Canadians did and still do (as approved by the US dept of State) train there yes but never have worked directly for BW. Pers in non security positions are PONTIS and do not count anyways.
 The simple facts are:

1. There is no current Canadian company that provides TCCS or a similar level of training that is backed up by experience in the field. The current courses are simply rehashes of the original precis created by Frank K Butler (USN) and have not been updated with current experience from the field.

2. Fill out your profile.

Armymedic:

Yes I agree that our medicail system is indeed flawed by years of a clinical mindset,but that does not excuse why the training is not or has not been conducted at a unit level,all it takes is a level of inatative on the part of those on the ground floor.I have talked to several MOs that would be willing to act as medical directors for such a course,yet every day admin and other bullshyte gets in the way. This has to be pushed from the bottom,not from the top. As for the tournquets, CAT is not needed when in house items such as triangular bandages ,a wooden dowel and a 1.5 inch ring will do the job just as well.There is no need for the gucci kit,but it sure as hell makes the job easier. BTW every soldier in the Inf BG will be issued a CAT. A 2 day intro is not exactly the required training but hell we will take waht we can get,although I will be going out of the box on this one and get the training on my own,and will be encouraging my troops to do the same if the system does not supply then we must go out elsewhere and damn the system.


----------



## Armymedic

MG34 said:
			
		

> This has to be pushed from the bottom,not from the top.



What do you think we have been doing for the last 5 yrs? How many incentives for change do you have to push up from the bottom before the CO and up get tired of playing "Wack the Mole Sgt". We have been pushing issues from the bottom for years. Unfortunately, we get headaches from all the smashing down we get. 

Let give an example. AEDs - IN 1998 Cdn Heart and Stroke recognized AED, particularly a Leaderal version. was the cat's meow. A Sgt presented his case to have AEDs put into all the UMS ambulances and into the unit lines. The CO of 2 CER was so impressed he even offered to pay for 3 out of his unit funds. It was fought all the way up to the Surg Gen....The Sgt was actually told he will cease all efforts and communications in hi  effort.
Do you know who was the last people on CFB Petawawa to be legally allowed to use AEDs in their job?.....Medics, we finally have one issued to us this past yr. As a first aider, I could use one in 2003, but not in my role as a med tech until 2005.

How does that pushing from the bottom work for you in the infantry world?

Besides medical people in CFMG HQ do no know what cbt arms need or want for training and skills, and the highers do not believe us lowly med techs when we tell them. But they sure do listen to the CDS.



> As for the tourniquets, CAT is not needed when in house items such as triangular bandages ,a wooden dowel and a 1.5 inch ring will do the job just as well.There is no need for the gucci kit,but it sure as hell makes the job easier. BTW every soldier in the Inf BG will be issued a CAT. A 2 day intro is not exactly the required training but hell we will take what we can get,although I will be going out of the box on this one and get the training on my own,and will be encouraging my troops to do the same if the system does not supply then we must go out elsewhere and damn the system.



When you go through the TSMT classes next 2 weeks, let me know how effective my instruction is for your troops before you go off looking. I can guarantee that we military instructors will do it more then sufficient for free then any outside agency will at their exorbitant price. I am one of the two Sgts instructing the CAT and introducing TCCC concepts.

And before we all get wound up about real time experience...how many people have you shot in cbt? About the same number as I have saved in a real tactical scenario. I am sure we will both do our job as best we can when the need arises.


----------



## MG34

Armymedic said:
			
		

> What do you think we have been doing for the last 5 yrs? How many incentives for change do you have to push up from the bottom before the CO and up get tired of playing "Wack the Mole Sgt". We have been pushing issues from the bottom for years. Unfortunately, we get headaches from all the smashing down we get.
> 
> Let give an example. AEDs - IN 1998 Cdn Heart and Stroke recognized AED, particularly a Leaderal version. was the cat's meow. A Sgt presented his case to have AEDs put into all the UMS ambulances and into the unit lines. The CO of 2 CER was so impressed he even offered to pay for 3 out of his unit funds. It was fought all the way up to the Surg Gen....The Sgt was actually told he will cease all efforts and communications in hi  effort.
> Do you know who was the last people on CFB Petawawa to be legally allowed to use AEDs in their job?.....Medics, we finally have one issued to us this past yr. As a first aider, I could use one in 2003, but not in my role as a med tech until 2005.
> 
> How does that pushing from the bottom work for you in the infantry world?
> 
> Besides medical people in CFMG HQ do no know what cbt arms need or want for training and skills, and the highers do not believe us lowly med techs when we tell them. But they sure do listen to the CDS.
> 
> When you go through the TSMT classes next 2 weeks, let me know how effective my instruction is for your troops before you go off looking. I can guarantee that we military instructors will do it more then sufficient for free then any outside agency will at their exorbitant price. I am one of the two Sgts instructing the CAT and introducing TCCC concepts.
> 
> And before we all get wound up about real time experience...how many people have you shot in cbt? About the same number as I have saved in a real tactical scenario. I am sure we will both do our job as best we can when the need arises.



Pushing from the bottom is a slow process in the Infantry but it does get results,most of the newer equipment we will have for this tour was the result of several SNCOs pushing for what was needed and not accepting the 'status quo",for example the new OBUA doctrine, the med bags issued to out TCCC pers (no not the inadequate one they were issued),new holsters, and a whole lot more. Simply giving up is not an option when there is a need for equipment or training regardless of how many toes are stepped on. 
  As for high priced courses I am deploying with 2 qualified paramedics in my Pl,who took the training at their own expense because it was not provided,these are Infanteers who are able to see beyond what the "system" provides and had the will to put their careers on hold to take the next step.If that kind of dedication was shown at all levels then we would not be having this discussion. Time will tell wether or not the 2 day "intro to concepts" course will make the difference when the time comes,I truely hope it does,but if not the possible preventable death of a soldier will be on the hands of those who lacked the vision and foresight to provide the proper training. That being said don't take this as a personal attack,it is the system to blame,at least you can say you did all you could have...or did you?? I know I have been in this and other fights with narrow minded careerists for over 20yrs and plan to continue with it unitl the higher ups start taking notice.
  WRT to experience,I'm not going to start telling elaborate war stories here but suffice to say that I have delivered aimed fire on hostile targets at the required time ,and when in my rights to do so under the appliciable ROEs, and also have felt the sting of hostile fire. I've been there and done it,those that know me already know this.


----------



## Armymedic

All good. Today my hackles are not up, and I am in a better mood.

We'll chat when you come over, there will be time betweeen classes etc.

Maybe with your suggestions I'll have more ammo for my push on getting all medics TCCC trained before we try to teach everyone else how to do it (again, cause its too late to stop it now). The basic premis: We are not qualified to do it according to CFMG, because they will not issue me the kit. So how are we qualifed to teach it?



> the med bags issued to out TCCC pers (no not the inadequate one they were issued)


I agree those CP gear packs for TCCC are garbage, mention it when you come over as well.


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## herseyjh

I am all for non-medic trades taking medical training. 

I remustered from the infantry over to the medical branch as I figured being a medic in the army would jive with what I was taking at school (nursing/paramedicine).   From my perspective, and observations of Med-As in the field, it is a lot easier to train someone with a tactical mind paramedicine than to go the other way around.  I have seen it time and time again when a medic is attached to a combat unit they just lack the know-how.  Take someone from the combat arms train them to be medics.

Now on to the next question: who should do the training?  St. John, obviously, is not the way to go but I don't think we should break the bank and pay some ex-SF guy to do the training.  If you look at TCCC and Lessons Learned you will see that the vast majority of tactical medicine is basic life support measures for the most part.  So, who can teach CF members BLS trauma medicine?  Any local EMS training program that has solid ED and EMS clinical time.


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## JANES

NOOO!  You are completely missing the point.  The whole point of TCCC is not medical skills.  It is how those medical skills are performed in the context of a tactical environment.  And a civi paramedic has no clue.  And given the skills to a tactical SME, like some infantry guy, doens't mean that they know how to incoporate them into a tactical context.  TCCC is filling in the blank.  Read the Dispatches again, especially the part that gives a tactical scenario and how the old civi way of approaching would be.  It's very dangerous.  This is the biggest problem with everybody teaching their own version of TCCC, with no standardization.  It is that some people completely miss the point.  Just because you are a medic in the Army doesn't make you a TCCC guru, and just because you are an infantry guy with a civi paramedic ticket doesn't make you a TCCC guru.  It's the understanding of the stuff in the middle that is so often missed, but is the heart and soul of TCCC.  Therefore, I think it is a good idea to hire outside agencies, with experience, as stated in this thread, at the very least, to train the trainers.


----------



## starlight_cdn

herseyjh said:
			
		

> I remustered from the infantry over to the medical branch as I figured being a medic in the army would jive with what I was taking at school (nursing/paramedicine).   From my perspective, and observations of Med-As in the field, it is a lot easier to train someone with a tactical mind paramedicine than to go the other way around.  I have seen it time and time again when a medic is attached to a combat unit they just lack the know-how.  Take someone from the combat arms train them to be medics.



The above statement runs counter to the American and British experience. Let's not "reinvent the wheel in the shape of a maple leaf". Tactical Combat Casualty Care is not BTLS but with bullets flying around. I'd like to see you strap an intubated patient to a backboard breathing for him as the troops fight through all around you. Read Capt Frank Butler,USN,  treatise on TCCC. He is the founder of modern TCCC concepts. LCdr Butler is a Medical Doctor and a Navy SEAL. There are different levels of TCCC care, all based on proper medical research and medical boards. They pertain to the enviroment, hostile activity, air superiority, level of trg of responder,....ad naseum. It is combat not rocket science. Everyone deployed in the CF must learn TCCC. Medics should be tactically trained to be a greater asset to the Warfighters we serve.

The problem is that the medical corp does not promote a tactical mindset. They assume security will always be there.....there will come a time when the warfighters will be to busy to protect us. On a personal note, I abhor the idea of relying on someone else for my protection. Self-defence is a human right. TCCC concepts are not hard to grasp for anyone who has been on ops. Those that have heard the bells chime believe it to be self evident. The medical corp must move away from this peace time mindset shake the rust off the cogs of military medicine and get to it.

Since most of the medical corp does not think tactically....subcontract out the training to a _'qualified, experienced company'_. Certain units in the CF train quite extensively at US facilities and/or bring in instructor from schools to train their people. One unit in Pet recognized a lacking skillset and brought in instructors from the UK to teach their men. They are looking at other options as we speak. It is called 'Alternative Service Delivery'.

It is not expensive as all the R&D, course development, instructor training and ancillary costs are cover by the company delivering the 'product'. It is those above costs that make a mil course development prohibitive. There are other benefits, NCOs will be able to take the course, lead their troops in scenario play and develop a team for deployment. This cannot be done with the NCOs with teaching the troops they have to lead and not getting a chance to learn in a induced stress environment. Making mistakes in training is a learning experience, mistakes in combat means someone dies.

The bottom line is: 
1. TCCC is the way to deliver life-saving aid in a active non-permissive environment .

2. Everyone in the CF should be train in TCCC, medics even more so. 

3. Find a solution, enact it before people die; Alternative Service Delivery may be the answer.

Check out the following links concepts of care:

http://www.drum.army.mil/sites/tenants/division/CMDGRP/SURGEON/journals/TACTICAL%20COMBAT%20CASUALTY%20CARE.htm
http://www.drum.army.mil/sites/tenants/division/CMDGRP/SURGEON/Ranger%20FR/2%20RFRTCCC.ppt
http://www.au.af.mil/au/awc/awcgate/medical/tacmed-butler.htm
http://www.tricare.osd.mil/conferences/2001/downloads/breakout/T201b_Butler.ppt


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## herseyjh

As for the idea of intubating a patient in the middle of a fire fight and then bagging the guy while a firefight rages around you is gung-ho and it would be awesome if that level of training could be achieved, and maintained; however, the reality is this level of ability is not achievable on a large scale.  Perhaps TEMS teams in a large urban center might function at that level or perhaps a SF medic, but by definition these are small groups of skilled and motivated people and there is by no means the number of individuals to provide total combat medical care to every forward unit.   So who does that leave on the battlefield?  A medic who should be skilled at basic life support measures and be switched on tactically.  Does this person have to have advanced life support skills?  No.

I reviewed you links and I think the material supports this statement.  For example CAPT Butler and LTC Hagmann wrote the following:

"Care under Fire"
The care rendered by the RFR/NREMT-B/ Ranger Medic at the scene of the injury, while he and the casualty are still under effective hostile fire.
 Available medical equipment is limited to that carried by the individual Ranger or medic in his gear.

"Care under Fire"
No immediate management of the airway should be anticipated at this point because of the need to move the casualty to cover as quickly as possible.

And they are talking about SF ops which by definition should have the best of the best medics.

Now on to the TCCC document:

However, there are no studies that document the ability of inexperienced medical intubationists to accomplish endotracheal intubation on the battlefield. Another major drawback is the use of white-light from the laryngoscope in a hostile environment. One study that examined first-time intubationists trained with manikin intubations alone noted a success rate of only 42% in the ideal confines of the operating room with paralyzed patients.

I hope you see my point here.  BLS is the way to go. Get them to a medical facility, surgery, and advanced skills, then from there treat or medevac, and you get them their by stopping bleeding, maybe some IV fluid.  These are skills that are live saving and can be maintained without making evryone a ALS provier, 18D, SF medic, ect...  And who can do this training?  People who have real world trauma experience and who has that?  Large trauma systems, so send people there to get up to speed.  That is not re-inventing the wheel.  We are doing it now.  I see army NOs in Vancouver training in the ED to go to Afghanistan.  Med-As doing ride alongs with Edmonton EMS.  It is the way to go.


----------



## Armymedic

Quote from Janes above:


> This is the biggest problem with everybody teaching their own version of TCCC, with no standardization.  It is that some people completely miss the point.  Just because you are a medic in the Army doesn't make you a TCCC guru



Until medics get a course for ourselves, and we develop medical instructors who will act as SME and enforce standards, Janes is absolutely right.


----------



## Armymedic

starlight,
I agree with everything you say above, except this.


			
				starlight_cdn said:
			
		

> subcontract out the training to a _'qualified, experienced company'_. Certain units in the CF train quite extensively at US facilities and/or bring in instructor from schools to train their people. One unit in Pet recognized a lacking skillset and brought in instructors from the UK to teach their men. They are looking at other options as we speak. It is called 'Alternative Service Delivery'.



Unless you mean we send out people down or bring people up to/from the US Army/Marine to teach us how to do this first.
I believe bringing in civilian instructors (regardless of the experience) to teach a military course of this context is not "correct" nor fiscally responsible.
I don't think you actually need to be punched in the nose to know it hurts, and accordingly, good knowledge and understanding of the principle of TCCC do not require cbt experience to be able to instruct the concepts to others.


----------



## Armymedic

herseyjh said:
			
		

> As for the idea of intubating a patient in the middle of a fire fight and then bagging the guy while a firefight rages around you is gung-ho and it would be awesome if that level of training could be achieved, and maintained; however, the reality is this level of ability is not achievable on a large scale.



In a military context, that could be 2 things: stupid and suicidal, either way, it'll get you, or worse, the casualty killed. Even a CF PA, who is capable and practiced in the skill of ET intubation would never do it in that context. This way of thinking is exactly why military tactical medicine should be required training for all military med techs. TEMS are civilian paramedics for police. Close but not quite the same thing, because they do not have the restraints of time, distance, enviroment, priority of mission, and the mass of casualties that may face a military medic.

Butler's documents were intially written with SOCOM medics in mind. Now the concepts have been adapted to the basic 91W cbt medic training of the US Army. A 91W is trainied very similar as our QL 3 Med Techs with good basic skills, and the knowledge of where to use them (PHTLS, Paramedic level prehospital care). Difference is that tactical medicine is a large part of thier program, whereas in Canada, it is nowhere to be found outside the brigade's Fd Ambs and a little spot south of Ottawa. 

Anyway, this is getting into medic's training. We should be talking about nonmedical persons, and leave the medic tng in the TCCC thread.


----------



## herseyjh

That is my point, it would be crazy, and I was trying to point out that some people do believe that is the skill set that is required for the job when it is not.  That is why I will stick by my BLS statement and if non medical pers want to go out and take medical training then by all means it is a good thing.  It is good because if you get the BLS, BTLS, TCCC, or what ever you want to call it, message to the troops then they can handle the initial injury and then respond to the tactical situation.  They can stop the bleeding, move the wounded to a safe spot, then maybe a CCP and back.  From there the medical branch can get involved with the evac.  I will just leave it at that so the forum stays on topic.


----------



## Armymedic

aye, I interpreted you were saying something else.

This does not "require" medical skills beyond a few basics, thats why it is so good. It how and when to use the skills you have is what the majority of the concept is all about.


----------



## medicineman

I actually sat down and read the QS today - rather interesting in that the cover sheet has all the MOC's that TCCC is to be an OSQ for.  The MOC's listed were all combat arms or combat support - no medical.  They did say inside in the working group notes that Medical Branch wanted a seperate course for the Med Techs, but didn't elaborate as to what (perhaps something along the lines of an abbreviated version of the Fleet Marine Force Field Medical School or something along that line).

MTF as things progress.

Armymedic - you catch any of the stuff flying around about the new "Combat Related First Aid" course that's being tossed together in Ottawa.  Strange, the power points look awfully like slightly revamped versions of all the courseware from Pet and Edmonton...except they want to condense it to 2 days.

MM


----------



## Armymedic

Yes, it is inside our private staff site on the CFMG page.

The OPI is LComd (Maj?) Torrie (sp) (TFSurg for Athena R4). I talked to him a bit about it in Apr/May 05 when he came to Kabul for Tac recce.


----------



## starlight_cdn

herseyjh said:
			
		

> As for the idea of intubating a patient in the middle of a fire fight and then bagging the guy while a firefight rages around you is gung-ho and it would be awesome if that level of training could be achieved, and maintained; however, the reality is this level of ability is not achievable.....



EXACTLY, my point. That is what a BTLS protocol would call for....it has no place in the CARE UNDER FIRE phase. BTLS, ABTLS, PHTLS or ALS all have there place within the TACTICAL FEILD CARE phase and CASEVAC phase. The unfortunate thing about the internet is you cannot understand the inflection or tone of a response. It was a sardonic response. But, you read the I sent links and that is the important part.



> BLS is the way to go. Get them to a medical facility, surgery, and advanced skills, then from there treat or medevac, and you get them their by stopping bleeding, maybe some IV fluid.  These are skills that are live saving and can be maintained without making evryone a ALS provier, 18D, SF medic, ect...



I agree. Some of standard BLS treatments have their place in the TACTICAL FEILD CARE. Taking a saying from a CQB instructor who I studied under " I've never seen an advance gunfight". The same holds true for any of the TCCC phases, it is all about the RSE, ABCs and the environment.



			
				Armymedic said:
			
		

> starlight,
> I agree with everything you say above, except this.
> Unless you mean we send out people down or bring people up to/from the US Army/Marine to teach us how to do this first.
> I believe bringing in civilian instructors (regardless of the experience) to teach a military course of this context is not "correct" nor fiscally responsible.



I think exchanges with Allied Units would be the most cost effective way to accomplish the desired endstate but we are at a critical state with troops deployed on combat operations without a skillset. We, the medical corp, bring in civilian instructors all the time to teach medical courses. Some of the courses taught at my unit alone, BTLS, ACLS, ATLS, Triage, EMR, EMR Instructor. What would difference be in bring in instructors from a civilan company (who already teach our allied military) to teach TCCC?



			
				Armymedic said:
			
		

> Difference is that tactical medicine is a large part of thier program, whereas in Canada, it is nowhere to be found outside the brigade's Fd Ambs and a little spot south of Ottawa.
> 
> Anyway, this is getting into medic's training. We should be talking about nonmedical persons, and leave the medic tng in the TCCC thread.



Some of us  outside the listed places have taken it upon ourselves to get training in this area. But, not enough.......

Enough said better left for the TCCC thread.


----------



## Spr.Earl

Why cant we go back and just teach Combat First Aid which mnay of us have learnt in the past by which I mean;All combat arm's knew how to give a I.V and moniter the drip,.give morhine,sucking chest wound's etc.
Now this training is lacking and it pee's me off,Why?
The faster I can treat my Bud's the better chance he has.


----------



## Fraser.g

The reason for the change has several facets.

The first of which is that although it is easy to teach the skill set it is not easy to get the time to maintain the set.
Second, allot of recent studies have shown that people fixate on the IV and forget the ABCs. Also there is a problem with over hydrating the patient, diluting the blood and simultaneously blowing out any clots.

All these have been covered in this and other threads in the past so I will not go into allot of detail. 
What TCCC teaches is the basic interventions that will preserve life until you can get to a medic. Unfortunately medical personal can not be out with every patrol or tasking. In order to maximize effectiveness we have to cluster and concentrate the skill sets with the equipment. What TCCC teaches is how to keep them alive with minimal equipment (any more and the troops would not carry it) until you can get your buddy to us for further treatment.


----------



## JANES

Spr.Earl said:
			
		

> Why cant we go back and just teach Combat First Aid which mnay of us have learnt in the past by which I mean;All combat arm's knew how to give a I.V and moniter the drip,.give morhine,sucking chest wound's etc.
> Now this training is lacking and it pee's me off,Why?
> The faster I can treat my Bud's the better chance he has.



With all due respect, please read the TCCC thread, especially that last few pages that talk about fluid resus before you post.  As RN PRN stated there are problems with teaching troops IV fluid resus, read the other threads.  Theres problems with morphine autoinjectors.  Do you carry Narcan with them?  This has been discussed too.  Give Morphine to someone who is shut down peripherally, doenst work, give him another, they get resus'd, opens his periphery, Morphine OD.  And lastely, I don't think this has been discussed, but the falacy of the sucking chest wound.  The hole in the chest has to be larger than the trachea, thats pretty big, and the intercostal muscles will usually seal any hole.  Air takes the path of least resistance, so if the hole is smaller than the trachea, it is going to enter the trachea.  If you look at casualty mortality curves, these casualties can survive for 6 hours with no treatment.  The three sided occlusive dressing does not work, the tape will not stick to blood and dirt and sweat.  The Ashermans are being phased out (at SOF levels anyway, and working its way down) the valve just doesnt work, and the latest treatment is completely occluding the hole and needle decompressing prn.  The needle doesnt need a condom or glove finger or heilmich valve, its to small to allow air passage in, becasue the trachea is so much bigger.

Combat First Aid is a thing of the past, lets leave it there.  We've evolved considerably into TCCC.  Please don't take the attitude of, well it worked for us in the past, why should we change it.  Thats old Army attitude.  It worked for us in the past, because it was never utilized on a large scale.  TCCC has been proven effective by the US, Brits, Israeli's, Canadians and others on current operational theatres.  It works well.  Proven to work well, backed up by tons of data.  Please educate yourself before saying we should go back to the old ways.


----------



## medicineman

JANES said:
			
		

> The Ashermans are being phased out (at SOF levels anyway, and working its way down) the valve just doesnt work, and the latest treatment is completely occluding the hole and needle decompressing prn.  The needle doesnt need a condom or glove finger or heilmich valve, its to small to allow air passage in, becasue the trachea is so much bigger.



Not to sound like I'm slagging you down or anyhting - is there any literature regarding that, since I'm supposed to be sitting on the TP writing board in Apr.   If that's the case, then maybe we can re-arrange that PO a bit to reflect that change and have the reference to support it.

Thanks.

MM


----------



## Armymedic

Ref the "sucking chest wound". I heard the same thing from the US medics last yr. Many of the holes self seal after a short period of time trapping air inbetween the lung wall and the lung itself.

Application of a needle to decompress does the trick. 

Also to confirm what JANES said - use of the Asherman over the needle = good. Use of the Asherman over wound not so good. 

This is what they were talking about this past summer, I am not sure if its in the journals yet.

(this is all TCCC stuff)


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## JANES

You can put an Asherman over the needle, but it doesnt matter.  The needle hole is so small when the casualty inhales the air will go in through the trachea, not the needle, so you dont really need it.  Though of course it can't hurt.  It is also much better than trying to rig up a heimlich valve with a three way stop cock and taping to the chest contraption.  All you need is a 10 to 14 gauge needle that is 3 inches long, and I stress that.  Please do not try use the 1.25 inch IV catheters, they are too short.  Just the needle, maybe an alchol swab, but you can keep it very very simple, and the needle and needle only will do the trick quite nicely.  Leave the Ashermans at home.


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## JANES

You know the other thing about the old morphine auto injectors; is nobody ever died of pain, so how did they think they were mitigating mortality by pushing this drug down to the lowest level?  Don't get me wrong, pain control is important, but the contraindications for morphine are most common in battlefield casualties.  I believe intranasal Ketamine was discussed.  So I'll throw out a little gem for discussion here.  Fentanyl lollipops.


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## Armymedic

well would that suck to have them?


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## JANES

I guess my point was, they are ideal for tactical field Tx of pain because of thier non-invasive self administration and short half life.  These should be implimented,  should be issued to deployed medics.


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## medicineman

There's definitely 2 sides to the fence regarding analgesia - the way I was taught, morphine was for palliating the dying and shutting up people - nobody likes listening to their friend screaming for his mommy.  The other is that pain, though it is a mechanism to keep you alive, can stimulate a catecholemines, and therefore up your BP and pulse rate some, and therefore make you bleed more.  The fentanyl would be a good idea - they have the popsicles for kids in ED's.  There is that caffiene gum in the system - maybe put the stuff into gum (though the control issue would be a bit interesting :).

MM


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## kj_gully

I have only recently heard of the phentynol (sp?) lolly, it as JANES is no doubt aware used by our USAllies in theater. Tape it to the pts hand, he lick/sucks it til he's dozy, then the thing hits the ground, next lick, dirty mouth, covered in stoned ants . We ( SAR) are supposedly going to the inhaled Ketamine, apparently a "kazoo" like the dude on survivor got when he fell in the fire. right now its either tylenol or Morphine for our pts. Something pt administered will be great.


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## Fraser.g

Yes, 

It is true that fentanyl can be admiistered by lolypop or any other oral means but has anyone here thought about what happens when there is an adverse reaction to such meds?

If you are going to have any opioid analgesic adminisetered then please have an IV access avaiable if there is an adverse reaction. 
And if you have an IV access, even a lock, than why don't you use the faster, more effective IV route for analgesic administration?

Rule of thumb:
If you don't have IV access, don't give opiates.
If you can't get IV access, don't give opiates.
If you are not qualified to get IV access, don't think about opiates.


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## JANES

You are so stuck in the hospital.  Fentanyl has a very short half life, so any reaction should be short lived and is much more powerful than Morphine, so a much smaller dose is required.  Narcan works quite nicely sq too.  Gulley is right, you tape it to their hand, they suck on it, get high, it wears off, they suck on it again.  Kinda like Nitros Oxide.  Thats what they're using, so go tell Butler your concerns, his address is Surgeon General, USSOFCOM.  I don't make this stuff up.


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## Fraser.g

You are stuck in where a nurse works and what one does. I am quite aware of what the adminstration routes and doses are. 

PM inbound


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## kj_gully

Well, JANES, I guess that pretty much sums up CFMG. Med A's, good luck in theater, hope youall can fight your way out of the clinic and onto the battlefield. I know you want to, but posts like 





			
				RN PRN said:
			
		

> Yes,
> 
> It is true that fentanyl can be admiistered by lolypop or any other oral means but has anyone here thought about what happens when there is an adverse reaction to such meds?
> 
> If you are going to have any opioid analgesic adminisetered then please have an IV access avaiable if there is an adverse reaction.
> And if you have an IV access, even a lock, than why don't you use the faster, more effective IV route for analgesic administration?
> 
> Rule of thumb:
> If you don't have IV access, don't give opiates.
> If you can't get IV access, don't give opiates.
> If you are not qualified to get IV access, don't think about opiates.



is exactly what I fear will keep you from doing your job.


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## Fraser.g

If a medic is authorized to use opiates he/she will also be trained to get IV access. If you have the med as an IV dose why would you want to give it as a lollypop?

In the snake eater world where evac chains may be protracted then a medic attached to the unit or a combat arms pers who is trained and AUTHORIZED can do what ever the transfer of function stipulates.

Once the Combat first responders initiate some BLS protocols and get them to the medics, the medics get them to the Facility (not clinic) you will see my smiling face. Heck, if the medic has started an IV, fantastic. If she/he has given some analgesic Fantastic if it is appropriate.

If not I will.

What I would love to see in theater is competent medics. what we don't need is a bunch of cowboys who don't stay in their scope.

See you in Kandahar


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## JANES

The fentanyl is a discussion topic.  This is what is currently being considered.  I don't know of any medics that are going out and buying fentanyl lollipops and using them at their own discretion outside their chain of command and scope of practice.  The fact remains that IV's can't or aren't always started for a many number of reasons, especially for tatical ones.  There's not a drawer full of angio-caths and normal saline in a medics pack like in the hospital.  If the dude doesnt need an IV, their is no risk of hypovolemia, and the medic doesn't have alot of supplies, he (and I also mean she) should save the gear for someone who needs it.  A sal lock, if their is time, and again, the gear.  An IV line is going to be more of a hastle for cas tpt than could potentially have benifit.  This isn't the back of an ambulance downtown Saskatoon with a nice hook on the roof to hang the bag.  And again, this is just a discussion topic, not all those cowboy medic's intensions to disregard their Medical Direction.


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## Fraser.g

You and I are not in disagreement there JANES. I am not talking about an Amb in Saskatoon, nor BC nor any where else in Canada.

I have done a fair bit of third world med both pre and in hospital. From my experience pre-hospital or even in hospital oral analgesic in a trauma situation is not one that I am comfortable. I have attended a few seminars on Trauma that the topic was brought up and overwhelmingly it was dismissed. 
I think of that line as a safety measure. Not a drip but simple access ie the SL.

This is my opinion from my experience and my studies. We could also open the fenatnyl vs Morph thread and then add the with or without Versaid (midazolam) as an adjunct for conscious sedation.


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## Journeyman

Hell, I'll jump in.....even if only for historical context. This debate is not new, merely the particular protocol/pharmacology.

During the Med phase of my SAR course, the school SAR Techs were augmented by 3 x MDs; 2 trauma guys from University of Alberta Med Centre, and the Base "Surgeon." The civies made a point of hanging around the classroom for each of the MO's lectures; they then spent the first 5-15 minutes of their assigned period basically saying "yes, that's how it was done 15 years ago, let me update you."

Take the straight-forward IV protocol, as but one example... The MO, and even many city EMT(P) folks during ride-alongs, said "always - - that way you have a line in." (hypovol contras, noted). Well, in arctic conditions, as well as thick scrub when you don't have a cushy amb/clinic nearby, that IV becomes a hindrance real quick.

Clinical treatment, (yes even Emerg), versus operational outside the city limits (yes even without incoming rounds) can be two different worlds. As such, definitive/doctrinal answers may add little to the thread.


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## JANES

Well said.


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## kj_gully

Nurse, your comments come off a little... patronizing, and it seems you are slightly out of touch with the potential scenario a platoon medic could be faced with. Without too far a stretch, I could suggest that a light armoured vehicle, perhaps a "G" wagon is being escorted on patrol, and is blown into 1 thousand pieces by a roadside bomb. the 4 occupants are all alive, thanks to their ballistic helmets and flak vests, but seriously injured. There is a traumatic amputation,  an airway compromise,as well as the requisite contusions abrasions lacerations penatrations & burns.The two in the back are dazed, possible closed head injuries, are deaf as posts (no hearing protection), one has lost an eye cause he wasn't wearing eye protection (Oakleys are too expensive). Simultaneously with the bombs detonation, the fore and aft of the route are closed by flaming wagons, and small arms and rocket propelled grenades are haphazardly directed into the kill zone. our well trained and gallant medic musters a few of the troops who are busy trying to supress the incoming fire and win the firefight, and evacs the wounded to a ramshackle ruin within shouting distance of the main battle. He uses all his improvised tourniquet material with amazing dextarity and manages to stop a rapidly exsanguinating hemmorrage without the aid of quikclot, which might cauterize so is too dangerous for field use.  Probably against protocol, but with good clinical judgement, darts a couple 14 guage IV catheters into a rapidly decompensating pneumothorax.After RBS ing the two deaf and dumb yellow/ less red than his bright reds (triage) he returns to the tk'd pt, and writes on his forehead. He then gets 2 iv sites on the 1st try, and locks off one,  starts running some NS 
( after 1st confirming his BP is sub 90 with the manual cuff, on the remaining arm).He manages to save the troops, and will probably get a couple medals and a feature article in the Maple Leaf as well as a serious dressing down from the receiving medical authority . He hears that there has been a chopper summoned, but they are busy with a blue on blue incident with the afghan National guard, and doesn't Canada have its own air casevac anyway? Buddy who lost his eye is grouchy, and all this medic wants to do is take the edge off this guys pain, so maybe he can get a little help, or at least some rear security. He doesn't need to have more IV lines hanging, does he?


But maybe I'm out of touch...


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## herseyjh

What are the medics carrying for pain management right now?  I know some people are of the opinion that pain is secondary and that pain doesn't kill but from my experiences that is a cruel and unprofessional approach to take.

I think the concept of fentanyl lollipops (Actiq - oral transmucosal fentanyl citrate) is an awesome idea as it is simple, low tech, and easy to administer to most patients.  I will post a few references soon so people please don't jump all over me just yet for not knowing what I am talking about.

On a side note does anyone out there have experience administering OTFC to patients?   Currently it is popular in peds and for pain management in cancer patients.


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## herseyjh

Sometimes if you put an IV saline lock extension set on the needle, then a 3cc syringe on the end you can pop on the Heimlich valve into the empty bore of the syringe.  Then the whole thing lays flat and it won't cam the whole thing over if you just use the 3-way.


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## medicineman

Let's put things this way - when I went to Kabul as part of the TAT in 03, I took a wack of morphine and demerol with me.  My MO and her boss, the BSurg, got crapped all over from great heights for delegating that to me.  It took a real fight to get some Morphine auto injectors into theatre for us after the amps were taken away (we only had a PA with us at the time) - however I and my partners in crime were allowed to carry them when they eventually arrived.  Same deal in Haiti.  I can't speak to what's happening at the moment.

MM


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## JANES

My whole point is you don't need a valve at all.  The air won't go in, because it takes the path of least resistance and will enter the larger trachea.  All you need is a needle.  KISS.


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## herseyjh

I wasn't comment on if a valve is needle or not, but rather technique for those who wish to place one.  The method I mentioned work way better than the 3-way.


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## Armymedic

Non medical people....

Move it over to TCCC thread.

BTW, KISS works. the less crap hanging off the patient, the less to get caught up of stuff.


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## Armymedic

herseyjh,
I get the idea that you are not familiar with the current realities of being a med tech in the Reg CF.
We are subject to policies and formularies, protocols and politics. We just can not do something without previous authorization from some MO or higher medical authority. Just because something makes sense and is avail on civie street, doesn't mean we can do it in our job.

As for morphine, peoples BP tends to rise when they give out autoinjectors to medics. We are in a garrison care mentality for alot of issues.


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## herseyjh

I understand that, but I am just wondering how the medical branch is responding the the pressures of providing field medicine in an operational AOR.  It seems that during such times is when policies change and new concepts are adopted quicker and I am just wondering what is new.  OTFC, antibiotics, TCCC, ect...  It would be nice to see this stuff come down the pipe.

The same thing also happens in the civi world.  Ambulance services with they had the newest drugs for intubation, or the coolest backup airways... ect.

I just hope we keep pace with what is needed to give our troops the best possible outcome.


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## JANES

So tell me more about the Tactical Elements courses.  I have checked out their website from the link provided here.  Can you give more specifics?  Are they running them on the bases?


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## JANES

http://www.cs.amedd.army.mil/courses/cats/cats2a/HumanTourniquet_USAISR.pdf

http://www.cinchtight.com/H16.pdf

A couple links of interest regarding tourniquet testing.  The second they actually soaked the tk's in a bloodlike substance, then rolled them in sand before application.  A much more realistic test!


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## JANES

Anybody heard of these guys?

http://tacmedtraining.com/


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## herseyjh

Janes,

I haven't heard of these guys before but I took a look at their web site.  The ERMT-1 looks like an EMR style of course geared at getting police thinking about patient care.  Might be useful if you are in that role but depending on the cost of the course I would say doing some home study and showing up for one practical day isn't going to be very useful.  The ERMT-2 looks like there is a bit more classroom time, but again I think unless you are in that role it would be a waste.  Are you on the police side of the fence and looking at it from that point of view, or are you looking at this couse to help with remote/contract sort of EMS care?  Just wondering.


----------



## Big Red

MG34 said:
			
		

> Blackwater has never hired foriegn nationals,if you had bothered to read *MY* post you would have seen that they use other corporations under contract to them.Canadians did and still do (as approved by the US dept of State) train there yes but never have worked directly for BW. Pers in non security positions are PONTIS and do not count anyways.



You are wrong.  As he said there are guys who made it in before the rule change and they do work for BW, not other companies. Yes, BW does have GS who hires foreigners, but there are foreigners working for BW from several countries.  Or are the guys in their old GROM uniforms Americans?


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## Armymedic

Thanks for that, gives verification as to effectiveness, and how long it takes to put on tourniquets.

We are now getting issued the Cook Pneumothorax set. I will try to get a picture for you. The kit comes with a specific 14 gu cathalon already attached to a syringe, tape, a 3 way stop cock and a hemlick valve (possible something else that is slipping my mind).

The good is that the cathalon is longer then the standard IV needle. The bad, is as it is packaged it is a bit bulky.

http://www.buyemp.com/product/1010803.html
Cook Pneumothorax Kit
Cook Pneumothorax Kit Description:
Used to treat simple and tension pneumothorax. Supplied sterile in peel-open packages which includes: catheter introducer needle, Heimlich Valve, connecting tube, one-way stopcock, syringe, molnar disc with pull tie, alcohol prep, povidone-iodine swabstick and a small roll of transparent tape.


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## medicineman

So much for the KISS principle.  

MM


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## JANES

medicineman said:
			
		

> So much for the KISS principle.
> 
> MM



Exactly,

Cook set is too big, too much crap.  Don't need the valve or all the other fancy stuff.  It's like using a FAST-1 when you could use a BIG.  It boils down to lots of little peices to drop and get lost and get dirty and fidle with in the dark, or use something very simple and effective.  The B.I.G is very effective and one peice.  The needle by itself is all you need, smaller, simpler and all you need.  Especially in a combat type environment.  The syringe on the needle brings up an interesting point.  You'll be lucky if the plunger moves on insertion.  It would take an awefuly developed tension to budge it.  However, if you are in a high noise environment, say the back of a helicopter and you are needling a chest, you can't hear the hiss to know if it was effective or not.  If you pull the plunger out of the syringe and fill a little NS in it (hold you thumb over the top until you get it in the meat or the NS will flow out) if you hit air you will see bubbles.  Doesn't always work.  A large gauge needle like a 10 or 12 sometimes gets clogged with meat and you have to remove the steel needle to let the air out the cath, you won't see the bubbles.  Its had to keep the NS from flowing out to.  You can put the plunger back in to prevent this, but again, there will have to be a lot of pressure in the chest to push the plunger.


----------



## Armymedic

Sorry, my mistake, the needle is not attached to the syringe. I thought I edited it earlier...guess not. 

The kit is perfect for the amb, panniers, fd UMS set ups, etc. Me and my dismounts are not carrying the hemlick valve or the stop cock...extra crap we don't need. Esp as I found a couple sources which confirm what JANES was saying earlier about not needing to cover the catheter with the ACS or one way valve. Battlefield reports with a longer evac time talk about a second and even a third catheter needing to be inserted, as the initial gets kinked or blocked by blood etc. But do you think I could find the link again?

I also have a feeling the needle is solid, not hollow...but I will have to double check.


----------



## JANES

Needle is hollow in the Cook set.  Big bore, gets plugged with meat.


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## medicineman

AM,

The SCOMR on CCC came to that conclusion - it came up during the writing board this past week for the TCCC course.  The trauma surgeon with us basically said that if the hole is less than 2/3 the size of the trachea, a one way valve isn`t needed.  We were trying to figure out what, if any protocol the TCCC providers are going to get if a repeat insertion is required.

MM


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## JANES

Depends on the gear they are using I guess.  If you're using the big cook cath, it probably wont kink, but the 14 gauge angiocath is prone to kinking, especially if they are getting moved around a lot.  If you're strapped for gear, you can needle them, remove it, cap it and tape it to their chest.  Then you can use it again on the same casualty.


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## Fraser.g

The up side to the cath getting kinked off is that as the lung expands to kink off the cath, the cath is no longer required. It is the pressure of the lung itself that does the bending.
If the lung colapes again then you will have to re-needle anyways.

Due to this and the small internal lumen of the cathlon, a heimlich valve is not usualy indicated. It won't hurt to put one on but I would not shed tears if it is not in place.


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## medicineman

Due to this and the small internal lumen of the cathlon, a heimlich valve is not usualy indicated. It won't hurt to put one on but I would not shed tears if it is not in place.
[/quote]

Again - back to the KISS principle.  I do remember when I was a baby medic a hundred odd years ago when we had to do the combat medical techniques courses in the field ambs, the old CFP 313-7 (Combat Medical Techniques for Medical Assistants) actually advocated inserting a chest tube (with Heimlich valve attached) directly into large GSW's to the chest.  After going through this TCCC board, it's made me want to dig around to find my old copy and compare how different things were then and now - and it's not really alot FWIC.

MM


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## JANES

Chest tubes are an interesting skill to push that far forward.  I definitely think they have their place in special operations, even domestic SAR operations (were's gulley?).  The Israeli's did a study that found that when doctors placed chest tubes in the field, i.e. battlefield, they were more often than not misplace, as in subcutaneously.  Not sure how you can screw that up.  Must have been the stress.  You can use an ET tube in a pinch too.  Needle is best for shorter evacs and has the advantage of being able to be pushed to the soldier level.  I'm not sure if a chest tube would make a big difference at a medic level unless they are operating far and away.  Chest tubes are great if you are isolated or far away.  Remember though, this guy needs a hospital.  That tube needs suction, it's easily dislodged if they are not in a controled environment, very painful and a big entry port for infection (especially in the desert).  Remember even when you needle a chest, you've commited that guy to a chest tube.  

By inserting a chest tube into the GSW do you mean a needle or a tube?  A tube is pretty big to get in a GSW.  And it will not necessarily be in the optimal place for tube placement.  

Having said all that, its a good tool in the box.


----------



## JANES

Its interesting to watch the way tactical medicine is evolving.  As we move away from invasion strategies and more into occupation strategies, we are seeing subtle injury pattern changes and considerable increases in efficiency and improvement in quality of TCCC resources.  CASEVAC's are becoming so fast and relying on ground more than air.  This is due primarily to the increase in FOB's, a larger footprint and more saturating presence and again a build up of resources over time.  Instead of waiting for a helicopter, casualties are occuring closer to bases, helo's are taking to long to crank up and get out there, it's faster to "load and go" (where have I heard that before?)  The poor PJ's are getting bored sitting on their duffs.  
What this is causing is less medic time with the casulaty.  For example medics aren't giving fluid because there is no time.  I'm not saying this is a bad thing.  This is good.  Faster evac=decrease mortality.  
TCCC when first came out was based largely on Viet Nam data with confirming data from Somolia, Gulf War 1 etc.  They originally emphasized the unimportance of C-spine precautions with penetrating trauma.  Whats happening now, with all these IED's going off and guys getting tossed around is more spinal injuries than they had originally been taught to be worried about.  I think the future is going to see increasing due diligence WRT spinal precautions from IED blasts.  Possibly a new guideline for spinal precautions in tactical environments.  The old example of putting a collar on "Blackburn" in the middle of the street whilst rounds fly overhead - from Blackhawk down is obviously the argument against C-spine precaution in this environment.  But the TCCC always advocated no precautions required for penetrating trauma.  It said you will take al precautions for blunt trauma and if tacticaly feasible.  I think that needs to be expanded and clarified for training sake to make it clear in everyones mind, and included in training to make soldiers and medics realize when to and when not to and exactly how to take spinal precautions in a tactical environment.


----------



## medicineman

The guidline is reduced likelihood of need for spinal precautions with penetrating trauma - they still want you to think about it though, especially for blunt trauma.  The chest tube deal I mentioned was in fact a tube - likely a smaller bore than you'd use if you were actually cutting the person open concerned, with a heimlich valve attached.  SQ palcement - sounds like these guys were in a hurry and in the dark - literally.  I could see it happening if they were going by feel for whatever reason.

On injury patterns, I remember reading an article in the Infantry Journal or ALLC Dispatches not many years ago that was talking about the Russian experience in Chechnya and the need to push medical units forward - like the Americans are doing in Iraq, as they were finding higher percentages of fatalities due to the close quarter fighting going on - enclosed space blast and fragmentation and close proximity to high velocity firearms were causing higher than expected mortality and morbidity rates.

MM


----------



## DartmouthDave

Hello,

I know that I am a little behind on this thread.  However, the service that I work with uses the Cook Pneumothorax Kit.  We don't use them 
very often (about once a year) but when we do we find  they work quite well.  In fact, on can make their own with standard medical supplies (14G  3inch IV extension tubing, ect......keeps cost down rather than tossing exp. kit all the time....or if you are in a bind)

The last time we used one was a tension pneumothorax (obvious I guess ;D) from a MVA.  A large pt. with lost of adipose tissue.  The needle didn't become obstructed and air was aspirated.  Also, compliance increased greatly (the two times that I have seen it done I have never heard that classic 'hiss').  

The syringe is used to attach the one-way (the blue end in the picture above) valve to the tubing which in turn is attached to the cath.  At least in our model....the tubing dose not fit on the end of the one-way valve.

So, I think the Cook set up and any modifications made to it meet the KISS principal.

Thank
D


----------



## herseyjh

I with making the kits yourself because it is cheaper and all the materials are at hand.

Some people might argue weather or not a valve is indicated, and I think that depends on when you received your training.  Most manuals still indicate it's use.  

Myself, I have gone both ways.  I just used just the needles during a PEA chest trauma.  I think my reason was we were just around the corner from the hospital and I only had one of the kits made up.  The second case was on a patient with a tension secondary to minor chest wall trauma.  It was an interesting case.  This guy was punched in the lower back during a fight which caused few broken ribs, which eventually caused the pneumo.  It was almost missed as he didn't have a pneumo when he first walked into the nursing station and the staff was busy with an other patient who had a stab wound to the groin.  We were there to medevac the guy with the stab wound.  It was a venous bleed but the guy who held direct pressure for the hour it took us to get there should have got an award!  All of a sudden it was like 'What about this guy?!'

He had all the classic symptoms of a tension pneumothorax except the tracheal deviation.  The guy was a bit stressed out about the whole thing especially when he saw the needle but some pre-medication took care of that.  It was kind of wild to stick this needle into the talking, breathing guy but still no hiss of air.  I ended up sticking a one way valve on the needle as we had the time, the kit, and I was about to stick this guy on a plane.

So, I guess to sum up the two cases, I think I will keep sticking valves on if I have one and I have the time.  That is until I track down some references that support that they are not required.


----------



## Armymedic

herseyjh said:
			
		

> He had all the classic symptoms of a tension pneumothorax except the tracheal deviation.



Tracheal deviation is only a sign of late, severe tension pnuemo. Often the pt will be beyond FUBAR by the time that sign is showing.

You should go off these indications for TCCC Needle decompression of the chest...(not for you, herseyjh, as I assume you already know this...but for everone else reading) 
a chest or suspected chest injury with:
Difficulty breathing with
Deceased LOC and / or
No pulse at wrist


----------



## JANES

Heres my two cents:

You should differenciate between penetrating and blunt trauma, but still keep it simple.

Penetrating trauma to the chest and increased respiratoru distress - needle the side of the penetration and hope for the best, if that didnt work then trouble shoot it.  Was it a bad needle or the wrong side?  Careful about bi-lateral needles, you've just commited them to bi-lateral chest tubes which is not fun to manage.

Blunt trauma to the chest, increased respiratory distress AND disappearing radial pulse on inspiration, or altogether - then they get the needle on the affected side.  Check carefully for asymetrical expansion and go for the side that isnt expanding.  

In a tensio pneumo, it is not the collapsed lung that kills, it is the increased intrathoracic pressure that occludes the vena cava (big vein that returns all the bodies blood to the heart then lungs then heart then back to the rest of the body, for those less medically inclined).  It's that decreased preload to the heart that causes the PEA (pulseless electrical activity) that casues death.

Beleive it or not its a blood issue, not a breathing issue.

Pericardial tamponade can mimic this, or any mediastinal pneumo or hemo.  Here a needle wont do much, but nothing less than an ER really will.  Same as a hemothorax, they need the surgeon.


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## medicineman

From the TPWB, we are only going to be teaching needle decompression to TCCC providers for use in an open chest injury that degrades into a tension pneumo, not for closed ones.  We tried, but were told N-O spells NO.  Full stop.

Tracheal deviation is in fact a very late (nasty late at that) sign, though IF you have the time, stethoscope and amount of quiet needed (like, not on a battlefield !!), you can HEAR a mediastinal shift - I've had the occasion to hear complete transposition of heart sounds from left to right side with left sided pneumos without actually visualizing/feeling a deviation (spontaneous, walk in, 70% or greater collapse).

MM


----------



## JANES

medicineman said:
			
		

> From the TPWB, we are only going to be teaching needle decompression to TCCC providers for use in an open chest injury that degrades into a tension pneumo, not for closed ones.  We tried, but were told N-O spells NO.  Full stop.



Do you mean "open" as only a sucking chest wound that seals itself and developes a tension.  But then its not really "open" anymore and they couldnt touch it.  Or do they close it themself and then it developes a tension, but then they can't needle it again because its closed again.  By you saying only an "open" one kinda defeats the point of putting a needle in because there is already an opening in the chest.  

What I am getting from this is you mean they are only treating pneumos secondary to penetration, not blunt trauma.  This is reasonable when pushing such an invasive skill so far down.  What about the medics?  They should be given full range.


----------



## kj_gully

I have been told by both civi ER physicians, and even more emphatically by military surgeons to dart every decompensating chest injury. Our protocol states absence of breath sounds on one side, Resp rate 22 or more,  o2 sat 92 or less gets one automatically. Apparently, the insult to the body is minimal ,and the improvement can be dramatic. I had one doctor speak to me for some time about pts in Iraq whose life had been saved by the porcupine approach to chest decompression. I guess it really would be more like an inside out porcupine. Basically keep darting until he feels better, obviously not in the absence of supporting the patient in all the other ways we can.


----------



## JANES

I agree 100%.  Save the guys life with needles.  But everyone need to know the procedure isnt without potential complications.


----------



## kj_gully

That's a big 10-4. As you know though, manytimes lifesaving interventions, ie the TK we're talking about elsewhere, have way too much emphasis on the downside complication, and not enough hype on the huge upside of saving your buddy. I'm sure you have heard the %10 chance of needle thoracentisis(sp?) causing pneumo. I say all the more reason to stick 2 in!


----------



## medicineman

JANES said:
			
		

> What I am getting from this is you mean they are only treating pneumos secondary to penetration, not blunt trauma.  This is reasonable when pushing such an invasive skill so far down.  What about the medics?  They should be given full range.



For some reason the reply didn`t get posted so I`ll try again.  What I`d written I thought was self expanatory, but apparently not.  So, to clear the air, non-medical TCCC providers are going to be taught to dart tension pneumothoraces secondary only to penetrating trauma.  As it stands, medics will continue doing what they`ve been trained to do.

MM


----------



## JANES

Nice.  Thanks for that.


----------



## herseyjh

Perhaps the reason for only allowing a needle thoracentesis on penetrating chest trauma is if there is a mis-diagnosis it is not all 'bad' as they might be getting a chest tube anyway.

If this, in fact, is the case it is a good compromise, as it opens this skill up to other providers while mitigating the chances of negative outcomes.  People might not agree with me on this point, but I have noticed sometimes when you train people in new skills for a specific indication, people tend to look for that.  In this case a tension penumothorax.  You only have to see a few B/L chest decompression and a FAST stuck into their sternum to appreciate this.

As for medical providers I assume it is going to be open or closed chest wall injuries.  This would be good, as from my experience, blunt closed chest trauma is the only patient population that I have seen tension pneumothorax in.


----------



## medicineman

It is simply trying to keep the standing orders for the providers to a minimum and simplified.  There is always the temptation to teach more than is really needed and the students as a rule (and their CoC) are always trying to learn more - they expect to be doctors or paramedics in 5 days of class room instruction and 5 days of field practice.

What the trauma surgeon and a few others on our TP board were saying was that the Americans weren`t seeing alot of the closed tensions we were expecting from primary blast trauma in Iraq.  Hence, it was decided to go with penetration injuries only - go with the evidence that was out there.

There is also going to be an analgesia protocol as well - pill packs for all and some sort of narcotic analgesic will be made available for providers to use.  Question is, will the narcs be for medics or for medics and TCCC providers and of course, what kind.  Watch and shoot kiddies.

MM


----------



## herseyjh

Well that is good news then.  If blast trauma is not showing the incidents of tension pneumo as one would expect, rather penetrating trauma is, then it is a win-win situation.  You don't have to worry about about excluding the blunt trauma strictly from a false-positive error perspective, as statically the chances are small that you will have one.  

Hmm now on to analgesia.  I like the pill idea as it is simple and straight forward.  I like the idea of oral transmucosal fentanyl even better.  There was a good article in the Annals of Emergency Medicine on this.  It was a small study, 22 patients in Iraq, but it is showing promise.  They had to reverse on patient with Narcan, so this could still prove to be a risk.  For now I think the NSAID or COX-2 route would be the way to go.  Speaking from a non-medic administration point of view.  From the medic point of view I would like to think soldier comfort would take president and a variety of medications would be made available.  The concept of 'ALS' pain control is common in most EMS systems, and I would hope this concept will be embraced and afforded to the field medic.  Having some poor guy yelling his head off, and chocking it up to the old saying that 'pain' never killed anyone drives me mad.  I could go on here, but perhaps I will stop, as I am sure many people share my view in this department.


----------



## medicineman

I think the analgesia thing will be forever debated.  I always remember being told medics carried morphine on a battlefield as much for pain relief as for shutting people up (or speeding people along).  We are there, after all, not only to conserve manpower, but also to boost morale and confidence.  A good start would be pain relief.  I guess time will tell.

MM


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## Armymedic

I am bringing this topic forward, as it is more relevent then ever.


----------



## Bruce Monkhouse

...and to go with the "more relevent than ever" theme, here is a post quoted from another thread that drives home the point.



			
				RHFC_piper said:
			
		

> Late reply, I know, but I can't sit at my computer all day (Hurts my legs).. with that said...
> 
> The TCCC should be manditory for all combat troops.
> 
> When I was hit with shrapnel (from the A-10) and I was crawling for my rifle (thought we were under attack) a fellow soldier found me, rolled me over and applied tourniquets to my legs... which stopped the bleeding from my femoral vein (not artery, thank god)... when the medic inspected the tourniquets, he said "these were done perfectly... text book"
> When I arrived at KAF, the docs there said that tourniquet probably saved my life.
> 
> We were all trained, by our TCCC's and medics from 2FA how to apply Tourniquets, Isreali Bandages (which they applied to the wound going through my arm) and quick clot, all of which was used the day I was wounded and the day before.
> 
> The level of professionalism demonstraited by the soldiers on the battle field in treating the casualties could only be described as absolutely amazing.  The less wounded were treating the more wounded.  And it is true what the article said about everyone pitching in; when I looked up from the stretcher, I was surrounded by a medic, an engineer, a sniper and a at least 2 others from the battalion. Everyone around me was calm and professional.
> 
> Anyway, enough ranting... to sum up; yes, the training provided was useful... it saved lives... may have saved mine.  Which is why, since I've been back home and close to my home regiment (RHFC) I have been pimping the idea of educating more reservists in TCCC.  Because we will probably be sending more reservists over seas with combat units, and the more they can be trained at home unit, the easier it will be for them to work with the Battalions.
> 
> C


----------



## Scoobie Newbie

I told many people that of all the training they needed to pay close attention to this one (well before knowing I was going).  I PRAY I won't need to apply this to me or anyone else.  I even signed for one while on leave to practise (the only one left in BN).  I also managed to snag another one from one of the guys back as well as 2 Israeli bandages.


----------



## vonGarvin

As an aside (hopefully relevant), as MM said, the medics are not only there to treat, but also to provide morale.  EFFECTIVE first aid (as the TCCC apparently is), is vital.  As I told the candidates this summer, that no matter what, TWO things were given out in Patrol Orders (even after the 80th patrol when most things were "as per SOP"):  they were:
Action on PW (Geneva Convention application)
Action on casualties.

If they failed to give either, I told them that they would receive an incident chit, and perhaps a fail on the assessment.  (reason why it wouldn't be an automatic failure?  No one single assessment factor will pass/fail; however, if someone forgets to give PW/Med, then they probably forgot alot of other stuff too).  The key was the incident chit (as a minimum), and depending on the situation, they were told that they could go to higher counselling, up to and including PRB.  (It is the commandant who removes people from training, not the course officer, not the candidate: the commandant only).  As it turns out, everyone remembered the actions on PW and action on Cas.

Here's hopoing that the TCCC becomes baseline for medical training for our soldiers...


----------



## Armymedic

Ref your patrol orders:

Did they read something like this?

Action on casualty: self aide: If you are wounded, provide self aide to yourself, stop major bleeding with direct pressure or a tourniquet, communicate that you are wounded, and retrieve your rifle to protect yourself.
Buddy aide: If a member of the patrol is wounded: provide aid to casualty as soon as possible, communicate to ptl comd the status of cas and thier ability to carry on with patrol.

COAs upon cas: 1. Attempt CASEVAC and carry on with mission, 2. Abort mission and attempt CASEVAC, 3. Bring cas with patrol and carry on with msn, or 4. Leave cas in place and carry on with msn.


----------



## vonGarvin

St. Micheal's Medical Team said:
			
		

> Ref your patrol orders:
> 
> Did they read something like this?
> 
> Action on casualty: self aide: If you are wounded, provide self aide to yourself, stop major bleeding with direct pressure or a tourniquet, communicate that you are wounded, and retrieve your rifle to protect yourself.
> Buddy aide: If a member of the patrol is wounded: provide aid to casualty as soon as possible, communicate to ptl comd the status of cas and thier ability to carry on with patrol.
> 
> COAs upon cas: 1. Attempt CASEVAC and carry on with mission, 2. Abort mission and attempt CASEVAC, 3. Bring cas with patrol and carry on with msn, or 4. Leave cas in place and carry on with msn.


Not quite like that.   But it was self aid followed by buddy aid, with the mission being paramount.  There was a go/no-go point for the ptl comds (eg: if you suffer x % cas, you will abort the patrol.  Given by the OC, and varied by mission).  
One point: cas were never to be left alone: always with someone (never leave anyone unattended: bad for morale and a whole bunch of other reasons).  So, if it were en route, then they "could" be left in place, with someone else, and retrieved on the way back.


----------



## Armymedic

Jokingly....I have to say I agree with them... ;D

In reality....WTF? My comments to follow.


http://cnews.canoe.ca/CNEWS/War_Terror/2007/04/11/pf-3982853.html

April 11, 2007 

Military says only brightest soldiers should have advanced first-aid training

By MURRAY BREWSTER

OTTAWA (CP) - As the casualties in Afghanistan mount, the army wants many more soldiers trained in highly realistic battlefield first aid, but military doctors are resisting. 

A recent report into a friendly-fire incident, in which an American plane accidentally strafed Canadian troops in Afghanistan last September, recommended more soldiers be qualified in this specialized care, a step above the standard combat first-aid course given to all troops deployed overseas. 

"This incident illustrates the requirement to have as many soldiers as possible . . . qualified," said the document, obtained by The Canadian Press under the Access to Information Act. 

"The training is considered critical given the (combat operating environment). Combat first aid should be a consideration like firepower when considering the building blocks of the forces." 

The Sept. 9 report recommended that two soldiers in each section be trained in combat casualty care to help save lives. Currently, the army requires only one soldier per section to be certified in advanced battlefield first aid, known as Tactical Combat Casualty Care. 

The need for first-aid training came brutally into focus Easter Sunday with the roadside bombing that killed six soldiers and injured four others. One of the wounded - Cpl. Shaun Fevens - managed to instruct another soldier on what to do in order to save Fevens' own life. 

The friendly fire review, completed in the immediate aftermath of the Labour Day incident that killed one soldier and wounded 36 others, has since been greeted with skepticism by Ottawa-based medical staff. 

All soldiers heading into war zones receive combat related first-aid training, a two-day course on how to stop bleeding, apply bandages and tourniquets and use QuickClot, a powder that quickly dries up bleeding. 

The proposal to put more troops through the advanced two-week course has been endorsed by army brass, saying it benefits all ranks, not just non-commissioned officers to whom the program is currently restricted. 

"This would allow the army to build a critical mass of qualified soldiers" in order to make it part of regular career training for combat arms soldiers, says an Oct. 3 memo from Land Forces Command. 

But the director of the military's health services branch, Col. Maureen Haberstock, has criticized the proposal, saying combat casualty care is training that should be reserved for "exceptional" soldiers. 

"Some of the skills taught, if performed unnecessarily or incorrectly can be harmful, or even fatal," she wrote in an Oct. 31 memo. 

Her assessment is supported by other senior medical staff at Defence Department headquarters. 

"Typically, any time (the army) finds something that is good, if a little is good a lot is better," Lt.-Cmdr. Ian Torrie, a physician and expert in combat casualty training, said in an interview. 

"The people who are going to get this extra training, you really want your brightest person. You really don't want everybody to have it." 

Since the lessons-learned document was written, the army has increased the number of soldiers qualified for casualty care, but Torrie refused to discuss numbers, citing security concerns. 

The soldiers given higher level first aid use elaborate mannequins. A variant of the course given only to full-fledged medics involves the controversial but limited use of injured live animals, specifically pigs. 

"What we're doing is very carefully scrutinized and goes through an animal ethics board," said Torrie. "Yes, we do use live animals. They are treated very humanely." 

He said the pigs are sedated and given spinal blocks so they don't feel pain. 

"We all find it very difficult to deal with live animals, but recognize the value and it actually is saving lives," said Torrie. 

The Canadian Forces first adopted combat casualty training after the first friendly-fire incident in 2002, which left four soldiers dead and eight wounded when an American pilot accidentally bombed Canadian troops in a training exercise outside of Kandahar Airfield.


----------



## Armymedic

So here it is from me on both sides of the argument.

Tactical combat casualty care involves skills and knowledge that should be taught to every soldier in the cbt arms as part of their basic trade/MOC training, it should rate as important as the skills of shooting your rifle and physical fitness. What is more precious then your or your buddies lives? Too often it is officers in the Health services (and usually not actual doctors or nurses) who have never gotten their boots dirty who decide what level of tng is sufficient for the nonmedical troops to provide to their peers. Our CF medical system must acknowledge that when it comes to medicine, more with clearly defined limits is better, and the limits that our system places on the NCO medical providers and the cbt arms soldiers are currently to restrictive and not in line with what our allies (the US) is learning and doing in the field. "They" (the Crystal Place they) are more worried about CYA and legal implications, then ensuring our Med Techs and soldiers have to skills to save lives. We as a military should be pressing ahead with MILITARY MEDICINE and not restricting knowledge skills and equipment.



Too often our training is done "check in the box style" and not with the time or effort actually required to maintain an acceptable skill level. To have and maintain these skills is not something you can only do once a yr as part of a IBTS or predeployment work up schedule, nor can you say, "I had a course 3 yrs ago, and I did it once". Constant practice and refreshing are needed to maintain a minimum standard of competency. Accordingly, medical skills are costly in both time and resources to teach and maintain. The CF has difficulty in getting all its medical pers onto the courses and training they themselves need to get all their required training. To be able to do this an individual must be motivate to learn and maintain, and be given permission and opportunity by the CoC to do so. In our training, do we practice casualty procedures and initial CASEVAC skills in most iterations on every exercise? Are the medical plans including proposed CCPs included in the Service Support portions of every order? If the Army wishes to convince the Medical group that it is truly serious about TCCC and wants its soldiers trained to a higher standard, then there is much work to do.


----------



## a_majoor

The title alone says it all. 

Would you really want to be standing next to the dimmest soldier when you get hit? How do you determine where the brightest guy is going to be when casualties occur? What happens when the brightest guy is hit?

Just like marksmanship with the rifle; advanced first aid training needs to be taught and practiced by every serving member.


----------



## Gardiners1

a_majoor said:
			
		

> The title alone says it all.
> 
> Would you really want to be standing next to the dimmest soldier when you get hit? How do you determine where the brightest guy is going to be when casualties occur? What happens when the brightest guy is hit?
> 
> Just like marksmanship with the rifle; advanced first aid training needs to be taught and practiced by every serving member.



I can only echo your thoughts as you have pretty much spelled them out.  Pity the poor soldier who gets hit and beside him is not one of the "brightest".  What concerns me is what constitutes being the brightest?  If a guy is average intelligence that means he isn't eligible for advanced first-aid?  So if I get hit I have to hope and pray there is a PH.D nearby to save my hide?  I think every soldier should be able to take advanced first aid.


----------



## geo

uhhh.... would you want the dumbest troops to be deployed? 
or retained as rear guard (or released?)

Only sharpest and brightest should be at your side - and they should have the advanced first aid trg.


----------



## COBRA-6

Why does this come to mind:


----------



## Journeyman

So now I'll wear a velro patch with my blood group...and those around me wear one with their IQ   

"Sorry, but I'll wait out this open pneumothorax sucking chest wound until someone with a higher IQ comes along." :

No, the training isn't easy, and not everyone _can_ get it (but your mom will still think you're special). But CF Health Services casually suggesting that _most_* are too stupid is arrogant to the point of harmful for the troops' well-being.  



* Based on my shaky knowledge of statistics indicating that 50% are below average.


----------



## Colin Parkinson

When the Coast Guard started the Rescue Specialist program with first Aid training to Advanced Occupational Level II, the senior management said they didn’t want us “deckapes” to be caring for a pregnant woman because we were to rough. Took about 5 years to kill that attitude. Either the soldier will pass the course or not, if the soldier fails basic first aid, don’t send them on a advanced course. It’s not rocket science.


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## medaid

huh... that's an interesting article. DO I agree with it? Not really. I mean after all, what do you call the last person to graduate from Med School? 'Doctor'. There are some of the 'brightest' people I have ever seen fail miserably on trauma calls when they are on the road, and some who freeze when they do their rotations at the hospital. Does it really mean that they're below average? Nope. They were high enough to get through some of the courses to get there in the first place, but just cant do it when brown, sticky stuff hits the fan. I agree with some of the previous thread. 

TCCC = for most combat/support soldiers
Med Tech skills = Med Techs

et voila problem solved on their high and mighty comments about 'bright and 'dim' troop. But honestly, there are those within the CF H Svc I would never let touch me. I'm sorry, but your CF provided training at times just scare me and makes me question allot of things with regards to training and doctrine. ESPECIALLY the 'check the box' type examinations that we do. But that's just my 2 rupees.


----------



## medicineman

Funny thing about first aid - it's pretty much a  hands on skill and about 95% is just common sense (I know that I say it's been bred out of the gene pool, but hear me out).  I've taught people on civvy street the old standard course before it got really dumbed down to people that only had a grade 4 education and could barely read the test, much less answer it.  Give them a task though, absolutely no problems.

The soldier I want learning this is the one who is most motivated - the one that wants to be on the course, who is responsible enough to carry and maintain and use the equipment - not necessarily the smartest.  The one who wants to be there will do well on the course and in the field for real.  Let's face it - in the end, we're training the guys and gals that are going to have to keep US alive if WE get smacked - do you want the one that was sent there against their will, didn't care and barely paid attention to anything in class looking after you?

The pilot course we ran in Gagetown had alot of people that were just tossed there as filler at the end of the PCF cycle.  Having said that, a fair number really wanted to be there and did quite well on the training - and not all of them were MENSA members.  As far as I'm concerned, if we're not going to teach everyone, then the troops should be screened vounteers, not voluntolds.  What they should have is an aptitude, and by the way, that doesn't necessarily equal brains (though that helps).

My two pieces of copper.

MM


----------



## Armymedic

This part I am surprised was put out into the media:



> The soldiers given higher level first aid use elaborate mannequins. A variant of the course given only to full-fledged medics involves the controversial but limited use of injured live animals, specifically pigs.
> 
> "What we're doing is very carefully scrutinized and goes through an animal ethics board," said Torrie. "Yes, we do use live animals. They are treated very humanely."
> 
> He said the pigs are sedated and given spinal blocks so they don't feel pain.
> 
> "We all find it very difficult to deal with live animals, but recognize the value and it actually is saving lives," said Torrie.



Animal labs are used extensively in the US (pigs mostly, 18D also use goats) for the hands on portions of their courses. The value added in working with live tissue is indescribable. There is nothing like pouring Quikclot on a real femoral bleed or tubing a real tension pnuemothorax on a pig. I am glad the CF has gone down that road.

Is Cdr Torrie the "SME" for cbt related first aid, or whatever we are calling TCCC now?


----------



## MediTech

I think it's very important that everybody have first aid training.  I watched a video of my troop's training.  While the Service Batallion was waiting for us to come onto the scene they decided that they'd try and drag all of the people out of the truck and killed all the soldiers with spinal injuries.  If they had some training they would have known to leave them there.  Not only can first aid be used to save lives, it can also be used to prevent you from killing people.


----------



## Staff Weenie

All right folks, let's get a few things absolutely straight here. 

First off - I work right next to some of these people in the HQ, and currently there is a great degree of upset over the fact that the article does not reflect the interview that was done. If I heard correctly, the quote, and headline, were taken from a document obtained under ATI, and are not reflective of the tone of the interview.

Second - The two Doctors involved in the article make me feel like a freaking useless newbie with all the tour ribbons they have - it's embarrassing to be in DEU beside them. These are extremely experienced clinicians who have deployed many times in more than a few crap holes. I know of some of the situations they've handled, they've punched their ticket......many times over!

Third - I'm part of the Standing Committee on Operational Medicine Review - I'm the Admin O (Staff Weenie). The Combat Casualty Care Working Group has only one non-clinician, non-deployed person on it - me! And I'm only there to book the rooms and handle the staffing of the results. The LCdr in the interview has stressed the need to have input from folks (medical and TCCC Cbt Arms) recently in  Kandahar to ensure that we remain up-to-date, and can adapt the training as rapidly as possible.

These decisions aren't being made by career desk jockeys.

Overall, prior to Afghanistan, the Army has had a pathetic approach to maintaining even St John's MSFA. Now, they've woken up - and as noted, they want everything, often times without understanding the full spectrum of the issue.

But here's the thing - everything is a matter of balance - do we teach everybody TCCC - even when we know that some of the skills could be dangerous in the hands of somebody that can't/doesn't maintain them? Do we blindly accept that yes, some of the folks on the course were there to fill spaces? How do we address the fact that CF H Svcs Gp is so tapped out right now, that providing the additional staff would be difficult at best? I've got no problem with 2x TCCC per Section - it's just a matter of ensuring that we are delivering the skills and knowledge to the right folks, and that we can actually support the training ourselves.

The folks that go on the course should be intelligent and motivated. That will ensure that they understand the material, and the need to keep themselves skilled.


----------



## proudnurse

COBRA-6 said:
			
		

> Why does this come to mind:



This "sign" in the picture was made by these Troops in reference to a speech that Senator Kerry had made, belittleing the Troops. He stated in a speech for Americans to "Get their Education or they would end up stuck in Iraq". He angered alot of people by what he had said. The Troops from this Minnesota National Guard Unit... thought that they would send him a "Message"   I've included the "Statement" from his speech also. Courtesy of U Tube

http://www.youtube.com/watch?v=vLuMWiQ6r2o

~Rebecca


----------



## medaid

Hehehehe Colin P, our medtechs were taught that a sign of 'unwarranted erection' was sometimes a way to check/confirm that the casualty had a head/spinal injury.  ;D

I've asked this question once and twice and over and over again, but WHEN are we going to move AWAY from St Johns?! It's really GREAT that St Johns has a great 'history' with the forces but honestly, the AMFR2 is not really recognized by anyone except the St Johns and us. Why dont we move to the EMR for our Reserve QL3 MedTechs so that they actually be EMPLOYED on the civi side if Para Medecine is something they would like to do? I mean we're always stressing about recruitment and retention, yet from my point of view, we cant offer many people anything if we give them AMFR2 and then tell them to wait a few years and maybe there's a chance on getting their PCP with the PRes. But sorry I digress. 

Seems like StaffWennie we're only getting a portion of the story and once again the media is printing what sells. Oh well. But since we're on the topic of TCCC and stuff, I've got a question. Recently there were a few msgs asking for volunteers to take TCCC from the PRes Fd Ambs, yet one of the pre-reqs was PCP. Here's my question, WHY, if we could take motivated cbt arms soldiers and train them to do TCCC do we need to have MedTechs  who have MORE medical training then they do, have PCP in order to take the TCCC? Isn't the nature of such a course Combat Fist-Aid, to be FIRST AID? This ties into alot of the arguments here that you know... hmmm... shouldnt anyone with motivation, drive and willingness be able to take the course? 

Here's another strange point,p before TCCC came out, we used to say St John's MSFA was good enough for al the troops. Uh... did we prove our selves wrong now? Just my frustrated, thrown in, two rupees.


----------



## MG34

2x TCCCs per Section!! We deployed with 2 per Platoon! As far as most Infantry NCOs are concerned everyone in the Section should be TCCC qualified,but that is a pipe dream. The question is why cannot an Infantry NCO who is TCCC qualified not get the Instructor course,or at least open more slots for the non medical branch types. Then the burden on the med system would be lessened by the units conducting their own training with the unit MO as the Med Director. It seems pretty simple to me,after all it isn't brain surgery, of course once you throw in the respective kingdoms and secret keepers it gets complicated.


----------



## GINge!

There seems to be some confusing regarding Standard First Aid, Combat Related First Aid, TCCC, and TacMed (formerly Med TCCC). Suffice to say they are all different courses and the SME's are better at describing the content than I. 

I would like to see some evidence that shows what skills taught on which course resulted in life saving or injury mitigation. I'm not sure this evidence has been collected, but if it is out there, it would be interesting to determine what percentage of injuries required CRFA skills and what percentage required TCCC skills to be applied. As most of the skills taught on CRFA are also taught on TCCC, how many of the preventable deaths treated required the additional 2 techniques taught on TCCC?   

As for everyone having TCCC, I ask this: Would it be nice to require all the anesthesiologists to qualify PWT Level 3? Sure. Would it be good to have all the LAV Gunners qualified to insert a chest tube? You bet. Somewhere in that facetious example there needs to be a balance that meets our "train to need". The thing is, TCCC is an ARMY course that is supported by MedTechs ( 3 x QL5, 3 x QL3, 1 x MO). If the Army wants 2 per section trained in TCCC, then that's what we will endeavour to support. If the Army wants 100% of the TF trained TCCC, we will try to support that, but I guarantee you it will be hugely taxing on the medical community, possibly at the cost of other training. I think the current path of 100% CRFA and 2 TCCC qual per section strikes that balance of need and what we can realistically sp.


----------



## one_speed

My Reserve unit has just recieved a call for clinicians to take the TCCC instructor course through 1 Health Service Group this May to support the Reg Force Instructor Cadre.
I've seen a lot of discussion about TCCC on this forum from over the last couple of years, and obviously the course has been developed and is being run.

Does anyone have any new info about this course, ie curriculum etc.  We have the timings for each serial being run this summer (10 days - 5 classroom 5 field).

Where does this training sit in the grand sceme of things (relative to say a civi first response course) for skills taught etc. ?

Thanks,

 Ian


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## Southern Boy

Everyone should be taught Advanced First Aid. Hey, that idiot next to you may end up being the guy who saves your hide.


----------



## HItorMiss

Hmmm I can't believe I missed this thread when it was active....

As someone here who actively used TCCC under contact (I am not the only one on the board I am sure, just the most vocal advocate) I can say without a doubt that there were not are not enough of us on the battle field. I spent the majority of a large TIC running back and forth like an idiot just to make sure some sort of medical assistance was available all over the place. I used just about everything on that course )minus treating a Tension Pneumothorax) from getting vitals to setting up a CCP to running triage. I completely agree we need more people with this course. I also agree that it is a skill that needs to be taught to those that want to learn it not space fillers. That being said the "space fillers" on my course all walked away really intrested in what they had learned so perhaps they were converted.

As for Med.Techs comment about spinal well if that vehicle is on fire or taking enemy fire I'm moving the cas ASAP cause I might kill him but I know for sure that the flames or the bullets will. We also don't do C-Spine control because once you start you cannot stop, TCCC medicine is basically quick and dirty stabilization or as near to it as you can get till the medic of the cas evac gets there to take over.

I seriously advocate TCCC as a QL4 course or as close to that as possible, it's a must have in a combat zone for as many people as possible.


----------



## aesop081

HitorMiss said:
			
		

> As for Med.Techs comment .....



Its ok...dont bother with anything he says


----------



## HItorMiss

Roger LOL

I just had to refute that little bit on nonsense in terms of TCCC medicine and the real world


----------



## medaid

Just remember brothers and sisters, that it is not I who say things like that  ;D


----------



## Donut

Perhaps you need to add a disclaimer to seperate you from the Island-dwelling variant  

And congrats to the GF...we'll have to go for drinks next month if you're in town.


----------



## stealthylizard

I have taken numerous first aid courses through out my life since I was young enough to be able to take them, as a civilian.  We have had people from all sorts of employment lines, sometimes even paramedics.  Constant training and retraining is necessary to retain the skills taught.  Some of the procedures for first aid change through the years, that are found more effective or safer for primary care.  Most people only re-certify when their ticket is about to expire, and if it hasn't been used, it is quickly forgotten.  I can't tell you how many times I have seen people, that are supposed to know first aid on a day to day basis, fail their re-certification.  It would be great for every member to be TCCC qualified, but they must consistently use the skill set, or it is forgotten.  Having a person do it once a year, isn't good enough, and that is what will most likely happen.  There either has to be a change in training to accommodate TCCC retention or it will be a "waste of time".


----------



## medaid

ParaMedTech said:
			
		

> Perhaps you need to add a disclaimer to seperate you from the Island-dwelling variant
> 
> And congrats to the GF...we'll have to go for drinks next month if you're in town.



Oh I'll be here... reasons for why in PM. Hmmm... I wander if we could just ask the Island-dwelling variant to change their handle? I don't want a disclaimer to be painted on my avatar  ;D


----------



## medicineman

stealthylizard said:
			
		

> There either has to be a change in training to accommodate TCCC retention or it will be a "waste of time".



Hmmm - trying to remember if this came up in the TCCC thread we had going awhile back - I'm pretty sure it did.  I was on the TPWB for the formalized course and we came up with retraining requirements for all providers to include refreshers while in theatre and to run the courses as close to deployments as possible to ensure the psychomotor retention.  There were also some required milestones to be met at various timelines vis a vis some of the important practical skills.

Since you're making that comment, can I assume that you are a TCCC provider that was on a locally developed/run course or took the new formalized version and weren't told about that?

MM


----------



## stealthylizard

Since you're making that comment, can I assume that you are a TCCC provider that was on a locally developed/run course or took the new formalized version and weren't told about that?

No, I am neither.  I was commenting based on other comments posted, some of which said the same thing I did.  I have just seen skills that are not practiced, in both the military and the civilian world.  When it comes time to actually utilize them, people are stuck trying to remember what to do, and how to do it.  We even had a medic in the oilfield that didn't know how to treat a heart attack, because it was not something she ever came across, except for her 2 year re certification practical.  If those skills are going to be of any use they must be constantly focused on.  It is kind of like 2nd language training, don't use it, lose it.  

I wasn't aware of it being brought up in a previous thread, I haven't read every single post on this site (I am still getting around to it.)  Since it was not mentioned on this one previously, it cannot be expected for all of us to know it.


----------



## Greymatters

HitorMiss said:
			
		

> I completely agree we need more people with this course. I also agree that it is a skill that needs to be taught to those that want to learn it not space fillers. That being said the "space fillers" on my course all walked away really intrested in what they had learned so perhaps they were converted.



If they see its relevant and useful, it tends to convert a lot of former 'space fillers'...


----------



## medicineman

Was just wondering - we had a couple of extensive threads going on TCCC for a bit - here are a few:

http://forums.army.ca/forums/threads/39915.0.html

http://army.ca/forums/threads/26415.0.html (this one is rather lengthy).

As for people forgetting stuff, especially if it's a primary responsibility, well all I have to say is they should lose their ticket if they can't remember to refresh themselves periodically.  It's as much their own responsibility (more so in fact) to stay abreast of changes and to keep their knowledge base up as it is their employers' to make sure that they do.  There's no difference in the military - you put through the CoC that you're due for refresher and crack the books at the same time and if necessary, use some initiative and talk to someone to scare up some training or do it yourself somewhere else and claim it later (had to go that route many a time myself).

MM


----------



## medicineman

GreyMatter said:
			
		

> If they see its relevant and useful, it tends to convert a lot of former 'space fillers'...



True enough - the problem is some of those space fillers are taking up spaces that people with more aptitude or who are much more motivated to do the course could be using.  Not that something like that ever happens in the CF...much  :.

MM


----------



## Greymatters

medicineman said:
			
		

> True enough - the problem is some of those space fillers are taking up spaces that people with more aptitude or who are much more motivated to do the course could be using.  Not that something like that ever happens in the CF...much  :.
> MM



Hmmm.... when I was instructing this several years ago everybody on the base had to take it as part of readiness for overseas postings, so there really werent any spaces wasted by 'space fillers'...... I guess that isnt the case anymore?


----------



## medicineman

Not the proper TCCC course - it tends to be run more like a PCF course with only some of the troops getting the full 2 weeks of training (it is an OSQ).  The "Combat Related First Aid" as it is now called is what the remainder of the masses get - a quick change of mindset, down and dirty TK and QC use and some scenario work.

MM


----------



## Journeyman

medicineman said:
			
		

> - a quick change of mindset, down and dirty TK and QC use and some scenario work.


I believe a _very useful_ change of mindset. 

If someone _is_ choking on that always-present piece of sausage, I'm not St John Amb current -- so no hind-lick (sp?) manoeuvre.


----------



## Greymatters

Journeyman said:
			
		

> I believe a _very useful_ change of mindset.
> 
> If someone _is_ choking on that always-present piece of sausage, I'm not St John Amb current -- *so no hind-lick (sp?) manoeuvre*.



Translation available?


----------



## aesop081

GreyMatter said:
			
		

> Translation available?




heimlich


----------



## medicineman

The Hind-Lick Manoeuver is the alternate method to the old standby the Heimlich and it is only taught in certain portions of Atlantic Canada.  To perform it, you require yourself situated in front of the choking victim with any person handy bent over in front of you with their bare bottom to your front - the rest is self-explanotory.  The patient usually will spontaneously vomit the offending piece of sausage up within 2 licks.

MM


----------



## Greymatters

I had a feeling it was something rude...


----------



## HItorMiss

Well that be a PO on the next TCCC course?


----------



## Journeyman

GreyMatter said:
			
		

> *I had a feeling it was something rude...  *


Hey, I'm just an infantry guy. I leave the spelling and details to the experts (like medics and aircrew), who _obviously_ have more experience at these things.   >


----------



## medicineman

Journeyman said:
			
		

> Hey, I'm just an infantry guy. I leave the spelling and details to the experts (like medics and aircrew), who _obviously_ have more experience at these things.   >



He of course fails to mention he was paramedical himself... :

MM


----------



## Journeyman

medicineman said:
			
		

> He of course fails to mention he was paramedical himself... :



Hmmmm...not in my profile; I guess it's not true


----------



## medicineman

We believe you - pity nobody else does...


MM


----------



## one_speed

Good Morning,

I just returned from CFB Edmonton after completing the TCCC instructor course and I am blown away by the shift has happened and it was the army that is pushing something so new  forward so quickly.  I should say that I am not surprised and that I am extremely pleased to be involved.  What a paradigm shift  as a medic to be able to put the "ownership" issue on medical skills  aside.  It seemed like the infanteers on this serial seemed to soak it up, integrating the skills very easily into their tactics and being very effective in the role.

I know what the perception from the medical side is very positive, and I am curious on hearing from combat arms people learning and applying these skills.  Comments ?


----------



## Blackadder1916

It seems that the US Army plans to deal with this issue on a much broader scale.


Army begins training combat soldiers to save lives 
Interventions may mean life or death 
http://www.courier-journal.com/apps/pbcs.dll/article?AID=/20070527/NEWS01/705270511/1008/NEWS01


> By Michael Felberbaum Associated Press Sunday, May 27, 2007
> 
> RICHMOND, Va. -- *The Army is increasing the medical training it gives to soldiers in the hope that those in combat can begin administering critical medical care to their wounded comrades on the battlefield, in some cases saving lives.
> 
> The service's five basic training bases will begin offering combat lifesaver training, including instructions on starting an IV and helping soldiers breathe through a tube, by June 15. The bases train up to 180,000 soldiers annually, including National Guard and Reserve components. *
> 
> Soldiers at Fort Knox and at Fort Sill in Oklahoma already have begun the training.
> 
> Officials said medical care given immediately after injuries like gunshot wounds and those caused by roadside bombs could mean the difference between life and death, and simple lifesaving techniques could cut down on long-term injuries and deaths.
> 
> "The most critical 10 minutes in a soldier's care in combat is the first 10 minutes," said Col. Kevin Shwedo, director of operations, plans and training for the Army Accessions Command, which oversees training. "We've focused on the skills that would give us the greatest opportunity to evacuate an individual to a higher degree of health care."
> 
> *Previously, a limited number of soldiers in each unit were trained on advanced lifesaving procedures, and most soldiers learned only basic first aid techniques, like bandaging and performing CPR. *
> 
> "You won't have to wait as long to find the one combat lifesaver you had trained," said Shwedo, whose command is based at Fort Monroe in Hampton, Va.
> 
> More in-depth medical training can also make the difference between bringing back a patient and bringing back a corpse, said Col. Patricia Hastings, director of the Army's Department of Combat Medic Training based at Fort Sam Houston in Texas.
> 
> "First aid is just not good enough anymore," she said.
> 
> Col. Annie Baker, commander of the 434th Field Artillery Brigade at Fort Sill, said *after only 10 days of basic training, soldiers there started the combat lifesaver certification, which includes sticking needles into each other to learn how to establish an IV.*
> 
> "We've had some soldiers that have been very timid and concerned -- because people don't like shots -- but not one soldier has not participated," Baker said. "Some looked a little peaked going in there, but between the medics and the drill sergeants coaching and mentoring, they've gotten through it."
> 
> Spc. John Hanson, who was a paramedic before he began training at Fort Sill, said it is important to learn the skills, even if it means getting "poked by a complete stranger or someone you've only lived with for a couple of weeks."
> 
> "We're used to getting shot at and people getting hurt," said the 29-year-old from Arlington, S.D. "With more of us knowing how to help our buddies, maybe it will make for a more successful outcome."
> 
> *The new training takes up about one week of the soldiers' nine-week training program, and only rifle marksmanship and physical training have more time devoted to them. *
> 
> When soldiers get to the battlefield, they can use combat lifesaver bags given to each unit to help tend to fallen comrades. Those bags include supplies like IVs and saline solution, tourniquets, nerve agent antidote, and simple items like gauze and bandages.
> 
> Shwedo said the skills not only help save lives in combat, but also improve how soldiers react in situations because they know there is responsive medical care to keep them alive.
> 
> "It makes a soldier not only more confident, but more importantly, more effective," he said. "When you focus on the mission instead of 'what could happen to me' you can now take the initiative to the enemy."
> 
> LIFESAVER TRAINING
> 
> The skills included in the Army's new combat lifesaver course in basic training:
> -  Evaluate a soldier's injury while under fire and under normal circumstances.
> -  Help soldiers unable to breathe on their own, including inserting a breathing tube.
> -  Control bleeding and treat burns, including dressing open wounds.
> -  Start an IV of saline solution.
> -  Get an injured soldier to a location for further medical care on foot or by vehicle.
> -  Perform CPR.
> -  Administer an antidote to counteract the effects of a nerve agent.
> -  Splint a bone that is suspected to be fractured.


----------



## KevinB

FWIW -- they are doing a lot of in theatre training as well -- most if not all deployed troops receive instructions on tourniquet use, needle decompression, quick clot etc.


----------



## medicineman

The Combat Lifesaver Course has been around for a number of years - just not on the scale they are now doing it.  It would seem that everyone is now getting it instead of just a couple of soldiers in a section or 1 in a vehicle crew.  Just hope they don't get stuck into the "must start IV" mode before they stop bleeding and such first...

MM


----------



## Blackadder1916

medicineman said:
			
		

> The Combat Lifesaver Course has been *around for a number of years * - just not on the scale they are now doing it.  It would seem that everyone is now getting it instead of just a couple of soldiers in a section or 1 in a vehicle crew.



True.  I remember meeting with their OPI for Combat Lifesaver when I was in the States years ago (though not quite when dinosaurs ruled the world).  I brought back a lot of info concerning their (then new) program and wrote a service paper for my boss about the feasibility of instituting a similiar program for the CF.  One of my concerns about adopting CLS in the same format as (then) done by the US Army was their reliance on distance learning and self-study for several aspects of the program.  It seemed at the time that they placed more emphasis on "checking the box" for record keeping rather than ensuring that the individuals had validated skills.  But that was a couple of wars ago and it now appears that the importance of hands-on training is realized.


----------



## medicineman

I (among others too it seems) was working on a similar scheme and had also presented a service paper to my boss as I have been involved quite a bit in teaching soldiers their first aid packages and thought something a bit different was in order to cover the wide variety of missions we were dealing with.  I was particularly concered with teaching advanced skills to designated personnel in infantry units and UNMO's due to their unique circumstances.

The distance ed stuff isn't too bad for some of the more cerebral things - it could also be used for threshold knowledge testing at the beginning of the hands on portion to weed out those who probably shouldn't or don't want to be there.  The US military seems to rely alot on these distance education packages to cut down on formal time spent in classrooms, something we only just seem to be catching onto up here.

BTW Blackadder, to put things in context, I became aware of the course about the time of GW1, and I'm sure it had been around for a bit prior to that.  So no, I'm not insinutating anyone is a mouldy  ;D.

MM


----------



## Greymatters

medicineman said:
			
		

> The distance ed stuff isn't too bad for some of the more cerebral things - it could also be used for threshold knowledge testing at the beginning of the hands on portion to weed out those who probably shouldn't or don't want to be there.  The US military seems to rely alot on these distance education packages to cut down on formal time spent in classrooms, something we only just seem to be catching onto up here.



And just as we are catching onto it, we are, as usual, far behind in the current trends.  Many major corporations in the US have realized that distance learning doesnt work as well as it should and an increasing number of companies are turning back towards class-based learning environments.  It cuts down a lot on cost and time away from work, but actual learning is limited due to a lack of people to exchange ideas with and discuss concepts that arent clearly represented.


----------



## Armymedic

Yes, we may be behind the current trends. But in an army whose troops are gone from family a lot and away from thier home base cutting down course length is cheaper and better for soldiers individual welfare.


----------



## KevinB

St. Micheals Medical Team said:
			
		

> Yes, we may be behind the current trends. But in an army whose troops are gone from family a lot and away from thier home base cutting down course length is cheaper and better for soldiers individual welfare.



Unless your the one lying on the ground sucking wind, and the guy doing aid can't remember that lesson -- or kinda breezed over it


----------



## Armymedic

good point, perhaps I should lay on the floor and re-examin that point of view.  

But seriously...most soldiers are motivated to learn knowledge, because it is the background for a skill they will be tried and tested on. But yes, you still need a classroom with an instructor to confirm knowledge.


----------



## medicineman

Whether the material gets learned by distance ed or not is back to the motivation principle - if you want to do it or have a good reason to do it, you will.  Distance ed BTW doesn't preclude having an instructor handy - I've done some very well facilitated university courses by CBL that had chat rooms and instructors you could reach by email and have answers to questions within an hour usually.  If it's set up well, it can be done.

I seem to recall that for the longest time, Emergency Medical Technicians in Alberta did all their didactic by CBL/Distance Ed and then came together to do their labs for the practical periods for a few days at a time every 1 or 2 months and that seemed to work well.  Food for thought.

MM


----------



## Jarnhamar

I just wanted to say how amazing this course was.  I was blown away by what I learned. Awesome instructors and awesome training aids. Expensive yes but it was great to actually be able to use the medical item's we'll be using overseas and getting hands on training instead of just watching videos. 
I've always been bored and uninterested in the St John's firstaid but this course really opened my eyes. My first aid confidence in myself jumped by about 50 times, it feels like light years ahead of what we learn in basic first aid. One of the best course's I've taken.

Even the practical portion (section comes up to a vehicle accident-react) felt more accurate and real than what I remember doing in the TMST practical role playing scenario.  Having combat arm types on hand to cover tactics was a great idea too.

Big thanks to the medical staff (and attachments).  In a perfect world everyone going overseas would be TCCC qualified.


----------



## Jarnhamar

For the medics out there how many people (obviously situation dictates) do you feel a TCCC guy can treat? Like should I aim for 2 or 3 or 5?

Obviously you're going to treat everyone but I have limited space in my TCCC bag and I'm wondering just how many cook sets I should pack, how many bandages (of what type) how many of those nose tubes etc..   More heavy on the bandages or go for more of a mix?
Can someone recommend a good balanced TCCC bag set up?

Thanks


----------



## Armymedic

1 serious (life limb eye sight).
so assume 1 airway kit, 2 limb injuries, 2 in and out wounds, etc., specifically 2 decompression needles (dump the Cook set for chest...too big and mostly useless)


and that is it.


----------



## Jarnhamar

Man I'm over packed. Had 5 airway sets, 4 cook sets heh

2 limb injuries and 2 in and out wounds, what bandages/stuff would you recommend for that?


----------



## Armymedic

Depends on what is available to you and what you prefer to use. I recommend min 2 triangulars, 2 ER dressing, 4 kerlix (kling, packing whatever) as a start.


----------



## HItorMiss

I would be more heavy on the penetrating trauma stuff IE: Israeli dressing, TQ, Kerlex, Fd dressings

And less concerned with Airway and cook sets. For chest go with Ashermans they worked like a charm for me.

My TCCC bag looked like

4xIsraeli
2xKerlex
4xTQ
2x Cdn Fd Dressing
4x Asherman
2xNeedles
2x QC
2xNPA

Of that the only things I never used was the NPA the Needles and the QC. This set up I found meant I could work and sustain life on 2 major WIA's or a whole whack of minor ones. Remember your job is to keep them alive long enough for the Medic to get there and get them stable (ish) 

Also remember the first rule do not become a casualty yourself!

SHUT UP DOC  ;D


----------



## Armymedic

BulletMagnet said:
			
		

> Also remember the first rule do not become a casualty yourself!
> 
> SHUT UP DOC  ;D



What?!? I didn't say anything...


yet.


----------



## HItorMiss

Prairie Dog said:
			
		

> What?!? I didn't say anything...
> 
> 
> *yet*.



Yeah thats what I am afraid of


----------



## DiverMedic

Cook sets have been recalled.  No longer used overseas as they aren't long enough, and bulky as hell.  Now using a 10G x 4".

Also bare in mind, ALL the vehicles overseas have trauma bags in them.  As well, every soldier has his own "med supplies".  So don't get too caught up in carrying a lot of extra kit.

DM


----------



## PhilB

I would second what others have said. Carry more penetrating trauma stuff. My bag had;

4x Israelis
2x Blast Bandage (these were GREAT for dismounted IED related incidents)
4x Kerlix
2x QC
2x TQ
2x NPA
2x De-Compression needles
4x Asherman
2x Glue (I cant remember what the name is, but the glue that works on skin)
2x Glow sticks (whatever you CAS marking SOP colour is)
1x Body pen
Lots of gloves


----------



## R711

PhilB 
It's called DermaBond, the medical grade skin glue.
R711 OUT


----------



## Tetragrammaton

I am hoping someone can help me out with any good and applicable references (both on and off site) to supplement training for someone starting out within a Tactical Combat Casualty Care (TCCC) role. 

I can do my own internet searches but I am sort of working in the dark having nothing more than level 1 First Aid.

My thanks in advance.  

http://forums.army.ca/forums/threads/33048.0.html

http://forums.army.ca/forums/threads/26412/post-162540.html#msg162540

http://forums.army.ca/forums/threads/26415.0.html

http://www.health.mil/Education_And_Training/TCCC.aspx


----------



## Gunner98

Three relevant articles of interest:

http://www.forces.gc.ca/site/commun/ml-fe/article-eng.asp?id=5883
http://www.army.forces.gc.ca/ws/Archives/5Mar09/5Mar09.pdf (See page 7)
http://www.forces.gc.ca/site/commun/ml-fe/article-eng.asp?id=3502

TCCC is designed to teach CF personnel deploying to Afghanistan how to treat casualties until medical support arrives – perfect for NBP members because they often operate without a medic in tow.

The two-week course starts with the practical. Students learn to use a tourniquet, pack a wound, insert a nasal breathing tube, insert a needle into the chest cavity to relieve air or fluid pressure, and how to do all this and more under fire.

The second week sends students into the field to work through scenarios such as a LAV striking an IED, suicide bombers at checkpoints, patrols through villages and injuries to civilians, with role-players as locals and enemies, and realistic simulated wounds. Students also practised transmitting the necessary information in calls for medical evacuations.


----------



## Tetragrammaton

Is this normally an all trades course?


----------



## Gunner98

Any trades working outside the wire or off the ship on operations!


----------



## one_speed

Having worked as a clinical instructor in both TCCC and CFMS within the CF, as well as
civilian First Response and EMS I have a good view of the spectrum of care.

TCCC focuses on teaching you how to keep tactically involved with combat while acting
as extra eyes for your medic while on deployment.  In a pitch (i.e combat) you can act 
as a second pair of hands to administer very specific life saving measures to your comrades.

This course doesn't teach you how to become the medic... but does start you thinking about and and recognising the
pretty simple things that will save lives.  It also gives you some of the tools you would need to augment the medics
capabilities in a mass cas situation.

I think that the best resource you could get to aurment your capabilities would be taking a civilian advanced first aid course.  More because the training gets your mind moving and sets you up with a specific mind set that can only help in your role as TCCC.  Granted the tools used to deal with injuries are different, and the approachand priorities are drastically different (hence TCCC) but it would be the mind set you have going into the situation that would be beneficial.

Best of luck...

Ian


----------



## feetfirstintoheck

Hi there. Just a quick question if anyone can shed some light. I'm going to be tasked as an ambulance driver for the next 6 months and will me around the medics daily. There will be a lot of down time and I was hoping to pick up any medical training I could while there, if the medics are willing and have the time and means.

My question is what courses are generally available to combat arms pers (I'm an engineer) and who is qualified to teach them? The only one I know of for sure is TCCC and you generally only get that if you're deploying.

Thanks.


----------



## Sythen

Though I can't answer your question, remember if you are TCCC trained you cannot use it outside of a combat situation without being liable for damages. Anything beyond First Aid is not covered, so you can be sued.


----------



## feetfirstintoheck

Sythen said:
			
		

> Though I can't answer your question, remember if you are TCCC trained you cannot use it outside of a combat situation without being liable for damages. Anything beyond First Aid is not covered, so you can be sued.



I'm aware of that but thank you.

I'm just looking to utilize my time as best as possible and get some quals while I'm away from the regiment. So basically I'm just wondering what could be available to me.


----------



## 392

Depending on which base your task is at, they may be running BTLS (Basic Trauma Life Saving - *I think* - it's been a while) at the base hospital, which is basically an advanced civy TCCC-style first aid course aimed at paramedic types. I took it back in '03 or '04 while I was posted to Gagetown the first time around, and although I am sure it most likely has a different name and content, it was fantastic. If you are able to do the combat first aid TMST stand with any kind of competency, you will not have issues with the practical portion of the BTLS, although the theory portion might be a different story. 

Although, it never hurts to wait until you are actually there and talk to the medic types and ask them - I am sure they would be able to assist in something.....


----------



## medicineman

Capt. Happy said:
			
		

> Depending on which base your task is at, they may be running BTLS (Basic Trauma Life Saving - *I think* - it's been a while) at the base hospital, which is basically an advanced civy TCCC-style first aid course aimed at paramedic types.



Basic Trauma Life Support...now ITLS (International TLS) is something we used to offer to the amb drivers, not sure if they do now, but they could audit and do the hands on training, so they had an idea of how use the equipment and anticipate our needs.  It's essentiall a course on how to assess and treat trauma patients in an organized fashion...not really a TCCC course for paramedics  , though there is some of that involved.  Another thing you can ask for is the Advanced Medical First Responder or Emergency First Responder course.  These help you learn the basics like using Oxygen and taking proper vital signs, as well packaging.

Also, don't be afraid to bug your medic - they're a wealth of information and are usually pretty forthcoming in teaching, or they should be, as training you is part of the deal.

MM


----------



## R933ex

You might even ask for the basics a HCP (Health Care Professional ) CPR Course is a good add on to the First Aid you already have


----------



## MedCorps

TCCC and Combat First Aid, on top of Military Standard First Aid are really the only CF Options. CPR Level C with HCP is also an option.  

You might also see if you can get an Advanced Medical First Responder or Emergency Medical Responder course, either via the CF (if someone is running one) or via St John Ambulance / Red Cross on the civi side.  

One of the best options, I think, would be to take a civilian Wilderness First Aid / Advanced Wilderness First Aid / Wilderness First Responder course(s).  Well run these are prime for people in the CF who are often a little further away from an ambulance / EMS service than our civilian friends. 

There are also a few other civilian courses, such as Battlefield Medical Response (Wilderness Medical Associates) or combat first aid (CTOMS) if you are willing to seek them out. 

MC


----------



## GnyHwy

It is good that you are interested and excited to do a good job as part of an Amb crew, and if you end up staying there you will get valuable experience.  Courses will come with time.

I am writing to remind you not to get ahead of yourself, and not to lose focus on what you are expected to do.  You are a driver, and that needs to be your priority.  Ensuring the vehicle is well maintained, organized, clean, and operational is the best thing you can focus on at this time.  Knowing your way around the truck, know the proper names for the equipment and supplies, and memorize the maps and areas you will be operating in.

Saving a person from a sucking chest wound certainly would be amazing work, but if your truck dies or you get lost along the on the way, all the bandages and first aid skill in the world won't help.


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## daftandbarmy

GnyHwy said:
			
		

> It is good that you are interested and excited to do a good job as part of an Amb crew, and if you end up staying there you will get valuable experience.  Courses will come with time.
> 
> I am writing to remind you not to get ahead of yourself, and not to lose focus on what you are expected to do.  You are a driver, and that needs to be your priority.  Ensuring the vehicle is well maintained, organized, clean, and operational is the best thing you can focus on at this time.  Knowing your way around the truck, know the proper names for the equipment and supplies, and memorize the maps and areas you will be operating in.
> 
> Saving a person from a sucking chest wound certainly would be amazing work, but if your truck dies or you get lost along the on the way, all the bandages and first aid skill in the world won't help.



Good points. It's important to be able to reduce the 'Golden Hour' to the 'Golden few minutes', and only a good driver of some kind can do that.


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## 392

medicineman said:
			
		

> Basic Trauma Life Support...



I knew I was close 



> ...not really a TCCC course for paramedics  , though there is some of that involved.



Absolutely - it is NOT a TCCC course, but the skills taught are close and I figured it was something he could relate to. No worries  


In any case, there is a lot of useful suggestions here  :2c:


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## Jarnhamar

feetfirstintoheck said:
			
		

> Hi there. Just a quick question if anyone can shed some light. I'm going to be tasked as an ambulance driver for the next 6 months and will me around the medics daily. There will be a lot of down time and I was hoping to pick up any medical training I could while there, if the medics are willing and have the time and means.
> 
> My question is what courses are generally available to combat arms pers (I'm an engineer) and who is qualified to teach them? The only one I know of for sure is TCCC and you generally only get that if you're deploying.
> 
> Thanks.


Awesome attitude.


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## ModlrMike

GnyHwy said:
			
		

> It is good that you are interested and excited to do a good job as part of an Amb crew, and if you end up staying there you will get valuable experience.  Courses will come with time.
> 
> I am writing to remind you not to get ahead of yourself, and not to lose focus on what you are expected to do.  You are a driver, and that needs to be your priority.  Ensuring the vehicle is well maintained, organized, clean, and operational is the best thing you can focus on at this time.  Knowing your way around the truck, know the proper names for the equipment and supplies, and memorize the maps and areas you will be operating in.
> 
> Saving a person from a sucking chest wound certainly would be amazing work, but if your truck dies or you get lost along the on the way, all the bandages and first aid skill in the world won't help.



Probably the best advice you'll receive on this question. Knowing what the stuff is and where it is located in the vehicle is probably more important at this stage. If your help is needed to treat a patient, your medic will tell you what to do. That being said, Standard First Aid is probably the most important medical course you can take at your stage.


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