medicineman 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.
Tactical combat casualty care ( TCCC )
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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.
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
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Gunner98 said:
I saw things in San Diego that I had never, ever dreamt of!!
Oh sorry, completely wrong thread ;D
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.
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?
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?
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.
What kind of tk was put on MCpl Franklin anyway?
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.
kj_gully said:
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
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JANES said:
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
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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.....
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.....
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JANES said:
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.....
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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.
They will all be issued CAT tourniquets (when, I am not sure).
A little more then your Dad's redeployment first aid training.
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.
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JANES said:
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.....
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