Tactical combat casualty care ( TCCC )

[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]

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.

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?

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]

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]

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)

 

[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.

 

[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.

 

[Armymedic]

well would that suck to have them?

 

[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.

 

[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

 

[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.

 

[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.

 

[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.

 

[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

 

[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

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.

 

[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

 

[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.

 

[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.