Tactical combat casualty care ( TCCC )

[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.

 

[JANES]

Well said.

 

[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...

 

[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.

 

[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.

 

[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

 

[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. 

 

[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.

 

[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.

 

[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.

 

[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.

 

[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?

 

[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!

 

[JANES]

Anybody heard of these guys?

http://tacmedtraining.com/

 

[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]

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? 

 

[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.

 

[medicineman]

So much for the KISS principle. 

MM

 

[JANES]

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.