Tactical combat casualty care ( TCCC )

[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]

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?