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    Combat Medicine & You


    Numinous

    Alrighty,

     

        This was asked of me yesterday, as to what order a combat medic should handle their patient.  Having served with the US navy for 12 years and 8 years of which as a combat medic, before becoming a paramedic in the civilian sector and working as a Tactical medic, I hope my insight can assist.  As such, i five the following:

     

    Overall Goals of all Medical and Non-Medical Personnel

     

    The world does not stop because you or a buddy has been shot. So the first rule is to shoot back!

     

    The immediate goals of all personnel are to:

    • Engage with and destroy the enemy,

    • Attempt to win the firefight,

    • Secure the casualty only if necessary and feasible,

    • Identity life-threats and/or injury extents,

    • Address life-threats aggressively, and,

    • Complete the mission!

     

    Combat Life Saver

     

    The Combat Life Saver is a first responded trained to immediately intervene to scene and to the casualty. They are a “bridge” between buddy aid and a combat medics responsibilities, which helps to streamline the transition of care during the lead-up to combat medic treatment. All in all Combat Life Savers carry additional medical gear loads and perform vital functions such as nasopharyngeal airway insertion with a high competency standard. The aims of a Combat Life Saver are to:

     

    • Preserve the casualty from additional wounds,

    • Protect the casualty with the primary weapon available, and,

    • Promote casualty recovery through interventions and procedures.

     

    The most important role for any Combat Life Saver is to: Keep yourself alive! Never expose yourself to enemy fire, if at all possible, and only move when you are sure it is safe.

     

    Combat Medic

     

    The Combat Medic is a step above the Combat Life Saver, he is responsible for not only immediate interventions but the co-ordination and control aspect of medical treatment and thus is normally coupled with the Command element to the unit.

     

    Refrain from:

     

    • Moving into the Kill Zone to retrieve the casualty,

    • Moving when the casualty is conscious and mobile, and can be directed verbally.

     

    The main life-saving activities a Combat Medic is involved in include:

     

    • Immediate tourniquet application to serious bleeding,

    • Field expediency to recover the casualty,

    • Insertion of nasopharyngeal airways,

    • Aggressive needle thoracostomy as required,

    • Emergency surgical airways when required,

    • Appropriate fluid resuscitation,

    • Appropriate use of analgesia, and most importantly,

    • Combining good tactics with good combat medicine.

     

    SOF Medic

     

    The Special Forces Medic is responsible for much more than a traditional Combat Medic. Cares may need direct intervention that goes beyond the scope and practice of other Medics. For example tranexamic acid can only be administered by Special Forces Medics with strict indications on internal bleeding within the pre-hospital environment.

     

    “Hearts and minds” campaigns often focus around hygiene, sanitation, dental health and other disciplines a Combat Medic is often not directed in. The mission spectrums that Special Forces are involved in also extends the limits of care because extraction may be non-existent or several hours away. The extension of capabilities leads to an expansion of latent and actual errors, the potential for medical cases; for example SCUBA missions may lead to oxygen toxicity, increased thoracic pressure and/or pneumothorax situations while in a combat swim, miles from the coast and hours from help.

     

    Flight Medic

     

    The Flight Medic is a part of the flight crew, who is capable of giving medical aid

     

    Sensory deprivation (loud, vibrating, lower visual horizon, banking and moving)

    Flight medicine

    More equipment, more medicines, a lot of more mobility, challenging to treat in that environment

     

    A Flight Medic has additional roles involved in the assessment and weighting of treatments given, the movement of the casualty in a stable manner best suited to the condition or physiological spectrum. The Flight Medic utilizes his or herself both within and outside the airborne environment, and is responsible for:

     

    • Guiding the helicopter,

    • Providing safe ingress points,

    • Halting any approach to the helicopter,

    • Providing helicopter security,

    • Taking initial charge of the Casualty Collection Point,

    • Triaging and clearing out non-medical persons,

    • Establishing Casualty Loading procedures, and, finally,

    • Working with Ground Medical Units to facilitate the handover and transport of casualties.

     

     

    Enjoy!

    The DRABCDs

     

    Note: The following modules are interchangeable, if you are a sole medic dealing with bleeding then that is the first area to attend. Swap them around and use them in a non-linear fashion. Memorize this as "Doctor ABCs", Doctor - alphabet.

     

    D - Danger

     

    Your initial approach must not endanger you or anybody else; you must therefore ensure it is safe to enter before beginning to assess the casualty. Danger indicators present must be assessed from afar, or away from the presenting danger. You have to observe and acknowledge the scene before first attempting to approach it.

       

    Subsequently to approaching the patient safely, you must determine the immediate priorities which include a sorting and assessment based on primary injuries as conducted through the primary survey. This is known as triage. A visual assessment may be conducted in time-critical moments but remember that it isn't as reliable in comparison.

       

    Danger examples include secondary explosives, incoming direct or indirect fire, linear danger areas and uncleared immediate areas. To understand the mechanisms of injury (MoI) is the single most important step. If you understand initially that an IED has went off, then you can understand the associated risks and protocols needed before you can approach the patient.

       

    Remember. Your own safety is the priority, followed by the safety of your allies who are not injured.

       

    R - Response

       

    The next observation you want to make is response, your patients response level. Unconsciousness is a state of unrousable unresponsiveness where the patient is unaware of their surroundings and no purposeful response can be obtained.

       

    We can use the sub-mnemonic AVPU. Alert, Verbal, Pain, Unresponsive. Is he alert? Move on. Does he respond to verbal? Move on. Pain pinch, does he respond to pain? Is he unresponsive? Yes or no. Re-assess the patient's response levels if noticeable vital signs changes are apparent or behaviours in patient condition, which is usually every ten minutes or so.

       

    And move onto your ABCs after certifying the patient’s response level. If he is unconscious and unresponsive it could be urgent, instantly move on and get to the vital category of airway.

       

    A - Airway

       

    Airway is the focus point.

       

    A patient cannot live without adequate oxygenation and ventilation. It is therefore apparent the first step to facilitate adequate oxygenation is to establish and maintain a patent (open) airway. If they're unconscious or unresponsive then it is vital what treatment you conduct in regards to airway, it could keep them oxygenated, it could keep them alive.

       

    Triple vs Double Airway Maneuver.

       

    You usually use the double airway maneuver with cases involving spinal precautions. Unless you have clear reason to, you should avoid a triple airway maneuver. Triple airway maneuvers are usually apparent in high-risk cases where the airway has to be established properly and urgently.

       

    We have numerous objects to be able to do this. The basics being the nasopharyngeal airway (NPA) and the oropharyngeal airway (OPA).

       

    B - Breathing

       

    This category comes after airway because it is directly related to it. If you establish an airway, it isn't any good if the patient isn't breathing!

       

    Breathing may include manual ventilation, initially breathing for the patient or support ventilation, supporting the oxygenation required to main adequate perfusion and oxygenation.

       

    We can conduct this initially through the airway assessment and placing our airway tools.

       

    C - Circulation

       

    A patient cannot live without blood!

       

    First, control any blood loss that is present. Then you can begin to compensate for the said blood loss. In most cases we are presented with, blood loss is apparent - sometimes major blood loss, including arterial bleeding with multi-trauma is presented. It is therefore vitally important you stop, prevent or slow down the rate of blood loss.

       

    Following this, you should check if the patient has a pulse, if they do not have a pulse, blood is not reaching their brain. This is generally detrimental to their health.

       

    Other meanings:

    /CPR

    /Controlling Hemorrhages

    /C-Spine Immobilization Manual or otherwise

       

    Your ABCs are the bread and butter of this whole mnemonic. Initially you will notice that C quite literally can stand for numerous priorities depending on the situation, so do not take this as an exact progressive way of conducting your assessment. If you see bleeding, jump straight to it, this mnemonic is modular for that purpose. Saving lives does not follow the same strict pattern.

       

    D - Drugs

       

    Judgement of drug use is not only initiated through observations of vital signs, patient history and redflags but through the physical assessment and investigation into the occurring factors and therefore what is needed from the pharmacological perspective of intervention. An example may include atropine during NBC events.

     

    /Defibrillation

    /Fluids

     

    CCP

    The Casualty Collection Point or CCP is

     

    Blood Sweep

     

    Find site injury (penetration site, injury site)

     

    Find bleeding site (Query)

     

    Point of injury, mechanism of injury

     

     

    The Casualty Assessment – The Primary Survey

     

    You arrive on the scene knowing very little to nothing. Yes, you may have witnessed the mechanism of injury but in most cases, as combat medics situated towards the back end of the organizational formation and/or the order of march, it is uncommon for this to be the case and therefore a critically apparent and essential skill to.

     

    DR-ABC-Ds

     

    Danger, Response - Airway, Breathing, Circulation, Drugs

    Consciousness level

     

    Your initial approach must not endanger you or anybody else; you must therefore ensure it is safe to enter before

     

    Subsequently to approaching the patient safely, you must determine the immediate priorities which include a sorting assessment based on primary injuries as conducted through the primary survey,

     

    Unconsciousness is a state of unrousable unresponsiveness where the patient is unaware of their surroundings and no purposeful response can be obtained.

    And move onto your ABCs by certifying the patient’s response level

     

    Airway

     

    Finalize first aid management

     

    Breathing/Bleeding

     

    Circulation

     

    The final D is for Drugs, and is to be administered only by those who are confident in what they are doing and medically aware of the consequences.

    If you are NOT a medic then calling for help should be included in this mnemonic towards the initial stages.

     

    Edited by Sarissa

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