Battlefield Medicine

20140519-10

Arterial bleed controlled by a tourniquet

 

20140519-11

Practicing IV procedures in dark conditions.

 

20140519-12

This photo shows the back of an armored personnel carrier set up as an ambulance. Given that this vehicle is designed to withstand attack from rockets, much of the equipment is concealed from view.

 

A medical corps is generally a military branch or officer corps responsible for medical care for serving military personnel. Such officers are typically military physicians. Since 90% of combat 1) ___ occur on the battlefield before the casualty ever reaches a medical treatment facility, Tactical Combat Casualty Care (TCCC) focuses on training major hemorrhaging, and airway complications such as a tension-pneumonthorax. This has driven the casualty fatality rate down drastically since the Vietnam conflict to less than 9%. Today, TCCC is quickly becoming the standard of care for the tactical management of combat casualties within the Department of Defense and is the sole standard of care dually endorsed by both the American College of Surgeons and the National Association of EMT’s for casualty management in tactical environments. TCCC is built around three definitive phases of casualty care: 1) Care Under Fire; 2) Tactical Field Care; 3) Tactical Evacuation Care.

 

Combat medics (also known as medics) are military personnel who have been trained to at least an EMT-Basic level (16 week course in the U.S. Army), and who are responsible for providing first 2) ___ and frontline trauma care on the battlefield. They are also responsible for providing continuing medical care in the absence of a readily available physician, including care for disease and battle injury. Combat medics are normally co-located with the combat troops they serve in order to easily move with the troops and monitor ongoing health. An eight-year process to transform the training and skills of Army combat medics culminated recently, as all members of the old 91B Military Occupational Specialty (MOS) became qualified as 68W Healthcare Specialists. A group of past and present leaders of Army Medicine gathered at Fort Sam Houston, Texas, to celebrate this event. This Corp was originally established in 1887.

 

68W medics all qualify as emergency 3) ___ technicians. They are trained in advanced airway skills, hemorrhage control techniques, shock management and evacuation. All Soldiers in the new MOS must re-certify their skills every two years, and must earn 72 hours of continuing education credits during those two years. Retired Lt. Gen. James B. Peake, former Army surgeon general and former Secretary of the Department of Veterans Affairs, spoke recently, “When you see a Soldier without a leg, and with an external fixator on his other leg, and he says, ?I was lucky that day because I was with my medic in my vehicle, that’s why I’m here,’ that’s what it boils down to,“ Peake said. Peake began the process that led to the 68W MOS when he commanded the Army Medical Department Center and School. He discussed the process of improving training, adding simulation technology and re-engineering the second-largest MOS in the Army. “This was an opportunity to take medical care much farther forward than we had been able to before, with a higher level of technical enablement and skill,“ Peake said. Peake added that the process of improving training continues. “It is made better by continually listening to Soldiers, continually shaping the way that training is done,“ he said. “When you talk to those who have earned the Silver Star or the Distinguished Service Cross, and we’ve had those in medics, they say, ?I was just doing my job. I was just doing what I was trained to do,’“ he said

 

Soldiers of the 232nd Medical Battalion stage practice events, which demonstrate the 68W’s advanced ability to save 4) ___ on the battlefield. Soldiers portray a modern squad treating a thigh wound. The 68W quickly applied a Combat Application Tourniquet and prepared the casualty for evacuation by a Stryker armored ambulance. The 68W medic’s patient was well on his way to advanced care at a combat support hospital. On today’s modern battlefield, medical care has made remarkable strides in saving the lives of the wounded. Soldiers and Marines who would have perished in yesterday’s wars are returning home in spite of devastating injuries. Our troops are equipped to stabilize their own injuries and those of their buddies, even in the absence of medical personnel. Medics and corpsmen are armed with advances in technology as they emerge, and our experience helps set new standards of trauma 5) ___.

 

Front-loading definitive medical care at the point of injury makes obvious sense. The patient’s own well-oxygenated blood, circulating in a system of relatively intact blood vessels, is the gold standard of perfusion. Does it make sense to lie still on the battlefield, bleeding and yelling “Medic!“ when the means exist for the injured to stop his own bleeding? Does it make sense for the casualty with a patched-up circulatory system to arrive at the hospital without an airway, suffering from irreversible hypoxic 6) ___ injury? Of the many advances in battlefield medicine, some of the most beneficial are also the simplest. Consider the tourniquet. The military has adopted newer tourniquets, manufactured with a sturdy nylon strap and an attached windlass instead of a stick. Today, every soldier is issued this one-handed 7) ___ to apply to their own injured limbs, stopping the loss of blood before significant hemorrhage occurs. These are much quicker and simpler to apply than yesterday’s homemade strip of cloth and a stick foraged from the woods. When penetrating trauma with significant 8) ___ occurs, the combat medic approach is often defined by the simultaneous efforts of more than one EMT. In this arrangement, one rescuer might well be spared to do nothing but provide direct pressure, elevation and squeeze a pressure point, while others tend to the airway. In the case of the military medic, however, they’re often presented with multiple casualties, many of whom may simultaneously suffer from severe penetrating extremity trauma with uncontrolled hemorrhage and airway compromise. Battlefield triage differs as well: sometimes, it’s necessary to return the most troops to the fight as quickly as possible in order to prevent the loss of additional lives. It is sometimes necessary to treat and return the lesser-injured to the fight first, so that they may defend the medics, while they attend to the more serious casualties. There are even times when the combat 9) ___ may save the most lives by taking up his own weapons and jump into the fight personally. This is a vastly different proposition from the civilian EMT staging at a safe distance while law enforcement makes the scene safe. In this setting, rapid application of the tourniquet makes good sense. The newer tourniquets are quick to apply, and every soldier carries one. Even with a compromised 10) ___, patients can survive a brief hypoxic event. Most can survive for the time it takes to apply the tourniquet. In deciding whether to address airway or bleeding first, the significance of the injury is considered. While penetrating trauma to an artery may require the rapid application of a tourniquet, one is often not needed in the case of a slower venous bleed. If there are numerous critical patients awaiting medical attention, however, the tourniquet may be the quickest way to stabilize the patient with the venous bleed, permitting a medic to move on to the next case and ultimately save the most life.

 

An experienced U.S. medic recounts:

After a 20-year career in EMS, during which I went on to become a registered nurse and worked part-time in an emergency department, I was deployed to Ramadi, Iraq, as a combat medic with the Vermont National Guard. Aside from my weapons, I found my three most useful tools were tourniquets, the new trauma dressings with built-in elastic bandages, and my laryngoscope. The new one-handed tourniquets are designed to be used by the casualty, and every soldier has one. When I was in Iraq, however, we did not have these in sufficient quantity to use them frequently on other people. Instead, we used simple ratchet straps cut down to size. These are inexpensive and available at any neighborhood hardware store. While they require two hands to apply, they are effective at controlling bleeding and cheap enough to be disposable. My next favorite innovation was the “Israeli“ dressing, consisting of a thick gauze pad sewn into an elastic bandage. Developed and manufactured in Israel, it is remarkably effective, simple to apply and inexpensive to manufacture. The thick gauze is held tight to the injury by the attached bandage. The more significant the hemorrhage, the tighter the bandage is applied. There were other tools at our disposal. The simple tampon does a phenomenal job of stopping the bleeding in a bullet hole or stab wound. The Asherman Chest Seal comes with a flutter valve and is used for sucking chest wounds, with or without a 14-gauge IV needle to decompress a pneumothorax. In addition to the traditional IV catheters and tubing, the military medic carries a spring-loaded device called a FAST1 to initiate intraosseous infusions in the upper part of the adult sternum when venous access is impossible.

 

The fluids we carried were also different. Subscribing to the logic of controlled hypotension, we no longer ran large volumes of Ringer’s lactate wide open in every case of trauma. I carried equal quantities of normal saline and Ringer’s lactate, knowing the NS was compatible with blood products to be used later and more useful in managing heat casualties. Farther from the hospitals, medics might use heat-starch, a hypertonic starch-based solution designed to draw interstitial fluid into the circulatory system and keep it there longer, thus providing more effective fluid volume replacement per liter of IV fluid administered. This is especially useful when medics must carry supplies over long distances in rucksacks. Water is heavy. Then there was QuikClot, a powder that undergoes an exothermic reaction in the presence of 11) ___, effectively cauterizing wounds it’s poured into. We also carried HemCon bandages, which are fabricated from chitosan and designed to stop bleeding by adhering to wounds. Both of these tools were expensive, in short supply and we were concerned about potential complications such as burns and foreign-body emboli in the bloodstream.While we carried these tools for hemorrhage that couldn’t be controlled through other means, I never used either of them.

 

While control of major bleeding was an obvious necessity, it was also imperative to provide definitive and reliable airways. In the civilian sector, we might have enough medical personnel to spare a rescuer who does nothing but attend to the airway, but in combat this is not always the case. The combat medic often has to give the patient their best chance of survival and move on to the next casualty. Just as in the civilian sector, there are a variety of tools to accomplish that task.

 

Traditionally, medical personnel did not carry weapons and wore a distinguishing red 12) ___, to denote their protection as non-combatants under the Geneva Convention. This practice continued into World War II. However, the enemies faced by professional armies in more recent conflicts are often insurgents who either do not recognize the Geneva Convention, or do not care, and readily engage all personnel, irrespective of non-combatant status. For this reason, most modern combat medics are armed combatants who do not wear distinguishing markings.Combat Medics in the United States Army and United States Navy Hospital Corpsman are virtually indistinguishable from regular combat troops, except for the extra medical equipment they carry. The colloquial form of address for a Hospital Corpsman is “Doc.“

 

ANSWERS: 1) deaths; 2) aid; 3) medical; 4) lives; 5) care; 6) brain; 7) tourniquet; 8) hemorrhage; 9) medic; 10) airway; 11) blood; 12) cross

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