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TACTICAL TRAUMA CARE

A 21^st century Approach

Compiled by: Brian C. Hartman

Resources: USASOCOM & NSW Conference Conclusions

Current Doctrine vs. Tactical Necessity & Obstacles

Doctrine for the U.S. Army Combat Medic is currently based on the principals of a Department of Transportation (DOT) Emergency Medical Technicians Basic course and the Advanced Trauma Life Support (ATLS). Unfortunately, ATLS was developed for physicians, not for combat medics. It is predicated on the idea that hospital diagnostic and therapeutic equipment is available, and most importantly, does not recognize the existence of the tactical combat environment. There is no provision or allowance for such factors as incoming fire, darkness, environmental factors (the casualty may occur in a swamp, in the snow, or in the surf zone), casualty transportation problems, long delays to definitive care, and the need to balance the management of casualties with the conduct of an ongoing combat mission.

Further complications may include the corpsman, medic or PJ being the first team member shot, while the individuals with the most severe wounds may not necessarily be the ones who should be treated first. Also, civilian equipment is often an unavailable luxury. Standard litters for patient transport are not carried into the field on many direct action Special Operations missions because of weight and bulk. Transport of the patient is accomplished with a shoulder carry or improvised litter. This works reasonably well when the casualty weighs 150 pounds and the rescuer weighs 250 pounds, less well when the roles are reversed. The contest becomes mission vs. welfare vs. situation vs. reality.

Corpsmen, medics and PJ's must be aware of the fact that good medicine can sometimes be bad tactics and that bad tactics can get everyone killed or cause the mission to fail. A medically correct intervention at the wrong time in combat may lead to further casualties.

The risk of injury to other personnel and additional injury to the previously wounded troops will be reduced if immediate attention is directed to the suppression of hostile fire. The medical personnel may therefore initially need to assist in returning fire instead of stopping to care for the casualty. The best medicine on any battlefield is fire superiority. Therefore the casualty should do everything in their power to continue to return fire if possible.

Tables

How People Die in Ground Combat

Preventable Causes of Death on the Battlefield

1. Bleeding to death from extremity wounds (60%)
2. Tension pneumothorax (33%)
3. Airway obstruction (maxillofacial trauma) (6%)

Phases of Care

Care Under Fire is the care rendered by the medic at the scene of the injury while he and the casualty are still under effective hostile fire. Available medical equipment is limited to that carried by the individual soldier, corpsman, PJ or medic in his aid bag.

Tactical Field Care is the care rendered by the medic once he and the casualty are no longer under effective hostile fire. It also applies to situations in which an injury has occurred on a mission, but there has been no hostile fire. Available medical equipment is still limited to that carried into the field by medical personnel. Time to evacuation to an MTF may vary considerably.

Combat Casualty Evacuation Care (casevac) is the care rendered once the casualty has been picked up by an aircraft, vehicle, or boat. Additional medical personnel and equipment that has been pre-staged in these assets should be available at this stage of casualty management.

Exsanguinations & Battlespace Tourniquet Applications

Injury to an artery or another major vessel may result in the very rapid onset of hypovolemic shock and exsanguinations (bleeding to death). Lack of hemorrhage control is the leading cause of preventable death on the battlefield. Hemorrhage control is therefore of paramount importance. This may include the use of temporary tourniquets.

Although ATLS discourages the use of tourniquets, they are appropriate in this instance because direct pressure is hard to maintain during casualty transport under fire. Ischemic damage is rare if left in place for less than 1 hour, and tourniquets are often left in place for several hours during surgical procedures.

As non-life-threatening bleeding should be ignored until the tactical field care phase, it is important to know the distinction between venous and arterial bleeding:

Arterial. Blood vessels called arteries carry blood away from the heart and through the body. A cut artery issues bright red blood from the wound in distinct spurts or pulses that correspond to the rhythm of the heartbeat. Because the blood in the arteries is under high pressure, an individual can lose a large volume of blood in a short period when damage to an artery of significant size occurs. Therefore, arterial bleeding is the most serious type of bleeding. If not controlled promptly, it can be fatal.

Venous. Venous blood is blood that is returning to the heart through blood vessels called veins. A steady flow of dark red, maroon, or bluish blood characterizes bleeding from a vein. You can usually control venous bleeding more easily than arterial bleeding.

The following points are emphasized about tourniquets:

1) Damage to the extremity is rare if the tourniquet is left in place less than an hour.

2) Tourniquets are often left in place for several hours during surgical procedures.

3) In the face of massive extremity hemorrhage, in any event, it is better to accept the small risk of ischemic damage to the limb than to lose a casualty to exsanguinations.

4) Both the casualty and the corpsman/medic are in grave danger while a tourniquet is being applied during the Care under Fire phase, so non-life threatening bleeding should be ignored until the Tactical Field Care phase.

5) If applied, the tourniquet should be applied as close to bleeding site as possible.

6) The time of application should be noted; and

7) They should be removed when feasible.

All special operators on combat missions must have a self-appliable

tourniquet readily available at a standard location on their battle gear

and be trained in its use.

Spinal Immobilization

In civilian trauma care, immobilization of the spine, and boarding of patients is a standard practice limited not only to impact injuries & falls, but gunshots, stabbings etc. Unfortunately, the special operations combat realm does not always allow for the time and number of personnel needed to properly stabilize a victim… especially if the unit is still under fire, assaulting or repelling an assault.

Mission commanders must rapidly assess the type of injury incurred and how this affects the need for immobilization, versus drop in volume of potential firepower due to occupation of rescuing personnel.

Thus it is crucial to note that in Vietnam only 1.4% of patients with penetrating neck injuries would have benefited from immobilization of the cervical spine. This data makes a strong case for spontaneous drag out's of gunshot victims if the reduction in firepower will not threaten the remainder of the team, or the mission (and team by proxy). Yet it is still recommended that parachuting injuries, fast-roping injuries, falls greater than 15 feet, and other types of trauma resulting in neck pain or unconsciousness should be treated with spinal immobilization unless the danger of hostile fire constitutes a greater risk in the judgment of the medic.

It is also worthy to note that an unrealistic expectation exists amongst many as to the effectiveness of cardiopulmonary resuscitation. Attempts to resuscitate trauma patients in arrest have been found to be futile even in the urban setting where the victim is in close proximity to trauma centers. On the battlefield the cost of attempting to perform cardiopulmonary resuscitation on casualties with what are inevitably fatal injuries will be measured in additional lost lives as care is withheld from patients with less severe injuries, and as medics are exposed to additional hazards from hostile fire because of their attempts.

Simply put, the tactical situation may or may not allow medical care to proceed. Medical care may solely consist of throwing a patient into a ground vehicle or helicopter and evacuating in extremis.

Scenario Based Training

"We must also have the intellectual agility to conceptualize creative, useful solutions to ambiguous problems....This means training and educating people how to think, not just what to think."

Gen. Peter Shoemaker (Chmn. JCS)

In the realm of small unit special operations, casualty scenarios typically present tactical as well as medical problems

Training only combat medics in tactical medicine is not enough. If tactical medicine involves complex decisions about both tactics and medicine, then we must train the tactical decision-makers - the mission commanders.

The realization that no single plan is optimal for all situations, led to the concept of scenario-based management plans. Scenarios chosen for discussion with mission commanders are ones that are thought to have a relatively high probability of occurring, have already occurred, require a difficult tactical/medical decision, or that require a major departure from standard civilian practice.

There are only two times that you can plan for what to do in a tactical casualty situation - before it happens and after it happens. That being said, it is still crucial to remember that any management plan for a combat casualty discussed in the planning phase should be considered advisory rather than directive in nature, since only infrequently will an actual tactical situation unfold exactly as planned.

Potential scenario based questions should include but not be limited to:

• Should the medic shoot first & treat later or should he treat immediately?
• Did the casualty occur during insertion, execution or extraction, & should/ can the mission continue?
• Should the casualty be moved to cover before treating?
• Should the medic immobilize the spine or move to cover immediately?
• Should this casualty have an IV started?
• Should the casualty receive immediate fluid resuscitation?
• What is the prognosis for the casualty if he has to wait 30 minutes for evacuation instead of being evacuated immediately?
• Are there concealment or defensive techniques (smoke, diversions, etc) that could be used in this scenario?
• Are there area denial techniques that could be used effectively in this scenario?
• What changes could be made in the gunfire support plan to make gunfire support more effective?