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You cease to be effectively under hostile fire once you achieve fire superiority. At that point, you are able to switch from delivering either Care Under Fire or casualty self-care to administering tactical field care.
If you didn't read Part 1: Care Under Fire please go ahead read it first.
What’s in this blog post
This post discusses the various ways and steps in priority that medical personnel can do a better job of saving lives in combat. This post also describes what should be considered the standard of care for tactical field care.
- Tactical Field Care
- MARCH Algorithm
- M - Massive bleeding
- A - Airway Management
- R - Respiration
- C - Circulation
- H - Head injury/Hypothermia/Hypovolemia
- PAWS
- P - Pain
- A - Antibiotics
- W - Wounds
- S - Splints
- The Enemy Combatant
- Conclusion
The hostile situation in which you find yourself can change in an instant, so don’t fool yourself into thinking you’re out of the woods when your team has achieved fire superiority or the other team’s weapons have fallen silent.
So be careful.
Before you start taking care of your casualty or casualties, make sure your place is secure.
- Maintain a 360-degree safety perimeter. Then begin triaging the casualties as needed.
This is the next stage of combat casualty care (COTCCC,the Committee on Tactical Combat Casualty Care) developed many of the care concepts presented here).
In this next stage of combat care, you should consider putting on latex gloves—before, during the firefight, there wasn’t time or opportunity to be concerned about minimizing infection risk; but, now, there definitely is.
Also, if you think the situation is bad because your casualty isn’t looking great (perhaps because of an unobvious massive hemorrhage), then you should listen to your “Spidey senses” and call for a MEDEVAC/CASEVAC ASAP.
And, whatever you do, don’t cling to this trauma care manifesto like its your bible—if you think your patient needs, for instance, a pericardial thumb, well, just do it.
Do everything within your power to help him.
- Tactical field care begins in earnest with the redistribution of resources (if that hasn’t already happened during the Care Under Fire stage).
For example, let’s say our guy is carrying sensitive mission items. You know, things like a portable communications system.
Sensitive mission items need to be placed in safe hands so that the casualty whose mental status might be messed up as a result of his injury doesn’t do something stupid, like calling in an airstrike on us (or something else equally demotivating to our team).
Similarly, we really don’t want him holding onto his weapon and grenades after dosing him with painkillers that make him high as a kite.
Besides, the weapon and grenades taken from him can be given to the security detail so they’ll have more ammo available for defending the perimeter.
- But here’s food for thought. Rather than strip the casualty of his weapon, you might leave it with him after you remove the magazine (plus the others in his pouches) and clear the chamber.
Letting him hold the emptied weapon can be psychologically helpful.
Specifically, it can give him hope, which is a powerful thing. After all, our casualty is still a warrior and he wants to help us. He doesn’t want to feel that he’s a liability or exposing the team to danger because of his injuries.
What about if you find a casualty who’s suffering polytrauma?
That, in plain English, means our guy is really fucked up—has no pulse, no respiration, no other vital signs. Him we do not resuscitate. Him we attempt no CPR on.
The reason is that we aren’t going to be successful saving him, and the effort to do so is going to take too many people away from the fight (which can result in many more casualties).
But the flipside is you have to be Semper Gumby—Always Flexible.
So, if you’re there on an evacuation platform, go ahead and do CPR (provided you have the ability, which you probably do, since you have hands, right?).
In this situation, doing CPR is proper because you’re supposed to do everything in your power to try and save him.
- The real work of tactical field care begins with an assessment.
For this task we use the MARCH PAWS algorithm.
MARCH stands for:
- Massive bleeding
- Airway management
- Respiration
- Circulation
- Head injury/Hypothermia/Hypovolemia
- Pain
- Antibiotics
- Wounds
- Splints
MARCH ALGORITHM
M — MASSIVE BLEEDING
Picking up where you left off during Care under Fire, go straight into a reassessment of how well you’ve controlled any hemorrhaging.
Check to see if the tourniquet is still holding or if he needs another (if another is needed, apply it side-by-side with the first one; skinny guys often need two TQs).
On the chance that you’ve not yet done anything, look for signs of massive bleeding. When you see such signs, apply a tourniquet, positioning it high and tight.
- If you can't control bleeding with a CAT, use a hemostatic agent.
Examine the casualty again and look for missed major bleeding in especially critical areas such as the neck, armpits, and groin.
Don’t forget to keep talking to the casualty throughout the entire process.
This is how you evaluate his degree of consciousness.
Moreover, him talking to you means his airway is patent/open—and if he’s making sense as he speaks, it means his brain is getting adequate blood/oxygen (a good indication that he’s not at the moment experiencing hemorrhagic shock).
Degree of consciousness—AVPU
- A – Alert: awareness of time and place
- V – Verbal: responds to your words
- P – Pain: reacts to it
- U – Unresponsiveness: no reaction to stimuli
As mentioned earlier, you need to disarm a casualty whose injury has caused him to enter an altered mental state (such as going out of his mind with delusion or psychosis), redistribute his sensitive items, and relieve him of his radio in order to prevent harm to others on your team.
A – AIRWAY MANAGEMENT
Assume you’ve got a casualty who’s not talking.
In that case, open his airway, look into his mouth, clean it, and listen for the sound of breathing.
Also, while you’re listening, look at his chest and note whether it rises and falls (signs of inhalation and exhalation). Stay on his breathing for at least 5 to 10 seconds (in other words, don’t just robotically run through the drill).
- In the event the casualty is unconscious, you’ll need to secure his airway.
Typically, this is accomplished by tilting his head back and keeping his chin lifted (this positions holds open the airway).
Alternatively, you can use a recovery position or give him an NPA (if you opt for an NPA, don’t forget to tape it down to his face, otherwise it’ll likely slip out—and don’t worry about the slight 1 percent or 2 percent chance of poking his brains with that NPA if his head’s split open since it’s far worse for him to be without a patent airway).
Let’s say our guy is awake and can’t breathe because you’re doing what you were taught in medic school and that is to try rolling him over onto his back.
What you should do instead is allow him to take any position that helps him breathe.
For example, a casualty with facial trauma and bleeding into his mouth or nose may be better able to maintain his airway by sitting up and leaning forward—avoid forcing him to lay down since that’s only going to cause all the blood and saliva to pool up in his airway.
Unconscious casualty with an airway obstruction
- Head tilt, chin lift
- NPA
- Recovery position
- Head tilt, chin lift
- NPA
- Allow the casualty to take any position that helps him breathe
- Recovery position
Expose the chest, then look for wounds and for indications that your guy is still breathing (note that stress can prevent you from hearing or seeing him inhaling/exhaling, so place your hands on his chest and feel for signs that respiration is occuring).
Apply an occlusive dressing to all wounds you find on the chest, armpits, and neck (rule of thumb: “from the nose to the hole deserves an occlusive dressing, why to the hole because the diaphragm moves so low”).
- Don't be afraid to let go. Use both hands for faster application.
- As you place the occlusive dressing, listen for any sucking or blowing sounds.
If you don’t put a halfway valve over the hole, make a mental note that you’re probably also going to have to do an NCD (or at least burp the wound).
Carefully check for broken clavicle, sternum, and ribs, but don’t press down like a maniac if you see discoloration or evidence of bruising in those areas.
Check his back by using the “buddy hug” technique—and while you’re at it you should also perform a minor check for any downside wounds.
Be on the lookout for a tension pneumothorax if your guy has an abdominal/chest wound.
- Remember that rule of thumb about how the diaphragm tends to move quite low.
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