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Operational Casualty Care Course 2006 Introduction
LCDR Fermin S. Godinez Naval Medical Center Portsmouth Department of Emergency Medicine Portsmouth, VA 23708
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Course Overview Brief Introduction Course Schedule
Navy Health Service Support of US Marine Corps Forces Introduction of Guest Panel
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Administrative remarks
Contact information Logistics of work space Disclaimer Acknowledgements 3rd Force Recon Combat Course TC3 SOCOM Recommendations Prior deployed HM’s, 18D’s,& MO’s
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Casualty Care Course Jan/Feb 2006
Course Schedule Casualty Care Course Jan/Feb 2006 Monday-30 January Check in Welcome/Admin remarks CDR CailteuxZevallos LCDR Walters BREAK Course Introduction/Overview LCDR Godinez The Primary & Secondary Survey Airway/Breathing Management Working Lunch/Discussion Panel Prior Deployed NMCP personnel AIRWAY SKILLS STATIONS
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Introduction The standards of care applied to the battlefield have always been based on civilian care principals. These principals while appropriate for the civilian community often do not apply to care on the battlefield. The 90% Solution
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Introduction Civilian medical trauma training is based on the following principles: Emergency Medical Technicians (EMT-B,I,P) Basic Trauma Life Support (BTLS) Advanced Trauma Life Support (ATLS)
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Introduction Guiding principles of this course
1. Treat the casualty safely 2. Complete the mission "We must remember that one man is much the same as another, and that he is best who is trained in the severest school."--Thucydides, The History of the Peloponnesian War
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Iraqi/Enduring Freedom Full Spectrum Operations
Full Spectrum of Medical Support Katrina/Rita Somalia Iraqi/Enduring Freedom Disaster Response Humanitarian Assistance Terrorist Response Peace Keeping Major Conflict Homeland Defense Full Spectrum Operations El Salvador HA East Timor HA/PK Kosovo
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Forward Surgical Capability
Critical Care Gap Historical Route From Injury to Definitive Care Air Transportable Hospital (ATH) TACEVAC Evac Policy - 7 Days STRATEVAC 15 Days Field Hospital Battalion Aid Station Definitive Care CASEVAC 1 Day - 24 Hours - Field Hospital SX CARE Self Aid / Buddy Care Forward Surgical Capabilities Casualty Evacuation 1 Hour – SX CARE Definitive Care - 48 Hours - SX CARE Forward Surgical Capability
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Marine Corps Structure & Health Service Support Capabilities
LCDR Eric Timmens, MSC, USN DEPMEDS Manager, Medical Resources, Plans and Policy Division Chief of Naval Operations 11-16 January 2004 Marine Corps Structure & Health Service Support Capabilities
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Marine Air Ground Task Force (MAGTF)
Marine Expeditionary Force (MEF) 20-90K Major Theater War Brigade (MEB) 3-20K Smaller Scale Contingencies Unit (MEU(SOC)) 1.5-3K Promote Peace and Stability
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Core Elements to the MEF
Marine Expeditionary Force (MEF) Marine Division Marine Air Wing Force Service Support Group
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Health Service Support (Deployable Capability Sets)
Marine Division (Battalion) Battalion Aid Stations 2 Medical Officers and 65 Hospital Corpsman FSSG (Medical Battalion) Shock Trauma Platoons (STP) Surgical/STP(S/STP) Forward Resuscitative Surgical System (FRSS) Surgical Company Expeditionary Medical Facility (EMF)
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Health Service Support
Larger Footprint Echelon I Echelon III
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Ground Combat Element Echelons of Care I II +/- III FEBA BAS Level I
STP Level I III - 48 Hours - FRSS Surgical Company Level II Fleet Hospital Level III LHD CRTS
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MARINE DIVISION 2 MO'S/65 HM's INFANTRY BATTALION
H&S COMPANY WEAPONS RIFLE COMPANIES MEDICAL PLATOON - 1 MO = Battalion Surgeon - 1 MO = Battalion Aid Station (BAS) - 21 HM's = Battalion Aid Station - 11 HM's = Weapons Company - 33 HM's = Rifle Companies (3) 2 MO'S/65 HM's
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MARINE DIVISION - Division Surgeon - Medical Administrative Officer
MARDIV TANK BATTALION HEADQUARTERS ARTILLERY REGIMENT ASSAULT AMPHIBIOUS LIGHT ARMORED RECONNAISSANCE COMBAT ENGINEER INFANTRY REGIMENTS - Division Surgeon - Medical Administrative Officer - Environmental Health Officer - Division Psychiatrist - Enlisted Personnel Assistants
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FORCE SERVICE SUPPORT GROUP
FSSG HEADQUARTERS & SERVICE BATTALION MOTOR TRANSPORT ENGINEERING SUPPORT LANDING MEDICAL MAINTENANCE SUPPLY DENTAL
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FORCE SERVICE SUPPORT GROUP
FSSG HEADQUARTERS & SERVICE BATTALION MOTOR TRANSPORT ENGINEERING SUPPORT LANDING MEDICAL MAINTENANCE SUPPLY DENTAL - S-1 - S-2/3 - S-4 - S-6 - Preventive Medicine - Chaplain - Shock/Trauma Platoons (8) H & S COMPANY SURGICAL COMPANIES
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FORCE SERVICE SUPPORT GROUP
FSSG HEADQUARTERS & SERVICE BATTALION MOTOR TRANSPORT ENGINEERING SUPPORT LANDING MEDICAL MAINTENANCE SUPPLY DENTAL H & S COMPANY SURGICAL COMPANIES - STABILIZATION SECTION 2 - MO NC 1 - PA HM's - COLLECTING/EVAC 1 - NC USMC 7 - HM's 0 OR's; 10 COTS SHOCK/TRAUMA PLATOONS (8)
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FORCE SERVICE SUPPORT GROUP
H & S COMPANY SURGICAL COMPANIES FSSG HEADQUARTERS & SERVICE BATTALION MOTOR TRANSPORT ENGINEERING SUPPORT LANDING MEDICAL MAINTENANCE SUPPLY DENTAL - HQ Platoon - Triage/Evacuation Platoon - Surgical Platoon - Holding Platoon - Combat Stress - Ancillary Service (Dental Detachment)
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FORCE SERVICE SUPPORT GROUP
H & S COMPANY SURGICAL COMPANIES FSSG HEADQUARTERS & SERVICE BATTALION MOTOR TRANSPORT ENGINEERING SUPPORT LANDING MEDICAL MAINTENANCE SUPPLY DENTAL MC MSC NC HM USMC - 3 OR's; 60 COTS
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Forward Resuscitative Surgery System (FRSS)
Supporting Marine Corps Strategy 21 This afternoon it is my pleasure to tell you about the Forward Resuscitative Surgery System. This is the Navy’s newest operational medical system. It brings many clinical advances to the battlefield of today, in a light, mobile package. It successfully completed Field Warfighting Evaluation here under the direction of 1st Medical Battalion in July 01. Joel Lees CAPT, MC, USN I MEF Surgeon
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FORWARD RESUSCITATIVE SURGERY SYSTEM (FRSS)
Where does FRSS apply in echelons of HSS support? STP+FRSS ECHELON I ECHELON II ECHELON III ECHELON IV & V Buddy Aid BAS STP Surgical Company Casualty Receiving Ships Eg BHR, Iwo Jima Fleet Hospitals Hospital Ships Out of theater Medical Centers Echelons of care, also called levels of care in the Joint World reflect complexity of therapy available and nearness to the battle. Echelon II is to provide stabilizing surgery and the Surgical Companies ashore or the CRTSs, the casualty receiving and treatment ships afloat are aimed at that task. Echelon III, the Fleet Hospitals or Hospital ships, provides more definitive and final surgery and many who have had Echelon II surgery will have to “go back in” for a more definitive repair when the subspecialist, and more capable facilities are available. Echelon 4 is out of theater, where rehab and lengthy recovery periods can occur. Marine Health Service
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FRSS Footprint - 1700 Sq ft Post Op Beds Operating Room Pre Op Beds
Supplies Litters on Stands
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Capabilities UNIT OR’s ICU/ICW USMC FRSS 1 Shock Trauma Platoon (STP)
N/A 10 Surgical Company 3 w/ 2 tables each 20/40 Casualty Receiving and Treatment Ships LHA 4+2 15/45 LHD 17/47 LHA R MPF F Medical capability on 2 ships of a 6 ship squadron 6 38/83 LPD-17 1+1 6/18 Fleet Hospitals- EMF-500 80/420 EMF 116 2 20/96 EMF-10 Hospital Ship TA-H 12 80/400
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OIF Lessons Learned The EMF in a combat zone worked well, but
Need smaller, more mobile capability and advanced shelter technologies Logistics support far forward is problematic Digital Radiography should replace conventional radiography at all care levels Concept of employment proved flexible, sustainable and responsive to changing casualty needs 116 bed EMF and further expansion to 250 bed FH worked well as aeromedical Level III evacuation hospital
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OIF Lessons Learned-cont
Forward Resuscitative Surgery System worked well Highly successful far forward capability Anecdotally, no one exceeded the “Golden Hour” Logistics support far forward is problematic Ambulance support of rapidly maneuver combat units is a challenge Force Health Protection successes Immunizations and chem/bio identification capability Anecdotally, battle casualties exceeded DNBI
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OIF Lessons Learned-cont
Displaced person and enemy prisoner of war medical care Trauma more severe than most coalition force casualties Enroute care support and capabilities Not ideal in practice – needs some improvement and further analysis Component UICs and Tiered Readiness Worked as planned in all cases Enabled rapid personnel identification and response Greater emphasis required on Individual Medical Readiness
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Combat Trauma Lectures
Airway and Breathing Hemorrhage and Shock Extremity Trauma Thoracic Trauma Head Trauma Spine Trauma CASEVAC Procedures
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Combat Trauma Skills Labs
Airway Management Hemorrhage Control Splinting Intravenous Access Casualty Carries Chest Wounds Abdominal Wounds
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Battlefield Care is Improvised Care
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Introduction Simple important principles –
The correct intervention at the correct time. In combat, errors may lead to further casualties
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Introduction Pre-hospital care continues to be critically important
Up to 90% of all combat deaths occur before a casualty reaches a Medical Treatment Facility (MTF) Penetrating vs. Blunt trauma
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Factors influencing combat casualty care
Enemy Fire Medical Equipment Limitations Widely Variable Evacuation Time
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Factors influencing combat casualty care
Tactical Considerations Casualty Transportation
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Photo courtesy of HM3(FMF) McCLain
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Photo courtesy of HM3(FMF) McCLain
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Photo courtesy of HM3(FMF) McCLain
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Photo courtesy of HM3(FMF) McCLain
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Photo courtesy of HM3(FMF) McCLain
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STAGES OF CARE Care Under Fire Tactical Field Care
TCCC Care Under Fire Over the barrier/berm Tactical Field Care Combat Casualty Evacuation Care
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Care Under Fire “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 soldier or the medic in his aid bag.
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Tactical Field Care “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, 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 a MTF may vary considerably.
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Combat Casualty Evacuation Care
“Combat Casualty Evacuation Care” is the care rendered once the casualty has been picked up by an aircraft, vehicle or boat. Additional medical personnel and equipment may have been pre-staged and available at this stage of casualty management.
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Care Under Fire
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Care Under Fire Attention to suppression of hostile fire may minimize the risk of injury to personnel Minimize additional injury to previously injured personnel.
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Care Under Fire Wounded personnel who are unable to fight should lay flat and motionless if no cover is available or move as quickly as possible to any nearby cover
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Care Under Fire Medical personnel are limited and if your injured…….
No other medical personnel will be available until the time of extraction during the CASEVAC phase
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Care Under Fire Control of hemorrhage is important since injury to a major vessel can result in hypovolemic shock in a short time frame Over 2500 deaths occurred in Viet Nam secondary to hemorrhage from extremity wounds
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Care Under Fire Use of temporary tourniquets to stop the bleeding is essential in these types of casualties
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Care Under Fire The need for immediate access to a tourniquet in such situations makes it clear that all soldiers on combat missions have a suitable tourniquet readily available at a standard location on their battle gear and be trained in its use.
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Care Under Fire Penetrating neck injuries do not require C-spine immobilization. Other neck injuries, such as falls over 15 feet, fast-roping injuries, or MVAs may require C-spine control unless the danger of hostile fire constitutes a greater threat in the judgment of the medical personnel
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Care Under Fire Litters may not be available for movement of casualties. Consider alternate methods to move casualties such as a SKED® or Talon II® litter. Smoke, CS, and vehicles may act as screens to assist in casualty movement.
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KEY POINTS Try to keep yourself from being shot
Try to keep the casualty from sustaining any additional wounds Stop any life threatening hemorrhage with a tourniquet Airway as required Reassure the casualty
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Tactical Field Care
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Tactical Field Care The Tactical Field Care phase is distinguished from the Care Under Fire phase by having more time available to provide care. A reduced level of hazard from hostile fire. The times available to render care may be quite variable.
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Tactical Field Care In some cases, tactical field care may consist of rapid treatment of wounds with the expectation of a re-engagement of hostile fire at any moment. In some circumstances there may be ample time to render whatever care is available in the field. The time to evacuation may be quite variable from 30 minutes to several hours.
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Tactical Field Care If a victim of a blast or penetrating injury is found without a pulse, respirations, or other signs of life, Do Not attempt CPR Casualties with altered mental status should be disarmed immediately, both weapons and grenades
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Tactical Field Care Initial assessment consists of:
Tactical Assessment Airway Breathing Circulation
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CASEVAC Care
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CASEVAC Care At some point in the operation the casualty will be scheduled for evacuation. Time to evacuation may be quite variable from minutes to hours.
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CASEVAC
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CASEVAC Care The Hospital Corpsman may be among the casualties
The Hospital Corpsman may be dehydrated, hypothermic, or otherwise debilitated
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CASEVAC Care There may be multiple casualties that exceed the capability of the medic to care for simultaneously.
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CASEVAC Care Additional medical equipment can be brought in with the EVAC asset to augment the equipment of the HM. This equipment may include:
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Summary How people die in ground combat: 31% Penetrating Head Trauma
25% Surgically Uncorrectable Torso Trauma 10% Potentially Correctable Surgical Trauma
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Summary 9% Exsanguination from Extremity Wounds 1st
7% Mutilating Blast Trauma 5% Tension Pneumothorax 2nd 1% Airway Problems 3rd 12% Died of Wounds (Mostly infections and complications of shock)
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Summary Three categories of casualties on the battlefield
Injured personnel who will do well regardless of what we do for them Injured personnel who are going to die regardless of what we do for them Injured personnel who will die if we do not do something for them now (7-15%)
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REMEMBER If during the next war you could do only two things,
(1) put a tourniquet on and (2) relieve a tension pneumothorax then you can probably save between 70 and 90 percent of all the preventable deaths on the battlefield COL Ron Bellamy
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Summary Medical care during combat differs significantly from the care provided in the civilian community. Earl Wilson Courage is the art of being the only one who knows you're scared to death!
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Summary These timely interventions will be the mainstay in decreasing the number of combat fatalities on the battlefield. We Serve So Others May Live
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QUESTIONS ?? Earl Wilson Courage is the art of being the only one who knows you're scared to death!
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National Stock Numbers
One handed tourniquet Hextend® Fluid FAST 1® Emergency Trauma Dressing® HemCon Chitosan Dressing® Sked Litter® Talon II Litter®
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