combat ems med csec 2010 slides
DESCRIPTION
Bringing Combat Medicine to the Streets of EMS MAJ Will Smith MD EMT Paramedic US Army Telluride Colorado Emergency Medical Technician Medic HealerTRANSCRIPT
BringingCombat Medicine
to the “Streets of EMS”
MAJ Will Smith MD, EMT-P
US Army www.wildernessdoc.com
June 11, 2010CSEC
Telluride, CO
Disclaimers
• No financial conflicts to disclose
• Board of Advisors for Chinook Med
• Volunteer Position - sample products
• This presentation is NOT an official position or endorsement from the United States Department of Defense/US Army
Objectives
• Briefly describe military tactical combat casualty care (TCCC)
• How to apply what we learn between austere environments (EMS?)
• Discuss products and protocols that should be adopted into EMS patient care
My Experience
• EMT - Basic 1990
• EMT- Intermediate 1992
• EMT - Paramedic 2005
• MD - 2001
• Emergency Medicine - 2004
My Experience
• Joined Army Reserve - Sept 27, 2001
• Deployments
• Iraq - Dec 2005 to Mar 2006
• Egypt - Oct 2007 to Nov 2007
• Iraq - Oct 2008 to Jan 2009
• El Salvador - Sept 2009
• Panama - April 2010
TCCC
Butler, et. al. Military Medicine 2006
• Tactical Combat Casualty Care - 1996
“Conventional civilian medicine was not appropriate for optimizing casualty care within the tactical environment.”
Levels of Combat Care
• Combat Lifesaver Skills (CLS)
• Rapid casualty assessment (Triage)
• Control hemorrhage
• Treat penetrating chest trauma
• Maintain BLS airway
• Initiate saline lock and IVF (Removing?)
• Package casualty for transport
Levels of Combat Care
• Medical Treatment Facilities (MTF)
• Level 1 - BAS
• Level 5 - CONUS
Rural Clinic to Trauma Center
Care Under Fire
• Return fire
• Provide basic care
• Stop bleeding (TQ)
• Move patient to CCP (if safe)
Scene Safety
Tactical Field Care
• No longer under direct fire
• AVPU
• Airway, Breathing
• NPA
• Recovery position (on side)
• Rescue breaths
Tactical Field Care• “Tourniquet First” for
extremity bleeding
• Use other methods as needed
• Direct pressure
• Pressure bandages
• Hemostatic agents
• Forget Pressure Points and Elevation!
Last Resort or First Choice?
Tactical Field Care
• IV Fluids
• Radial pulse - Saline Lock
• No Radial - 500 ml Hextend
• 30 min - No Radial - 500 ml Hextend
Limited Resources
Tactical Field Care
• Splint obvious fractures
• Combat Pill Pack• Acetaminophen (Tylenol)
• Meloxicam (Mobic - NSAID)
• Gatafloxacin
Early Field Antibiotics
Combat TACEVAC
• TACEVAC - Tactical Evacuation
• CASEVAC - Casualty Evacuation
• MEDEVAC - Medical Evacuation
!
Combat Medic
• Narcotics
• Morphine Auto-Injectors (5-10 mg)
• ACTIQ - ‘Fentanyl Pop’
• Intranasal Ketamine
• Narcan, Fentanyl
• Versed, Glucagon
Bleeding Control
• Direct Pressure
• Elevation (above heart)
• Pressure Points
• Tourniquet (LAST RESORT)
Old Algorithm
“Hemorrhage due to penetrating trauma is the leading cause of preventable death during military operations” Butler, JEMS 2008
What makes a good TQ?
• Width >1”, Mechanical arm (cam)
• Easily application (<60 sec)
• Self-applied, adjustable, non-slip
Harmful effects of Granular Clotting Agents
• Kheirabadi, J Trauma 2009
• Exothermic local effect of complete vessel occlusions (injured and surrounding)
• Embolic events (PE/Stroke)
Hypothermia Kills
• Even in Iraq, 18% of pts arrived T<36C (96.8F)
• Temps in critical trauma pts < 34C (93F) = near 100% mortality
Summary
• “Tourniquet First” for severe extremity bleeding
• Adapted protocols for EMS and Tactical Settings
References
• The War on Trauma, Lessons Learned from a Decade of Conflict. Supplement to JEMS October 2008, sponsored by North American Rescue, Inc. Download at: www.NARescue.com
• War Surgery in Afghanistan and Iraq. A series of cases, 2003-2007. Ed. Nessen, et. al. 2008. Office of the Surgeon General.
References
• Combat Lifesaver Course: Student Self-Study Guide. Subcourse IS0871, Edition B. Army Institute for Professional Development. Ft. Sam Houston, TX.