In the tactical environment, a tactical medic may be the only care provider able to assist a working dog that has been injured. The goal of the following article is introduce medics to common problems associated with working dogs in a tactical environment. In addition to this article, medics ought to find a veterinarian that has experience with working dogs and work with them to become more familiar with anatomy and what is “normal” for canines, as well as become comfortable working with them.
The following article is from the Journal of Special Operations Medicine, vol. 7, edition 2, pg 33-47.
Bombs aimed at civilian populations are the most common
weapon used by terrorists throughout the world. Over the last
decade, we have been involved in the management of more
than 20 mass casualty incidents, most of which were caused
by terrorist bombings. Commonly, in these events, there may
be many victims and many deaths. However, only a few of the
survivors will suffer from life-threatening injuries. Appropriate
and timely treatment may impact their survival. Due to the
complex mechanism of injury seen in these scenarios, treatment
of victims injured by explosions is somewhat different
from that exercised in blunt and penetrating trauma from
other causes. The intention of this article was to outline the
initial medical treatment of the injured victim arriving at the
emergency department during a mass casualty incident
caused by a terrorist bombing. Treatment protocols for stable,
unstable, and in extremis patients are presented.
In a previous entry, we discussed improvising in the field and demonstrated a method of creating a scalpel handle out of its wrapper. This entry will focus on the safety pin and several of its uses. It’s always a good idea to have 4 or 5 of these in your kit. They can be used to solve many medical and non-medical problems. They are inexpensive, don’t expire, and take up hardly any space.
Here is a list of a few things you can do with a safety pin:
-Pin the tongue to the lip to maintain the airway
-Splint a finger
-Make a sling out of a casualty’s shirt
-Close abdominal wounds or large lacerations
-Make a tracheal hook
-Secure an ET or Cric tube.
Like most improvised medicine, these techniques are not definitive treatments, but in certain situations you may not have any other option. You can never carry everything, so knowing how to employ items you have can be a life saver…literally.
A new training company is offering a course in Florida for those interested in attending. The company is formed of current and former Military and LE personnel. Here is an excerpt from the course flyer and a link:
Sign up today for an intensive program geared towards the certified Tactical Medic Provider. This 24hr course over 2 days will provide you an opportunity to evaluate your current skill level in both the medicine and tactics involved in SWAT missions.
This study was designed to identify the most effective underbody
position when using the patient’s own body weight as an
infusion device. Twenty volunteers had an air-less 500ml bag of
saline located at various under-body positions. Mean pressures
and flow rates through a 14G cannula were measured in vitro at
room temperature. Locating the fluid bag at the buttock cleft
delivered the highest mean flow rate at 135ml/min. This underbody position may provide flow rates sufficient to achieve the clinical aim of fluid resuscitation in the military pre-hospital
environment.
A dictum of tactical medicine is to carry equipment that has dual use. In the case of fluid infusion, medics are instructed to use their blood pressure cuffs or the patient if no other device is available. Medics have the option of carrying pre-made fluid infusers or an extra BP cuff, but the former violates the rule of dual use and the latter may be too bulky. The above article offers a valid, though not new, solution, because it explores the best location if a medic chooses to use the casualty.
This video is a supplement to training and is neither comprehensive nor a replacement for proper instruction.
A surgical airway/cricothyroidotomy is the advanced airway of choice in combat, due to the types of injuries encountered. Severe maxofacial trauma secondary to blasts are common and may require more invasive treatment when neither the recovery position nor NPA nor King Oropharyngeal Airway (King-LTD) will suffice. It is important to note that only airway management is generally best left to the Tactical Field Care (TFC) phase of treatment. Furthermore, less than 1% of trauma casualties require an airway, so prudence is required when deciding to intervene. The indications and contraindication are as follows:
Indications:
–Airway obstruction due to maxillofacial trauma that cannot be corrected by positioning or a nasopharyngeal airway
–Anaphylaxis that is or is about to compromise the airway
–Inhalation burns injury
–Where other means to secure the airway have failed
Contraindications:
–Airway can be maintained by other means
Please note that we illustrate a vertical incision instead of the traditional horizontal, because we feel it is the preferred method in the tactical environment. First, a vertical incision minimizes the risk of involving (e.g., cutting) the vascular structure of the neck. Second, it creates a larger “window,” thereby simplifying landmark identification. Finally, a vertical incision allows one to select a different location above or below the initial site, if one should misplace the initial cut, due to lack of familiarity with the procedure.
Below you will find an article published in Military Medicine. It argues that traditional ways of providing a surgical airway in a tactical environment are flawed. Therefore, the authors continue, a new approach is needed. Three-step Cric
Objective: Surgical cricothyroidotomy is the airway of choice in combat. It is too dangerous for combat medics to perform orotracheal intubation, because of the time needed to complete the procedure and the light signature from the intubation equipment, which provides an easy target for the enemy. The purpose of this article was to provide a modified approach for obtaining a surgical airway in complete darkness, with night-vision goggles. Methods: At our desert surgical skills training location at Nellis Air Force Base (Las Vegas, Nevada), Air Force para-rescue personnel received training in this technique using human cadavers. This training was provided during the fall and winter months of 2003-2006. Results: Through trial and error, we developed a “quick and easy” method of obtaining a surgical airway in complete darkness, using three steps. The steps involve the traditional skin and cricothyroid membrane incisions but add the use of an elastic bougie as a guide for endotracheal tube placement. We have discovered that the bougie not only provides an excellent guide for tube placement but also eliminates the use of additional equipment, such as tracheal hooks or dilators. Furthermore, the bevel of the endotracheal tube displaces the cricothyroid membrane laterally, which allows placement of larger tubes and yields a better tracheal seal. Conclusion: Combat medics can perform the three-step surgical cricothyroidotomy quickly and efficiently in complete darkness. An elastic bougie is required to place a larger endotracheal tube. No additional surgical equipment is needed.
When planning for a mission, a medic must pack relevant equipment that reflects the highest percentages of injuries he could face (e.g, splinting material for air ops) . More important, medics must pack in accordance with the priority of treatment. That is to say, medics ought to pack their gear in three levels.
Level 1:
Level 1 equipment is needed for life threatening injuries. It ought to be carried on your person. For example, tourniquets, bandages, NPAs, etc, are needed to prevent death from the high-percentage killers. These items ought to be carried in IFAKs (your personal as well as your operators’), in leg-rigs, or on your vest. Accessibility is key, especially if you are going to use the equipment in the CUF phase. Also, medics must train to use the casualty’s equipment first, so he does not exhaust his equipment too rapidly. This requires operators to carry their own gear, not rely on the medic to carry it for them. Finally, do not use your personal first-aid kit unless absolutely necessary.
