COMBAT EMERGENCY MEDICAL SERVICES…ARE YOU CURIOUS…???!!!

Hi Guys…...............................!!!!!!!!!!!!!!!!!!!

Just in case you are wondering how Emergency Medical Service works in the war zones, here is my personal review…..so enjoy it.

War emergency medicine means just a simple foundation concept:

10-1-2;

10: Immediate life saving procedures must be applied within 10 minutes of wounding.

1: advanced stabilization manouvres must commenced within 1 hour of wounding (Enhanced field care).

2: if necessary Emergency war surgery must be performed within 1 hour but not later 2 hours of wounding.

How these numbers are fulfilled??!!

As in every military sector even war medicine requires a meticulous tactical planning, defining means and professional figures to be employed in specific theatres of operation.

This is how it works in Afghanistan:

Everything starts in the HOT ZONE (zone of fightings) where usually the wounding happens;

What can be done?!

Very few things!!! 

This is what we call “Care under fire”:

1) Respond to fire and search for fire cover; reach for the wounded only when possible… Heroism could be  rewarded just with two wounded instead of one!!!!  

2)Stop bleedings with combat tourniquet or compressive dressings, mantained by self aid if able.

3)Airway management is generally best deferred until Enhanced field care (EFC) phase.

4)Bring the wounded ASAP in the WARM ZONE for Enhanced field care(EFC).

Who perform these manouvres??!!

Bleeding control can be performed by the wounded himself; if uncounscious could be performed by a buddy ("Buddy to Buddy Aid") or the combat medic (a soldier trained in Immediate life support techniques, if present); usually there is one in every company.

In the WARM ZONE or semipermissive zone:

Personnel could be still threatened by indirect fire but Enhanced field care (EFC) manouvres can be put in place under cover;

What I mean for under cover:

The ideal would be  a true Company Aid Post, in reality  EFC is performed on the back of a tank or everything can provide protection from fire.

Who perform EFC:

It depends on the Nation: US army has specifically trained Medics and Paramedics, EUropean forces often have a nurse or a doctor on the field; 

Italian Army itself is implementing a new strategy: A rescue helicopter with a critical care Physician and nurse on board, already on area of operations; the aim of this strategy is to save the time between the call for a MEDEVAC and  the MEDEVAC itself, that,I guarantee,in Afghanistan could be very long; furthermore it allow advanced stabilization manouvres right on the field or straight during flight.

What does it mean Enanched field care (EFC)??!! 

In small words what we call Damage control resuscitation in the civilian setting; 

anyway battlefield is very different from an Highway or every other possible civilian scenario so also life support techniques allowed are different;

On the field (Tactical Field Care):

<C> catastrophic haemorragy control: If not yet performed bleeding control is essential: Combat  Tourniquet and compressive dressings.

A: open airways ; If the wounded is unconscious: naso-orofaringeal cannula or recovery position or SGA (Supraglottic airways - Usually the iGel) if airway obstruction. 

What about the Neck Collar??

In military setting Neck collar is kept just for victims of  Blasts and vehicles accidents.

B: Breathing problems and torso trauma??... we go straight to needle decompression and occlusive medication in case of of open or sucking chest wounds; SGA if necessary.

C: IV (Intravenous infusion line) or IO (Intraosseous infusione line), (In the last times we tend to go straight by IO); Thus TXA (Tranexamic Acid) and start Normal Saline infusion,following damage control resuscitation guidelines.

Every nurse or physiscan present on the field are trained to perform those manouvres; 

Anyway More advanced techniques could be performed whereas  critical care trained personnel is available and this usually happens just before or during trasport on MEDEVAC helicopters.

These advanced techniques usually are Emergency CRIC to control airways, finger thoracostomy for PNX; Italian MEDEVAC is implementing PENTAX VL intubation instead of CRIC, but evidences are still very few…

Some MEDEVAC service such the US one have 0-neg on board and can even start blood transfusions…..this is great stuff!!!!!

Surgical treatment:

Definitive surgical treatment not always can be performed between 2 hours of wounding in  an advanced medical facility (a role 3 Field Hospital)…To obviate this problem NATO forces invented FST (Forward surgical teams): Highly versatile operating rooms deployed in advanced military outpost, able to perform just damage control surgery; this strategy permits to gain time and transport patient to an  AMF (Advanced Medical Facility) for definitive treatment in a following time.

Usually an FST is manned by 20 - person team: 1 Orthopedic surgeon, 3 General surgeons,2 Anaesthetists or certified registered nurse anesthetists (CRNAs) 3 Registered Nurses, 1 administrative officer, 1 detachment sergeant, 3 licensed practical nurses (LPN)'s, 3 surgical techs and 3 medics. 

To sum up current War EMS organization is the result of experiences gained during the most recent  conflicts: IRAQ and Afghanistan and is constantly  evolving; 

endeed in next combat operations could become obsolete……Just Think to a war in a place where the enemy has air supremacy……Helicopter MEDEVAC that now is so important, in a moment could become useless…………..

…..Have a good day on the Edge and Bye Bye……..

References:

1, For debate: the Operational Patient Care Pathway

2, TCCC: Tactical Combat Casualty Care Guidelines

3, Emergency War Surgery: The Survivalist's Medical Desk Reference 
4, 21st Century Emergency War Surgery Textbook by the U.S. Army - Weapons Injuries, Triage, Shock, Anesthesia, Infections, Critical Care, Amputations, Burns, Specific Injury Treatment
5, First to Cut: Trauma Lessons Learned in the Combat Zone, Real-World Scenarios of Patient Care and Surgery, Valuable Advice for Surgeons (Emergency War Surgery Series)
6, Wilderness Medicine: Expert Consult Premium Edition - Enhanced Online Features and Print, 6e (Auerbach, Wilderness Medicine)