Download 9 Patient Scenarios - Prolonged Field Care

Patient Scenarios:
Below are seven scenarios we identified that would not only strain the skills and
preparedness of any SOF medic, they may even be difficult for the SRT to manage for 24 hours.
These scenarios seem well within the initial pre-hospital management capability of a SOF
medic, but could also result in serious complications if improperly managed for 24 hours. It
should be recognized that some of the below injuries that are more serious than
stated will likely result in the death of a patient in an “extended pre-hospital
management” environment. The goal is to take a patient who has self-triaged himself
as a “survivor,” and optimize his medical care so that he has the best chance of
recovery once he arrives at a hospital. Any of the scenarios could present in any of
the major AORs. These will be just as relevant for the 7th Group guys in Bolivia, or
the 1st Group guys in Papua New Guinea, as they are for the 10th and 3rd Group guys in
Africa.
Here are some “situational facts” that medics should keep in mind, and that these scenarios are
meant to reinforce:
1. In the world of Trauma, even within the best hospitals in the US, some patients die.
Trauma teams begin cases knowing that some patients are unlikely to survive certain
injury patterns. Shouldn’t medics be aware of those patterns, as well?
2. If you haven’t had “hands on” trauma experience, you cannot be expected to perform
exceptionally under the most stressful of circumstances. Shouldn’t there be more
emphasis on real patient contact? Live tissue is not a substitute for this.
3. If a US soldier in a remote site was sick or injured and required evacuation or 24 hours of
care, it would be a HUGE deal and would be visible all the way to the top, both medically
and tactically. Have we been provided all the necessary support to at least have a chance
of helping your mates? Does our chain of command know this is a problem?
4. 72 hours is not a realistic time to “sit on a patient”. An FST only has a 72 hour “hold”
capability by doctrine. How are you expected to do as much as an FST with a fraction of
the people, equipment, and skill?
5. When your mate is seriously hurt or sick in front of you in a remote setting, that is not the
time to figure it all out by yourself. Why do we train to be a lone trauma solution, when
reality points to a mandatory team solution and if comms are ALWAYS available, why
isn’t this an option?
6. These situations would be difficult for any Doctor or Surgeon to handle if they were
presented with a patient in the remote site by themselves. Why don’t we plan to engage
every possible avenue of help available, especially when civilian systems are available
for teleconsultation?
7. There is a HUGE difference between doing your best with a local national and doing
your best for one of your mates. If you didn’t call for help, would you be able to look the
family in the eyes and say you did your best? You may be very experienced in indig
medicine, but when it comes to US soldiers, you owe it to them to call for help.
8. If this patient was in the best hospital in the US, there would be a team of experts
handling this. Did you train your non-medical guys to function as your trauma team?
Will their first scenario be a crisis?
Common Evacuation Timeline for all scenarios: While in Africa (or wherever), patient
evacuation requires the team to contract a CASA 212 from 3 hours away, to land at their
location, and then to move the patient to a runway capable of landing U.S. military aircraft (i.e.
C-130/C-17) in the nation’s capitol, 4 hours away. It is estimated that it would take 12-24 hours
for a US Air Force plane to land, and it will likely not have any medical assets onboard. The
team will need to initiate care at their camp, prepare the patient for a 4 hour flight on the CASA,
and then wait for the C-17, which will then have a 9 hour flight to LRMC once mobilized.
Scenario 1: A U.S. service member sustains a GSW to the calf when the host nation soldier fails
to clear his weapon properly. The soldier had no tourniquet on the range and bled for
approximately 5 minutes. With vascular injury to the popliteal artery, the SOF medic can only
gain complete hemorrhage control with a well-positioned tourniquet, although the patient has
already lost a significant amount of blood. This patient may appear to be an easy TCCC case,
but consider how this can spiral out of control. Will the medic just give him two bags of hextend
and hope for the best, or will he resus appropriately to a decent UOP? Was he even going to
measure UOP? Does he remember how to put in a Foley? How will he decide whether or not to
transfuse him with FWB? How will he manage his pain for 24 hours? Will he be too aggressive
and snow him with Ketamine, or will he keep him awake and coherent with Morphine? Will he
call for help? Will he attempt to remove the TQ, or convert it to a wide band? What are the
metabolic consequences of a TQ in place for 24 hours straight?
Scenario 2: A U.S. service member sustains a mild TBI /Closed Head Injury from an ATV
crash (we have had three of these patients in the past four months). The patient had
a transient loss of consciousness, without any other significant associated injuries.
The patient complains of a severe headache, and the medic notices a decreasing
trend in GCS while waiting for evacuation. Does the medic have a strategy to secure
his airway without RSI medications? Does he know how to properly task his team to
help? Will he devote one person to watch the airway at all times? What is the plan to
keep the patient comfortable with his ET tube for the next 24? Will he call for help?
Will he remember the CPGs for management of the head injury? Does he know how to
properly trend a GCS?
Scenario 3: A U.S. service member sustains a Blunt LUNG injury from a fall from height.
The patient complains of rib pain, but no obvious fractures. Other than tachycardia,
the patient’s initial vital signs are within normal parameters. Four hours into the
situation, the patient has an obvious decrease in his pulmonary status (i.e. increasing
RR, decreasing SpO2, increase work of breathing, etc.). Will the medic opt to put in a
chest tube? When the chest tube does not help, what are his next actions? If he does put
in a chest tube, is he prepared to put one in properly with clean technique? Does he
know how to troubleshoot the tube? Is he prepared to intubate, and what medications
will he use? What will his report sound like if he calls for help?
Scenario 4: A U.S. service member sustains pelvic trauma secondary to a motor vehicle
collision. The patient complains of a severe pain and the medic opts to control his
pain with morphine, and now he is unaware of the decrease in mental status. As the
medic tries to check on his sleeping patient, the patient has a decreased loc, and does
not answer questions. Was the medic taught to treat pelvic trauma as a pelvic bleed
until proven otherwise? Taught to recognize the slight increases in diastolic BP and
changes in pulse rate? Is he trending vitals at all? If he would have put in a Foley, his
UOP would have shown less than 30ccs for the last few hours. Is he clear on the
indications to initiate FWB? Did he give TXA early? Did he call anyone for help?
Scenario 5: A U.S. service member sustains deep partial thickness burns to both arms
and the chest while burning the trash. Does the medic recognize this as a life
threatening burn requiring calculated fluid therapy? Does he understand that LR is
the fluid of choice? What is the pain control strategy for 24 hours? Is he ready to place
a Foley? Does he have a plan to measure UOP? Will he call for help?
Scenario 6: An ODA Team Sergeant complains of what seems like GERD but might be
chest pain. Is the SOF Medic aware of the red flags for Acute Coronary Syndrome? Does
the medic realize the importance of an O2 generator? Is he prepared to use any sort of
EKG and will he be able to transmit it via email? Does he have someone to call who is a
competent ACLS provider or will he attempt to manage this without help?
Scenario 7:
A Special Forces Engineer tried to take a crack at solving the Team house’s electrical problems
and received a massive electrical shock to his right hand. He presents visibly shaken, needing to
lie down, and breathing rapid and shallow. Does the medic understand electrical burn
pathology? Will he call for help? This patient will develop severe pain. Will the medic sedate
him and lose the ability to trend mental status, or choose to control his pain with opiates? Over
the course of 7 hours, the patient develops rhabdomyolysis. Will the medic monitor UOP and
does he know what rate to run fluids? The patient’s exit wound is in between his toes, will the
medic do a complete exam, and be suspicious of a developing compartment syndrome in his
lower leg? Will the medic be able to execute a fasciotomy?
Scenario 8:
Your senior medic presents with RLQ abdominal pain x 3 days, and is convinced that he does
not have appendicitis. You witness him sneeze while working at his computer and then wince in
pain and then guard his stomach. Has the medic been given clear guidelines for when to
consult? Will the medic defer to his senior medic? The next day, the patient feels the pain
completely subside and claims he is better. Four hours later the patient’s abdomen is tender to
palpation, although more generalized and the patient is not feeling well. What now?
These scenarios highlight how TCCC alone will not get a medic through a true extended prehospital management situation. If this occurred in a developed theatre, the above patients would
be quickly evacuated to a military treatment facility, and even a delay of up to four hours would
be manageable.