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11/11/2013
Military Medicine
Battlefield Concepts
Dane S. Harden
COLONEL - SP
Senior Flight Surgeon
U.S. Army
Military Review
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Anewetak, Marshall Islands, South Pacific (Sapper Team Operational - 1978)
Tallinn, Estonia - Medical Contact Team 20th GRP – 1994.
Atlanta, Ga., Olympic Games (SOC/NG 1996) – bombing response.
Georgia Disaster Response 20th Grp 1998-1999
Camp Bondsteel, Kosovo KFOR/NATO 2000-2001
Camp Comanche, Eagle Base, Bosnia-Herzegovina SFOR/NATO 2001
Port of Kopar, Slovenia FS - NATO 2001 – 3rd Inf. Div.
Taborfalva, Hungary FS - NATO 2002 – 3rd Inf. Div.
Bagram AFB, Kabul Afghanistan SFS - 10th Mt. Div. 2003-2004.
Iraq CFLCC 2004-2005 - 3rd Army and 5th Grp. AVN.
Hurricane Katrina - SOC 2005 - Search and Rescue - 20th Grp. AVN.
Dominican Republic - SOC 2007 5th Grp. AVN.
Republic of Georgia – Tbilisi - 2008
Deputy Commander – MEDCOM (2011 to Present).
Purpose
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A basic review and discussion of the interrelated
lessons learned in military medicine - as they
relate to changes in the combat and operational
environments. TCCC principles and a review of
the current tactical pain control guidelines.
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Goal
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At the end of this block of instruction you
should have a better understanding of the subtle
differences in managing patients in wartime
operations, peacekeeping missions, state and
local disaster operations.
Introduce new concepts in tactical battlefield
care and our approach to pain control.
The Past…The Future…
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Ancient
Middle Ages
Colonial
Civil War
Transitional
Modern
Technological future
History
Gates of Baghdad
Ancient Minaret
Propaganda
an ancient tool
Royal Palace
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A Shamal…or Haboob…Sand Storms were written about by Alexander…Operation Environment
Gates of Babylon
Udais’ Palace on the Euphrates River
Historical Perspectives…
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Middle Ages…the Byzantine Empire around the
Fourth Century A.D. preserved the Roman System.
Islamic Empire increased the medical knowledge base
by assimilating the useful practices of conquered
territories.
Feudal Europe around A.D. 800, Charles the Great
(Charlemagne) created a loose confederation that used a
standing Army and military medics in units. It would
last until the fifteenth century!
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Castle DuleGrad near Austro-Hungarian border
…we flew over this area during the Balkans
war…this castle was used as a Hospital when
it was taken by the Moors in the 1400 Century.
Entrance to DuleGrad
Castle during SFOR-9
Historical Perspectives…
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The Moors created mobile hospitals…later
copied by the Spanish in 1453.
Then came “gunpowder” and the nature of War
changed dramatically…it also changed what the
physicians saw!
The Aristocracy were always Officers and nearly
always had access to a physician. The enlisted
commoner had access to a barber-surgeon who
was trained OJT…so to speak…
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The Eighteenth Century
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Jean Louis Petit 1718, invented the screw
tourniquet.
Pierre-Joseph Desault 1740, pioneered necrotic
debridement.
John Pringle 1740, introduced the idea of
infectious disease to military doctrine.
U.S. Military Medical Experience
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Dr. Joseph Warren, Breeds
Hill, 1775
Hospital Salaries: Director
General $4.00/day, Surgeons
$1.66/day, Apothecary
$1.66/day, Nurses
$2.00/month
Field Hospitals established by
Dr. Johnathan Potts
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Dominique Jean Larrey and
evacuation under Napoleon
Florence Nightingale
Crimean War
Jonathan Letterman and the
Army of the Potomac
Dr. Lyster
WWI, WWII, Korea, Viet
1900 Century and Field Sanitation
Rat Catcher
Soldiers thrown…
Vector control
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Disease Non-Battle Injuries
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Historically killed nine soldiers to every one soldier who would
die from wounds.
Enemy is poor hygiene, disease, and accidental injury.
For every one sick and injured soldier, it takes three soldiers to
render care.
Good sanitation and field hygiene are utmost in maintaining an
Army…General George Washington, 1779, address to Congress
requesting funding of hospital tents, soap, and listers…
Washington made Smallpox vaccinations “Mandatory for all
Continentals”…and you thought the mandatory Anthrax series
was controversial!
DNBI’s
Cholera
anthrax
The very young and the very
Old…Potocari Massacre 1998
Plague
Katrina
Cajun saving his
weed wacker
Meanwhile not 25 feet away…
Hurricane Katrina…24 hours after!
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Ted Kopple
TC-3 Medicine
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Paradigm shift in philosophy
Different approach but similar
basic principles
Doc’s are part of the team.
Managing pain far forward.
Tactical Medicine is a different way
of practicing medicine in a disaster.
Suppressing enemy fire has
priority.
Treatment may be a secondary
option.
Pain management early. Tactical
considerations.
Tactical Management - Fallujah 2004
Assess MOI and lethality
Medics must learn scene
Assessment!
Avoid traps
NTOI
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Scene Security…Basrah 2005
My Helmet after getting my Bell rung
Modern Medical Principles
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Triage
“Old” Golden Hour
DIME Method
Marking
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Evacuation
Categories
Modes
Tracking
Arrival at definitive care
Early Pain management
Early use of Ketamine.
Tourniquets.
Levels of Care
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Self Aid-Buddy Aid (L-I)
Combat Lifesaver
Combat Medic (L-II/S)
BAS (L-II-III)
ASMC (L-III/Hold)
FAST (L-II-III/S)
RMC’s (IV-V/Hold)
CONUS (IV-V/Hold)
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Treatment Room Bosnia
MFST
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Mobile Field Surgical Teams
DART: Downed Aircraft Recovery Teams
FST: Forward Surgical Teams
MASH…Dinosaurs…too large to move
effectively.
CASH…Combat Area Support Hospitals…also
phasing out…
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DART
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Flight Surgeon
Flight Medic
Two Path Finders
DART Drill
Photographic bag
Survival bag
Medical bag
Pyro bag
Specials
Teams Travel Light
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All the equipment is
carried and man portable
MFST the gear weighs
around 600 pounds total
DART the gear is about
350 pounds total
FST are heavy
Teams Continued
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DART Team has it’s
own air asset
MFST Teams do not…
FST Teams do not…
C4 training at Ft. Sam Houston
The real deal!
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Operational Conditions
Kosovo
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Often Remote
Lacking amenities
Must at least be secure
for the MFST
DART teams function
almost always in hostile
environments and under
indirect or direct fire
Kosovo
Evacuation Assets?
OEF
Ground
OIF
SFOR9
Air
Wheeled
Extraction
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Requires the medic or Doc’ to understand the specifics
of scene command and control.
Established TC-3
Understand ground slopes, directional headings, blade
clearance, lift capacities, over flight abilities, established
primary and secondary ground evacuation routes,
marking parties, clearing parties, patient movement,
MRO, and your MORE…it can get complicated.
SINGARS Commo, versus open text, or SARDOT.
SIGINT is always evolving.
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Asymmetric Warfare
Tactical Combat Care
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MROE
Doc’s will suppress enemy fire actively in a firefight. Treatment
on rare occasion will be your second duty.
Once a secure perimeter is established then triage, treatment, and
evacuation can occur.
Pain management from the point of injury.
Tactical mind set is VERY important LMA’s Combitubes instead of white light intubation
Rapid use of tourniquets…IO/IV…Rapid Pain relief with
Ketamine and Morphine - etc.
Anecdotal Evidence in reduction of PTSD with rapid pain
control.
TBI and Hemmorrhage
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Blast Injuries - Pain
See diagram below!
Follow on attacks
Pain and Wound Signatures
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Stationary or moving VBED and IED
Generally set to block and MSR
Remotely detonated and spray the area with nails, metal
shards, glass, marbles, pellets.
Tactical Assessment
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Suppress and return fire.
Control bleeding
Control pain (IO/IV)
Drug selection considerations
Less focus on C-spine control
Airway
Breathing
Circulation
Disability
Exposure
Follow-up
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Technology and Wounds
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NVG’s
Flack Vest’s
Shoulder, Elbow, and Knee pads
One handed tourniquets
HEMCON, QuikClot
Tactical Training and early self
management of pain.
Reduced IR heat signatures for
uniforms, equipment, aircraft.
Early pain control reduces PTSD.
Can they still fight is the key
question. Doc’s now fight back ~
consideration on their role as a
non-combatant.
Advances in Airway
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Intubations, combitubes, LMA.
Needle Crich’s. (time/exposure)
Chest Decompression. (time/exposure)
Mechanical Ventilation Assist Devices. (noise/power)
Portable Suction Devices. (noise)
Compressed Oxygen versus concentrators.
(noise/exposure)
Thought about that one while loading patients in
Fallujah?
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Airway Selection
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The Combitube™ is a double-lumen
tube with an esophageal obturator
airway and a standard cuffed ET tube.
It is inserted blindly and "seals" the oral
and nasal pharyngeal cavities.
Ventilation in normal and abnormal
airways
Airway management in trapped patients
Patients with intact gag reflexes
Patients with known esophageal
pathology
Use in patients under 5 feet with
standard Combitube™, under 4 feet
with Combitube™ SA (small adult)
Requires minimal training
May be more useful in non-fasted
patients
Successful passage and ventilation in
many patients via esophageal route
Portable, useful in remote setting
Functions in either the trachea or
esophagus
Airway - Chest
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Traditional Chest tubes
Ashermans one way valves
Watergel’s…the Watergel
actually worked well as a
secondary sealer on an SCW.
This has been mitigated well
secondary to developments
in flack vest technology.
Hemostasis
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HEMOSTASIS is critical.
Most common cause of death in Iraq and Afghanistan
– bleed out.
Impregnated bandage technology.
Quick Clot.
HEMCON Dressings.
One Handed Tourniquets.
IVF’s with Heta Starch versus LR.
Depends on who you are and where you are…in my
opinion.
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Hemostasis - HemCon ®
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HemCon bandages have demonstrated superior hemorrhage control on the
battlefield without reported adverse reactions and numerous lives have been
saved due to this medical advancement.
Here's how they work: Red blood cells and bacteria have a negative surface
charge. A chitosan bandage carries a positive charge.
When the HemCon dressing is pressed on a severely bleeding wound, it binds
electrostatically in one to five minutes.
The bandage also forms a muco-adhesive glue that seals to the tissue, but the
bandage can be easily removed with water.
*Chitosan is derived from shrimp shells.
"This is a tremendous validation of our technology by an important partner
and customer, the U.S. military," said HemCon Chief Executive John Morgan
Shrimp allergic soldiers remain the only minimal issue…they number less
then 1% of soldiers in the filed.
Hemostasis
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As was the case with the original QuikClot® hemostat,
the new product was co-developed with the United
State Navy and Marines and was tested by the
Uniformed Services University of Health Sciences
(USUHS) and the Naval Medical Research Center
(NMRC).
Quick Clot ® hemostat, an inorganic molecular sieve.
Both products have 510(k) clearance from the FDA.
Hemostasis
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Hemostasis - Tourniquets
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The SPECOP’s one on
top has a single hand
applications with a
rotating windlase which
works the best.
Tourni-Kwik is not as
effective…in my
opinion…
Dressing Technology
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How It Works
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When removed from their vacuum
pouches the bandage expands and
returns to its original shape. When
unrolled the coverage area will be a
thick 8"x10" absorbent pad. All
bandages have a coated steel
tension hook sewn on the side
away from the absorbent pad, and
Velcro strips at both ends of the
bandage for easy anchoring and
attachment.
Self Cinching dressings
Primed Gauze with Chitosan
Shock and Pain Considerations
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Crystalloid: LR, NSS…
Colloid: Albumin, Heta Starch, Dextran, and Gelatin
Hypertonic: 3, 5, 7.5% +/- Dextran
Designer Crystalloids: Ethyl Pyruvate Ringers
Hemoglobin Based Oxygen Carriers
Some indications that Ketamine will maintain BP and
doesn’t effect Respiratory drive like Morphine.
Down side is there is evidence the Ketamine can
increase myocardial oxygen consumption.
Population is at low risk for predisposing heart disease.
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Shock and Pain
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We had young healthy soldiers and even though there
are issues with HETA Starch. It was our tactical fluid
of choice.
You have better bioavailability for volume expansion.
Two 500 cc bags of HETA had the same effect for
expansion as did four liters of LR.
If you were non-tactical then our Protocol was HTS
and Dextran for hypovolemic shock management.
Good plasma expansion, reduced ICP’s, reduced
vasospasm, reduced immunomodulation and fewer
neurochemical effects. (Doyle et al, J Trauma 2001)
Blood Replacements
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Poly-Heme (Northfield Labs): *Pre-Hospital trial
sponsored by the DOD is in phase II.
Hemopure (Biopure): *DOD Trial was on going and
was being used for trauma victims. It is in phase III.
Hemolink (Hemosol): Being used for anemia trials and
completed Phase III multicenter trial in the UK for
CABG patients.
The Brit’s were using Hemolink in Basra with some
success.
IO Gun
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EZ-IO™ from VidaCare™ is hand held battery powered device
that provides fast, safe and controllable vascular access within
seconds via the intraosseous route.
The intraosseous space is a specialized area of the vascular
system where blood flow is rapid and continues even during
shock. Drugs and fluids infused via the intraosseous route reach
the central circulation as quickly as those administered through
standard IV access.
EZ-IO™ is an alternative to failed emergency IV access.
Plus…it’s another GUN and we like GUNS!
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Disability
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How often is C-Spine control and absolute?
When there is no other choice but movement,
how do you do it.
Improvised C-Collars
SAM Splint and Duct Tape
Two items in every soldiers Pack or AID Bag!
Exposure
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You have to look at everything
NBC environments and medical operations
Harsh tactical environment - VEST on or OFF
Extremes in heat and cold
Exceptions to all rules - Murphy’s Law!
Asymmetric warfare.
Follow-Up
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Constant reassessments of the patient, the scene,
the situation
Command and control with communication to
higher is vital for a Doc’ in the field during
treatment
TELEMED is a viable option that is being
refined daily…Fallujah experience.
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Pain Management
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Able To Still Fight – these medications are now
carried by the soldier and can be self
administered.
Mobic, 15 mg po Qd.
Tylenol, 650 mg bi-layer caplet, 2 PO every 8
hours.
Pain Management
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Unable To Fight.
Does not otherwise require IV/IO access.
Oral transmucosal fentanyl citrate (OTFC), 800
mcg transbucally.
Recommend taping lozenge on a stick to
casualty’s finger as an extra safety measure.
Reassess in 15 minutes – add a second lozenge
and monitor for respiratory depression.
Have naloxone readily available.
Pain Management
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Ketamine 50 – 100 mg IM or 15-30 mg IV.
Repeat dose every 30 minutes to 1 hour as
needed to control severe pain or until the
casualty develops nystagmus (rtythmic eye
movement back and forth).
Tactical considerations with Ketamine. TBI and
IOP issue.
Also – spontaneous utterances and jerking. Not
good in a tactical setting.
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Pain Management
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Ketamine 50 mg intranasal (using a nasal
atomizer device) Repeat the dose every 30
minutes to 1 hour as needed to control sever
pain or until nystagmus develops.
Pain Management
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IV or IO access obtained:
Morphine sulfate, 5 mg IV/IO.
Reassess every 5-10 minutes.
Repeat dose every 5-10 minutes as necessary to control
sever pain or until the casualty develops nystagmus.
Monitor for respiratory depression and agitation.
Promethazine, 25 mg IV/IM/IO every 6 hours as
needed for nausea or for synergistic analgesic effect.
Rules Change
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TC-3
Advances in pain management.
SASO
MOOTWA
Peacekeeping Missions
Homeland Emergencies
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Katrina
Establish C-2
Establish C-2
Begin Coordination
Katrina, Special Forces and Ted
Koppel ?...Civil Affairs…
The Boys
Crazy Cajun!!!
Great now we’re responsible for Ted Koppel
Photo Ops!
Hoist Operations and Evacuees’
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Peacekeeping and NATO
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The MROE is different
JTF’s will have numerous nationalities: The US,
German, Japanese, Italian, Spanish…you need to have a
broad operational understanding that different
countries operate with systems that can be confusing.
SFOR and KFOR NATO operations are ongoing and
the learning process has never stopped. It is a medical
benefit for those involved.
Turkey, Slovenia, Hungary…and 9-11
Kenny
Brooks
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During SFOR/KFOR-9, I had the unique chance to work with
Providers from: Hungary, Slovenia, Turkey, Norway, Germany,
Croatia, Bosnia, Serbia, Kosovo, Macedonia, and Italy.
On 9-11, I was with the Special Operations team on a beach in
Slovenia…the medical mission changed!
Balkans War
Sarajevo
We were in armor vehicles most of the
Time…
I was in Black Hawks
Tuzla
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Republic of Georgia
Me
This fellow rolled up on Camp
with a wagon full of weapons
For turn in…plus over 100
Pounds of TNT…
Bosnia - Kosovo
Iraq
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Afghanistan
Katrina
Hungarian Twilight…Taborfalva Range Complex
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Home again…
References
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Jennings PA, Cameron P, Bernard S, et. al. “Morphine and Ketamine is Superior to Morphine
alone for Out-of-Hospital Trauma Analgesia: A randomized controlled trial”. Annals of
Emergency Medicine 2012.
MD0405 Military Medical History, 2011 ed. U.S. Army Publication. Ft. Sam Houston.
Coleman SD, Gaeta RR: Principles of Pain Management. In: Auerbach PS: Wilderness Medicine:
Sixth Edition. Elsevier: Mosby, Philidephia: 2012: 354-362.
Wedmore IS, et. al. “Pain Management in Wilderness and Operational Settings” Emerg Med Clin
N Am 2005: 23: 586-601.
Holbrook TL, Dye JL et. al. “Morphine use after combat injuries in Iraq and PTSD” N Engl J
Med 2010; 362: 110-117.
Buckenmaier C, Bleckner L. “Military Advanced Regional Anesthesia and Analgesia Handbook –
Chapter 26: Acute Battlefield Pain Management. Office of the Surgeon General, Army, USA
2008. P. 85-99.
Guldner GT, Petinaux B, Clemens P, et al. “Ketamine for Procedural Sedation and Analgesia by
Nonanesthesiologists in the field” A review for Military Health Providers. Military Medicine
2006; 171 (6): 484-490.
Filanovsky Y, Miller P, Kao J. “Myth: Ketamine should not be used as an Induction Agent for
Intubation in Patients with Head Injury.” CJEM 2010: 12 (2): 154-157.
USAF Trauma Refresher Course Handbook for Flight Surgeons, Camp Comanche, BosniaHerzegovina. 2001
C-4, US Army Course Handbook (s), Ft. Sam Houston, TX. 1995, 2001, and 2009.
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