Post by Cartwright on Jul 1, 2008 9:13:14 GMT -5
What is a Combat Medic?
The combat medics assigned duties are as follows: provide emergency medical treatment, limited primary care, force health protection and evacuation in a variety of operational and clinical settings from point of injury or illness through the continuum of military health care. These entail to administer emergency medical treatment to battlefield casualties including minor surgery, and to coordinate and perform aeromedical evacuation procedures. They will also conducts duties in respect to first aid and health education programs, ensure observance of field sanitory measures and preventative measures.
Objectives of the Combat Medic
1. Treat the casualty
2. Prevent additional casualties
3. Complete the mission
The nature of the tactical combat environment includes factors such as incoming fire, darkness, environmental factors (the casualty may occur in a swamp, in the snow, or in the surf zone), casualty transportation problems, long delays to definitive care, and the need to balance the management of casualties with the conduct of an ongoing combat mission.
Therapeutic measures that are taken for granted in the emergency department, such as CPR, c-spine immobilization, endotracheal intubation, starting two large-bore IVs, insertion of nasogastric tubes and foley catheters, supplemental oxygen therapy, and the complete undressing of the patient to complete a secondary survey would be inappropriate in the middle of an ongoing firefight.
Corpsmen and medics must be aware of the fact that good medicine can sometimes be bad tactics and that bad tactics can get everyone killed or cause the mission to fail.
This is the reality ladies. What is best for the casualty and what is best for the mission may be in direct conflict. The question is often not just whether or not the mission can be completed successfully without the wounded individual or individuals. The issue may well be that continuing the mission may adversely affect the outcome for the casualty. If the mission is to be successfully accomplished it is down to the combat medics and your NCOs to make some very difficult decisions about the care and movement of casualties.
With helpful bullet points the following presentation outlines how you will make those decisions and execute your mission.
Basic Combat Trauma Management Plan
There are three phases to the trauma plan as follows:
1. Care under Fire
This is defined as the care rendered by the medic or corpsman at the scene of the injury, while he/she and the casualty are still under effective hostile fire. The available medical equipment is limited to that carried by the individual operator or by the corpsman, aerorescueman or medic in their Advanced Medical Kit (aka Aid Bag) and/or Medical Pack.
2. Tactical Field Care
The care rendered by the corpsman, aerorescueman, or medic once the unit is no longer under effective hostile fire. This term also applies to situations in which an injury has occurred on a mission, but there has been no hostile fire. The available medical equipment is still limited to that carried into the field by mission personnel. Time prior to evacuation to an aid station or hospital in the sky is very variable.
3. Combat Casualty Evacuation (CASEVAC) Care
The care rendered once the casualty (and usually the rest of the mission personnel) have been picked up by a aerospace, ground, boat or submersible vehicle. Personnel and medical equipment that may have been previously staged in these assets will now be available.
Now, let’s explore these phases in more detail.
Care Under Fire Protocol
1. Return fire as directed or appropriate
2. The casualty(s) should also continue to return fire if able
3. Try to keep yourself from getting shot
4. Try to keep the casualty from sustaining additional wounds
5. Stop any life-threatening hemorrhage with a tourniquet
6. Take the casualty with you when you leave
I cannot stress the following point more: the best medicine on the battlefield is fire superiority! The immediate action protocol when hot is for the combat lifesaver and the casualty is to continue to return fire if able to do so effectively. If you are conveniently close to a wounded Marine, administer care to him. If you are not conveniently close, don't bother.
As harsh and unheroic as that sounds, your priority is always to eliminate the immediate threat before taking care of a wounded Marine. If the threat is not eliminated, another medic will be needed to take care of you as well as the original casualty. Do not treat in the open and either make the wounded Marine come to you or wait for the threat to pass. Choose a location of maximum available cover to treat a casualty, and only move when there is solid supressive fire from other Marines. I also strongly recommend buddying up with another Marine, ideally a Combat Life Saver (CLS) who can carry a second Advanced Medical Kit so you do not have to fumble with or dump your kit in the middle of a firefight to reach important equipment and supplies.
The fact that control of hemorrhage is the top priority is also emphasized by pointing out that exsanguination from extremity wounds is the number one cause of preventable death on the battlefield. The most reasonable initial choice to stop potentially life-threatening bleeding remains the one-handed tourniquet, which can be applied by the casualty themself where it is expedient. It is the combat medics responsibility to ensure that a tourniquet is part of the routine pre-mission equipment check for all members of their fire team, and I expect all of you to carry three or more on your person in addition to those in your kit during every op.
Tactical Field Care Objectives
1. CPR should not be attempted on the battlefield for victims of blast or penetrating trauma who have no pulse, respirations, or other signs of life.
2. The nasopharyngeal (tube in the nose) airway is the airway of first choice for unconscious patients until the CASEVAC phase. Patients who are shot in the face may require a surgical airway.
3. Progressive, severe respiratory distress in the setting of unilateral blunt or penetrating chest trauma on the battlefield should result in a presumed diagnosis of tension pneumothorax and that side of the chest should be decompressed with a thoracotomy needle.
4. Casualties who have controlled bleeding without shock do not need emergent IV fluid resuscitation.
5. Casualties who have had bleeding that is now controlled but who are in shock should receive 1000cc of Hespan.
6. Casualties who have uncontrolled hemorrhage from penetrating wounds of the chest or abdomen should receive no IV fluid in the field.
7. An exception to rule number 6 above is that casualties who have uncontrolled hemorrhage from penetrating wounds of the chest or abdomen and develop decreased mental status should either receive 1000cc of Hespan or be fluid resuscitated to an end point of improved mentation.
8. Saline locks (plastic IV catheters without fluids attached) may be used instead of IVs if fluid resuscitation is not required (for IV antibiotics and morphine, if required).
9. Morphine is to be used IV (5 mg) instead of IM.
10. IV antibiotics should be used as soon as possible for patients with penetrating abdominal trauma, grossly contaminated wounds, massive soft tissue trauma, open fractures, or any patient in whom a long delay until definitive treatment is expected.
11. Casualties should not be completely undressed for a secondary survey in the field. Removal of clothing should be limited to that necessary to expose known or suspected wounds. Use trauma shears when neccessary to remove armour to reach the wound site.
Combat Casualty Evactuation (CASEVAC) Care
The term "CASEVAC" is used to describe this phase instead of the commonly used term “MEDEVAC" because the evacuation may require that the aerospacecraft or other evacuating asset enter an area where the danger of hostile fire is imminent.
Patients with certain conditions or injuries have a priority for treatment and transportation over others.
1. Priority "URGENT" must be treated first at the scene and transported immediately. Injuries/problems would include the following:
a. Airway and breathing difficulties
b. Cardiac arrest
c. Uncontrolled or suspected severe hidden bleeding
d. Open chest or abdominal wounds
e. Severe head injuries with evidence of brain damage, however slight
f. Several medical problems: poisonings, diabetes with complications, cardiac disease with failure
2. Priority "PRIORITY": transportation and hospital treatment can be delayed. The following are typical problems or injuries:
a. Burns without complications
b. Major or multiple fractures
c. Back injuries with or without spinal damage
3. Priority "ROUTINE": these are transported or treated last.
a. Minor fractures or other injuries of a minor nature
b. Obviously mortal wounds where death appears reasonably certain
c. Obviously dead
Leadership is paramount during triage. Someone must be in command to guide what is being done and to utilize any help as it arrives. This is the duty of the most highly trained Marine or a medic or corpsman. The Marine must establish priorities and, depending on the availability of transport vehicles and local conditions, determine how the patients will be managed.
This means that identification and treatment of fractures, spinal injuries, and other injuries are crucial. Proper immobilization or splinting of a fracture is the simplest procedure in evacuation, of which inflatable compression cuff bandages are the ideal methods of achieving both haemostasis and orthontic immobilisation in the quickest time.
Once the casualty has recieved treatment, preparations must be made for
aeromedical evacuation. This will often involve movement to reach a secure DZ where a CASEVAC dropship can safely extract the casualty. Transportation of the sick and wounded is the responsibility of medical personnel. Each fireteam should include a Tactical Extraction Device (highly collapsible litter) in its gear list, and the T.E.D. is safer and more comfortable for the casualty than by manual means; it is also easier for you. Manual transportation, however, may be the only feasible method because of the terrain or the combat situation.
Tactical Radio Brevity Codes
The following are the authorised brevity codes for initiating medical treatment of a casualty and casualty evacuation.
Request for a medic should always been made on the platoon/squad radio net by the code “BAND-AID”.
Marines are reminded to only request a medic in the event they have suffered a battlefield injury that cannot be self-treated and requires immediate medical attention. In ascending order, the protocol when injured is to adminster self-aid if possible, followed by buddy aid and aid from a combat lifesaver.
The proper code for an aeromedical evecuation (medical dust-off) is “DUST-OFF”, preceded by the callsign of the unit or bird which is being requested to respond.
When the casevac dropship acknowledges in the affirmative you should use the following medcodes to inform the dropship, and the recieving team at the aid station or hospital in the sky, the number of casualties and their status by the following medcode system.
MEDCODE 0 - Patient severely injured beyond reasonable expectation of survival or is deceased (bagged and tagged).
MEDCODE 1 - Condition critical, patient requires immediate care and evacuation.
MEDCODE 2 - Condition fair to poor, patient's need for care is not so acute, but will require care before evacuation.
MEDCODE 3 - Condition good to fair, patient with injuries which do not require hospitalization; some medical care may be needed, but not on a time critical basis.
Appendix A
How People Die in Ground Combat
KIA 31% Penetrating Head Trauma
KIA 25% Surgically Uncorrectable Torso Trauma
KIA 10% Potentially Correctable Surgical Trauma
KIA 9% Exsanguination from Extremity Wounds
KIA 7% Mutilating Blast Trauma
KIA 5% Tension Pneumothorax
KIA 1% Airway Problems
DOW 12% (Mostly infections and complications of shock)
Appendix B
Preventable Causes of Death on the Battlefield
1. Bleeding to death from extremity wounds (60%)
2. Tension pneumothorax (33%)
3. Airway obstruction (maxillofacial trauma) (6%)
The combat medics assigned duties are as follows: provide emergency medical treatment, limited primary care, force health protection and evacuation in a variety of operational and clinical settings from point of injury or illness through the continuum of military health care. These entail to administer emergency medical treatment to battlefield casualties including minor surgery, and to coordinate and perform aeromedical evacuation procedures. They will also conducts duties in respect to first aid and health education programs, ensure observance of field sanitory measures and preventative measures.
Objectives of the Combat Medic
1. Treat the casualty
2. Prevent additional casualties
3. Complete the mission
The nature of the tactical combat environment includes factors such as incoming fire, darkness, environmental factors (the casualty may occur in a swamp, in the snow, or in the surf zone), casualty transportation problems, long delays to definitive care, and the need to balance the management of casualties with the conduct of an ongoing combat mission.
Therapeutic measures that are taken for granted in the emergency department, such as CPR, c-spine immobilization, endotracheal intubation, starting two large-bore IVs, insertion of nasogastric tubes and foley catheters, supplemental oxygen therapy, and the complete undressing of the patient to complete a secondary survey would be inappropriate in the middle of an ongoing firefight.
Corpsmen and medics must be aware of the fact that good medicine can sometimes be bad tactics and that bad tactics can get everyone killed or cause the mission to fail.
This is the reality ladies. What is best for the casualty and what is best for the mission may be in direct conflict. The question is often not just whether or not the mission can be completed successfully without the wounded individual or individuals. The issue may well be that continuing the mission may adversely affect the outcome for the casualty. If the mission is to be successfully accomplished it is down to the combat medics and your NCOs to make some very difficult decisions about the care and movement of casualties.
With helpful bullet points the following presentation outlines how you will make those decisions and execute your mission.
Basic Combat Trauma Management Plan
There are three phases to the trauma plan as follows:
1. Care under Fire
This is defined as the care rendered by the medic or corpsman at the scene of the injury, while he/she and the casualty are still under effective hostile fire. The available medical equipment is limited to that carried by the individual operator or by the corpsman, aerorescueman or medic in their Advanced Medical Kit (aka Aid Bag) and/or Medical Pack.
2. Tactical Field Care
The care rendered by the corpsman, aerorescueman, or medic once the unit is no longer under effective hostile fire. This term also applies to situations in which an injury has occurred on a mission, but there has been no hostile fire. The available medical equipment is still limited to that carried into the field by mission personnel. Time prior to evacuation to an aid station or hospital in the sky is very variable.
3. Combat Casualty Evacuation (CASEVAC) Care
The care rendered once the casualty (and usually the rest of the mission personnel) have been picked up by a aerospace, ground, boat or submersible vehicle. Personnel and medical equipment that may have been previously staged in these assets will now be available.
Now, let’s explore these phases in more detail.
Care Under Fire Protocol
1. Return fire as directed or appropriate
2. The casualty(s) should also continue to return fire if able
3. Try to keep yourself from getting shot
4. Try to keep the casualty from sustaining additional wounds
5. Stop any life-threatening hemorrhage with a tourniquet
6. Take the casualty with you when you leave
I cannot stress the following point more: the best medicine on the battlefield is fire superiority! The immediate action protocol when hot is for the combat lifesaver and the casualty is to continue to return fire if able to do so effectively. If you are conveniently close to a wounded Marine, administer care to him. If you are not conveniently close, don't bother.
As harsh and unheroic as that sounds, your priority is always to eliminate the immediate threat before taking care of a wounded Marine. If the threat is not eliminated, another medic will be needed to take care of you as well as the original casualty. Do not treat in the open and either make the wounded Marine come to you or wait for the threat to pass. Choose a location of maximum available cover to treat a casualty, and only move when there is solid supressive fire from other Marines. I also strongly recommend buddying up with another Marine, ideally a Combat Life Saver (CLS) who can carry a second Advanced Medical Kit so you do not have to fumble with or dump your kit in the middle of a firefight to reach important equipment and supplies.
The fact that control of hemorrhage is the top priority is also emphasized by pointing out that exsanguination from extremity wounds is the number one cause of preventable death on the battlefield. The most reasonable initial choice to stop potentially life-threatening bleeding remains the one-handed tourniquet, which can be applied by the casualty themself where it is expedient. It is the combat medics responsibility to ensure that a tourniquet is part of the routine pre-mission equipment check for all members of their fire team, and I expect all of you to carry three or more on your person in addition to those in your kit during every op.
Tactical Field Care Objectives
1. CPR should not be attempted on the battlefield for victims of blast or penetrating trauma who have no pulse, respirations, or other signs of life.
2. The nasopharyngeal (tube in the nose) airway is the airway of first choice for unconscious patients until the CASEVAC phase. Patients who are shot in the face may require a surgical airway.
3. Progressive, severe respiratory distress in the setting of unilateral blunt or penetrating chest trauma on the battlefield should result in a presumed diagnosis of tension pneumothorax and that side of the chest should be decompressed with a thoracotomy needle.
4. Casualties who have controlled bleeding without shock do not need emergent IV fluid resuscitation.
5. Casualties who have had bleeding that is now controlled but who are in shock should receive 1000cc of Hespan.
6. Casualties who have uncontrolled hemorrhage from penetrating wounds of the chest or abdomen should receive no IV fluid in the field.
7. An exception to rule number 6 above is that casualties who have uncontrolled hemorrhage from penetrating wounds of the chest or abdomen and develop decreased mental status should either receive 1000cc of Hespan or be fluid resuscitated to an end point of improved mentation.
8. Saline locks (plastic IV catheters without fluids attached) may be used instead of IVs if fluid resuscitation is not required (for IV antibiotics and morphine, if required).
9. Morphine is to be used IV (5 mg) instead of IM.
10. IV antibiotics should be used as soon as possible for patients with penetrating abdominal trauma, grossly contaminated wounds, massive soft tissue trauma, open fractures, or any patient in whom a long delay until definitive treatment is expected.
11. Casualties should not be completely undressed for a secondary survey in the field. Removal of clothing should be limited to that necessary to expose known or suspected wounds. Use trauma shears when neccessary to remove armour to reach the wound site.
Combat Casualty Evactuation (CASEVAC) Care
The term "CASEVAC" is used to describe this phase instead of the commonly used term “MEDEVAC" because the evacuation may require that the aerospacecraft or other evacuating asset enter an area where the danger of hostile fire is imminent.
Patients with certain conditions or injuries have a priority for treatment and transportation over others.
1. Priority "URGENT" must be treated first at the scene and transported immediately. Injuries/problems would include the following:
a. Airway and breathing difficulties
b. Cardiac arrest
c. Uncontrolled or suspected severe hidden bleeding
d. Open chest or abdominal wounds
e. Severe head injuries with evidence of brain damage, however slight
f. Several medical problems: poisonings, diabetes with complications, cardiac disease with failure
2. Priority "PRIORITY": transportation and hospital treatment can be delayed. The following are typical problems or injuries:
a. Burns without complications
b. Major or multiple fractures
c. Back injuries with or without spinal damage
3. Priority "ROUTINE": these are transported or treated last.
a. Minor fractures or other injuries of a minor nature
b. Obviously mortal wounds where death appears reasonably certain
c. Obviously dead
Leadership is paramount during triage. Someone must be in command to guide what is being done and to utilize any help as it arrives. This is the duty of the most highly trained Marine or a medic or corpsman. The Marine must establish priorities and, depending on the availability of transport vehicles and local conditions, determine how the patients will be managed.
This means that identification and treatment of fractures, spinal injuries, and other injuries are crucial. Proper immobilization or splinting of a fracture is the simplest procedure in evacuation, of which inflatable compression cuff bandages are the ideal methods of achieving both haemostasis and orthontic immobilisation in the quickest time.
Once the casualty has recieved treatment, preparations must be made for
aeromedical evacuation. This will often involve movement to reach a secure DZ where a CASEVAC dropship can safely extract the casualty. Transportation of the sick and wounded is the responsibility of medical personnel. Each fireteam should include a Tactical Extraction Device (highly collapsible litter) in its gear list, and the T.E.D. is safer and more comfortable for the casualty than by manual means; it is also easier for you. Manual transportation, however, may be the only feasible method because of the terrain or the combat situation.
Tactical Radio Brevity Codes
The following are the authorised brevity codes for initiating medical treatment of a casualty and casualty evacuation.
Request for a medic should always been made on the platoon/squad radio net by the code “BAND-AID”.
Marines are reminded to only request a medic in the event they have suffered a battlefield injury that cannot be self-treated and requires immediate medical attention. In ascending order, the protocol when injured is to adminster self-aid if possible, followed by buddy aid and aid from a combat lifesaver.
The proper code for an aeromedical evecuation (medical dust-off) is “DUST-OFF”, preceded by the callsign of the unit or bird which is being requested to respond.
When the casevac dropship acknowledges in the affirmative you should use the following medcodes to inform the dropship, and the recieving team at the aid station or hospital in the sky, the number of casualties and their status by the following medcode system.
MEDCODE 0 - Patient severely injured beyond reasonable expectation of survival or is deceased (bagged and tagged).
MEDCODE 1 - Condition critical, patient requires immediate care and evacuation.
MEDCODE 2 - Condition fair to poor, patient's need for care is not so acute, but will require care before evacuation.
MEDCODE 3 - Condition good to fair, patient with injuries which do not require hospitalization; some medical care may be needed, but not on a time critical basis.
Appendix A
How People Die in Ground Combat
KIA 31% Penetrating Head Trauma
KIA 25% Surgically Uncorrectable Torso Trauma
KIA 10% Potentially Correctable Surgical Trauma
KIA 9% Exsanguination from Extremity Wounds
KIA 7% Mutilating Blast Trauma
KIA 5% Tension Pneumothorax
KIA 1% Airway Problems
DOW 12% (Mostly infections and complications of shock)
Appendix B
Preventable Causes of Death on the Battlefield
1. Bleeding to death from extremity wounds (60%)
2. Tension pneumothorax (33%)
3. Airway obstruction (maxillofacial trauma) (6%)
