ProlongedFieldCare.org – Improving Far Forward Care
10th Special Forces Group Prolonged Field Care ExerciseSituation: You are a SFODA operating at a Host Nation Army outpost in ###, ###. Friendly forces include ### Army Commandos and local police forces. You are operating under the request of the President and Government of ###, and have a well-established status of forces agreement with stipulation to not engage terrorist combatants unless in self-defense.Mission: SFODA #### trains, advises, and assists ### Army Commandos IVO of ###, ###, to interrupt and interdict illegal transnational terrorist activities over a 5 month period, 2016, in order to improve ###’s sovereignty and deny local terrorist safe-havens. Insert Imagery HereExecution: Your ODA is at a Host Nation (HN) military base conducting range training. This training area is located 45-60 minutes (by truck, unimproved road) from the base where your team house is located. You have been training in small arms and explosives, with the intent of conducting live fire Immediate Action Drills (IADs). You are currently conducting a grenade familiarization range with live grenades. All training personnel are throwing from makeshift grenade pits. There is an explosion from the far right side of the range, in the area of a grenade pit. There is a dust cloud dispersing directly in the area of the pit, and yells and screams are coming from the area. Upon arrival, there are three apparently injured personnel on the ground, two USSF and one HN Soldier. Sustainment: Your HN outpost has a primitive FLS capable of supporting STOL, twin engine aircraft (CASA, Cessna), and the ISOS and contract MEDEVAC takes approximately 8 hours from notification to reach your AO. They will not fly at night. They will not fly in the rainy season due to muddy runway. There is a local hospital 30 minutes away from your outpost, but it is considered “unsafe” by US standards, but there is a ### trained general surgeon and local blood supply there. There is an improved runway which can support anything up to C-130, just across the border in neighboring ###. This is the nearest place to get US Air Force Aircraft onto the ground. ### is a friendly country and the border crossing is usually open, but there is currently a Military Junta underway, and forces are divided in loyalty. Additionally, all ground and air transit into the sovereign territory of ### requires country clearances. Command and Control: Your commo PACE plan includes normal channels to higher HQs, including the TSOC at ###. They will launch and C2 MEDEVAC. You have DIRLAUTH to communicate with the 24 hour on-call Medical Consultation hotline at LRMC, Germany, for consultation and medical assistance during your scenario (CALL EARLY and as OFTEN!)TRAINING INTENT: Dynamic, performance-based, and educational. The scenario will pause at certain points to conduct “rolling” AARs and brief teaching points. The patient(s) will respond appropriately to treatments, and your scenario will become more complicated if your interventions are inappropriate or inadequate. Use the scenario to exercise team SOPs for C2, Comms, and transport as you see fit.Training will proceed from this point with standard TCCC phases, moving into a prolonged casevac scenario, back of a van for 45 minutes transport back to your outpost, where most of your commo and medical equipment is located.Consolidated Supply List for setup of exercise:Personnel: 4-12 OpERATORS WITH AT LEAST 1 18d1 X pATIENT (18d)1-2 manikin operatorBN Surgeon/PA to serve as proctorMedical Equipment: 1-2 mANIKINS WITH APPROPRIAte injuries or Moulage KitIFAKS for all personnel and patients1 x AID BaG per 18D (stocked)Trauma roll to set up Ambulance (optional)1-2 littersCLASS VIII: aid bags and ifaks stocked according to unit sopSpace Requirements: outdoor space with room for 3 patients and 12 operatorsVehicles: unit specific/mission specific organic vehicles (at least 1 to serve as casevac platformCommo: handheld radios, cell phones, other unit commo as desiredExternal Support: Manikin support/operator as neededPFC Script and reference book2349559055CRITICAL ACTIONS-Patient #11. Interpret Vital Signs2. Control Hemorrhage3. Pain control and maintenance of pain control4. Monitor for shock5. Fresh Whole Blood (FWB) Transfusion6. Document Properly (Patient flow-sheet)7. Activate MEDEVAC Chain8. Reassess Tourniquets within 2 hours; convert to pressure dressings if possible (1x extremity wound CAN be converted)9. Assess and manage chest wall contusion/broken ribs (consider PTX/hemothorax; supplemental oxygen if possible)OTHER TREATMENTS:1. Monitor I+O’s2. Advanced monitoring (EtCO2…)3. Antibiotic treatments4. Monitor Labs (follow lactate, follow Hgb, UA)\5. Package patient/prevent hypothermia00CRITICAL ACTIONS-Patient #11. Interpret Vital Signs2. Control Hemorrhage3. Pain control and maintenance of pain control4. Monitor for shock5. Fresh Whole Blood (FWB) Transfusion6. Document Properly (Patient flow-sheet)7. Activate MEDEVAC Chain8. Reassess Tourniquets within 2 hours; convert to pressure dressings if possible (1x extremity wound CAN be converted)9. Assess and manage chest wall contusion/broken ribs (consider PTX/hemothorax; supplemental oxygen if possible)OTHER TREATMENTS:1. Monitor I+O’s2. Advanced monitoring (EtCO2…)3. Antibiotic treatments4. Monitor Labs (follow lactate, follow Hgb, UA)\5. Package patient/prevent hypothermia63307154305CRITICAL ACTIONS-Patient #21. Assess initial vitals – determine STABLE2. Assess after conscious: full neuro exam3. Secondary survey: identify injuries4. Splint Arm5. Treat pain00CRITICAL ACTIONS-Patient #21. Assess initial vitals – determine STABLE2. Assess after conscious: full neuro exam3. Secondary survey: identify injuries4. Splint Arm5. Treat pain63610154719CRITICAL ACTIONS-Patient #31. Assess initial injuries2. Determine to be EXPECTANT after initial interventions, DO NOT waste exorbitant supplies on management.3. Occlusive dressing on chest4. Manage Airway5. TQ on leg00CRITICAL ACTIONS-Patient #31. Assess initial injuries2. Determine to be EXPECTANT after initial interventions, DO NOT waste exorbitant supplies on management.3. Occlusive dressing on chest4. Manage Airway5. TQ on legPhase 1 (TCCC, PT Transport and Arrival)Duration: In actual exercise 1.5 Hours (here 45 min)Equipment Required: 3 x patients, either moulaged or manikin, 3 x litters, IFAKs for each participant and patient, commo or cell phones, 1 x aid bag per medic, evacuation vehicles standing by, Casualty Cards and pensArea Set up: patients displaced around a grenade pit (basically all strewn around in a 30 foot diameter circle) One uninjured team member calls the rest of the team to the scene by yelling.Phase 1, Part A- TCCC:Situation: You are at the range on the base of your partner force training Soldiers to throw hand grenades. The location is a 45 minute drive from your team house. Two personnel from the team are still at the house. You have Satcom and cell coverage to communicate with the team house.Across the range there is a explosion close to a throwing position. There are immediate yells and calls for help. Upon arrival there are three Soldiers on the ground. Two are moving, one is not. -541020-349885Instructions to Proctor and RoleplayersPatient 1: (CAN be manikin or live Moulage)30 y/o AD SF Soldier with penetrating extremity wounds x2 (arm and leg wounds requiring initial tourniquet placement), Class 2-3 hemorrhage; Patient also has chest wall contusion/1-2 broken ribs (not PTX or pulmonary contusion). V/S: HR 125, BP 92/62, RR: 22 (splinting with breaths), O2 sats: 92-93% on room air. GCS 15Instructions to Role Player:lying on the ground moaning with pain in the chest and bleeding from arm and leg. You can only answer yes/no questions because of your pain. When they put on tourniquets, it will be even more painful.Patient 2: (SHOULD be live patient and Medic)30ish y/o AD Medic: broken right forearm and initially knocked unconscious (mild TBI without brain injury), and ruptured tympanic membrane. Will spontaneously awaken after 2-3 minutes of assessment and be confused for about 10-15 minutes. Hard time hearing. V/S: HR 85, BP 120/78, RR: 16, O2 sats: normal on room air.Instructions to Role Player:you are unconscious, then slowly regain consciousness. You will be confused at first, and have a hard time hearing. You will become fully conscious eventually, but you’re unsure what happened.Patient 3: (CAN be manikin or live moulage) 23 y/o Local National Soldier: unconscious with facial wound, compromised airway, multiple open wounds to chest, amputated leg, V/S: HR 140, BP 70/40, RR: 28, O2 sats: 82% on room air, unconscious/unresponsive to pain.. He will eventually die after 15-20 minutes of treatment. Instructions to Role Player:unconscious, hard time breathing. Eventually die00Instructions to Proctor and RoleplayersPatient 1: (CAN be manikin or live Moulage)30 y/o AD SF Soldier with penetrating extremity wounds x2 (arm and leg wounds requiring initial tourniquet placement), Class 2-3 hemorrhage; Patient also has chest wall contusion/1-2 broken ribs (not PTX or pulmonary contusion). V/S: HR 125, BP 92/62, RR: 22 (splinting with breaths), O2 sats: 92-93% on room air. GCS 15Instructions to Role Player:lying on the ground moaning with pain in the chest and bleeding from arm and leg. You can only answer yes/no questions because of your pain. When they put on tourniquets, it will be even more painful.Patient 2: (SHOULD be live patient and Medic)30ish y/o AD Medic: broken right forearm and initially knocked unconscious (mild TBI without brain injury), and ruptured tympanic membrane. Will spontaneously awaken after 2-3 minutes of assessment and be confused for about 10-15 minutes. Hard time hearing. V/S: HR 85, BP 120/78, RR: 16, O2 sats: normal on room air.Instructions to Role Player:you are unconscious, then slowly regain consciousness. You will be confused at first, and have a hard time hearing. You will become fully conscious eventually, but you’re unsure what happened.Patient 3: (CAN be manikin or live moulage) 23 y/o Local National Soldier: unconscious with facial wound, compromised airway, multiple open wounds to chest, amputated leg, V/S: HR 140, BP 70/40, RR: 28, O2 sats: 82% on room air, unconscious/unresponsive to pain.. He will eventually die after 15-20 minutes of treatment. Instructions to Role Player:unconscious, hard time breathing. Eventually dieScene securityPerforms appropriate Tactical Combat Casualty Care (TCCC) interventions in a timely mannerAchieves hemostasisYes- BP low, PT anxious. HR trends up to 130 and BP stays in high-80’s/high 40’s. Lots of PAIN due to TQ’s. IF treat pain then HR drops to 110-120, but BP drops to low 80’s/low 40’sNo- Weak, rapid radial pulse, PT HR 130, creeping up to 140 and higher as needed. and rising, PT becomes obtunded, and later unresponsive – BP: drops to 85/45 then 80/40, then 72/30, then can’t read it.Airway-performs cricothyrotomy on patient #3Yes – obtains definitive airway; pt still unresponsiveNo – Pt immediately expires, ? performs CPR?Respirations-recognizes chest wall injuryYes – obtains definitive airway; pt still unresponsiveNo – Pt immediately expires, ? performs CPR?Circulation-recognizes shock, initiate IVYes – Pt remains stable with no change in Mental StatusNo – Pt mental status worsens, HR increasesHypothermia-patient are covered, blanketedYes – Pt remains stable with no change in Mental StatusNo – Pt mental status worsens, HR increasesObtain vital signs, complete casualty cards, appropriately triaged patient's for transportTeam recognizes limitations of transport, may designate personnel to remain with the patient #3 on scene. Patient #2 recognized as most critical, is continuously municates with higher about casualty status; timeline for movement off OBJEnd forms of event, location, number and status of casualties, and intended plan/timeline for transportPrepares patients for transport (CASEVAC – van/pickup/NSTV)Proper use of litters, vehicle loading to allow ongoing care of patient #2Prevents hypothermia, initiate active warming as availableTeam communication-all team members are aware of the patient's status and planPhase 1, Part B- Transportation:Situation: Your teammates bring the team vehicles around (or helicopter arrives), and you load the patients onto the truck and begin movement to the team house. The ride will be at least 45 minutes along bumpy unimproved roads.-753745-862965Instructions to Proctor and RoleplayersPatient 1: Instructions to Role Player: IF they treat your pain, you become groggy. You may pass out if the instructor tells you to. IF they DON’T treat your pain, continue to moan and complain of pain in tourniquets and chest.Patient 2: Medic: VS wnl: HR 70-80; BP 120/75, RR: 16; sats 96% on room air Instructions to Role Player:You become completely conscious and can help direct the care of the other guy. You cannot use your dominant arm and need to have it splinted.Patient 3: 23 Y/O Local National Soldier, Deceased Instructions to Role Player:DEAD00Instructions to Proctor and RoleplayersPatient 1: Instructions to Role Player: IF they treat your pain, you become groggy. You may pass out if the instructor tells you to. IF they DON’T treat your pain, continue to moan and complain of pain in tourniquets and chest.Patient 2: Medic: VS wnl: HR 70-80; BP 120/75, RR: 16; sats 96% on room air Instructions to Role Player:You become completely conscious and can help direct the care of the other guy. You cannot use your dominant arm and need to have it splinted.Patient 3: 23 Y/O Local National Soldier, Deceased Instructions to Role Player:DEADINITIAL CASEVAC FORMCHECKBOX Advanced monitoring – patient connected to monitor, vital signs trendingCommunicates with higher about casualty status, timeline for movement to secure location/next level of careYes – Resources available at next level without delay, MEDEVAC timeline stays on scheduleNo – Resources at drop-off limited, MEDEVAC delayed by up to 2 hoursPerform/re-assesses interventions (airway adjuncts ,IV access, wound care) during tactical movement in vehicle/aircraft Yes – Pt remains stable, no decompensationNo – TQ loosens, pt bleeding resumes, IV no longer patentAchieves Pain ControlYes- Pt HR and BP decreases; PT LOC decreases as BP drops No- PT HR remains High; PT verbalizes discomfort with bumps during transportation; PT anxiety High; PT BP is normotensiveAdministers TXAYes- No- Airway - obtain definitive control as needed. BVM/Cric/RSIAppropriately identifies emergency decompensation, changes in patient status during transport, stops movement if indicatedTeam communication-all team members are aware of patient's status and planPhase 2 (Arrival, Stabilization and Urgent Care)Duration: In actual exercise 2-3 Hours (here 45 min)Equipment Required: Monitor, iSTAT (optional), Fake drug vials, Transfusion Kit, Foley and foley manikin.Area Set up: Simulated Team house with litter stands and medical equipment ready for use, desks and chairs if possible, ODA organic communications equipment. Think about prepositioning commonly used charts and references which the team would have downrange. Charts such as HITMAN, Normal Vitals, Normal Labs, Telemedicine Script, Ketamine drip sheet, Drug Cheat Sheet, Burns Formula, Standard Ventilator Settings, DOPE for airway tubes would be helpful.Situation: You just arrived at your Team House and got your patient/s inside. The team should be aware that you are coming and how many patients and their severity. They will only know what they have received from the team during the previous phases. The patients will be moved in and treatment begins again.center0Instructions to Proctors and RoleplayersPatient 1: AD SF Soldier with penetrating extremity wounds x2, Class 2-3 hemorrhage, 6-8 hours evac before “definitive” treatment (handoff). Patient also has chest wall contusion/1-2 broken ribs (not PTX or pulmonary contusion). V/S: should be bad enough (HR >120, systolic BP <90) to prompt FWB transfusion. Urine output is about 15-20 mL/hour until FWB transfusion, then 75 mL/hour.Instructions to Role Player: Conscious, in pain based on pain management00Instructions to Proctors and RoleplayersPatient 1: AD SF Soldier with penetrating extremity wounds x2, Class 2-3 hemorrhage, 6-8 hours evac before “definitive” treatment (handoff). Patient also has chest wall contusion/1-2 broken ribs (not PTX or pulmonary contusion). V/S: should be bad enough (HR >120, systolic BP <90) to prompt FWB transfusion. Urine output is about 15-20 mL/hour until FWB transfusion, then 75 mL/hour.Instructions to Role Player: Conscious, in pain based on pain managementINITIAL HAND OFF/RECEIPT OF CASUALTIESPatients prepared for off load and documentation completedAppropriate hand off reports to receiving medical authorityReceiving medical team- previous interventions/IVs/02/monitor/secondary survey/patient warming in the first 2 minutesAll injury/pathology correctly identified, advanced adjuncts/treatments initiatedFlip (patient transferred to appropriate bed/padded later, pressure sore prophylaxis), Foley (empty bag, measure over 60 minutes to 10 mL accuracy), G-tubeADVANCED SKILLSVentilationBVM with PEEP valveVentilator basics (Set rate, volume, PEEP at 5, DOPE mnemonic)CapnometryPain control and sedation - Ketamine+midazolam (500mg+25 mg in 250 NS bag) cocktail, infuse at ? body wt in kg = to ml/hr, titrate to effectTourniquet conversion – pressure dressing applied, monitored for bleeding, prepared for toxic metabolite bolus upon takedownLabs- POCT – Istat basics, CLU update/calibration, critical values for CMP, CBC, VBGFresh Whole Blood Transfusion – blood typing, Eldon cards, donation, filtered tubing, infusion, vitals monitoring, recognize transfusion reaction (tGVH disease) and treatmentAfter transfusion: HR 85, BP: 105/60, RR: 16-18, UOP 75mL/hrNursing Care - Wound cleansing/washout, dressing revisions, head of bed elevation, G-tube feeds vs. decompression, patient re-positioned every 60 minutes (use sleeping pad, pillows, etc. to shift pt position)Vital signs trending and documentation, recognition of improvement/degradation of statusFluid resuscitation – choses appropriate fluids (LR, Plasmalyte) and can apply Rule of 10s formula for burns, and hypertonic saline (3%) for head injury with evidence of increased ICP. Titrates fluids to appropriate UOP.Phase 3 (Extended Holding, Reassessment of supplies on hand, Work/Rest, Feeding)Duration: In actual exercise 2-3 Hours (here 45 min)Equipment Required: Team House Medical EquipmentArea Set up: Try to replicate a team house medical room. If possible include furniture, and desks to allow team to set up a commo station, and giving work spaces for team members to plan for future evac.Situation: Your Team will be holding your patient/s at least 24 hours due to mission constraints or AC unavailability. During this period you will have to use the limited supplies and personnel you have to ensure the best possible outcome and do it in a way which does not put the Team or Mission at additional risk.23304587630Patient 1: AD SF Soldier with penetrating extremity wounds x2, Class 2-3 hemorrhage, 6-8 hours evac before “definitive” treatment (handoff). Patient also has chest wall contusion/1-2 broken ribs (not PTX or pulmonary contusion). V/SInterventionsMonitoringInstructions to Role Player:00Patient 1: AD SF Soldier with penetrating extremity wounds x2, Class 2-3 hemorrhage, 6-8 hours evac before “definitive” treatment (handoff). Patient also has chest wall contusion/1-2 broken ribs (not PTX or pulmonary contusion). V/SInterventionsMonitoringInstructions to Role Player:Medic Gives ODA members Nursing Orders and Rounding InstructionsSet Work and Rest CyclesManpower assignmentsMedic wake up criteriaPatient positioning and movementIns and Outs loggedFeeding and Watering scheduleClass VIII Supply reassessment/inventory/resupplyCommunication with higher for transport updatesTelemedicine Trending/ChartingBlood WorkMove to BedPad LitterRoll/reposition PatientChapstickTube CareIV CareBrush TeethLabsTeleconsultTetanus TXGastric TubeUA DipstickSedationAnalgesiaPEEP Phase 4 (Prep for Transport, Logistics, Movement, Prep of Aircraft PRN)Duration: In actual exercise 1-2 Hours (here 45 min)Equipment Required:Area Set up:Situation: Arrangement for evacuation has been made, however due to adverse weather the dirt airstrip nearby cannot be used. There is no rotary wing asset within range. After making arrangements with higher, you will need to drive to an improved airfield. It is a nine hour drive. It will involve crossing a border. You will need multiple vehicles due to the remote route, in case of vehicle breakdown. An Air Force C-130 will arrive at the airfield in 12 hours. There will be no medical capability on the C-130, so you will need to care for the patient for the next 12 hours until lift-off and also plan to provide care during the 7 hour flight to Germany.7703161842Patient 1: AD SF Soldier with penetrating extremity wounds x2, Class 2-3 hemorrhage, 6-8 hours evac before “definitive” treatment (handoff). Patient also has chest wall contusion/1-2 broken ribs (not PTX or pulmonary contusion). V/SInterventionsMonitoringInstructions to Role Player:00Patient 1: AD SF Soldier with penetrating extremity wounds x2, Class 2-3 hemorrhage, 6-8 hours evac before “definitive” treatment (handoff). Patient also has chest wall contusion/1-2 broken ribs (not PTX or pulmonary contusion). V/SInterventionsMonitoringInstructions to Role Player:Full PACE communications plan for higher HQ and medical, LRMC SOF Hotline – 49-162-296-3962Telemedicine: patient presentation format (modified MIST)- clearly states: Current diagnosis – “I have a 30 y/o male s/p vehicle accident with___________” Condition, trends, “Vitals currently____________, showing improvement/worsening over last ____hours, with drop/increase in _________Treatments/Limitations- ““He has had 2 x TQs converted with pressure dressings, received 1 unit of FWB, splinting applied, oxygen, and Foley placed showing ongoing UOP of ______ml/hr.” “I need_______” – “I’ve been speaking with Dr. X at XXX HQs, and the patient needs immediate transport to higher level care for ____________”Addresses non-standard, non-attended medical evacuation and medically-supported MEDEVAC capabilities (who will pick-up the patient and what can they do during transport?)Consider stressors of flight:G: G-Forces & Gases (brain, eye, sinus, chest, GI, cast? SCD’s?) H: Humidity Decrease (mucous membranes) O: Oxygen Partial Pressure Decreased (pO2 60, Sat 90% at 8000 ft cabin pressure – chest/pulmonary issues) S: “Shakes”/Vibration (fractures, pain) T: Thermal Changes (coagulopathy) B: Barometric Pressure Changes A: Autograph – signed and complete documentation N: Noise (can’t hear patients, or each other, so, game plan & signals) Plan Equipment Needed for Flight:Oxygen (how much, what flow), Airway adjuncts, IV Fluids, Monitor (send yours, or MEDEVAC brings??), securing straps (floor load), paddingPlan Medications Needed for Flight – S – Sedation (Ketamine/midazolam, Fentanyl, Phenobarbital, Phenergan)E - Emergency (Epinephrine, Adenosine, Lidocaine, nitroglycerine), Zofran (vomiting when restrained = emergency)R - Reversal – Flumazenil, Naloxone, GlucagonE – Epilepsy (Head Injury) – fosphenytoin(15-20mg PE/kg IV x1), phenobarbital, diazepam, hypertonic salineA – Airway – RSI meds, consider succinylcholine, etomidate in addition to above. Albuterol.B – Bugs – Antibiotics (consider meropenem, levofloxacin, acyclovir, anti-malarials, and topical, eg bacitracin, silvadeneC – Circulation – (consider heparin/LMWH, furosemide)Patient packaging and preparation for flight – critical care transport: monitor, ventilator, oxygen, IV infusions, Foley all packaged per USAF CCATT standard (with available equipment), ET-tube air replaced with fluid, documentation completeAvoid hypotension, hypoxia, hypothermia:Maintain intravenous (IV) access with large bore peripheral IV’sConsider taking blood products for continued resuscitationBe prepared to perform needle thoracostomyand/or perform chest tube placementMaintain adequate oxygenation and ventilation (FiO2 at least 40%) (Tidal volumes of 6-8 ml/kg); keep O2 Sats > 93%Carefully evaluate/document neurologic status pre-flightPotential for compartment syndrome (extremity wounds -consider pre-flight fasciotomies)Moderate/Severe TBI - seizure prophylaxis, elevate head of bed and prevent jugular vein obstruction (C-collar?)DVT prophylaxisLeverages advanced commo technology, sending images, video teleconference for telemedicine ................
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