TC3 Continued...

Medical continued……

Tactical field care 

Ok…..so, Joe’s bleeding leg has been brought under control via tourniquet and the enemy seems to have broken contact. A secure perimeter is established as everyone cross levels remaining ammunition. The QRF is still a ways off as you turn your attention back to Joe. 
   You see that Joe is struggling to breath…..that’s when you notice the blood pooling under him. You check the tourniquet on his leg, thinking that it must not be tight enough. You suspect he may have another wound and begin to check him when you see it; a bullet wound just below his right pec. You open up his shirt and can see the blood running out of the wound….you apply direct pressure with your hands and call for assistance. You calm yourself and recognize that this is a classic “sucking chest” wound and will need some kind of occlusive dressing to prohibit any air flow. Steve shows up with an aid bag and pulls out a chest seal dressing and slaps it on over the bloody wound. You roll Joe to his side to check his back and find an exit wound directly posterior to the entry. That’s a good sign you think to yourself as it appears to be an “icepick” wound as opposed to the bullet tumbling and taking the scenic route through Joe’s torso. There is more blood coming from the exit wound so you open a combat gauze and begin to pack some in the wound as you unroll it….you then apply an occlusive dressing.  Your mind races as you go through the treatment protocols in your head…..MARCH…(a variation of the old ABCDE)

Massive hemorrhage
Airway
Respiration
Circulation
Head & Hypothermia

Massive hemorrhage: OK, tourniquet on the leg has controlled that wound and the two occlusive dressings and gauze have controlled the chest bleed. Joe is having a difficult time breathing…..you ask him a question but he mutters incoherently. Okay, he was able to speak so his airway is intact…..but he is really struggling to take breaths. As you look at him you notice the vein in his neck standing out….then it dawns on you – his lung is collapsing due to the atmospheric pressure inside his chest cavity from the wound. You grab a 14 gauge needle, place your finger on his the middle of his clavicle (wounded side) and draw a line straight down through his nipple. On this line you find the second or third rib from the top, aim the needle just over the top edge of the rib and press in till you hear air escaping from the cath. After a moment, Joe seems to start breathing easier. You debate giving Joe morphine, but decide against it as you recall it is bad to give morphine to a patient in respiratory distress. 
You decide to check Joe for any other wounds you may have missed. Once you are satisfied, you pull out his poncho liner and wrap him in it. Joe becomes more lucid and notes his intense discomfort. You give him some water, oral antibiotics and Tylenol/acetaminophen since it will not disrupt his blood clotting ability. Steve takes a set of vitals from Joe and writes them down. Steve asks you to start a saline lock on Joe, but delay any IV therapy for the time being. You finish taping down the lock and wrap a blizzard blanket around Joe as you hear the faint sound of the approaching QRF….


OK….lets break this down.
First off; this is the portion of TCCC where most of your medical work happens. In the first stage – Care Under Fire – you limit yourself to stopping severe bleeds, since the primary concern at that point is stopping the threat. The reason we address severe bleeds is that a human can bleed to death in a matter of minutes from an artery.

Side note:
I would also note that the cross-leveling of ammunition occurs once everyone has roger’d up an ACE/LACE report:

Ammunition left
Casualties if any
Equipment status
(some units report liquids status – as in water)

Reason for this practice is that the guys on the skirmish line or making the most contact are going to have a lot less ammo remaining than the guy that was pulling rear security – fairly academic.  Cross-level to make the entire unit equally effective for follow on actions. 

Joe discovers a chest wound that he did not initially see…..hey it happens. One thing to note is that it can be tricky getting the occlusive dressings to maintain a seal on wet, bloody skin. If you are able to blot it dry real quick, you will get more mileage out the dressing. Once he has the dressings in place he recognizes that Joe is suffering from a tension pneumothorax and treats it with a needle decompression. Notice that Joe is careful to insert OVER the rib as there is a vascular bundle that runs on the bottom of the ribs.
I have seen several variations of the MARCH acronym – MARCH-E, ABCDE, SCAB, etc – point is, control the severe bleeds first, then airway, breathing, etc.
So, the couple of questions I can hear folks asking is: 1) Wouldn’t he be in shock? 2) Why not give him Morphine? 3) Why not start him on IV fluids?

1) He was indeed showing some outward signs of early shock. Joe covering him was an important first step. Any serious injury of this nature can quickly lead a patient into a hypothermic condition.
2) Morphine is contraindicated when a patient is in respiratory distress as it further depresses respiratory function. Ketomine or Acetometaphine may be better options.
3) This can be a tough one….adding saline or Ringer’s in the field to boost blood volume will raise blood pressure, but….it also can have a negative effect on clotting factors. I have seen this issue go back and forth over the years. I like the approach of getting a lock in place so you have easy access if the decision is made to introduce fluids. The most recent TC3 protocol is to administer a drug called TXA (tranexamic acid ) with the fluid if there has been substantial blood loss. This will aid in clotting as it inhibits the body from breaking down clots.

One last thing I would point out again is the importance of getting the patient warm. Even in a blazing hot desert, blood loss will lead to hypothermia and death. The Blizzard blanket is a very useful item that I would encourage everyone to have in their kit.

…….More to follow……