Prolonged Field Care (PFC): Lessons Learned from SOF

1. Prolonged Field Care (PFC):Lessons Learned from SOF COL Sean Keenan, MD FAAEM FAWM

2. DISCLAIMER The opinions and/or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the view of USSOCOM, the Department of the Army or the Department of Defense . Financial disclosures: The presenter has nothing to disclose.

3. PART 1: THE PROBLEM

4. Case Study South Sudan Cases (compiled by SOCAFRICA Surgeon’s Cell), December, 2013: Situation: At approximately 0815Z (1015L) while conducting a Noncombatant Evacuation Operation (NEO) of the U.S. Embassy three CV-22 aircraft carrying SOCCENT Crisis Response Element (CRE) came under small arms fire when they attempted to land at the Bor civilian airport in South Sudan, East Africa. All three aircraft suffered heavy damage during the small arms attack. Four U.S. personnel sustained injuries on one of the aircraft. Casualty Report: Patients will be referred to as Patients 1, 2, 3, and 4 for the duration of this document. Patient 1: Active Duty (AD) Service Member (SM) sustained a Gun Shot Wound (GSW) to left buttock, above the gluteal crease, through to left thigh with profuse hemorrhage. Patient 2: AD SM sustained a GSW to right mid-thigh. Patient 3: AD SM sustained a GSW to left hip through to left thigh. Patent 4: AD SM shrapnel wound to left lower back.

5. Case Study (cont.) Onboard the CV-22, Patient 4 (Navy SEAL E-5 Corpsmen) treated Patients 1, 2, and 3 after receiving small arms fire during over-flight of the airstrip. Each had a GSW to a lower extremity. Patient 4 applied tourniquets to Patients 2 and 3, and hemorrhage control via manual pressure to Patient 1. Within 15 minutes of the attack, Patient 4 triaged the patients and immediately relayed injuries through the aircrew to the Special Operations Forces Medical Element (SOFME) located at Entebbe International Airport in Uganda (2 hours south of incident). Patient 1 was the most critical due to wound proximity and sustained bleeding. The SOFME requested and received blood types for patients 1, 2, and 3, and collected donor fresh whole blood from a walking blood bank. Patient 4 administered fentanyl lozenges to Patients 1, 2, and 3. Due to heavy damage to the aircraft, the CV-22s were forced to land at Entebbe International Airport (not the planned airfield at Djibouti).

6. Case Study (cont.) At approximately 1130L (H+75 minutes), the CV-22s carrying casualties arrived on the commercial side of Entebbe International Airport and were met by United States Air Force Para Rescue Jumpers (PJs). The CV-22s then relocated to the military side of the airport and were met by a team of six US Military providers. The group included the SOFME Team of one USAF Flight Surgeon (FS) and one USAF Independent Duty Medical Technician (IDMT) which was assisted by a United States Army (USA) Special Forces Medical Sergeant (18D); Also present were a United States Navy (USN) Physician Assistant (PA) with two medical technicians who were passing through Entebbe at the time. The patients were offloaded from the CV-22s, and Patients 1 and 2 were loaded into a converted van—three rows of seats were removed and replaced with two litters.

7. Case Study (cont.) Treatment provided in Entebbe included: Patient 1: Patient 1 was given one gram of Tranexamic Acid (TXA) … (and) two units of whole blood—one obtained from a donor using walking blood bank protocol in Entebbe and the second was received from a PJ and administered by the USAF IDMT. Vital signs indicated Class III hemorrhagic shock (low blood pressure, reduced pulse pressure, and HR greater than 120 beats per minute). Patient 2: Patient 2 had a tourniquet on the right thigh at arrival …(and) it was determined that the patient’s condition necessitated the placement of a second tourniquet to control hemorrhaging. Patient was tachycardic but normotensive, indicating a Class II hemorrhagic shock. He was in extreme pain from GSW and tourniquet. …the wound packed with combat gauze and secured with ACE wrap. Patient 3: Patient 3 was found to have palpable pedal pulses due to improperly tightened tourniquet but was left as is since hemorrhage control seemed adequate. Patient 4: Patient 4 (The Navy SEAL Corpsmen) was evaluated by the 18D and deemed that treatment could wait until arrival at Nairobi General Hospital.

8. Case Study (cont.) A USAF C-17 was preparing for departure on an unrelated mission and was redirected to transport the four patients to HKJK (instead of the pre-planned C-130) for further treatment at Nairobi General Hospital (Kenya). The aircraft departed at 1200L (H+1:45) with all four patients, along with the USAF FS, the IDMT, the 18D, and the Navy PA for an approximately one hour flight to Nairobi. Patient 2 was floor-loaded first on the aircraft and then Patients 1 and 3 were loaded onto litter stanchions. Treatment en-route to Kenya included: Patient 1: Patient 1 … was given a femoral block with lidocaine for pain control, which provided only minimal relief. Patient 1 remained stable (after 2x units FWB) throughout the flight though pain was only partially controlled. Patient 2: Patient 2 was administered 1 ml of Ketamine (500mg/5mL) = 100mg IM in the left thigh at the Entebbe airfield while waiting for departure. Patient descended into delirium while on the C-17 and remained delirious during the course of the flight…after the IVs were patent, one gram of TXA was administered with the initiation of 500mL of normal saline.

9. Case Study (cont.) Treatment enroute (cont.): Patient 3: During the flight Patient 3 became somnolent and then unconscious, but breathing, likely secondary to the Versed (midazolam) given prior to administration of 100 mg of Ketamine IM. An NPA was placed and oxygen was given via an emergency O2 tank and aviator mask. Patient’s Sp02 and respirations continued to drop, so he was ventilated via bag valve mask. Patient 3 awoke after administration of the benzodiazepine reversal agent, Romazicon, and did not require respiratory support the remainder of the flight. The C-17 arrived in Kenya at approximately 1315L (H + 3 hours). Ambulances took the patients to Nairobi Hospital, where the team of surgeons and anesthesia personnel were waiting. Transport time from aircraft to hospital was approximately 45 minutes. Approximate time from initial injury to arrival at the Nairobi Hospital emergency department was four hours.

10. Case Study (cont.) • Kinda makes you pause… • Realistic? • Probable? • Textbook PFC scenario • Fog of War • Planes, trains, and automobiles • Multiple patients • Ad hoc CASEVAC • TCCC executed flawlessly…but then what???

11. OBJECTIVES • Define Prolonged Field Care • Introduce SOCOM PFC Working Group • Discuss Lessons Learned in analysis and training of PFC in SOF

12. Iraq

13. Afghanistan • Raleigh • Memphis • Atlanta • New Orleans

14. Africa: “Tyranny of Distance”

15. Current Paradigm

16. WHY?

20. “Non-TCCC Events” • Those things which keep medics awake at night…. • Examples include: • Accidental GSW • ATV rollover with suspected TBI • Fall from roof with blunt lung injury • MVA with Pelvic fracture • House-fire with smoke inhalation • 40% TBSA burn • Electrocution • ACS • Near drowning • Envenomation

21. What should we focus on?Scope of Practice – TCCC vs. PFC TCCC: combat trauma Practitioner (lowest level): Combat Life Saver, Combat Medic WITHIN doctrinal planning guidelines PFC: all-causes mortality or significant morbidity in austere environments (Opens the aperture on medical and traumatic conditions) Practitioner (lowest level): Independent SOF practitioner (SOCM, 18D, IDMT, IDC); Physician/PA – deployed for FID or Humanitarian Assistance (non-combat roles) BEYOND doctrinal planning guidelines

22. DEFINITION • Field medical care, applied beyond ‘doctrinal planning time-lines’, by a SOCM or higher, in order to decrease patient mortality and morbidity. Utilizes limited resources, and is sustained until the patient arrives at an appropriate level of care.

23. The SOF Truths Humans are more important than Hardware. Quality is better than Quantity. Special Operations Forces cannot be mass produced. Competent Special Operations Forces cannot be created after emergencies occur. Most Special Operations require non-SOF assistance

24. “The PFC Truths” If you think you need a surgeon or intensivist in the Field, put one there. No magic piece of kit will give you the capability. PFC is not a qualification or skill set, it is an operational problem or situation that you find yourself in. Competent (PFC medical) Forces cannot be created after emergencies occur. Most Special Operations require non-SOF assistance (especially if you have a smaller deployed force).

25. PFC Working Group and Lessons Learned

26. SOCOM PFC Working Group • Started at SOMSA, December, 2013 with the “Extended Care Working Group” • Interested individuals met over two lunchtime sessions • From this meeting a list of priorities emerged, as well as WG member e-mail list • OVER THE PAST 24 MONTHS: • Established Steering Committee: 2 docs, 3 medics • E-mail list grew to over 150 names • Representatives from all major Commands in SOF, partner agencies, civilian and military academic faculty and international representation • Established websites (SOMA and independent site) and multimedia education and discussion tools

27. PFC WG Products and Projects • Position Papers, Guidelines, PFC-specific References, Podcasts • Website/discussion forums • Established Journal of Special Operations Medicine (JSOM) “Ongoing Series” • Collaboration with JTS/ISR • Case series for epidemiologic analysis • Pre-hospital Clinical Practice Guidelines (CPG’s) • Burn, Crush Injury, Pain Control, TBI

28. Lessons Learned • TCCC is the foundation of care for PFC • Master the Basics • TCCC absolutely decreases mortality • TCCC is the “what (to do),” PFC is the “why (we do it)” • “What” = technician (EMT-B, CLS) • “Why” = clinician (independent practitioner) “If you don’t know TCCC, don’t even bother trying to learn PFC” • Prioritize your medical training

29. Lessons Learned (cont.) • PFC scenarios require a higher level of care => independent practitioner • Medical Planners, Operations Personnel and Commanders must be informed of the risk of operating in austere environments • Basic medics (68W) should not be expected to succeed in PFC scenarios – without significant back-up • PFC core skills include secondary survey and problem list development • TCCC training has de-emphasized the history/physical exam/problem list • You must identify your targets before you can engage them

30. Lessons Learned (cont.) • By definition, the provider on the ground will be overwhelmed. We must develop systems which model current medical practice, to include: • Decision aides • Update references: TMEPs, SOF Med Handbook, Ranger Handbook • Clinical Practice Guidelines (CPG’s) • Using existing technology • Tele-consultation • How do you call • Training • Technology • Who do you call? (VC3, TSOCs, unit docs)

31. Lessons Learned (cont.) • Mission planning by the medics must be much more comprehensive than previous experiences • Evac chain • Referral facilities • Logistics • Multiple references in blogs and posts on website • Continuous evaluation and re-evaluation • Trending of vital signs is essential in any serious or critical patient • Blogs, decision aids, patient care flowsheets available on website

32. Lessons Learned Summary • Many of the products on the website address previous requirements • PFC is a new operational reality for many of our deployed forces – both SOF and conventional • Many of the PFC Capabilities are not new or unique, but require a shift in focus of training once you have Mastered the Basics (TCCC) • Ref: PFC Position Papers (Capabilities and Operational Context of PFC)

33. Questions? PFCare.org