Improvised Medicine: Part 2

In a previous entry, we discussed improvising in the field and demonstrated a method of creating a scalpel handle out of its wrapper. This entry will focus on the safety pin and several of its uses. It’s always a good idea to have 4 or 5 of these in your kit. They can be used to solve many medical and non-medical problems. They are inexpensive, don’t expire, and take up hardly any space.

Here is a list of a few things you can do with a safety pin:

-Pin the tongue to the lip to maintain the airway
-Splint a finger
-Make a sling out of a casualty’s shirt
-Close abdominal wounds or large lacerations
-Make a tracheal hook
-Secure an ET or Cric tube.

Like most improvised medicine, these techniques are not definitive treatments, but in certain situations you may not have any other option. You can never carry everything, so knowing how to employ items you have can be a life saver…literally.

Casualty as a Fluid Infusion Device: IV Bag Placement

Summary

This study was designed to identify the most effective underbody
position when using the patient’s own body weight as an
infusion device. Twenty volunteers had an air-less 500ml bag of
saline located at various under-body positions. Mean pressures
and flow rates through a 14G cannula were measured in vitro at
room temperature. Locating the fluid bag at the buttock cleft
delivered the highest mean flow rate at 135ml/min. This underbody position may provide flow rates sufficient to achieve the clinical aim of fluid resuscitation in the military pre-hospital
environment.

Fluid Infusion IV Bags

A dictum of tactical medicine is to carry equipment that has dual use. In the case of fluid infusion, medics are instructed to use their blood pressure cuffs or the patient if no other device is available. Medics have the option of carrying pre-made fluid infusers or an extra BP cuff, but the former violates the rule of dual use and the latter may be too bulky. The above article offers a valid, though not new, solution, because it explores the best location if a medic chooses to use the casualty.

Surgical Airway/Cricothyroidotomy: How to

This video is a supplement to training and is neither comprehensive nor a replacement for proper instruction.

A surgical airway/cricothyroidotomy is the advanced airway of choice in combat, due to the types of injuries encountered. Severe maxofacial trauma secondary to blasts are common and may require more invasive treatment when neither the recovery position nor NPA nor King Oropharyngeal Airway (King-LTD) will suffice. It is important to note that only airway management is generally best left to the Tactical Field Care (TFC) phase of treatment. Furthermore, less than 1% of trauma casualties require an airway, so prudence is required when deciding to intervene. The indications and contraindication are as follows:

Indications:

–Airway obstruction due to maxillofacial trauma that cannot be corrected by positioning or a nasopharyngeal airway
–Anaphylaxis that is or is about to compromise the airway
–Inhalation burns injury
–Where other means to secure the airway have failed

Contraindications:

–Airway can be maintained by other means

Please note that we illustrate a vertical incision instead of the traditional horizontal, because we feel it is the preferred method in the tactical environment. First, a vertical incision minimizes the risk of involving (e.g., cutting) the vascular structure of the neck. Second, it creates a larger “window,” thereby simplifying landmark identification. Finally, a vertical incision allows one to select a different location above or below the initial site, if one should misplace the initial cut, due to lack of familiarity with the procedure.

Three-Step Cric?

Below you will find an article published in Military Medicine. It argues that traditional ways of providing a surgical airway in a tactical environment are flawed. Therefore, the authors continue, a new approach is needed. Three-step Cric

Objective: Surgical cricothyroidotomy is the airway of choice in combat. It is too dangerous for combat medics to perform orotracheal intubation, because of the time needed to complete the procedure and the light signature from the intubation equipment, which provides an easy target for the enemy. The purpose of this article was to provide a modified approach for obtaining a surgical airway in complete darkness, with night-vision goggles. Methods: At our desert surgical skills training location at Nellis Air Force Base (Las Vegas, Nevada), Air Force para-rescue personnel received training in this technique using human cadavers. This training was provided during the fall and winter months of 2003-2006. Results: Through trial and error, we developed a “quick and easy” method of obtaining a surgical airway in complete darkness, using three steps. The steps involve the traditional skin and cricothyroid membrane incisions but add the use of an elastic bougie as a guide for endotracheal tube placement. We have discovered that the bougie not only provides an excellent guide for tube placement but also eliminates the use of additional equipment, such as tracheal hooks or dilators. Furthermore, the bevel of the endotracheal tube displaces the cricothyroid membrane laterally, which allows placement of larger tubes and yields a better tracheal seal. Conclusion: Combat medics can perform the three-step surgical cricothyroidotomy quickly and efficiently in complete darkness. An elastic bougie is required to place a larger endotracheal tube. No additional surgical equipment is needed.

How long Is Your Needle?

Chest Wall Thickness in Military Personnel: Implications for Needle Thoracentesis in Tension Pneumothorax

Author(s)
HARCKE H. Theodore ; PEARSE Lisa A. ; LEVY Angela D. ; GETZ John M. ; ROBINSON Stephen R. ;

Journal Title
Military Medicine ISSN 0026-4075

Abstract

Needle thoracentesis is an emergency procedure to relieve tension pneumothorax. Published recommendations suggest use of angiocatheters or needles in the 5-cm range for emergency treatment. Multidetector computed tomography scans from 100 virtual autopsy cases were used to determine chest wall thickness in deployed male military personnel. Measurement was made in the second right intercostal space at the midclavicular line. The mean horizontal thickness was 5.36 cm (SD = 1.19 cm) with angled (perpendicular) thickness slightly less with a mean of 4.86 cm (SD 1.10 cm). Thickness was generally greater than previously reported. An 8-cm angiocatheter would have reached the pleural space in 99% of subjects in this series. Recommended procedures for needle thoracentesis to relieve tension pneumothorax should be adapted to reflect use of an angiocatheter or needle of sufficient length.

Chest Wall Thickness

Improvised Medicine Part 1

As mentioned in earlier entries, one of the keys to success in the tactical environment is flexibility. A Medic’s ability to improvise with his equipment or other items greatly increases their level of flexibility. Improvising can allow you to reduce in size and lighten your load, or to treat an injury you didn’t think you had the ability to treat.
While these solutions are generally not definitive treatments, they are often better than nothing at all. If you have the right gear, use it. The point is to be prepared for when you don’t.

In this first entry, we will cover some basic principles:

1. Think ahead- know the equipment you have and think of other ways to use it.

2. Don’t “pre-improvise”-Yes it can save time, but chances are if you modify a supply or component it is a permanent change that will either eliminate its ability to perform its original task or at least reduce that ability. This does not apply to everything so use your head and do what makes sense.

3. Don’t improvise with highly specialized items unless you have no other choice- It makes little sense to use a 14ga angiocath to improvise a trach-hook if I can do the same thing with a safety pin. There are few ways to improvise an angiocath, none of which I’d want to try or have tried on me. That’s an item that is specialized.

4. Don’t bury your head in your aid bag- The great thing about improvising is that you have the world at your disposal. Just because an item in not labeled “medical” does not mean you can’t use it.

Planned improvisation
An example of planned improvisation is the decision to not carry scalpel handles or full-sized disposable scalpels. I can carry 10 blades of differing design to one disposable scalpel that only offers me one blade choice. By using the blade wrapper to create a handle (see the video for a demo) I now have a functional instrument that I can use to perform just about any procedure that requires a scalpel. The control of the blade is not as fine, but it is more than acceptable (if practiced) for the majority of emergency procedures conducted in the field.

Developing a Tactical Emergency Medical Support Program

This post is geared toward TEMS Medics. We will be posting a video in two weeks detailing medical equipment improvisation techniques for the field. Dr. Schwartz recently published a book that examines TEMS programs in greater detail. There is a link to it in the right margin of the page, under the heading Recommended Readings.

By Joshua S. Vayer, BA; Richard B. Schwartz, MD, FACEP

The development of a tactical emergency support (TEMS) program is an involved process. Multiple TEMS models effectively function and there is no “best model” for every agency. This article summarizes common components that must be considered in the development of a TEMS program. Components discussed include: goals of TEMS program, structure of the TEMS element, training for TEMS providers, law enforcement status, TEMS provider skill level, arming of TEMS providers, operating location, liability issues, insurance issues, and equipment for TEMS units. The proper development of a TEMS program will meet the primary goal of enhancing the tactical unit’s mission accomplishment. Key words: CASEVAC, explosive ordinance disposal, hostage rescue team, special weapons and tactics, special response team, tactical combat casualty care, tactical emergency medical support, tactical medicine.

TEMS ARTICLE

Post-engagement Hearing Loss and Factors Affecting the Use of Diagnostics

One of the challenges associated with tactical medicine is the lack of diagnostic equipment at the point of injury and throughout the evacuation process. The tactical situation can limit the ability to use exam lights (of any color) and post-engagement hearing loss or environmental noise can eliminate your ability to use a stethoscope or to hear at all.

It is important to practice different techniques for assessing your casualties’ status that do not require the use of diagnostic tools or one specific sense. Hearing is the most regularly affected sense in the combat environment and it is the sense medics rely on the most heavily. Large blasts or firing a weapon can cause a significant ringing or a muffle in your ears. Therefore, when listening for slight variations in breath sounds or a fading pulse, it can be next to impossible to hear. That is why you must learn alternate methods for assessing your casualties’ status.

One skill that is often affected is measuring blood pressure. If you don’t know how to take a palp. blood pressure or know how pulse presence roughly correlates to levels of BP, you need to learn and practice the techniques. They also come in handy when working in the back of a helicopter or loud vehicle such as a track-vehicle or Stryker that are on the move. Here are some examples of pulse pressures associated with the presence of a pulse in various locations.

Pulse Location/Correlating Pulse pressure

Dorsalis-pedis pulse/90
Tibialis-posterior pulse/90
Radial pulse/80
Femoral pulse/70
Carotid pulse/60

These are very rough estimates and should only be used when no other means of measuring pressure are available. Studies have shown that this method often causes medical personnel to overestimate their patients’ pressure. We suggest this method be used to note which pulses are palpable during the initial set of vitals. Mark the location of these pulses with a Sharpie® when they are found. If a pulse that was present becomes weaker or disappears as time elapses, your casualty may be deteriorating, and you need to do something to address the cause of that deterioration. As stated earlier, this method should not be used if an accurate pressure is required.

The inability to use the sense most suited for the evaluation of a casualty is not just limited to taking blood pressure. It affects your ability to assess a needle decompression in a helicopter, looking for unilateral rise and fall of the chest, feeling for injuries and many other portions of your assessment. Regular practice of alternate methods of assessment should be included in your training regimen, because it’s too late to practice after your ears are ringing from the IED blast.

Training Company or Product Peddler? You Make the Call

Who is providing your training? Is it a company that manufactures or distributes products? If so, beware. We receive emails and calls weekly regarding training. We do not offer training, because it is difficult—perhaps impossible—to offer students quality training without conscious or unconscious biases impeding. Therefore, we recommend finding companies that do not have a vested interest in selling products. Finding quality training is difficult. Budget, geographical, and time constraints may limit your ability to receive quality TEMS/TCCC training. Unfortunately, factors beyond your control may force you to attend a class provided by a company that peddles their products behind a guise of training.

Below you will find a list of topics that ought to be covered by a training program, as well as telltales of product peddling.

1)Care Under Fire Phase techniques and considerations
2)Tactical Field Care Phase techniques and considerations
3)Patient evacuation methods, movement, equipment
–Litters (e.g., rigid, semi-rigid, pole-less)
–Rescue Tactics, which is the most important part, and equipment
–Hypothermia prevention/treatment
4)Hemorrhage control and treatments
–Tourniquets, Bandages, Gauze, Hemostatics how to use each
5)Airway/Breathing treatment techniques and considerations
–NPAs, Crics, occlusives, and needle decompression
6)Fracture ID/management/Splinting techniques and considerations
7)IV/IO techniques and considerations
8)Multiple Casualty/triage methods and documentation
9)Casualty model scenarios (live and simulated, the former being preferable)

Signs of product peddling: Instructors might display multiple products in one category (e.g., tourniquets) that you might see in your theater of operation. Next, they discuss the pros and the cons of each product. However, watch for the “cons” identified when discussing the product they sell. Instructors will highlight all the negatives of other products, often citing anecdotal cases or out-of-context research, while offering “vanilla” cons, if any at all, for their product.

That said, test products after learning their proper implementation in a course. Instructors do not hold a monopoly when it comes to knowledge. They may be basing their “facts” on assumptions, one poor experience or hearsay. Test items yourself. Call the company that provides products and ask the benefit of its product. Gauze, for example, is gauze. Therefore, if a company tries to tell you it has the best, question its judgment.

In the end, you ought to seek the best training and the best equipment, because yours is a business that saves lives. Do not become enamored with a company’s products because they provided training. Furthermore, because a national organization approves a course, product, or methodology do not assume it is best.

Here are a few US companies, with which we have no affiliation, that offer training and do not push products:

JTM Training Group
http://www.jtmlasvegas.com/

Mobile Asset Security and Training Group
(http://www.mastsolutions.com/training.html)

Teir 1 Group
(http://www.t1g.com/)

Tactical Rescue: Considerations When Planning

In the last few years the topic of tactical rescue/high threat extraction has become increasingly popular. New techniques and products enter the field almost weekly. While some of the techniques have merit, some do not. Some of these are presented as a panacea, but have extremely limited application in the tactical or combat arena.
When performing a tactical rescue the most important component is the employment of proper tactics. Failing to have a well rehearsed tactically sound plan for varying terrain, building structures and locations (e.g., hallways, stairwells, rooms etc. ) within that structure will seriously hamper your efforts. We will not cover how to conduct a rescue due to the open nature of this blog, but we will cover several things to consider when developing your plan and selecting techniques.

Fitness levels/size
Keep in mind you will be moving a significant amount of weight when using a drag-device. For example, have your smallest operator move your largest operator and see how effective they are.

Terrain/surface
A technique that works well on a buffed tile-floor may not work well on a concrete walkway leading to the front of a house, or in the middle of a road in Baghdad. Increased levels of friction will seriously hamper your movement out of the danger area. If the surface is slick enough to facilitate casualty movement it also increases the risk of a rescuer losing their footing due to pooling blood or other bodily fluids.

Size of the rescue team
Find the balance between efficiency and clutter. A larger team brings more guns, but it is also a big target. A four-man rescue team can rapidly turn into a four-man team in need of rescue. Minimize the amount of human assets you place in harm’s way whenever possible, especially if they can more effectively engage from another position.

Who will provide security?
Will the rescuer provide their own security? How effective are they with their weapon when pulling the heaviest member of your team? Generally, they are not effective at all. If the rescuer is the only person available to provide security, it may make more sense to delay the rescue. All other options should be considered before this is chosen. It makes more sense for a security element to establish an over-watch position from a position of cover to provide security than to expose itself to an adversary that has the advantage of cover and deciding whether to engage or not. In a military setting this is less of a concern if suppressive fire can be placed on the enemy position during the rescue attempt.
Do I have a ballistic shield? How can I employ it into my rescue plan?

Determined enemy vs. just a bad guy
All bad guys are not created equal. A truly determined enemy will take risks and make sacrifices far beyond what you would see in a “regular” bad guy. This also holds true for the mentally ill or chemically impaired. Suppressive fire from a crew-served weapon may not deter some enemy combatants; do you think a lone soldier or officer firing his M-4 one-handed from the hip will? Most likely not. If your enemy is determined to kill you he will not be scared of a few rounds. You need to be in a position to make those rounds count, not just wildly spray a doorway or wall.

Abort criteria
At what point does this not make sense anymore? Set your limits and stick to them if possible. These limits should be set before emotions get involved. Don’t wait until it’s time to do it for real.

There is an old saying, “speed is security,” and this is a scenario where it holds true. The primary focus of the rescue team should be rapid movement out of the danger area. You cannot perform every task of a tactical rescue by yourself, while performing those tasks to standard. You cannot move casualties and effectively engage hostile personnel at the same time. It briefs well, but it does not go much farther than that. Instead of practicing 50 ways to use tubular nylon, pick 5, and then spend the rest of the day working as a team to save a friend’s life.