# For the tactical medic/ military/ those who wanna try combat related trauma.



## Afflixion (May 19, 2009)

So a few weeks ago one of our trucks got hit by an EFP (explosively formed projectile) not going to go into detail but it's basically molten brass moving at extreme speeds. My junior medic was the one who was there not me personally. The EFP went through the drivers side door taking off the drivers left arm from the forearm down, the over pressure caused bilateral collapsed lungs and a few fx ribs causing flail chest. The TC or passenger had the left buttock taken off with pelvic fx, and possible femur fx. Both suffered third degree burns. The gunner was fine with the exception of second degree burns to bilat LE. Medevac bird is a 15-30minute wait so you have that long to treat with limited resources in your aid bag. provided the area was cleared and had 360 security what would you have done?

According to my junior medics report he triaged threw a tourniquet on the driver, then proceeded to work on the TC he packed the wound with kerlix the best he could used cravats to stabilize the pelvis and here's where he messed up ignored the femur fx. granted we have no traction splints here I feel he could've SAM splinted the femur and had a CLS keep manual traction until medevac arrived. We also have a product called "Combat Gauze" which has a clotting agent in it I believe he could've used that rather than kerlix. IMO i believe he did a fairly good job seeing as it was his first deployment and first major casualty.


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## Mountain Res-Q (May 19, 2009)

WOW!  You all have my respect here.  We can all fight over what is true EMS, but hot damn, you are probably the only ones practiving true *EMERGENCY* MEDICAL SERVICES!  My respect and my admiration goes to you guys.  Very few of us will ever put our lives on the line like that or have the awesome responsibility of treatng those who come close to giving their lives selflessly.

As for the scenerio.  IMH-untrained-O, obvioulsy combat medicine is so differnet than what we do in the states, that any of our cookbook protocols are goona be inadequate.  Hell, scene safety does right out the window.  3 patients?  Triage the amputation as #1 critical, the the pelvic practure as #2 critical because of the pelvis involvement, and then the burns as a walking wounded.

I guess I agree with all the treatments, including the pelvic/femur splinting.  One question, what do you guys carry for decompression of colapsed lungs?  I didn't see anything mentioned about that for your driver; or for the flail.  Or was he viewed as unsalvagable and primary care went to the passanger?

Bigger Question.  Did our boys make it?

BE SAFE!!!!!  No matter what the political views are of the nation... we are all supporting you and your selfless actions... especially your brothers and sisters in EMS!


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## Afflixion (May 19, 2009)

ah forgot that... if your a 20 your allowed to initiate a chest tube if your a 10 you got a 2 and a half inch 14 ga cath. He was a 10 (PV1-SPC= 10, SGT= 20, SSG= 30, SFC and up is a 40) so he did a bilat needle chest decompression (though he wasn't showing JVD he did it as a preemptive thing) and he obviously wasn't spontaneously breathing so he tried to drop a tube but missed and went to king LT instead and ventilated. He also used kerlix and duct tape for the flail chest. As to the question the TC received ten units of blood that night. The driver is recovering in another country. the TC is still listed in critical condition but expected to pull through. The gunner got some silvadine and some crazy enzymatic debridment cream I have never seen. Combat medicine isn't all that different from CONUS EMS just we dont get yelled at for "improvising" we also triage slightly different and Hemmorhage always comes before Airway. It's "H-ABC" for us.


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## SauceyEMT (May 19, 2009)

Afflixion said:


> Hemmorhage always comes before Airway. It's "H-ABC" for us.



I'm assuming thats because the bleeds you'll encounter from high velocity rifle fire, and/or explosives will empty your arteries quicker than the lack of O2 will kill ya, correct?


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## Afflixion (May 19, 2009)

that and it's typically pretty difficult to ventilate a PT out here. Most Pts that are not spontaneously breathing after establishing an airway are triaged as expectant unfortunately.


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## mycrofft (May 19, 2009)

*Crikey.*

Buy that man a beer!
Can fasten one femur to the other if you have cravats or duct tape, better if you can pad between, but watch for swelling causing a pseudo compartmentalization by "filling up" the space betwen the bone and the cravat/duct tape causing them to cut off circulation distal if there is enough  circ intact to "fill up". 

DEROS is going to be a real letdown after that sort of stuff. Maintain low tones, manitain low profile!


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## Afflixion (May 19, 2009)

i'm suspecting sometime in route to the MTF he did slice his femoral because we got word back he got 10 units of blood that first night... But both are suspected to pull through so thats always a good thing in my book.


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## mycrofft (May 19, 2009)

*"Suspected to pull through". Tells stories right there.*

With that much force, femoral and other major bleeds expected, maybe in other areas. Amazing what carnage there can be under a 1/4 inch puncture wound from close-by explosive shrapnel.

Did he also sprinkle sulfa on the wound and give em a cigarette? (I AM old!).

You should revive or start a thread on TK's.


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## Afflixion (May 19, 2009)

yeah if anyone gets a chance I suggest taking a BTLS or ATLS class teaches you about ballistics and kinetic energy. No I don't s'pose he poured sulfa on the wound but might've given him a cigarette. I just brought this up because it's not often you get someone with their buttocks missing.


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## mycrofft (May 19, 2009)

*Not alive.*

I treated a guy with half of one missing, .357 at under ten feet aimed at the groin and he moved.

Buttoks are hard to dress.


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## Afflixion (May 19, 2009)

Yeah me personally I've never had to deal with it though it would be a hard thing to bandage properly and it's to high for a tourniquet too so direct pressure is the only way to go really. (I'm aware in civilian EMS tourniquets are the bane of all that is good in medicine)


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## Aidey (May 19, 2009)

Afflixion said:


> According to my junior medics report he triaged threw a tourniquet on the driver, then proceeded to work on the TC he packed the wound with kerlix the best he could used cravats to stabilize the pelvis and here's where he messed up ignored the femur fx. granted we have no traction splints here I feel he could've SAM splinted the femur and had a CLS keep manual traction until medevac arrived. We also have a product called "Combat Gauze" which has a clotting agent in it I believe he could've used that rather than kerlix. IMO i believe he did a fairly good job seeing as it was his first deployment and first major casualty.



IMH-also-untrained-for-combat-medicine-O I was thinking this was a good case for a clot activating gauze since that area would be hard to pack/bandage with enough pressure. 

Although, thinking about it, this is one of those cases MAST pants could have been used to splint the leg and pelvis together, and put pressure on the dressings to keep them in place. 

Also, even though your medic didn't put a splint on the femur, a traction splint would have been contraindicated in this cause because of the unstable pelvis. A splint would have been good, but not a traction splint.

That is all I've got, nothing too critical. It's gotta be hard for one guy to treat 2 people with multiple serious injuries at the same time. Its awesome that both guys are going to make it.


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## Afflixion (May 19, 2009)

this is true it slipped my mind with the pelvic fx was to caught up on the fx femur that possibly sliced his femoral... Wow see even "senior" medics make mistakes. I still like the idea of anatomically splinting the legs seeing as a SAM splint most likely isn't long enough to do much good ( we don't carry the longer ones.) It's kind of funny that a lot of EMS still lug around MAST pants when the military doesn't even use them anymore. Yeah the only thing I kind of picked at was his lack of using combat gauze granted we just got it (it's kerlix with the *new* non burning quikclot embedded into it. Prior to that we used HemCon (chitosan) dressings which would've been useless in this (and most) cases.


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## Afflixion (May 19, 2009)

also in regards to the one person aspect We have CLS (combat Life Savers.) They're mostly useless except a select few but an extra set of hands is always helpful. "Hey you go get the litter" "hey you breathe into this tube" "hey you hold his head just like this and don't let go if you do I'm going to beat you with an inflatable sheep!" etc.


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## Aidey (May 19, 2009)

Ok, I wasn't sure if the military still used the MAST pants or not. 

Like someone above said, splinting one leg to the other is a good idea. Or a board/pole etc would work too since you can't put traction on it and you are just trying to keep it straight.

Ok, thanks for explaining what CLS is. So basically they are first responder types?

Total side note, but I know someone with a blow up sheep....not sure why they have it, or where they got it, but they do.


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## Afflixion (May 19, 2009)

basically only most don't enjoy it as the army is starting to force "100% CLS" and in reference to the side note i believe the website is www.muttonbone.com for the LOVE EWE! lol yes we infantry companies are a strange lot...


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## mycrofft (May 19, 2009)

*Not going there.BAAAAAAA nuts!*

Anatomic splinting is fast and you don't need to go looking for that perfect pole or crutch or whatever. "Scene safety" means get down and get away THEN make pretty.
SKED looks good for that except you'd be dragging a sled through SW Asia. under Murphy's Law that wold attract fire since you look funnydifferent.
Hey, for a new thread, any such thing as Murphy's Laws of CLS?


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## Afflixion (May 19, 2009)

theres a Murphy's Law of War?

http://www.emtlife.com/showthread.php?p=146835#post146835


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