Frontline Medicine

[jjesusfreak01]

http://www.bbc.co.uk/programmes/b017ld7n

Interesting show, however it almost seems a little dated. They talk about military style tourniquets like they're the newest tech. They've got military evac helicopters with docs on them (which allows them to give painkillers and infuse blood, can't have the paramedics doing that). The coolest thing on the first episode was the discussion of hypothermia for trauma victims. I've heard a lot about this, but apparently human trials will be starting soon if they haven't already.

 

[DPM]

The CAT has only been routinely issued to British troops for the last 3/4 years. The introduction of them, pressure dressings (like the Emergency Care Bandage) and hemostatic agents like Hemcon and Celex has had a remarkable impact on survivability. All troops now carry these on them and are trained in how and when to use them.

The hypothermia issue was something I encountered in both Iraq and in Afghan. A casualty that's already hypovolemic and shutting down, with his clothes removed, and very often wet from his own sweat and blood... they get cold fast! IIRC a study found that a body temp below 35c in these cases had a 0% survivability.

 

[bigdogems]

So far every study I've seen using hypothermia in trauma pts has had negative results

 

[DPM]

So far every study I've seen using hypothermia in trauma pts has had negative results

I wish I could remember where I read it, but there's a journal article that sums up a fair few pieces of research and it pretty much kicks the idea of therapeutic-hypothermia into touch.

Just had a quick google, the body temp I was looking for was 32c. You hit that or lower and there was 100% mortality.

 

[jjesusfreak01]

As a clarification, this isn't the "cool them down a little so the brain and heart aren't injured" method, like we do for cardiac arrests. We're talking about the "replace their blood with fluid and cool them down to 10 Celcius in a few minutes to give the surgeons time to plug the holes before they bleed out" method. This is being tried for patients who we would normally expect to die on the table.

 

[DPM]

So you would have to 'replace' or somehow rapidly cool the PT's blood... I can't see a practical, pre-hospital way of doing this.

And with respect to battle casualties, in Afghan we could get the MERT wheels up in around 10 mins with a 15-20 min flight time to us. A Dr, Nurse and 2 paramedics within 30 mins is fantastic, but it can take longer than that to extract a casualty and longer still to secure an appropriate HLS. Ether way, would you be able to administer this treatment (along with the normal CABCD stuff) in the back of a helicopter? If you've ever been in a chinook you'll know that there's isn't a lot of room, and very often there's more than ones casualty.

If the research is being done then I'd love to read it, but I'm not convinced it would be useful or practical.

 

[BF2BC EMT]

http://www.bbc.co.uk/programmes/b017ld7n

Interesting show, however it almost seems a little dated. They talk about military style tourniquets like they're the newest tech. They've got military evac helicopters with docs on them (which allows them to give painkillers and infuse blood, can't have the paramedics doing that). The coolest thing on the first episode was the discussion of hypothermia for trauma victims. I've heard a lot about this, but apparently human trials will be starting soon if they haven't already.

Why aren't medics allowed to give pain meds to the injured?

 

[RocketMedic]

From the US Army perspective, our ability to give pain medication depends on who you are, what your position is, and who your provider is.

I was an infantry platoon medic and was allowed to carry 1 10mg morphine sulfate dose. That was it for 30 guys, with many potential injuries involving mass-casualty incidents (ie an IED strike, rollover, fire, etc). We were approximately 15-30 minutes from most medevac assets optimistically, and I was often responsible for Iraqis as well. Our PA was arrogant, restrictive, and an example of the Army's finest mediocrity. To his credit, I could give OTC medications and some prescription medications when indicated (motrin, naproxyn, Tylenol, etc).

Treatment medics were not allowed to give any meds. In general, they were not the most experienced medics at the time, hence their assignment to the aid station.

 

[DPM]

In the British Army each soldier is supplied with x2 Morphine auto-injectors. The "battle casualty drills" that every man is trained in teaches soldiers when they can and cannot use it.

I know of very few cases where it hasn't been used, and the team medics and combat medics will carry extra.

The only down side is that it is IM. I've seen it take 10-20 minutes to have any significant effect, and these effects can vary greatly from person to person.

 

[RocketMedic]

I wish we had that. Some battalions don't even get to issue analgesics due to fears of misuse by their undisciplined soldiers and lazy NCOs, which is poor patient care all around.

 

[BF2BC EMT]

Wow, I'm very suprised. I actually thought the meds were widely available due to the nature of the job. That is just sad to be laying there in pain because you're only allowed 10 of morphine. Guess I've been watching to much tv. Now I don't know the different classes of medics but the 68w is restricted with the meds? And so are the guys that fly the dustoffs?

 

[DPM]

I'd just like to add, most Combat Medics and Team Medics in the British army are not paramedics. (hardly any are, and most of them are reservists.) The Combat Medical Technician's (CMT) scope of practice is a lot smaller and almost entirely trauma based.

British infantrymen don't have diabetes or MIs or strokes... The CMT rarely, if ever, treats 'sick' people. Instead they're treating extremely fit and healthy young men suffering from massive trauma. Accordingly, the scope for a CMT deals with CABCD in depth, and not much else. ET intubation is not required, because in contact there is no way to bag a casualty that is begin carried to an HLS. If an OPA/NPA won't do it then there's not a lot that can be done. The same goes for spinal boarding. The CMTs know how to use them, but boards aren't taken out on the ground. If you're a casualty you'll find one or two of your mates grabbing you by the shoulders and dragging you into cover. C-spine goes out the window when you're getting shot at.

It may sound very limited but it is a tried and tested system that works very well. It would be nice to establish IV's for many of these casualties, but carrying an extra 2-4L of fluid that you might need, can't drink and will burst, isn't practical. The focus is on stopping the bleeding
ASAP rather than replacing fluids. If you can stop the bleeding and keep your casualties alive until the MERT arrives then their prognosis is pretty good.