Inside combat rescue-surgical cric

[rwik123]

Very cool series. Around the 37:38 mark they perform the cricothyrotomy. Amazing watching them operate in the austere envirnonment.

[YOUTUBE]http://www.youtube.com/watch?v=U6j5fJ4HEVA[/YOUTUBE]

 

[Meursault]

Very cool series. Around the 37:38 mark they perform the cricothyrotomy. Amazing watching them operate in the austere envirnonment.

That was pretty impressive, even if I was cringing that whole episode watching them wipe blood on their pants and everything else.

Anyone willing to explain why it was the right choice? Editing makes it hard to tell, but they seem to have jumped straight from NRB to scalpel without any of the interventions I'd expect to see tried on the ground. Is that just a good, bold decision given limited time and environmental constraints?

 

[Anjel]

That is pretty bad ***.

I was just going to watch the cric and ended up watching the whole thing.

Very cool.

 

[RocketMedic]

That was pretty impressive, even if I was cringing that whole episode watching them wipe blood on their pants and everything else.

Anyone willing to explain why it was the right choice? Editing makes it hard to tell, but they seem to have jumped straight from NRB to scalpel without any of the interventions I'd expect to see tried on the ground. Is that just a good, bold decision given limited time and environmental constraints?

Not sure if they suctioned his airway or if they've got ETI in their protocols, but without RSI, a crike would be the most appropriate intervention (predicating the failure of BLS suction and positioning).

 

[blachatch]

Yeah I watched it last night and wondered why the didn't try to suction first. It didn't look like they had any suction equipment, after they got the tube in they were getting blood out of the tube with syringes:unsure:

 

[MMiz]

I think it's a cool series to watch, but I can't help but notice how little they actually do in the chopper. Maybe it's the short commute time, or just the nature of battlefield medicine, but it seems like they attempt to get an IV, IO, admin pain meds, and that's pretty much it.

In one episode I noticed that one crew rarely wore gloves, and blood was everywhere.

Lastly, everyone there keeps talking about racing the golden hour. From command central to the guys on the helicopter, the golden hour appears to be their biggest motivator.

Battlefield medicine is a whole different game. It's fascinating to watch.

 

[chaz90]

I think it's a cool series to watch, but I can't help but notice how little they actually do in the chopper. Maybe it's the short commute time, or just the nature of battlefield medicine, but it seems like they attempt to get an IV, IO, admin pain meds, and that's pretty much it.

In one episode I noticed that one crew rarely wore gloves, and blood was everywhere.

Lastly, everyone there keeps talking about racing the golden hour. From command central to the guys on the helicopter, the golden hour appears to be their biggest motivator.

Battlefield medicine is a whole different game. It's fascinating to watch.

I'm thinking part of it is the editing, and part of it is the fact that it's really all trauma. At least from my experience, I'm used to dealing with primarily medical patients. Pre-hospitally, what do really do for trauma besides what we see? I mean, establishing an airway, maintaining said airway, needle decompression, potential for fluid resuscitation (or not), and giving pain meds is basically what we can do. We've seen them do all those things, plus give blood on almost every patient.

I would bet that they moved down a list of less invasive procedures before they got to the surgical cric. I would imagine they have some kind of suction equipment, even if it is manual, but the editors want people to see the "cool stuff." I figured a cric was coming up this episode after we watched them training in it earlier.

I would be curious too if this emphasis on the "Golden Hour" is actually as pervasive in military medicine as they're portraying on this show. I cringe a little bit every time they mention "breaking the golden hour," or how a patient's chances dropped because they transported to a hospital in 61 minutes instead of 59.

 

[Akulahawk]

I think it's a combination of short transport times and these are the stories that they allowed to air. There's also some amount of editing involved...

While I'm not exactly enamored with the "Golden Hour" per se, it's not exactly difficult to understand the concept that some patients will benefit from rapid transport to definitive care. Each patient and their injuries essentially dictate how long their "hour" really is.

In this episode, I saw those guys doing a few things a bit differently than perhaps I would have, but what they do may be somewhat dictated by their working environment, local protocols, and their unit practices. Still, it's amazing watching them work around the problem of not being able to listen to their patients with a stethoscope and be very reliant on their other senses to assess the patient.

 

[RocketMedic]

The golden hour is a theme at AMEDD.

 

[Household6]

I would be curious too if this emphasis on the "Golden Hour" is actually as pervasive in military medicine as they're portraying on this show. I cringe a little bit every time they mention "breaking the golden hour," or how a patient's chances dropped because they transported to a hospital in 61 minutes instead of 59.

Yes, it is.. 80% battlefield casualties are a result of blood loss. They also push a concept called "the Platinum 10 [minutes]"..

It's a completely different animal, did you know that we're not taught CPR in CLS? They say that if you have to preform chest compressions on a casualty then it's too late, and they're already dead. Move on to the next patient, don't waste time with CPR.

 

[MrJones]

The golden hour is a theme at AMEDD.

It's also a theme in wilderness medicine, but from a different angle: You're not going to get the patient to a hospital w/in the golden hour, so what are you going to do to maximize the chance of survival?

 

[Veneficus]

It's also a theme in wilderness medicine, but from a different angle: You're not going to get the patient to a hospital w/in the golden hour, so what are you going to do to maximize the chance of survival?

You can't leave it there, what are you going to do?

 

[MrJones]

You can't leave it there, what are you going to do?

Yes, I can leave it there. My point was a general one that should require no further clarification.

And your question as presented is unanswerable. You can't plan a course of action without a complete scenario to work with - were are you, what and who do you have with you, what's wrong with the patient, etc....

 

[Grumpy]

That was pretty impressive, even if I was cringing that whole episode watching them wipe blood on their pants and everything else.

Anyone willing to explain why it was the right choice? Editing makes it hard to tell, but they seem to have jumped straight from NRB to scalpel without any of the interventions I'd expect to see tried on the ground. Is that just a good, bold decision given limited time and environmental constraints?

I don't think this has been answered yet. In the show the person injured was having an airway issue the mouth was swelling and blood was filling the airway. The PJs needed to get an airway on this person and due to the situation a cric was the acceptable method. Combat medicine has no medcontrol, its operated by the military members and training they receive prior to deployment. Training these men get are very extensive, to the point and led by other experienced providers and doctors. Cadaver labs are used for training purposes at a select few military courses.

 

[mycrofft]

It may be that due to experience with the degree of insult and intimate knowledge of what they have to work with and what condition is best for the ROLE 2 to receive them, they go to a surgical airway more directly.

I'm interested in the reappearance of "The Golden Hour". My understanding was that the concept sort of took off during the Korean War and was codified/promoted by Dr Cowley. I JUST read his statement; it was that in one hour OR LESS the measures to assure a positive outcoem, even if it was much later, were decided.
http://en.wikipedia.org/wiki/Golden_hour_(medicine)
That may have reflected concurrent concepts of survivability, technic, and care before and during transport different than we use today Stateside.

 

[Veneficus]

It may be that due to experience with the degree of insult and intimate knowledge of what they have to work with and what condition is best for the ROLE 2 to receive them, they go to a surgical airway more directly.

I'm interested in the reappearance of "The Golden Hour". My understanding was that the concept sort of took off during the Korean War and was codified/promoted by Dr Cowley. I JUST read his statement; it was that in one hour OR LESS the measures to assure a positive outcoem, even if it was much later, were decided.
http://en.wikipedia.org/wiki/Golden_hour_(medicine)
That may have reflected concurrent concepts of survivability, technic, and care before and during transport different than we use today Stateside.

Personally, I am really not sure how or where that golden hour was decided. I have heard multiple accounts from a bar to the battlefield.

I find the idea of "assuring" a good outcome on trauma during a time when MVA (and therefore largely multisystem blunt and penetrating simultaneously) was the major civilian injury.

Given the facts about blunt trauma resuscitation, I can only conclude that 60 minutes was more of a realistic number than an actual medical truth.

As was accurately stated above, on the battlefield, we are talking about penetrating trauma, on adults selected for their health. The answer to bloodloss is blood replacement, but that is not the end of injury.

Otherwise, we would just sew people up, give them some blood, and they should be ready to return to work.

But something that needs to be understood is that the military trauma system is inherently different from civilian trauma. (Not just because they reverse the number designations on their centers.)

They have a multi-layered approach that is extraordinarily expensive. Likely it will never be replicated in the civilian world becase of this cost. From my study and experience of trauma, for certain it is superior to the civilian side.

But that also means that the factors involved cause completely different outcomes.

For example, a wounded soldier is taken to forward surgery to stop ongoing damage, 10minutes to an hour. Once that ongoing insult is reduced, if not stopped, they are then transfered to a higher level of care.

In the civilian world, ineffective treatment is often initiated that does not stop the insult, because what does is some sort of modern surgical intervention which is not available at the outlying facility.

Instead "resuscitation" is attempted medically, while they wait to transfer. By the time they actually wind up someplace that can help them, they are looking at perhaps an hour or more of ongoing insult, even as they sat in a healthcare center getting "treatment."

When they finally do hit their destination, the idea of and time for rapid surgical stabilization is over. The idea becomes definitive surgical repair and punt to ICU where the goal is discharge ASAP.

This creates a whole different reality in medical therapy. Both for survival and maximizing function after hospitalization.

It is why not everything that works in the military works in the civilian world. Unless you can replicate the entire system, many things are just not going to port over.

Do I wish we could set up a trauma system similar to modern first world militaries?

Hell yes, and twice on Sunday!

But it will require a massive overhaul, from the very way surgeons and critical care experts are trained, to where they are placed, to how they are paid, to purposefully prolonging patient time in the higher levels of the system (Surgery and ICU)

For trauma alone, it will take a massive increase in funding, in a patient population that is basically indigent.

We can marvel at what the military does all day, but we cannot expect the same outcomes trying to implement the "cool looking" parts without the behind the scenes things that really make it work.

 

[RocketMedic]

I don't think this has been answered yet. In the show the person injured was having an airway issue the mouth was swelling and blood was filling the airway. The PJs needed to get an airway on this person and due to the situation a cric was the acceptable method. Combat medicine has no medcontrol, its operated by the military members and training they receive prior to deployment. Training these men get are very extensive, to the point and led by other experienced providers and doctors. Cadaver labs are used for training purposes at a select few military courses.

False. Medical control comes from company or battalion-level medical officer, generally with fairly restrictive protocols (SF, PJs and independent duty corpsmen are the only ones I can think of). It is as dependent on training as the unit wants it, and can be extremely sporadic.

 

[RocketMedic]

Personally, I am really not sure how or where that golden hour was decided. I have heard multiple accounts from a bar to the battlefield.

I find the idea of "assuring" a good outcome on trauma during a time when MVA (and therefore largely multisystem blunt and penetrating simultaneously) was the major civilian injury.

Given the facts about blunt trauma resuscitation, I can only conclude that 60 minutes was more of a realistic number than an actual medical truth.

As was accurately stated above, on the battlefield, we are talking about penetrating trauma, on adults selected for their health. The answer to bloodloss is blood replacement, but that is not the end of injury.

Otherwise, we would just sew people up, give them some blood, and they should be ready to return to work.

But something that needs to be understood is that the military trauma system is inherently different from civilian trauma. (Not just because they reverse the number designations on their centers.)

They have a multi-layered approach that is extraordinarily expensive. Likely it will never be replicated in the civilian world becase of this cost. From my study and experience of it, for certain it is superior to the civilian side.

But that also means that the factors involved cause completely different outcomes.

For example, a wounded soldier is taken to forward surgery to stop ongoing damage, 10minutes to an hour. Once that ongoing insult is reduced, if not stopped, they are then transfered to a higher level of care.

In the civilian world, ineffective treatment is often initiated that does not stop the insult, because what does is some sort of modern surgical intervention which is not available at the outlying facility.

Instead "resuscitation" is attempted medically, while they wait to transfer. By the time they actually wind up someplace that can help them, they are looking at perhaps an hour or more of ongoing insult, even as they sat in a healthcare center getting "treatment."

When they finally do hit their destination, the idea of and time for rapid surgical stabilization is over. The idea becomes definitive surgical repair and punt to ICU where the goal is discharge ASAP.

This creates a whole different reality in medical therapy. Both for survival and maximizing function after hospitalization.

It is why not everything that works in the military works in the civilian world. Unless you can replicate the entire system, many things are just not going to port over.

Do I wish we could set up a trauma system similar to modern first world militaries?

Hell yes, and twice on Sunday!

But it will require a massive overhaul, from the very way surgeons and critical care experts are trained, to where they are placed, to how they are paid, to purposefully prolonging patient time in the higher levels of the system (Surgery and ICU)

For trauma alone, it will take a massive increase in funding, in a patient population that is basically indigent.

We can marvel at what the military does all day, but we cannot expect the same outcomes trying to implement the "cool looking" parts without the behind the scenes things that really make it work.

This is why taking a patient to a non-trauma ER (Cat 4 rural band aid station) sees the same care as a progressive EMS service?

 

[Handsome Robb]

I'll let y'all know in about a year

 

[mycrofft]

We're producing thousands of young people with battlefield medic training....