OEMS, some tips...

HNcorpsman

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hey so, while in the navy i have had the opportunity to go to OEMS (operational emergency medical skills) this course has been by far the BEST course i have ever attended in my entire life!!! im not exaggerating... the BEST... the class was taught by a retired army COL. his name is Dr. Hagmann. the class is also staffed with ALL Special forces medics... Navy seals, 18Delta, and SAS... anyways i cant really go into details to much about the class but there was alot of learned tips and i would like to share some of them... some of you guys probably already know all this stuff but hey, if i can get to some of the other guys i have done something right? here it is...

*this is specifically for combat medics, and corpsman*

PT assessment
M-massive bleeding
A- airway
R- respiratory
C- circulation
H- head inj/hypothermia
O- open wound/infection
N- no pain/anesthesia

tension pneumo thorax in a combat setting is VERY common, be aware that a classic sign is grunting upon exhalation... also the absence of bilateral chest rise and fall... JVD and tracheal deviation can happen up to two hours after the tension, so dont rely on it. you dont have to do needle decompression on the PTs chest.. you can also do it on the PTs axillary area... about a palms width from the armpit... (better if PT is wearing a flak jacket.) dont ventilate a PT with tension Pneumo either, it will make it worse.

chest tubes must be done CLEAN!!! speed is NOT important... if you cant keep it clean, or dont have time. DONT DO IT!!

IVs- only give an IV if you can no longer feel the PTs radial pulse.... this is when the PTs blood pressure is so low that they MUST have IV fluids... this method is called hypotensive resuscitation. the idea is that giving fluids to a trauma PT with loss of blood will only make things worse... it will raise their blood pressure causing them to bleed more, and it will dilute their blood with water... either NS or LR... they are essentially the same thing. once they regain that radial pulse discontinue the IV. dont use 14g either... 16 or 18 is fine. use the fast 1 if you have it... it dosnt hurt THAT bad, i have had it done to me... in the sternum...

evisceration, if evac is longer than 2 hours put guts back in... if less than 2 taco.

these are just SOME of the things we learned... there is much more, much more... we also got to do IVs in the jugular using back pressure. IVs in the femoral using back pressure, FAST 1 IO (fun), we got to use lidocaine extensively while doing IVs and numbing the area in prep for a chest tube.
 

Afflixion

Forum Captain
320
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hey so, while in the navy i have had the opportunity to go to OEMS (operational emergency medical skills) this course has been by far the BEST course i have ever attended in my entire life!!! im not exaggerating... the BEST... the class was taught by a retired army COL. his name is Dr. Hagmann. the class is also staffed with ALL Special forces medics... Navy seals, 18Delta, and SAS... anyways i cant really go into details to much about the class but there was alot of learned tips and i would like to share some of them... some of you guys probably already know all this stuff but hey, if i can get to some of the other guys i have done something right? here it is...

*this is specifically for combat medics, and corpsman*

PT assessment
M-massive bleeding
A- airway
R- respiratory
C- circulation
H- head inj/hypothermia
O- open wound/infection
N- no pain/anesthesia

tension pneumo thorax in a combat setting is VERY common, be aware that a classic sign is grunting upon exhalation... also the absence of bilateral chest rise and fall... JVD and tracheal deviation can happen up to two hours after the tension, so dont rely on it. you dont have to do needle decompression on the PTs chest.. you can also do it on the PTs axillary area... about a palms width from the armpit... (better if PT is wearing a flak jacket.) dont ventilate a PT with tension Pneumo either, it will make it worse.

chest tubes must be done CLEAN!!! speed is NOT important... if you cant keep it clean, or dont have time. DONT DO IT!!

IVs- only give an IV if you can no longer feel the PTs radial pulse.... this is when the PTs blood pressure is so low that they MUST have IV fluids... this method is called hypotensive resuscitation. the idea is that giving fluids to a trauma PT with loss of blood will only make things worse... it will raise their blood pressure causing them to bleed more, and it will dilute their blood with water... either NS or LR... they are essentially the same thing. once they regain that radial pulse discontinue the IV. dont use 14g either... 16 or 18 is fine. use the fast 1 if you have it... it dosnt hurt THAT bad, i have had it done to me... in the sternum...

evisceration, if evac is longer than 2 hours put guts back in... if less than 2 taco.

these are just SOME of the things we learned... there is much more, much more... we also got to do IVs in the jugular using back pressure. IVs in the femoral using back pressure, FAST 1 IO (fun), we got to use lidocaine extensively while doing IVs and numbing the area in prep for a chest tube.

Don't mean to nitpick but you want to start a line 16ga or larger if you can get it as soon as you can. Waiting to start a line until they are in hypovolemic shock is a bad waste of time and you most likely guarenteed that mans death. One other thing, If you have time to use lidocaine on a chest tube chances are it could wait until the casualty is in definitive medical care. I'm three deployments down the road and have yet to do a chest tube in the field, done a few moonlighting in the CASH, but that's it.
 
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HNcorpsman

HNcorpsman

Forum Lieutenant
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i hear yah... yeah definitely get the IV started but dont actually give the PT fluids until you loose the radial pulse... make sense?

yeah the Dr. that taught us basically told us that you shouldn't do a chest tube in the field... there are just some cases where you might consider it... for example extremely long evac times, over 24 hrs. also the use of lidocaine is important because of the massive amounts of pain associated with pushing a giant plastic tube in someone pleural space... that much pain could cause that PT to crash. but yeah, if you dont have time to use lidocaine that you dont have time to do a chest tube.

are you in the army? i know when i went to OEMS they sent a army medic, i think he was SF though...
 

mycrofft

Still crazy but elsewhere
11,322
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Median time from call to dustoff to second echelon care makes the difference.

Ech2 (Echelon 1 was [is?] self-aid/buddy care) is closer to battle area now and better commo and transport make a different ball game, where TK's are cool, and delaying some forms of rescusitation is good.
It's good that "lessons learned" aren't thrown away as they were after Nam, but flexibility is still needed to medically meet today's challenge instead of yesterday's.
Soldiers in Nam were initially given technology and practice basically from WWII, the difference between WWII, Korea then Nam being primarily the reduction in time from injury to definitive if "meatball" care (and widespread use of antibiotics) and much fatter suppply line with disposible plastic items.
 

Afflixion

Forum Captain
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Roger, you are definitely going to hold off on fluid resuscitation until the Pt takes a turn for the worse. In regards to busting clots I believe the magic number for that is 93/P bp if I remember correctly. Yes, I'm in the Army and I have been through W1 ASI school.

In regards to Mycrofft, are you wondering the time for dustoff? In good conditions and depending on how far away you are from the base it's about 20-30m from the time you first spout out that 9-line on the net. Some placesd are quicker some are slower... Some damn medevac's feel the need to not monitor the net either... Also the Army has decided to make an entire center for "Army Lessons Learned" Took them long enough to realize that learnin from past mistakes is necessary
 
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HNcorpsman

HNcorpsman

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20-30 mins!!! wow thats good!!

one of my buddies just got back from a embedded training team deployment in afghanistan and he said some medevacs were several hours, and thats the best they could do!
 

Afflixion

Forum Captain
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Yeah, in Iraq medevac is well set every sheriff has at least 3 crews with ione on call 24/7. This has changed drastically since my first deployment in 05 out in Tikrit at FOB Danger it would take hours... The problem is these modern day pilots don't fly if theres a cloud in the sky...
 
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HNcorpsman

HNcorpsman

Forum Lieutenant
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yeah i hear that...
 

Afflixion

Forum Captain
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military flight medics = Glorified Taxi drivers.... Us bullet sponges treat and stabilize...flight medics just fly them to the nearest MTF. Just one non-POG's experience and opinion though.
 

arsenicbassist

Forum Crew Member
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FYI on IV

Don't mean to nitpick but you want to start a line 16ga or larger if you can get it as soon as you can. Waiting to start a line until they are in hypovolemic shock is a bad waste of time and you most likely guarenteed that mans death. One other thing, If you have time to use lidocaine on a chest tube chances are it could wait until the casualty is in definitive medical care. I'm three deployments down the road and have yet to do a chest tube in the field, done a few moonlighting in the CASH, but that's it.

Fluid resuscitation in the field is about worthless unless you're going to sit on it for a lengthy period. Studies show that around 63% of GSW pts survived after recieving IV fluids in the field....while around 70% survived with no fluids. Point being, don't waste time unless you are certain. And if you're going to, at least go with Hetastarch...500cc to start, but no more than 1000cc total.

Cheers
 

arsenicbassist

Forum Crew Member
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NS and LR...the same?

hey so, while in the navy i have had the opportunity to go to OEMS (operational emergency medical skills) this course has been by far the BEST course i have ever attended in my entire life!!! im not exaggerating... the BEST... the class was taught by a retired army COL. his name is Dr. Hagmann. the class is also staffed with ALL Special forces medics... Navy seals, 18Delta, and SAS... anyways i cant really go into details to much about the class but there was alot of learned tips and i would like to share some of them... some of you guys probably already know all this stuff but hey, if i can get to some of the other guys i have done something right? here it is...

*this is specifically for combat medics, and corpsman*

PT assessment
M-massive bleeding
A- airway
R- respiratory
C- circulation
H- head inj/hypothermia
O- open wound/infection
N- no pain/anesthesia

tension pneumo thorax in a combat setting is VERY common, be aware that a classic sign is grunting upon exhalation... also the absence of bilateral chest rise and fall... JVD and tracheal deviation can happen up to two hours after the tension, so dont rely on it. you dont have to do needle decompression on the PTs chest.. you can also do it on the PTs axillary area... about a palms width from the armpit... (better if PT is wearing a flak jacket.) dont ventilate a PT with tension Pneumo either, it will make it worse.

chest tubes must be done CLEAN!!! speed is NOT important... if you cant keep it clean, or dont have time. DONT DO IT!!

IVs- only give an IV if you can no longer feel the PTs radial pulse.... this is when the PTs blood pressure is so low that they MUST have IV fluids... this method is called hypotensive resuscitation. the idea is that giving fluids to a trauma PT with loss of blood will only make things worse... it will raise their blood pressure causing them to bleed more, and it will dilute their blood with water... either NS or LR... they are essentially the same thing. once they regain that radial pulse discontinue the IV. dont use 14g either... 16 or 18 is fine. use the fast 1 if you have it... it dosnt hurt THAT bad, i have had it done to me... in the sternum...

evisceration, if evac is longer than 2 hours put guts back in... if less than 2 taco.

these are just SOME of the things we learned... there is much more, much more... we also got to do IVs in the jugular using back pressure. IVs in the femoral using back pressure, FAST 1 IO (fun), we got to use lidocaine extensively while doing IVs and numbing the area in prep for a chest tube.

Be mindful...NS and LR are not the same thing. Essentially, LR is converted to Bicarb in the liver and is a good choice for combating systemic acidity. Probably wouldn't be a big deal in the short scheme of things, but if you're gonna sit on someone for a while, it's probably a good thing to know.

Cheers
 

mycrofft

Still crazy but elsewhere
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In WII they used the original colloid...plasma.

But evac to care beyond a dressing station could take days.
 

Afflixion

Forum Captain
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Fluid resuscitation in the field is about worthless unless you're going to sit on it for a lengthy period. Studies show that around 63% of GSW pts survived after recieving IV fluids in the field....while around 70% survived with no fluids. Point being, don't waste time unless you are certain. And if you're going to, at least go with Hetastarch...500cc to start, but no more than 1000cc total.

Cheers

The reasoning behind not to give more than 1L of hetastartch is rationing of supplies. You must ensure that you wait for ten to fifteen minutes prior to starting the second bag of hetastartch as it takes some time for it to work. The reason why I stated to start a line is because though in fancy civilian hospitals they change out the line when they get to the hospital in a CSH they keep that line until they get evac, and I don't know about others but I can start a line in a few seconds, there isn't much time wasted there. One should always remember BLS before ALS though. Your going to have some time to wait for that bird even if medevac conditions are all green it will still take fifteen minutes minimum for that bird to get to you provided your reasonably close to a FOB with medevac. also IO with the FAST1 is acctually quite fast just palpate the angle of louis use the introducer and hook up your line and your good to go.
 

Akulahawk

EMT-P/ED RN
Community Leader
4,814
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Fluid resuscitation in the field is about worthless unless you're going to sit on it for a lengthy period. Studies show that around 63% of GSW pts survived after recieving IV fluids in the field....while around 70% survived with no fluids. Point being, don't waste time unless you are certain. And if you're going to, at least go with Hetastarch...500cc to start, but no more than 1000cc total.

Cheers
A problem with administering Hetastarch while it does work, you must be careful that you don't over administer it. You could end up with enough fluid in the vascular system that you raise the BP to the point where you pop the clot and your patient begins bleeding again... Permissive hypotension allows for the clot to stabilize and you provide only enough fluid to keep things going... so to speak.

One of the good outcomes from combat operations is that a LOT is learned about field trauma care...
 

arsenicbassist

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A problem with administering Hetastarch while it does work, you must be careful that you don't over administer it. You could end up with enough fluid in the vascular system that you raise the BP to the point where you pop the clot and your patient begins bleeding again... Permissive hypotension allows for the clot to stabilize and you provide only enough fluid to keep things going... so to speak.

One of the good outcomes from combat operations is that a LOT is learned about field trauma care...

Excellent point. That, in my opinion, is the true reason for not administering over 1L. While it is an excellent volume expander, it brings with it a whole new chain of complications.
 

Akulahawk

EMT-P/ED RN
Community Leader
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From memory: Hetastarch, when used as a volume expander, will ultimately draw about 3x the amount of what's infused into the bloodstream. So... your 500 mL infusion results in about a 1500 mL expansion of fluid drawn into the intravascular space at about 1 hour post administration. Conversely, of 1000 mL of NS or LR infused into the intravascular space, results in about 300 mL retained fluid in that intravascular space. IMHO, you can maintain better control of blood volume with regular crystalloid fluids than you can with colloidal fluids. Of course, the colloidal fluids do take less space in the pack than crystalloids do, for a given end result.

I'd probably prefer to use 250 mL or 500 mL hespan bags due to weight/size considerations and just be judicious in administering that fluid, under combat conditions. Remember that most persons in combat will be younger... and better hydrated. If the patient is already dehydrated... there won't be as readily available reservoir of fluids to draw into the intravascular space from the other fluid compartments.
 

arsenicbassist

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From memory: Hetastarch, when used as a volume expander, will ultimately draw about 3x the amount of what's infused into the bloodstream. So... your 500 mL infusion results in about a 1500 mL expansion of fluid drawn into the intravascular space at about 1 hour post administration. Conversely, of 1000 mL of NS or LR infused into the intravascular space, results in about 300 mL retained fluid in that intravascular space. IMHO, you can maintain better control of blood volume with regular crystalloid fluids than you can with colloidal fluids. Of course, the colloidal fluids do take less space in the pack than crystalloids do, for a given end result.

I'd probably prefer to use 250 mL or 500 mL hespan bags due to weight/size considerations and just be judicious in administering that fluid, under combat conditions. Remember that most persons in combat will be younger... and better hydrated. If the patient is already dehydrated... there won't be as readily available reservoir of fluids to draw into the intravascular space from the other fluid compartments.

3x may be a stretch, but don't quote me...i think it's more along 1.5-2x. Still a fairly large amount in the long run.... In combat, when you have a guy who's lost 3 liters, do you really have enough crystalloids to replace that? or even give him a reasonable chance or survival? Which takes us back to the length of time for some MEDEVACS to arrive...1 hour might not be the time you're getting, it may be a lengthy time. I suppose this may be more of a situation dependent type of choice. If they're your guys, you should already be making sure they are well-hydrated warriors. All good points that are brought up though. I just don't think any medic is carrying around 9 bags of NS or LR to replace large quantities of fluid over long periods of time. I tend to roll with 1L LR, 1.5L NS, and 1L Hetastarch... sometimes with some Dex, depending on how I feel about things, all by personal choice, with my operators each carrying their own 500mL Hetastarch. Keep the faith though guys...I like hearing people discuss things like this...we're only making military medicine better.
 

arsenicbassist

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or if you're really feeling saucy....try something like 6% NS in Dextran.... it's about 7 times more effective than 0.9%, with less of a chance of normal anion gap metabolic acidosis. extreme hypertonics are an amazing thing if you can get your hands on them.
 
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