So here’s the game:
Step 1: Observe the image/video case presented
Step 2: Imagine the patient out of their current environment and mentally place them on the “X” of the battlefield.
Step 3: Develop and verbalize your own treatment plan, strictly using TCCC guidelines; starting from care under fire and ending with tactical evacuation care
Step 4: Compare your answers with the suggested treatment plan and discuss with your team!
**Disclaimer: This exercise is not intended to criticize the incredible work done by the heroes in the videos or speculate on the unknown variables that may or may not have affected their performance or patient outcome. To all of those who created or participated in these videos; thank you for your tremendous sacrifice for the world, as well as your transparency that has allowed us to learn and perfect our own practices.
Suggested Treatment Plan:
Care Under Fire
- High and tight or clearly proximal tourniquet for the right leg
Tactical Field Care
S: Maintain security of the area; triage the casualty (suspected Minimal or Delayed; based on ability to walk and provide self-care)
M: Remove clothing as tactically feasible; look for life-threatening hemorrhage in the extremities or junctional regions to confirm no additional wounds
A: Casualty is alert, airway appears patent; no intervention needed
R: Check for additional wounds on the chest and back; If none, continue to observe for signs of an occult tension pneumothorax
C: Convert tourniquet into hemostatic gauze packing w/ pressure dressing; establish IV access; assess for for AMS or absent radial pulses (Hemorrhagic shock not suspected from known MOI)
H: Maintain dry clothing; minimize exposure; utilize HPMK if needed and available.
E: No occular injuries noted; give a quick visual acuity test
*Initiate vitals monitoring
P: Patient appears conscious and stable; Tylenol (two 650mg caplets PO), Meloxicam (5mg PO), and Fentanyl lozenge (800mcg)
A: Moxifloxacin (400mg PO)
W: Perform a full secondary assessment; clean the patient as needed
S: Check for fractures in the right leg; splint as needed
B: No burns suspected based on MOI
*Communicate w/ patient and leadership; prepare the patient for evacuation (Priority evac suspected); Document treatment and vitals
Tactical Evacuation Care
- Continue to monitor patient and reevaluate interventions
- Monitor for additional analgesics
Suggested Treatment Plan:
Care Under Fire
- No life-threatening noted in extremities; remove the patient from any immediate dangers
Tactical Field Care
S: Maintain security of the area; triage the casualty (suspected Delayed due to AMS)
M: Remove clothing as tactically feasible; look for life-threatening hemorrhage in the extremities or junctional regions to confirm no additional wounds
A: Casualty is alert, airway appears patent; no intervention needed
R: Check for additional wounds on the chest and back; If none, continue to observe for signs of an occult tension pneumothorax
C: Establish IV access; assess for for AMS or absent radial pulses (Hemorrhagic shock not suspected from known MOI, but fluid resuscitation may be needed later to ensure systolic BP >90 for possible TBI )
H: Maintain dry clothing; minimize exposure; utilize HPMK if needed and available.
E: No occular injuries noted; give a quick visual acuity test
*Initiate vitals monitoring
P: If able to take PO: Tylenol (two 650mg caplets PO) and Meloxicam (5mg PO); additional analgesics do not appear to be needed.
A: Open injury noted; Moxifloxacin (400mg PO), if tolerated
W: Perform a full secondary assessment; clean the patient as needed
S: Check for fractures additional fractures; possible C-spine injury
B: No burns suspected based on MOI
*Communicate w/ patient and leadership; prepare the patient for evacuation (Priority evac suspected due to AMS and potential for TBI); Document treatment and vitals
Tactical Evacuation Care
- Monitor mental status; additional airway and circulation measures may be indicated to maintain perfusion and oxygenation.
Suggested Treatment Plan:
Care Under Fire
- No life-threatening noted in extremities; remove the patient from any immediate dangers
Tactical Field Care
S: Maintain security of the area; triage the casualty (suspected Immediate due to AMS and MOI)
M: Remove clothing as tactically feasible; 2 penetrating wounds noted in the neck w/o notable external hemorrhaging; may be packed w/ hemostatic gauze or closed w/ iTclamp but must take special precautions not to further compromise the airway; shrapnel injuries note along both legs w/o major hemorrhage; no immediate interventions needed.
A: Casualty is not fully alert; requires surgical cric w/ suction due to penetrating trauma to the neck and the risk for airway compromise; continuous airway monitoring needed.
R: Check for additional wounds on the chest and back; possible penetrating trauma noted along the left side of the torso as well as just lateral to the sternum; cover with chest seals/occlusive dressing; remain suspicious of blast lung injuries; monitor for signs/symptoms of tension pneumothorax and treat as needed; provide ventilatory support if feasible
C: Blast injury indicates potential need for pelvic binder; establish IV access (may need IO due to hypovolemic state); AMS is present w/ penetrating trauma so fluid resuscitation is indicated; whole blood preferred; resuscitate until AMS improves, radial pulse are present, or systolic BP of 80-90 is achieved. 1 gram of TXA should be administered; followed by a second 1 gram after the first infusion.
H: Maintain dry clothing; minimize exposure; utilize HPMK; fluids given should be warmed
E: Assess for ocular injuries; patient not likely to be able to participate in visual acuity test
*Initiate vitals monitoring
P: Patient is hemodynamically unstable; Ketamine (20mg slow IV/IO preferred over 50mg IN/IM due to noticeably poor peripheral perfusion)
A: Open injuries noted; Ertapenem (1 gram IV/IM)
W: Perform a full secondary assessment; dress shrapnel wounds along the legs
S: Check for fractures additional fractures;
B: No noticeable burns are seen
*Communicate w/ patient and leadership; prepare the patient for evacuation (Urgent evac suspected due to airway compromise and hemodynamic instability); Document treatment and vitals
Tactical Evacuation Care
- Maintain airway; suction as needed; provide supplemental O2 if available
- Monitor for tension pneumothorax; burp chest seals as needed
- Reevaluate vitals and provide further fluid resuscitation as needed
- Monitor for signs/symptoms of TBI from blast wave
Start at 1:19 for the discussed patient….
Suggested Treatment Plan:
Care Under Fire
- Tourniquet on the left upper extremity; “high and tight” or clearly proximal to the injury; return the patient to a secure environment
Tactical Field Care
S: Maintain security of the area; triage the casualty (suspected Immediate due to mechanism and near-amputation)
M: Remove clothing as tactically feasible; reassess tourniquet on the left extremity and tighten as needed or apply second tourniquet side by side; assess the extremities and junctional regions for massive hemorrhaging; penetrating wound noted in the left axillary region w/o noticeable external hemorrhage hemorrhage; pack w/ hemostatic dressing and apply pressure dressing as needed
A: Casualty is alert and speaking, airway appears patent; no intervention needed at the moment
R: Check for additional wounds on the chest and back; penetrating trauma noted along the left lateral portion of the torso; cover with chest seal/occlusive dressing; monitor for signs and symptoms of developing tension pneumothorax and treat as needed.
C: Convert high and tight tourniquet to deliberate tourniquet on left upper extremity if needed (tape and time); assess for AMS or absent radial pulses (hemorrhagic shock may be suspected due to mechanism and partial amputation). Treat w/ fluid resuscitation as needed; whole blood preferred; resuscitate until AMS improves, radial pulse are present, or systolic BP of 80-90 is achieved. 1 gram of TXA should be administered; followed by a second 1 gram after the first infusion.
H: Maintain dry clothing; minimize exposure; utilize HPMK if needed and available; all fluids should be warmed
E: No ocular injuries noted; give a quick visual acuity test
*Initiate vitals monitoring
P: If able to take PO: Tylenol (two 650mg caplets PO) and Meloxicam (5mg PO); additional analgesics do not appear to be needed. Patient is potentially unstable; Ketamine preferred (20mg IV/IO or 50mg IM/IN).
A: Open injury noted; Moxifloxacin (400mg PO), if tolerated
W: Perform a full secondary assessment; clean the patient as needed
S: Check for fractures additional fractures; splint the left upper extremity
B: No burns noted on the casualty
*Communicate w/ patient and leadership; prepare the patient for evacuation (Urgent evac suspected due to mechanism); Document treatment and vitals
Tactical Evacuation Care
- Monitor mental status
- Monitor for developing tension pneumothorax; burp chest seals as needed
- Reevaluate vitals and provide further fluid resuscitation as needed
- Monitor for signs/symptoms of TBI from blast wave
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