05 PREHOSPITAL & MILITARY MEDICINE (36)

Question 1

SMEACS

Answer 1

This is a Military Briefing Acronym

• S = SITUATION = what the big picture is
• M = MISSION = what our job is
• E = EXECUTION = how we are going to do it
• A = ADMIN & LOGISTICS = get who and what from where, tell whom
• C = COMMAND & CONTROL* = who is in charge
• S = SIGNALS = what the Comms plan is

* NOTE: in most cases, the 2 words are conjoined and no distinction is drawn between them, although ‘command’ = issuing orders (what to do) whereas ‘control’ = how to do it: the higher up the command chain, the less control.

Question 2

MARCH

Answer 2

= the combat medics version of C-ABC:

• M = MASSIVE HAEMORRHAGE = put CAT on
• A = AIRWAY = if unconscious, insert NPA
• R = RESPIRATION = look for holes in the chest: seal smallest on 3 sides, all others on 4, reinforce with Israeli bandage over
• C = CIRCULATION = control lesser bleeds, check carotid and radial pulses, splint limb #
• H = HYPOTHERMIA = roll to check back, place blanketed litter under, roll flat, wrap blanket over

Question 3

C COLLARS FOR BATTLE CASUALTIES?

Answer 3

• whilst the usual blunt trauma indications apply (including blast), C collars are not indicated for penetrating head or neck trauma unless there is neurological loss

Question 4

WHY ARE TOURNIQUETS APPLIED “HIGH AND TIGHT”

Answer 4

• This is the combat medics doctrine aimed at maximising the chance of getting above all injuries under duress, rather than a reflection on the effectiveness of tourniquets more distally*
• * tourniquets actually work *better* on the narrower, more distal parts of a limb, even if double boned*

Question 5

HIGH n TIGHT TOURNIQUETS & BLEEDING FEMURS

Answer 5

• Long bones get their blood supply at the ends, including at hip level for the femur, so even ‘high n tight’ tourniquets cannot stop femurs bleeding.
• They are primarily intended for controlling major vascular injury.

Question 6

MANAGEMENT OF PATIENTS WITH TOURNIQUETS ON

Answer 6

Consider whether you really need it*, because once placed you are committed to

• removal within 2 hrs, or risk unecessary limb loss
• managing serious ischemic pain, eg with Ketamine

On arrival at the Role2+, replace with a wider pneumatic tourniquet**, and decide:

• OR now? (surgery reqd/ reperfusn syndrome likely), or:
• Deflate in ED and confirm bleeding controlled & limb circulation returns
• * and remove it if you dont*
• **these are more effective than narrow tourniquets : wounds controlled by CATs often rebleed as BP is restored*

Question 7

REASONS FOR CAT FAILURE

Answer 7

1. Not tight enough: to maximise tightness:
   
   • dont apply over clothing
   • remove all slack prior to cranking
   • use both FRICTION BUCKLE slots unless applied one handed
   • add a 2nd one adjacent
2. Missed injury above it : expose the entire leg
3. Ongoing osseous bleed

Question 8

7 OPTIONS FOR UNCATTABLE BLEEDS : EG JUNCTIONAL

Answer 8

1. Point pressure with finger directly on the bleeder*
2. Packing, esp with haemostatic agents
3. Junctional tourniquets
4. Balloon tamponade of wound (foley in wound with balloon up)
5. External aortic compression
6. Resuscitative thoracotomy and aortic X Clamp
7. REBOA

* this is the most effective measure! albeit with tactical difficulties

Question 9

HAEMOSTATIC DRESSINGS

Answer 9

Are dressings designed to be PACKED INTO difficult to control wounds, esp junctional, where they control bleeding via 3 mechanisms

1. exerting pressure on the wound edges, either passively, or by active expansion*
2. activation of clotting, either by absorbing water, or by containing procoagulants**
3. physically adhering to wet & bleeding tissues, sealing them (Chitosan)

• *the Polymer Sponge types can generate up to 100mmHg*
• ** the physical tamponading effect of the packing is more important than any additive it contains*

Question 10

IF A DRESSING BLEEDS THROUGH:

Answer 10

• remove the dressing and apply POINT PRESSURE to the source
• simply adding another bandage over the existing dressing will hide the bleed for a while but wont apply enough pressure to stop it

Question 11

HOW TO DO MANUAL AORTIC COMPRESSION TO CONTROL SUBDIAPHAGMATIC HAEMORRHAGE

Answer 11

• Best is a single knee in the epigastrium* and most of the rescuers body weight
• alternately, press VERY HARD with one fist bolstered by the other hand

* go high: remember the aorta bifurcates at the umbilicus

Question 12

4 IMPORTANT SITES TO LOOK FOR HIDDEN GSW & FRAG WOUNDS

Answer 12

1. the hair
2. inside the mouth (suicides)
3. axilla, and
4. perineum/natal cleft

should all be specifically examined in ballistic casualties

Question 13

HOW TO USE ‘READY HEAT’ BLANKETS

Answer 13

• these are self heating iron oxide blankets that produce ~40C for 8h when exposed to air
• apply over AND under the casualty, with a layer of material in between

Question 14

WHAT IS TCCC?

Answer 14

‘T-Triple C’ = TACTICAL COMBAT CASUALTY CARE, the combat medics doctrine which combines an appreciation of tactical conditions and recognition of the common causes of preventable battle casualty death to divide CARE OF THE BATTLE CASUALTY into 3 phases:

1. CARE UNDER FIRE: (while they are shooting at you):
   
   • control massive bleeding with CAT, preferably self applied, then get back to shooting
2. TACTICAL FIELD CARE: (once immed threat over)
   
   • address the ABCs with MARCH
   • send a 9 LINER
   • prepare a MIST handover
3. EVAC CARE:
   
   • disarm
   • de-equip
   • package for transport

Question 15

WHAT ARE THE COMMON PREVENTABLE CAUSES OF MODERN BATTLE CASUALTY DEATH?

Answer 15

Analysis of coalition battle-deaths in the recent Afghan and Iraq wars has shown 87% occur before reaching the surgeon, but that 1 in 4 are potentially preventable with better Rx of

• haemorrhage (90%): 2/3 truncal, 1/3 extremity & junctional
• airway obstruction (9%) - mainly with an injured/bloody airway, requiring surgical crike
• tension PT (1%)

Question 16

WHAT IS A NATO 9-LINER?

Answer 16

• The 9 Liner is a standardised military CASEVAC request format

Question 17

MIST

Answer 17

sometimes called the 10th LINE of a NATO 9-Liner, it adds clinical detail and may also be used as a handover tool

• M = MECHANISM of injury
• I = INJURIES SUSTAINED
• S = SIGNS & SYMPTOMS (ABCs)
• T = TREATMENT GIVEN

sometimes AT is added at the start : Age/time of incident

Question 18

HOT HELO HANDOVER

Answer 18

Go over patient twice, head to toe, indicating by hand signals:

1. Injuries & mechanism, treatment & effectiveness (fanning fingers for explosion, finger & thumb gun for GSW)
2. Overall Physiology : give thumbs up/equivocal/down for:
   
   • Airway
   • Breathing (use hand to mimic R & L chest motion)
   • Circulation (carotid and radial pulses)
   • D: Consc state (point at temple)

Question 19

WHAT IS THE JTTS?

Answer 19

• The JTTS = the Joint Theatre Trauma System, a US military medical surveillance system which collects data about battlefield injury occurrence, treatment given and outcomes, and uses it to develop evidence based CPGs, and to monitor compliance and effectiveness

Question 20

ALERT

Answer 20

this is the SUICIDE BOMBER IDENTIFICATION ACRONYM

• A = ALONE (and the streets emptying)
• L = LOOSE CLOTHING (to hide the bomb)
• E = ELECTRICAL WIRES may be showing
• R = RIGID TORSO (from the vest)
• T = TIGHT HANDS (on the trigger: esp if a deadman switch)

Question 21

COMMONEST BLAST PRESSURE INJURIES

Answer 21

1. Ruptured Eardrums
2. Blast Lung
3. Ruptured Intestines

Question 22

RAPID SCREENING OF BLAST VICTIMS

Answer 22

• if obviously injured: follow ATLS
• if apparently OK: check eardrums
  
  • if intact, release from hospital
  • if not : observe 8h for onset of GIT or Resp signs and symptoms

Question 23

SA TRIAGE COLOURS

Answer 23

• RED = P1 = IMMEDIATE
• ORANGE = P2 = URGENT
• BLUE = P3 = EXPECTANT
• GREEN = P4 = WALKERS
• WHITE = DEAD

Question 24

MIMMS : MEDICAL COMMANDERS ROLE AT A DISASTER

Answer 24

1. Declare a MAJOR INCIDENT
2. Send a METHANE SITREP
3. Designate a CCP
4. Commence TRIAGE

Question 25

MIMMS TRIAGE SIEVE =

Answer 25

= the quick initial assessment, usually done where found

1. Can they WALK?: Y = GREEN
2. If they cant walk, are they DEAD?: Y = WHITE
3. If they cant walk, but arent dead, are the ABCs abnormal? Y = RED, N = ORANGE

Question 26

CAREFLIGHT TRIAGE HANDSHAKE

Answer 26

This is another rapid triage tool:

1. Separate off the walkers and tag GREEN
2. Take the nonwalkers hand, feel for a radial pulse and ask where it hurts: if you cant feel a pulse or get a sensible reply = IMMEDIATE, otherwise URGENT

Question 27

WHATS IN A METHANE SITREP?

Answer 27

1. M = MAJOR INCIDENT: Declare it
2. E = the EXACT LOCATION is:
3. T = the TYPE of incident is:
4. H = HAZARDS present are:
5. A = ACCESS to the scene is via:
6. N = NUMBER of casualties =
7. E = EMERGENCY SERVICES present and required are:

Question 28

HOW TO CONFIGURE TREATMENT AREA IN A DISASTER?

Answer 28

• Separate off the walkers
• Set up a central kit dump with the RED & ORANGE patients radially around it, heads facing in

Question 29

PRIMARY SAYINGS

Answer 29

• SCOOP to skin
• Trousers off before PELVIC BINDER

Question 30

WHAT TO ADD WHEN USING A PELVIC BINDER

Answer 30

• consider a Figure of 8 around the feet to prevent external rotation of the hips

Question 31

BASIC WORKING DOG GA (for fit 30kg Shepherd)

Answer 31

• ALWAYS muzzle injured dogs*, either with a purpose item, or a bandage around the snout
• PREMEDICATE: for initial restraint:
  
  • KETAMINE** 75mg +
  • MIDAZ 7.5mg IMI into the lumbar para spinal muscles
• MONITORING:
  
  • ECG dots to foot pads: (N HR = 80)
  • INFANT NIBP to tail base: (N = 120/80)
  • SpO2 to tongue or lip
  • N Temp is up to 39.5C, but can spike to 41 with exertion
• INDUCTION: - usually IV (but gas induction OK) via cannula in any leg above paw or IO above a hind ‘knee’, secure with over and under circumferential tape
  
  • PROPOFOL 150 mg for fit, unpremed dog (much less if premedicated or sick)
  • Intubate in sternal recumbency with long straight blade and 9.0+ ETT***
• MAINTAIN: - should SV on 1 MAC Vapour but may need some bagging
• FLUIDS: Xtal 10ml/kg/h
• POSTOP ANALGESIA:
  
  • MORPHINE**** 5mg IV or IMI 4/24, avoid NSAIDs or PARACETAMOL

• *but note hot dogs MUST be able to open mouth pant*
• **never Ketamine alone as the dreams are dangerous*
• ***tie before inflating cuff or may cough out as no relaxant*
• **** dogs are fluid and morphine sponges*

Question 32

LEAD TOXICITY FROM RETAINED BULLET FRAGMENTS

Answer 32

• ‘PLUMBISM’ from systemic absorption of lead is only a risk from fragments in joint spaces or discs, but….
• There is growing concern that COPPER jacketed (as opposed to cupro-nickel) bullets may be more of a problem

Question 33

VINEGAR and JELLYFISH STINGS

Answer 33

• Although vinegar has long been advocated for deactivating unfired venom cells after JELLYFISH stings, this measure is now discouraged as it:
  
  • increases venom injection from already fired cells
  • HURTS ++
• FIRST AID for Jellyfish stings now concentrates on the ABCs for life threatening issues, and hot water or cold packs for local analgesia

Question 34

MANAGEMENT OF DROWNINGS

Answer 34

• Drowning is defined as respiratory impairment due to submersion in liquid
• the drowning person initially defends the airway by swallowing, spitting & breath holding, but INVOLUNTARY INSPIRATION of water soon occurs, producing HYPOXIA then APNOEA then ASYSTOLE*
• MANAGEMENT
  
  • unlike primary cardiac arrest, the ‘problem to be fixed’ in drowning is HYPOXIA and ventilation should be commenced whilst still in the water
  • patients who fail to respond rapidly are in cardiac arrest also and need ALS protocol CPR as soon as they are removed from the water.
  • the key clinical problem immediately after resuscitation is lung injury due to water** ingestion, with bronchospasm, shunting and massive pulmonary oedema.
  • small children are occasionally resuscitatable after prolonged immersion in very cold water due to the protective effects of rapid hypothermia.

• * VF is rare and may indicate a prior cardiac event*
• ** and the clinical picture is similar for both salt & freshwater drownings, irrespective of theoretical osmotic differences*

Question 35

SNAKE TEMPERAMENTS AND BITE CHARACTERISTICS

Answer 35

The 3 commonest snake bites encountered in SA are the Red Belly Black, the Brown Snake and the Tiger snake.

• RED BELLY BLACK SNAKES are typically non aggressive and bite only if significantly molested. Their bites are locally painful but not usually dangerous, producing mainly myotoxic effects.
• BROWN SNAKES are much more venemous and aggressive than RBB (although their small fangs result in many dry bites), with painless bites producing principally anticoagulant effects.
• TIGER SNAKE BITES are painful, and produce neurotoxic effects.

Question 36

ACTIONS UPON CAPTURE

Answer 36

1. Give name, rank and serial only: any other questions reply “I cannot answer that question”
2. Do not sign anything, including ‘release papers’ etc
3. Read media scripts verbatim and without emotion, especially including errors, poor grammar etc
4. Be passive, not confrontational
5. If longterm, build rapport with guards by talking about family etc

Question 37

MINIMUM SAFE DISTANCE TO DRAW and SHOOT A KNIFE ARMED OPPONENT?

Answer 37

21 feet!

Question 38

EPONYMS protocol

Answer 38

2 shots to the chest and one to the head (in case of body armour)