Patient Movement & Field Considerations

• Unit 1 discusses patient movement and field considerations

Objectives

• Recognize the connection of facts and ideas related to moving patients and field medicine.
• Triage patients in the field without help from a teacher.
• Evaluate and care for trauma patients who have multiple injuries without being overseen.

Overview

• The following topics will be covered: patient transport, CASEVAC which is casualty evacuation, 9-line MEDEVAC requests, MEDEVAC which is medical evacuation, AIREVAC which is aeromedical evacuation, TRAC2ES, contract evacuation, field triage, considerations for CBRN (Chemical, Biological, Radiological and Nuclear ) incidents, and caring for trauma patients with multiple injuries.

Types of Patient Movement

• The forward line of conflict (FEBA) evacuates casualties to an MTF by medical or nonmedical personnel.
• The evacuation of causalities may or may not include medical care.
• Crew or aircraft can be exposed to hostile fire.
• Rotary-wing aircrafts returning from the battlefield are typically used.
• Ground transports or other vehicles of opportunity may be used.

MEDEVAC

• A MEDEVAC transports casualties from one point of established treatment to another within the tactical theater in a timely and efficient manner

• Usually medically equipped aircrafts such as a rotary-wing or tactical fixed-wing aircraft will be used.

Aeromedical Evacuation

• Aeromedical evacuation is the transportation of a casualty from a point of care within the theatre to another more rearward location, for example: regional hospital or CONUS.
• Fixed-wing aircraft, like the C-17 and the C-130, are used.

Considerations

• Rotary-wing aircraft provide relatively short transport.
• Alternative vehicles, such as vehicles and watercraft, may be used.
• Because those requiring CASEVAC have typically been recently wounded, they might be rather unstable.
• Focus on life-saving tactics that increase survival without endangering the casualty, the mission, or the crew.
• Pre-mission planning is needed for a successful mission.

Nine Line Request

• This is the standard method of requesting medical evacuation

• Line 1: Location of casualty/Helicoptor landing zone, or HLZ

• Line 2: Radio frequency and call sign

• Line 3: Evacuation precedence

• Line 4: Special Equipment

• Line 5: Number of patients by litter or ambulatory

• Line 6: Evacuation site security

• Line 7: The marking of the site

• Line 8: Nationality and status?

• Line 9: NBC/Terrain specifics

• Urgent casualties should be evacuated within 2 hours, as should urgent surgical cases.

• Priority casualties should be evacuated within 4 hours, and routine within 24 hours.

MEDEVAC Considerations

• Prepare casualties for flight. Ensure any urgent medical treatment like splinting, providing bandages, or putting in IV lines are done while still on the ground.
• Protect the ears with earplugs and protect the eyes with goggles or bandages.
• Casualties need to be loaded as affected.
• As examples, there will be movement of causalities from resuscitation areas, such as Battalion Aid Stations, Shock Trauma Platoons and Forward Resuscitative Surgical Teams to surgical support facilities (CSH, or EMEDS).
• A MEDEVAC may also move patients from a CSH/EMEDS to a staged regional facility.
• CASEVAC and Aeromedical Evacuation missions can be mixed for "hybrids" that vary greatly in duration and scope.
• For short missions, operative considerations resemble CASEVAC.
• Longer missions using fixed wing aircraft more closely resemble Aeromedical Evacuation.
• Missions are generated with coordination through with HMTF/Preceptor.
• Requests are submitted through TRANSCOM Regulating and Command and Control Evacuation System (TRAC2ES).
• TRAC2ES training is required before gaining access.
• If information is not entered into TRAC2ES, an AF 3899 will be sent to Preceptor/HMTF.
• Patient movement precedence and classification are determined by the preceptor/originating physician.

Patient Considerations

• Ensure the airway is secure using an ET tube or supraglottic airway device if airway comproise is suspected
• Inflate cuff with normal saline.
• Ensure a Heimlich Valve or approved collection system is used before the patient transfers to the flight line, in patients with a chest tube.
• Cervical, Thoracic, and Lumbar spine must be cleared via CT or immobilized with C-Collar, and a spine board.
• The patient has to be hemodynamically stable.
• Hemoglobin has to be greater than 8.0 and hematocrit has to be greater than 25.
• Splint fractures, and try to avoid air splints if possible
• Casts should be 48 hours old if possible, and always bivalve if swelling is expected.
• Use bags not bottles for IV fluids
• Make sure the catheter cuff is inflated using normal saline.
• Ensure the patient has enough IVs, medications, and supplies to reach destination facility.
• Use ONLY NATO and army litters.
• NATO Litters have a maximum weight of 250 lbs.
• Army Decon Litters have a maximum weight of 350 lbs.
• Nylon litters are not approved.
• Ensure 3 litter straps are used.

TRICARE Overseas Program (TOP)

• TRICARE Overseas Program (TOP) Prime and TOP Prime Remote are available through the TOP Regional Call Center.
• TRICARE Overseas Program (TOP) Standard beneficiaries can access DoD aeromedical evacuation services when their situations are medically necessary, and there is space available.
• Contact the Regional Call Center if military evacuation is not available.
• Each overseas area has its own rules and procedures for aeromedical evacuation.

Purpose of Triage

• To sort and prioritize casualties based on the tactical situation, mission, and available resources.
• It helps establish order in a chaotic environment and provide the greatest good to the greatest number within the limitations of time, distance, and capability.
• It is a constant and dynamic process as casualties move within and through the system of care.
• A mass casualty event overwhelms available medical resources to include personnel, supplies, and/or equipment.

Types of Triage

• Peacetime Triage is intended to get those with life threatening injuries care first, then to secure care for all others.
• Ensure all patients receive the best care possible and categories may vary between civilian agencies.

Field Triage

• The goals of combat medicine are the return of the greatest possible number of war fighters to combat, and the preservation of life, limb, and eyesight.
• Resources should be committed based first on the mission and immediate tactical situation and then by medical necessity.

Wartime Triage Categories

• In the Immediate category, attention is required within 2 hours of arrival to prevent major disability or death.
• These patients have a good chance of survival using immediate interventions.
• Injuries include airway obstructions or potential comprise, a tension pneumothorax, uncontrolled hemorrhage, many amputations, head injuries requiring emergent decompression, and torso, neck, or pelvis injuries with shock.
• In the Delayed category, patients likely require surgery.
• Injuries are not immediately life threatening, but whose general condition permits delay in treatment without unduly endangering life, limb, or eyesight.
• Sustaining treatment like fluid resuscitation, the stabilization of fractures, and the provision of antibiotics and pain relief will be required.
• Blunt or penetrating torso injuries without signs of shock, facial fractures without airway compromise, globe injuries, soft-tissue injuries without significant bleeding, and survivable burns without immediate threat to life are some of the injuries that apply.
• People with relatively minor injuries, ( e.g., minor lacerations, abrasions, small bone fractures, and minor burns) who can care for themselves with minimal care are in the Minimal category.
• Casualties may assist with helping others move or by caring for the injured.
• Those with injuries that overwhelm current resources are in the Expectant category.
• These casualties are unlikely to survive.
• Do not leave them alone, but separate them from other casualties.
• Reassess injuries frequently.
• Injuries include any casualty without vital or signs of life, regardless of the mechanism of injury, transcranial gunshot wounds with coma, open pelvic injuries with uncontrolled bleeding, and high spinal cord injuries.
• Segregate and treat these last.

Special Wartime Triage

• Special Wartime Triage Considerations should be made for retained, unexploded ordinance.
• Screen enemy prisoners/internees/detainees and check for weapons prior to moving them into treatment areas.

Combat Stress

• Rapid identification and stress casualties will improve the odds of rapid recovery, and expeditious care can result in 80% of casualties returning to their duties.
• Do not use them as litter-bearers because this may increase the trauma you seek to treat.

CBRN Considerations

• Triage should be performed on standard standards, then adapted by the radiation injury level.
• Patients with medical or traumatic injury will require a higher triage priority.

Nuclear Injuries

• Radiological battlefield casualties may occur with improvised or conventional nuclear devices or radiological dispersal devices ( Dirty bombs).
• Signs and Symptoms are: Nausea, vomiting, diarrhea, fever, ataxia, seizures, prostration and hypotension.
• Treatment will require decontamination, because removing clothing eliminates up to 90% of contaminants
• Follow normal decontamination procedures. Once decontaminating the patient, they are not longer radioactive.
• Potential injuries from nuclear devices include Thermal/Flash burns as a result of infrared radiation, Blast injuries as a result of Direct Overpressure Forces and Indirect Wind Drag Forces.
• Radiation Injuries, secondary to radiation releasing.
• Flash Blindness as a result of intense light injuries.
• Retinal Burns as a result of scarring and permanent damage
• Treating means remembering that the injuries will increase the risk of immunosuppression.
• Treat ABC's first.
• Delayed treatment can create surgical procedures.

Chemical

• The most likely battlefield agents that will be seen include the nerve agent sarin, chemical, and cyanogens.

Signs and Symptoms include

• Nerve: miosis, rhinorrhea, dyspnea, seizures, paralysis and copious secretions
• Vesicants: skin blisters, airway injury mucous membrane burns
• Chemicals: pulmonary edema, ENT irritation, coughing and choking and Cyanogens- seizures- Cardio/Respiratory Arrest.
• Triage depends on sign and symptom of the patient presentation.
• Decontaminate by removing the patient from exposure, following normal decontamination procedures.
• For treatment of
• Nerve - ATNAA
• Supportive care.
• To manage choking, use Oxygen, manage airway secretions.
• Cyanogen’s treatment includes 100% oxygen and Gastric lavage and activated charcoal if ingested

Biological

• First indication of an attack may be when large numbers of patients present with the same signs and symptoms.
• Biological toxins include Botulinum- cranial nerve palsies, paralysis, and respiratory failure and Ricin- fever, SOB, arthralgias, and pulmonary edema.
• Bacterial agents include Anthrax- malaise cough, SOB, cyanosis. Pague- high fever, headache, cough, SOB, cyanosis.
• Viral agents include Smallpox- malaise rigors- headache followed by vesicles that turn into pustules
• Triage depends on the sign and symptom presentation
• Decontamination requires following normal decontamination procedures.
• Treatment will provide supportive care, Bacterial requires to IAW antimicrobial, Viral requires providing supportive care.
• Prevention with immunization

Trauma

• Trauma is defined as damage to living tissue caused by external factors.

The goal of medical care is to triage so those with traumatic injuries are diagnosed and are taken care of in a way that minimizes the risk of death of permanent injury

• Assess patients: First priority: Massive blood loss- Stop The Bleed.

• Assess patient responsiveness or level of consciousness.

• Treat Airway, Breathing and Circulation, (ABCs)

• Massive Hemorrhage requires

  • Limb tourniquets 2-3 inches above bleeding site to control hemorrhage, that is amendable to tourniquet or amputation.
  • If bleeding site is not controlled, apply a second tourniquet above the first
  • Do NOT loosen any tourniquets.
  • External hemorrhages that limb tourniquets not reach, apply Hemostatic Dressings with Pressure Dressing -Apply pressure no less than 3mins.
  • If doesn’t work, remove dressing and apply a new dressing for 3 minutes of pressure.

• If dressings doesn’t work, apply firm and direct along with pressure bandage

• Do Not Remove initial bandages.

• Airway Management requires assessing patients first

• Assess patent airway:

  • Consious, unobstructed- no airway needed
  • Unconsious assess for airway obstruction
  • No airway – place in recovery position. Head tilt chin lift vs jaw thrust
  • With airway insert NPA
  • With patients with any other injury, a surgical cricothyroidomy may be required

• Assess patient breathing by -

  • Assess respiration and initiate appropriate oxygen therapy
  • Nasal cannula, Non breather, Bum
  • Assess to mange any rates and injuries that are causing it, Tension, Sucking

• Occlusive vs Needle Dressings.

• Perform secondary assessment by evaluating the Head, Body and Circulation.

• Check patients pulse: Throbbling v diminished vs absent.

• Assess any color/temp/conditon: Cool v warm, pale cyanotic and clammy or dry.

• Control any bleeding, elevate feet.

  • Treat the shock:
  • Provide a blanket
  • Control any bleeding, elevate feet
  • Fluid resuscitation:
  • Provide access to IV of IO, consider hemorrhagic shock, saline lines and assess to check every 1-2 hrs.

• To determine priority you should be tracking vitals, and baseline and injuries to The Head/Neck-Chest.

• Always look in back, and check for the upper and lower extremities to provide transport.

• Assess Abdomn/Pelivs, check any Posterier thorax/lumbar/buttock.

• Assess any and all injuries.