Military Prehospital Care Research Articles

Atención Pre-Hospitalaria de combate y cuidado del herido, ángeles en medio del infierno: una visión al interior de la APH Militar

Las Fuerzas Militares de Colombia desarrollan operaciones en todos los rincones del país, como parte de su misión constitucional de defender la soberanía, la independencia y la integridad del territorio nacional, para esto cuenta con un equipo de militares especialistas en diferentes áreas, una de ellas es la atención pre-hospitalaria, cuyo objetivo es brindar atención medica inicial al herido o lesionado en combate. Este artículo de revisión, se centra en el análisis documental de datos enfocados a la situación actual de la labor de la atención pre-hospitalaria militar en Colombia, especialmente en la Armada Nacional. Entre los principales hallazgos, se muestra el contexto de esta labor al interior de la Fuerzas Armadas, luego se hace una mirada a la historia de la atención de enfermería de combate, posteriormente se hace un análisis a la importancia del Socorrista Militar y Enfermero de Combate desde la percepción interna de los actores y finalmente se enfatiza la necesidad de brindar una educación en atención pre-hospitalaria de calidad, basada en el contexto real y mediante un modelo pedagógico que facilite el aprendizaje significativo de los estudiantes de estos cursos.

Prehospital Analgesia and Sedation: a Perspective from the Battlefield

Battlefield medicine is a dynamic and chaotic environment in which to provide care. However, it is critically important for the medical practitioner to provide adequate analgesia for the wounded. Throughout the last two decades of conflict, there have been several changes to how analgesia and sedation are provided in the prehospital setting. Despite the recommendations from the Committee on Tactical Combat Casualty Care (CoTCCC), adherence to the guidelines has been poor to moderate. Additionally, Prolonged Field Care (PFC) guidelines offer additional recommendations, which can differ from CoTCCC guidelines. There are several factors that impact adherence including conflicting references, leadership, and logistical issues. Expanding the current prehospital approach to analgesia and sedation may help increase adherence. The two prominent guidelines for military prehospital care, TCCC and PFC, offer an evidence-based approach to providing analgesia and sedation on the battlefield that should help increased optimal battlefield analgesia.

Fatty Acid-Saturated Albumin Reduces High Mortality and Fluid Requirements in a Rat Model of Hemorrhagic Shock Plus Tourniquet and Hypotensive Resuscitation.

Military prehospital care for hemorrhage is often characterized by use of tourniquets (TQ) and permissive hypotensive resuscitation (PHR) with crystalloids or colloids, but these treatments have not been previously combined in an animal model. Although albumin resuscitation solutions have been tested, the potential effects of nonesterified fatty acids (NEFAs) bound to albumin have not been evaluated in vivo, and few studies have investigated concentrated albumin solutions to reduce fluid requirements. We created a militarily relevant rat model of trauma and hemorrhagic shock (T/HS) (27 mL/kg hemorrhage) with TQ and PHR. We investigated the ability of resuscitation with concentrated (250 mg/mL) albumin, followed by Plasmalyte as needed to maintain PHR, to reduce fluid volumes (vs. Plasmalyte alone, N = 17). Albumin was free of nonesterified fatty acids (N = 15) or saturated with oleic acid (OA; N = 13). The model resulted in high (53%) mortality within 3 h of injury. Only OA-saturated albumin was able to significantly reduce mortality (from 47% to 8%) and fluid requirements (from 56 to 6 mL/kg) compared to Plasmalyte alone. Plasma NEFA-binding capacity was saturated earliest in the OA-saturated albumin group. Likewise, OA-saturated albumin tended to increase cell-free hemoglobin in the broncheoalveolar lavage fluid, which was significantly associated with survival. Our findings suggest incorporating TQ and PHR in T/HS models may result in high mortality and fluid requirements and that OA-saturated albumin, but not NEFA-free albumin or Plasmalyte alone, may provide a benefit to early survival and resuscitation volume, though a hemolytic mechanism may have later consequences, so caution is advised.

A review of ketorolac as a prehospital analgesic

The provision of multimodal analgesia is a core concept in the management of acute and chronic pain. In the prehospital setting, non-steroidal anti-inflammatory drugs (NSAIDs) can be used alongside paracetamol and opioids to provide such analgesia. Ketorolac is an NSAID which can be administered by injection and is used internationally in civilian and military prehospital care. This CPD article discusses Ketorolac as an analgesic option for paramedics.

Twenty Years of Military Prehospital Care in the Eastern Sovereign Base Area, Cyprus

IntroductionThe Medical Reception Station (MRS) in Dhekelia provides a prehospital emergency care (PHEC) service for the Eastern Sovereign Base Area and surrounding Cypriot towns. This service has been evaluated previously...

Field and en route resuscitative endovascular occlusion of the aorta: A feasible military reality?

Severe noncompressible torso hemorrhage remains a leading cause of potentially preventable death in modern military conflicts. Resuscitative endovascular occlusion of the aorta (REBOA) has demonstrated potential as an effective adjunct to the treatment of noncompressible torso hemorrhage in the civilian early hospital and even prehospital settings-but the application of this technology for military prehospital use has not been well described. We aimed to assess the feasibility of both field and en route prehospital REBOA in the military exercise setting, simulating a modern armed conflict. Two adult male Sus Scrofa underwent simulated junctional combat injury in the context of a planned military training exercise. Both underwent zone I REBOA in conjunction with standard tactical combat casualty care interventions-one during point of injury care and the other during en route flight care. Animals were sequentially evacuated to two separate forward surgical teams by rotary wing platform where the balloon position was confirmed by chest x-ray. Animals then underwent different damage control thoracic and abdominal procedures before euthanasia. The first swine underwent immediate successful REBOA at the point of injury 7 minutes and 30 seconds after the injury. It required 6 minutes total from initiation of procedure to effective aortic occlusion. Total occlusion time was 60 minutes. In the second animal, the REBOA placement procedure was initiated immediately after take off (17 minutes and 40 seconds after the injury). Although the movements and vibration of flight were not significant impediments, we only succeeded to put a 6-French (Fr) sheath into a femoral artery during the 14 minutes flight due to lighting and visualization challenges. After the sheath had been upsized in the forward surgical team, the REBOA catheter was primarily placed in zone I followed by its replacement to zone III. Both animals survived to study completion and the termination of training. No complications were observed in either animal. Our study demonstrates the potential feasibility of REBOA for use during tactical field and en route (flight) care of combat casualties. Further study is needed to determine the optimal training and utilization protocols required to facilitate the effective incorporation of REBOA into military prehospital care capabilities.

A Serious Game for Massive Training and Assessment of French Soldiers Involved in Forward Combat Casualty Care (3D-SC1): Development and Deployment.

BackgroundThe French Military Health Service has standardized its military prehospital care policy in a ‘‘Sauvetage au Combat’’ (SC) program (Forward Combat Casualty Care). A major part of the SC training program relies on simulations, which are challenging and costly when dealing with more than 80,000 soldiers. In 2014, the French Military Health Service decided to develop and deploy 3D-SC1, a serious game (SG) intended to train and assess soldiers managing the early steps of SC.ObjectivesThe purpose of this paper is to describe the creation and production of 3D-SC1 and to present its deployment.MethodsA group of 10 experts and the Paris Descartes University Medical Simulation Department spin-off, Medusims, coproduced 3D-SC1. Medusims are virtual medical experiences using 3D real-time videogame technology (creation of an environment and avatars in different scenarios) designed for educational purposes (training and assessment) to simulate medical situations. These virtual situations have been created based on real cases and tested on mannequins by experts. Trainees are asked to manage specific situations according to best practices recommended by SC, and receive a score and a personalized feedback regarding their performance.ResultsThe scenario simulated in the SG is an attack on a patrol of 3 soldiers with an improvised explosive device explosion as a result of which one soldier dies, one soldier is slightly stunned, and the third soldier experiences a leg amputation and other injuries. This scenario was first tested with mannequins in military simulation centers, before being transformed into a virtual 3D real-time scenario using a multi-support, multi–operating system platform, Unity. Processes of gamification and scoring were applied, with 2 levels of difficulty. A personalized debriefing was integrated at the end of the simulations. The design and production of the SG took 9 months. The deployment, performed in 3 months, has reached 84 of 96 (88%) French Army units, with a total of 818 hours of connection in the first 3 months.ConclusionsThe development of 3D-SC1 involved a collaborative platform with interdisciplinary actors from the French Health Service, a university, and videogame industry. Training each French soldier with simulation exercises and mannequins is challenging and costly. Implementation of SGs into the training program could offer a unique opportunity at a lower cost to improve training and subsequently the real-time performance of soldiers when managing combat casualties; ideally, these should be combined with physical simulations.

An overview of the Medical Emergency Response Team (MERT) in Afghanistan: a paramedic's perspective

This article gives an overview of the Medical Emergency Response Team (MERT) while deployed in Afghanistan during Operation Herrick. The article is an information piece giving a brief history, training background and an overview on how the MERT works and is governed. It will give an insight into the clinical procedures used by a multi-disciplinary pre-hospital care team, the decision-making process and the advances made in military pre-hospital care. It is written from a paramedic's perspective and develops the understanding of how MERT and wider military developments during this conflict have impacted on civilian trauma care and what potential it has in the future.

Aspects of military prehospital care

The military prehospital care experience has adapted civilian practice to reflect the nature of injuries sustained in recent conflicts. The main adaptations stem from differences in the mechanism of injury, clinical timelines and personnel. The large number of blast injuries and resulting extremity trauma means that an emphasis is placed on the control of catastrophic haemorrhage using a number of novel haemostatic strategies. This paradigm of <C>ABC is now universally followed and differs from civilian practice in a number of other ways— particularly in the management of C-spine, airway, chest injuries and circulatory access. This review highlights these differences in practice and outlines military techniques and protocols. It also emphasizes those areas in which civilian practice has borrowed from its military counterparts and successfully employed their techniques. This may become more relevant in the modern, post-September 11th era, in which urban mass casualty incidents are no longer a fictional fear.

Doctor on board? What is the optimal skill-mix in military pre-hospital care?

BackgroundIn a military setting, pre-hospital times may be extended due to geographical or operational issues. Helicopter casevac enables patients to be transported expediently across all terrains. The skill-mix of the...

British Military Experience of Pre-Hospital Paediatric Trauma in Afghanistan

IntroductionTrauma is a leading cause of death in children. Life support courses have been developed to reduce the mortality and morbidity of children suffering trauma; differences in anatomy and physiology...

Ambulance Use in a Military Population: Epidemiology and Implications

Because no studies have been reported on ambulance use in military populations, a 2-year epidemiologic study of all ambulance responses on Hickam Air Force Base was conducted. Findings included a higher utilization rate and a greater proportion of pediatric patients than might be expected in comparable civilian populations. Serious trauma was uncommon, but a wide spectrum of serious medical emergencies was seen. Advanced life support was indicated in 22% of all responses, and its availability improved patient outcome. Based on these and other findings, recommendations are made for upgrading military prehospital care to meet both base population needs and current civilian community standards.