It was a spring day in early March once I met Nick Gaines. He was our instructor Extended care in the sphere (PFC) that I’ll endure for the subsequent 48 hours. Gaines was a former 18D and Special Operations Forces Austere Course (SOFAC) instructor. He currently works as a paramedic in East Texas. To our knowledge, this was the primary time a PFC course was offered nationwide to civilians over the weekend. The only condition for participation within the classes was the completion of the Tactical Combat Casualty Care (TCCC) program previously. Among the willing students were bizarre people in addition to paramedics, law enforcement officers, nurses and myself. On the primary day, we reviewed the 75-page guidelines last published in December 2021. The second day was a hands-on scenario.
Where TCCC focuses on the immediate care of the casualty, PFC focuses on what happens after a life-threatening injury is stabilized and evacuated to the next level of care. Transporting a casualty to final care can take hours and even days. An example can be something like this: A mass accident has occurred. On-site segregation will happen and the MARCH protocol might be initiated. The casualty collection point (CCP) would then receive casualties before being transported to the Field Hospital (FH). Upon arrival at FH, the casualty is repeatedly assessed and treated appropriately. Any casualty who requires further treatment is then evacuated for final care.
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The first day
The daunting task of reducing 75 pages of PFC guidance (www.prolongedfieldcare.org) for an eight-hour course was a challenge that Gaines handled well. The initial disclaimer he stressed was, “Everyone is predicted to take part in their very own survival.” Thus, he had a captivated audience that desired to know more about increasing their odds in a stark setting.
After the initial remarks, we began with a temporary overview of the TCCC concept. Gaines kept saying all day that in case you’re in a mass casualty situation and do not know what to do, return to the MARCH algorithm. As a reminder, the abbreviation MARCH stands for Massive Hemorrhage, Airways, Respiration, Circulation, and Head Trauma. In PFC MARCH it was prolonged to MARCH PAWS L. This added communication as a second “C” in MARCH and continued in pain, allergies, wounds and logistics. After the initial triage, it was needed to efficiently transfer the patient to the subsequent level of care. We have been given the acronym MISTE which stands for mechanism of injury, kind of injury/disease, signs and symptoms, treatment and ETA to the subsequent level of care. This was considered one of the areas where a lot of us mistakenly took shortcuts on day two of the script.
We then reviewed the ten PFC tasks. The PFC working group has developed them to find out the minimum, higher and best practice for the victim’s PFC. For the sake of simplicity, I’ll list the tasks and you may read further in the rules I provided within the link above. The first task is to (1) monitor the casualty to create a useful trend in vital signs. Then (2) resuscitate with blood products if needed. (3) Ventilate and/or oxygenate the patient. (4) Control the airways. (5) Use a sedation or pain control protocol that permits the provider to finish all tasks. (6) Perform physical examination and any diagnostic measures. (7) Provide nursing care or comfort measures. (8) Performing surgical procedures (e.g. chest tube, cricothyrotomy). (9) If needed, conduct a telemedicine consultation, and at last (10) prepare the patient for transport. Students within the classroom picked up on a lot of these tasks given a temporary overview in such a compressed classroom.
Then Gaines recognized the giddiness of the postprandial hypersomnia that followed dinner. He decided to point out us around his medical bag within the truck and identified that he had items that had multiple uses. He suggested that it could be inconceivable to choose up a medical bag if we tried to plan for each medical emergency we encountered. Since it took about half an hour to undergo the contents of his bag, there wasn’t any space left unused. I even have to confess my bag is not as sexy as his, but you may see mine in Bag Drop at RECOIL OFFGRID, number 51.
In the last a part of the didactics, we discussed the results and justification of tourniquet conversion. The purpose of TQ conversion is to maneuver towards a hemostatic agent or compression dressing. This will be safely done in a window of 30 to 120 minutes so long as the bleeding has stopped. A window of two to 6 hours can be considered protected, but not ideal. After six hours, TQ conversion is just not beneficial unless the casualty is in the ultimate care setting. Tissue damage risk, kidney problems, and elevated potassium levels are all issues that may occur when TQ is on for greater than six hours.
The first day ended with preparations for the scenario of the second day. We identified the strengths of the participants and assigned them roles to perform the subsequent day. It took us about 90 minutes to arrange this a part of the category.
We began the morning with an hour-long summary of yesterday’s classes. We then continued to separate our group into their final roles. There were a complete of 24 people in the category. In this scenario, we had a further 12 casualties. Our roles within the scenario were broken down as follows: Protection (two), Search and Rescue (two), Triage (five), FH (4), Transportation Team (three), Asset Manager (one), Operations Manager (one), Operations Manager communications officer (one), medical director (one), logistics coordinator (one), dispatcher (one), and incident commander (one). We gave two hours for ready-made resources like first aid kits, litters, and logistics.
When the scenario began, security (two people), SAR team (two people), triage team (five people), communications manager, transport teams (two people) and logistics coordinator traveled from FH to CCP. SAR went with the CCP to locate the incident. After identifying the scene, they radioed triage and transport to mobilize to the scene. SAR conducted an initial assessment of TCCC/MARCH. Triage arrived on the scene and commenced secondary assessments with the needed documentation. The victims were then prioritized and transported to the CCP, which was about 500 yards from the incident.
Upon reaching CCP, Triage conducted their assessment and documentation to organize for transportation to FH. The transport from KPK to FH took 13 minutes. We used one vehicle for transport from the scene to the KPK and one for transport from the KPK to FH. Later within the scenario, we used other vehicles to move the victims to hurry up the scenario. At one time, 4 people served as nurses in FH. We arrange a 12-bed FH with one ward nurse and three circulation nurses. The total execution time of the scenario was from 1000 to 1515 hours and not using a break for a meal. Post-action review/briefing took 45 minutes.
There was consensus that it was a successful learning experience for all involved. We have proven that the fundamentals of PFC will be taught to civilians with various degrees of medical skill. The exercise was complete chaos for five hours, but everyone did a unbelievable job fulfilling their role. Victims were only given a number of elements to include into their role-playing to maintain things easy. They also did an incredible job. During practice, we used Zello to speak, which worked quite well. There were gaps within the flow of knowledge throughout the exercise, but given the chaos and inexperience of the scholars, I assumed they did an ideal job. Transportation logistics was also a little bit of a bottleneck on the scene and CCP. If there have been more participants, this may be an area to strengthen aid.
All in all, it was a successful PFC exercise for civilians. During the script, everyone was actively involved and nobody had any downtime throughout the event. Gaines did an exceptional job presenting the data and we were pleased with how things turned out. Everyone, including myself, got here away with more knowledge so as to add to their skill set.
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David L. Miller, DO, FACOI, has been an internist in private practice for 20 years. His experiences outside of the office included time as a health care provider fighting in regional MMA events and as a team doctor for 10 years at a mid-sized university within the Midwest. He currently serves because the chief medical instructor for the civilian emergency response team based in Indianapolis.