Page 115 - Journal of Special Operations Medicine - Winter 2016

Prolonged Field Care of a Casualty
With Penetrating Chest Trauma

Case Report

Graham Barnhart, 18D; William Cullinan, 18D; Jason Pickett, MD

ABSTRACT

As Special Operations mission sets shift to regions with a medical treatment facility. Implications of prolonged
3
less coalition medical infrastructure, the need for qual- evacuation times are profound in today’s conflicts, be-
ity long-term field care has increased. More and more, cause TCCC does not address prolonged prehospital
Special Operations Medics will be expected to maintain care of the trauma casualty. As part of an analysis of
casualties in the field well past the “golden hour” with current and future SOF missions, the Special Operations
limited resources and other tactical limitations. This Medical Association (SOMA), in conjunction with US
case report describes an extended-care scenario (>12 Special Operations Command (SOCOM), initiated the
hours) of a casualty with a chest wound, from point of Prolonged Field Care Working Group in December of
injury to eventual casualty evacuation and hand off at 2013, with the intent of creating guidelines and position
a Role II facility. This case demonstrates the importance papers to support training and education for medics to
of long-term tactical medical considerations and the conduct extended casualty care in the field.
effectiveness of minimal fluid resuscitation in treating
penetrating thoracic trauma.
Case Presentation
Keywords: prolonged field care; chest trauma, penetrating; A partner-enabled helicopter assault operation was
resuscitation, fluid planned and conducted by a US Army Special Forces
(SF) Operational Detachment Alpha (ODA) and the
Afghan counter narcotics interdiction unit (NIU) tar-
geting a series of narcotics manufacturing facilities.
Introduction
The target objective was well within the golden hour
With the drawdown of combat troops and medical as- of medical evacuation (MEDEVAC) flight, so prolonged
sets in Afghanistan, smaller deployed forces operate in field care was not expected to be a necessity during mis-
areas of low-intensity conflict globally, with minimally sion planning. Additionally, because the mission called
developed US medical facilities. The Special Operations for a helicopter assault, supplies were limited to what
Forces (SOF) Medic must be prepared to care for sur- could be easily carried and dispersed among the partner
gical casualties for an extended time until arrival at a force. Threat assessment led the 18Ds to bring a North
facility with definitive surgical care, and may need to American Rescue WALK Kit Bag (http://www.narescue.
rely on host-nation medical capabilities within many com) stocked with additional supplies in anticipation
theaters of operation. Terrain, weather, and operational of prolonged field care. This included North American
considerations also may impact evacuation times in ar- Rescue hypothermia kits, Chinook chest-tube kits, and
eas where prolonged field care would not otherwise be field blood-transfusion kits (Tactical Medical Module
expected. Movement of casualties may cross national FBTK). However, it was assumed that use of the field
borders, using multiple evacuation platforms, many of blood-transfusion kits would be reserved for Ameri-
which may not be outfitted for casualty care. can casualties (US to US) as the blood types of the Af-
ghan NIU members were unknown—dried plasma was
Application of Tactical Combat Casualty Care (TCCC) unavailable. Each 18D carried an identical supply of
principles at the point of injury has helped reduce tranexamic acid (TXA), narcotics, and antibiotics suf-
the number of troops dying of potentially survivable ficient to provide prolonged care to several casualties.
wounds among US casualties—from 24% to 3% in
Operation Iraqi Freedom and Operation Enduring During the assault, a male Afghan officer, approximately
Freedom, respectively. Nevertheless, the majority of 32 years old, was injured when the enemy initiated a co-
1,2
combat deaths occur before the casualty ever reaches ordinated small arms attack at around 1300. An 18D

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