Page 116 - Journal of Special Operations Medicine - Winter 2016

collocated with the casualty conducted an initial as- and 1g ertapenem IV through the previously established
sessment under fire, identifying what appeared to be a access. Within 20 minutes, the casualty’s level of con-
gunshot wound to the left upper chest approximately sciousness improved enough to maintain conversation.
3 inches below the clavicle and 1 inch medial to the Over the next hour, radial pulses returned, decreasing
midclavicular line. Further assessment also revealed a to 120 bpm. Blood pressure averaged 90mmHg. Respi-
4-inch contusion with significant ecchymosis along the rations remained approximately 30/min. The casualty
casualty’s left lower posterior rib cage. The casualty was complained of pain on his left side and upon deep in-
conscious, ambulatory, and able to move under his own halations but otherwise no difficulty breathing. Breath
power with direction from the 18D to a covered posi- sounds were diminished but present on the affected
tion south of the main element, which remained engaged side, and strong and regular on the unaffected side. The
from the north. compound was under direct enemy fire from the north,
west, and south for the remaining daylight hours. Dur-
After placing a nonvented occlusive chest seal (HALO ing this time the 18Ds rotated between casualty care,
Chest Seal; Curaplex, http://www.curaplex.com/), the sniper overwatch/breach security, and assessing minor
18D conducted a thorough secondary assessment, not- fragmentation wounds among partner force and inhala-
ing crepitus and a significant pain response across the tion injuries of fellow teammates from a drug labora-
entire left torso with no apparent exit wound. The tory destroyed several hours earlier.
casualty was warm and diaphoretic with a weak ca-
rotid pulse of 120 bpm, absent radial pulses, and 32 Based on the casualty’s apparent stability, a chest-tube
shallow respirations per minute with bilateral chest kit was prepped, but administration was delayed barring
expansion. He complained of extreme pain on his left any worsening of the casualty’s condition and security
side and difficulty breathing. These findings suggested priorities of work. The 18Ds considered a course of IV
that the round, having struck the upper chest, was re- ketamine but opted for a second dose of 800μg fentanyl
directed down through the torso, fracturing ribs and to maintain the casualty’s responsiveness and preserve
lodging somewhere in the vicinity of the identified con- the limited supply of medical resources in anticipation
tusion. The casualty was diagnosed with uncontrolled of an increasingly prolonged time on target. The casu-
internal hemorrhage along with likely traumatic hemo-/ alty was positioned on an incline with feet slightly el-
pneumothorax. Air MEDEVAC was requested. The evated, and allowed to sleep. Water intake was reduced
casualty then received 800μg of oral transmucosal fen- to a minimum because it was expected he would enter
tanyl citrate and a needle thoracentesis on the left side, surgery immediately following exfiltration. The 18Ds
which provided minimal relief. Intravenous (IV) access continued to closely monitor the casualty’s vital signs
was acquired in the right antecubital fossa. (initially recorded on a casualty evacuation card and
later on their smartphones) and twice performed finger
The casualty was transferred to a litter and covered thoracostomy for decompression relief. Hours of dark-
with a hypothermia-prevention management kit (outer ness allowed the main element to transport the casualty
shell; HPMK, North American Rescue Products), but 1600m across two ridgelines to an HLZ for exfiltration.
further treatments were deferred in order to move the
casualty to an emergency helicopter landing zone (HLZ) Despite extremely inhospitable terrain navigated by
approximately 400m away. On reaching the proposed litter teams without night-vision goggles, the casualty
HLZ, heavy enemy fire coming from the south and remained stable and arrived at the HLZ alert and con-
west on the exposed position resulted in the Afghan lit- scious with a heart rate of 110 bpm, respirations of 24/
ter team abandoning the casualty and 18Ds for distant min, and systolic blood pressure averaging 110mmHg.
cover. MEDEVAC was denied because of heavy enemy On arrival at the final exfiltration point, an approaching
machine gun and rocket-propelled grenade fire, forcing storm deterred the team’s departure indefinitely. Tenta-
the 18Ds to drag the casualty into a nearby sewer for tive plans were made to find defensible real estate for
defilade. The casualty’s level of conscious gradually de- the next 24 hours. Effort was necessary to keep the ca-
creased, shifting between verbal and pain responses as sualty warm and dry during a brief rain shower and to
his carotid pulse increased to 136 bpm. The 18Ds con- monitor him over the next several hours while awaiting
tinued to monitor the casualty and return effective fire, a delayed departure time. No further treatments were
but were unable to provide further treatment until the administered until the casualty was delivered to a Role
main element breached and occupied a nearby walled II emergency department around 0200, 13 hours after
compound approximately 45 minutes later, providing a injury.
safe working area with cover from direct fire.
Upon arrival at the American Role II surgical facility, a
Inside the compound, the casualty was given 500mL Hex- focused assessment by sonogram for trauma (FAST ex-
tend (BioTime, http://www.biotimeinc.com/), 1g TXA, amination) revealed fluid in the pelvis. A chest tube was

100 Journal of Special Operations Medicine Volume 16, Edition 4/Winter 2016