Page 117 - Journal of Special Operations Medicine - Winter 2016

placed that drained 600mL of blood. Four fractured ribs being isolated from the main element and to delayed ap-
and subcutaneous emphysema were identified in initial plication of treatments, specifically Hextend and TXA,
radiographs, but no bullet was located. The casualty was which subsequently stabilized the casualty. Our recom-
then taken to the operating room for a laparotomy. No mendation is that while engaged in a developing and un-
injuries to the abdomen were identified. After surgery, stable tactical situation in which the HLZ is not secured,
the casualty remained intubated and stable for 2 days, consider delaying MEDEVAC requests and develop a
during which further imaging revealed the bullet lodged casualty collection point pending all other attempts to
in soft tissue in the vicinity of the L3 vertebral body. The stabilize the casualty or significant change in the tactical
casualty remained in hospital care for the next 2 weeks environment.
with few complications. He developed a climbing white
blood cell count, fever, and worsening pleural effusion Prolonged field care should be central to a medic’s provi-
adjacent to the left lower lobe. A broad spectrum of an- sion considerations, and mission parameters will dictate
tibiotic treatment with meropenem, vancomycin, and the load out between team members and “speed-ball”
levofloxacin was initiated and his symptoms resolved. air resupply feasibility in the field. The 18Ds possessed
A number of pulmonary embolisms were also identi- the supplies and ability to perform higher interventions
fied. Three weeks after injury, he was discharged with on this casualty prior to exfiltration. However, it is im-
a prescription for rivaroxaban for his pulmonary em- portant to weigh improving an individual casualty’s vi-
bolisms and continued his recovery at home. Checkups tal signs against the prospect of uncertain extraction or
at 1 and 3 weeks after discharge revealed an unremark- air resupply, further casualties in the immediate future,
able postoperative course. The casualty complained of and tapping into finite supplies. When exfiltration was
mild discomfort on the affected side and some difficulty accomplished 4 hours later, the casualty’s vital signs
breathing when lying prone, but both of these symp- were stable. The 18Ds did not transfuse (US) blood to
toms diminished over time. the casualty, but having identified universal or type-spe-
cific donors among the partner force prior to the mis-
sion would have been an effective method for prolonged
Discussion
casualty hemostasis in lieu of MEDEVAC or air resup-
Supportive care in casualty transport and management ply of blood products. There is a need in this setting to
for prevention of hypothermia proved crucial during identify indicators for further resuscitation, such as se-
this scenario of limited advanced treatment options. The rum lactate, pulse oximetry, end tidal carbon dioxide, or
ability of the partner force to provide these supportive physiologic parameters to help medics preserve limited
measures in addition to standard TCCC care allowed resources such as blood products.
the 18Ds to effect , safe casualty transport and increase
the overall capabilities of the ODA by freeing up man- References
power. Prolonged field care situations many times tax
the sole medical provider(s), and cross-training team 1. Kelly JF, Ritenour AE, McLaughlin DF, et al. Injury severity
members allows the medic to view the overall casualty and causes of death from Operation Iraqi Freedom and Opera-
assessment and develop and modify treatment plans tion Enduring Freedom: 2003–2004 vs 2006. J Trauma. 2008;
64(suppl):S21–S27.
rather than participating in work that can be delegated 2. Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating
to people with less medical training. preventable death on the battlefield. Arch Surg. 2011;146:
1350–1358.
A tube thoracostomy was indicated by mechanism of 3. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield
injury and physical findings, the casualty’s difficulty (2001–2011): implications for the future of combat casualty
care. J Trauma Acute Care Surg. 2012;73(suppl 5):S431–S437.
breathing, and evidence of uncontrolled, internal hem-
orrhage. However, the application of less invasive treat-
ments first and close monitoring eventually suggested
a field tube thoracostomy was unnecessary. Although a SSG Barnhart is an 18D with B/2/19 Special Forces Group
chest tube would have enabled the 18Ds to reclaim lost (Airborne).
blood and transfuse it to the casualty, using the field
blood-transfusion kit, the casualty’s stable presentation SSG Cullinan is an 18D with A/1/20 Special Forces Group
led the medics to suspend further treatments pending (Airborne).
continued assessment and vital signs trending. MAJ Pickett is a practicing emergency physician and Bat-
talion Surgeon for 2/19 Special Forces Group (Airborne). He
Despite the casualty’s initial presentation as urgent sur- is the director of the Center for Prehospital and Operational
gical, a MEDEVAC request could have been delayed. Medicine at Wright State University Boonshoft School of
This decision may have prevented developments in the Medicine, Dayton, Ohio. E-mail: jrpickett@mac.com.
tactical situation that led to the casualty and caregivers

Extended Care of Casualty With Chest Trauma 101