Page 172 - JSOM Spring 2018

8. Time to Death in Noncompressible Hemorrhage: Dr John of 2016. LTC Miles practical pointers for using whole blood
Holcomb shared some of his most recent work that highlights far forward include:
the importance of providing lifesaving interventions as soon as 1. Use 2 large-bore IV lines if possible
possible in casualties with noncompressible hemorrhage—in- 2. They have found good flow rates with the FAST-T
cluding in the prehospital setting whenever possible. As a point 3. IO devices MUST be flushed with 20mL of saline or LR
of emphasis, he noted a factor VIIa study in which the mean time 4. They expedite TXA administration: 1g in 10mL, then 10mL
to drug administration was 5 hours—which is not optimal con- flush
sidering that most patients who die from hemorrhagic shock do 5. Ranger First Responders are very helpful in expediting
so within 2 hours after injury. He discussed the recent article in transfusions.
the Journal of Trauma by Oyeniyi that examined the impact of a 6. Cold chain management is essential
“bundle of care” for bleeding patients. This bundle consisted of: 7. Different resupply options are being evaluated
o o “Identify the bleeding patient 8. Train, train, train!
o o Prehospital and hospital damage control resuscitation
o o Prehospital and hospital extremity and junctional In the Question and Answer period, LTC Miles was asked
tourniquets what the difference is between the 75th Ranger Regiment and
o o Prehospital and hospital pelvic binders the rest of the military with respect to ensuring casualty sur-
o o Prehospital and hospital hemostatic dressings vival. He enumerated four factors:
o o Resuscitative endovascular balloon occlusion of the aorta 1. Will
o o Coagulation monitoring with thromboelastography TXA 2. Leadership
for patients with significant fibrinolysis 3. TCCC
o o Decreased time to operating room 4. Having physicians and PAs trained in TCCC.
o o Decreased time to interventional radiology
o o Goal-directed resuscitation with blood products as 10. TCCC Web Mobile and Social Media Projects: Mr Harold
bleeding slows” Montgomery, the Operational Forces Liaison for the CoTCCC
and the JTS, discussed the importance of reaching out to the
current generation of active duty combat medics in their pre-
Through implementation of these steps, Memorial Hermann
Hospital documented a decrease in deaths from hemorrhage— ferred modes of communication—or, to quote, Monty: “Email
from 36% to 25% (p <.01). is for old people.” Mr Montgomery provided an excellent per-
Dr Holcomb also discussed the recent Harvin article that spective by noting that 80% of the US military is less than 36
found that the mortality rate for hypotensive patients requiring years old and that everyone in this demographic volunteered
a trauma laparotomy has remained unchanged over the past two to serve their country after the war on terrorism had started.
decades at 46%. In discussing hemostatic interventions that can An important observation is the requirement to adjust TCCC
help stop bleeding faster, he cited the work done by Cantle et al. messaging and training to the communication and learning
that examined 402 patients who underwent trauma laparoto- methods of the next generation of medics.
mies and found that 90% had their primary bleeding above the Since his arrival, Mr Montgomery has been helping the
aortic bifurcation. This means that if REBOA is to be used in CoTCCC and the JTS with improving the outreach and the
this setting, the balloon would have to be inflated in Zone 1 and messaging to the new generation of young combat medics,
the authors found that Zone 1 REBOA would have controlled Corpsmen, and PJs. A brief summary of his accomplishments
bleeding in 87% of the patients in this study. The Abdominal in this area includes:
Aortic Junctional Tourniquet, in contrast, would have helped – Establishing a TCCC presence on Facebook, Twitter, Insta-
only 8%. If the AAJT or the balloon in REBOA is inflated dis- gram, LinkedIn, and YouTube.
tal to the site of vascular injury, it is more likely to exacerbate – Working with the DHA deployed medicine team to help
NCTH than to control it. Dr Holcomb emphasized that REBOA develop a TCCC application that can be downloaded onto
could potentially be employed in the prehospital setting, since personal electronic devices and used in deployed environ-
the only skill required for its use is the ability to gain femoral ments when there is no Internet connectivity.
access. Zone 1 REBOA can only be used for 60 minutes before – Working with the DHA deployed medicine team to help
distal ischemia becomes a problem for the patient. establish an operational medicine website, with TCCC as
the cornerstone of the site’s content. A key feature of this
website is that it does not require a Common Access Card
9. POI Whole Blood Use in 75th RR: LTC Ethan Miles is the
Regimental Surgeon for the 75th Ranger Regiment. The Ranger for access. Since it went live in November 2016, the cotccc.
Regiment has aggressively implemented the use of whole blood com website has had over 35,000 users from 174 coun-
in caring for the casualties in the prehospital setting. Their tries. 50% of these users came from social media. As of
“ROLO” (Ranger Type O Low Titer) program was established September 2017, the cotccc.com website has transitioned
several years ago and was the prototype for such a program in to the www.deployedmedicine.com website and is the cor-
the DoD. Everybody in the Regiment gets typed and screened, nerstone of the mobile app “Deployed Medicine” that is
and those individuals who are found to be type O and have low now available for download.
anti-A, anti-B titers are then considered to be universal donors. – Developed a medic-friendly TCCC Quick Reference Guide
At this point, they have also started to field cold-stored to provide a concise yet comprehensive collection of the
type O low titer blood, thanks to the assistance of the Armed most important TCCC information.
Forces Blood Program office in supplying that product. The The importance of this outreach to the new generation of mili-
Regiment has 11 cases of prehospital whole blood transfu- tary Medics was underscored by Mr Montgomery’s observa-
sions to date—all cold-stored WB units. LTC Miles noted tion that one of the combat medics at a CoTCCC meeting 2
that whole blood is a preferred resuscitation fluid over dried years ago mentioned that he had never even seen the TCCC
plasma and that they have not used dried plasma since January Guidelines until that meeting.

166 | JSOM Volume 18, Edition 1/Spring 2018