Page 125 - JSOM Summer 2018

An Ongoing Series

Nursing Interventions in Prolonged Field Care

2
1
3
Dawn Ostberg, RN *; Paul Loos, 18D ; Elizabeth Mann-Salinas, RN ; Cody Creson, 18D ;
4
5
Douglas Powell, MD ; Jamie Riesberg, MD ; Sean Keenan, MD ; Stacy Shackelford, MD 8
7
6
Introduction Cross-training all team members on these interventions prior
to deployment will lessen the demand on the medic, especially
This Role 1, prolonged field care (PFC) guideline is intended when caring for more than one patient.
to be used after Tactical Combat Casualty Care (TCCC)
Guidelines when evacuation to a higher level of care is not im- Assessment
mediately possible. A provider of PFC first must be an expert
in TCCC. The intent of this guideline is to provide medical After initial stabilization, every patient requires regular assess-
professionals who encounter extended casualty evacuation ments. Document results on a PFC flowsheet (Appendix A)
times in austere environments the evidence-based guidance for and monitor trends to identify signs of decompensation. Initi-
nursing interventions necessary to improve patient outcomes. ate nursing interventions early to prevent further harm.
Recommendations follow a “minimum, better, best” format • Minimum: Manual blood pressure (BP) cuff, stetho-
that provides alternate or improvised methods when optimal scope, thermometer, pulse oximeter, glucometer, urinary
hospital options are unavailable. catheter, flashlight, watch
• Better: Digital, wrist BP cuff
Basic activities of daily living become impaired or nonexis- • Best: Portable monitor providing continuous vital-signs
tent depending on the severity of wounds. Simple tasks such as display and capnography capability, glucometer
brushing teeth, breathing, drinking, coughing, moving extrem-
ities, and turning become impossible for an injured or uncon- Vital Signs
scious patient. Thus, the patient requires regular assessments Obtain BP, heart rate, respiratory rate, temperature, oxygen
and nursing interventions to monitor their condition and pre- saturation, end-tidal CO (when available), Glasgow Coma
2
vent the development of complications. Scale score, pain score, and peripheral pulses.
Nursing interventions may not appear important to the med- Inspect and Monitor Tubes
ical professionals caring for a patient, but such interventions Examine all tubes (e.g., endotracheal tube [ETT] or cricothy-
greatly reduce the possibility of complications such as deep roid tube, nasogastric [NG] tube, intravenous [IV] line, chest
vein thrombosis (DVT), pneumonia, pressure sores, wound tube, urinary catheter) for correct placement and appropriate
infection, and urinary tract infection. Critically ill and injured function, and ensure they are secured properly. High-volume
casualties are at high risk for complications that can lead burn resuscitation results in global edema and ETT/cricothy-
to adverse outcomes such as increased disability and death. roid tube position must be closely monitored. Securing tubes
Nursing care is a core principle of PFC to reduce the risk of with circumferential ties is required when burned skin weeps
preventable complications and can be provided without costly fluid. Caution: NG tubes should only be placed when radio-
or burdensome equipment. graphic or intraoperative confirmation is available, or when
the benefit outweighs the risk. Routine NG placement for un-
Using a nursing care checklist assists with developing a sched- conscious or intubated patients is not recommended in austere
ule for performing appropriate assessments and interventions. environments.
*Correspondence to dawn.d.ostberg@socom.mil

1 CPT Ostberg, NC, USA, is an instructor for the Special Operations Combat Medic Course/Special Forces Medical Sergeant Refresher Course at
2
the Joint Special Operations Medical Training Center, Special Warfare Medical Group at Fort Bragg, NC. SFC Loos, 18D, USA, is noncommis-
sioned officer in charge of Special Forces Medical Sergeant Surgery, Anesthesia, Records, and Reports at the Joint Special Operations Medical
3
Training Center, Special Warfare Medical Group. COL (Ret) Mann-Salinas, NC, USA, is a critical care clinical nurse specialist, burn specialist,
and nurse scientist currently conducting research at the US Army Institute of Surgical Research supported by the Combat Casualty Care Research
Program. SFC Creson, 18D, USA, is a senior instructor and course writer for the Special Operations Combat Medic Course at the Joint Special
4
Operations Medical Training Center, Special Warfare Medical Group. MAJ Powell, MC, USA, is an intensive care physician currently serving
5
as the 4th Battalion 3rd Special Forces Group (Airborne) Surgeon and a staff intensivist at Womack Army Medical Center, Fort Bragg. LTC
6
Riesberg, MC, USA, is the 10th Special Forces Group (Airborne) surgeon and is the coordinator for the Special Operations Medical Association
Prolonged Field Care Working Group. COL Keenan, MC, USA, is command surgeon, Special Operations Command, Europe. He has previously
7
served as battalion surgeon in both the 1st and 3rd SFG (Airborne) and as group surgeon, 10th SFG (Airborne). He is a member of the Special
Operations Medical Association Prolonged Field Care Working Group Steering Committee. Col Shackelford, MC, USAF, is a trauma surgeon
8
and chief of performance improvement, Joint Trauma System, San Antonio, TX.
123