Page 124 - JSOM Summer 2019

An Ongoing Series

Update

Five Years of Prolonged Field Care in Special Operations Medicine

Jamie Riesberg, MD*; Paul Loos, 18D

ABSTRACT
This brief quarterly update from the SOMA Prolonged Field • Regarding sedation, what are you carrying? How much do
Care (PFC) Working Group focuses on the first of ten sequen- you have, and how long will that last your intubated or
tial reviews of the PFC Core Capabilities, starting with ad- “cric’ed” patient? Consider where the endotracheal tube is
vanced airway management. in the patient’s airway. A well-placed cricothyrotomy falls
below the vocal folds, meaning there is no requirement for
What makes for successful training? Do difficult, realistic tasks a paralytic agent, and possibly less sedation!
build confidence? Is it repetition to develop an “automatic” re- • Are you proficient in cricothyrotomy? (What training mod-
sponse that will become default during periods of high stress? els have you practiced upon? Are you prepared for com-
Or is it high-quality instruction that harnesses experience and plications? How do light and exposure affect your success
shares it in meaningful ways? Whatever you believe the key is rate?) Again, the working group’s recommendation:
to successful training, one truth is non-negotiable—one must
train to build proficiency! Cricothyrotomy training should be included in most medical
training. It is considered a final common definitive solution
for securing an airway. It allows a cuffed tracheal tube to
As we celebrate 5 years of PFC in Special Operations medi-
cine, we will journey back to the recent past and review our be placed, and will allow adequate administration of PEEP,
initial guidelines. Some topics have undergone change as new and use of a ventilator. Additionally, unlike placing and
evidence emerges from the battlefield. Other topics, such maintaining an endotracheal tube placed from the oral route
as PFC airway, have remained largely unchanged due to re- (standard orotracheal intubation), maintaining a cric with
sources, training requirements, or our medics’ most precious sedation alone is much more feasible in an austere setting.
resource—time. Nowhere is the topic of required training Of course, there are many considerations for the advanced aus-
time (and number of repetitions) more contentious than in ad- tere airway. Training and proficiency are key. How much time
vanced airways.
must be dedicated to the medic’s acquisition and maintenance
of this critical skill is still debated. A recent informal review by
Consider how you would manage airway (and in many cases, a forward surgical team provider of 10 combat cricothyroto-
breathing) problems in an austere or PFC environment. For mies performed by medics in the field found several misplaced
many advanced paramedics, the answer is simple—intubate! endotracheal tubes and complications. This is a sobering re-
But, before you jump to that endotracheal tube and a rapid minder that there is no replacement for high-quality, realistic
sequence intubation (RSI), consider the following:
training. As we seek to build our PFC airway capabilities, let
• Are you extremely proficient and recently trained in RSI? us ensure we take due time to remain proficient at the basics
Our initial PFC Working Group Airway authors believed while expanding our advanced capabilities. Remember, with-
that “constant training and maintenance of the skill sets are out expertly applied Tactical Combat Casualty Care, there is
required to ensure a medic is sustained and able to safely no PFC. Happy training!
1
practice them.” If you are not working in a clinical envi-
ronment where you are performing a significant number Reference
of intubations at least quarterly, you are probably NOT 1. PFC Working Group. Airway comments. 14 April 2014.
proficient. https://prolongedfieldcare.files.wordpress.com/2014/11/pfc
• Are you competent in the use of paralytic agents for RSI? -wg-airway-recommendations-april-14.pdf
Do you have a paralytic agent available? (Remember, this is
PFC—you probably don’t have a reliable supply of refriger- Keywords: prolonged field care; PFC; PFC Working Group;
ation.) What is your backup plan? advanced tactical airway; cricothyrotomy

*Correspondence to jamie.c.riesberg.mil@mail.mil
LTC Riesberg and SFC Loos are SOMA PFC Working Group Co-Chairs.

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