Page 123 - JSOM Winter 2019

FIGURE 1 (left) Materials used for the improvised junctional a go-around to give time for the primary medic to conduct a
tourniquet. (right) Use of the improvised junctional tourniquet. cricothyroidotomy on CTM-A and then radioed to the team
leader and requested the CASEVAC helicopter do a 2-minute
fly away. The cricothyroidotomy was performed on CTM-A
due to hidden fragmentation to the temporomandibular joint
causing an inability to open the mouth for direct laryngoscopy,
an increasingly unstable airway, and a helicopter ride where
airway management would be more difficult.

Before moving to the aircraft, PJ2 requested to have a team-
mate look at CTM-C for any serious concussion injuries. The
helicopters then landed, and the team began moving to the
aircraft. CTM-B was loaded second. On the aircraft the crew
handed PJ2 a headset, but it did not work, and PJ2 was unable
to speak over intercom to the crew in the back. PJ2 pointed
out to the crew who was the most severe casualty, and the
crew began administering blood products to the most critical
Due to the blood loss, CTM-B was now only able to follow casualty. The aircrew began delivering bag-valve-mask venti-
basic commands slowly. PJ2 assessed the radial pulse and lation to the other casualty, while PJ2 assisted by gathering
placed a pulse oximetry to find a 97% saturation reading and the intraosseous needle for placement into CTM-B’s right hu-
a strong heart rate of 68. He had equal rise and fall of the merus and pushed 1 unit of blood. During the flight, PJ2 con-
chest, and it was decided that needle thoracentesis was not tinued to reassess vital signs and treatments on CTM-B and
necessary. With assistance, CTM-B was placed in an HPMK the other critical casualty.
blanket (hypothermia prevention kit) and the heater blan-
ket was positioned on top of the chest. Intramuscular (IM) When the CASEVAC helicopters landed at the forward sur-
ketamine 60mg was administered in the deltoid with 50 mg gical team (FST) and mobile forward surgical team (MFST)
en route due to continued pain, and 50mg was given before location, the litter teams loaded both casualties onto a flatbed
loading on the CASEVAC helicopter [casualty evacuation he- truck and moved to the FST/MFST (surgical unit) where PJ2
licopter]. After the first dose of ketamine a MIST report was gave a verbal handover to the surgical teams and remained at
provided to the team leader stating “IED blast, groin bleed, the FST and assisted with treatments. The JTQ was consid-
TQ on the right leg and junctional tourniquet in place, patient ered effective enough that there would be no need for damage
is in Urgent Condition.” control surgery at the forward surgical site. Damage control
resuscitation was administered as 2 units of blood. All other
When asked what else was needed, PJ2 stated, “A JTAC [tacti- injuries were considered non–life threatening and were treated
cal air controller] to get us an HLZ,” which was already being later.
worked. With the CASEVAC helicopters en route, it was time
to move CTM-B and the other urgent casualty to the HLZ. Be- When evacuated to a higher level of care, a venous blood clot
cause the most seriously wounded casualty had been placed in of approximately 25cm was discovered distal to the location
the primary medical vehicle, the team coordinated an alternate of the junctional tourniquet. The blood clot, which reportedly
medical vehicle, a Toyota Hilux, for CTM-B. He was placed “hurt pretty bad,” required daily injections of a blood thinner.
across the bed of the truck on the litter. Team members started Exploration of the primary wound discovered a 7mm frag-
an intravenous (IV) line in the right antecubital fossa and set ment that damaged CTM-B’s femoral artery and lodged in his
“to keep open” rate (TKO). PJ2 then told the driver to call out hip. This required an open surgery with disarticulation of the
any bumps along the way and not to drive too fast. hip to remove the fragment. A second fragment had entered
CTM-B’s left quadriceps, passing through the patellar tendon;
Upon driving to the HLZ several kilometers away, PJ2 reas- this resulted in arthroscopic exploration of the knee joint and
sessed injuries and treatments. CTM-B’s TQ, JTQ, and chest multiple open surgeries of his left quadriceps for fragmenta-
seals remained in place and he continued to have good chest tion removal and washouts. Functional rehabilitation took
rise and fall. CTM-B had a heart rate of 70, respirations of 16, approximately 7 months for both injuries.
and pulse oximetry reading of 98%. PJ2 noticed that CTM-B
was still in severe pain and administered another dose of IM Further complications of the blast injury included a traumatic
ketamine 40mg. Once the team arrived at the HLZ, a team brain injury (TBI) with brief loss of consciousness, causing
member and PJ2 offloaded CTM-B onto the ground and ad- inability to self-treat or self-evacuate. Initial neuropsychiat-
ministered tranexamic acid (TXA) 1g IV by pinching off the ric evaluation results were “pretty bad.” The patient reports
lower tubing and injecting it into the upper IV tube, allow- that a clear treatment plan for the TBI was not outlined. For
ing it to flow wide open from the IV bag. PJ2 administered several months, CTM-B felt dizzy and had poor short-term
an additional two doses of IM ketamine 50mg before moving memory and sluggish reactions. At 7 months postinjury, he
to the helicopter, and then a casualty treatment card was cre- failed his return to duty neuropsychiatric evaluation and was
ated. The primary medic treating the other critical casualty sent to the brain treatment center in San Diego for 6 weeks to
requested help filling out a casualty treatment card. PJ2 then receive magnetic resonance treatment, after which he passed
filled out some data and immediately noticed the primary his neuropsychiatric evaluation without issue.
medic could use additional help and asked a team member
to assist the primary medic while he continued to work on Two months postinjury laboratory test results showed that
CTM-B. PJ2 was tracking that the helicopters needed to do both total and free testosterone levels were abnormally low.

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