Page 128 - JSOM Fall 2020

intubation (RSI), continuous sedation, ventilator management, “mad minutes” (tactical pauses to review the situation). This
and management of difficult airways with intubation adjuncts combined the knowledge, experience, and critical thinking of
such as video laryngoscopy. the entire group of experienced medical providers. Addition-
ally, by sharing a common mental model of the tactical and pa-
Pain and Sedation Management tient care requirements, the team has a better chance of overall
There is a real need to train with and use more effective long- mission completion.
term and oral and parenteral analgesics, and for monitoring
vital signs in anticipation of additional medication require- Experienced Team Members
ments. Subtherapeutic analgesic dosing was noted commonly Making every effort to bring experienced members on these
and postulated to be due to inexperience with administering infrequent, high-profile missions has helped with operational
these drugs. The first time a medic gives ketamine should not details such as appropriate pack out, positioning, and tactics
be on a real-world mission but rather in an in-garrison or ci- for infiltration, ship boarding, and onboard operations. Ad-
vilian hospital clinical experience so the provider knows what ditionally, these experienced rescuers are adept at obtaining
range of patient doses and responses to expect in the future. detailed medical assessments, formulating treatment plans,
and executing infrequently performed procedures. One of the
Reference Materials patients in this cohort required a surgical airway due to head
Whenever possible, the use of memory aids and reference ma- and neck burns and supraglottic edema; however, an initial
terials is recommended when performing advanced procedures attempt by a PJ was unsuccessful due to edema and loss of
such as RSI, escharotomy, fasciotomy, and so forth. Checklists typical landmarks. Another PJ on scene who had performed
have been suggested as a means to improve performance of three cricothyroidotomies in Afghanistan was immediately
low-repetition, highly complex procedures such as RSI. 15,16 successful in the salvage attempt.
Compact, possibly digital, references are not a replacement Work/Rest Cycles
for training, but they help augment the rescuer skillset when Multiday missions require the team members to divide shifts
performing life-saving interventions at the point of care. Addi- and allow adequate rest to maintain cognitive and physi-
tionally, the use of telementoring during complex procedures cal performance. In several instances, the rescuers had been
has been described and may also improve outcomes when tac- awake for 24 hours prior to initial patient contact. This time
tical availability allows. 17 was consumed by gear pack out, lengthy flights, parachute
insertion into the ocean, unpacking and inflating a Zodiac
Burn Care boarding craft, recovering supply bundles from the ocean,
Almost half of the patients (n = 10 of 22) in our review sus- and ship-boarding procedures. Sleep deficit can be mitigated
tained burns primarily, with several documented as exceeding through en route napping on the aircraft and assigning sleep
the usual 20% TBSA burn, which qualifies for admission to shifts after initial patient assessment and treatment.
a burn intensive care unit. Given the confined quarters and
combustible fuels found on ships, frequency of burn injuries in Limitations
this dataset is not surprising. The initial training of PJs focuses The limitations of this work revolve around its retrospective
on the management of traumatic injuries, and there is not a nature and the use of AARs to create the dataset. Missing mis-
formal rotation focusing on burn care. The establishment of sion profile and patient-care details were obtained through di-
burn-unit clinical rotations during initial or sustainment train- rect communication with the rescuers. It is possible that this
ing would undoubtedly improve burn care competency, bolster introduced recall bias.
core PFC skills, and improve the management and outcomes
of this patient population.
Conclusion
This report of long-range ocean rescue operations for ill and
Crew Resource Management
injured patients describes PJs providing critical care beyond
Rescuer Incapacitation the expected skillsets and usual timelines of many military
Particularly at great distances from established medical care, and civilian medics. We have highlighted the most common
protocols for rescuer incapacitation must be established. injuries and illnesses treated, and provided a framework from
Preparation for management of motion sickness and other which to train, prepare, and plan for these complex rescue op-
ailments and injuries improved the likelihood of a successful erations. Although the PJs who performed these missions are
mission. Lyon et al. reported on seasickness as a feature of primarily combatants, the lessons learned highlight the train-
8
maritime medical rescues; in a survey of the incidence of mo- ing balance needed to ensure they are safe as operators and
tion sickness among PJs, approximately 75% of Air National competent as advanced medical providers.
Guard PJs reported symptoms of motion sickness at some
point during performance of their duties. Of those who tried Disclosure
various medications, only 21% found relief. It may be useful The authors have nothing to disclose.
8
to ground test antiemetics among providers who have a rea-
sonable expectation of performing maritime rescue. References
1. US Air Force. Pararescue – 1T2X1. https://www.af.mil/About-Us
Group Decisions /Fact-Sheets/Display/Article/104514/pararescue-1t2x1/. Accessed
One of the tenets of CRM is the use of all available person- 22 April 2019.
nel, information, and physical resources to conduct a mission 2. US Coast Guard. Acquisition Directorate. https://www.dcms.uscg
.mil/Our-Organization/Assistant-Commandant-for-Acquisitions
safely and effectively. In several missions, prior to critical pro- -CG-9/Programs/Air-Programs/MRR-MH-60T/MRR-MH-60/.
cedures (e.g., intubations, cricothyrotomies), the team held Accessed 5 November 2019.

126 | JSOM Volume 20, Edition 3 / Fall 2020