Page 138 - JSOM Fall 2020

parachute jumps within visual range of the TAMAR, with mild clear, but inspection of the oropharynx revealed progressive
sea conditions and zero illumination. To mitigate risks during oropharyngeal edema, prompting the decision to intubate the
shipboard operations and facilitate transfer of all equipment on patient. The patient was informed and agreed to proceed with
board, the TAMAR came to a dead stop during the insertion sedation and intubation. After induction with ketamine and
until all personnel and equipment were safely loaded on board. midazolam, the video laryngoscope was used to visualize the
cords; however, the first two attempts at intubation failed.
Phase 3: Prolonged Field Care The patient vomited after the second attempt and was rolled
Patient contact was made at approximately 0100 EST, April to the side, suctioned, and successfully intubated on the third
25th. The two patients were physically isolated, so a casualty attempt without a paralytic. Placement was confirmed with a
collection point (CCP) was designated and cleaned. Medical portable capnometer and auscultation. An Impact 731 porta-
supplies and both patients were brought to the CCP. The ship’s ble battery powered ventilator (Zoll Medical Co., Chelmsford,
crew also directed the team to the location of the two deceased MA) was used to ventilate the patient on room air resulting in
sailors. The absence of vital signs was confirmed, and each pulse oximetry saturations of 94%.
sailor was placed in a body bag and secured in a refrigerator.
Around 0700 EST, patient 2 began to decompensate quickly
Patient 1 was a 23-year-old man with 60% total body sur- with rapid onset of dyspnea, anxiety, sonorous respirations,
face area (TBSA) burns in severe pain. Deep partial- and full- drooling, and subcostal retractions. After induction with ket-
thickness burns were noted on the head, face, circumferential amine, video laryngoscopy was performed, but supraglottic
neck, anterior chest, bilateral arms, circumferential forearms, edema obscured the vocal cords and the team opted to pro-
and circumferential hands. There were no signs of hemorrhage. ceed with a surgical airway. The procedure was complicated
He had neck, maxillofacial and perioral edema, however his by loss of the usual landmarks due to neck edema requiring
airway was intact and his phonation was normal. Respirations a second provider to complete the procedure. Endotracheal
were unlabored with no audible grunting or stridor. The pa- placement was confirmed by auscultation and capnography
tient was alert and oriented with normal vital signs with report and ventilation was supplied with the Impact 731 ventilator
of recent void. without supplemental oxygen resulting in pulse oximetry sat-
urations >90%.
Patient 2 was a 44-year-old man with 50% TBSA burns in
severe pain. Deep partial- and full-thickness burns were noted Sedation was maintained for both patients using alternating
on the head, face, circumferential neck, chest, and bilateral boluses of intravenous ketamine 100mg, fentanyl 100µg, and
arms. There were no signs of hemorrhage. He had maxillofa- midazolam 5mg. A bolus was administered when the patients
cial and perioral edema with an intact airway. His respirations began to show signs of movement. This occurred generally
were unlabored but his voice was hoarse. The patient was alert every 20–45 minutes. Over time, boluses doses were titrated
and oriented with normal vital signs. down to conserve resources. Both patients maintained oxy-
gen saturation >90% on the ventilators without supplemental
Initial interventions followed the MARCH-PAWS format for oxygen. Bottled oxygen was reserved for extenuating circum-
each patient with focus on airway patency, attaching moni- stances because of the limited supply.
tor leads, obtaining intravenous access, starting fluid resusci-
tation and controlling pain. Propaq MD (Zoll Medical Co., Prior to intubation, patient 1 reported severe pain in the left
3
Chelmsford, MA) monitors were used. Initial pain manage- hand and forearm with significant tense swelling. Telemed-
ment was with 20mg ketamine IV and 50 mg IM ketamine icine consultation was obtained to confirm the need for an
on patients 1 and 2, respectively. Fluid resuscitation with LR escharotomy. After the patient was intubated and sedated,
followed the United States Army Institute of Surgical Research medial and lateral longitudinal incisions were made over the
(USAISR) “Rule of 10” with an initial fluid rate of 600mL/hr circumferentially burned portions of both proximal forearms,
and 500mL/hr for patients 1 and 2, respectively. Both patients hands, and fingers. The burned tissue was adequately released
4
were covered with blankets to prevent hypothermia, and satel- and weeping of serous fluid from the incision sites was ob-
lite communication with the FS in New York was established served. Hemostasis was obtained with direct pressure using
to discuss the patient findings and treatment plan. Subsequent hemostatic gauze and the wounds were dressed. The second
telemedicine consultation was performed every 6–12 hours patient experienced a similar course and also required fore-
and emergently as needed. The TL instituted work-rest cycles arm, hand, and digital fasciotomies.
for each two-team-member patient care team, with 90 minutes
on and 3 hours of rest. Phase 4: Exfiltration
Coordination between the TC, home station, and Portuguese
Care during the first 4 hours focused on pain management, Air Force determined the ship would come into the range of
fluid resuscitation, and initial wound care. Wounds were de- rotary wing evacuation assets near the Azores. Plans were
brided of loose skin using scrub brushes and scissors prior to made to evacuate both patients and three PJs. The patients
dressing with dry sterile gauze. Pain management continued were packaged in Skedco litters (Skedco Inc, Tualatin, OR)
with intermittent alternating doses of IV ketamine and fentanyl with all vents, lines, and tubes secured and medications for
titrated to effect for each patient. Initially, urine output was the flight were prepared. The patients were lowered with rope
measured by estimating void volumes in a cup; however, after systems through two flights of narrow, high angle staircases to
telemedicine consultation, Foley catheters were placed and flu- the main deck.
ids were titrated to achieve a urine output of 30–50mL/hr.
The patients and PJs were hoisted into the helicopter by a
Around 0600 EST, patient 1 complained of dyspnea and was Portuguese rescue swimmer while the ship was underway. On
breathing in the tripod position. Auscultation of the lungs was board the helicopter, a Portuguese Air Force flight surgeon

136 | JSOM Volume 20, Edition 3 / Fall 2020