Page 139 - JSOM Fall 2020

directed the PJs to continue primary care in flight. On an are not adequate to appropriately assess, treat, and deliver the
Azores airfield, the patients were transloaded to a Portuguese patient to the next level of care. Additionally, they expressed
Air Force aeromedical transport team for fixed wing transport the importance of early inclusion of the flight surgeons in mis-
to burn centers in Lisbon, Portugal. The total time from ini- sion planning to ensure appropriate tasking for the mission.
tial patient contact to transload to the aeromedical evacuation
team was 37 hours. The PJs on the TAMAR transferred to a Discussion
tugboat to the Azores where the team reunified and flew home
the next day via HC-130P. This mission represents the most complicated medical care
ever provided by PJs, and possibly any other Department of
Defense medic, for an extended period of time. It validates
Mission Debrief
the role for PJs on complex medical missions that other more
A week after the mission, a 6-hour flight surgeon led debrief advanced medical teams cannot get to, and the potential for
was held and postmission surveys were administered to all SOF medics to train for PFC.
Operators involved with the mission, soliciting impressions re-
garding mission planning and execution as well as suggestions Severely burned patients are the most complex care scenarios
to optimally prepare for future missions. All team members Special Operations medics will face. The care including anal-
felt adequately prepared to execute this mission, but several gesia, airway/ventilator management, sedation, wound care,
recommendations were made. and monitoring/nursing skills is demanding and competes with
other skills that are required for tactical and technical com-
Training petency. The care of significant burn patients is a challenge
Nearly every Operator suggested the use of full mission pro- in any hospital setting as intensive care unit (ICU) mortality
files including PFC to be performed on a regular basis (i.e., rates for burn patients with >50% TBSA exceed 44%. Care
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quarterly). Inclusion of PFC in these training iterations allows is more challenging than in an ICU when considering PJs are
reinforcement of the tactical context for medical care and the paramedic level providers with limited gear due to insertion
potential for extended patient care periods. Training rotations constraints on a ship with no medical resources. Consequently,
through a burn center were suggested for exposure to the mul- the approach to burn care is guided by protocols specific to
tidisciplinary care needed to treat these complex patients. the environment, as we have made every attempt to adopt best
practices for care based on guidance from physicians at the
More training in ventilator management and intermittent San Antonio Burn Center, the New York Presbyterian Hospi-
bolus sedation, and more regular cadaver labs (every 6–12 tal Burn program (FDNY burn unit), and from USAF trauma
months) were suggested. Documentation with a simple flow- surgeons.
chart with columns was endorsed over the more complicated
“anesthesia style” charting with multiple symbols denoting Fluid Resuscitation
vital signs on a grid scale. Finally, the team unanimously pre- In 2010, PJs adopted the rule of 10 for initial fluid resuscita-
ferred maintenance of sedation with intermittent boluses of tion in burn patients. This simple formula calculates the initial
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medications compared with continuous infusions. fluid administration rate as the percent TBSA burn multiplied
by 10mL/hr. Additionally, the rule of 10 tended to produce a
Equipment starting value closer to the modified Brooke formula, which is
The team suggested creating condition specific medical bags half the rate of the Parkland formula and results in markedly
with an associated logistics quick reference card indicating the lower 24-hour fluid requirements without increased mortal-
bag contents. These would optimize team medical kit manage- ity. This lower fluid rate has the benefit of reduced potential
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ment by tailoring the supply and resupply to the most com- for overresuscitation, leading to fluid overload, compartment
mon civil SAR conditions: burn, trauma, and acute abdomen syndromes, airway swelling and obstruction, and acute respi-
and GI bleeding. An additional quick reference guide was also ratory distress syndrome. Operationally, this reduces the size
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suggested for attachment to the Impact 731 ventilator outlin- of parachute bundles and improves logistics and safety. The
ing instructions for implementation and adjustment. The addi- key to this fluid resuscitation approach is appropriate moni-
tion of monitors with integrated video teleconferencing would toring of urinary output, so that initial rates can be adjusted
improve telemedicine consultation. to provide adequate volume for perfusion while avoiding
fluid overload. More sophisticated fluid management is pos-
Tactics sible with software such as the Burn Navigator (Acros Inc.,
The larger team size deployed for this mission was found to be Missouri City, TX), which could be incorporated into patient
ideal as it provided greater depth in the broad range of skillsets monitors or a handheld device for use on missions or as an
needed including medicine, insertion, extraction, and commu- adjunct to telemedical consultation.
nications. The larger team also allowed for effective division
of work and rest cycles to limit team exhaustion. To combat Airway and Ventilator Management
the sometimes debilitating effects of seasickness, home station Immediate versus delayed airway intervention in an austere
ground testing of antiemetic medications was suggested. setting is different from in a hospital. Traditional hospital air-
way management of burn patients includes establishing a de-
Organization and Culture finitive airway for thermal injury to the airway and inhalation
The sentiment was raised that the PJ medical skills required to injury. With all the expertise and resources available, more
save the patient are of equal importance to the skills such as aggressive management in a hospital is warranted.
open water parachute insertion needed to deliver the PJs to the
patient. It makes little sense to advocate for deployment in a Deciding to secure the airway before respiratory collapse is a
high-risk mission if the Operator’s medical acumen and skills time-sensitive, difficult decision to execute and maintain in PFC.

Critical Burn Patients During Ocean Parachute Rescue | 137