Page 141 - JSOM Fall 2020

TABLE 1 Lessons Learned cadaver and simulation labs to enhance and maintain critical
Provide clinical rotations in anesthesia or emergency medicine with airway and surgical skills and emphasize PFC tenets.
focus on RSI, intubation skills, and vent management.
Use a condition specific pack-out checklist. Conclusion
Bring 2400mg ketamine, 2400µg fentanyl, and 240mg midazolam
per patient per day. This mission illustrates that PJs and SOF medics are capable of
Use cadaveric models for escharotomy training and have references basic critical care for multiple critically injured patients in an
available during the procedure. austere PFC environment. Successful execution of critical med-
Train with full mission profile events including PFC segments and ical and surgical skills is possible in this setting but requires
high fidelity simulators. recurrent training. Mission readiness depends on a culture
Incorporate regular cadaver and simulation labs to enhance which prioritizes medical training in operational contexts and
and maintain critical airway and surgical skills and emphasize is realistic regarding the limitations of the environment and
PFC tenets. the Operators. We need to implement these practices widely in
anticipation of PFC missions in which we are only able to get
Operators, and not physicians or advanced practice providers,
required local healthcare system support. Use a condition spe- into the fight.
cific pack-out checklist.
Author Contributions
Medication supply for pain management and sedation pre- M.H. and J.S. participated in the mission and S.R. provided
sented a unique challenge due to experience and training only medical control. S.R. conceived the manuscript concept and
with the bolus administration. We estimated a single intubated obtained approval. J.S. and M.H. were responsible for survey
patient would require alternating ketamine 100mg, fentanyl administration, data collection, and analysis. B.S., E.D., C.P.,
100µg, and midazolam 5mg every 45 minutes. Despite plan- M.H., and S.R. drafted the manuscript. All authors were in-
ning for 72 hours, we nearly depleted analgesics and sedatives volved in revisions and approve the final manuscript.
over the course of 37 hours. The mission debrief identified
the need to pack larger quantities of these medications, build- Financial Disclosures
ing on experience from other PJ burn mission jumps. Bring The authors have no financial relationships relevant to disclose.
2400mg ketamine, 2400µg fentanyl, and 240mg of midaz-
olam per patient per day. References
1. Keenan S. Deconstructing the definition of prolonged field care. J
Spec Oper Med. 2015;15(4):125–125.
Differing directions of the forearm incision of the escharot- 2. DeSoucy E, Shackelford S, DuBose JJ, et al. Review of 54 cases of
omy for both patients resulted in very different levels of bleed- prolonged field care. J Spec Oper Med. Spring 2017;17(1):121–129.
ing. Less bleeding occurred with the escharotomy approach 3. Rush S. Recent considerations in tactical medicine. J Spec Oper
which started proximally and moved distal; senior physicians Med. 2013;13(2):54-58.
at NYP/Cornell Burn Unit agreed with this approach, which 4. Chung KK, Salinas J, Renz EM, et al. Simple derivation of the
is critical for reducing blood loss in a PFC scenario. Although initial fluid rate for the resuscitation of severely burned adult
the escharotomies were correctly performed from memory, we combat casualties: in silico validation of the rule of 10. J Trauma.
2010;69(suppl 1):S49–S54.
have created a policy that escharotomy and fasciotomy must 5. Pavoni V, Gianesello L, Paparella L, et al. Outcome predictors
be performed with reference materials out at the time of the and quality of life of severe burn patients admitted to intensive
procedure and all incisions must be drawn on the skin prior care unit. Scand J Trauma Resusc Emerg Med. 2010;18:24. Pub-
to incision. Practice on human cadavers mandating use of the lished 2010 Apr 27. doi:10.1186/1757-7241-18-24
diagrams and using the skin marker ingrains these routines. 6. Lednar WM, Poland GA, Holcomb JB. Subject: Tactical Combat
Casualty Care burn management Guidelines. August 2010.
Use cadaveric models for escharotomy training and have ref- 7. Chung KK, Wolf SE, Cancio LC, et al. Resuscitation of severely
erences available during procedure. burned military casualties: fluid begets more fluid. J Trauma.
2009;67(2):231–237; discussion 237. doi:10.1097/TA.0b013e31
Based on the postmission survey, the main educational item 81ac68cf.
needed was continued training in burn care with emphasis 8. Klein MB, Hayden D, Elson C, et al. The association between
on airway control and ventilator management. We have ad- fluid administration and outcome following major burn: a multi-
dressed this need at the 103rd Rescue Squadron by creating a center study. Ann Surg. 2007;245(4):622–628. doi:10.1097/01.
sla.0000252572.50684.49
day-long training event in a state-of-the-art patient simulation 9. Chahraoui K, Laurent A, Bioy A, et al. Psychological experience
room using a script based on the TAMAR mission. Train with of patients 3 months after a stay in the intensive care unit: A de-
full mission profile events including PFC segments and high- scriptive and qualitative study. J Crit Care. 2015;30(3):559–605.
fidelity simulators. 10. Crewdson K, Lockey DJ, Røislien J, et al. The success of pre-hos-
pital tracheal intubation by different pre-hospital providers: a sys-
We attribute the success of this mission to the training culture tematic literature review and meta-analysis. Crit Care. 2017;21
of the NY PJ team. Over the past decade we prioritized train- (31). doi:10.1186/s13054-017-1603-7.
ing for complex medical missions during our regular medical 11. Konrad C, Schüpfer G, Wietlisbach M, et al. Learning manual
skills in anesthesiology: Is there a recommended number of cases
training events and during our annual and biannual paramedic for anesthetic procedures? Anesth Analg. 1998;86(3).
recertification courses. Multiple yearly cadaver labs to per- 12. Sabri A, Dabbous H, Dowli A, et al. The airway in inhalational
form direct and video laryngoscopy, practice surgical skills, injury: diagnosis and management. Ann Burns Fire Dis. 2017;30
and train to the tenets of PFC with work-rest cycles, nursing (1):24–29.
skills, and telemedicine consultation all contributed to mission 13. Madnani DD, Steele NP, Vries ED. Factors that predict the
success. While we identified areas for improvement, there were need for intubation in patients with smoke inhalation in-
jury. Ear Nose Throat J. 2006;85(4):278–280. doi:10.1177/
no catastrophic shortfalls or missteps. Incorporate regular 014556130608500421.

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