Page 66 - JSOM Fall 2020

TABLE 1 Cont. TABLE 2 Equipment-Related Comments
Cricothyrotomy Logistical Constraints
Discussion: Despite the advent of the 91W EMT-B [EMT-Basic] The greatest difficulty our unit, and I personally, faced was the com-
program, very few indicated prehospital airways were placed in the plete lack of medical resupply. We began ordering supplies to fill
field. Less than 5% of required airways are placed in the field. Many specific shortfalls weeks prior to deploying to Kuwait, and contin-
medics do not even carry ambu bags for BVM ventilations. ued placing orders on a weekly basis after arriving in theater. We
continued to place repeat orders on a weekly basis after moving into
Lessons Learned: Improve 91W and CLS [combat life saver] invasive Iraq after the beginning of the war. We never received any of the
airway skills.
specific supplies that we ordered until the last part of April, after
Authors Recommendation: 91W school to emphasize cricothyr ot- the offensive part of the war was over. The only medical supplies
omy and BVM [bag-valve mask] over Combitube. Ensure that all that were received during the war were push packs designed for
line medics carry and are trained in the use of BVM. Forward Surgical Teams that were prepositioned in warehouses in
Discussion: Emergency surgical airways are often performed in field Kuwait. None of the vital medical supplies specific to the delivery
conditions, under duress, by inexperienced providers. Many emer- of anesthesia were delivered when needed. Our unit, and individual
gent cricothyroidotomies performed in the field and transported to providers, did bring small amounts of critically needed supplies and
the CSH [combat support hospital] were done incorrectly and expe- equipment from home station in anticipation of shortages. These
rienced complications. Upon arrival to the CSH, each of them was small amounts of supplies were vital in maintaining our operational
easily intubated. Admittedly, intubation was performed in a more capability. We were forced to wash and reuse disposable, single use
controlled setting by a provider skilled in that procedure. items such as endotracheal tubes, anesthesia machine circuits, anes-
thesia face masks, and even syringes, when the number of casualties
Lessons Learned: none was highest.
Authors’ Recommendation: More emphasis should be placed on the Pediatric Casualties
nonsurgical airway management and airways adjuncts when training Pediatric Supplies (UXO) [unexploded ordinance]. All our sets are
nonphysician healthcare providers in combat casualty care to reduce for adults. During combat operations, we treated children as well.
the risk and complications of poorly performed surgical airways. Injuries from unexploded ordinance, accidents, and direct combat
Throughout my deployment, I have seen a dramatic increase in the operations. Have some basic items available: IO [intraosseous] lines,
number of patients being treated with attempted surgical airways in IV [intravenous] catheters in small gauges, appropriate size endotra-
the field, only later to be intubated very easily. Many of the surgi- cheal tubes, Tylenol suspension, antibiotic suspensions . . .
cal airways were poorly performed or aborted, leading to increased Carried Equipment
morbidity and mortality of the patients. Although surgical airways
are frequently needed to save the lives of trauma victims, this mo- Most of the 91Ws in attendance either carried the standard M9 bag
dality is properly placed VERY LOW on the algorithm for airway or a commercially available medic bag. No one carried the MOLLE
maintenance. Only providers with extensive experience should be [MOdular Lightweight Load-carrying Equipment] aid bag. Their
attempting these maneuvers. In 15 years of treating trauma victims, packing lists were determined by individual preference and/or unit
I cannot remember five patients who required surgical airways. SOP [standard operating procedure]. Most carried cervical collars
although they were infrequently used. Also, most carried interme-
Paralytics diate airway management equipment (e.g., Combitube), but these
We have seen an inordinate use of paralytics in patients through- were also infrequently used. Most did not carry advanced airway
out the theater, especially when being transported by MEDEVAC management devices. Their focuses were primarily on hemorrhage
[ MEDical EVACuation].There appears to be a feeling, in the trans- control and relief of tension pneumothorax.
ferring facilities, that it is inherently safer to transport an intubated Key equipment required on scene included a suction apparatus and
patient. Also, there appears to be a feeling that the only safe way to advanced airway intervention capability.
transport an intubated patient is if they are paralyzed.The unsuper-
vised use of paralytics by field medics and flight nurses is a danger- Suction apparatus were not available on ground ambulance and only
ous practice. Better education of field medics and flight nurses as to limited suction devices were available on air MEDEVAC transports.
the implications of their decision is imperative . . . Silver 90 L O tanks are worthless.15 minutes of O is of zero use
2
2
Nasopharyngeal Airway to you.
Soldiers understood that casualties with airway management issues Medevac is usually 3–4 hours and has been as long as 14 hours.
needed an NPA, but they seemed very uncomfortable with inserting
it.
clinical competencies given the lack of live patient encounters
in supervised, clinical settings. 14
Discussion
This paradox of the least-trained individual (the far-forward
We reviewed >600 military lesson learned entries spanning combat medic) being singly responsible for the sickest and
the recent conflicts in Afghanistan and Iraq and found ap- most severely injured patients is not unique to military med-
proximately 70 items specific to management of the combat icine. It is similarly shared by civilian EMTs and paramedics,
casualty airway. Most of the airway-specific feedback from particularly in rural and remote locations. The pressure on
the field related to training shortfalls and equipment deficien- the combat medic, however, is amplified by the criticality of
cies. Our panel of eight experts, both military and civilian, many casualties, limited equipment, infrequent trained assis-
reviewed these lessons learned and provided recommendations tive personnel, prolonged evacuation times, limited real-life
based on our interpretations. experiences and, of course, the hazards of combat. Our analy-
sis of lessons underscored this paradox, with most comments
Medical providers at the farthest-forward (and often lowest focused on a perceived lack of skill maintenance training and
ranking) aspects of the battlefield, who deliver point-of-in- lack of command emphasis on clinical proficiency.
jury and prehospital trauma care, reported insufficient pre-
deployment medical training. A commonly cited issue was a Medical providers within fixed military medical facilities (e.g.,
perceived lack of deploying unit prioritization on medical sus- combat support hospitals) continually cited deficiencies in
tainment training. When predeployment medical training was prehospital airway interventions. Multiple reports described
conducted, combat medics expressed that it was not adequate. improperly performed cricothryotomies and, concerningly, un-
Combat and flight medics also noted difficulties maintaining necessary cricothyrotomies. Many hospital providers echoed

64 | JSOM Volume 20, Edition 3 / Fall 2020