Page 131 - JSOM Summer 2022

Arctic Tactical Combat Casualty Care

Introduction warmth. If the patient is not transferrable to an area of sus-
tained warmth, we recommend shifting to an alternate “Arctic
Multidomain operations (MDOs) have the potential to span a TFC,” with an emphasis on CWI prevention. Next are some
variety of environments. While the military strives to improve recommendations highlighting particularly challenging por-
operations in all environments, from land and sea to space tions of TFC.
and cyberspace, the need for Arctic capable forces is grow-
ing. In light of increased competition with peer and near-peer Tactical Field Care
adversaries with Arctic territories, we wish to draw increased Addressing massive hemorrhage is the first step in the TFC
attention to combat casualty care in the extreme cold. In an- MARCH algorithm. One boon of extreme cold is that exposed
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ticipation of Arctic MDOs in the near future, the medical mili- wounds freeze and slow or stop continued exsanguination un-
tary community must proactively identify knowledge gaps and til rewarmed. To assess for unrecognized hemorrhage, medics
areas for improvement.
and providers often learn to strip a casualty naked, though not
explicitly recommended in the TFC guideline. However, in an
Background Arctic environment, removing protective garments may hasten
hypothermia and death. Frostbite can occur in 30 minutes or
History less of dry skin exposure to less than –25°F ambient tempera-
US military forces have been involved in numerous conflicts in ture, sooner with superimposed hemorrhage, wet skin, and
cold environments but relatively few in extreme or hazardous direct contact with cold surfaces. I recommend striking the
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cold, defined by the Army as –25 to –40°F and below –40°F, notion of “trauma naked” from the lexicon of Arctic field care.
respectively. The Attu (Aleutian Island) Campaign in World
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War II and Battle at Chosin Reservoir during the Korean War Addressing the airway in an Arctic environment is perhaps
are two such examples. In each, there were numerous cold even more challenging. The standard equipment of airway
weather injuries (CWIs)—about 30% of casualties at Attu management has been nasopharyngeal airways, extraglottic
and about 40% at Chosin suffered from CWIs. In each it- airways, endotracheal intubation, and cricothyroidotomy kits.
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eration of arctic warfare, the military has made small, steady In Arctic conditions, secretions freeze and can obstruct tubes,
improvements to standard issue equipment. Despite advancing and there are cold-related risks of equipment failure and equip-
equipment, CWI prevention and casualty care in extreme cold ment-induced harm. Contact with metallic surfaces at 5°F and
remain challenges.
below can cause frostbite within seconds. Nonmetallic ma-
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terials, like the iGel, also freeze and may cause contact frost-
Tactical Combat Casualty Care bite if not thoroughly warmed prior to insertion. Mechanical
Tactical Combat Casualty Care (TCCC) is the mainstay of ventilation using ambient air will decrease core temperature
casualty care in the military. While care under fire/threat and exacerbate hypothermia. Some units have air warmers,
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(CUF/T) tenets are largely applicable in Arctic environments, but most are battery powered. From field experience it has
extreme cold temperatures present hurdles for tactical field been found that most batteries fail within 2 hours of exposure
care (TFC). Further study and modifications are required to to cold. Cricothyroidotomies require too much dexterity for
ensure feasibility and safety of TFC in the Arctic.
providers to complete effectively while wearing protective gear
to prevent frostbite. Unfortunately, there is no simple solution
Areas for Improvement for this problem. At this time, additional research is needed to
rigorously test current tools and techniques and find alterna-
The following concerns and recommendations discussed are tives if suboptimal.
in the setting of trauma care in Arctic environments, where
temperatures frequently remain at or below –25°F. See Table In regard to respiratory conditions, treatment options are lim-
1 for a consolidated list of concerns and recommendations for ited as well. The standard is to listen for equal breath sounds
improvement.
bilaterally or look for equal chest rise. If the casualty is ap-
propriate dressed, a provider will not be able to reliably see
Care Under Fire/Threat chest rise or hear breath sounds. This makes diagnosing chest
Once a casualty begins to lose blood and heat to the envi- wounds and pneumothoraces very difficult. A possible solution
ronment, the risk of hypothermia increases and their chance is to use a limited evaluation by unzipping the armpit vents in
of survival further decreases. Therefore, in the CUF/T phase the Extended Cold Weather Clothing System (ECWCS) level 5
of TCCC, we recommend a modified initial triage pathway jacket and using that “window” for evaluation. This approach
for Arctic care: (1) place a hasty tourniquet on any obvious would also allow for improved auscultation, minimize heat
hemorrhaging limb, and (2) move the patient to an area of
loss, and allow lateral placement for needle decompression

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