Page 132 - JSOM Summer 2022

TABLE 1 Actionable Areas of Concer
Area of Concern Potential Issues in Extreme Cold Recommended Course of Action
Assessment for unrecognized hemorrhage Exposure of bare skin Limit duration of exposed skin. use wind breaks.
Application of tourniquet to skin Exposure of bare skin Use Hasty Tourniquet technique.
Establish airway with iGel iGel freezes, risk of contact frostbite Develop nonfreezing equipment.
Establish airway with cricothyroidotomy Requires provider hand dexterity, risk of Develop hand warmers for medical providers to
contact frostbite maintain dexterity.
Assessment and treatment for tension Exposing the chest can hasten hypothermia Consider alternate chest evaluation (e.g., ECWCS
pneumothorax level 5 side vents).
Pulse oximetry Does not reliably detect accurate Spo due to Need improved pulse oximeters.
2
peripheral vasoconstriction
Battery life in extreme cold Current equipment battery life is rapidly Further research to improve batteries.
drained.

of pneumothorax. This would then allow for closure of the of –25°F and below. Medical technology and field care prac-
jacket vent to maintain warmth with access for “burping” of tices have evolved since the last extreme-cold conflict involv-
chest seals if needed. ing US forces. However, information on equipment ability to
withstand extreme cold and freeze–thaw–freeze cycles is lim-
For the cardiovascular portion of TFC, the mainstay is main- ited, and our current tools and practices require further study
taining hemodynamic stability, often with warmed whole and revision. I recommend consideration for a dedicated eval-
blood or crystalloids. There are multiple steps that make this uation of our current TCCC equipment and development of
challenging. Obtaining intravenous (IV) access requires signif- new arctic-durable equipment. In addition, the creation of a
icant exposure of patient skin and provider dexterity. Intraos- multiservice Arctic working group will allow for a unified ef-
seous (IO) access circumvents these issues, but then comes the fort toward a modified Arctic TCCC algorithm.
challenge of warming resuscitation fluids. Most fluids will —Captain Kyle Samblanet, MD
freeze while carried in aid bags and, even if thawed, the fluids Bassett Army Community Hospital,
will remain at temperatures low enough to induce hypother- Fort Wainwright, AK
mia if not adequately warmed. Current fluid warming systems, arctictc3@gmail.com
like the Buddy Lite, are battery operated, but again, battery — Molly Booy, MD
life is limited in extreme cold temperatures. Solutions for this
would be finding insulators efficient enough to maintain warm
fluids while stored in extreme cold. In addition, development References
1. Department of the Army. Regaining Arctic Dominance: The U.S.
of batteries that last for 72 hours in extreme cold may make Army in the Arctic. https://api.army.mil/e2/c/downloads/2021/03
adequate fluid warming possible in the field. /15/9944046e/regaining-arctic-dominance-us-army-in-the-arctic
-19-january-2021-unclassified.pdf. Accessed 9 Jan 2022.
Evaluation for hypothermia remains vital. We have already 2. Army Techniques Publication. Mountain Warfare and Cold
discussed strategies to decrease hypothermia by maintaining Weather Operations, 29 Apr 2016. https://irp.fas.org/doddir/army/
atp3-90-97.pdf. Accessed 9 Jan. 2022.
vigilance throughout preceding steps of the MARCH algo- 3. DeGroot DW, Castellani JW, Williams JO, Amoroso PJ. Epidemi-
rithm. During the dedicated hypothermia evaluation, provid- ology of U.S. Army cold weather injuries, 1980-1999. Aviat Space
ers must also take care to check for frostbite. Providers and Environ Med. 2003;74(5):564–570.
medics must be trained in prevention, diagnosis, and treat- 4. McNeil GH. Chapter V: The Aleutians. In: History of the Medical
ment of these conditions in the field to prevent mismanage- Department in Alaska in World War II. 1944:401–477. https://
ment. For example, an untrained provider might immediately achh.army.mil/history/book-wwii-coldinjury-chapter05. Accessed
rewarm a frostbitten area, unaware of the risks of additional 9 Jan 2022.
injury if warmth cannot be maintained, or roughly transport 5. Pandolf KB, Burr RE, Paton BC. Cold, casualties, and conquests:
the effects of cold on warfare. In: Medical Aspects of Harsh En-
a patient if unaware of the cardiac irritability and risk of ar- vironments. Vol 1. Office of the Surgeon General, United States
rhythmia caused by hypothermia. While most providers are Army; 2001:313–344.
versed in managing cold weather injuries, few have experi- 6. Department of Defense, Joint Trauma System. Tactical Combat
ence practicing TCCC or prolonged field care in extreme cold Casualty Care (TCCC) Guidelines, 15 Dec 2021.
temperatures. A dedicated Arctic medical and general survival 7. Northern Warfare Training Center. Cold Weather (CWLC, CWOC
course would be an appropriate pre-deployment training to $ CWIC) Student Handout, 2015. https://api.army.mil/e2/c/down
loads/440625.pdf. Accessed 9 Jan 2022.
help educate on both prevention and treatment. 8. Geng Q, Holmér I, Hartog D, et al. Temperature limit values for
touching cold surfaces with the fingertip. Ann Occup Hygiene.
2006;50(8):851–862. doi:10.1093/annhyg/mel030
Conclusion
The shift in focus to Arctic military readiness must be accom-
panied by an effort to optimize Arctic medical practices. Ca-
sualty care in the Arctic has historically and will continue to Keywords: Arctic; Tactical Combat Casualty Care; multidomain
involve the provision of medical care in sustained temperatures operations

128 | JSOM Volume 22, Edition 2 / Summer 2022