Page 17 - JSOM Summer 2022

is imminent. Given the severity of this casualty’s burns, swallowed sea water in this individual and he should be placed
however, she is unlikely to survive her injuries. Providing in the lateral decubitus position to avoid aspiration.
a surgical airway will probably not increase her long-term After Immediate Action care has been provided, it would be
probability of survival. It will help her airway status in the very useful to have direct communications between medical
short term and should be done, but should not take prece- personnel on the casualty ship and medical personnel on the
dence over immediately lifesaving interventions that may LHA to discuss evacuation priorities, obtain additional ca-
be required for other casualties.
sualty management guidance and request additional TCCC
The following comments on Casualty 5 were provided by equipment that might be needed. Satellite phones and GPS-
COL Jennifer Gurney, US Army Institute of Surgical Research based texting that would enable this direct medical-to- medical
Burn Center: communication are now available and discussed below. Exam-
ples of critical information to be passed to the LHA include:
“Given that she is complaining of pain and not ob- the number of casualties; the nature of the injuries; their evac-
tunded, this could potentially be a survivable injury if uation categories; whether or not whole blood is needed and if
the burns are mostly partial thickness. She should be so, how much; and what additional medical personnel, capa-
placed in warmed blankets to prevent hypothermia, bilities, and equipment should be transported to the casualty
which is common with burn patients and be provided ship on the first evacuation helicopter that launches.
pain medicine. She is likely going to be expectant if her
TBSA is really 90%; however, this is very difficult to Shipboard Tactical Field Care
judge on initial assessment. Given that she is talking These actions should be undertaken by the IDC with the assis-
and has pain, she should be given the chance to resus- tance of the junior corpsman and other shipboard TCCC pro-
citate. Resuscitation is classically with IV fluids; we are viders, all of whom, including commissioned officers, warrant
learning more about the value of enteral resuscitation officers and more senior non-commissioned officers, should
and the risks and benefits, especially in mass casualty function under his or her guidance with respect to the medical
events and limited resources. Large amounts of intra- care to be provided. In this setting, the IDC will have to func-
venous fluid resuscitation will result in her requiring tion not only as a medical provider, but as the team leader for
expeditious intubation; this patient will most certainly this mass casualty event, directing and overseeing the actions
require an airway, earlier rather than later. Her survival of others to ensure that all required tasks are addressed.
is completely contingent upon whether she can get an
airway, be ventilated (not have severe inhalation injury), The embarked STP on the LHA offers an excellent resource for
avoid burn shock, undergo early and appropriate resus- augmenting the medical treatment capability on the casualty
citation (plasma, crystalloid and enteral fluids if she can ship. The Emergency Medicine physician and a corpsman from
tolerate enteral resuscitation with an Oral Rehydration the embarked STP could be brought to the casualty ship on the
Solution) and get to a burn center or a location that first helicopter that lands there; the value of mobile medical
has burn expertise. If she were 90% burned with all full capabilities has been demonstrated over the last 20 years of
thickness burns, then she is extremely unlikely to sur- ground conflict in Iraq and Af ghanistan. The physician and the
vive. However, given how challenging it can be to assess corpsman could then remain on the casualty ship and augment
the TBSA and burn depth shortly after injury, it is rea- the medical capability there. The SMT on the evacuation he-
sonable to allow a casualty the opportunity to declare licopter would provide care for the first two litter patients on
themselves by supporting them with an airway, venti- the return flight to the LHA. When the Emergency Medicine
lation, hypothermia management, pain control and IV/ physician from the STP arrives on the casualty ship, then he or
enteral resuscitation. However, in general, a 90% full she would assume the role of medical team leader.
thickness burn in a MASCAL scenario with limited re- One consideration that applies to all of the casualties but is
sources is absolutely expectant” (COL Jennifer Gurney, most important for the bleeding and burned casualties, is hy-
personal communication, 7 November 2021).
pothermia prevention, despite the warm (95 degree) ambient
Casualty 6’s oxygen saturation is 76%. The radial pulse is air temperature and the thermoneutral 93-degree water tem-
strong and regular. There are no external signs of head trauma. perature. The casualties who were recovered from the water
– He needs needle decompression as initial management of should have their wet clothing removed quickly to avoid heat
his suspected right-sided tension pneumothorax. loss from evaporation. There is not presently a hypothermia
– This should be followed by 100% oxygen (15L/min via prevention wrap on the medical equipment list for destroy-
reservoir facemask) for his presumed cerebral arterial gas ers, but warmed blankets and other improvised hypothermia
embolism (CAGE), which is being manifest by his slurred prevention options should be used. This aspect of treatment
speech and focal neurologic deficits. As soon as other ca- will become more important during the casualties’ flight to
sualties have undergone their initial TCCC MARCH pro- the LHA, during which there will be additional heat loss via
tocol, and trained personnel with the requisite equipment convection due to the windy helicopter environment.
become available, this casualty will need a tube or finger
thoracostomy. Casualty 1
When Casualty 1’s left trouser leg is cut away with trauma
Casualty 9 is in respiratory distress from his drowning event shears, he is found to have a gaping injury to his left anterior
with an oxygen saturation of 68%. He needs 100% oxygen medial thigh, likely due to penetrating injury from a fragment
(15L/min via reservoir facemask initially.) (secondary blast injury.) Since the casualty’s weak and rapid
radial pulse indicates that he has lost a significant amount
The current JTS Clinical Practice Guideline for drowning ca-
sualties calls for a target hemoglobin oxygen saturation in this of blood, the previously applied “high and tight” tourniquet
casualty of 92–96%. The IDC should be alert for vomiting of should not be loosened for evaluation, but a second tourni-
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quet should be applied directly on the skin 2–3 inches above
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