Page 48 - JSOM Summer 2022

options as well as managing relatively large wounds on both appropriate extrication equipment on hand or the training to
sides of the injured limb. In essence, there is a tradeoff be- extricate a trapped casualty properly and safely. While this is
tween a compartment syndrome problem and a significant ultimately the decision of the tactical leader on the ground, the
wound care problem. If not done properly, fasciotomies can medic needs to be an advocate for their patient and request
be complicated by iatrogenic nerve and vascular injury. The support for the extrication as soon as they realize it will be
procedure itself will require large amounts of local anesthetic necessary. This may mean getting a rescue kit out of a vehicle
or regional nerve block, followed by postprocedural analgesia. or calling in a combat search and rescue capability such as
Therefore, a medic should perform a fasciotomy only if they pararescuemen (PJs) to provide the necessary expertise. Either
have the teleconsultation available and the skillset or scope of way, extrication and evacuation need to be requested early and
practice allowing him or her to perform this procedure. If not, everything should be put in place to free the patient while the
this information should be provided to the receiving facility medic continues to work. The faster the patient is extricated
and attempts should be made to cool the affected extremity to and evacuated to a critical care capability, the better their
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reduce swelling in that limb. Continued pain management is chances of survival. 3
important throughout treatment of this patient. Figure 3 out-
lines treatment options during the immediate, extrication, and Medics also need to consider the likelihood of a crush syn-
evacuation phases of management of crush injuries. drome developing in a non-traditional setting. While it is easy
to understand a patient stuck under a vehicle for hours may
FIGURE 3 Immediate response to crush injury.
be at risk of developing crush syndrome, it is harder to con-
ceptualize the Soldier who is stuck in a tree after a training
parachute insertion and has been hanging from his harness
with combat equipment for hours may be at equal risk. Un-
derstanding the physiology and knowing when to consider the
possibility of this condition developing is essential.

Unless the team was alerted from their team house that they
would be responding to a crush scenario, it is unlikely a medic
will have all of the medications and fluid discussed above in
their assault aid bag to be successful in treating their patient.
Having premade “crush kits” with the medication and fluid
necessary to manage a patient pre-staged can set the medic up
for success. These can be left in a truck bag, set up in the medi-
cal treatment area of a team house, aid station, or coordinated
to be left on a helicopter if the team has air assets, but there
needs to be a plan to get this kit to the medic when they need
it. If working in areas with greater risk of becoming crushed
(e.g., dilapidated, multi-story buildings are common), it would
benefit the medic to have crush kits closer to the POI, such as
in a truck bag. As soon as the medic realizes they are dealing
with a potential crush scenario, they need to request the crush
kit to their location early.
Tactical Considerations
As with any scenario that a Special Operations medic may be Another consideration in this situation is pain management.
faced with, there is more than just medicine to worry about. Many medics simply are not carrying enough pain medication
Medics can set themselves up for success by considering these in their assault aid bags to control a patient’s pain for hours
conditions early and being prepared ahead of time. with IV bumps. The time to start thinking about this is not
when a medic has burned through all their ketamine with IV
Every medic—civilian or military—is taught that scene safety bumps and realizes the extrication can still take hours. A medic
is the first part of their primary assessment; this is paramount still needs to follow their organization’s pain management
in the scenario of a crushed service member. While a vehicle protocols, but this might be the time to set up intravenous
rollover causing a crush injury might seem to be the most likely infusions for prolonged pain management. Another option is
case a medic may experience, the team may be responding to supplementing the standard ketamine bolus protocol—which
a structure collapse with trapped service members or local na- seems to be most medics’ go-to—with opioid administration,
tionals, or a myriad of other situations within an inherently such as IV fentanyl. Hydromorphone, which has longer dura-
unstable environment. As a medic, one needs to ensure they tion of action than ketamine, may also be considered. Using a
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do not become a casualty themselves. This is an easy concept multimodal analgesia approach will likely provide better pain
when bullets are flying but is much more difficult in a setting relief overall. Depending on what body part is crushed and
such as what is likely to be experienced when responding to a the access to said body part, a medic can consider performing
crushed patient. Medics need to be aware of their surround- a regional block with an anesthetic such as lidocaine or bupi-
ings when moving to a casualty and be certain they are mini- vacaine as well, if appropriately trained. Last, if the medic on
mizing the threat of being injured by the environment around the ground is not comfortable with any of these options and
them when providing care to the patient. wants to continually give IV boluses, they need to have a plan
to get a pharmacological resupply before it becomes a need.
Getting the patient evacuated as quickly as feasible should be Ultimately, having a plan for pain management early in the
the focus in this situation. It is unlikely a team will have all the scenario is necessary.

46 | JSOM Volume 22, Edition 2 / Summer 2022