Page 92 - JSOM Fall 2024

An Ongoing Series

Use of Loco-regional Anesthesia in Austere Environments

A Review by and for Special Forces Medics

Anonymous

pecial Forces increasingly operate in austere environ- medical skills. They also have an obligation to provide the best
ments, which are known to have limited medical sup- possible care to patients regardless of tactical setting, using all
Sport and prolonged evacuation times. On the battlefield, available means and the most current techniques and technol-
pain remains the first complaint of casualties and can impact ogies. Recently, SOF have been advised that their focus will
1,2
direct autonomic stability, recovery, and the development of shift to irregular and hybrid warfare, which increases support
3
posttraumatic stress disorder (PTSD). Although medical ed- challenges further. The experience of simply placing a casualty
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ucation has been improving, medical providers still encoun- into a helicopter within the “Golden Hour” for timely trans-
ter difficulties, such as lack of human and material resources, port to a surgeon via predictable evacuation lines will likely be
while trying to achieve pain management. This article summa- a thing of the past or an exceptional circumstance. In aus-
8,9
rizes a survey sent to 35 Special Operations medical providers tere environments, managing pain in polytraumatic patients
and suggests possible strategies to address challenges to pain can be a risky process that requires personnel and material re-
management on the battlefield. Potential solutions have been sources to handle airway, respiratory, or hemodynamic prob-
gathered through medical texts, medical/NATO documents, lems caused by systemic drugs. High-quantity or prolonged
and medical expertise. Nerves blocks have been identified as opioid analgesia may be difficult to sustain due to their avail-
valuable tools for pain management in the current battlefield ability, toxicity, and side effects, as well as patient tolerance.
environment, where prolonged evacuation and limited free- Optimizing loco-regional anesthesia and multimodal analgesia
dom of movement are the norm. may reshape the way we manage pain by allowing the medical
provider to handle complex medical issues while improving
The survey showed that, although the vast majority of provid- analgesic effects on the nervous pain pathway. 3,10,11
ers had already received lectures on regional anesthesia, 83%
were not trained in it, and 54% had never been made aware of Regional anesthesia is a little-known technique within most of
multimodal analgesia. This lack of familiarity highlights knowl- the SOF world, and its administration can have serious conse-
edge and training gaps in nerve block techniques. Diffusion quences if poorly executed. This article attempts to highlight
blocks are a very low-risk, useful, and safe pain management gaps in education and training with the aim to further educate
3,4
technique, which requires less skill sustainment and resources our community about the existence of safe alternatives to re-
than more complex techniques. The use of epinephrine as ad- gional anesthesia, the benefits of loco-regional anesthesia, and
5
junct can be useful for decreasing local anesthetic toxicity and how this technique can be performed.
increasing long-term pain management. The need for both
6–7
education on and training in the use of nerve blocks has been Survey
identified by the Special Operations health provider community. A questionnaire composed of 12 questions (6 multiple choice
and 6 open-answer questions) was sent to various Special Op-
Keywords: Special Operations Forces; regional anesthesia; erations medical providers from the U.S., Germany, Greece,
multimodal analgesia; local anesthetics; nerve block; hybrid the Netherlands, Norway, Italy, Switzerland, and Belgium. Re-
warfare; unconventional warfare; prolonged casualty care sponses were received from 35 NATO tactical-medical provid-
ers comprising 12 NATO Special Operations Combat Medics
(NSOCM) and Special Operations Combat Medics (SOCM)
(34.3%), 11 paramedics (31.4%), 8 SOF team medics (22.9%),
Introduction
2 nurses (5.7%), and 2 NATO Special Operations Medical
Special Operations Forces (SOF) have an inherent responsi- Technicians (NSOMT) (5.7%). The number of responses was
bility to be innovative in everything they do. Frequently de- low due to the operational tempo, the small size of our com-
ployed as the first elements in an operational theater, they are munity, and the anonymous nature of the survey, which made
often isolated with little to no support. These operators must sending reminders difficult. Nonetheless, our survey findings
therefore keep themselves current on and capable in advanced represent a reality in the SOF healthcare community.
Correspondence to michael.hetzler@JSOMonline.org

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