Unit Collective Medical Training in the 75th Ranger Regiment.

The 75th Ranger Regiment's success with eliminating preventable death on the battlefield is innate to the execution of a continuous operational readiness training cycle that integrates individual and unit collective medical training. This is a tactical solution to a tactical problem that is solved by the entire unit, not just by medics. When a casualty occurs, the unit must immediately respond as a team to extract, treat, and evacuate the casualty while simultaneously completing the tactical mission. All in the unit must maintain first responder medical skills and medics must be highly proficient. Leaders must be prepared to integrate casualty management into any phase of the mission. Leaders must understand that (1) the first casualty can be anyone; (2) the first responder to a casualty can be anyone; (3) medical personnel manage casualty care; and (4) leaders have ownership and responsibility for all aspects of the mission. Foundational to training is a command-directed casualty response system which serves as a forcing function to ensure proficiency and mastery of the basics. Four programs have been developed to train individual and collective tasks that sustain the Ranger casualty response system: (1) Ranger First Responder, (2) Advanced Ranger First Responder, (3) Ranger Medic Assessment and Validation, and (4) Casualty Response Training for Ranger Leaders. Unit collective medical training incorporates tactical leader actions to facilitate the principles of casualty care. Tactical leader actions are paramount to execute a casualty response battle drill efficiently and effectively. Successful execution of this battle drill relies on a command-directed casualty response system and mastery of the basics through rehearsals, repetition, and conditioning.

Life and Limb In-Flight Surgical Intervention: Fifteen Years of Experience by Joint Medical Augmentation Unit Surgical Resuscitation Teams.

BACKGROUND: Expedient resuscitation and emergent damage control interventions remain critical tools of modern combat casualty care. Although fortunately rare, the requirement for life and limb salvaging surgical intervention prior to arrival at traditional deployed medical treatment facilities may be required for the care of select casualties. The optimal employment of a surgical resuscitation team (SRT) may afford life and limb salvage in these unique situations. METHODS: Fifteen years of after-action reports (AARs) from a highly specialized SRTs were reviewed. Patient demographics, specific details of encounter, team role, advanced emergent life and limb interventions, and outcomes were analyzed. RESULTS: Data from 317 casualties (312 human, five canines) over 15 years were reviewed. Among human casualties, 20 had no signs of life at intercept, with only one (5%) surviving to reach a Military Treatment Facility (MTF). Among the 292 casualties with signs of life at intercept, SRTs were employed in a variety of roles, including MTF augmentation (48.6%), as a transport capability from other aeromedical platforms, critical care transport (CCT) between MTFs (27.7%), or as an in-flight damage control capability directly to point of injury (POI) (18.2%). In the context of these roles, the SRT performed in-flight life and limb preserving surgery for nine patients. Procedures performed included resuscitative thoracotomy (7/9; 77.8%), damage control laparotomy (1/9; 11.1%) and extremity fasciotomy for acute lower extremity compartment syndrome (1/11; 11%). Survival following in-flight resuscitative thoracotomy was 33% (1/3) when signs of life (SOL) were absent at intercept and 75% (3/4) among patients who lost SOL during transport. CONCLUSION: In-flight surgery by a specifically trained and experienced SRT can salvage life and limb for casualties of major combat injury. Additional research is required to determine optimal SRT utilization in present and future conflicts.

Advanced Resuscitative Care in Tactical Combat Casualty Care: TCCC Guidelines Change 18-01:14 October 2018.

TCCC has previously recommended interventions that can effectively prevent 4 of the top 5 causes of prehospital preventable death in combat casualties-extremity hemorrhage, junctional hemorrhage, airway obstruction, and tension pneumothorax- and deaths from these causes have been markedly reduced in US combat casualties. Noncompressible torso hemorrhage (NCTH) is the last remaining major cause of preventable death on the battlefield and often causes death within 30 minutes of wounding. Increased use of whole blood, including the capability for massive transfusion, if indicated, has the potential to increase survival in casualties with either thoracic and/or abdominopelvic hemorrhage. Additionally, Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide temporary control of bleeding in the abdomen and pelvis and improve hemodynamics in casualties who may be approaching traumatic cardiac arrest as a result of hemorrhagic shock. Together, these two interventions are designated Advanced Resuscitative Care (ARC) and may enable casualties with severe NCTH to survive long enough to reach the care of a surgeon. Although Special Operations units are now using whole blood far-forward, this capability is not routinely present in other US combat units at this point in time. REBOA is not envisioned as care that could be accomplished by a unit medic working out of his or her aid bag. This intervention should be undertaken only by designated teams of advanced combat medical personnel with special training and equipment.

TCCC Guidelines Comprehensive Review and Update: TCCC Guidelines Change 16-03.

Based on careful review of the Tactical Combat Casualty Care (TCCC) Guidelines, the authors developed a list of proposed changes for inclusion in a comprehensive change proposal. To be included in the proposal, individual changes had to meet at least one of three criteria: (1) The change was primarily tactical rather than clinical; (2) the change was a minor modification to the language of an existing TCCC Guideline; and (3) the change, though clinical, was straightforward and noncontentious. The authors presented their list to the TCCC Working Group for review and approval at the 7 September 2016 meeting of the Committee on Tactical Combat Casualty Care (CoTCCC). Twenty-three items met with general agreement and were retained in this change proposal.

Leadership and a casualty response system for eliminating preventable death.

Combat casualties who die from their injuries do so primarily in the prehospital setting. Although most of these deaths result from injuries that are nonsurvivable, some are potentially survivable. Of injuries that are potentially survivable, most are from hemorrhage. Thus, military organizations should direct efforts toward prehospital care, particularly through early hemorrhage control and remote damage control resuscitation, to eliminate preventable death on the battlefield. A systems-based approach and priority of effort for institutionalizing such care was developed and maintained by medical personnel and command-directed by nonmedical combatant leaders within the 75th Ranger Regiment, U.S. Army Special Operations Command. The objective of this article is to describe the key components of this prehospital casualty response system, emphasize the importance of leadership, underscore the synergy achieved through collaboration between medical and nonmedical leaders, and provide an example to other organizations and communities striving to achieve success in trauma as measured through improved casualty survival.

Prehospital analgesia with ketamine for combat wounds: a case series.

BACKGROUND: No data have been published on the use of ketamine at the point of injury in combat. OBJECTIVE: To provide adequate pain management for severely injured Rangers, ketamine was chosen for its analgesic and dissociative properties. Ketamine was first used in the 75th Ranger Regiment in 2005 but fell out of favor because medical providers had limited experience with its use. In 2009, with new providers and change in medic training at the battalion level, the Regiment implemented a protocol using doses of ketamine that exceed the current Tactical Combat Casualty Care recommendations. METHODS: Medical after-action reports were reviewed for all Ranger casualties who received ketamine at the point of injury for combat wounds from January 2009 to October 2014. Patients and medics were also interviewed. RESULTS: Unit medical protocols authorize ketamine for tourniquet pain, amputations, long-bone fractures, and pain refractory to other agents. Nine of the 11 patients were US Forces; two were local nationals (one female, one male). The average initial dose given intramuscularly was 183 mg, about 2 to 3 mg/kg and intravenously 65 mg, about 1 mg/kg. The patients also received an opioid, a benzodiazepine, or both. There was one episode of apnea that was corrected quickly with stimulus. Eight of the 11 patients required the application of at least one tourniquet; four patients needed between two and four tourniquets to control hemorrhage. Pain was assessed with a subjective 1-10 scale. Before ketamine, the pain was rated as 9-10, with one patient claiming a pain level of 8. Of the US Forces, seven of the nine had no pain after receiving ketamine and two had a pain level of four. Two of the eight had posttraumatic stress disorder. CONCLUSIONS: In this small, retrospective sample of combat casualties, ketamine appeared to be a safe and effective battlefield analgesic.