We anticipate the future threat environment may require casualty care holding that exceeds current evacuation planning factors (i.e. the Golden Hour).— LTG Nadja West, Army Surgeon General addressing the Senate Committee on Appropriations, March 2017
The Army Medical Department is pushing for medics to be capable of caring for a wounded patient in the event of a delayed MEDEVAC. The Army Surgeon General, LTG Nadja West, reinforced this concept during an address to Congress. The push comes in anticipation of future large-scale combat operations (LSCO) where evacuation will present a significant logistical challenge, but there are plenty of stories from the last 20 years where a MEDEVAC has been slow or delayed.
What is Prolonged Field Care (PFC)?
Prolonged Field Care is field medical care applied beyond doctrinal planning timelines until the patient can be delivered to definitive care. PFC is not a defined set of skills or a phase of care. PFC is an operational problem. COL Sean Keenan, a former Special Forces Group Surgeon, put it “a really [bad] situation to be in”. Prolonged Field Care is “taking care of a patient who you know needs to be somewhere else for much longer than you are comfortable with.”
How Does this Apply to a Combat Medic?
In its original form, PFC applied only to Special Operations medics and corpsmen operating in regions where medical support was limited. This is no longer the case. Over the last two decades, we have become accustomed to well-developed theaters of war where medical assets were positioned close to the fighting. Often, a wounded Soldier or Marine could expect to be in an operating room within 45 minutes of being injured. Medical personnel of all ranks take for granted the rapid response of medical evacuation assets.
However, there have been many occasions where evacuation was delayed by hostile fire or “red” grounding weather conditions. Even armed evacuation assets like Pedro, the U.S. Air Force’s Pararescue Squadrons, can be grounded in bad weather. As we draw down in places like Iraq and Afghanistan, many medics and corpsmen have since realized that a delay in medical evacuation is not only possible but increasingly likely. As we move into places without the benefit of the robust evacuation capability we are used to, we will be faced with the operational problem of PFC. The question is, will we be ready?
Doctrinally, Role I medical providers, whether that’s the platoon medic, or the Physician Assistant working in the battalion aid station (BAS) do not have patient holding capabilities. They have neither the equipment nor the space to take care of a patient who isn’t either being evacuated or returned to duty. PFC isn’t intended to create holding capability. PFC is meant to address the training gap which becomes apparent when MEDEVAC isn’t on their way and you are forced to hold your sick patient.
What Are the Ten Capabilities?
PFC is built around ten core essential medical capabilities. This short and simple list gives providers an idea of the basic skills and equipment needed to prepare for “sitting on a patient”.
- Monitor. Be able to obtain, interpret and understand a patient’s vital signs. Use a method to accurately document what you see.
- Resuscitate. Be able to initiate appropriate fluid resuscitation to improve outcomes. This includes whole blood.
- Ventilate & Oxygenate. Provide positive pressure ventilation while protecting the lungs from further injury.
- Airway Management. Control and maintain a patient’s airway to prevent hypoxia or aspiration.
- Sedation & Pain Control. Use adequate and appropriate pain control. Use sedation to accomplish any procedural tasks.
- Physical Exam & Diagnostics. Be able to obtain information about your patient’s present condition and predict unseen injuries.
- Ongoing (Nursing) Care. Ensure your patient is kept warm, clean, and dry. Manage biological needs. Perform wound care. Prevent further illness.
- Advanced Procedures. Perform interventions necessary for preserving life, preventing morbidity, and improving outcome.
- Telemedicine. Establish communication with a medical provider capable of guiding medical treatment. Communicate the patient’s condition effectively.
- Prepare for Evacuation. Ensure patient stability during transport. Prevent further injury.
How Does this Match Up to the 68W MOS?
At a glance, PFC can seem far outside the wheelhouse of the average Combat Medic or FMF Corpsman. If you take a closer look, this isn’t the case. Most of the skills needed to perform good prolonged field care are in STP 68W13-SM-TG (CAC Required). Make sure to download a copy for reference.
1. Monitoring. At a minimum, the average combat medic or corpsman should be able to measure a patient’s blood pressure, pulse, respiratory rate, and temperature without any advanced equipment. Add a pulse oximeter and you’ve got a complete set of vital signs all within the 68W 10-level task list. Add a Foley urinary catheter to measure urine output (a 20-level task) and you’ve got a complete ability to monitor a critical patient’s status in a field care environment.
- 081-831-0010 Measure a Patient’s Respirations (Skill Level 1)
- 081-831-0011 Measure a Patient’s Pulse (Skill Level 1)
- 081-831-0012 Measure a Patient’s Blood Pressure (Skill Level 1)
- 081-831-0013 Measure a Patient’s Temperature (Skill Level 1)
- 081-831-0164 Measure a Patients Oxygen Saturation (Skill Level 1)
- 081-833-3017 Insert a Urinary Catheter (Skill Level 2)
- 081-833-0006 Measure a Patient’s Intake and Output (Skill Level 2)
2. Resuscitation. One of the principles of Remote Damage Control Resuscitation (RCDR) is aggressive fluid resuscitation with fresh whole blood (FWB). 68W combat medics have been pushing blood for years, starting with the Vampire program in 2012. The ability to collect and transfuse whole blood in the field is covered under three tasks. You can find more information on FWB transfusions in this post.
- 081-833-0033 Initiate an Intravenous Infusion (Skill Level 1)
- 081-835-3000 Administer Blood (Skill Level 3)
3. Ventilation & Oxygenation. It all comes back to the basics with respiration. The goal here is to optimize ventilation and mitigate or prevent ARDS or other positive pressure ventilation associated illnesses. One of the useful tools we can carry to help us is the PEEP valve, a small device which attaches to the BVM. If you do not already carry PEEP valves with your BVMs, you should correct the deficiency. If you can provide supplemental oxygen from a vehicle mounted tank or oxygen concentrator, great! If you can free your hands by attaching them to a ventilator, awesome! But remember, it’s all about the basics.
- 081-833-0017 Ventilate A Patient with a Bag-Valve-Mask System (Skill Level 1)
- 081-833-0098 Set Up an Oxygen Tank (Skill Level 1)
- 081-833-0158 Administer Oxygen (Skill Level 1)
4. Managing the Airway. While the “gold standard” for an airway is a cuff inflated in the trachea, evidence shows that even well-trained medics and corpsmen have difficulty achieving endotracheal intubation. This is likely due to having never performed an intubation on a live casualty or even a cadaver. Endotracheal intubation can be extremely difficult in a casualty with maxillofacial injuries. At the 68W level, unless otherwise trained and experienced, stick to supraglottic airways. The iGel is considered the first line supraglottic airway (SGA), but many units still rely on the King LT-D. Practice your complete airway sequence using the MS. MAID mnemonic.
- 081-833-0230 Insert a King LT (Skill Level 1)
5. Controlling Pain. The current Tactical Combat Casualty Care (TCCC) guidelines (Jan 2017) offer triple option analgesia consisting of a Combat Wound Medication Pack (CWMP) with acetaminophen, oral transmucosal fentanyl citrate (OTFC) lozenges, and IV/IO or IM Ketamine.
- 081-833-0304 Administer Common Medications (Skill Level 1)
- 081-835-3002 Administer Medications by IV Piggy Back (Skill Level 2)
6. Patient Assessment. Being able to examine your patient and take away information you need to treat them is a fundamental task for all healthcare providers. A basic assessment requires no additional gear, and knowledge weighs nothing in a rucksack. All medics should be able to perform a physical exam without the use of advanced diagnostics and develop an awareness of unseen injuries. In addition to the basic assessments below, make sure your medics and corpsmen are good at assessing each system (for example a neurological assessment)
- 081-833-0053 Perform an EMT-B Trauma Assessment (Skill Level 1)
- 081-833-0156 Perform a Medical Patient Assessment (Skill Level 1)
7. Ongoing Care. While there are few specific tasks associated with nursing care, it is a vital component of keeping your patient relatively healthy and happy. Aggressive ongoing care will prevent long-term complications resulting from being immobilized and having common emergency interventions. Documentation is a vital skill both for continuity of care as the patient travels from point-of-injury, and for the bleary-eyed medic troubleshooting problems. The PFC Flow Charts are an excellent tool with which to train and become familiar.
- 081-833-3022 Insert a Nasogastric Tube (Skill Level 2)
- 081-833-0012 Perform Wound Irrigation (Skill Level 2)
- 081-833-0145 Document Medical Care: SOAP Note Format (Skill Level 1)
Ask for classes about the following topics, ideally from a Nurse Educator.
- Deep Vein Thrombosis (DVT) Pulmonary Embolism (PE) Prophylaxis
- Pressure Ulcer Prevention
- Oral Hygiene for the Intubated Patient
- Wound Care
8. Performing Procedures. One of the most common arguments I receive from 68W NCOs is that “Special Forces Medics can do surgery and there is no way I’m letting my guys get carried away like that.” This is both untrue and unnecessary. Basic interventions save lives. Advanced procedures are just ways to make the basic interventions work better. While 68Ws going through the SOCM course learn about escharotomy, the incision of burned skin, the two skills below are available to all 68Ws.
- 081-833-3005 Perform a Surgical Cricothyroidotomy (Skill Level 1)
- 081-833-0168 Insert a Chest Tube (Skill Level 3)
9. Calling for Help. Communication is a base-level warrior task in which all Soldiers, Sailors, and Marines should be proficient. What is said once communication is established, on the other hand, takes practice. There are plenty of great resources on the Prolonged Field Care website, including this Telemedicine Cheat Sheet.
10. Preparing for Evacuation. Combat medics and corpsmen aren’t expected to plan and execute long-distance multi-country evacuations. However, having the knowledge to effectively anticipate and prepare for common problems encountered with evacuation will pay dividends for patient outcome.
Where are the Training Gaps?
As noted above, there are many opportunities to engage with your medical director and learn more.
Ongoing Care. Even the most critical patient is managed with basic skills while in the field. However, there are certain skill sets which, if developed, can pay huge dividends in a PFC scenario. One of these skill sets is that of nursing. Being able to develop a nursing plan by prioritizing procedures and create a care plan for each injury and intervention will really improve your game.
Pathophysiology. The worst situation to find yourself in is chasing one problem after the next while never really getting done what you need to get done. Understanding how systems function in sickness and trauma will help medics and corpsmen anticipate problems before they occur.
Medication Administration. This is one of the biggest deficiencies we have seen over and over. Medics and corpsmen who don’t have the opportunity to work in clinics or hospitals regularly, to practice medicine, must take the time to know the drugs they will have, inside and out.
Experience. Successful Prolonged Field Care is more about knowledge and skill than equipment. Practice is key to building experience. If able, medics and corpsmen should consider shadowing nurses in an ICU or another critical care setting. Getting a feel for how to rank-order patients and prioritize care plans comes from performing exams, trending vitals, and other “low-level” but critically important processes. Network through your providers and seek out opportunities to gain experience.
What Do I Need to Start Training?
Ultimately, prolonged care requires core clinical and battlefield medicine competencies at every skill level; and competency requires repetition. —LTG Nadja West, Army Surgeon General
Start With TCCC
All battlefield care begins with high-quality Tactical Combat Casualty Care (TCCC). You will never get to PFC if your patient doesn’t survive TCCC. Basic medical care should constitute a majority of your medical training. Brilliance in the basics is what allows you to be advanced. What you do in the first hour of care will affect the problems you face in prolonged field care. Once TCCC skills are mastered, it is then possible to begin incorporating critical care best practices into all levels of training.
While the skills of PFC are within the scope of 68W MOS training, the knowledge to use your assessments to make a plan of care requires you to be well informed. Start by reading the Clinical Practice Guidelines (CPGs) published by the U.S. Army Institute of Surgical Research. The PFC Working Group has already published several CPGs and has many more in the pipeline.
Then, ensure you’re up to par on your basic sciences. There are several courses offered through the ATRRS Self-Development Center (CAC Required) which will help you boost your core knowledge. We recommend 081SDL13-DMSMY-0001 Anatomy and Physiology, 081-18DSOCM Special Operations Combat Medic Prep Course, 081-18DPREP Special Operations Medical Sergeant Prep Course, and 081-18D Special Operations Medical Sergeant Sustainment Course. You’ll have the added benefit of maxing out your DL promotion points!
Then, head over to the Prolonged Field Care website to read and listen to their posts. They invite experts from all over military medicine to weigh in on topics surrounding the PFC problem set. The planning materials and other resources available are invaluable.
Build a Plan
Start with getting your medics and corpsmen together to talk about Prolonged Field Care and how it affects them. You can put together classes that fill the identified training gaps. Introduce the idea of adding RAVINE or HITMAN to the end of their MARCH PAWS algorithm. Go over some of the checklists and documentation they will be using during scenarios. Include your PA and MD in these classes to ensure everyone is on the same page.
Get Leadership Support
There are many tasks a commander must prioritize. Leadership support is essential for building and maintaining a robust casualty response system. Medical training is usually not at the forefront. Making a respectful but convincing case as to why additional training time should be allotted to Prolonged Field Care scenarios can be a challenge. Thankfully, the Army Surgeon General is in our corner. With the recent push from organizations such as the Special Operations Medical Association (SOMA) to shed light on the number of potentially survivable deaths resulting from battlefield injuries, it would be hard to argue against increased training.
Running PFC scenarios is also very manpower intensive. Each scenario must have a provider, MD or PA, overseeing it. Human role players with medical training are better than non-medical role players. Mannequins should be a last resort or used only to demonstrate a skill.
Prolonged Field Care scenarios are long. Excluding classes, workshops, and other labs, the PFC scenarios for 68Ws should be 8-12 hours in duration. During this time, the lead medic or corpsman should be able to complete all skills, pass all decision points, and generally meet all the objectives of the scenario.
Get a Script
Scripts are important both to keep the scenario on track and to ensure all graders are on the same page. Scripts also decrease the cognitive workload for the graders and allow them to concentrate on the medic’s or corpsman’s performance. The PFC website has a great template script for your providers to flesh out.
TCCC. Download the TCCC Quick Reference Guide here.
SOMA. The Prolonged Field Care Teaching and Training Recommendations were first published in 2015 on the SOMA website.
PFCare.org. The official website of the PFC Working Group. This site is a treasure trove of austere care knowledge.
Kotwal, RS; Montgomery, HR; Miles, EA; et. al. Leadership and a casualty response system for eliminating preventable death. J Trauma Acute Care Surg. 2017 Jun;82(6S Suppl 1):S9-S15
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