12/10/2014 Operations PFN: SOMTCL02

12/10/2014

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Slide 1JSOMTC, SWMG(A)

Special Operations Combat MedicPFN: SOMTCL02

Hours: 2.0

Instructor:


Terminal Learning Objective

Action: Communicate knowledge of the Special Operations Combat Medic

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards


Reason

The SOCM must program their reactions and learn from their responses

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Agenda

Define the Special Operations Combat Medic

Outline SOCM trauma training

Identify Combat Medic variables

Describe environment based thinking

Identify Combat Medic equipment

Identify SOCM packing principles

Determine death and resuscitation termination

Identify SOCM Pearls of Wisdom


Special Operations Combat Medic


“ Special Operations Combat Medics (SOCMs) may often find themselves in austere tactical environments where evacuation of a teammate to a medical treatment facility may not be possible or may be severely delayed. They must be prepared for any injury within any environment.”

SOCM

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SOCM Abilities

Capability to treat numerous different types of traumatic wounds

Aptitude to increase team survivability

Comprehension of multisystem trauma patients

Dexterity to operate in all types of environments tactically and medically

Competence to self adjust shortfalls


Core Attributes

Integrity

Courage

Perseverance

Personal Responsibility

Professionalism

Adaptability

Team Player

Capability


SOCM Trauma Training

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Trauma 1

ACLS

PEPP

Military Medicine

Lecture / PMST II


Trauma 2

Trauma Patient Assessment (TPA)

Trauma Surgical Skills (TSS)

Combat Trauma Management (CTM)


Trauma 3

K9 Instruction

Tactical Combat Casualty Care

Military Triage

MASCAL

Advanced Trauma Management (ATM)

Field Training Exercise (FTX)

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Summation

Each training block is built to add onto the next section

Skills are introduced and reinforced

The medical information will always be changing and the SOCM needs to be informed and integrating the new knowledge


Combat Medic Variables


Two Types Of Variables

Controllable

Uncontrollable

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Controllable Variables

What are the variables we can control?

1. Preparation/ Training/ Contingency Plans

2. Mental Capacity/ Composure/ Emotion

3. Education/ Medical Updates


Mental Capacity

Developed securely through experience

The ability to filter out what is important in relation to all stimuli

Maturity to distinguish threat from non‐threat medically and tactically

Maturity of reaction


Preparation

Preparation entails:

1. Team training

2. Medic training

3. Augmentee training in medical skills

4. Indigenous integration

5. Equipment placement (individual vs. aid bag)

6. PCI checks for mission

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Training

Medical skills are perishable

Team Medical SOP’s (must be enforced)

Medical training should not be a separate event from other training

Focus on the basics when training teammates (BLS, bandaging and splinting)


Numerous Concerns


Beyond Medical Concerns

Mini‐gun

Feed mechanism for the Mini‐gun

Load plan for rounds(mini‐gun)

Round box maintenance

Pindle configuration for Mini‐gun

Power Layout

Feed tube immediate action

Trigger operation

Trigger maintenance

M240 operation (butterfly trigger)

M249 operation

M4 operation

M9 operation

DAMA

MERC Chat

MBTIR fill

MBTIR zero

MBTIR operation

Winch operation (GMV)

Compressor

Power converter

AT‐4 safety

AT‐4 operation

Carl Gustav safety

Carl Gustav operation

60mm mortar

Trigger fire operation

Mortar round settings

102 SAT

Team internal chat

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Preparation is Controllable

There are many, many competing considerations besides medical proficiency and training (weapons maintenance)

As a medical operator, stressing medical training will be a non‐stop job requirement

Training and preparation is a controllable variable that needs to be stressed in terms of the medical component


Uncontrolled Variables


Uncontrollable Aspects

Weather

Follow‐on missions

Enemy activity

Unavoidable equipment malfunction

Changing environment

Number of casualties

Evacuation response time

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Variables Continued

Resupply response time

Time of day

Augmentee additions to mission

Force strength (teammates leaving or entering theatre)

Loyalties of Indigenous forces


Key points

Categorizing variables helps the operator define the battlefield

“How can I deflate this variable which is uncontrollable?”

Each mission requires a different thought process for the SOCM

The mission may be constant but the execution will change (multi‐use items)


Key points Continued

“The operator cannot wait for information to come to them, they must first establish what information they need and then seek it out until they find a required answer”

Developing initiative for preparation will save more lives than any other skill

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Environment Based Thinking


All Actions Depend on Environment


Casualty Movement

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Casualty Aid


Casualty Movement


2nd Soldier Shot

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What is the Environment?


Review of Reaction

Casualty appears in open area

Rescuer responds by running to casualty (unknown suppressive fire extent)

Casualty weight is overwhelming limiting speed of exit to solid cover

2nd rescuer responds in same manner

One rescuer becomes casualty

Rescuer retreats from open area to regroup


Schematic

Road

Road

Wood Building

Enemy fire

Enemy fire

Rescuer direction of travel

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Environmental Factors

Enemy position unknown or well covered

Large open area, little solid cover

Casualty is unresponsive, no help with extraction

Casualties equipment adds weight

Daylight, full visibility

Distance to solid cover extensive


Keys to Rescue/ SOCM Thought Process

Enemy position located (fire superiority)

Location for casualty located (solid cover)

Method of extraction (casualty carry)

Aided rescue tactics (smoke, vehicle cover)

Factors of speed (equipment necessity)

Factors of speed (# of rescuers, pros, cons)

Coordination/ Orchestration (effective fire)

Communication


Schematic

Road

Road

Wood Building

Enemy fire

Enemy fire

Rescuer direction of travel

Vehicle

Which way to bring casualty?

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Tactical Principles

3 F’s of Combat

Find

Fix

Finish

Finding the enemy is easier said than done

Fixing the enemy requires accurate suppression

Finishing may require any number of possibilities


Medic Considerations

The thought process and communication requirements for the Medic revolves around the 3 F’s.

Care Under Fire phrase is misleading

Limited medical care should be given to the casualty until SOLID cover is between you and the enemy

SOLID cover will be different for every environment


Considerations Continued

SOLID cover examples

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Environment Scenario


Suicide Bomber

Your clinic has been targeted by suicide bombers

As the only medic involved in the clinic you need to make the clinic safe due to this threat


Schematic

Two way road

10 meter mud wall

Door Entrance

Female Clinic

Male Clinic

Door Entrances

50 meter distance

Suicide Bomber Threat is imminent from cross checked intelligence reports and HUMINT resources.

SafeArea to the West

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Resources available 2inX4inX8ft wood planks (unlimited)

Nails unlimited

5 Camp workers with necessary tools (shovels, hammers, etc)

1 loader

3ftX3ft Hesco containers

(unlimited amount)

30 man Afghan Infantry Co

All the mud you want


Exercise

With the schematic and the resources given you must make the clinic safe for your patients, the host nation doctors working for you, your teammates, and any other guests which may visit the clinic at any time

You now have 10 minutes to think about and draw out a strategy for safety

Questions?


Schematic Review

Two way road

10 meter mud wall

Door Entrance

Female Clinic

Male Clinic

Door Entrances

50 meter distance

Suicide Bomber Threat is imminent from cross checked intelligence reports and HUMINT resources.


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Answer Considerations

The Threat: suicide bomber

Characteristics : On foot?

More than one individual?

Armed with one bomb, weapon and bomb, just grenades, RPG’s

Male, female, child?

Channelize threat

Increase time to react

Address cultural concerns

Use Host Nation Soldiers whenever possible


Schematic Review

Two way road

10 meter mud wall

Female Clinic

Male Clinic


Hescos

Female (Host Nation) Searcher/ Guard

Male (Host Nation) Searcher/Guard

Exit

PatientExit


Conclusion Clinic safety involves environment based thinking

In theatre the available resources may be limited and creativity comes into play for success

Have contingency plans for botched attempts (CCP’s, rally points designated)

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Key Operational Points

If Hescos are scarce, digging trenches for VBIED protection is an alternative (remember channelization)

Static site security is executed in layers

Outer layer is made up of host nation

Inner layermay be U.S. regular army or more host nation Team layer for all

team members


Changing Environments


Firebase Clinic

Medicine in this environment requires a different approach than the situation we just critiqued

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Rural Vehicle Combat

* Courtesy SFC Elwood (1SFG)


Urban Foot Combat


7000 Feet Logar Province, Afghanistan

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Jungle Combat


Operating in Rotary Wing Aircraft


Darkness Considerations

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Combat Medic Equipment


Soldier Load

Soldier load given the terrain

Mobility requirements given combat action

Mission dependent variables for equipment considerations


Soldier Kit Issues

Very bulky on the anterior

The posterior camelback makes movement difficult

The prone shooting position is almost impossible

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Principles for Equipment Selection

Mission specific (don’t forget contingencies)

Multi‐use items

Contents should be mission tested

Packaging should be water resistant/durable

Equipment should be team‐member specific in certain cases

Chosen articles need to address possible injuries seen at each level of the mission


Mission Dependent/ Operator Dependent Medical Gear Matrix

Designated by GradesIFAK/Blowout Kit AID BAG EVAC Ground/ AIR FireBase/FAST/CASHGrade 1 MED gear Grade 2 MED gear Grade 3 MED gear Grade 4 MED Gear

NPA Cric kit Extra fluids UltrasoundTourniquet IV (2) IV supplies ECG/MonitorsChest Seal Drugs Israeli Litter VentilatorACE Wrap Airway Kit Blankets/Hypothermia kit OxygenKerlex Chest Tube Kit Thermal Angel Field Blood Supply

14ga (ND) Kerlex/Ace Wrap Traction Devices Extra/Additional DrugsAlcohol/Betadine Sam Splint C‐collar Foley/NG

CravatsExtra‐Bandages/ Ace

wraps SuctionABD dressing Tourniquets PleurovacTourniquets Skedco

BVM with maskStethescopeHemostats

Bandage ScissorsOPA


Grade I

Operator equipment is stream line

IFAK worn on left side‐rear

Pros and Cons for IFAK position

Mobility needs to be considered when placing Grade I gear

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Grade II

M9 Medic Bag

Low profile

Used mainly for assaults or short term missions

May be used for long range patrol; weight and equipment decisions become potential issues


Grade II Continued

Larger medical bag

Used for vehicle operations

May be used as “drop and go bag” when assaulting

Medical bag for range operations

More room more possibilities


Grade III

GMV, ATV, or any alternate place where follow on medical gear may be stored for use on the battlefield

This Grade is open to places of experience or creativity of the operator and the team

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Grade IV

Firebase medical clinic

Usually a stable place to set up continued operations

Larger medical equipment used for treatment

The facility is fixed and continuous


Grade IV Continued

FAST Operating Room

The Forward Area Surgical Team is staffed with U.S. surgeons

They have life saving stabilization and damage control capabilities


Summation of Grades

Grade I gear is defined as a small kit on a person

Grade II gear is a Medic Bag which may be worn or used as a “drop off” before assault

Grade III items are “cached” for later use whether in a vehicle or at an ORP, CCP

Grade IV equipment is located at the Firebase or established CSH, FAST location

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SOCM Packing Principles


Packing Gear Principles

Waterproof and preferably CBRNE proof

Compact

Easy to locate within the bag

Contents ordered in terms of use


Gear Principles Continued

Extra items available

Sterility kept with products

Kits made for procedures

Items are tested and familiar to operator

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Waterproof Contents


Vacuum Sealing Pros

Excess air is evacuated decreasing size of medical components or kits

All contents are sealed and dry

Gives the operator the ability to package kits for a team member to carry

Gives the Medic freedom to include what contents are deemed personally necessary


Vacuum Sealing Cons

Time consuming

Resource intensive (vacuum sealer and vacuum bags)

May not have the ability to perform in austere conditions

Some products don’t seal well

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Compact

Cricothyroidotomy Kit Repackaged 6” Ace


Easy to Locate Inside Medic Bag


Contents Ordered in Terms of Use

Tape on tape

Trash stays with cravat

Contents may be placed in order of use

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Retrieving Contents


Extra Items Available


Sterility Kept with Products

* Courtesy Mr. Resurreccion

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Drug Box Design


Kits Made for Common Procedures

Cricothyroidotomy Contents Cricothyroidotomy Kit


Battle Tested Products

DO NOT use untested equipment while performing missions

There is a tendency to throw new products in your bag without training or testing them first

Just opening the package does not count

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Discussion

This is the modified ET tube for the Cricothyroidotomy Kit

Why is there a STYLETplaced inside the tube?

* RAISE your hand with the answer


Answer

The stylet is used only to keep the tube open while it is stored inside the kit

Without the stylet the tube will be flattened and during use may be altered, decreasing the flow of air through the tube


Determine Death and Resuscitation Termination

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Obvious death

Decapitation

Massive crush injury and or penetrating trauma with evisceration of heart, lung or brain

Incineration

Decomposition of body tissues

Rigor Mortis or post mortem lividity



Termination of resuscitation efforts

After 15 minutes if MOI is unknown or due to trauma, PLUS

After 30 minutes if MOI is hypothermia, lightning strike, electrical injury, cold water drowning PLUS

Persistent absent pulse and respirations when adequate ventilation, fluids and medications have been administered



Termination of resuscitation efforts

Persistent absent pulse and respirations

Pupils are fixed and dilated

No deep pain response

Absence of end tidal CO2 from a correctly placed ET tube or alternate airway device

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SOCM Pearls of Wisdom


Tourniquet Requirements

Operators coming home have stated the need for 3 tourniquets on each Soldier

The need for 2 tourniquets on some leg wounds has driven the change

Remember in harsh environments check tourniquet serviceability regularly


Products Seen Downrange

Combat Gauze

S‐Rolled Kerlex

Saline Lock Kit

Altered Cric Tube

Altered Scalpel for Cric

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Tourniquet Placement

Tourniquets may be placed anywhere for easy access

Inside this GMV there are numerous tourniquets accessible at any time

They were secured to many different non‐removable features of the GMV by electrical tape

The idea used was for breakaway capability of use


Low Visibility Operations

Low Visibility Operations create issues for medical requirements

Prior planning and medical kit component choices are the keys

What do you bring for this mission?


Firebase Clinic Safety

Patients screened prior to entrance to clinic (Indigenous then U.S.)

Holding area established

No vehicles allowed to deliver patients to clinic (VBIED concerns)

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Firebase Cultural Concerns

Treating women in Afghanistan is culturally sensitive

In this picture the curtain is a shield for the male medical personnel to conceal himself while verbally treating females

*Courtesy SFC Elwood (1SFG)


Table 8. OIF Medical Reasons for Evacuations (as of August 31, 2010)

Number Percentage

Wounded in Action 8,954 18.1%

Non‐Hostile Injuries 10,383 21.0%

Disease/Other Medical 30,053 60.1%

Total 49,390 100%

Source: Department of Defense, Defense Manpower Data Center, http://siadapp.dmdc.osd.mil/personnel/

* The Department of Defense defines a “non‐hostile injury” as an injury that is not directly attributable to hostile action or terrorist activity, such as casualties due to the elements, self‐inflicted wounds, or combat fatigue.

OIF Statistics


OEF Statistics

Table 9. OEF Medical Reasons for Evacuation (as of August 31, 2010)

Number Percentage

Wounded in Action 2,788 20.1%

Non‐Hostile Injuries 2,771 20.0%

Disease/Other Medical 8,292 60.0%

Total 13,851 100%

Source: Department of Defense, Deployment Health Support Directorate, http://siadapp.dmdc.osd.mil/

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Statistical Meaning for the SOCM

81.1% of Injuries were non‐action issues (OIF)

80% of Injuries were non‐action issues (OEF)

Wounded in Action results in approximately 20% of the injuries seen

That 20% will be the most serious injuries the SOCM will see while deployed

Do not become complacent with preparation and skills given the make‐up of injuries


Amputations for OIF,OEF, EtcTable 3. Count of Individuals with Amputations by Service for OIF, OEF, and Unaffiliated Conflicts, 2001 to

September 1, 2010

Theater Type of Amputation Army Marine Navy Air Force Foreign Other Total

OIF Major Limb 620 158 18 8 4 8 816

Partial(Hand/Foot,Toes/Fingers) 272 49 7 11 0 3 342

OEF Major Limb 145 53 5 6 4 4 217

Partial(Hand/Foot,Toes/Fingers) 24 6 0 2 0 0 32

Unaffiliated Major Limb 94 12 25 31 1 26 189

Conflicts Partial(Hand/Foot,Toes/Fingers) 20 1 2 1 0 1 25

Total 1,621

Source: Personal correspondence with Dr. Michael J. Carino, Army Office of the Surgeon General, September 21, 2010.


TBI Incidence

Table 2. Traumatic Brain Injuries in the U.S. Military (2000 to 2010 Q1)

Year 2003 2004 2005 2006 2007 2008 2009 2010 Total

Incident 12,886 13,271 12,025 16,873 23,002 28,557 27,862 7,604 178,876

Source: The Defense and Veterans Brain Injury Center, http://www.dvbic.org/TBI‐Numbers.aspx, last updated on May 20, 2010.

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Lessons

Be aware and prepared for the TBI patient

Have systems in place to deal with TBI suspected casualties

Extremity injury is very common

Focus on courses of action for extremity trauma (teach your teammates)


Discussion

You are the Senior medic without a Junior medic tasked with a vehicle mounted direct hit on a small collection of buildings 20km East of Bagram, Afghanistan. Provide a medical load out plan for all 9 personnel and the 3 GMV’s in your team. All answers will be written. All materials will be collected with your name attached.


Your Target Landscape

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Carrying Load for Personnel

NPA (1)

Tourniquet X 3

Cric Kit

2 inch Ace with 1 Kerlex

1 pack Combat Gauze

Needle Decompression Kit (2:14ga Needles)

2 Asherman chest seals


Possible Outload Plan

Driver

TC

Gunner

Large MED Bag

Marks the

position of break away tourniquets attached to the vehicle. The front 2 are attached to the sun visors and the rear 2 to the frame cross bar.


GMV Med Bag Contents

Tourniquet (4)

Compressed Kerlex (8)

6in Ace Wraps (8)

Abdominal Bandage w/cravat (2)

Chest tube Kit (1)

IV kits with 500ml Hextend (2)

FAST 1 IO (1)

SAM Splints (3)

Cravats (8)

Sodium Chloride 100ml (2)

Airway Kit with Laryngoscope (1)

Field Dressings (5)

Cricothyroidotomy kit (1)

Hypothermia Kit (1)

Nine Line Casevac Card (2)

BVM w/mask

KTD Traction device (1)

Combat Gauze (2)

Penlight (2)

Stethescope (1)

BP cuff (1)

C‐Collar (1)

Trauma Shears (1)

Sharpies pens (3)

Head lamp (1) Extra Batteries

Drugs: Invanz (3 vials)

Moxifloxacin (2 vials)

Fentanyl Lollipops

Morphine (3 Vials)

Snivel Drugs

Indigenous Drugs

Any Extra contents

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Contingencies

The mission starts as vehicle mounted, remember concerns for dismounted operations

Your proposed CASEVAC time is just proposed and will probably be longer

Mass casualty events are always a concern

Pre‐hit and Post‐hit travel

Nail down CASEVAC plan with the pilots if possible


Questions?


Terminal Learning Objective

Action: Communicate knowledge of the Special Operations Combat Medic

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards

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Agenda

Define the Special Operations Combat Medic

Outline SOCM trauma training

Identify Combat Medic variables

Describe environment based thinking

Identify Combat Medic equipment

Identify SOCM packing principles

Determine death and resuscitation termination

Identify SOCM Pearls of Wisdom


Reason

Documents

12/10/2014 Operations PFN: SOMTCL02