Can it get any worse?
The vehicle has rolled, it’s unusable, and the driver is trapped by vehicle damage, resting position and injuries. We are not supposed to be here. We need help. I can’t call for it, I can’t draw attention to us, I can’t just sit here and let our team and situation deteriorate…
This is just one example of many real-world situations that could easily happen, and you may not have the option to call for additional resources to help, due to location and nature of operating. It’s now starting to go dark, you can smell burning in the accident vehicle – you need to act, you always knew situations like this could happen. How prepared are you now for this reality?
We have raised awareness previously in Circuit Magazine issue 39, about the benefit of rescue provision, and having a medical capability. Rescue tools as we have shown, are now lightweight, portable and it really is possible to rescue yourself or team from a situation that previously you would have been at the mercy of. As important as the tools to carry out rescue, along with the skill and aptitude to use them, is the ability to medically manage a team member or even a principle!
Consider the option of this in an environment totally unfamiliar to you, or one that has hostile implications. What are the effects of location; time of day; weather; injured people; local infrastructure; and your ability to achieve your task of safe and secure transport of important people or whatever it maybe. These are odds that are now stacking against you.
In this incident, we may have one or several trapped and injured people, and if the ability existed to effectively deploy use of rescue tools, light and portable and incredibly effective – rescue could begin straightaway. If another vehicle or team was also at location, this rapid reactive response would allow access into the vehicle to treat injured people. If the tools were accessible in the accident vehicle itself, and if occupants were able to, they could be potentially used to make egress and escape out of it if no other vehicle or teams were at location to help. There is therefore significant potential with a light portable bespoke rescue kit. So, we can now facilitate a rescue in a self-sufficient manner, of equal capability to UK Fire and Rescue, and begin it sooner than you would get a rescue response in UK and wherever in the world!
What is needed now is to assess and begin to manage the injuries and develop a med plan to execute. Given the problems of location, time of day, severity of injuries and all the other odds stacking up – it is imperative to have a plan and the means to carry it out as best as practicable. Planning and preparation must be the key and never an assumption that a situation and scenario can be managed.
Getting back to the incident example, – in this present situation the injured team member or members changes the game. Due to operational theatre of location and those stacked odds, we can’t get this casualty to medical care and treatment in the same way we may take for granted back home. Our only choice maybe; to manage the casualty ourselves. Now, who has thought and prepared for that? The team may be hours away from a safe point of care; how on earth could this care be achieved? You simply cannot afford to run out of options or hope; you must believe you can make a difference.
Any algorithm-based checklist can be used to treat a trauma casualty, but what happens at the end of that checklist? It is well known that in the U.S, all military personnel are taught the three phases in Tactical Combat Casualty Care (TCCC). These are Care under Fire, Tactical Field Care and then Tactical Evacuation Care. A civilian version now exists contextualised for US emergency medical services in a civilian environment Tactical Emergency Casualty Care (TECC).
These systems are evidence based, but they rely on getting the casualty to a higher and more capable skill set within a small timeframe. You do not or may not have this luxury in austere, remote or hostile environments. Now there is only you and your team to manage this casualty. Welcome everyone if you were not aware, to the concept of ‘prolonged field care’ (PFC). Within military and tactical settings, small teams have looked after injured casualties over an extended amount of time, for many hours and even days. What was once the territory of Special Operations Forces (SOF) is now beginning to develop wider. US forces have pioneered this concept and the 10th Special Forces Group, operating out of Fort Carson in Colorado have developed a whole framework of evidence-based education and methods. I do absolutely take my hat off to US forces here; their medical skill and capability is superb. This is seen by many now, as part of the potential future to military medical capability.
PFC can be carried out at a high level of capability, with equipment, drugs, medicines, interventions & techniques. This, I suppose, if the aptitude of the operator is proficient enough, is where it is at its most potent. It can also be carried out at a simpler level too; it is about the concept, planning and preparation. Of course, with simpler interventions and lower levels of medical capability supporting an injured casualty for 72 hours will be difficult. However, we can still use the concept for benefit once we reach the end of our checklist and are not sure what to do next – because that will happen. Nothing can be left to chance, because the concept of PFC when you grasp it fully enables you to see and realise problems and contingencies you might not have considered or thought about previously.
It is all about capability along the continuum of care, from the point of injury to the point where you can get a casualty to the next higher level of care.
*Below the continuum of care estimated times only
Initial algorithm-based treatments in the first hour from point of injury
The casevac – shock, vital signs, casualty’s presentation managed on the move in a vehicle – timeframe 3 – 6 hours
The patient hold – using nursing practices to try and manage and improve casualty outcome – timeframe 3 – 72 hours
Medical evacuation with the whole team for movement and management of casualty to the next level of care 7 hours to UTC (co-ordinated universal time)
Of course, all this depends on location, context, situation and severity, but it is valuable even at the more basic level. It is difficult to justify the training approach in written form from here. PFC training is extremely cost effective and can be as complex or basic as it needs to be. The U.S approach is to replicate realism as much as possible, which is certainly advantageous. This must be weighed against scenario-based training with high focus on high quality casualty care. What also must be borne in mind is use of equipment and techniques that are usable in the real world.
Can you predict these types of occurrences? You cannot, and with the greatest planning, intelligence, topography and risk profile information, unexpected occurrences can and will still occur. So maybe the way to consider this is to expect the unexpected and this may go some way towards adopting the correct mind-set.
This is considered to be a proven method of thinking. Top performers, regardless of profession, know the importance of picturing themselves succeeding in their minds before they do so in reality. In a similar vein, if you can forwardly visualise an adverse event in your mind, it is proven potentially that you may react better to it in real world. Of course, you do not know how you will react until your first ‘contact’ but afterwards you have that answer for future occurrences. The power of psychology and how that affects decision making is a powerful weapon in your armamentarium of capability; use it to your advantage.
These are some of the approaches we incorporate into our training and methodologies. PFC concepts are also part of our approach and if you would like to know more we would be happy to hear from you. Please visit our contact page to find our full contact details. We would be happy to answer any questions you may have on how we can assist your teams.
Specialist Instructor IRRTC
International Road Rescue and Trauma Consultancy ltd – “IRRTC”
The article was first published in the Circuit Magazine issue 40. Click here to see the full editorial spreads on pages 74-80.