«FINAL REPORT 30 January 2013 U.S. Central Command Pre-Hospital Trauma Care Assessment Team Russ S. Kotwal, MD MPH COL, MC, USA Director of Trauma ...»
6. Review and refine a career pathway for military pre-hospital nurses. Some nurses will obtain a highly valued skill set in emergency, critical care, and transport medicine. Sustainment and training of these skills is paramount. Advancement opportunities within this career field must be created. Standardize the equipment, training, protocols, and readiness level progression for ECCNs. Establish training for medical directors to approve ECCN specific protocols. Establish ECCN PROFIS positions, assign ECCNs to MEDEVAC units prior to pre-deployment training, and deploy ECCNs with the MEDEVAC unit for the duration of the unit deployment.
7. Review and refine a career pathway for military pre-hospital physicians. Pre-hospital emergency medicine is truly a multi-disciplinary area of medical practice. Traditionally, physicians have volunteered to work in this area without any formal training or career structure.
Continue to support, refine, and expand the military Emergency Medical Services fellowship to accommodate needs of all services. A physician mentorship program needs to be developed.
Additionally, review and adopt best practices from pre-hospital emergency medicine subspecialty programs found in other nations (e.g. United Kingdom model).
8. Currently, there is no one entity focused on pre-hospital and battlefield medicine. Create and maintain a command structure for pre-hospital and battlefield medicine. For battlefield trauma care, obtain best-practice recommendations and guidelines from the Joint Trauma System.
9. Review service trauma training center programs (ATTC, NTTC, CSTARS) and consider creating Joint Trauma Training Centers (JTTCs). We should train as we fight. All services work jointly in theater, home station trauma training programs should accommodate the same. Best practices from current service trauma training center programs should be cross-leveled. Other services would benefit from reviewing current US Air Force trauma training center model.
Increase civilian community visibility and ownership of National defense efforts through civilianmilitary trauma training center partnerships. JTTCs should accommodate pre-hospital trauma training for combatant unit (ground and aviation) medical personnel.
10. Mission requirements and standards of care should dictate medical training standards. All military pre-hospital medical providers should receive initial and sustainment training to accommodate all administration routes (PO, IV, IM, etc.) of all medications recommended by TCCC for optimal provision of pre-hospital trauma care on the battlefield.
11. Crew chiefs and gunners on tactical evacuation missions should be trained at least to a minimum standard of Emergency Medical Technician-Basic as they may be requested to assist in casualty care.
12. As the DoD joint military medical school, the Uniformed Services University of the Health Sciences (USUHS) must continue to expand and institutionalize their direct participation, research, and training in trauma and combat casualty care delivery across services and throughout the continuum of care. USUHS should also develop and formalize a partnership with the Joint Trauma System.
Research and Development Commanders:
1. Elevate the priority of pre-hospital trauma care research and funding and emphasize the need for advances in non-compressible hemorrhage control and resuscitation of casualties in shock in the pre-hospital environment.
2. As all on the battlefield have the potential to be a casualty and a first responder, explore information technology (IT) solutions for pre-hospital documentation that are first responder centric, not medic centric, and integrated into tactical communications in a manner that surpasses the proven TCCC card method.
3. As nausea and emesis can occur with opiate administration, develop an oral transmucosal fentanyl citrate lozenge with ondansetron (“fentanyl-ondansetron swirl lollipop”).
4. Develop an oral transmucosal ketamine lozenge product (“ketamine lollipop”).
5. Similar to the IM auto-injector used for morphine, develop a ketamine 50mg IM auto-injector for pre-hospital trauma care. Explore other potential routes of ketamine administration to include intranasal and transcutaneous.
6. Determine whether TXA administered IM is equal in efficacy to TXA given IV. If this is found to be the case, develop a tranexamic acid (TXA) 1g IM auto-injector for pre-hospital trauma care.
7. As malaria chemoprophylaxis mitigates morbidity and mortality caused by malarial infection, develop an animal model research protocol to study the safety, efficacy, risk, and benefit of oral TXA consumed prophylactically for mitigation of uncontrolled hemorrhage.
8. According to the 2011 Eastridge et al DOW study and the 2012 Eastridge et al KIA study, no deaths occurred as a result of a sucking chest wound. However, 11 deaths were attributed to tension pneumothorax. Although the report is pending publication, a recent study conducted by the USAISR to evaluate benefit versus non-benefit of a chest seal valve noted a benefit for a chest seal valve. Another study should be conducted to ascertain the need for applying a chest seal to a sucking chest wound, as a sucking chest wound may still be inadvertently converted into a life-threatening tension pneumothorax.
9. New FDA-approved technology to control junctional hemorrhage should be compared and further evaluated. Compression devices used in the hospital setting (e.g. FemoStop) should also be included in future head-to-head evaluations of junctional tourniquet devices to determine potential for use in the pre-hospital setting.
10. Evaluate outcomes as a function of pre-hospital fluid resuscitation (none vs. hextend vs.
plasma vs. PRBC vs 1:1 plasma and PRBC) provided by evacuation platforms.
11. Take the best features of the CAT tourniquet and the SOF-T tourniquet and develop a hybrid that outperforms both.
12. Study the safety and efficacy of pre-hospital pelvic binder use on casualties with known or suspected pelvic trauma.
14. Develop a centrally packaged and distributed Combat Wound Pill Pack. This pack must include extended shelf life for components as well as packaging that will ensure integrity of components against crush and humidity.
15. As meloxicam (Mobic) is preferred over platelet-inhibiting NSAIDS for personnel at risk for wounding and subsequent hemorrhage in a combat zone, review and evaluate whether meloxicam truly requires 7 day ground testing for rated aviation personnel.
16. Conduct a retrospective study of combat casualty outcomes in the DoD Trauma Registry as a function of the type and route of pre-hospital analgesia used as well as the type and severity of wounds sustained and physiologic parameters indicative of circulatory or respiratory status.
17. Information Technology systems must be employed to optimize the consolidation, synthesis, and analysis of information and data for tactical and medical performance improvement.
18. Many potential first responders routinely play popular combat video games (e.g. Halo, Call of Duty, Gears of War). Partner with the makers of these games and integrate accurate first responder TCCC treatment protocols for casualties in the game, based on injuries and injury requirements.
19. Integrate and solicit input from medics, and other pre-hospital trauma experts, from the onset and throughout the process of pre-hospital trauma research and development in order to optimize requirements-based solutions.
20. DoD research efforts must meet the needs of the combatant commander and the mission.
As health, wellness, and disease prevention should continue to serve as focal topics of advancement through non-DoD funded medical research, DoD funded medical research must maintain focus on unique aspects of “military” medicine and fund projects designed to fill gaps in force health protection, human performance, injury prevention, and combat casualty care.
CENTCOM Commander and Surgeon:
1. Continue support for the Joint Theater Trauma System (JTTS) Deployed Director position in CJOA-A.
2. Create and support the position of JTTS Pre-Hospital Care Director in CJOA-A to be filled by a physician with experience in POI pre-hospital combat trauma care
3. Minimize use of platelet-inhibiting drugs (e.g. aspirin, Motrin, other COX-1 NSAIDs, SSRIs) in individuals who leave secure areas for combat missions in CJOA-A
4. Expand TCCC-endorsed trauma guidelines, training, and use of 1) tranexamic acid (TXA);
and 2) ketamine to all pre-hospital medical providers in CJOA-A (e.g. USSOCOM model)
5. Implement JTS endorsed pre-hospital guidelines in the same fashion as JTS endorsed hospital guidelines
6. Maintain, update, and publish a list of platelet-inhibiting medications and nutraceuticals that should not be used in individuals who depart secure areas and conduct combat missions, as these individuals are at higher risk for trauma and increased morbidity and mortality from hemorrhage.
7. Review and improve the theater policy and approval pathway for off-label use of medications in the pre-hospital battlefield environment in order to mitigate restrictions placed on beneficial practices endorsed by the medical literature and subject matter experts (e.g. tranexamic acid, oral transmucosal fentanyl citrate, ketamine).
8. In addition to creating a deployed JTTS Pre-Hospital Care Director, deploying and deployed command surgeons must be knowledgeable on pre-hospital battlefield trauma care and its impact on battlefield morbidity and mortality. These providers must dedicate additional resources toward equipping and training all personnel on pre-hospital care and documentation.
9. The JTTS should provide routine performance improvement feedback to combatant commanders and surgeons on pre-hospital trauma care to include POI treatment, documentation, and appropriateness of evacuation categorization.
10. Explore all options to enable intranasal ketamine for pre-hospital analgesia in combat casualties.
11. Standardize the requirement for a critical care trained provider on critical care transfers, and ensure trained medical directors are available to approve ECCN specific protocols.
12. MEDEVAC Standard Operating Procedures (SOPs) vary between units. Consider publishing frago to align MEDEVAC procedures and protocols in CENTCOM, and recommend the same throughout FORSCOM.
13. Role III medical providers in theater provide medical documentation for 100% of trauma casualties. Role II and Role I medical providers should provide the same. Mandate medical documentation at all levels of medical care in theater. Consider publishing frago to align specific medical documentation and after action report requirements.
Joint Trauma System
1. Conduct routine DoD Trauma Registry analysis on pre-hospital (POI and TACEVAC) care documentation and TCCC interventions and provide feedback to JTTS and CENTCOM Commanders and Surgeons.
2. Request additional resources, or realign existing resources, to accommodate pre-hospital (POI and TACEVAC) performance improvement.
3. Using Eastridge et al categorization for KIA (instantaneous versus acute), reconfigure study of evacuation times to include acute KIAs in the analysis.
4. Consider partnership with US Army Aeromedical Research Lab (USAARL) on evacuation study protocols.
5. Plan for and conduct recurring internal and external reviews of pre-hospital trauma care in active combatant command areas of operations.
6. Plan for and conduct recurring in-theater pre-hospital trauma conferences.
Committee on Tactical Combat Casualty Care
1. Add CENTCOM Pre-Hospital Care Review as agenda item to next CoTCCC meeting.
2. Send a TCCC update package to theater when changes are made to TCCC Guidelines.
3. Ensure that CSTARs, NTTC, and ATTC are on the direct mail TCCC curriculum update list.
4. Consider adding current theater TACEVAC blood protocol to the TACEVAC chapter in the PHTLS Manual.
5. Add to TCCC instructional materials: A thorough security check and complete search must be done on all enemy and LN casualties before loading onto evacuation platforms.
6. Add to TCCC instructional materials: Evacuation platforms should be prepared to provide resupply bags to ground medics.
7. Add to TCCC instructional materials: Don’t tape the casualty’s head to the litter when a cervical spine injury is suspected without taping and securing the rest of the body.
8. Add to TCCC instructional materials: Some carry tourniquets in lower leg location. This is a suboptimal practice as the lower leg is often affected by IEDs.
9. Reinforce in TCCC instructional materials: Ground medics need to fill airway cuffs with saline prior to air evacuation, otherwise inflated cuffs will expand at altitude.
10. Discuss with DMMPO: UK IFAK has “roll-out” configuration and standardized storage compartments like that commonly seen with roll-out bags on evacuation platforms. This expedites finding and applying critical life-saving equipment, especially at night.
11. Consider simplification of TCCC pre-hospital pain management protocol to three treatment options: 1) Able to fight - Mobic and Tylenol, 2) Unable to fight and in no risk of shock – OTFC 800 mcg, 3) Unable to fight and in or at risk of shock – Ketamine 50 mg IM.
12. Conduct literature review of acetaminophen IV and/or IM and determine cost and benefit for pain management on the battlefield as compared to PO route as well as other analgesics.
13. Clarify in TCCC instructional materials that ketamine should not be given IV push.
14. Clarify in TCCC instructional materials that OTFC lozenges should not be chewed, but allowed to dissolve.
16. Consider adding ondansetron as an option for managing nausea and emesis on the battlefield.