A New Decade

&
A New Approach
to
Rural Trauma Care
***
Military Trauma Care as the model

Norman McSwain MD
FACS, NREMT-P
Professor
Tulane School of Medicine
Trauma director
Charity Hospital
 Thanks
for including me
in the summit
 Interactive lecture
with yourself
How can I change
my state?

How can I change

Rural Trauma Care as a national system
 Do we need a change in
Rural Trauma Care
• Effect of War on prehospital care
• Effect from current conflicts
This Summit should set
– Iraq, Afghanistan and others
in motion
Rural
• CoTCCC Trauma Care
& TCCC
• Specific treatmentinto
techniques
• Military ->next
Ruraldecade
benefits
• Louisiana Rural Trauma Care system
 Connection
through

PreHospital Trauma Life support

&
Tactical Combat Casualty Care
6
 Understanding patient care
n
• Principle – medical standardce
for good patient carec i e that is necessary
S
• Preference – how the standard is achieved
– Conditions
– Circumstances

rt
– Knowledge, Skill , Ability, & Affect of the operator
– Resources available A
Goals of Prehospital care
• Improve survival
– Arrival on the scene
– Arrival at the hospital
– At worst “do no further harm”
• Reduce pain
– Stabilization
– Medication
• Reduce hemorrhage
– Stop on the scene
– Prevent additional hemorrhage
– Stabilize Fractures
– Deliver to correct hospital
 Principles
• Do no further harm
• Preserve and improve energy production
• Airway/Ventilation management
• Hemorrhage control
• Transport patient to correct hospital
• Do not transport dead patients
• Appropriate resuscitation
• Reduce pain
 Proof based patient care
Evidence based medicine
Prominence based patient care
Eminence based medicine
Perceptive based patient care

Understanding based medicine

 Understanding

If you cannot answer the question

“WHY”
then you do not understand.
Impact of Wars
on
EMS
 Changes of the Wars

• Napoleon Wars – Dominique-Jean Larrey

– Foundation elements of prehospital care
– Rapid response
– Trained attendants
– Close hospitals
• War of Northern Aggression (1861)
– Development of Ambulance services
 Changes of the Wars

• WWI
– Thomas Splint
– Ground evacuation
• WWII
– Training of corpsmen in early management of injured soldiers
– Plasma
• Korea
– Use of helicopter for rapid transportation
– Front line hospitals (MASH)
 Changes of the Wars
• Viet Nam – advanced scene care by corpsmen
– IV
– Airway
– Bypass CAS for MASH
– Large volumes of crystalloid resuscitation
• Iraq/Afgahnistan
– Advanced care en route to the next medical care
– Damage control Surgery
– Damage control Resuscitation
– Military Echelon of Casualty Management
– Tourniquets/hemostatic agents
– Interosseous vascular access

Larrey’s Principles
 EMS Changes in Current Conflicts
• CoTCCC
• TCCC
• Military Echelon Casualty Management (MECM)
• Medical Evacuation (CCAT)
• Hemorrhage control
– Tourniquets
– Hemostatic agents
• Resuscitation
• Surgical management
• Interosseous Access
• Field Assessment
• Field trauma management
Committee on

(CoTCCC)
 CoTCCC Members –
Recent and Present
• U.S. Surgeon General
• Chairman – ACS Committee on Trauma
• Trauma consultants for Army, Navy, and Air Force
Surgeons General
• 5 Trauma Directors for Level 1 Trauma Centers
• White House Medical Officer
• 2 Command Surgeons, U.S. Special Operations
Command (USSOCOM)
• Command Surgeon for the Army Rangers
• Senior Enlisted Medical Advisor, USSOCOM
• Senior Medic for the Army Rangers 18
 Changes to the TCCC Guidelines
Published Direct Input
Prehospital From
Trauma Combat Medical
Literature Personnel

CoTCCC

Service Medical Research

Lessons Learned Facilities
Centers
20
Unclassified
 Assistant Secretary of Defense
Health Affairs
Surgeons General

Defense Health Board

Trauma and Injury Subcommittee

Committee on
Tactical Combat Casualty Care
 TCCC Changes 2008/2009
• No hemostatics in Care Under Fire
• Updated tourniquet use plan
• Combat Gauze
• Mgt of Tension Pneumothorax
• Mgt of Sucking Chest Wound
• Mgt of Penetrating Eye Trauma
• TCCC Casualty Card
• Third phase of care: “Tactical
Evacuation Care”
22
Unclassified
 2 Special Operations Units
Experience with TCCC
• Kotwal – TCCC First Responders Conf 9/08
Practice
– 75th Ranger Regiment
– 482 casualties – 37 fatalities
• Pennardt – CoTCCC Practice
meeting 2/09
– Army Special Forces unit
– 201 casualties –Practice
12 fatalities
• Neither unit identified any preventable
deaths
• Both units train all combatants in TCCC
23
Tactical Combat Casualty Care

The Course
 PHTLS Seventh Edition
• Introduction – Frank Butler
• Care Under Fire – Shawn Johnson
• Tactical Field Care – Frank Butler
• CASEVAC – Jay Johannigman, Tom Rich
• Triage – Paul Cordts
• CASEVAC, MEDEVAC, and Aeromedical
Evacuation – Jay Johannigman, Tom Rich
• Injuries from Explosives – Howard Champion
• Medical Support of Urban Ops – Bob Mabry
• Ethical Considerations – Frank Anders
• Burns in TCCC – Booker King
• Theater Medical Care – Brian Eastridge
• Pre-Mission Medical Planning – Russ Kotwal, Harold 25
Montgomery
Revised TCCC Curriculum
Completed
• Powerpoint presentations (5)
• Skill sheets (9)
• Instructor guides (5)
• Training videos (16)
• Maintain on websites – public domain
– MHS
– PHTLS
• Update with each change in guidelines
26
 TCCC Training Options

• Use curriculum from PHTLS website

• Military-to-Military
• PHTLS – like structure
• Commercial TCCC Training Vendors
• Other options?

27
Requests for TCCC
Training
• Sweden
• Spain
• Portugal
• Argentina

28
 PHTLS support of TCCC
• Certification card
• TCCC Registry
• Instructor qualifications
• Test
• Curriculum used
• Skills sets trained
29
 Combat
Trauma Care
Civilian Trauma Care

31
 Is this
rural/wilderness
or
military
Principles vs Preferences

• Situation
• Conditions
• Skill, Knowledge, Ability, & Affect
• Resources
Military Field Triage
TCCC
 Stages of Medical Care
• Care Under Fire • Echelon I
• Tactical Field Care
• Tactical Evacuation
• Echelon II
• Field Hospital
– FST
• Echelon III
– CSH
• MedEvac • Echelon IV
• Definitive medical care
• Echelon V
Care under Fire
Questions?

36
 Care Under Fire
Guidelines
1. Return fire and take cover.

2. Direct or expect casualty to remain engaged as a

combatant if appropriate.

3. Direct casualty to move to cover and apply self-aid

if able.

4. Try to keep the casualty from sustaining

additional wounds.
37
 Care Under Fire
Guidelines
5. Airway management
Deferred Tactical Field Care phase
6. Stop life-threatening external
hemorrhage if tactically feasible:
– Direct casualty to control bleeding self-aid .
– tourniquet for hemorrhage control
– Tourniquet
– proximal to the bleeding site,
– over the uniform, tighten,
– move the casualty to cover.
38
 Care Under Fire

• Prosecuting the mission and caring for the

casualties may be in direct conflict.
• What’s best for the casualty may NOT be
what’s best for the mission.
• When there is conflict – which takes
precedence?
 Care Under Fire
• Suppression of hostile fire
minimize the risk of both
new casualties
additional injuries already injured
• The firepower
– essential to tactical fire superiority.
– medical personnel
– the casualties themselves may be
• The best medicine on the battlefield is Fire
Superiority.

40
 The Number One
Medical Priority

Early control of severe hemorrhage is

critical.
– Extremity hemorrhage is the most frequent
cause of preventable battlefield deaths.
– Over 2500 deaths
• Vietnam
• extremity wounds.
– Injury to a major vessel can quickly lead to
shock and death.
– Only life-threatening bleeding warrants
intervention during Care Under Fire. 41
 Vietnam

Over 2500 deaths

occurred in
Vietnam
secondary to
hemorrhage from
extremity wounds.
These casualties
had no other
injuries.
Vietnam. Medical Evacuation. Marines of Company E, 2nd Battalion, 9th Marines, while under heavy
firefight with NVAs within the DMZ on Operation Hickory III, are carrying one of their fellow Marines
to the H-34. 07/29/1967
 Tourniquets – Kragh et al
Annals of Surgery 2009

• Ibn Sina Hospital, Baghdad, 2006

• Tourniquets are saving lives on the battlefield
• 31 lives saved in this study by applying
tourniquets prehospital rather than in the ED
• Author estimates 2000 lives saved with tourniquets
in this conflict (Extrapolation provided to MRMC) 43

Unclassified
 C-Spine Stabilization

Penetrating head and neck injuries do not

require C-spine stabilization
– Gunshot wounds (GSW), shrapnel
– In penetrating trauma, the spinal cord
is either already compromised or is in
relatively less danger than would be
the case with blunt trauma.

44
Berator

45
45
 Tactical Field Care
Guidelines
2. Airway Management
b. Casualty with airway obstruction or impending airway
obstruction:
- Chin lift or jaw thrust maneuver
- Nasopharyngeal airway
- assume position that best protects the airway
- Place unconscious casualty in recovery position.
- If previous measures unsuccessful:
- Surgical cricothyroidotomy (with lidocaine
if conscious)

46
 IV Access – Key Point
• NOT ALL CASUALTIES NEED IVs!
– IV fluids not required for minor wounds
– IV fluids and supplies are limited – save them
for the casualties who really need them
– IVs take time
– Distract from other care required
– May disrupt tactical flow – waiting 10 minutes
to start an IV on a casualty who doesn’t need it
may endanger your unit unnecessarily

47
 Tactical Field Care
Guidelines
Shock management
6. Fluid Resuscitation
• Assess for hemorrhagic shock;
– altered mental status (in the absence of head injury)
– weak or absent peripheral pulses
• best field indicators of shock.
Not in shock:
- No IV fluids necessary
- PO fluids permissible if conscious and can
swallow
48
 Tactical Field Care
Guidelines
Shock management
6. Fluid Resuscitation
b. If in shock:
- Hextend, 500ml IV bolus
- Repeat once after 30 minutes if still
in shock.
- No more than 1000ml of Hextend

49
 Hypotensive Resuscitation
Goals of Fluid Resuscitation Therapy
• Improved state of consciousness (if no TBI)
• Palpable radial pulse
– Corresponds roughly to systolic blood
pressure of 80 mm Hg
• Avoid over-resuscitation of shock from torso
wounds.
• Too much fluid volume may make internal
hemorrhage worse by “Popping the Clot.”
50
 Pulse Oximetry Monitoring
• Pulse oximetry –
– heart rate
– percent of oxygenated blood (“O2 sat”)
• Sea Level
– 98% or higher
• 12,000 feet
• 86% = normal

51
Resuscitation
 Resuscitation
• Damage Control Surgery (DCS)
– Control of hemorrhage
– Shunt vascular injury
– Staple bowel injuries
– Stabilize fractures
– Vac Pac Dressing
Does NOT have to
• Follow up surgery be done in same hospital
– 24-48 hours
– Definitive vascular care
– Repair bowel injuries
– Assure hemostasis
Damage Control Resuscitation
• Replace what is lost
• Whole blood
– PRBC
– Plasma
– Platelets
– Cryoprecipitate

• Ratio
– 1 PRBC : 1 plasma : ?
– 1 platelets : 1 Cryoprecipitate
– No crystalloid
Damage Control Resuscitation

Military – Holcomb, Rhee and others

Civilian – Duchesne & others
 Damage Control Resuscitation
Prehospital Rural Care
Restricted Fluid Resuscitation (Mattox)
Indicators - Pulse character & mentation
(Holcomb)
Short transports - Minimal Crystalloid
Future
Long transports - colloid plus hypotensive care
Resuscitation
Replace what is lost
WITH
what is lost
 Resuscitation
• Blood is lost – replace blood
• Crystalloid is lost – replace crystalloid
• Presser agents are lost – replace pressor agents
What happened to blood?
Military uses it why can’t we?
 Next best option
- Reconstitute blood -

• Packed Red Blood Cells

• Plasma
– Frozen
– Liquid
• Platelets
• Cryoprecipitate

Where is this available?

 Uncontrolled hemorrhage
Hypotensive, hypovolemic
Raising blood pressure Pressure Gradient
blood loss blood pressure
*********************************
Add more fluids Hematocrit
Oxygen delivery Anaerobic metabolism
Energy (ATP) Production

Fatal
Cycle
 Fluid
administration
without
easy vessels
William Blaisdale, MD Alex Haller, MD
Scudder Orator 1982 Scudder Orator 1994
Sternal Screw for IV fluids Intraosseous IV fluids in
pediatric patients

Walter Estell Lee, MD

Scudder Orator 1941
Intraosseous fluids done by
Tocatins in Philadelphia.
The needles were 15 gauge
and initially made by
George Piling Company in
Philadelphia
 Intraosseous Fluid Administration
• Tibia Cook BIG
• Sternum
• Humerus
Success rates
95% FAST - 1
90 seconds

EZ - IO
Intraosseous Fluid Administration
Hemorrhage
Control
 Hemorrhage control
• Compression bandages
• Tourniquets
• Hemostatic agents
– Cutaneous/local
– Systemic
• Factor XIV

Where is factor XIV available?

 Tourniquets
Do they belong in civilian
EMS ?

YES!
 Tourniquets
• Why were we wrong?
– Don’t confuse me with no data, my mind is
made up?
– The data does not support their use
– Data? What data?
– Well if you put them on, that determines the
level of the amputation. They distal extremity
will die.
– If they are too tight, the artery will be damaged.
– If they are too tight, the nerve will be damaged.
 Hemorrhage control

• Iraq – most common cause of preventable death

– 10% of deaths distal to axilla or groin
• Compressible
– Tourniquet-able
– Non-tourniquet-able
• Non-compressible Champion & Holcomb
SOMA 2005
 Factor XIV
• Suture
• Ligature
• Hemostat

Can be applied in the OR

Therefore the importance to deliver the patient
to the Hospital with a trauma team that
can and will immediately place the patient in an OR
Open the abdomen/chest
and
FIX THE HEMORRHAGE
 Tourniquet

• Triangle bandage & windless

• Commercial devices
• Blood pressure cuff
• Used in military since 1674

Swartz , Surg ‘58

 Albert Sidney Johnston
General, Confederate Army
• Gun shot would to thigh
• Blood ran down into boot
• Directed medic to another
solder
• Exsanguinated
• Tourniquet would have
saved his life
• Reportedly in his pocket.
 Tourniquets
Clinical experience

• Kandahar AFB - 4 months (2006)

• 134 patients treated
• 6 patients – 8 tourniquets
• Lives saved = 4 patients – 5 tourniquets
• Misuse = 1 venous tight only => Bleeding
• Prolonged use = 1 (4 hours) no complications
Tien et al
JACS ‘08
 Tourniquets
Clinical application

• Combat operations => delay in transport

• 16 hours = no complications
• Patient life saved

Kragh et al
J Ortho Trauma ‘07
 Tourniquets
Clinical Experience
• UK Joint Trauma Registry
• 66 months
• 1375 patients
• Tourniquets = 70 (5%) patients
• Tourniquets used = 107
• 2 or > = 24%
• 87% survival Brodie et al
JR Army Med corps ‘07
 Tourniquets
Clinical Experience
• Vietnam KIA exsanguination = 9%
• OTF 31st Combat Support Hospital
• 12 months = 3444 patients
• Major vascular, traumatic amputation, tourniquet
• 165 patients
• Prehospital tourniquet = 67 (TK)
• Severe extremity injury no tourniquet = 98 (No TK)
• Bleeding control = TK=83% vs No TK-60%
• Secondary amputation = TK=6% vs No TK =9%
• Potentially preventable deaths = 57%

Beekley et al
J Trauma ‘08
 Tourniquets
Clinical Experience
• Israeli Defense Forces
• 550 patients
• 91 prehospital tourniquets (16%)
• Injury to application 15 minutes
• Ischemia time = 83 minutes
• 78% effective
Lakstein et al
J Trauma ‘03
Special Operation Forces Tactical
Tourniquet
SOFT-T
Combat Applied Tactical
Tourniquet
CATT
Application of CATT
Emergency Medical Tourniquet
EMT
 Tourniquets

Cravat/Windlass 85
 Tourniquets in WWII
Wolff AMEDD J April 1945

“We believe that the strap-and-buckle

tourniquet in common use is
ineffective in most instances under
field conditions…it rarely controls
bleeding no matter how tightly
applied.”

86
Hemostatic Agents
• QuikClot
• Hemcon
• Wound Stat
• Combat Gauze
Mechanism of action
• Absorb water
– QuikClot
– Combat Gauze
• Increase clotting
– Hemcon
 Hemostatic Agents
• Complications
• Vascular damage
– WoundStat
• Local hypothermia
– QuikClot
• Difficulty in placement
– All powder/granular agents
Courtesy Dr. Bijan Kheirabadi 90
 Combat Gauze
• 3 inch x 4 yard roll of gauze
• Impregnated with kaolin
• Material that causes blood to clot

Kaolin is a white clay used for many purposes,

among which is the medication Kaopectate.
Also eaten by the ‘clay eaters’ of Georgia
and other rural areas
To improve digestion
 Factor XIV

Delivery of the patient to the correct

hospital is the
MOST IMPORTANT
step EMS can take
 Field Hemorrhage Control
Non-combat patient care
Direct hand pressure

Pressure Bandage Yes

Hospital
Nocontinues
Hemorrhage

Torso Extremity
Hemostatic Agent Tourniquet

Hospital
 Tactical Field Care Guidelines

2. Airway Management
a. Unconscious casualty without airway obstruction:
- Chin lift or jaw thrust maneuver
- Nasopharyngeal airway
- Place casualty in recovery position

94
Open chest
wound
 Open chest wound
• Re-establish ventilation
• Air movement out airway not chest wall
– Close open hole
• Relive compartment syndrome
– Needle into pleural cavity
– Needle not stop in chest wall
– 8 cm
– 14 gauge
 Open Pneumothorax Mgt

Frank, I finally got to test the open pneumothorax treatment

algorithm. We had a SWAT call-up, our second of the day, with a guy
threatening to kill himself with two hostages. He finally shot himself at
point blank range in the left chest with a .357 magnum hollow point. I
was only about  30 feet away and got to him immediately and sure
enough he had a hole as big as a golf ball in his left chest. He had an
open pneumo so I put my hand over it and it stopped blowing. I asked
the medic for some vaseline gauze and he handed me, yes, an
Asherman chest seal. Of course it did not stick, but we used it until we
got him intubated and then I put on a EKG pad which worked great.
He is now in the OR getting whatever fixed. We had another GSW at
the same time through the back with no exit who DOW. Now I have to
try to get all the blood out of my uniform. See you in a few days,
Semper Fi, Mel
 Pain Control
Pain Control When Able to fight:
• Mobic and Tylenol are the medications of
choice
• Both should be packaged in a COMBAT PILL
PACK and taken by the casualty as soon as
feasible after wounding.

98
 Pain Control – Fentanyl
Lozenge

Pain Control - Unable to Fight

• If casualty does not otherwise
require IV/IO access
– Oral transmucosal fentanyl citrate, 800 µg
(between cheek and gum)
– VERY FAST-ACTING; WORKS ALMOST
AS FAST AS IV MORPHINE
– VERY POTENT PAIN RELIEF
99
Trauma Center

Is this a gadget too?

 Hemorrhage control timelines
68 minutes

Access
Trauma
12 10 30 0
10 012 5
Scene
Center
transport
ED
Surgeon
Community 12 10 12 10 25 25 15 10 20 OR staff
Hospital
Ready OR
to OR
0 50 100 150 Hemorrhage control
Minutes
 Indications to bypass
Severe trauma
• Physiologic reasons
– Shock
– Airway & ventilation
– Major Hemorrhage
• Anatomic
– Penetration - head, neck, torso, proximal limbs
– Crush torso
– Major fractures
• Mechanism of injury
– Major vehicle damage
– Fall from height
Failure to fly syndrome
 Contra-indications to bypass4
Time
• Technical difficulties
– Inability to maintain airway
• BVM is not working
• Separation of esophagus & trachea required
– Intubation in the field unsuccessful or not trained
• Surgical airway necessary
– Uncontrollable hemorrhage
• External
• Internal
• Critical conditions
– Cardiac Arrest
– Ventilation compromise
• Tension pneumothorax
• Major fail chest
• Medical Control decision
– Shock
– Transportation time > 50 minutes
 Contra-indications to bypass2

Mechanism of injury
• How important is it ?
• > 75 % go home within 6 hours
• 1 year
– 641 patients in AR
– 2 deaths
– 59 operations
– 120 admissions
 Plan for
Louisiana Trauma Care
System
 Stages of Medical Care
• Care Under Fire • Echelon I
• Tactical Field Care
• Tactical Evacuation
• Echelon II
• Field Hospital
– FST
• Echelon III
– CSH
• MedEvac • Echelon IV
• Definitive medical care
• Echelon V
Louisiana Echelon for Trauma Care
• Echelon I
– EMS system
– ALS care
– State wide communication
• Echelon II
– Critical Access Hospitals
– <25 beds
– ED Provider in-house
– Physician available
• Echelon III
– Rural Hospitals 25-60 beds
– ED physician staffed
– Surgeon available
– Orthopedics available
– OR staffed
– Blood bank
 Louisiana Echelon for Trauma Care
• Echelon III
– Level III trauma center
– Neurosurgeon available
– OR rapid access 24 hours
– 24 hour blood bank
– CT, MRI
– Interventional Radiology
• Echelon IV
– Level II/I Trauma Center
– In house OR
– 24 hour everything – 15 minutes
– ED physicians & Surgeons dedicated to patient care
 SE Louisiana Trauma system
Field to Trauma Center
• Physiologic reasons
– Shock
– Airway & ventilation
– Major Hemorrhage
• Anatomic
– Penetration - head, neck,
torso, proximal limbs
– Crush torso
– Major fractures
• < 50 minutes
 Rural Trauma Organization
System
Patient care movement
• EMS triage
– Hospital best able to care for patient
• Minor - closest hospital
• Major
– level III
– DCS
– DCR
• Serious – Trauma Center
– ACS anatomical
– ACS physiological
 Rural Trauma Organization System
• Trauma patient care
• Critical Access
– No serious patients via EMS
– Treat and release
– Understand trauma if walk-in
• Rural
– DCR
– DCS
– Rapid assessment & move
• Trauma Center (III, II, I)
• Totally prepared
Rural Trauma Organization System
• Trauma Educational System
– Critical Access
• RTTCS
• ATLS ?
– Rural
• ATLS
• DCR/DCS
– Level III
• ATOM
• DCS/DCR
– Level II, I
• Teaches above
Rural Trauma Organization System
• Trauma Transportation System
• EMS triage
• ACS Anatomic & Physiologic
– Trauma center (within 50 minutes)
– Rural hospital
• DCS/DCR
• Immediate transfer to Trauma Center
 EMS triage Hospital Triage

Tulane Center for Trauma

Life Support Education

Regional Regional
Medical
Medical
Center
Center

Acute Acute Acute Acute Acute Acute

Access Access Access Access Access
Access
Hospital Hospital Hospital Regional Hospital Hospital
Hospital
Medical
Center

Acute Acute Acute

Access Access Access
Hospital Hospital Hospital
 Trauma Education System
ATLS/PHTLS
Trauma Center

Level III Level III Level III

Rural Rural
Rural Rural
Critical Access Critical Access
Critical Access Critical Access

Rural Rural
Critical Access Critical Access
 Trauma Education System
ATOM
Trauma Center

Level III Level III Level III

Rural Rural
Rural Rural
Critical Access Critical Access
Critical Access Critical Access

Rural Rural
Critical Access Critical Access
 Trauma Education System
RTTDC
Trauma Center

Level III Level III Level III

Rural Rural
Rural Rural
Critical Access Critical Access
Critical Access Critical Access

Rural Rural
Critical Access Critical Access
 Summary
• Re-assess rural trauma patients needs
• Re-assess rural trauma care
– EMS
– Critical Access hospitals
– Rural Hospitals
– Trauma Center

• Re-assess Rural Trauma Training

– EMS
– Critical Access hospitals
– Rural Hospital
– Trauma Center

• Re-assess rural trauma transport

• Develop Rural Trauma Patient Care System
 PHTLS 6th edition
7th edition 2010/11
Tactical Edition Tactical Combat
Casualty Care
• Basic principles of patient care
committee
– non combat situation
• Tactical principles of patient care
– Situation Assessment & management
• Combat situation
– Scene
– Safety,
– Combat contingencies vs non-tactical contingencies
– Patient assessment & management
• Unique Primary assessment & care requirements
• Unique Secondary assessment & care requirements
 A New Decade
&
A New Approach
to
Rural Trauma Care

Change your mind set

Develop a plan
 Disarm Individuals with Altered
Mental Statues
• Armed combatants with an altered state of
consciousness may use their weapons
inappropriately.
• Secure long gun, pistols, knives, grenades,
explosives.
• Common causes of altered mental status are
Traumatic Brain Injury (TBI), shock, and
pain medications.
• “Let me hold your weapon for you while the
doc checks you out”

121
 Transportation of dead patients is bad

• ~ 40% increased crash when EMS is traveling

lights & siren
• Patients who are dead need to be pronounced via
radio
• ACS & NAEMSP have a combined policy
statement JACS March 2003
• Stop it !!!
Committee on

CoTCCC
 Open Pneumothorax Mgt

Frank
What Mel isn't telling you is that he saved this
guys life. I happened
to be in the bay when they got here. The patient is
recovering following
a Left upper lobectomy and chest wall
reconstruction
Would echo Mel's comments
EKG/Defib pad yes
Asherman no
j