PRE-DEPLOYMENT Medic Training

Medic! Medic!" the wounded soldier calls. Chaos, darkness and smoke add confusion to the battlefield scene. There is only one medically trained individual present to render emergency care: the soldier-medic. How do you prepare a 20-year-old combat medic for the intensity and chaos of war? The U.S. Army has a soldier-medic training program that works to do just that, with the ultimate goal of saving the lives of American soldiers in combat.

     Since many medics in the National Guard and Army Reserve don't work as medics in their civilian jobs, the Army developed a program to provide necessary medical training prior to these medics' deployment for duty in Iraq and Afghanistan. This course was designed to provide intensive medic training, refresh and update skills, and reorient the focus of soldier-medics from civilian prehospital care to lifesaving battlefield skills. This was a large undertaking. The Army and Army Medical Department Center and School developed a plan to mobilize Army Reserve nurses, medics and other medical personnel with teaching experience to take on the task of providing pre-deployment medic training.

     The Pre-Deployment Training (PDT) course is a concentrated 21-day program that begins with a 12-day EMT-Basic course and refresher. Army medics have previously completed medic training, and many hold certifications as NREMT-Bs. The Army now requires all medics to transition to a minimum of NREMT-Basic status. The PDT course provides an opportunity for the noncertified medic to sit for the National Registry exam and meet this transition requirement. This certification not only provides a basic knowledge of emergency medical care, but also leaves the soldier-medic with a marketable civilian skill once he or she leaves the Army.

     The next five days of the PDT course are dedicated to Combat Medic Advanced Skills Training (C-MAST). It is during this course that the soldier-medics alter their focus from civilian prehospital emergency medical training to combat medical skills that save lives on the battlefield. The final three days of the course consist of "lanes" training under simulated battlefield conditions that allow the medics to utilize skills learned in the classroom. This training combines all the assessment and treatment skills learned during the previous 18 days and requires the medic to make instant decisions regarding triage and treatment under increasingly difficult conditions.

A WORLD of DIFFERENCES
     Emergency medical care on the battlefield differs from civilian care in several distinct ways. Three differences are resources, time and environment. On the battlefield, the only supplies available to medics and soldiers are those that can be carried on their backs. This often means the medic not only has to triage his patients, but must also triage his supplies to do the most good for the most people. The time involved in receiving or transferring the injured to additional medical care is variable, and medical evacuation assets must often be summoned. When there are multiple casualties during combat, the medic must triage and treat the injured soldiers immediately and correctly with only the assistance of other soldiers who have been taught basic first aid concepts like "self aid" or "buddy aid" or soldiers who have "combat lifesaver" training. Lastly, the medic and injured soldiers may be involved in ongoing fighting, which makes provision of medical care challenging as well.

     In contrast, civilian medical emergencies have the benefit of fully stocked ambulances and life flights that are typically on their way to scenes in a matter of minutes, and then systematically transfer the injured to definitive care. Civilian medicine also has the advantage of quickly increasing resources when there are multiple casualties, such as summoning more ambulances to a scene. And most notably, when civilian EMTs face a medical emergency, they do not approach the injured until the scene is safe. The combat medic is taught that he is a soldier first and a medic second. This reinforces that his firepower may be the best treatment for the injured soldier.

     In Vietnam, 2,500 soldiers died on the battlefield because they bled to death from extremity wounds. Their lives could have been saved had the bleeding been stopped immediately. Another 6% of soldier deaths were from airway problems and tension pneumothoraxes. This translates to around 4,000 lives that could have been saved if prompt medical treatment had been rendered.

     The tenets of C-MAST teach the medic to return fire if necessary, apply a tourniquet if the casualty is bleeding from an extremity, and remove the casualty from danger as soon as possible. No other treatment should be initiated while the medic and his patient are under fire. Once the soldier is out of immediate danger, airway, breathing and circulation can be addressed, and a complete rapid trauma assessment is performed. If the casualty has sustained a neck, open chest or upper abdominal wound, an occlusive dressing should be applied. If there are indications of tension pneumothorax, such as deteriorating respiratory status, needle chest decompression is performed without delay. If there is a severe extremity bleed, with or without partial or complete amputation, a tourniquet is applied, if not already done. As in civilian emergency medicine, life threats are treated first, followed by secondary injuries. Outside of differences in tourniquet use, fractures are splinted, wounds are dressed and the casualty is prepared for transport as in civilian practice. In addition, the soldier-medic has dressings and other supplies such as QuikClot and chitosan dressings that are geared to facilitate treatment in a tactical setting.

     Another change has been the concept of fluid resuscitation for soldiers on the battlefield. The standard treatment in civilian emergency medicine is to initiate two large-bore IVs and rapidly infuse either normal saline or lactated Ringer's solution to any patient suffering hemorrhage or hemorrhagic shock. This is not the standard for the Army medic treating battlefield injuries. Army guidelines for fluid resuscitation are as follows:

• Start a saline lock for IV access;
• In the absence of a brain injury, if there is no palpable radial pulse or change in mentation, initiate fluid resuscitation with hetastarch (500 cc).
• If there is no improvement in mentation or return of palpable radial pulse within 30 minutes, a second 500cc bag of hetastarch is initiated.
• Fluid will only be infused until a radial pulse returns. Research indicates that too much fluid resuscitation increases the casualty's blood pressure and loosens newly formed clots, possibly causing subsequent hemorrhage.

Training The Trainers
     Prior to training the soldier-medics, PDT instructors had to themselves be trained in the principles of battlefield medicine. The instructors were put through a rigorous 80-hour course at the Department of Combat Medic Training (DCMT) at Fort Sam Houston, TX, by Col. Patricia Hastings and her experienced staff of physician assistants, nurses and combat medics. The PDT instructors completed CPR instructor classes and C-MAST training, including practicing needle chest decompression and surgical cricothyrotomy on the SimMan patient-simulation manikin. The instructors were taught moulage techniques in order to create simulated injuries and received a review of core EMT-B knowledge and skills. They were given the opportunity to practice and hone their classroom teaching skills and develop training schedules that would be used during the combat medic PDT.

     Instructors were divided into mobile training teams (MTTs) and sent to various mobilization sites such as Fort Indiantown Gap, PA; Fort Stewart, GA; Camp Atterbury, IN; and Fort McCoy, WI, to conduct classes. Most of the training equipment and classroom and medical supplies were taken by truck to the training site or provided by the post. Necessary equipment is too extensive to list in full, but included human simulators (SimMans) for needle chest decompression and surgical cricothyrotomy, CPR instructional items, airways, oxygen equipment, bandages, splints, tourniquets, occlusive dressings, IV supplies, aid bags, long boards, cervical collars, evacuation litters, simulated weapons and evacuation vehicles. Patient assessments, splinting and bandaging could be practiced on manikins or fellow soldiers. During lanes training, students were moulaged to simulate battle injuries and acted the parts of the wounded.

     These exercises were conducted in various locations, inside buildings and in remote areas, in order for the medics to utilize previously learned skills such as clearing buildings and locating casualties who may be hidden from view or trapped under vehicles. During this training, students wore battle gear to add to the realism of treating casualties in a combat environment.

Conclusion
Although pre-deployment training is physically and mentally challenging, statistics show the wounded soldier has a better chance of returning home alive because of the skills the soldier-medics learned during this course. During World War II, 30% of injured soldiers died from their wounds. During the Vietnam conflict, 24% did. In Operation Iraqi Freedom, only 10% of injured soldiers have died of their wounds.

As the PDT progressed, we received positive feedback from medics who had completed the training before facing combat in Iraq or Afghanistan. Many soldier-medics reported that they were able to save lives because of the intensive, high-quality instruction they received during their pre-deployment training.

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense or U.S. government.

For more, see sidebars below:

Guard Changes Could Better Serve Disaster Responses
State and local first responders will always be the backbone of response to disasters. But the Army could give them better support by changing the way it responds to major domestic events, RAND Corp. researchers suggested in a study released in June.

In Hurricane Katrina: Lessons for Army Planning and Operations, authors led by political scientist Lynn Davis, PhD, produced a series of recommendations to facilitate faster, better-tailored responses to incidents within the U.S., whether natural disaster or terrorist attack.

Primary among the group's suggestions is to make homeland security an official federal mission of the National Guard and specially train units for it. The training would be integrated into the Army's ARFORGEN (Army Force Generation) unit-readiness process, which is a series of preparedness levels Army, Army Reserve and National Guard units cycle through.

Under ARFORGEN, units begin in Reset/Train mode, then move up to the Ready pool, where they receive a specific mission. They prepare for that, then progress to the Available pool, from which they're deployed.

"We believe this process lends itself to preparing for domestic emergencies," says Davis, a senior fellow at RAND who served as Under Secretary of State for Arms Control and International Security Affairs during the Clinton administration. "When they come through this process, units could prepare not only for potential overseas missions, but train to be able to respond quickly here at home. And as the overall number of units deployed overseas comes down in the future, some of them could be given the mission of preparing and standing ready for domestic emergencies."

Authors also urge the creation of 10 standing Guard task forces, corresponding with FEMA's current regional structure, that would work to prepare for and respond quickly to major events. These would have around 900 members and be able to respond across state lines within 18 hours.

This idea originated in a previous RAND publication, Army Forces for Homeland Security. The authors believe it was validated by Katrina, after which even the fastest Guard deployments from outside Louisiana and Mississippi took 24 hours.

Operating regionally, a task force could even have been positioned prior to the storm's landfall and able to begin rescue operations immediately once it passed. It would also have been in place to help direct and coordinate further resources arriving after the storm.

"The case study of a major domestic emergency gave us a basis to test the idea," Davis says. "What we discovered was that had the task forces been in place prior to Katrina, they could have made a difference."

That ties into another recommendation of the paper: that governors take steps to enable faster deployment of their Guard units, both within their states and without.

To expedite such responses, the authors suggest a range of steps that include prearranging commercial or military air transport, designating fill-ins for units serving overseas, and being more willing to activate their units, rather than waiting for volunteers. They must also be aware of, and willing to call on, other states' specialized resources under agreements like EMAC.

A final recommendation concerned problems with reconciling command and control between National Guard and active military units following Katrina. In response, authors propose a set of four alternative command-and-control structures from which leaders can choose when an incident occurs.

For more, see www.rand.org.

-John Erich, Associate Editor

The Combat Benefits of Hetastarch
     Multiple studies using uncontrolled hemorrhage shock models have found that aggressive fluid resuscitation before surgical repair of a vascular injury is associated with either no improvement in survival or increased mortality when compared to no resuscitation or hypotensive resuscitation. This lack of benefit is presumably due to interference with vasoconstriction as the body attempts to adjust to the loss of blood, and interference with hemostasis at the bleeding site. Some studies have noted that fluid resuscitation proved to be of benefit only after previously uncontrolled hemorrhage was stopped.

     Hespan (6% hetastarch) was recommended in 1996 as a better alternative for fluid resuscitation during tactical field care than lactated Ringer's (LR) solution. LR is a crystalloid, which means that the primary osmotically active particle is sodium. LR moves rapidly from the intravascular space to the extravascular space. This shift has significant implication for fluid resuscitation. For example, if a trauma patient is infused with 1,000 cc of LR, only 200 cc of that volume will remain in the intravascular space one hour later. This presents a problem in the military setting because several hours may elapse before a casualty arrives at a higher level of care.

     In contrast, the large hetastarch molecule is retained in the intravascular space, and there is no loss of fluid into the interstitium. Hetastarch osmotically promotes fluid influx into the vascular space from the interstitium such that an infusion of 500 cc of hetastarch results in an intravascular volume expansion of almost 800 cc, and this effect is sustained for eight hours or longer.

     A 1993 Texas study found that aggressive prehospital fluid resuscitation of hemorrhagic shock resulting from penetrating trauma to the chest or abdomen produced a greater mortality than TKO fluids only. As a result of this study, the Army's TC-3 course (the precursor to C-MAST) guidelines were to withhold aggressive fluid resuscitation from individuals with penetrating torso trauma. However, the course guidelines make it clear that a casualty with uncontrolled hemorrhage and mental status changes or who becomes unconscious (which correlates to a systolic blood pressure of 50 or less) should be given enough fluid to resuscitate him/her to the point where mentation improves (which correlates to a systolic of 70 or above). The medic's goal is not to achieve "normal" blood pressure in the field setting, but to get the patient to the surgeon with a sustainable blood pressure.

Battlefield TBI Fluid Resuscitation Guidelines
     Fluid resuscitation guidelines for the battlefield casualty with traumatic brain injury are as follows:

• There is a need to ensure adequate central perfusion pressure.
• The casualty should receive IV or IO fluids until he/she has a palpable radial pulse which correlates to a systolic blood pressure of 80 mm Hg.

Fresh, Frozen Plasma and a Big Bag of Blood
     Blood products carried on the ambulance, delivered in the field by prehospital personnel? That's a logical implication of recent directions in trauma research.

     Military data drawn from Iraq suggests great success for the Army's current massive-transfusion protocol. And early data from a major civilian test of the approach is seemingly echoing that benefit. What it all could mean for EMS in coming years could be intriguing.

     The protocol, implemented by the Army and Air Force a few years back, essentially calls for giving less crystalloid and faster blood and plasma to badly bleeding patients. This has now been done extensively in Iraq, and the improvements have been notable.

     "We've seen, in some cases, a 50% to even 100% improvement in mortality-it's huge," says Col. John Holcomb, MD, commander of the U.S. Army Institute of Surgical Research at Fort Sam Houston, TX.

     The concepts have arisen in civilian trauma literature in the past several years, and the current conflict has given military physicians ample opportunity to test them. They've cut the crystalloid, and now give red cells and plasma, typically in a 1:1 ratio, to those meeting certain physiologic criteria. Civilian docs are pursuing the strategy too, including those at 25 major trauma centers involved in testing the protocol in nonmilitary populations.

     There again, early results have been striking: mortality rates roughly halved. "It's almost too good to be true," says Holcomb. "These are all retrospective data, but there's a very strong signal."

     These results should be published in coming months; meanwhile, the question for us is, how much faster should that blood and plasma be? Like, prehospital?

     Potentially so. Once the criteria are refined, it could mean carrying blood products, including fresh, frozen plasma, on the rig and giving them to patients in the field.

     After all, in severe trauma, time is what counts.

     "Does this translate into prehospital care? I think it does," says Holcomb. "What we need to do is sort out whom to give plasma and red cells to, and in that group of patients, give it to them early, rather than diluting them out with crystalloid and making their coagulopathy worse. That's the big research question right now."

     -John Erich, Associate Editor

Sources
Combat Medic Advanced Skills Training Student Manual. Department of Combat Medic Training, U.S. Army Medical Department Center and School, Fort Sam Houston, TX.
National Institute for Clinical Excellence. Pre-hospital Initiation of Fluid Replacement Therapy in Trauma, Jan. 2004.
Tactical Combat Casualty Care. Department of Combat Medic Training, U.S. Army Medical Department Center and School, Fort Sam Houston, TX.
Tactical Combat Casualty Care Handbook: Tactics, Techniques, and Procedures. Center for Army Lessons Learned, Ft. Leavenworth, KS.

LTC Marilyn E. Yergler, MSN, RN, CCRN, NREMT, is the Officer in Charge of Task Force Med Trainers, which trains all National Guard and Army Reserve medics prior to deployment to Iraq or Afghanistan.

Maj. Mary Byrnes is currently an Army Reserve nurse mobilized for over two years with the Task Force Med Trainers based at Ft. Sam Houston, TX. She is an RN, MSN, clinical specialist in adult health nursing and also a certified EMT-B.

Maj. Dannie L. Maddox, RN, MSN, served 29 years in the Army, including a tour in Vietnam. He was activated in 2005 to train medics being deployed to Iraq and Afghanistan. He is a nurse practitioner in the Central Arkansas Veterans Healthcare System's Substance Abuse Section.

Maj. Kathleen Maddox, RN, BSN, joined the U.S. Army Reserve in 1992. She was activated in 2005 and spent the next year training medics prior to deployment overseas. She is a nursing educator at Little Rock Veterans Hospital in Arkansas.

Lt. Col. Karen S. Wilson, MSN, RN, was mobilized by the Army from December 2004 to December 2005 to train combat medics. She is the EMS Program Coordinator for Trinity College of Nursing & Health Sciences in Rock Island, IL.

Maj. Jean Terrell, BSN, RNP, has been in the Army Reserve for 20 years. She is a nurse practitioner in Arkansas and currently works as a school health nurse. She was mobilized for one year for Operation Enduring Freedom as a trainer for the PDT course.

Maj. Billy W. Wooten, RN, taught medics prior to deployment from December 2004 to December 2006.