Hot zone care: How to keep everybody safe - พ.ท.สุธี อินทรชาติ, พ.ต.ธนานันต์ อิศรางกูร ณ อยุธยา

1. Care in HOT ZONE
Major Thananan Isarangul Na Ayudhya
Emergency Physician,
ANANDAMAHIDOL Hospital

2. Scenario
• Your unit is in a 5-vehicle convoy moving
through a small Iraqi village when an IED
explodes under the 2nd vehicle
• Moderate sniper fire follows and the rest of
the convoy is busily engaged in suppressing it

3. Scenario
• You are a medic in the disabled vehicle which
is not on fire and Rt side up
• You are not injured and able to assist

4. Scenario
• The person next to you has bilateral mid-thigh
traumatic amputations
– Heavy arterial bleeding Lt stump
– Mild oozing from Rt stump
– Conscious and in moderate pain

5. What phase of care are you in?
• What is you immediate concern?
• Should you treat the casualty or return fire?
• Why?
• What is your next action?
• Should you put a tourniquet on the second
stump?
• Why?
• What are your next actions?

6. Objectives
• DESCRIBE the role of firepower supremacy in
the prevention of combat trauma
• DEMONSTRATE techniques that can be used
to quickly move casualties to cover while the
unit is engaged in a firefight
• EXPLAIN the rationale for early use of a
tourniquet to control life-threatening
extremity bleeding during Care Under Fire

8. Phases of Care in TCCC
• Care Under Fire
• Tactical Field Care
• Tactical
Evacuation Care

9. Care Under Fire
• Care rendered by the first responder or
combatant at the scene of the injury
• Still under effective hostile fire
• Available medical equipment is limited

10. Care Under Fire Guidelines
1. Return fire and take cover
2. Direct or expect casualty to remain engaged
as a combatant if appropriate
The best medicine on the battlefield
is Fire Superiority
If the firefight is ongoing - don’t try to
treat your casualty in the Kill Zone!

11. Care Under Fire Guidelines
3. Direct casualty to move to cover and apply
self-aid if able
4. Try to keep the
casualty from
sustaining additional
wounds

12. Casualty Movement Rescue Plan
If you must move a casualty under fire, consider
the following:
– Location of nearest cover
– How best to move to the cover
– The risk to the rescuers
– Weight of casualty and rescuer
– Distance to be covered
– Use suppression fire and smoke to best advantage!
– Recover casualty’s weapons if possible

13. 1) While under fire and without a weapon,
Gunnery Sgt. Ryan P. Shane runs to Sgt. Lonnie
Wells, to pull him to safety during USMC combat
operations in Fallujah

14. 2) Gunnery Sgt Shane attempts to pull a fatally
wounded Sgt Wells to cover

15. 3) Another Marine comes to help

16. 4) Gunnery Sgt. Shane (left) is hit by enemy fire

17. 5) Gunnery Sgt Shane, on ground at left, was hit by
insurgent sniper fire

18. Types of Carries for Care Under Fire
• One-person drag with/without line
• Two-person drag with/without line
• SEAL Team Three Carry
• Hawes Carry

19. One-Person Drag

20. Two-Person Drag

21. Two-Person Drag Using Lines

22. SEAL Team Three Carry (1)

23. SEAL Team Three Carry (2)

24. Hawes Carry

25. Care Under Fire Guidelines
5. Casualties should be extricated from burning
vehicles or buildings and moved to relative
safety
– Do what is necessary to stop the burning process

26. Care Under Fire Guidelines
6. Airway management is generally best
deferred until the Tactical Field Care phase

27. Care Under Fire Guidelines
7. Stop life-threatening external hemorrhage if
tactically feasible:
– Direct casualty to control hemorrhage by self-aid if
able
– Use a CoTCCC-recommended tourniquet for
hemorrhage that is anatomically amenable to
tourniquet application
– Apply the tourniquet proximal to the bleeding
site, over the uniform, tighten, and move the
casualty to cover

28. Care Under Fire Guidelines
Direct casualty to control hemorrhage by self-aid if able

29. Care Under Fire Guidelines
• Use a CoTCCC-recommended tourniquet for
hemorrhage that is anatomically amenable to
tourniquet application
1. Combat Application Tourniquet™ (C-A-TTM)
2. SOF® Tactical Tourniquet (SOF®TT)
3. Emergency and Military Tourniquet (EMT™)

30. Combat Application Tourniquet™ (C-A-TTM)

31. SOF® Tactical Tourniquet (SOF®TT)

32. Emergency and Military Tourniquet
(EMT™)

33. Semi-Automatic Tourniquet : SIAM-III

34. Care Under Fire Guidelines
• Apply the tourniquet proximal to the bleeding site,
over the uniform, tighten, and move the casualty to
cover

35. Tourniquet Application
• Non-life-threatening bleeding should be ignored
until the Tactical Field Care phase
• Apply the tourniquet without removing the uniform –
make sure it is clearly proximal to the bleeding site
• Tighten until bleeding is controlled

36. Tourniquet Application
• May need a second tourniquet applied just
above the first to control bleeding
• Don’t put a tourniquet directly over the knee
or elbow
• Don’t put a tourniquet directly over a holster
or a cargo pocket that contains bulky items

37. (Data based on the Wound Data Munitions Effectiveness Team (WDMET) during the Vietnam War between 1967 and 1969)
NEXT

39. Safety of Tourniquet Use
Kragh - Journal of Trauma 2008
• Combat Support Hospital in Baghdad
• 232 patients with tourniquets on 309 limbs
• CAT was best field tourniquet
• No amputations caused by tourniquet use
• Approximately 3% transient nerve palsies

40. Impact of Tourniquet Use
Kragh - Annals of Surgery 2009
• Ibn Sina Hospital, Baghdad, 2006
• Tourniquets are saving lives on the battlefield
• Better survival when tourniquets were applied
BEFORE casualties went into shock
• 31 lives saved in this study by applying
tourniquets prehospital rather than in the ED
• Estimated 1000-2000 lives saved in war to date by
tourniquets (data provided to Army Surgeon General)

41. Preventable Death on the
Battlefield: OEF and OIF
Eastridge 2012 Study:
• 4,596 U.S. deaths
• 87% pre-hospital deaths
• 24% of pre-hospital deaths
were potentially survivable
Holcomb, et al, 2005 – US SOF Preventable Deaths = 15%
Kelly, et al, 2008 – US Military Preventable Deaths = 24%
Eastridge, et al, 2011, 2012 – US Military Preventable Deaths = 27.6%
Unclassified 4

42. Hot zone TCCC PHTLS
Scene Care under fire
Return fire and take cover
Fire superiority
Scene size up
Universal precaution
Goal Mission >> Casualty Save patient
Harm Continue Controlled (mostly)
Resource Limit Level of EMS
Personnel Self aid
Buddy aid
Combat life saver
EMS team

43. Hot zone TCCC PHTLS
Sequence of care C – A – B A – B – C
Airway & C-spine Deferred Significant
Breathing &
Deferred Significant
Ventilation
Circulation Significant Also significant
Control of bleeding Tourniquet
Ignored
Pressure dressing
Tourniquet (lessly)
Cardiac Arrest No CPR Perform CPR
Moving Drag or carry Immobilized as need

44. Tactical Field Care
• Safe situation in battlefield,
not under the enemy fire
• Recheck bleeding control measure

45. Priority is A-B-C
No attempt to CPR

46. Life Threatening condition in Tactical
Field Care
• Airway Obstruction: tongue, saliva, blood
• Breathing: tension pneumothorax
• Circulation: exsanguinate and shock
• C-spine ?

47. CASEVAC
Combat Casualty Evacuation Care
• Care En Route
• Keep warm

48. Convoy IED Scenario

49. Convoy IED Scenario
First decision:
• Return fire or treat casualty?
– Treat immediate threat to life
– Why?
• Rest of convoy providing suppressive fire
• Treatment is effective and QUICK
• First action?
– Tourniquet on stump with arterial bleed

50. Convoy IED Scenario
Next action?
• Tourniquet on second stump?
– Not until Tactical Field Care Phase
– Not bleeding right now
Next actions?
• Drag casualty out of vehicle and move to best
cover
• Return fire if needed
• Communicate info to team leader

51. Summary of Key Points
• Return fire and take cover!
• Direct or expect casualty to remain engaged
• Direct casualty to move to cover
• Keep the casualty from additional wounds
• Get casualties out of burning vehicles or buildings
• Airway management : deferred
• Stop life-threatening external hemorrhage

52. Questions?

53. Airway – Will Cover in Tactical Field Care
No immediate management of the airway is
anticipated while in the Care Under Fire phase
– Don’t take time to establish an airway while
under fire
– Defer airway management until you have
moved casualty to cover
– Combat deaths from compromised airways
are relatively infrequent
– If casualty has no airway in the Care Under
Fire phase, chances for survival are minimal

54. 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

55. C-Spine Stabilization
Blunt trauma is different!
– Neck or spine injuries due to falls, fast-roping
injuries, or motor vehicle accidents may require
C-spine stabilization
– Apply only if the danger of hostile fire does not
constitute a greater threat