Saturday, September 13, 2014

Sunday, August 17, 2014

Tuesday, June 10, 2014

COMBAT EMERGENCY MEDICAL SERVICES…ARE YOU CURIOUS…???!!!

Hi Guys…...............................!!!!!!!!!!!!!!!!!!!


Just in case you are wondering how Emergency Medical Service works in the war zones, here is my personal review…..so enjoy it.

War emergency medicine means just a simple foundation concept:
10-1-2;

10: Immediate life saving procedures must be applied within 10 minutes of wounding.

1: advanced stabilization manouvres must commenced within 1 hour of wounding (Enhanced field care).

2: if necessary Emergency war surgery must be performed within 1 hour but not later 2 hours of wounding.



How these numbers are fulfilled??!!

As in every military sector even war medicine requires a meticulous tactical planning, defining means and professional figures to be employed in specific theatres of operation.

This is how it works in Afghanistan:



Everything starts in the HOT ZONE (zone of fightings) where usually the wounding happens;
What can be done?!

Very few things!!! 



This is what we call “Care under fire”:

1) Respond to fire and search for fire cover; reach for the wounded only when possible… Heroism could be  rewarded just with two wounded instead of one!!!!  

2)Stop bleedings with combat tourniquet or compressive dressings, mantained by self aid if able.

3)Airway management is generally best deferred until Enhanced field care (EFC) phase.

4)Bring the wounded ASAP in the WARM ZONE for Enhanced field care(EFC).



Who perform these manouvres??!!

Bleeding control can be performed by the wounded himself; if uncounscious could be performed by a buddy ("Buddy to Buddy Aid") or the combat medic (a soldier trained in Immediate life support techniques, if present); usually there is one in every company.



In the WARM ZONE or semipermissive zone:
Personnel could be still threatened by indirect fire but Enhanced field care (EFC) manouvres can be put in place under cover;

What I mean for under cover:
The ideal would be  a true Company Aid Post, in reality  EFC is performed on the back of a tank or everything can provide protection from fire.



Who perform EFC:
It depends on the Nation: US army has specifically trained Medics and Paramedics, EUropean forces often have a nurse or a doctor on the field; 

Italian Army itself is implementing a new strategy: A rescue helicopter with a critical care Physician and nurse on board, already on area of operations; the aim of this strategy is to save the time between the call for a MEDEVAC and  the MEDEVAC itself, that,I guarantee,in Afghanistan could be very long; furthermore it allow advanced stabilization manouvres right on the field or straight during flight.



What does it mean Enanched field care (EFC)??!! 

In small words what we call Damage control resuscitation in the civilian setting; 
anyway battlefield is very different from an Highway or every other possible civilian scenario so also life support techniques allowed are different;



On the field (Tactical Field Care):

<C> catastrophic haemorragy control: If not yet performed bleeding control is essential: Combat  Tourniquet and compressive dressings.

A: open airways ; If the wounded is unconscious: naso-orofaringeal cannula or recovery position or SGA (Supraglottic airways - Usually the iGel) if airway obstruction. 



What about the Neck Collar??
In military setting Neck collar is kept just for victims of  Blasts and vehicles accidents.

B: Breathing problems and torso trauma??... we go straight to needle decompression and occlusive medication in case of of open or sucking chest wounds; SGA if necessary.

C: IV (Intravenous infusion line) or IO (Intraosseous infusione line), (In the last times we tend to go straight by IO); Thus TXA (Tranexamic Acid) and start Normal Saline infusion,following damage control resuscitation guidelines.




Every nurse or physiscan present on the field are trained to perform those manouvres; 

Anyway More advanced techniques could be performed whereas  critical care trained personnel is available and this usually happens just before or during trasport on MEDEVAC helicopters.
These advanced techniques usually are Emergency CRIC to control airways, finger thoracostomy for PNX; Italian MEDEVAC is implementing PENTAX VL intubation instead of CRIC, but evidences are still very few…



Some MEDEVAC service such the US one have 0-neg on board and can even start blood transfusions…..this is great stuff!!!!!

Surgical treatment:
Definitive surgical treatment not always can be performed between 2 hours of wounding in  an advanced medical facility (a role 3 Field Hospital)…To obviate this problem NATO forces invented FST (Forward surgical teams): Highly versatile operating rooms deployed in advanced military outpost, able to perform just damage control surgery; this strategy permits to gain time and transport patient to an  AMF (Advanced Medical Facility) for definitive treatment in a following time.
Usually an FST is manned by 20 - person team: 1 Orthopedic surgeon, 3 General surgeons,2 Anaesthetists or certified registered nurse anesthetists (CRNAs) 3 Registered Nurses, 1 administrative officer, 1 detachment sergeant, 3 licensed practical nurses (LPN)'s, 3 surgical techs and 3 medics. 



To sum up current War EMS organization is the result of experiences gained during the most recent  conflicts: IRAQ and Afghanistan and is constantly  evolving; 
endeed in next combat operations could become obsolete……Just Think to a war in a place where the enemy has air supremacy……Helicopter MEDEVAC that now is so important, in a moment could become useless…………..





…..Have a good day on the Edge and Bye Bye……..


References:



Friday, May 30, 2014

Code Black.......

It's Adrenaline addicting....it's a mess....It's noisy...sometime very noisy....It's crowded.......It's Dirt....just the dirt of blood when you are lucky.....it's dangerous....It's exhausting....It's the BEST!!!....It's the ER.......!!!!


Wednesday, April 23, 2014

SMACC (Social Media & Critical Care ) GOLD Conference 19-21/03/2014 : Gold Coast, Queensland, Australia...... Oops I Did It Again ! !

Hi Guys......
this time I had the honor  to be guest of one of the best #FOAM websites in Italy: www.medicinadurgenza.org
My post is a review of The BEST CONFERENCE EVER: SMACC Gold 2014....Yes!!!! I did it again .....Second round!!!!!!
Obviously the post is in Italian but the translation programme attached to the website is great!!! so can be read also in English without problems.....
Follow the link below and enjoy!!!......
From docvpb.... Have good Day on the Edge!!!!.....and See you at SMACC CHICAGO (May 2015)!!
http://www.medicinadurgenza.org/content/smacc-social-media-critical-care-gold-conference-ooops-i-did-it-again-tenente-valerio-pisano



Tuesday, December 24, 2013

Medical Planning for Extended Remote Expeditions

Hi Guys!!!!....
Recently I read a great paper from the Wilderness & Environmental Medicine Journal about Medical Planning for Extended Remote Expeditions (follow the link below):




It gives not only 10 guidelines to help planners on the key, medically relevant elements of a workable remote healthcare system, but it gives also,as explanation for every point, a summary of a real clinical case.
This is my personal brief review:
Remote travelers have long been concerned about their medical care. Alexander the Great traveled with his personal physician, Philippus, as he conquered the world. In the early twentieth century, Admiral Robert Peary took Dr Frederick Cook on his 1891 Greenland expedition, where he set Peary’s fractured leg. Ernest Shackleton brought Eric Marshall on Antarctic expeditions as his chief surgeon/cartographer/surveyor. On his ill-fated 1912 expedition, Robert Falcon Scott chose Edward Wilson as his doctor/marine biologist/ornithologist.


Remote expedition medicine provides medical diagnosis and treatment to teams traveling to the developing world or to remote geographical regions “where access to definitive medical care will involve prolonged evacuation over many hours or days.”1 The practice of remote medicine involves many challenges, including dealing with isolated environments, limited clinical diagnostic support and specialist services, limited resources and equipment, altered treatment protocols, and longer patient contact times. Medical practitioners on these expeditions must have increased clinical acumen, public health knowledge, and a cross-cultural understanding of their team members and the region’s indigenous populations. They also must be able to provide and use diagnostic and management advice via telecommunications, devise and implement innovative practice methods, work beyond their normal scope of practice, make independent decisions, and assume increased responsibility….”

N°1) Optimize workers fitness
Before every kind of Expedition is important to perform workforce predeployment screening medical examinations in order to identify ailments and abnormalities and therefore anticipate and be prepared to cope with common and less common chronic illnesses, such as Allergies, Asthma, Diabetes, Hypertension, Epilepsy, Cardiovascular deseases and so forth….(General Dental screening could be also useful….Statistical studies showed that 5% to 15% of all offshore oil workers evacuations were due to Dental problems).

 N°2) Anticipate Treatable Problems
“Improvisation is the name of the game”
Planners should base their medication and equipment stock on the most common presentation to EDs; a good resource could be : “ED section of the annual National Hospital Ambulatory Medical Care survey based on US hospitals”.
In general most commonly encountered problems during expeditions are minor conditions: Gastrointestinal diseases, skin deseases, minor trauma…furthermore dental and ophtalmological problems must not be forgot and underestimated.

 N°3) Stock appropriate Medications
   A) Stock FIRST-LINE medications for the commonly anticipated illnesses; If possible supply first-line medications with multiple uses such as Adrenaline and diphenhydramine.
   B)Stock additional medications for specific environments: for instance otitis externa medications and O2 for diving expeditions or Acetazolamide, Dexamethasone, Salmeterole, Nifedipine and O2 for High Altitude ventures.
   C)Quantity: “(probable numer of pts. Needing the medication) x (the number of doses needed to treat one pt.).

N°4) Provide appropriate Equipment
“The major criterion is to provide what clinicians will need to diagnose and treat common problems, to convert patient evacuations to restricted duty, or to convert emergency evacuations to scheduled departures. This includes most equipment required for ophthalmologic, otolaryngologic, dental, traumatic, orthopedic, and extraction/evacuation situations.”
Additional equipment such as advanced airways, ventilation, laboratory testing and diagnostic imaging depends on remoteness of location, expedition size, Medical provider experience and expertise.
It’s very important to test every piece of equipment before departure in order to avoid bad surprises.....for example in the midth of the Ocean…….

N°5) Provide adequate logistical support
“Given the situational constraints and the need for frontline medical providers to have the tools they need, planners should ensure that expedition logistics function as smoothly as possible using proven healthcare supply systems.

N°6) Provide Adequate medical communication
Large Extended expeditions require as a minimum Internet access with sufficient bandwidth;
Indeed the internet can be used not only to send clinical images and Ultrasound movies but even for specialist referrals (VolP) for particular clinical cases.

N°7) Know the Environmental Limitations on Patient Access and Evacuation
When planning an expedition patient accessibility in terms of weather, local environmental conditions and availability of trasportation must always be considered;
Time requested for an eventual Medical Evaquation must be took into account;
Moreover before an expedition the clinician must be aware of local healthcare facilities and quality of Medicare available.

N°8) Use qualified Providers
Expedition doctor should have previous experience  in Emergency and prehospital care, expedition medicine and the ability to operate effectively in remote environments.
Familiarity with the specific conditions of the expedition (for instance altitude related illnesses or Barotrauma) is desiderable.
In my opinion ability to IMPROVISE is the most important skill of an expedition doctor!!!!

 N°9) Arrange for Knowledgeable and Timely Consultations
Before departure is important to make Arrangements to have a team of base specialists (possibly expert of remote medical problems), ready for consultation even from remote locations.

N°10) Establish and Distribute Rational Administrative Rules
Before the expedition medical personnel must be aware of all administrative rules Sponsor’s specific and Country setting of expedition specific..

 To sum up the following are the golden rules for medical planning of a Remote expedition:
1. Optimize workers’ fitness
2. Anticipate treatable problems
3. Stock appropriate medications
4. Provide appropriate equipment
5. Provide adequate logistical support
6. Provide adequate medical communications
7. Know the environmental limitations on patient 
access and evacuation
8. Use qualified providers
9. Arrange for knowledgeable and timely consultations
10.  Establish and distribute rational administrative rule

Remember that a good planning concurs for about 70% of success of a remote expedition and this is true even for medical planning….
But remember also that while practicing medicine in Extreme Environments Improvisation skills could make the difference…..

Hoping you will enjoy this publication and my review…….as always… have a good day on the Edge!!!!









Saturday, December 21, 2013

Hi Guys......
this time I had the honor  to be guest of one of the best #FOAM websites in Italy: www.medicinadurgenza.org
Thanks to Gemma Morabito (twitter ash.: @MedEmit...follow her) for hosting me...
My post is a review on a Great Conference I recently attended: Essentials of Emergency Medicine 2013 in San Francisco!!!!
Obviously the post is in Italian but the translation programme attached to the website is great!!! so can be read also in English without problems.....
Follow the link below and enjoy!!!......
From docvpb.... Merry Christmas on the Edge!!!!
http://www.medicinadurgenza.org/content/essentials-emergency-medicine-2013-io-cero-tenente-valerio-pisano-brasca-md-ufficiale-medico