Medicine:Prolonged field care

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Short description: Medical (prehospital) subspecialty
U.S. Army General Barbara Holcomb delivering a keynote speech on prolonged field care at the 2017 Military Health System Research Symposium

Prolonged field care refers to the specialised medical care provided to individuals who have sustained injuries or illnesses in situations where timely evacuation to a medical facility (or next tier of healthcare provision) is delayed, challenging, or not feasible.[1][2] This concept is applicable in various contexts, including military operations, wilderness emergencies, and disaster response scenarios.[1] Definitions exhibit slight variation, but they convey the same fundamental meaning:

"Field medical care, applied beyond doctrinal planning time-lines"[3]

"Field medical care that is applied beyond “doctrinal planning time-lines” by a tactical medical practitioner in order to decrease patient mortality and morbidity."[4]

"Prolonged care is provided to casualties if there is likely to be a delay in meeting medical planning timelines"[5]

While the concept itself is well established, since 2012 it has become rapidly codified, with changes in the global political environment and the nature of combat operations around the world.[6] This led to increased research and academia in the area of prolonged field care, first in Special operations teams[7] and then more broadly.[8][9][10]

History

The concept of prolonged field care evolved from lessons learned in military conflicts,[11] humanitarian missions,[12] and disaster response efforts. It has become a vital component of prehospital, emergency and military medicine. Prolonged field care as a subspecialty relies on the transmission and adaptation of guidelines between civilian and military organisations. This can take the form of adapting civilian clinical practices to a military setting,[5] undertaking civilian research to inform military practices[8] or adapting military training for a civilian audience.[13]

Core capabilities

There are twelve core capabilities of Prolonged Field Care:[1]

  1. Monitor: Possess the capability to acquire, analyze, and comprehend a patient's vital signs, employing a reliable approach for precise documentation of observations.
  2. Resuscitate: Have the equipment and competence to commence suitable fluid resuscitation to enhance patient outcomes, encompassing the administration of whole blood and blood products when necessary.
  3. Ventilate & Oxygenate: Administer positive pressure ventilation while safeguarding the lungs from additional harm.
  4. Airway Management: Gain control of a patient's airway to prevent hypoxia, asphyxiation and aspiration.
  5. Sedation & Pain Control: Use adequate and appropriate pain control. Use sedation to accomplish any procedural tasks.
  6. Physical Exam & Diagnostics: Conduct a thorough physical examination and diagnostics to gather information about the patient's current status and anticipate concealed injuries..
  7. Ongoing (Nursing) Care: Continuously provide nursing care that includes maintaining the patient's warmth, cleanliness, and dryness, managing biological needs, performing wound care, and proactively preventing additional illness.
  8. Advanced (Surgical) Procedures: Undertake advanced procedures essential for preserving life, reducing morbidity and enhancing overall outcomes.
  9. Telemedicine: Establish telemedicine connections with medical providers capable of guiding treatment and effectively communicate the patient's condition.
  10. Prepare for Evacuation: Prepare for safe evacuation by ensuring patient stability during transport and taking measures to prevent further harm.
  11. Logistics: Understand the chain of care and evacuation.
  12. Communication: Establish and maintain reliable communication with operational and medical control.
Special Warfare Medical Group training in prehospital care, this stage would be the "ruck" stage, equipment used must be carried to the patient in a rucksack

The first ten capabilities originates in military practice[14][15] with the last two being later additions for a civilian audience. Each of the core capabilities can be considered in terms of Minimum, Better, Best in relation to aiming to provide a high standard level of care,[16] and in relation to Ruck, Truck, House and Plane[17] to discuss the stages of care and logistical issues which may limit equipment provision.

These stages of care can be further explained as:

  • RUCK: the equipment and medications carried to the furthest point of an expedition or mission. Generally (or conceptually) carried in a rucksack.
  • TRUCK: Additional medications and equipment carried on a transportation medium during an expedition or operation (Four-wheel drive vehicles, boats etc).
  • HOUSE: Equipment and medications available at a team's house, warehouse or other staging post building.
  • PLANE: Plane is used here to represent the formal medical evacuation platform, this will vary but may have the staffing, equipment and capabilities very close to the receiving hospital.

Core interventions

There are two acronyms used to prompt the provision of prolonged field care after completing a Primary and Secondary Survey, those being HITMAN coined by the UK Military[18][19] and SHEEPVOMIT created by the then Dean of the College of Remote and Offshore Medicine.[20][21]

H
Head to Toe examination; a full secondary survey to identify illnesses or stigmata of disease.
I
Infection
T
Tubes and tidy
M
Medications
A
Administration
N
Nursing care; utilising the SHEEP VOMIT acronym.[22]

The second acronym, SHEEP VOMIT details the nursing care needs of a patient and how best to address these.[23][24]

S
Skin protection
H
Heat regulation
E
Elevate head
E
Exercises
P
Pressure points
V
Vital signs
O
Oral hygiene
M
Massage (DVT prophylaxis)
I
Ins and Outs (diet and fluid)
T
Turn / cough / deep breath

Education

A number of civilian and military prolonged field care courses exist. While many follow the core capabilities outlined above some do not. Many prolonged field care courses align closely with the 12 capabilities. Typical course contents may include:

  • TECC/TCCC practical scenarios
  • Four Horsemen of the Apocalypse scenarios (Catastrophic Hemorrhage, Burns, Crush, TBI)
  • Austere nursing care scenarios
  • Austere and prehospital ultrasound (APUS)
  • Disaster response / mass casualty
  • Improvised medicine
  • Austere Critical Care
  • Austere Nursing Care
  • Full-day (or longer), immersive exercise

Terminology

A variety of terminology is used for the same concept, this is partly due to the differences between military and civilian practice. The following terms are used fairly interchangeably, but there may be specific differences between the association dogma, guidelines and protocols.

  • Prolonged Casualty Care - A preferred civilian term
  • Austere Emergency Care - A preferred civilian terminology relating to training and education[1]
  • Prolonged Field Care - A commonly used military term
  • Prolonged Prehospital Care - Terminology used by the British Armed Forces in addition to Prolonged Hospital Care.[5]

See also

References

  1. ↑ 1.0 1.1 1.2 1.3 O'Kelly, Aebhric; Mallinson, Tom (2023-09-02). "Prolonged field care (austere emergency care) principles in UK paramedic practice" (in en). Journal of Paramedic Practice 15 (9): 359–366. doi:10.12968/jpar.2023.15.9.359. ISSN 1759-1376. http://www.magonlinelibrary.com/doi/10.12968/jpar.2023.15.9.359. 
  2. ↑ Smith, Michael; Johnston, K.; Withnall, R. (2021-04-01). "Systematic approach to delivering prolonged field care in a prehospital care environment" (in en). BMJ Mil Health 167 (2): 93–98. doi:10.1136/jramc-2019-001224. ISSN 2633-3767. PMID 32111674. https://militaryhealth.bmj.com/content/167/2/93. 
  3. ↑ Keenan, Sean (2016). "Deconstructing the Definition of Prolonged Field Care". Prolonged Field Care. https://prolongedfieldcare.org/wp-content/uploads/2016/01/deconstructing-prolonged-field-care.pdf. 
  4. ↑ Dolan, Connor P.; Valerio, Michael S.; Lee Childers, W.; Goldman, Stephen M.; Dearth, Christopher L. (2021-02-04). "Prolonged field care for traumatic extremity injuries: defining a role for biologically focused technologies" (in en). npj Regenerative Medicine 6 (1): 6. doi:10.1038/s41536-020-00117-9. ISSN 2057-3995. PMID 33542235. 
  5. ↑ 5.0 5.1 5.2 Allied Joint Publication-4.10: Allied Joint Doctrine for Medical Support (Edition C Version 1 ed.). NATO STANDARDIZATION OFFICE (NSO). 2019. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/922182/doctrine_nato_med_spt_ajp_4_10.pdf. 
  6. ↑ MD, Brad Kinney (2022-01-25). "Prolonged Field Care" (in en-US). https://kinneticmedicine.org/2022/01/25/prolonged-field-care/. 
  7. ↑ Keenan, Sean; Riesberg, Jamie C. (June 2017). "Prolonged Field Care: Beyond the "Golden Hour"". Wilderness & Environmental Medicine 28 (2): S135–S139. doi:10.1016/j.wem.2017.02.001. ISSN 1080-6032. PMID 28601206. 
  8. ↑ 8.0 8.1 Mould-Millman, Nee-Kofi; Dixon, Julia M.; Lategan, Hendrick J.; Beaty, Brenda; Fosdick, Bailey; Fleischer, Chelsie; de Vries, Shaheem; Schauer, Steven G. et al. (August 2023). "Feasibility of conducting a military-relevant multicenter cohort study to assess outcomes of early trauma resuscitative interventions in a prolonged care civilian setting" (in en). Journal of Trauma and Acute Care Surgery 95 (2S): S88–S98. doi:10.1097/TA.0000000000004066. ISSN 2163-0763. PMID 37212617. 
  9. ↑ Suresh, Krithika; Dixon, Julia M.; Patel, Chandni; Beaty, Brenda; del Junco, Deborah J.; de Vries, Shaheem; Lategan, Hendrick J.; Steyn, Elmin et al. (2022-10-17). "The epidemiology and outcomes of prolonged trauma care (EpiC) study: methodology of a prospective multicenter observational study in the Western Cape of South Africa" (in en). Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 30 (1): 55. doi:10.1186/s13049-022-01041-1. ISSN 1757-7241. PMID 36253865. 
  10. ↑ Mould-Millman, Nee-Kofi; Baidwan, Navneet Kaur; Beaty, Brenda; Suresh, Krithika; Dixon, Julia M.; Patel, Chandni; de Vries, Shaheem; Lategan, Hendrick J. et al. (August 2022). "Prolonged casualty care: Extrapolating civilian data to the military context" (in en). Journal of Trauma and Acute Care Surgery 93 (2S): S78–S85. doi:10.1097/TA.0000000000003675. ISSN 2163-0763. PMID 35546736. 
  11. ↑ "Review of 54 Cases of Prolonged Field Care". https://www.jsomonline.org/SharedScience/20171121DeSoucy.pdf. 
  12. ↑ Paul (2018-03-29). "Episode 37: PFC from the NGO Perspective With Alex Potter of GRM" (in en-US). https://prolongedfieldcare.org/2018/03/29/episode-37-pfc-from-the-ngo-perspective-with-alex-potter-of-grm/. 
  13. ↑ Keenan, Sean (2020). "AUSTERE EMERGENCY CARE CAPABILITIES – Specialized Medical Standards". https://specializedmedicalstandards.org/austere-emergency-care-capabilities/. 
  14. ↑ "Prolonged Field Care for the Combat Medic" (in en). 2017-06-15. https://nextgencombatmedic.com/2017/06/15/prolonged-field-care-for-the-combat-medic/. 
  15. ↑ "Position Paper – 10 Essential Core Capabilities for Prolonged Field Care" (in en-US). 2015-02-10. https://prolongedfieldcare.org/2015/02/09/10-essential-core-capabilities-for-prolonged-field-care/. 
  16. ↑ "Prolonged Field Care: Beyond the "Golden Hour" – MED-TAC International Corp.". 2019-07-07. https://tactical-medicine.com/en-gb/blogs/news/prolonged-field-care-beyond-the-golden-hour. 
  17. ↑ Mohr, Christopher; Keenan, Sean (2015). "Prolonged Field Care Working Group Position Paper: Operational Context for Prolonged Field Care". Journal of Special Operations Medicine 15 (3): 78–80. doi:10.55460/1T85-6NB9. PMID 26360359. https://prolongedfieldcare.org/wp-content/uploads/2015/09/mohr_keenan-jsom-fall-2015-edition.pdf. 
  18. ↑ Carden, Richard (2019-05-07). "Prolonged Field Care...in the ED. St Emlyn's" (in en-GB). https://www.stemlynsblog.org/prolonged-field-care-in-the-ed/. 
  19. ↑ Smith, Michael; Johnston, K.; Withnall, R. (2021-04-01). "Systematic approach to delivering prolonged field care in a prehospital care environment" (in en). BMJ Mil Health 167 (2): 93–98. doi:10.1136/jramc-2019-001224. ISSN 2633-3767. PMID 32111674. https://militaryhealth.bmj.com/content/167/2/93. 
  20. ↑ Development, PodBean. "Eric Pirie - Prolonged Care in the Field | BASICS Scotland Podcast" (in en). https://basicsscotland.podbean.com/e/basics-scotland-prolonged-care-in-the-field/. 
  21. ↑ "Nursing mnemonic SHEEP VOMIT". 2018. https://prolongedfieldcare.org/wp-content/uploads/2018/09/pfc-nursing-mnemonic-sheep-vomit.pdf. 
  22. ↑ Marsden, Max. "https://twitter.com/MaxMarsden83/status/959041807802912768" (in en). https://twitter.com/MaxMarsden83/status/959041807802912768. 
  23. ↑ O'Kelly, Aebhric; Jarvis, Jason. Remote and Offshore Medicine: Field Guide for Practitioners (2nd ed.). College of Remote and Offshore Medicine. ISBN 9789995791308. 
  24. ↑ "AUSTERE Nursing Care". 2023. https://open.spotify.com/episode/0qiCVjRGScy5MbgnIkShFW?si=Pu4VihHnRgqmNn3pHdjPSA. 



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