GSACEP Lecture Series: Long Range Medicine by CAPT Travis Deaton, MD

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Episode Transcript

Travis Deaton (00:15):
Standard disclosures, right? Nothing
financial disclose. But theimportant one is these are my
views on my views alone. TravisDeaton is talking to you today.
I'm going to be very opinionatedon my thoughts. And I'm looking
for feedback. And I'm lookingfor people to have some some
other thoughts and ideally somedissenting thoughts on where
we're going here.
I like to start off operationalbriefs with this slide right

(00:36):
here. So the defense casualtyanalysis system, this is a
public facing website, anybodycan go on your smartphone right
now. And you can look at this.
And they will track our casualtystatistics for not just the five
named overseas contingencyoperations that you see up here.
But you can go back and look atWorld War Two data, Vietnam
data. Don't worry about all thenumbers that are up there, draw
your attention to this number inthe bottom right hand corner,

(00:58):
over 60,000 patients, 60,000patients roughly 20 years,
that's 10 patients a day, everysingle day, there were
casualties coming back fromoverseas contingency operations
for 20 years in a row, thecollective we have a huge amount
of experience, about what ourpatient dataset looks like. I'll

(01:19):
be it from a different theaterthan what our next theater is
likely going to look like, underdifferent conditions. But this
knowledge of 60,000 people wasearned through blood, sweat and
tears. We can't forget aboutthat. So I think it's a good
place to go look at every oncein a while. I think it grounds
us as to why we're here and whywe're doing what we're doing.
Obviously, when we talk a littlebit about taking physicians or

(01:45):
providers that are trained in ahospital, that's climate
control, it's secure, it's gotgood lighting. We've got all
sorts of backup staff that arehelping us out on any given day.
And when typically, when you askfor a piece of equipment, that
piece of medical equipment orgear is usually readily
available available as anybodyactually dropped a wire from a

(02:07):
central line on the ground everbefore their careers. And then
you turn and you say, give meanother kid, right, another kid
magically appears out ofnowhere. That's the paradigm
we've all been trained to workin and that we're comfortable
working in. Now go back andremember the first time that you
did an EMS ride along. I'm gonnawatch about you, but mine was a
total disaster. Right? We arenot trained, nor do we practice

(02:29):
working in low light conditions,moving conditions, places where
you don't have backup, placeswhere you're not necessarily
secure. You'll see this in thehospital every day, right? If
you respond to a code,especially if there's some
junior residents, that's in a ina non traditional medical
facility, where there's not apatient and a gown sit in the
bed. So for example, you know,the fast food, the fast food

(02:51):
joint, it's the to the hospitalor, you know, the floor or the
pharmacy, people get out oftheir loop right there, what
they've trained to do, theydon't know how to react that
situation. There are all sortsof great civilian organizations
that are out there that willhelp you with that problem set,
right, I just listed a few theseare just kind of representations
that are out there. Obviously,the pre hospital trauma Life

(03:13):
Support class is a great coursethat's tied very closely with
the military as well. People canget a fellowship, right, we got
I'm sure there's plenty offellow train EMS folks in the
room. But then there's alsothose folks that you know that
if you want to go take care ofsomebody who's sailing on a ship
out the middle of sea, orsomebody on extended hike in the
wilderness or in backcountryskiing, there's some fantastic

(03:34):
organizations that will that'llhelp you through that. But
that's not what we're gonna talkabout today. We're gonna talk
about this as an extreme exampleof what long range medicine is
gonna look like for the Navy. SoI'm sure there's there's plenty
of folks in the room who arevery familiar with distributed
operations. We're gonna parkhere for a little bit, and we're
going to try to try to shapethis. So we all have a pretty

(03:56):
good understanding of what thismeans going forward. This is an
unclassified reef. This is anopen source map chip that I
pulled off, randomly pulled offthe internet, specifically off
the marines.mil public facingwebsite. And it shows the anti
access area that AI capabilityof a random country in this
case, it's focused on Japan, orI'm sorry, on China. So what

(04:19):
you're seeing are those rangerings the project away from
China, or cruise missiles, antiship missiles, anti aircraft
missiles, ballistic missiles,fighter aircraft, or fighter
attack and bomber aircraft. Thisis how far out away from the
coast of China they are able toproject lethal munitions.

(04:42):
There's a concept that AdmiralHancock refer to the first
island chain. The first islandchain stretches from Japan,
South through the Ryukyu andOkinawa through Taiwan. Further
south through the PhilippinesThat's right. Those are the
close island chains, you can seethat those island chains are

(05:04):
very well covered by the rangerings, and are considered in the
weapon zone, the West, those areinside of the West for a
potential conflict.
There's a second island chain alittle further out, right
stretches from northern Japanout to a why some might say all
the way down to New Zealand,Australia even, that's a little

(05:24):
further out that isn't quite asincluded in that that weapons
Engagement Zone that dangerzone. So let's let's what what
you don't see depicted, here area few things, you don't see the
maritime naval assets that haveindividual range range with
capabilities they can reach outand touch people with because
they're moving around on a dailybasis, right. But they're out
there. You don't see the sensingcapabilities. Right. So we

(05:49):
talked about sensingcapabilities, it's o'clock
crossed the entireelectromagnetic spectrum, this
is going to be importantspecific stimuli for our long
range medicine response. Sowe're going to talk about, but
when I say sensing, that'severything from the mark one mod
zero eyeball, right? Being ableto look at something and say,
Hey, I see something that isdifferent that might not

(06:10):
necessarily be here. Andspecifically, how many Chinese
fishing vessels do you think arein this region? 1000s, right,
all with eyeballs able to get ona VHF radio or cell phone and
report back to say what they'reseeing up to, you know, we
talked about sensingcapabilities, we're talking

(06:30):
about 20 year old low tech,relatively satellites, that just
have not even high resolution,so low resolution, visibility,
all the way up to some insanesensing technologies that we're
not gonna talk about in thisparticular space today. But I'll
tell you are driven by AI to beable to sift through massive
amounts of data that are lookingvery specifically at this

(06:54):
region. The third thing youdon't see on there are the
electronic warfare capabilities.
So we've been operating for thelast 20 years in the overseas
contingency operations. Under avery permissive communication
environment, we were able toreach out and talk talk to
people when we wanted to thatbeing said, Who has ever
struggled in the military, onradio, trying to talk to

(07:15):
somebody that's 100% permissiveenvironment we've been in. Now,
what happens when we startdegrading those capabilities? So
keeping that in mind, I promisethis is going somewhere. Let's
look at the paradigm for let'sjust let's take a generic medium
sized rule to capability that webrought into the Overseas

(07:35):
Contingency Operations last 20years. So what are we talking
about talking about what 20 To40 Medical packs somewhere in
that range? About for medium tolarge sized tents, to
generators, some communicationsequipment, but two or three
field ambulances, you may be colocated next to rotary wing
aircraft that are parkedalongside to help you get

(07:58):
patients to and from your roleto facility. Right. It's not
just that the medical folksright we had to have attached
security communicators,logisticians, cooks, maybe
planners, all those folks neededa place to sleep, so we build
extra tents for him. I'm sureI'm missing out like fuel, all
the other sort of logisticalsupplies that are coming along

(08:19):
with a roll to facility. Are yougoing to need a high fidelity
high resolution satellite or ISRplatform to see that footprint
on this battlefield? Now? Mark,one mod zero eyeballs gonna tell
you exactly where we put thatmedical capability. Now, our
potential future enemies in apacing enemy threat near peer

(08:41):
conflict. They have the sameKill Chain issues that we do. So
we talked about a kill chain.
You got to find a target, assessthe target and figure out if you
want to execute that target. Somy very simple Travis Deaton
mind somebody's looking on ascreen. Well, I found something

(09:02):
that's got like 610s and acouple of vehicles. I only have
so many missiles do I push thebutton or not? And I would argue
that if you've got a footprintthat big, that is a very juicy
potential target. Right. Solesson number one, we got to get
small. That's just a visualaspect. We like power, right?

(09:24):
We'd like to run our lights andour medical equipment requires
power. What what do you thinkhappens every time we fire up
one of those generators, theyput out a whole lot of heat,
right? From a sensing capabilitythat he's gonna get found in a
heartbeat when we call forpatient transport, or where we
receive a nine line request,assuming we can because we're a
calm, degraded environment. Whatare we doing? We're giving away

(09:46):
the position and potentiallywhat we're doing and what we're
moving. So we've got to staylight mobile, in stay off the EM
spectrum. This has nothing to dowith medicine. We're talking
long range medicine. We haven'teven touched on the medical
piece yet. But these areimportant concepts and their key
concepts. We talked a little bitabout rule two, I'd like to go

(10:07):
back and talk about rule one oldparadigm.
cooperations rule one medicine,you are good medic, and you're
on the ground, you were alreadycalling for that nine line chasm
back. Before you were evenfinished on your initial
assessment, right. So obviously,the gates effect looking at look

(10:28):
at our time to get rotary wingaircraft on station.
Realistically, when things weregoing well, you had under 30
minutes from the time you callthat chasm back, the time there
was a rotary wing on deckpicking up your patient,
typically, you didn't give it tomake, make it through your
entire assessment and get itpackaged up for they're ready to
take off your hands. In thisenvironment, where we do not

(10:48):
have air superiority, we've gotto break that thought process,
nobody's coming in 30 minutes topick up your patient, the time
distance is too great. And thefact that they can't safely get
surface connectors, airconnectors, ground connectors
in, is going to severely limitour abilities to medevac folks
out in a hurry. We'll talk abouta little bit about planning

(11:10):
factors, but I'm gonna throw outexpect 72 plus hours, which are
gonna be holding on to apatient. So as we wrap this up,
we think about the problems thatyou got to be small, you don't
want to get found you got to beable to move fast, you can't
have a lot of gear and you can'temit anything on the EM
spectrum. You're talking aboutsmall teams, not just medical

(11:31):
teams, I'm talking smallmilitary teams, 2030 people ish
Max, right, and one locationthat can move in a hurry, once
they get sense, and they gottagotta move to a different
location. So what's your medicalsupport for that? You got 20 or
30? warfighters? Out there nonmedical? How many medical folks
do you put with them to takecare of I don't know about you

(11:52):
guys. But I have trained myentire career to be the best
that I could possibly be. Ifsomebody gets injured on the
battlefield, I want to bestanding next to him. That's
what I've dedicated my lifetowards. The reality is, it's
not going to be us. Reality isit's going to be a junior
corpsman, or junior medic, whois going to be our center of

(12:13):
influence, right? That's gonnabe taking care of those folks.
So we'll train we'll learn it.
But at the end of the day, wehave to learn how to man train
and equip our forces goingforward. Alright, so with that
good news. This is how I look atthings, right. So we put things
on a spectrum of care. We heardanimal Hancock talk about phase

(12:33):
zero shaping operations, right.
This is where nobody's shootingat this point. But the military
actions that are happening in acompetition phase, we've got
folks deployed away from thecontinental United States. And
we really got to focus on on thedisease in that battle injury.
So this is our non trauma skillsin the emergency department.

(12:55):
These are our sick call skillsfor folks who are in operational
units. And we can't forget thatthere's a couple of kind of
unique things right are tropicalmedicine, the mental health
orthopedic injuries, obviously,the unique women's health issues
that come up on deployment. I,in this spectrum, we're going to
have to assume at some point,things are going to go kinetic.
And that's what that little fakeexplosion of they're supposed to

(13:16):
look like. When that happens, wetipped from phase zero to phase
three operations were combatnow. And you should expect to
see more combat trauma, and alittle bit less D MBI. Now,
we've got some programs that arein place to help people work
through this long range medicinebecause remember, you might not
be able to call for help you gotlimited amount of equipment,

(13:37):
limited on personnel, and you'dhave to hold on to it for 72
plus hours. The way I look at itin my mind is we've got tactical
combat casualty care, we gotplenty of data that shows for
the first 15 to 30 minutes wellexecuted tactical combat
casualty care will save lives.
That's got to be the foundationof where we focus our efforts.
So if everybody in this roomdoes not feel like they are the
absolute subject matter experton tactical combat casualty

(14:00):
care, I'd ask that we we go backand look that again, right, we
need to be at the end of 30minutes, you kind of run through
your TC three protocols, andyou're sort of stuck what I do
now. And then we've also proventhat whole blood saves lives. So
what we've done, First MarineDivision is instituted what we
call a Valkyrie blood program,but it's nothing more than a low
titer role, whole blood programthat can be executed by medics

(14:23):
with the assistance of Marines,with no medical officers present
to be able to continue thatresuscitation. What do I
estimate cash that might beanother 6090 minutes. And then
what because helps still notcome? This is when we went back
and we looked at our prolongcasualty care programs to really
try to figure out how to trainpeople for that 72 plus hours

(14:45):
hold on to a patient before youcan get somebody to come help
pick you up. This is why I don'tsleep at night, right? Trying to
solve this problem set.
Again, nobody has interrupted meand challenge me yet. Please do.
We'll start a little bit withsome tactical combat casualty
care stuff.
The kind of plug for the theimage on the bottom right there.

(15:08):
So deployed medicine. I love oneof my favorite pastimes is
complaining about DHA. I loveit. But there is one thing that
DHA got absolutely right. It'sthis app. And if it's not on
your phone, you don't have itdownloaded yet, I implore you
beg you deployed health, it'sfree. That does a couple things
for you. It's got all of the JTSkiller clinical practice

(15:31):
guidelines on it. Back in thedays, I don't know, if you
remember, we would deployeverything like hey, do you have
the newest one? Or did you getthe new one over email or kind
of find the updated version, assoon as they're updated, they go
up on this app, you can pullthem down and download them if
you need offline, you know,offline access to them. And not
only that, it's got all of thetraining materials. So if you
have to give an impromptu classfor TC three, or prop two class

(15:55):
for like any of your your yourkind of roll to roll things up
all those training materials areincluded on there makes it
really easy this free app theyactually did, right. So I'd ask
you to please go take a look atI'm not going to insult
anybody's intelligence. But I'mjust going to briefly cover what
the purpose behind the fourdifferent tiers of tactical
combat casualty care where whenthey say tears, it's just target

(16:16):
audience. Right. So the in theidea being, you know, teaching a
paramedic, to do a bunch ofinterventions in tactical combat
casualty care is gonna take alittle bit of time and they come
in with a little bit of ofinformation and skill set
beforehand. But the all servicemembers like anybody that's
that's working in a maybeadministration or logistical

(16:36):
position, they don't need a weekand a half course, but they also
don't need to know how to dohigh level procedures. So we've
kind of tiered it out. So Tierone is your all service members.
Tier Two, are your combatlifesavers. Tier three are your
combat medics in your corpsmanand then tier four is your
paramedics your providers sir.
Somebody saying Hey, hold onall tail officers you're asking?

(17:22):
For medical school that's alsoan expectation. I don't know

(17:47):
about you all, but I'm gonna runout a square hole. Admiral
clearly agreed, right? When Iwant to go back to this this

(18:11):
slide, right. What are we askingof our combat medics in our
corpsman I want you to be afamily care doc on the left side
of this, right, with a littlebit of OB experience and a
little bit of mental healthexperience. And then I want you
to be an ER doc and an ER nurse.
And then I want you to be atransfusion assist. And then
ultimately, I'm going to ask youto be a critical care nurse or
critical care provider and an RTfor a 20 to 21 year old target

(18:38):
audience who hasn't been tomedical school. This is a big
ask the problems that we'relooking at, and we didn't brief
the casualty statistics ornumbers, is it's a numbers game,
there are not enough of us totackle what the likely
casualties of a near peercompetitor gonna look like. So
we've got to enable some of theskills for the folks that that

(18:59):
are going to be their point welltaken out and all that. It's a
numbers issue that obviouslywe're concerned about as well. I
will say just from anadministrative perspective, tier
one, tier two, tier three, allthe training curriculum, all the
videos are up on deployedmedicine, the one that's still
in works is tier four. So youcan't get access to tier four
yet. It's still being built out.
Don't worry about this chart.

(19:21):
Right. So this is just anorganizational chart chart that
looks at what you know who's incharge of JTS. And who does what
for who don't worry about that.
I want you to pay attention towhat's on the bottom here.
Right. This is not one of thosesituations where JTS the Defense
Committee on trauma is an usversus them. JTS and Defense
Committee on trauma is all ofus, right? We are the ones that

(19:45):
contribute to this body of workin this body of knowledge, the
CPGs the curriculums that comeout. This is the joint
curriculum. This is the purplecore curriculum. The medicine is
purple. If you look for samplecommittee on T Triple C that
puts out the guidelines both forTC three and PCC has 106 GP 106,
or GP doc assigned to thatparticular person that's filling

(20:12):
that billet right now is CaptainDrew, who was also a command
surgeon. Right? This is hiscollateral duty he does on the
weekends. We as a community, arewhat make this up all the
services, getting together,validating, doing the research,
literature, literature search,looking at what our levels of
recommendations are figuring outhow to write the guidelines,

(20:34):
update the guidelines, and Howto Teach this to people. So this
is a coalition of the willingfrom all services. And I would I
would, I would challenge you, ifyou have an interest in this,
and you're not engaged in this,let me know, come talk to me, we
have more projects in morerequirements than we have people
to fill in, it's gonna be anextra job, right. But I also

(20:55):
think it's one that that we canbind to JTS is not us versus
them. We collectively are JTS.
There's a couple people thatkeep the lights on for us on a
day to day basis. I put this DoDup instruction up there. They
came out early in 2022. Thatsaid a couple of things, but you

(21:17):
know, cross cross the DOD. I'llread a couple things out here.
So tactical combat casualty careis the standard of care. Right?
It is the DoD standard of carecleared Clear, clear steps. And
that all service members fromall services should take this
because it meets the J Robbinsrequirements that are out there.
It also said that this is wherewe got to deploy medicine.com

(21:41):
website saying that that's goingto essentially be the repository
to where we find these resourcesgoing forward. Luckily, we got
some buy in right so after thiscame out as the DoD Instruction,
the Air Force, were the firstones to the streets and yeah,
understood.
Um, you know, less than threeweeks later, the Air Force says
we in the Air Force will do thepurple medicine, the joint

(22:02):
medicine, a little bit laterDepartment of Navy, about a
month later came out and said,Alright, Air Force, Navy is
gonna do the same thing. We'llpractice the purple medicine
took a little bit longer. Butthe Marines in the summer said
we will practice the purplemedicine as well. So what do you
think next slide, Army, SpaceForce. haven't come on board

(22:24):
yet. The DoD instructions but onthe street for over a year
haven't come on board yetformally as a service. Again, we
as a community, these drivers.
Gonna talk a little bit aboutthe change payment process
because this is what we do.
Right, we go back and werevisit, we look at what new
data what new information is outthere are the recommendations

(22:46):
and guidelines that we put outpreviously, are they still
valid? Or do we need to changethem around a little bit? If you
looked at the fluidresuscitation for hemorrhagic
shock recommendations, and TCthree previously, it would walk
through your blood options. Butit would pay a little bit of
respect to the fact that takingblood in the battlefield is

(23:07):
hard. It's logisticallydifficult. And we left on two
things. We left on the colloidHexton. And we left the clear
fluids, Plasma Light, andwholesale. Now, if you're a
medical logistician trying tofigure out well, I got a bunch
of Cold Blood options, I got tofigure out a source. Or I could

(23:28):
just drop ship, some Hexton. Andthat's got a two or three year
shelf life, which you're gonnachoose. Excellent, for sure.
Right? How easy is that done?
Don't even think about it again.
Who here has given Hexton fortheir primary traumatic research
or resuscitation fluid of choicein a hospital? Right? We know,
we know that that harms peopleand probably kills them. So we

(23:53):
have to go back and look atthese. I think this is a good
one to look at, because it'snew. When we look at what the
current recommendations are forfluid officer for shock,
coldstore, low titer Oh, wholeblood. So these are coming out
of our CONUS based militaryblood banks, right. These are
screened, they're FDA compliant,and their universal blood

(24:14):
products, whole blood productsthat can be given to anybody who
comes to the door. They'regreat. But they're not easy to
get a hold of and volume, right?
There's not a whole lot of themout there. So they can work for
submissions when you gooverseas. We're still playing
around a little bit with theadditives. But right now we're
looking at about 42 days, orwhat the current shelf life of
these are. But again, they getdropped. That's when the data

(24:34):
drawn, they get drawn intoCONUS. Hospital, they have to go
through the testing process thathas to get reported, then they
have to get shipped. So ifyou're sitting in Indo PAYCOM,
or Africa, you're probablylooking at about 25 Useful days
of service life left on the coldstored level blood by the time
it gets to you. So it is asolution. It's a safe solution.

(24:55):
There's no harm involved in thisbut it is a logistically
challenging solution. Second onthe list, and these are these
are an order of preference. Bythe way, it's like a whole list
prescreen low titer, oil, fresh,whole blood. We're gonna hear a
lot about this program later ontoday. We got some folks in the
panelists, the panels gonna talkabout maybe a little bit, yeah,
right afterwards. So that'sgoing to be kind of good talk

(25:19):
about and this is where we we'venamed our Valkyrie program. But
there's other programs that areout there. And we'll go into
that a little bit. After that,obviously, plasma RBCs and
platelets and One to One to One,knowing that you're not going to
get platelets. Next, next on thelist is just plasma RBCs and a
one to one because platelets areso hard to find in overseas
locations. And then at thebottom, if you can't get a one
to one and just get plasma orgive our red blood cells. Let's

(25:41):
go through these just a littlebit. Which of these require
refrigeration? Is this one? Yes,this one. This one? Yes. Yes.
Kind of Yes. But I mean, this isthis is unicorn, right? If you
can find it great. But the restof it doesn't initially. But
it's hard to get a hold of anysort of volume. But all the rest
of these do. So what's reallyour only non refrigerated

(26:03):
option. So if you are a groundforce going forward, trying to
figure out your blood solution.
That's all you got, right? 2022.
That's all Yeah. If you'relooking for anything in volume.
So we put this to the service,specifically to the Marine Corps
and said, Look, we got aproblem. We can't keep

(26:24):
reinventing the wheel. Sothere's something called a
universal needs statement, youcan put up with the help of
cabin dog. And we'll Hancockseveral other folks in this
room, we were able to get theMarine Corps to sign this on as
a program of record.
And people that aren't familiarwith program of record. You
think this is where you get togo to the inside endzone and

(26:45):
spike the football turns outit's not right. So you got to go
through the entire.mil PFprocess to figure out funding
and education and where it goes.
We're getting there. We'reclose, we're much closer than we
were. So it is now officially aprogram of record. And now we
got to figure out all thedetails to make sure that we've
got these access to low titleFresh, fresh, Old Blood programs
going forward. This, this is agreat article. This is a really

(27:07):
good one to have has anybody.
There's a couple of older folksin here. Has anybody tried to do
anything with blood products andbeen told by a lab officer?
Absolutely not. We're not doinglow title. We're not doing cold
storage. All right. So I justhad that experience within the
last couple of months. And sothis came from a blood officer,

(27:28):
have you met? And I said, Hey,you know, I hear what you're
saying. I know you have someconcerns, but you work for the
armed services blood program,correct? Like that's essentially
your your higher headquarters?
Are you aware of a jointstatement that came out between
the joint trauma system and thesenior author on the paper was
our services blood program, andthey say that we shouldn't be

(27:48):
doing this though. The end ofthe end of the argument pretty
quickly. This is a good goodpaper to have in your back
pocket. Because there is alittle bit of disconnect
sometimes right? We are going tohave to accept what I what I
think is to be you know what,we're gonna take moderate risk
by doing low tide roll buddy tobuddy transfusions, we can
mitigate that to low risk, butit's not no risk. And that's

(28:10):
what this position paper issupposed to help people be able
to go out to their commands. Andsay we understand that and
everybody's on board with a lowrisk program like we have set
up. Just couple storyboards.
This is, you know, NSW islooking to formalize their
programs. We were training somefolks up with the seals to make

(28:32):
sure that they were theyunderstood how to use the
Valkyrie program. This is theone I thought for sure I was
gonna lose my job over and Ididn't yet. We have some unique
assets within First MarineDivision with our force
reconnaissance teams becausethey're small. And they asked if
they could do send their Marinesthrough with no corpsman. So
this is a course that we heldfor some force connoisseurs

(28:54):
Marines, there is no medicalpersonnel that went through this
course. And they scored higheron their practicals and their
written exams than as an averagethan any other class that we've
run through so far. So they'recapable now great. These are
these are kind of self selectingright. These are these are
Marines who are pretty hardcharging. But yeah, they're
capable of it. Absolutely. Andwe took that information and we

(29:15):
realized we may not want our,all of our Marines, transfusing,
necessarily, but we cancertainly teach them how to draw
blood. And they can certainlyrun the administrative acts
aspects of making sure thatwe've got, you know, people who
are pre screened and identifiedand labeled appropriately. And
so our Marines have been hugeforce force multipliers for us

(29:38):
in our low Tyro, low bloodprograms. I'm not going to talk
too much about these because Ithink he's going to come up a
little bit later. But there'ssome folks in this room who did
some excellent work, overseastraining our partners on our
best best practices for lowtiter oil programs. And those
certainly, were used in somevery real world circumstances
that we're gonna talk aboutlater on this conference as

(30:00):
Well, just in your mouthstealing a thunder, am I? Okay,
so this is a couple a couple oftext messages back and forth
with some folks on the ground.
When you see the acronym CTM upthere, and I'll read it for you.
That's so CTM is our combattrauma management course that we
run. It's nothing. So it soundsgood. Yeah. time ago, it's tough

(30:22):
to long. You got it, sir Gaby,all the way to the tactical
combat here, the tactical combatcare course, right? That is
purple medicine. It's justmedicine, medicine doesn't
change, no matter what coloruniform you're wearing, or where
you're where you're working onhow you apply that medicine to

(30:42):
your platform, to your aircraftto your Bradley assault vehicle
to your ship to your submarine.
That's the platform applicationcourse the medicine doesn't
change, or too too littledifferent things. We got to look
at them. So our platformapplication course, is our
combat trauma management, ourCTM course this is teaching
ground force Marines how to workout of a backpack and the dirt

(31:03):
while it's raining at night.
That's how we apply our T TripleC. So the comments that came out
of the HK attack right all ofthe corpsman except to have been
to combat trauma management.
Will irk the two didn't go we'reworking on that. All the Marines
were CLS combat Lifesaver train.
So our requirement is to havetwo per every corpsman, which
would only give us about 120Marines out of a battalion

(31:27):
landing team. Instead, theytrained up 1000 Right there are
there was about 100 150 Thatdidn't get chance to get that
training, they turned 1000sdead. And the all of them that
were involved were combatLifesaver train before
deployment.
A handful from each platoon,Marines, sailors, Marines, rebel
crew trained Marines as well toassist. I wasn't around for the

(31:51):
blasts of the casualties, butthe boys performed. They said if
it wasn't for CTM and Valkyriethat they wouldn't have known
what to do. We can teach thismedicine in the hospitals. But
if we're not working on theplatform application stuff,
we're not given people theconfidence to use these skills
forward. We're potentially setthem up for failure. I'm gonna
talk very briefly aboutprolonged Casualty Care for a

(32:14):
couple of reasons. So first ofall, prolonged field care.org.
So Sean Keenan who used to cometo these and still does
occasionally, retired ER docstill works at JTS. He he was a
visionary, right, he worked witha special forces, he realized,
my situation might be a littledifferent. I might be holding on
to folks for an extended periodof time. And we really don't
know how to train people to dothat the special forces. And he

(32:36):
really along with some smart,smart folks, pushed this
prolonged field care concept.
This website, prolonged fieldcare.org is a great resource for
podcast for case studies forsome training, documentation,
all sorts stuff, it's reallygood to go take a look at. But I
want you to notice something.
His website he called prolongedfield care, right. And I'm

(32:57):
calling this prolonged casualtycare what was a different term
turns out, I'm gonna give you anexample. If you're, if you're on
a submarine submarines reallyrarely take physicians on they
have an independent dutycorpsman mission that submarine
is to go and stay hidden. Right?
Number one priority, stayhidden, do not come to the
surface. You got a medicalproblem that you have to deal

(33:19):
with and you can't come toservice and you're in the middle
of nowhere trying to hide? Isthere a better definition of
like prolonged casualtyscenario, right that that is
what submarines do. We took hisprogram the surface fleet, we
took it to the submarine fleet.
We said, Hey, prolonged fieldcare, we got to figure this out.
And they said, we know we don'tgo to the field, or summary. We

(33:40):
don't deploy to the field. Yeah,but you gotta understand there's
a lot of parallels here. Wedon't go to the field. Would you
consider it if we changed thename and called it prolong
casualty care instead of yeah,we can go on board them. So even
though there's still referencesto the prolonged field care,
we're really trying to go incall it more prolonged casualty

(34:01):
care, because, again, themedicine is purple. Doesn't
matter what uniform you'rewearing. So this, the initial
CPGs just came out at the end oflast year there again, on
deployed medicine, if you wantto pull up the newest version.
They're not perfect. This isversion one. They're good.
They're not great. And we needsmart people to look at this

(34:24):
problem sets for people likefolks in the room that are
willing to come to JTS and helpus with version two and version
three. Is there a startingpoint? Now? What's what's not
there? Initially comes theguidelines, and then the
guidelines drive the curriculum.
So we're in the process ofwriting the curriculum right
now, again, folks that areinterested in curriculum
development. Excellentopportunity. That's a huge, huge

(34:45):
beast that we're trying totackle. I'm trying to figure out
the prolong Casualty Care piece,but we're on timeline. I think
when battle Hancock says thathe's never just career felt like
we were closer to this potentialconflict than today. Do we need
the help we need? We need folksthat are smart here to help us
through it. Let's talk about acouple cases. If I can make it

(35:06):
short in time, someone's gonnaweigh me. You give me my, um, we
have to get comfortable withbeing uncomfortable. So I'll
paint the situation here alittle bit for you. This is a
very small try service surgicalteam. You got a general surgeon,
a ER doc a CRNA. And a PA. Samecountry with his partner forces

(35:29):
got a call. They're about 150miles away saying hey, we took a
bunch of casualties bunch ofgunshot wounds. That there's
there's no medical resourcesthere. Can you guys help out?
That surgical team was engagedin a mission 150 miles away
supporting us US servicemembers? The answer is no, we
can't come to you. But if youcan, if you can get your

(35:49):
patients to us, then we'll we'lldo what we can do can't promise
you anything. Good enough. Sothey loaded up half dozen
patients G SW the chest,abdomen, pelvis. And then this
gentleman who had a G SW to theleft side of the brain, as you
can see here. 150 miles in somecountries coming down from
mountainous terrain in anunimproved roads turns out to be

(36:10):
an eight hour car ride. Thispatient had zero interventions
for eight hours. This contractone of that shows up GCS of 10.
Following commands with norights moving on the right side
of the body. And then obviously,the entry exit wound that you
see up there.

(36:30):
So let me ask you, what do youdo? There's no there is no
neurosurgeon in this countrythat that patient's never going
to see a neurosurgeon. There isno neurocritical care bed in
this country. You've got limitedresources that you're there for
a reason. What do you do withthis robot for the quarter to
die? Give it a shot. Is iteasier if he came in with GCS of

(36:57):
three that make the decisionprocess a little easier? My mind
it does a 10? What if thispatient went from 10 follow
commands and was compensated aneight hour car ride in the back
of the truck through themountains, they got to you, in
front of your face goes from aneight or from a 10 to a seven to

(37:19):
a six and the first 30 minutesto your assessment that change
your calculus at all. There's noright answers, just some to
think about. This team decidedthat they're gonna get to shop
right. Like other folks thathave either trepanation or
craniums as a moderate as aregular part of their practice
in this room, I kind of doubtNo, but we, we all think about

(37:42):
it, especially as militaryphysicians. And I in my mind,
like I had, like, this is whatI'm going to do when this
situation arises. And I thinkback to the pictures and the
drawings and you know, go intothe cadaver lab and we practices
so the cadaver lab. Andeverything in the cadaver lab
was pristine and out like theolder but pristine anatomy in

(38:03):
terms of an intact calvariumskin everything. Everything in
the picture showed perfectanatomy before you start this
procedure. And then you get youraha moment where you're like, Oh
man, there's like bonefragments. Soft tissue
disruption, and my plan didn'tsurvive first contact going in
to see this patient right. Soyou can see here, obviously, the

(38:24):
scalpel station had to bemodified to incorporate the
wounds flaps raised. I'm gonnaforget the name, the rainy
clips, a little clips here rainyclips. Obviously we're not
carrying any clips. So when youcut that scalp and start to
bleed Whitesnake, well that'sgonna take a half a minute to
sit down and run some mock andsutures and try to get some
hemorrhage control. Andobviously, nobody nobody was

(38:44):
available for for this case. Wehad a percentage gain we saw
Roger elevator and of course,one of the first things that
happens is this thing. You can'treally see a therapist duct
taped together because it didn'tsurvive the initial initial
procedure. bone fragments wereremoved to get to the gig we saw
under the wound right theelevator used to free the dura

(39:07):
devitalized brain tissue. Weknow what devitalized brain
brain tissue looks like. Yeah, Idon't either. Looks good. This
doesn't stain something washedout and then without a bogey.
We've never I've never seen anybuddy publish a paper plate
saying they put combat gauzeinside a woman like this to try
to get some hemostatic controlbut what are you gonna do? The

(39:31):
Durva was there it was closedand the obviously a drain was
placed in the skin was juststapled. So that patient was
excavated about our six or sevensomewhere in there. Did okay.
That team got a call post op dayto a retasked you got a critical
mission. You're moving. What todo about this patient right.

(39:57):
There were some folks that hadzero medical training They're
gonna be there. All right, we'regonna teach you about Cute, cute
24 hour antibiotics that aregonna go through that IV line.
This is how you do it. Watchthis once. Rest is on you
feeding somebody for extendedperiod of time. Wow. What are
you do? You look around? Well,we got baby formula in the, in

(40:21):
the village here and we got someprotein, protein powder. We got
some electrolytes and did someback of that napkin calculations
and give it through an NG tube,right? It's not perfect. That's
what we do. We figure things outin our community. 10 days later,
Tim gets back takes a look athim, right. Obviously, he
continues to be paralyzed on theright side, but he's eating,
he's talking he's up to awheelchair. Never get

(40:43):
neurocritical care, rehab. He'sliving, right. These are hard.
These are hard questions. Weneed to get uncomfortable or we
need to get comfortable beinguncomfortable. That's a I think
that's what our next featureconflicts will look like. What
does that mean trepanationtrainees, limb amputations. I
guarantee you the morbidity andmortality associated with me
performing a limb amputation isgoing to be significantly higher

(41:05):
than an orthopedic surgeon doesit. But I can also guarantee at
some point and a vascularnecrotic limb is getting
infected. That's going to have ahigher morbidity mortality than
me giving it a shot right? Weneed to get comfortable with
being uncomfortable. That'sGrotius fasciotomy. And for me,
my worst feared procedure outthere dental extractions right
just hate to can't do but one ofthe most common things we're

(41:28):
going to be called on to do.
Alright, right. I'll make thisquick. Just run through
especially for the residents inhere right think about your aim
general team, your oral boards.
Look at all those resources. Youhave em docks, trauma surgeon
anesthesia, you got residentsrunning around nurses, techs or
T BloodBank security clerks.

(41:50):
Look at all your resourcesright? IR suite CT surgical
subspecialties blood banking,but took you forward and took
those away. And I left you withthat. This is the construct of
the Navy's roll one shock traumasquad that goes out with the

(42:10):
Marine Expeditionary units waswhat you got in pride are a PA
emergency nursing and put a dutycorpsman you're working with
limited Class A portableultrasound, portable monitor,
portable ventilator, and I statand maybe a cooler to take some
blood products with you ifyou're lucky. We got to get
comfortable being uncomfortable.
Ibo to monitor right rolls offeverybody's tongue in this room.

(42:31):
Let's talk a little bit aboutideas. John, anybody in this
room know John, there's no doubtJohn is the one of the world's
sneeze when it comes to IO. Iocannulation. Jonathan, I also
own a fishing boat together inSouthern California for offshore
fishing. The problem is offshorefishing in Southern California,
two to three hours to get up tothe fishing grounds. Two to

(42:54):
three hours of which I have tolisten to IO stuff about which
is great. I like them, butthey're fast with a required
training. It's the first skillset when we're tasked saturating
a small team that we give to themedical the corpsman and you got
to train for it. And they'retemporary. I'll talk a little
bit about cortices right so Ithink everybody's probably

(43:14):
tracking first thing I do is Itoss out all the triple lumen
catheters on deployment stuffwhy you need triple lumen
volume. Right good to get aquarter and you're gonna get a
Cordis. Why do I say sevenFrench? Why is that the only
size I want? Rainbow right? Itcompatible. But you know,
obviously you got to make surethat that seven French is gonna
be compatible. If you're goingto take Ribault that you bring

(43:35):
this up in French where youdidn't put it up there. But if
you're gonna go for an AC line,like why not the ric? Why
doesn't every AC line getfollowed up with a Rick more
stable, less chance it's gonnablow on. Oxygen always is a hot
issue. I love oxygen too. Ifyou're talking about hanging on
to a patient for 72 hours, itcomes down to Cuban weight. And
to a certain extent the factthat compressed highly

(43:57):
compressed oxygen and a tankwith a lot of hot lead flying
around on the battlefield istypically not a great thing. But
just the straight volume of whatyou need for for long range
medicine. It is very challengingif you have it fantastic. But
from planning factor, it'sreally challenging. If you've
got young people with relativelygood, good good physiology, pre
pre injury, and we're talkingjust trauma, right? Just trauma.

(44:19):
I look at fixed you know, welook at the equation for oxygen
delivery. I can't change thevariable on one side. The two
that we really have to look atit the hemoglobin, oxygen,
oxygen saturation, right? Thereare certain things I can do like
put a chest tube in if there'sif there's a lung problem to fit
the saturation, but what can Ifix the most out of that one
compared to give him a littleoxygen taken from 70 to maybe

(44:40):
like low 90s I could fill themback up with hemoglobin. So I
don't sweat not have access tooxygen i Of course I'd like it
but it's not it's not a gamechanger for me. And finally,
monitoring right? That's anursing skill that we put in
physician hands. Like everybodyknows a watch, watch a resident
go in a room patients go Goingcrazy the monitors going off. We
know how to hit the silencebutton. I walk out to tell the

(45:03):
nurse like I don't even knowwhat's wrong with the monitor
like without you look at thevital signs to see if there's a
reason the monitors going off inthe first place, right? But But
it's more than just that right?
It's not just Do you know how todo the button ology it's Do we
know how to appropriately usethe monitors, so we know how to
use in tidal co2, we're doingstations or substations. And

(45:25):
then I always probably put aplug in for low tech solutions.
Very similar receive patients,you know, cut out that last
situation, again, in a pickuptruck coming from hours and
hours away, the onlyintervention that they had done
to him. And it was across theboard, half dozen patients the
only intervention, not woundwash out not splints, not

(45:46):
tourniquets, or Foley catheter.
Everybody had a Foley catheter.
It took me a while to wrap myhead around, like why did we
take the time to drop six fulllength catheters throw these
guys in the truck and get themto somebody else to take care of
them? Because if you don't havea monitor, and you're in a
country where you don't haveaccess to a monitor, that's a
pretty good monitor, right?

(46:07):
What's the urine output looklike over time. So useful? Well,
other low tech solutions, pulseox, right? If you're one except
a little bit of, you know,potential infection control
risk. You can carry the pulse oxaround from patient to patient
patient. Within 60 seconds, geta pretty good snapshot.
Everybody poo poos the risk BPcuffs, right? And I'm gonna

(46:28):
agree the values you get welldocumented in the literature are
low fidelity numbers, what Ilove them for if you keep the
patient in the same positionevery time you use it, you can
follow your trends over time.
That's what I care about. Idon't care about the numbers
much they care about the trendover time. All right, I'm out of
time. Okay, let me tell a verybrief story here. Iwo Jima has

(46:51):
what is known, not called EvaTau has a reunion with honors
every year.
They're actually wrapped becauseof COVID. They've they've
finished this up now. But theywould bring World War Two
veterans from Japan and fromUnited States, the small island,
the very, very middle of thePacific Ocean for a really,
really important ceremony. Itwas right. And so of course,

(47:15):
they asked for some medicalmedical folks to help out. Hey,
can you bring your shock traumaplatoon just to make sure
nothing happens with these folkswho are in their 90s that are
coming out this island in themiddle nowhere? Yeah, we'll
support you but like I'm gonnaI'm gonna need some medical
equipment. We're going to justbring just bring it back back.
It's fine people to pass andjust use the backpack. No, no,
no, no. We're gonna bring a biga small kit with real supplies,

(47:38):
and I'm gonna need an aircrafton standby. Like you're telling
me you need to see 130 stateYeah, I need to see 130 Standby
on here. Okay. So we thought andthought and thought. We got
there a couple days ahead oftime. We set up all of our
monitors. We plugged them in, wewere ready to go. This gentleman
who was at Mount Suribachi onIwo Jima the first time was
being driven there. There was acorporal that was driving the

(47:59):
bus he said Stop the bus at thebottom of the hill. First time I
was here, I walked up, but towalk up it again. Court was
like, Okay, sir. They need mid90 year old gentleman walked up
to the top of Mount Suribachi tojust find gotta ride back down.
The ceremony was kind of at thebase of the bottom the island.
Halfway through the ceremony, hecodes. Right. So we're

(48:21):
cardiovert ng getting callsback. Grab all of our equipment,
we go to the C 130. That weasked to be parked there. Within
10 minutes, the first monitordies. We had that thing plugged
in for two days, right? Nobodydid better maintenance on the
monitor center warehousesomewhere. That's okay, we got
two more. Your second monitorwe're gonna do crapped out.

(48:44):
Third monitor. We are not 45minutes off of this island
trying to get someplace likeGuam or Hawaii. Before we lost
all monitoring capabilities on aRoss patient on multiple drips.
We've got intubated, I'll see130 So my risk BP cuff and my
pulse ox they were money. Makefun of him if he wants to, but
they were money.

(49:05):
All right, we're gonna flythrough a couple of these. So
I'm gonna get to this one righthere. So I get there too. I'm
unapologetic about beingemotional about these cases.

(49:29):
Sergeant Vargas Andrew's 29surgeries. This kid is doing
great. Right? He is alive.
Living at Walter Reed right nowwith his mom because of some
heroes in this room right nowthat we're taking care of.

(49:51):
When his mom calls me, and shedoes on a daily basis, right?
This is a kid who lost vitalsmultiple times. He spent a whole
lot of time on ECMO. He's got along road recovery ahead of me.
But she says, Thank you, for hissecond, and his third and his

(50:13):
fourth chance at life. There'spurpose in what we're doing
here. And we have heroes in thisroom, who are responsible for
this young man still beingalive. And I'm on apologetic
about caring about that. So onthat note, one of my favorite
pictures ever, some of our bloodtraining on one of our Marines
Blue Diamond as a seal for FirstMarine Division. Marines are a

(50:34):
big deal to have on your arms.
Apparently, this one, they kindof looked the other way when he
got this tattoo. But I like it alot. So any questions or
concerns? I know I went a littlebit over if I need to take them
afterwards. I'm happy to do so.
Okay, yeah, sir.

Unknown (51:02):
Blue there. In a case, there needs to be logistics

(51:24):
being pushed forward, becauseyou're gonna run out of stuff
that we think about trauma allthe time, as much as trauma,
every patient, right? Whateverit is.
It's gonna be a bigger problem.
For the juniors in the roommoving forward, you've hit on it

(51:48):
a couple of subtle, subtlemoments, but I just wanna
highlight it because I thinkit's not something in our
forefront. It's not somethingthat we train for often. The
casualty estimates that you arelooking at, you had a sign that
showed 60,000, the last 20 yearsof war. If we go to war with
China, we're talking 40,000 intwo weeks. And with that comes
prolonged field care andexpectation management, we've

(52:09):
come out of 20 years of warwhere our expectation is 99% of
people who touch a physician aregonna make it home. That is not
what's going to happen if wehave 40,000 casualties in two
weeks. So these medics arecoming into it thinking I need
to be a master because everybodywill live if they can meet me.
But that's not what's going tohappen. So the mental health
aspect of training your teamsand debriefing afterwards. I

(52:30):
love that text message becauseright above it, you said how are
you mentally? And that isincredibly important. We don't
ask those questions and we don'task that of our medics. We don't
ask that of our residents. Weneed to

Travis Deaton (52:43):
be tastic alright, I talk to you long I
apologize if there are any otherquestions please grab me during
the conference and I was seriousif there are folks that want to
contribute to the joint missionright we are looking for people
at T Triple C we're looking forpeople to PCC groups we need the
help and we quite honestly weneed fresh eyes young folks
folks with different experiencesto come in and give us handsome

(53:06):
thank you again. Next year

Laura Tilley (54:21):
right, so that was like a 10 minute break and then
1345 We're back here for thepanel discussion.