Special Forces Medical Sergeants Surgical Training Rick Kelly,

Special Forces Medical Sergeants Surgical Training Rick Kelly, SFC/18D (Ret), GS-11 Primary Instructor for Surgery SFMS, SARR Joint Special Operations Medical Training Center (JSOMTC)

DISCLAIMER The opinions and/or assertions contained herein are the private views of the author and are not to be construed as official nor as reflecting the view of USSOCOM, SWMG(A), the Department of the Army or the Department of Defense . Financial disclosures: None. The presenter will not discuss patients or wounds mentioned in this presentation beyond what is presented.

Introduction

Objective My intent is to enlighten the many health care providers that have the opportunity to advise and support Special Forces Medics, in order to reduce misunderstandings and confusion when providing this needed support. By understanding what the Special Forces medic is taught and why, you will better understand how to assist him.

AUSTERE vs. AUSTERE Military medical units vs. International Committee of the Red Cross (ICRC) and SF Medics

AUSTERE (Military)

AUSTERE (Military)

AUSTERE (Military)

AUSTERE (Military) We know that the conditions a Forward Surgical Team works under is much more challenging that working in a fixed treatment facility The Forward Surgical Team does have many luxuries that the 18D does not have This is rightfully so, our troops deserve the best forward medical treatment in the world

AUSTERE International Committee of the Red Cross (ICRC)

AUSTERE International Committee of the Red Cross (ICRC)

AUSTERE International Committee of the Red Cross (ICRC)

AUSTERE International Committee of the Red Cross (ICRC) The ICRC has been highly successful without many of the luxuries that an American Forward Surgical Team has Without these luxuries, the ICRC have found a way to be successful 18D’s will be working in conditions much more aligned with the ICRC

Why we have adopted the ICRC Military Medicine Triad Evidence vs. Equipment (resources) vs. Environment The ICRC has abundant evidence of success, working in the environment and with resources similar to the 18D

Topics Background What we learned What we teach and why

Single Slide on Anesthesia Monitored Anesthesia Care Light sedation Regional Nerve Blocks Sciatic Femoral Posterior approach to the inner scalene All associated lower blocks IV Ketamine bumps, or drips (TIVA) with a Benzo for failed blocks Back to the good stuff

Background NATO Emergency War Surgery Introduction of ICRC methods Abandonment of ICRC methods Procedures performed as in Military MTF Reintroduction of ICRC methods

Background What we teach now Wound excision Closure (DPC, Secondary) Fasciotomy (lower leg, forearm) Amputation Conditions they perform under now Only the items in their Tactical Medical set Only with the personnel that they will have 2 medics, one or two team mates.

Facts The 18D who receive war wounded Pts (often wounds a day or two old) will sometimes be, not only the prolonged-care provider but, the definitive care provider Conventional techniques are BY FAR a better way to treat these types of injuries. They preserve function better by retaining more tissue, with less scarring, in addition to decreasing pain and healing times in situations that: Are relatively clean Time is available Manpower is available Supplies are available The 18D is rarely, if ever, be afforded such luxuries

What We Learned During our conventional way of performing surgery Full OR staff High-tech, power-hungry equipment Wounds Relatively clean wounds Visited surgically within 1 hour of injury Resulted in extremely high post-op infection rates 2 things that we immediately changed were Discontinue electric cautery Discontinue high pressure pulsatile lavage

What We Learned ICRC method 1 medic “surgeon,” 1 medic anesthesia, 1 or 2 “helpers” Equipment inherent to the 18D TAC sets Wounds Extremely contaminated Wounds visited surgically after 24 hours Immediate and dramatic drop in post-op infection rates

JSOMTC Infection Rates, using Conventional Methods Generally 30%-50% Some attributed to leaving vulnerable tissue in the wound Wound not “matured” Cautery, high-pressure pulsatile irrigation Separating involved (injured) muscles was not emphasized The surgical technique and the treatment of tissues We now stress the importance of gentle treatment of the viable tissue which will remain in the wound The biggest culprit likely the daily “wet to dry” dressing changes Dressing changes in an austere environment (even if the dressing directly covering the wound remains) leaves tissues in or adjacent to the wound to collect contaminants which will grow and invade the wound

JSOMTC Infection Rates, using ICRC Method Approximately 1% Almost all can be attributed to having the bandage come off the wound prior to DPC or the bandage gets saturated with water Either by mistake or purposeful Very small percent due to missing something during excision or not incising long enough (tension) Not separating involved muscles to determine the full extent of the injury An extremely small percent post-closure due to closure under tension

ICRC Doctor Robin Coupland Anecdote Dr. Robin Coupland gave an example of a conflict in which the important people had their wounds tended to daily and the unimportant people were left forgotten in the bowels of the ward. The ones which were tended to daily suffered great infection, but for the ones which were forgotten about, their wounds healed fine.

What we Teach and Why So as I continue, you may scratch your heads and think that something is amiss. I cordially and enthusiastically invite any and all to come visit us and witness for yourselves what we do, what we do it with, how we do it and the results that we get. I believe that we will make a believer out of you, as the many providers who have personally witnessed what we do in our ORs.

ICRC References Designed to help surgeons and non-surgical physicians to understand the nature of the injuries encountered and the medical working environment in a war-torn country The ICRC has been successfully been treating patients under these conditions for decades – they literally wrote the book(s) on it! This is exactly what we are expecting from our Special Forces Medics Many of the .pdf versions are free to download in multiple languages

What We Teach and Why Reference: War Wounds of Limbs: Surgical Management, Coupland, ICRC 2008, first print 1993

What We Teach and Why Reference: War Surgery: Working with Limited Resources in Armed Conflict and Other Situations of Violence, Vol. 1, C. Giannou, M. Baldan, ICRC, May 2010 Available for free download: https://shop.icrc.org/referencepublications-military.html

What We Teach and Why Reference: War Surgery: Working with Limited Resources in Armed Conflict and Other Situations of Violence, Vol. 2, C. Giannou, M. Baldan, A. Molde, ICRC, March 2013 Available for free download: https://shop.icrc.org/referencepublications-military.html

What We Teach and Why 11.5 hours of surgery lecture 9 hours of surgery demonstration 4 days of wound-excision practical exercise 4 days of wound-closure practical exercise 4 days of amputation/fasciotomy practical exercise We teach the ICRC method of amputation and the standard 2incision, 4-compartment release of the lower leg and forearm, as advocated by the USAISR, so we will not go into these details in this presentation 24/7 nursing care for the entire 12 training days by the students Telemedical consults also available 24/7, via on-call instructors

What we Teach and Why Why the ICRC method works for us Easy to understand references Basics, basics, basics oh yeah, did I say basics? We take young, but talented enlisted men: give them an old, contaminated and even infected wounds give them only the bare and crude necessities to perform the procedure A few instruments 4x8 gauze packs Cloth drapes They sterilize in a pressure cooker or use formaldehyde or gluteraldehyde Give them non-compliant patients that live in filth Allow the students to make all the treatment decisions and plans With all this, these medics are HIGHLY successful!

Average SF Medic Surgical Pack Emesis basin 4x8 gauze Hand towels/sterile wraps (draping material) Volkmann retractors Lewis rasp Gigli saw/handles Adson forceps Tissue forceps Needle drivers Mayo dissecting scissors General operating scissors #3 scalpel handle/#10 surgical blade Allis forceps (for both procedure and as use as sponge forceps) Hemostats Towel clamps

Sterilization

What We Teach and Why Who are these soldiers? They are extremely well trained Special Forces Medical Sergeants They are not medics whose primary mission is to provide medical care They are NOT Civil Affairs medics, Psyops medics, JSOC medics, infantry medics, etc. These men are a part of a small team whose primary mission is the planning and performance of fullspectrum combat and combat-related missions Their mission set dictates their time utilization This is but one constraint

SF often work in split teams or cells in which each individual is needed for a successful combat mission

What We Teach and Why What are some other constraints? Supplies A team usually deploys with a pallet, sometimes 2, depending on the mission This pallet space is shared with personal gear, weapons systems, demolition and ammo, communications equipment, other tools needed for the mission, food, and other miscellaneous stuff as well as the medical gear Resupply may or may not be available when needed, especially in the amounts needed Manpower There are only 2 qualified medics on a detachment (at best). Other detachment members have limited medical knowledge Cross training is dependent on the medic and time available

edical Equipment Loadout Team Loadout Typical space for medical equipment

Sterile Surge pack 4 Chlorhex scrubbers 2 Surg Masks 2 Surg Caps 2 Gowns 2 Double sets of gloves 2 Sterile scalpel blades 1 Sterile Coban 4 plastic Steri drapes 2 suture packs 2 ligature packs Sterile rubber bands Compression Socks Casting/padding material Surgical Debridement or Amputation (sterilization takes over 2 hou Sterile Surge pack 4 Chlorhex scrubbers 2 Surg Masks 2 Surg Caps 2 Gowns 2 Double sets of gloves 2 Sterile scalpel blades layed Primary Closure 7days after insult 1 Sterile Coban 4 plastic Steri drapes 2 suture packs 2 ligature packs Sterile rubber bands Compression Socks Casting/padding material

Supplies ice daily dressing changes x 6 days for 1 patie (Does not include fluids nor drugs)

edical Waste is a Concern in Some Environmen ice-daily dressing changes x 6 days for 1 patie (Does not include fluids nor drugs)

Medical waste in a non-permissive environment with near-peer competitor? Probably not feasible

Man-Hours Needed Initial procedure takes about 10 man-hours total 1 Hour Initial Assessment 2 Hours Manual Labs to ensure patient stable– Hematocrit, Platelets, WBC Plus Each Subsequent Procedure takes another 6-7 man hours 2 Hours for equipment cleaning and sterilization 1 Hour for pre-anesthetic exam 1 Hour for equipment layout and room prep 1 Hour for pre-procedure sedation/regional anesthesia 1 Hour for procedure 1 hour (minimum) for post-op monitoring

What We Teach and Why What does this mean? It means that even when the SF medic exercises economy of time, supplies and motion, conventional treatments will still overtax the medics situation and probably have an unsuccessful outcome These men will be performing truly austere medicine; not just operating in austere country They perform these procedures to save lives and limbs; usually on old, mismanaged or neglected wounds of indigenous people Often the definitive provider

AUSTERE HMC Lust (Philippines)

Sweetwater Resort Turned Aid Station HMC Lust (Subic Bay, Philippines)

HMC Lust (Jolo, Philippines) April 2014 - 81 Patients Over 6 MASCAL Events

Serial Debridement Although the ICRC does mention serial debridement in their references, they (the ICRC) do not normally practice this technique because of: Time Supplies Manpower For the same reasons as the ICRC, we do not recommend this technique for the SF Medic, unless: He knows for a fact that this casualty will be in the hands of a qualified surgeon within a day or two

Wound Excision No S/SX Infection DPC 4-7 days after injury Antibiotics S/SX Infection Redebridement Secondary intent if later than 7 days post injury DPC if done within 7 days of injury DPC performed but closure becomes infected At DPC, the wound is infected Redebride prn/pulse irrigation Antibiotics Infrequent dressing change (Q 4-5 days) (secondary intent) In the OR remove sutures, redebride prn, Antibiotics Signs/Symptoms of infection Yes No Continue infrequent dressings Daily sugar or honey dressings Not effective Effective Continue sugar or honey dressings or convert to infrequent dressings Redebride prn/pulse irrigation

ICRC Principles Surgical treatment of war wounds is completed in 2 stages Wound excision – leaving the wound open Delayed primary closure or closure by secondary intent

ICRC Principles Basic Principles Stop hemorrhage and maintain hemorrhage control Make adequate skin and fascial incisions Decompression Drainage Exposure Remove culture medium Leave the wound open To decompress To drain Re-establish physiological function Handle tissue gently and treat the tissues with respect Do not create culture medium

Patient Prep What we do Start early administration of war wound therapy (anaerobes, tetanus) and continue for 5 days or until closure Make patient clean as possible (wash) prior to the OR Emplace tourniquet -- but not inflate unless needed We recommend 90 mins max tourniquet time Will often have to use sphygmomanometer Once in the OR, wash and rinse entire extremity (especially the wound, hands, feet, groin, & axilla) Plenty of irrigation while we’re already making a mess Once gowned and gloved, get organized Pay particular attention to sterility

Wound Excision What we do Prep the patient Longitudinal skin and facial incisions Exposure and decompression Excise wound edges (minimally) Separate involved muscles to examine for full extent of injury Do not separate uninjured muscles; this needlessly opens up new avenues for pathogens to hide and harbor.

Wound Excision What we do Excise fat generously Excise muscles using the four C’s of viability Understand factors that may affect the four C’s Excise blood-stained and contaminated fascia Perform fasciotomies over compartments in CS-prone injuries Remove dead, unattached or contaminated bone Excise shredded or heavily contaminated tendon

Wound Excision What we do Any tendons, nerves or bone that is exposed should be covered by skin, a temporary myoplasty or covered with a wet-to-dry dressing that needs to be changed daily Vessels that have the potential for moderate-to-severe bleeding should be transfixed with fine, absorbable suture Always use fine, absorbable suture materials for ligation Low-pressure irrigation using NS, sterile water or potable water is fine 1-3 L cool fluid or until it looks clean

Wound Excision What we do One of the most important steps either after final irrigation or drying the wound: Final Look “Fine-toothed comb” objective to ensure that we are not leaving anything in the wound that might become culture medium for bacterial growth Clots Contusion/unfit consistency Tissue not perfusing appropriately Contaminants Areas of tension I tell the students that if the tissue is questionable, then there is no question: that tissue must be removed Ensure all bleeding is controlled Take a look at every ligation that was placed

Wound Excision What we do Why is this so important? We are going to dress and bandage the wound and keep it bandaged until we revisit the wound 4-7* days later, at DPC Any tissue that is not clean, healthy and does not have good perfusion will become susceptible to bacterial invasion *4-7 days refers to days post-injury, not post-debridement

Wound Excision What we do Dressings and bandages Placed so as not to create pressure or form a plug Should contact all tissue affected by the injury so it can serve as a wick for the exudate Big, bulky bandages to protect the dressing and surrounding tissues, as well as soak up all the exudate If bandage becomes soaked with exudate, simply reinforce it A note about wound VACs It primarily does the same as leaving an ICRC style dressing and bandage in place for several days It keeps the patient from “fiddling” with the wound It protects wound from the environment Allow for serous exudate (wound VACs actually drain better) It is expensive and not in our TAC set Medic will most likely have hand-pump suction device, not constant lowpressure devices It requires training and vigilance

Wound Excision What we do All moderate to extensive soft tissue injuries, with or without fracture, should be immobilized with a posterior splint for at least the first 48 hours and placed in elevation Patient mobilization can begin immediately The affected limb should be elevated and rested for 48 hours and then gentle active range of motion exercises can begin Focus on extension Not so vigorous as to cause injury or delay healing

Delayed Primary Closure Performed 4-7 days post injury Closures never performed after 7 days post-injury The dressing should be dry Dry and hard, almost cast like Discolored by the breakdown of the serosanguinous exudate Have a slight “ammonia” like odor (good-bad odor)

Delayed Primary Closure The dressing should be adherent to the wound Removal should pull off all the collagen within the wound Tissues will contract away and reveal a bleeding base Any collagen noted in the wound should be scraped off with gauze or instrument The wound margins are undermined as needed to reverse the retracted and inverted edges, and to relieve any tension

Delayed Primary Closure The wound is closed without tension If tension is encountered Undermine 5cm from wound margin Close what you can and allow the rest to close by secondary intent Resist any temptation to close with tension Drains are discouraged unless there is sizable dead space Drains should be removed within 24 hours, unless indications warrant longer

Delayed Primary Closure Suture line rolled and dressed Dressing to cover suture line until suture removal We do not advocate for the use of topical antibiotics Closure by secondary intent Gentle washing and redressing Q 4-5 days until closure achieved Large deficits can be aided by the use of sterile rubber bands shoe-laced and stapled across the wound to help keep the skin from retracting

Delayed Primary Closure In the event of infection At time of DPC Do not close Reinstate antibiotics If abundance of exudate Daily sugar or honey dressings until exudate subsides We have used this in the past with great results Closure by secondary intent We do discuss the use of antiseptics (Dakin’s solution) but emphasize that this should be last ditch effort to get control over the infection We have used ¼-strength Dakin’s followed by good irrigation and still observed some degree of damage to the tissues The ICRC recommends that the use of antiseptics in the wound should be reserved as last ditch efforts

Delayed Primary Closure In the event of infection After delayed closure has been performed Remove all sutures Clean wound Need for exploration and re-excision possible Reinstate antibiotics Closure by secondary intent

Army Surgeon General LTG Nadja Y. West Statement before the House Committee on Appropriations Subcommittee on Defense Second Session, 114th Congress on Defense Health Program, March 22, 2016 “I would like to highlight our partnership with the US Army Special Operations Command, Joint Special Operations Medical Training Center (JSOMTC), to identify where we can collaborate to identify best practices and disseminate those to the entirety of the total force. JSOMTC provides a unique opportunity to capture lessons learned from the battlefield as special operations medical personnel provide support. The best practices they identify are instrumental in educating our medical personnel in the conventional force. To that end, we will continue efforts to bring the conventional and unconventional forces closer together and learn from each other.”

In Summary We teach these men the basics of wound care which work in our training model, for graduates of this course who are OCONUS, and for the International Committee of the Red Cross. All performed in austere conditions and working with limited resources. Hopefully an understanding of what these men are taught, along with their mission set -- and corresponding constraints -- will enable providers relate and give appropriate advice.

Questions?

Thank You! Again, I cordially and enthusiastically invite any and all to come visit us and witness for yourselves what we do, what we do it with, how we do it and the results that we get. I believe that we will make a believer out of you, as with the many providers who have personally witnessed what we do in our ORs.