Step 1: Return fire as directed or required., Inspiration for your Doc Wagon campaign Options

[Method]

Hello gang.

I was doing some research for school and I came across an article in Military Medicine titled Tactical Combat Casualty Care 2007: Evolving Concepts and Battlefield Experience. I thought it would add some flavorful details to any campaign featuring combat medicine (Doc Wagon or any character with First Aid even).

The full article is restricted to subscribers but I found a rather long (and ugly) text version HERE.

The best part though are the treatment guidelines. I'll post them in spoiler tags to save people the trouble of mucking through the paper in HTML.

1996 Guidelines

[ Spoiler ]

TABLE III
1996 TCCC GUIDELINES
Care Under Fire
1. Return fire as directed or required
2. Try to keep yourself from getting shot
3. Try to keep the casualty from sustaining additional wounds
4. Airway management is generally best deferred until the Tactical Field Care phase
5. Stop any life-threatening external hemorrhage with a tourniquet
6. Take the casualty with you when you leave
Tactical Field Care
1. Airway management
Chin lift or jaw thrust
Unconscious casualty without airway obstruction: nasopharyngeal airway
Unconscious casualty with airway obstruction: cricothyroidotomy
Cervical spine immobilization is not necessary for casualties with penetrating head or neck trauma
2. Breathing
Consider tension pneumothorax and decompress if a casualty has unilateral penetrating chest trauma and progressive respiratory distress
3. Bleeding
Control any remaining bleeding with a tourniquet or direct pressure
4. IV
Start an 18-gauge IV or saline lock
5. Fluid resuscitation
Controlled hemorrhage without shock: no fluids necessary
Controlled hemorrhage with shock: Hespan (1,000 mL)
Uncontrolled (intra-abdominal or thoracic) hemorrhage: no IV fluid resuscitation
6. Inspect and dress wound
7. Check for additional wounds
8. Analgesia as necessary: morphine (5 mg IV)
Wait 10 minutes
Repeat as necessary
9. Splint fractures and recheck pulses
10. Antibiotics
Cefoxitin: 2 g slow IV push (over 3-5 minutes) for penetrating abdominal trauma, massive soft tissue damage, open fractures, grossly contaminated wounds, or long delays before casualty evacuation
11. Cardiopulmonary resuscitation
Resuscitation on the battlefield for victims of blast or penetrating trauma who have no pulse, no respirations, and no other signs of life will not be successful and should not be attempted
CASEVAC Care
1. Airway management
Chin lift or jaw thrust
Unconscious casualty without airway obstruction: nasopharyngeal airway, endotracheal intubation, Combitube, or laryngeal mask airway
Unconscious casualty with airway obstruction: cricothyroidotomy if endotracheal intubation and/or other airway devices are unsuccessful
2. Breathing
Consider tension pneumothorax and decompress with needle thoracostomy if a casualty has unilateral penetrating chest trauma and progressive respiratory distress
Consider chest tube insertion if a suspected tension pneumothorax is not relieved by needle thoracostomy
Oxygen for significantly injured casualties
3. Bleeding
Consider removing tourniquets and using direct pressure to control bleeding if possible.
4. IV
Start an 18-gauge IV or saline lock if not already done.
5. Fluid resuscitation
No hemorrhage or controlled hemorrhage without shock: lactated Ringer's at 250 mL/hr
Controlled hemorrhage with shock: Hespan (1,000 mL)
Uncontrolled (intra-abdominal or thoracic) hemorrhage: no IV fluid resuscitation
Head wound patient: Hespan at minimal flow to maintain infusion unless there is concurrent controlled hemorrhagic shock
6. Monitoring
Institute electronic monitoring of heart rate, blood pressure, and hemoglobin oxygen saturation
7. Inspect and dress wound if not already done
8. Check for additional wounds.
9. Analgesia as necessary:
Morphine (5 mg IV)
Walt 10 minutes
Repeat as necessary
10. Splint fractures and recheck pulses if not already done
11. Antibiotics (if not already given): Cefoxitin: 2 g slow IV push (over 3-5 minutes) for penetrating abdominal trauma, massive soft tissue damage, open fractures, grossly contaminated wounds, or long delays before casualty evacuation

2003 Guidelines

[ Spoiler ]

TABLE IV
2003 TCCC GUIDELINES
Care Under Fire
1. Expect casualty to stay engaged as a combatant if appropriate
2. Return fire as directed or required
3. Try to keep yourself from being shot
4. Try to keep the casualty from sustaining additional wounds
5. Airway management is generally best deferred until the Tactical Field Care phase
6. Stop any life-threatening external hemorrhage:
Use a tourniquet for extremity hemorrhage
For nonextremity wounds, apply pressure and/or a HemCon dressing
7. Communicate with the patient if possible: offer reassurance, encouragement
Tactical Field Care
1. Casualties with an altered mental status should be disarmed immediately
2. Airway management
Unconscious casualty without airway obstruction: chin lift or jaw thrust, nasopharyngeal airway, place casualty in recovery position
Casualty with airway obstruction or impending airway obstruction:
chin lift or jaw thrust, nasopharyngeal airway, place casualty in recovery position
Surgical crlcothyroidotomy (with lidocalne if conscious) if above measures unsuccessful
3. Breathing
Consider tension pneumothorax and decompress with needle thoracostomy if casualty has torso trauma and respiratory distress
Sucking chest wounds should be treated by applying a petroleum gauze during expiration, covering it with tape or a field dressing, placing the casualty in the sitting position, and monitoring for development of a tension pneumothorax
4. Bleeding
Assess for unrecognized hemorrhage and control all sources of bleeding
Assess for discontinuation of tourniquets after application of hemostatic dressing (HemCon) or a pressure dressing
5. IV
Start an 18-gauge IV or saline lock, if indicated
If resuscitation is required and IV access is not obtainable, use the 10 route
6. Fluid resuscitation
Assess for hemorrhagic shock; altered metal status in the absence of head injury and weak or absent peripheral pulses are the best field indicators of shock
If not in shock: no IV fluids necessary, oral fluids permissible if conscious
If in shock: Hextend (500-mL IV bolus), repeat once after 30 minutes if still in shock, no > 1,000 mL Hextend
Continued efforts to resuscitate must be weighed against logistical and tactical considerations and the risk of incurring further casualties
If a casualty with TBI is unconscious and has no peripheral pulse, resuscitate to restore the radial pulse
7. Inspect and dress known wounds
8. Check for additional wounds
9. Analgesia as necessary
Able to fight: Rofecoxib (50 mg po qd), acetaminophen (1,000 mg po q6 hours)
Unable to fight: morphine (5 mg IV/IO), reassess in 10 minutes, repeat dose every 10 minutes as necessary to control severe pain, monitor for respiratory depression, promethazine (25 mg IV/IO/IM every 4 hours
10. Splint fractures and recheck pulse
11. Antibiotics: recommended for all open combat wounds Gatifloxacin, 400 mg po qd
If unable to take orally (shock, unconscious, or penetrating torso injuries): cefoxitin, 2 g IV (slow push over 3-5 minutes) or IM every 12 hours
12. Communicate with the patient if possible: encourage, reassure, explain care
13. Cardiopulmonary resuscitation
Resuscitation on the battlefield for victims of blast or penetrating trauma who have no pulse, no respirations, and no other signs of life will not be successful and should not be attempted
CASEVAC Care
1. Airway management
Unconscious casualty without airway obstruction: chin lift or jaw thrust, nasopharyngeal airway, place casualty in recovery position
Casualty with airway obstruction or impending airway obstruction: chin-lift or jaw-thrust, nasopharyngeal airway, place casualty in recovery position or laryngeal mask alrway/ILMA or Combitube or endotracheal intubation or surgical crlcothyroidotomy (with lidocaine if conscious)
Spinal immobilization is not necessary for casualties with penetrating trauma
2. Breathing
Consider tension pneumothorax and decompress with needle thoracostomy if casualty has torso trauma and respiratory distress
Consider chest tube insertion if no improvement and/or long transport anticipated
Most combat casualties do not require oxygen, but administration of oxygen may be of benefit for the following types of casualties: low oxygen saturation by pulse oximetry, injuries associated with impaired oxygenation, unconscious patient, TBI patients (maintain oxygen saturation >90)
Sucking chest wounds should be treated with a petroleum gauze applied during expiration, covering it with tape or a field dressing, placing the casualty in the sitting position, and monitoring for the development of a tension pneumothorax
3. Bleeding
Reassess for unrecognized hemorrhage and control all sources of bleeding
Assess for discontinuation of tourniquets after application of hemostatic dressing (HemCon) or a pressure dressing
4. IV
Reassess need for IV access: if indicated, start an 18-gauge IV or saline lock; if resuscitation is required and IV access is not obtainable, use 10 route
5. Fluid resuscitation
Reassess for hemorrhagic shock; altered mental status (in the absence of brain injury) and/or abnormal vital signs
If not in shock: oral fluids permissible if conscious, IV fluids not necessary
If in shock: Hextend (500-mL IV bolus), repeat after 30 minutes if still in shock; continue resuscitation with PRBC, Hextend, or LR as indicated
If a casualty with TBI is unconscious and has no peripheral pulse, resuscitate as necessary to maintain a systolic blood pressure of 90 mm Hg or above
6. Monitoring
Institute electronic monitoring of pulse oximetry and vital signs if indicated
7. Inspect and dress wound if not already done
8. Check for additional wounds
9. Analgesia as necessary
Able to fight: Rofecoxib (50 mg po qd), acetaminophen (1,000 mg po every 6 hours)
Unable to fight: morphine: 5 mg IV/IO, reassess in 10 minutes, repeat dose every 10 minutes as necessary to control severe pain; monitor for respiratory depression, promethazine: 25 mg IV/IO/IM every 4 hours
10. Reassess fractures and recheck pulses
11. Antibiotics: recommended for all open combat wounds Gatifloxacin, 400 mg po qd
If unable to take orally (shock, unconscious, or penetrating torso injuries): IV cefotetan, 2 g IV (slow push over 3-5 minutes) or IM every 12 hours
12. MAST trousers may be useful for stabilizing pelvic fractures and controlling pelvic and abdominal bleeding. Their application and extended use must be carefully monitored. They are contraindicated for casualties with thoracic and brain injuries

2006 Guidelines

[ Spoiler ]

TABLE V
2006 TCCC GUIDELINES
Care Under Fire
1. Return fire/take cover
2. Direct/expect casualty to remain engaged as a combatant, if appropriate
3. Direct casualty to move to cover/apply self-aid if able
4. Try to keep the casualty from sustaining additional wounds
5. Airway management is generally best deferred until the Tactical Field Care phase
6. Stop life-threatening external hemorrhage if tactically feasible:
Direct casualty to control hemorrhage by self aid if able
Use a tourniquet for hemorrhage that is anatomically amenable to tourniquet application
For hemorrhage that cannot be controlled with a tourniquet, apply HemCon dressing with pressure
Tactical Field Care
1. Casualties with an altered mental status should be disarmed immediately
2. Airway management
Unconscious casualty without airway obstruction: chin-lift or jaw-thrust maneuver, nasopharyngeal airway, place casualty in recovery position
Casualty with airway obstruction or impending airway obstruction: Chin-lift or jaw-thrust maneuver, nasopharyngeal airway: allow conscious casualty to assume any position that best protects the airway, to include sitting up; place unconscious casualty in recovery position
If previous measures are unsuccessful, surgical cricothyroidotomy (with lidocalne if conscious)
3. Breathing
Consider tension pneumothorax and decompress with needle thoracostomy if casualty has torso trauma and respiratory distress
Sucking chest wounds should be treated by applying a three-sided dressing during expiration and monitoring for development of a tension pneumothorax
4. Bleeding
Assess for unrecognized hemorrhage and control all sources of bleeding
Assess for discontinuation of tourniquets once bleeding is controlled by other means. Before releasing any tourniquet on a patient who has been resuscitated for hemorrhagic shock, assure a positive response to resuscitation efforts (i.e. a peripheral pulse normal in character and normal mentation if there is no TBI)
5. IV
Start an 18-gauge fV or saline lock, if indicated
If resuscitation is required and FV access is not obtainable, use the 10 route
6. Fluid resuscitation
Assess for hemorrhagic shock; altered mental status in the absence of head injury and weak or absent peripheral pulses are the best field indicators of shock
If not in shock: no FV fluids necessary, po fluids permissible if conscious
If in shock: Hextend (500-mL FV bolus), repeat once after 30 minutes if still in shock, no >1,000 mL Hextend
Continued efforts to resuscitate must be weighed against logistical and tactical considerations and the risk of incurring further casualties
If a casualty with TBI is unconscious and has no peripheral pulse, resuscitate to restore the radial pulse
7. Prevention of hypothermia
Minimize casualty's exposure to the elements. Keep protective gear on or with the casualty if feasible
Replace wet clothing with dry if possible
Apply Ready-Heat blanket to torso
Wrap in Blizzard Rescue Blanket
Put Thermo-Lite Hypothermia Prevention System Cap on the casualty's head, under his/her helmet
Apply additional interventions as needed/available
If mentioned gear is not available, use dry blankets, poncho liners, sleeping bags, body bags, or anything that will retain heat and keep the casualty dry
8. Monitoring
Pulse oximetry should be available as an adjunct to clinical monitoring. Readings may be misleading in the settings of shock or marked hypothermia
9. Inspect and dress known wounds
10. Check for additional wounds
11. Analgesia as necessary
Able to fight: these medications should be carried by the combatant and self-administered as soon as possible after the wound is sustained: Mobic 1(5 mg po qd), Tylenol, (650 mg bilayer caplet, 2 po every 8 hours)
Unable to fight (have naloxone readily available whenever administering opiates):
Does not otherwise require IV/IO access: OTFC (800 µg transbuccally)- recommend taping lozenge-on-a-stick to casualty's finger as an added safety measure, reassess in 15 minutes, add second lozenge, in other cheek, as necessary to control severe pain; monitor for respiratory depression;
IV or 10 access obtained-morphine sulfate (5 mg IV/IO), repeat dose every 10 minutes as necessary to control severe pain, monitor for respiratory depression; promethazine (25 mg IV/IO/IM every 4 hours, for synergistic analgesic effect, and as a counter to potential nausea
12. Splint fractures and recheck pulse
13. Antibiotics: recommended for all open combat wounds
If able to take po: moxifloxacin (400 mg orally qd)
If unable to take po (shock, unconsciousness): Cefotetan, 2 g IV (slow push over 3-5 minutes) or IM every 12 hours or Ertapenam, 1 g IV or IM every 24 hours
14. Communicate with the patient if possible
Encourage, reassure
Explain care
15. Cardiopulmonary resuscitation
Resuscitation on the battlefield for victims of explosion injury or penetrating trauma who have no pulse, no ventilations, and no other signs of life will not be successful and should not be attempted
16. Document clinical assessments, treatments rendered, and changes in casualty's status. Forward this information with the casualty to the next level of care
CASEVAC Care
1. Airway management
Unconscious casualty without airway obstruction: chin-lift or jaw-thrust maneuver, nasopharyngeal airway, place casualty in recovery position
Casualty with airway obstruction or impending airway obstruction: Chin-lift or jaw-thrust maneuver, nasopharyngeal airway-allow conscious casualty to assume any position that best protects the airway, to include sitting up, place unconscious casualty in recovery position;
If measures above are unsuccessful-surgical cricothyroidotomy (with lidocaine if conscious) or laryngeal mask airway/ILMA or Combitube or endotracheal intubation
Spinal immobilization is not necessary for casualties with penetrating trauma
2. Breathing
Consider tension pneumothorax and decompress with needle thoracostomy if casualty has torso trauma and respiratory distress
Consider chest tube insertion if no improvement and/or long transport anticipated
Most combat casualties do not require oxygen, but administration of oxygen may be of benefit for the following types of casualties: low oxygen saturation by pulse oximetry, injuries associated with impaired oxygenation, unconscious patient, TBI patients (maintain oxygen saturation >90), casualties in shock, casualties at altitude
Sucking chest wounds should be treated by applying a three-sided dressing during expiration and monitoring for development of a tension pneumothorax
3. Bleeding
Assess for unrecognized hemorrhage and control all sources of bleeding
Assess for discontinuation of tourniquets once bleeding is controlled by other means. Before releasing any tourniquet on a patient who has been resuscitated for hemorrhagic shock, assure a positive response to resuscitation efforts (i.e., a peripheral pulse normal in character and normal mentation if there is no TBI)
4. IV
Reassess need for IV access-if indicated, start an 18-gauge IV or saline lock; if resuscitation is required and IV access is not obtainable, use IO route
5. Fluid resuscitation
Reassess for hemorrhagic shock; altered mental status (in the absence of brain injury), and change in pulse character
If not in shock: no IV fluids necessary, po fluids permissible if conscious
If in shock: Hextend (500-mL IV bolus), repeat once after 30 minutes if still in shock, no > 1,000 mL Hextend
Continue resuscitation with PRBC, Hextend, or LR as indicated
If a casualty with TBI is unconscious and has a weak or absent peripheral pulse, resuscitate as necessary to maintain a systolic blood pressure of 90 mm Hg or above
6. Prevention of hypothermia
Minimize casualty's exposure to the elements. Keep protective gear on or with the casualty if feasible
Continue Ready-Heat Blanket, Blizzard Rescue Blanket, and Thermolite cap
Apply additional interventions as needed (see Table I)
Utilize the Thermal Angel or other portable fluid warmers on all IV sites if possible
Protect the casualty from wind if doors must be kept open
7. Monitoring
Institute electronic monitoring of pulse oximetry and vital signs if indicated
8. Inspect and dress known wounds if not already done
9. Check for additional wounds
10. Analgesia as necessary
Able to fight: Mobic (15 mg po qd), Tylenol 650 (mg bilayer caplet, 2 orally every 8 hours)
Unable to fight (have naloxone readily available whenever administering opiates): does not otherwise require IV/IO access: OTFC (800 µg transbuccally)-recommend taping lozenge-on-a-stick to casualty's finger as an added safety measure, reassess in 15 minutes, add second lozenge in other cheek as necessary to control severe pain, monitor for respiratory depression; IV or IO access obtained-morphine sulfate 5 mg IV/IO, reassess in 10 minutes, repeat dose every 10 minutes as necessary to control severe pain; monitor for respiratory depression; promethazine, 25 mg IV/IO/IM every 4 hours, for synergistic analgesic effect, and as a counter to potential nausea
11. Reassess fractures and recheck pulses
12. Antibiotics: recommended for all open combat wounds. If able to take po: moxifloxacin (400 mg po qd)
If unable to take po (shock, unconscious, or penetrating torso injuries): cefotetan, 2 g IV (slow push over 3-5 minutes) or IM every 12 hours or ertapenam 1 g IV or IM every 24 hours
13. Pneumatic antishock garment may be useful for stabilizing pelvic fractures and controlling pelvic and abdominal bleeding. Their application and extended use must be carefully monitored. They are contraindicated for casualties with thoracic and brain injuries
14. Document clinical assessments, treatments rendered, and changes in casualty's status. Forward this information with the casualty to the next level of care

[DTFarstar]

I like the fact that from 1996 to 2003, Tactical Field Care 1 has changed from airway management to "Disarm them if they are crazy!"

Both sad and amusing both that that happens enough to need to be said and that that isn't obvious enough without having to put it down in writing.

Chris

[GoldenAri]

I find the note at the end of the 2003 Field Care section about trying to recusitate dead people doesn't work sad as well because of what it implies.

I also found the change in tone in the 2006 from "fight if you have to" to "whatever you do, keep fighting" interesting.

[nezumi]

I also found the change in tone in the 2006 from "fight if you have to" to "whatever you do, keep fighting" interesting.

Keep in mind, if you stop putting down suppressive fire or otherwise gakking the bad guys, they can take a more favorable tactical position and gak both the casualty, the care-giver, and everyone around them. So unless you're in full retreat, keeping the situation under control really is the first concern.

Doc-wagon are a little difference in that they're obviously non-combatants and generally accepted as non-targets however their patient still is. I have to imagine Doc-wagon has special equipment and methods to keep down aggressors in the area, protect the casualty, but not kill anyone who isn't being aggressive and just happens to be around. Gurneys probably involve a lot more kevlar, for one.

[BRodda]

Keep in mind, if you stop putting down suppressive fire or otherwise gakking the bad guys, they can take a more favorable tactical position and gak both the casualty, the care-giver, and everyone around them. So unless you're in full retreat, keeping the situation under control really is the first concern.

Doc-wagon are a little difference in that they're obviously non-combatants and generally accepted as non-targets however their patient still is. I have to imagine Doc-wagon has special equipment and methods to keep down aggressors in the area, protect the casualty, but not kill anyone who isn't being aggressive and just happens to be around. Gurneys probably involve a lot more kevlar, for one.

In a game I played in SR3 were were doing a hit on a corp. Took the guy out, his platinum Doc Wagon bracelet went off. Just as we were leaving the building the security guards got a luck shot and hit our mage... who had a Doc Wagon bracelet.... and we had to figure what the hell to do when the same evac unit that picked up our target swooped down to pick him up too. We ripped the bracelet off of the mage and hightailed it out of there.

*sigh*

Lack of planning I tell you. Gets you every time.

[kzt]

The rule I saw was, "before ABCs, establish fire superiority". You can't conduct medical care when shot yourself. That's why everyone is supposed to carry a one-handed tourniquet, so they can keep from bleeding out before the medic can help them.

The other issue that often gets missed is that DocWagon would have fire support from their birds and combat drones with them.

[nezumi]

The other issue that often gets missed is that DocWagon would have fire support from their birds and combat drones with them.

Is there anything on under what conditions Doc-wagon uses suppressive fire or when they use aimed fire and what sort of ammunition they pack?

I mean consider the following possibilities...

Doc-wagon is responding to a call, some guy has been nailed by Lone Star in the public space. Doc-wagon approaches and the shootout is going on, with the casualty's friends holding back Lone Star. Does LS figure 'well, Doc-wagon will turn the guy over to us when he gets to the hospital, therefore we can let them get through' and avoid firing on DW? Does LS figure 'well, Doc-wagon has a history of 'protecting patient confidentiality' and doesn't release prisoners to us, therefore we want to nail the guy dead/drive off DW'? Or do they think 'DW won't let us arrest the guy, but we can't risk firing on legal citizens, therefore this criminal has given us the slip and we'll need to use some other method to catch him now that we know where he's going'?


Doc-wagon is responding to a call where a Lone Star officer has a private DW account and has been downed in a shoot-out, but his fellow officers are holding back the criminal attackers until DW can get him out of there. Does DW figure 'these guys are criminals, we can't depend on them giving us the space to operate, let's try to nail them, killing them where we can, to insure we get our customer out safely'? Do they figure 'use suppressive fire, gel rounds, gas and smoke to create a defensive zone but reducing the chances of any further casualties, balancing the safety of all parties with making sure the customer gets out safely'? Or do they decide 'don't risk harming anyone unnecessarily, that can result in serious litigation/hurting our own customers/whatever, only fire when fired upon and only fire enough to protect the customer and employees, no more'? Does this answer change whether or not the attackers have SINs? If they're known Doc-Wagon customers?

I've never really considered these things and I'm curious what other people do in their games.

[kzt]

My assumption is that typical rules are that if you don't shoot at DW, they don't shoot at you. Once you shoot at them, there are no rules other then protecting the patient, the team and avoiding excessive collateral damage to bystanders and property. None of this namby bamby gel round crap. tribarrel .50s on the helos in chin mounts shooting AP. And the patient or his estate gets to pay the bills for collateral damage, so...

In terms of the cops, I'd assume DW has a deal with them and won't casually release criminals, so the cops are willing to let DW through. Probably Dw will grab any severely injured cops too as part of this. In appropriate situations they will work with the cops to get customers out as the situation allows.

No player has ever wanted to carry around an electronic tracking beacon on runs in any game I've run. . . And the PCs are typically in and out fast enough that DW isn't on scene yet. So it hasn't come up.

[PBTHHHHT]

Doc-wagon is responding to a call, some guy has been nailed by Lone Star in the public space. Doc-wagon approaches and the shootout is going on, with the casualty's friends holding back Lone Star. Does LS figure 'well, Doc-wagon will turn the guy over to us when he gets to the hospital, therefore we can let them get through' and avoid firing on DW? Does LS figure 'well, Doc-wagon has a history of 'protecting patient confidentiality' and doesn't release prisoners to us, therefore we want to nail the guy dead/drive off DW'? Or do they think 'DW won't let us arrest the guy, but we can't risk firing on legal citizens, therefore this criminal has given us the slip and we'll need to use some other method to catch him now that we know where he's going'?

If I was running the game...
Depending on what the corporations have worked out with the particular jurisdiction in providing the local services, with Lone Star on the scene, the DocWagon personnel would hold back until the situation is resolved, and then they would go in and treat all those that need medical attention (well, those with a DocWagon contract and the Lone Star personnel since they're likely to have coverage since it's cheaper to contract it out with a known provider rather than having it done in-house). It would be stipulated by procedures that have been already hammered out by the legal departments that those who are arrested/detained by Lone Star would be treated at DocWagon facilities under supervised watch until they can be discharged to Lone Star. Well, that's for those with basic, gold and silver contracts...

Those who have Platinum or higher contracts with DocWagon or with special favors, things do happen at medical facilities or in the transport to there where patients manage to escape, it's a dangerous world in 2070.

I envision the Lone Star and DocWagon folks having, at times, friendly relations with each other, especially the guys on the ground since they often times will see each other at incidents and handling/cleaning up the messes. They know they're doing their jobs and don't want to get gacked and they hope that the respective folks from the other company would help them out if they're in a mess. Such as a DocWagon unit being pinned down by some gangers and the Lone Star folks coming in to help them out, those would go a long way and the people will remember when they happen to help each other out.

Doc-wagon is responding to a call where a Lone Star officer has a private DW account and has been downed in a shoot-out, but his fellow officers are holding back the criminal attackers until DW can get him out of there. Does DW figure 'these guys are criminals, we can't depend on them giving us the space to operate, let's try to nail them, killing them where we can, to insure we get our customer out safely'? Do they figure 'use suppressive fire, gel rounds, gas and smoke to create a defensive zone but reducing the chances of any further casualties, balancing the safety of all parties with making sure the customer gets out safely'? Or do they decide 'don't risk harming anyone unnecessarily, that can result in serious litigation/hurting our own customers/whatever, only fire when fired upon and only fire enough to protect the customer and employees, no more'? Does this answer change whether or not the attackers have SINs? If they're known Doc-Wagon customers?

See above, in my world, I'd have the Lone Star officers have a special DocWagon account just for employment since it's cheaper to have a contract with DocWagon then having to provide medical coverage/response in-house. Maybe there's another service they decided to go with, but for this scenario it's DocWagon. In this case, yeah, the DocWagon folks would use their equipment on hand to provide a defensive zone to help out the Lone Star officers.

As for the litigation situation, they probably have statutes passed concerning those that provide emergency response services for the city, especially for government employees and those who are contracted with the government. If the attackers do not have SINS, heh, they don't have much legal rights in the Shadowrun world. If they do, well, they were shooting at DocWagon personnel and you better believe DocWagon probably pushed for legislation that allows for the DocWagon personnel who are legally and properly performing their duties to be shielded from criminal and civil repercussions to protect themselves. If the attackers are DocWagon customers? They should have checked in their contract concerning what happens when they attack DocWagon personnel. Their contracts with DocWagon may be voided and/or also get charged for any injuries to DocWagon personnel.

[Method]

There was a book... NAGEE maybe? that had a bunch of detailed information about how DW operates. I think it basically comes down to three criteria (in order of importance):

1.) How much the client pays.
2.) Where the client goes down.
3.) The locations of any other DW clients in the area.

If a platinum contract holder goes down in the Barrens and there are no other clients in the area, its guns blazing- shoot, question.

And with the autonomous nature of corporations, I see little reason to think that DW and LS have any loyalty to each other. I image LS maintains their own medical corps and HRT rescue squads. DW's loyalty is to the customer. Ultimately, (I mean in the long long run) DW profits from violent crime, so its not like they have a vested interest in aiding the police. You could argue that in some sense LS (prevention) and DW (response) are in direct competition...

[PBTHHHHT]

That's why I said that in my game it'd be this way mainly because Lone Star in their cost cutting will use DocWagon to provide emergency services for their members while on duty. I don't see the smaller corporations (unlike megacorporations) entirely going in-house for some services. Similar to things such as legal, yes corporations will have their own in-house attorneys but for specialized things such as litigation, it's best to call in the firms. Similarly, medical response services, it's better to contract someone who are specialized and it's cheaper than running your own in-house unit. Anyway, that's my personal take on it.

As for loyalty to each other, no, I didn't say loyalty, just a friendly relation. DW's loyalty to the customer will mainly be reflected on the management levels, meanwhile this sometimes may clash with the individual employees' wishes which makes for a great plot hook.

If you've read what I wrote, that's the scenario I imagine along with the legal implications especially with those contracting with a local governmental authority. You may argue such, it's your game, whatever, I'm just trying to figure what would work or not especially from a legal standpoint. But what do I know on that matter.

[Riley37]

"Doc-wagon is responding to a call, some guy has been nailed by Lone Star in the public space...
Doc-wagon is responding to a call where a Lone Star officer has a private DW account and has been downed in a shoot-out, but his fellow officers are holding back the criminal attackers until DW can get him out of there..."

Those questions came up at the DocWagon training session for pilots, gunners and EMTs last week (last week being October 20th, 20X6) and the answers given by new recruits varied wildly with the answers given by long-time field staff. DocWagon reminds all its field staff that they are expected to use their initiative and best judgement while complying with established DocWagon best practices. DocWagon staff who are former military or former employees of CrashCart are particularly reminded to read their manuals and stay aware of differences between the practices of their current and former employers.

...which is my way of saying: the staff ALSO find these situations confusing, and they either follow the drill, or they make a decision on the fly while hopped up on adrenaline and possibly Jazz/Cram, depending on how well they're trained. Sure, it's worth thinking about what the three-ring binder says to do, but that's not always what the pilot will do. There might be times when the three-ring binder says to use minimal force, yet a sufficiently stressed-out pilot, or a pilot whose habits were formed while they were flying for the Aztlan military, may well err on the side of eliminating any possible threats.

Side question: does the manual say that the ambulance driver is in charge and makes any sudden tactical decision, or does it say that the senior medtech is in charge and gives orders to the driver?

[Method]

PBTHHHHT: didn't mean to argue against your post specifically. Just "thinking out loud" so to speak. I think the scenario you've described is perfectly feasible.

More so I was just thinking about the implications of a pay-for-service emergency response company. If you're DW, crime is good for business. It doesn't get any grittier than that.

Riley37: what manual is that? The TCCC guidelines I posted?

[PBTHHHHT]

Ah, sorry about that, didn't want to be too argumentative. Just that I know about the difference in the terms of the goals for the respective companies, but I also wanted to bring in some of the legal implications. Especially since LS has the contract with the local government and really, it's not good to have DW personnel pissing off the LS guys. They would have more authority on the streets, can you imagine a DW response unit versus an LS HRT unit. I can see LS personnel physically preventing the DW folks from going to treat client patients at an incident just by saying the area is not safe. Oh? you're going in guns ablazing? Well, time to call for LS backup units to respond and god help the DW guys if they hurt an LS guy. Nothing would be nastier than saying officer down if LS operates similar to cops nowadays and DW is operating on non-corp property so there's no extraterritoriality issues, hence LS would trump.

Hmmm... either ways the lawyers on both sides win. (IMG:style_emoticons/default/wink.gif)

[DocTaotsu]

If I recall DocWagon typically has a policy of handing over criminals unless those criminals pay well enough to convince them otherwise. Either way I'm sure a corps like DW and a corp like LS have bumped heads a number of times and that that conflict would make for some excellent run fodder. However, I highly doubt that two corps would ever willingly fire on one another over someone over a 20 grand contract. All the legal fees would start to add up.

Riley: What sort of decision making are we talking about? When to go, when to stay?
This question was intriguing enough that I actually chased down someone who's actually been to the sandbox. Generally speaking the driver is indeed the final word on decision making. The driver is ultimately responsible for the vehicle and it's occupants and as such is well within his rights to say "We have to go now doc!" and floor it right the fuck out of there. That said it's not unheard of to have corpsmen drive ambulances (in 3 man teams; one attends patients, one drives, and one handles everything else like comms and navigation). I can't see this practice changing much except to have the ambulance rigged remotely with 2 techs working the patient (senior guy handles the medical stuff and coordination, other guy just waiting till they build drones cheap enough to do the heavy lifting).

From the civilian side I know that ambulances and cops either have terrific working relationships or antagonistic. As such I'd feel confident that it'd really be up to the interplay between the regional DocWagon directors and LS directors. Some cities probably have good working relationships where petty criminals are picked up but turned over and big ticket platinum criminals have to jump through additional hoops to get away. In other places where DW and LS don't get along it's probably a game of tag/urban brawl with both units racing to make pickup and claim extraterritoriality first. I still don't think that DW is ever going to fire on an LS unit, it just doesn't seem like good business.

I tend to think that DW pilots and gunners are specifically chosen for their ability to follow the 3 ring binder rules of engagement. If I recall the basic DW rule is "The gear is worth more than the client" which is why you can't call in DW as fire support if a run goes sour. If you have some gun crazy PTSD Azzie nutjob of flips the APDS switch before he even heads out, well, that cost DW money. Sure the clients estate is technically supposed to cover extraction costs but what if they can't pay half a million dollars in damages? Put them in debtors prison to make fine crafted jewelery for 200 years? Sell them to a bunraku parlor? What if there isn't an estate? Etc etc. DW doesn't profit from doing property damage to sovereign corporate states. If it did those corps would probably stomp on them in corporate court until the changed their policies. Of course, if you, Joe Runner, start lighting up 100k combat drones and taking pot shots at million dollar HTR vehicles... that's another matter entirely. In my game DW rolls with big tubs of freeze foam. Spray the whole street down. Let their credit limit sort them out.

Back to TCCC. These documents do an excellent job of showing how corpsmen roles have changed in the last few years. There was a time, not too long ago, that corpsmen weren't even issued rifles (technically prohibited under a strict interpretation of the Geneva Convention). The "Book" doctrines for medics that involved hanging back, collecting casualties, and staying out of the fight have been steadily going out the window. Most corpsmen recognize that the best medicine is preventive medicine and that the best way to keep Marines alive is to make sure they don't become patients. I've never been comfortable with the notion that I was going to stand outside a building for 30 minutes waiting for my team to clear a building. Something about snipers, bounties on corpsmen/medics, and the fact that I only have a single rifle. And those are just the practical concerns, ignoring that you train with these guys for months and they typically make it a point to keep your happy ass alive. A doc that Marines don't think would crawl through hellfire from brimstone for them is not a doc they are going to want to keep around.
Or as my instructor once replied to "So we'll be right there shooting at the enemy?!"
"Well if you don't want to die..."

Tourniquets are great and that's what all the doc's I've talked to said to go to first. It's been established that tourniqueting (not a word evidently) an extremity is good for a couple of hours and with evac times to surgical care hovering from 30 minutes to 2 hours you still have a pretty good chance to keeping most of that distal tissue. On top of that our training is "Life Over Limb", a credo I'm sure is even truer in a world with type O limbs.

Another point is field resuscitation. During training we were told point blank that if we did chest compressions on a patient under fire, we were wrong. There are very solid tactical reasons for this, namely that tactical triage (because when is there ever just one patient?) dictates that dead people (people you do CPR on) get bumped to the back of the line as far as treatment. This also plays into the latest research on CPR. Namely, the most important thing you can do for someone who is dead/dying is to get them to someone or something who can do something about it. Unless you're a doctor/surgeon with a full code team and a 4 foot tall crash cart and defibrillator, this isn't you. CPR doesn't bring people back from the dead, only AED's and really good drugs can do that with any regularity. The time you spend pounding on their chest and tearfully declaring "Don't die on me damnit!" you could be spending shooting people, dragging them to evacuation, or some combination thereof.

Now in Shadowrun I see a lot of this "definitive care" getting shifted down the evacuation chain to the field level, maybe even the buddy aid level. You're buddy goes down, you slap in an IV, start his biomonitor/medikit/autoinjector/NanoMagic! device and go back to killing people. I'd hate to say it but highly trained field medics might be a dying breed in 2070, being steadily reduced in number as it's easier to have a protocol based automatic machine stim the hell out of a casualty long enough for the Nightingale Autodoc to roll over to them. SpecOp and higher level of care units will undoubtedly have techs for extended care. Why spend all that time and money training a corpsman when you can spend that same cash adding another big gun to the fight?

Erm... I think I'll stop now.

[kzt]

Hey, we have a subscription! Thanks

[DocTaotsu]

kzt: Eh?

A look at the 6th world wiki seems it indicate that LS doesn't maintain a dedicated medical corps. I'm sure they have trained first responders and so forth but it's probably cheaper to outsource general emergency medical needs to DW/CC/whatever (possibly paid for by the city as part of their contract). Their employees are probably happier about that too.

If you want to throw in some interesting flavor text you can show the differences between and traditionally trained medtech against a grunt medic against a sprawl survivor.
A medtech is going to want all the right tools, clean medikits and what not. He'll do AR checkoffs, run all the diagnostics and generally follow "the book". He'll probably want and have the best and the brightest gadgets, burn paste, chem neutralizers, and as such he'll be ready for a broad range of eventualities. He's also going to plan on getting to a proper hospital pretty quickly and long term care might not be his strong point.

A grunt medic is going to strip all his gear down to the lightest load he can and spread it out amongst the people in his team. He'll do a lot of improvisation but much of it will be done ahead of time, like rigging a medkit to open in a certain way or making some gear specific to his team. Perhaps bundling some heavy densiplast sticks with duct tape to use for a splint on his team's 400 lbs troll. He'll meticulously plan but gear himself towards a set of common Very Bad Days ™ and forgo that latest doodad because it takes up room he could fill with more gauze or that really heavy tape he likes. He probably plans for rapid evacuation but has a few tricks (read:drugs) for those long unplanned but cynically expected overnight stays in water filled holes. He still plans on seeing the inside of at least a shadow clinic pretty quickly and having access to a broader bag of goodies.

A sprawl survivor is probably going to be all about improvisation using whatever he has on hand. Why bring gauze? Clothes work just fine! Use the hurt dude's clothes first! Need a splint for the troll? Glad I brought my cutting torch! I'll just saw off a few lengths of rebar to bind him up, maybe some lighter grade densiplast to give him some stability. He'll probably have some homebrewed urban wilderness medicine and know have about 20 medicinal uses for things that come out of vending machines. That sucking chest wound should normally be covered with a special one way valve but today it's covered with a the wrapper from a fruity roll taped down with a vent hole. I also think that he'll have a bigger eye for long term care since he's not at all used to delivering patients to the sterile comfort of a hospital. Where others might go for the quick and dirty solution he might take that extra half second to clean that wound out before spraying it with antiseptic. After all, you never know when how long you might wait to see a street doc on a busy night. I see a lot of these sprawl doc's familiar with "traditional" treatment, archaic things like wet to dry dressings, delayed wound closures, and putting a hot rag on a stye to bring it to a head before draining it. Procedures that no one uses anymore because they have the cure in a bottle or a drone can fix it in half the time.

[kzt]

The one that started the thread.

" You have access to the full text article

You, or the institution you are accessing from, have subscription access to this publication.
View now:"

[DocTaotsu]

Ah! Cool beans.

[Drogos]

DocTao: I must say, some very insightful approaches and I appreciate the input. Now, I'm even more psyched to play my combat medic!!!!

[PBTHHHHT]

Another thing that I almost forgot of why DocWagon might wait till after a fight (between LS and runners/gangers) before getting their patient. They get more for resuscitation services from the clients that way. AND... all the other wounded/dying folks on the field, the DocWagon folks can ask if they want to subscribe to any health services. A bit of a captive audience thing by giving them the option that they can bleed to death or give money to DocWagon and they'll get some patched up.

[DocTaotsu]

Drogos: Well of course you should be psyched to play a combat medic (although you win points for playing a UCAS Navy Corpsman (IMG:style_emoticons/default/wink.gif) )! It's only the coolest job ever, take a couple levels in biotech and you'll be running you're own shadow clinic in no time!

PBTHHHHT: Why that's totally unethical!

And probably about how it works.

*leans over a mangled not-patient* "Okay! We're leaving! Blink twice if you want to purchase our special "field expedient" service plan! Only a 10% service charge! And we'll waive that if- hold on a second." *uses AR to direct a combat drone to hose a no quiet dead gangeR* "-if you sign up today! It's a good deal! Way better than CrashCart." *waves pointedly at the smoking wreckage of a CC Ares Citymaster.*

[kzt]

It would be a "time and materials + 'late contract upcharge'" deal, but only offered to those people with the ability to pay.

[nezumi]

I agree, great material, both from Doc and from PBTHHHHHHT. Definitely fills in a lot of details.

[Method]

DocTautsu: Very cool to here your perspective. Makes me want to create a combat medic myself...