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