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The PFC Puzzle




Story time.

Pull up a camp chair for something a little different with an update on the RAVINES mnemonic to help the austere clinician with prolonged care...


You reflect on the quiet week you’ve had during this trip deep in the mountainous woods. The roaring fire warms your face and dimly lights the surrounding campsite and that of your friends. You sit near a makeshift table telling spooky GWOT war stories to the new guys. It's overcast and a light mist drifts down blanketing everything with a flickering sheen from the fire’s reflection. There is no cell service out this far in the remote wilderness.  The dopamine detox may not be what you intended, but probably needed. Suddenly, and startlingly, a stranger appears from the darkness near your group as if out of nowhere. 


Oooh. Spooky.


Instinctively, you reach for your pistol, but he smirks in your direction, unimpressed, and you know deep down that this situation is not amenable to violence. The hooded man speaks in an ancient, raspy tone that belies his younger appearance.  You sense a familiar, chilling scent on the breeze that instantly brings you back to one of your first trips where things went terribly wrong one night... The hairs on your neck stand up and everyone in the group solemnly recognizes the gravity in the air. 


The hooded stranger begins slowly dropping handfuls of pieces from a large leather pouch on the table in front of you and the group with an offer that you can’t refuse. Unceremoniously, he informs you that you have an undetermined amount of time to complete the puzzle before....

 

Where were we? Ah yes...

The hooded stranger informs you that you have an undetermined amount of time to complete the puzzle before one of your group meets a gruesome end. He gives no clues as to the theme of this puzzle as he glances at the grains of sand trickling through the thin neck of the hourglass he meticulously placed on the table.


The odd shaped pieces clatter in a jumbled pile, some spilling onto the matted leaves and needles below. No one else in the group has ever completed a puzzle like this before. Certainly not in these circumstances or this complexity. It is apparent that there are many thousands of pieces.  They are unusually small, and you are the only one who has had any useful experience with this. Another handful of pieces spill on the table and members of the group begin frantically trying to force random pieces together. It is chaos, making the situation worse and even more complicated. With a rising sense of panic, you have a strong inclination to join them. Sure, you could jump in, helping with no set strategy to eventually get it done; But time is slipping away, and you're already behind. You need to work smarter. You remember to breathe and do what you’ve learned, but first...


Doctors go through years of residency which gives them thousands of hours of patient contacts, developing a deep understanding of the clinical process required to adequately assess and treat patients in the most efficient means possible. Not only are they refining the process of how to put a clinical puzzle together, but they are also learning to identify each piece, eventually just knowing where each goes before the whole puzzle takes shape. This is what is referred to as gestalt, or an innate clinical judgment. Intuitively knowing the direction, a case is going from initial history and physical exam, sometimes earlier, while continuing to follow a process without even thinking about it. 


Operational clinicians such as the medic deployed to an austere environment often do not enjoy a similar level of experience and expertise. This is not an admonishment on any medic, it's just the way it is with precious training time historically focused on other operational requirements. Proper utilization and training are required to hone a highly perishable set of skills.  Many medics placed furthest forward are routinely the most junior. They are only relatively recently introduced to a process with less idea of what a given clinical puzzle will look like when finished. Not only are they potentially seeing each piece of a puzzle for the first time, but they are also still refining, and getting comfortable with a process to organize and manage the many pieces being dropped in front of them as they work through the problem. 


Recognizing that the pieces will continue to pile up in the form of constantly changing casualty information, they will need to quickly and efficiently synthesize and organize the information into a usable framework while also actually performing timely interventions, acting as both the technician and clinician. Therefore, a usable process must be intuitive, user friendly, and forgiving to the point that when the medic is overwhelmed, they can perform emergent procedures in a crisis and then quickly resume where they left off. It must promote a proactive mindset and aid in the identification of impending patient deterioration.  My thinking has evolved to now look at PFC as a process.


In tactical combat casualty care (TCCC) medics routinely fall back to implementing the interventions in line with the MARCH (Massive Bleeding, Airway, Respirations, Circulation, Hypothermia/Head Injury) mnemonic to prioritize addressing the most common life threats on the battlefield in a systematic way.  Additional treatments performed during the Tactical Field Care (TFC) phase have added an addition to the mnemonic: E-PAWS-B which translates to Eyes, Pain, Antimicrobials, Wounds, Splints. When a clinical issue is the problem and not trauma, the medic must pivot to a different approach, gathering information in the SOAP (Subjective, Objective, Assessment, Plan) format while conducting a history and physical exam. Both strategies require practice and experience that can be gained in high quality role-play/simulation and adequate utilization in the prehospital environment.  Routinely performing sick-call for the team or platoon, riding an ambulance, and rounding in a hospital can help provide the baseline experience to begin developing gestalt while refining critical thinking within a usable framework. 


To be good at something, you must practice it. 

-Common Sense (Probably)


As the basics are developed and mastered, the clinician can become more comfortable in opening their aperture to the wider situation at hand and where it will likely lead clinically. Understanding what comes next may aid in formulating a plan and an impetus in performing early interventions to standard but this knowledge may not be available.  In this case, as the medic transitions from initial lifesaving care, or history and physical exam for DNBI (Disease, Non-Battle Injury,) a systematic approach to a patient in an austere environment will help gather and organize the pieces of the puzzle, direct the team available and implement a treatment plan according to emerging trends. Treat what is in front of you and go back to a checklist or mnemonic to ensure that you don’t skip over anything. Sure, you could probably stay very busy without a plan, but adhering to principles and triaging action should make you more efficient in addressing the most important issues. (A study to explore this observation would be awesome.) Training beyond the initial 30 minutes of care will allow you the time to let a case develop to realize where your action or inaction will impact the care of the patient and the likely outcome.


No training will better illuminate the importance of doing good TCCC as the prolonged care of your own patient who has received poor TCCC.


Not following any structured principles-based method after MARCH or SOAP would result in simply caring for a patient for a long time, not practicing effective Prolonged Field Care. I developed the RAVINES mnemonic on a red-eye flight to Denmark in 2016 where I was to share early lessons learned from our prolonged field care working group with our Nordic counterparts. (Thanks Pac and Poul) The question that I was aiming to address at the time was, “when and how do you make the transition from TCCC to PFC?”

This mnemonic should aid the austere clinician to prioritize PFC interventions after completing traditional TCCC in the form of the MARCH PAWS algorithm, or after completing an initial history and physical exam as part of a clinical encounter. As soon as one is able to complete a thorough head-to-toe secondary exam a detailed problem list and corresponding treatment plan should simultaneously be developed. This is most easily done on a dedicated flowsheet. RAVINES can be used as a process to simplify some of the chaos for the medic or resuscitative surgical team with the goal of improving the morbidity and mortality of a patient. If the RAVINES mnemonic is not utilized, other systematic tools and checklists should be considered to help prioritize interventions in order of importance by the small team with limited manpower. Here is and updated explanation of the RAVINES mnemonic:


Resuscitating a hypovolemic casualty with the appropriate type and volume of fluids is an important first step in the process. This is often started in TCCC or during the initial interventions of a life-threatening clinical case. Resuscitation strategies vary widely depending on the etiology such as utilizing whole blood for a casualty in hemorrhagic shock or utilizing crystalloid solutions to the proper hemodynamic goals in the case of burn, crush or sepsis. In order to more easily and quickly recognize potential hemodynamic decompensation, we borrow the idea of trending vital signs from critical care and anesthesia. That is not to say that we are attempting to provide intensive care out of hospital but taking best practices from a well-developed in-hospital specialty and borrow those best practices for use in the austere environment. Ideally this would include as many of the puzzle pieces available of the developing patient picture and would include ETCO2, respiratory rate, Shock Index (from dividing heart rate by systolic blood pressure,) urine output and mental status. Other non-invasive means of assessing hemodynamics may also include passive leg raise (even a unilateral PLR can be helpful when one is immobilized or missing,) or the use of the ultrasound for those highly adept and equipped.


The R in RAVINES also stands, secondarily, for Reducing (or "Replacing") tourniquets as a reminder that if not already done, it should be completed soon to avoid complications prolonged replacement or conversion. The crush injury clinical practice guideline was the first written by our working group to provide recommendations to care for the prolonged removal or conversion of a tourniquet when evacuation was not possible.


Airway, and Analgesia and Sedation is next in the PFC priorities as it easily correlates with what has already been done in MARCH. If a definitive airway has already been established in Tactical Field Care, often it is done hastily and should be reassessed to ensure that it is still effective via capnography, inserted to the correct depth, secured, cleaned, that a Heat, Moisture Exchanger (HME) has been applied, and that adequate suctioning is occurring as needed. Properly preparing for airway emergencies or planned upgrades can be accomplished utilizing the MSMAID mnemonic.

Analgesia and Sedation strategies can make or break a situation depending on the experience of the medic and complexity of the case. You don’t want to find yourself riding this roller coaster and reactively chasing your tail. This is a clear area where leveraging a simple strategy of documenting the time and dose of a given med can help you form a plan to be proactive and anticipate when the therapeutic effects are likely to wear off. A tool to help with performing procedural sedation with minimal technology would be the circle of awareness as practiced in the 18D Special Forces Medical Sergeant Course and Refresher. This method positions the "anesthetist" seated at the head of the patient in a continuous workflow of checking airway, sedation level, breathing, circulation, and reporting, recording and performing tasks every 5 mins.


Ventilation and oxygenation adequacy should be assessed utilizing the MOVE (Mechanics, Oxygenation, Ventilation Eval and Equipment) mnemonic developed by Wayne Trainor at Ragged Edge with our MOVE assessment tool taught to students who attend our courses. Traditional ventilation training seems to focus on troubleshooting issues with a ventilated patient as opposed to optimizing the use of the bag valve mask or mechanical ventilator and assessing the effectiveness when applied to the patient. 


Initiating telemedicine early and often (when available) is an important part of this process and was included in this algorithm as a way to remind medics and those providing austere care that external consultation is expected and not seen as a sign of weakness. The telemedical consultation script was designed to be utilized in conjunction with the PFC Flowsheet and other documentation resources.


Nursing care is next in the algorithm and an important part of PFC. It may incorporate common nursing care mnemonics such as HITMAN, SHEEPVOMIT, FASTHUGSINBEDPLEASE, or others. (A quick Google search will illuminate each.) A mnemonic is only as good as it aids the clinician in reminding the clinician to do things otherwise forgotten. The use of a dedicated nursing care checklist, such as is provided in the Nursing Care Clinical Practice Guideline either on this site or that of the Joint Trauma Service’s (JTS). As part of nursing care, it is important to continue to gather patient information in a systematic way and then plot it in a usable format. With enough trained personnel, this vital task can be delegated to a dedicated recorder as long as they clearly understand normal parameters. When personnel are limited to only one or two, it is recommended that the most senior medic record and trend vitals so that emerging trends are immediately recognized by the entire team. 


Detailing all problems will aid in creating a comprehensive plan that the whole team can work from.  Simply recording vital signs is not enough with minimal experience, late at night when sitting with patients over prolonged periods of time. The most efficient method that I have seen is to capture vitals on a simple chart and then graph them on a dedicated flowsheet as described here. This should be the cover sheet of your documentation to allow you to glance over and instantly perceive trends.  


Environmental considerations are often forgotten or not addressed in traditional nursing care due to the normal, in-hospital environment where nursing is usually performed. It is therefore emphasized here to remind the clinician or medic to address these environmentally specific needs of the patient. Some examples include applying shade or sunscreen where shade is not possible such as in an open back truck, applying mosquito netting or bug spray in malaria endemic locations, or Chapstick and eye drops in extremely dry locations. Unconscious patients being transported in loud, rotary wing aircraft should be shielded from the noise and debris with appropriate ear and eye protection. The bottom line is, if a medic does it for themself, they should do it for the patient as well.


Surgical procedures are last in this mnemonic as every effort should be made to avoid additional potential iatrogenic (clinician caused) complications via an unnecessary or ill-advised surgical procedure. Sometimes, however, there is no other choice but to perform a timely invasive intervention. Our Austere Anesthesia and Surgical checklist should help the medic and their team plan, prepare and perform some surgical interventions on affected extremities as described in the many free resources provided by the International Committee of the Red Cross (ICRC) in their online shop.


At Ragged Edge Solutions we have perfected these processes through hundreds of iterations of medical training with every level of Medic and Non-Medic Responder. This expertise maximizes training time by delivering the highest yield lessons learned without the fluff. Our curriculum provides our participants with practical tools and strategies that they can begin implementing immediately upon returning to their units, without the need for expensive technology. Principles and analog strategies stand the test of time and the abuse of the worst operational environments.


Back at our retreat-gone-wrong in the woods, you stand up and take a step back from the table to delegate roles and responsibilities, putting someone in charge of each critical task with the instructions to ask for help if stuck... Gather new pieces, disseminate common shapes or colors, frame the edges, work in sections. You quickly emerged as the de facto leader and resist getting sucked into any one area unless absolutely critical. You maintain awareness of the overall situation and that of the emerging picture in front of you.  You disseminate information across the group so that everyone is complementarily working toward the same goal. When one of the group flounders or obviously can't handle the stress, you switch them out with another.


The creepy hooded apparition finishes dumping the last pieces on the table and begins to fade back, pausing only slightly each time a piece dropped or misplaced.  As the sand trickles down through the antiquated hourglass still in his grasp, the image begins to take shape on the table. The familiar scene is strikingly clear and apparent to all.  With work still left to be finished, no one dares yet to pause and take it in. 

It is your campsite. 

Your group. 

With a hooded stranger fading into the background. 

As the last piece is placed, the stranger is nowhere to be seen.

The puzzle finished.

The group relieved.


MUHUHUHAHAHA


The woods are lovely, dark and deep.

But I have promises to keep…


-Paul Loos

Vice President of Special Projects

Ragged Edge Solutions, LLC



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