AAR - DMI’s (SOF)OEMS course at Gig Harbor, WA 12 – 21 May 2014.
NOTE - I’ll say up front that I struggled with breaking this AAR down in a way that made sense. I would generally write it chronologically (T-day 1 through T-day 9) but I didn’t break my notes up that way. As such, I decided to just write the AAR as the class appears in my notes. I apologize if it’s hard to follow.
Instructors –
The course was taught by Dr. John Hagmann, Dr. James Goff(sp?), Mark D., Shorty and Mark A. Primary instruction during the lecture portions of the class was handled by Dr. Hagmann and Shorty.
Dr. Hagmann is a retired Army Doctor, sat on the TCCC committee for several (10?) years and is currently working as an emergency physician in WA.
Dr. Goff(sp?) is a Brit. Can’t make coffee to save his life and works out of Hereford with the military (may or may not know the color of the boat house. I didn’t ask.).
Mark D and Shorty are both former 18Ds. Shorty and I worked together in Basra for Triple Canopy seven or eight years ago so it was a surprise to see him again. Mark A. is a former SF soldier turned civilian paramedic with 20+ years of experience on the civilian side of emergency medicine.
Admin -
This class was made up of 22 students. Among them were 1 thoracic surgeon, 2 physicians, 4 Nurse Practitioners (all seven of the above were from DOS), 1 Army PA, 5 corpsmen from NSW, 1 AF medic, 2 medics from Switzerland, 2 medics from Latvia, 1 medic from Norway, 1 Canadian contractor (medic), another American contractor(18D) and myself.
On a personal note, my background in medicine is almost entirely window-licker level stuff. I attended an EMT-B course my senior year of high school. Combat Life Saver in the military and then the usual training that’s given to people carrying guns for a living (team training, medical training at requals, etc.). At no time have I been a professional medical provider in any capacity. Please keep that in mind reading this AAR. Some of the stuff that blew my hair back might be old hat to you.
Administratively the class was broken up into lecture in the morning and lab/prac-app in the afternoons. We trained Mon-Fri, half day Sat, Sun off, then Mon-Wed with an FTX the final two days. Training days were generally 0800 – 1700 with breaks about every hour and at mid-day for lunch.
POI -
The class was centered around the MARCH ON algorithm. Because so much attention in training is generally focused on the Massive bleeding and Airway skills, the algorithm was approached in reverse order to get some time on the lesser practiced/taught skills and information. This being the case, we started the class talking about “N” – No pain.
“N” No Pain – One good thing about music, when it hits you, you feel no pain…. Music and ketamine that is.
As a non-medic, this was largely new information to me. My pain management options in the military were a 10mg morphine auto injector. Since then it’s been “wait for the medic”.
Some of the studies cited were eye opening (fast pain mgmt leading to reduced cases of PTSD, better healing, etc.) and the skills were completely new. The lecture portion focused on the history (morphine ampules, morphine auto injectors, pill packs, etc), the science behind the drugs being used and why they’ve evolved to what they’re teaching now. Micro and macro dose ketamine was discussed and protocols explained, in addition to the pros and cons of each in a combat environment. The lab portion focused on nerve blocks in the extremities and we were able to practice them on each other as often as we could find another student to be our pin cushion.
“O” Open wounds. - Two Latvians cutting dead tissue out of a shotgun wound…. It was like watching Hostel in real life.
The lecture portion focused on longer term care for open wounds. Time lines and causes for infection, prevention of and treatment for infection, and debriding wounds. I’ll hang my head in shame and say that I’d put very little thought into the extended aspects of care before this class. If I’m working on someone my job is to keep the blood going round and round and the air going in and out. Then I give them to someone with magic machines and they make everything better (over the course of multiple surgeries). I’d rarely if ever considered what I should be doing if I can’t get the casualty to the higher standard of care in a reasonable amount of time (1-3 hrs). Casualty care at 6, 12, 24, 48hrs and beyond wasn’t really something I’d studied up on or planned for. This portion of the class was cold water to the face.
“H” Hypothermia/Head Injuries – Naked slumber parties and trying to restrict fluids.
As a climber I’ve been pretty well versed on treatment for hypothermia for quite a few years. The science behind why the treatments that work, work was really interesting to me, but I had a pretty good idea what I needed to be doing going into it (even if I didn’t know exactly why). Likewise the head injuries. The issues that closed head injuries raise with fluid management was a good take away for me from the science side, but my team medics have been preaching from that hymnal for quite a few years.
“C” Circulation – You want to put that needle where?!
This portion of the class focused on fluid management and shock. The science and studies on shock were some of the most interesting material in the class for me. First of all Dr. Hagmann made the distinction between massive hemorrhage (loss of all your blood volume leading to death) and shock (tissue hypoxia due to decreased effective cardiac output). Basically, to keep people from dying of shock, we need to keep the rest of their body getting oxygen.
The various fluid products on the market were discussed and ordered in least – most effective. It should be no surprise that the most effective fluid to give to wounded people is whole blood. For the lab portion we ran typing kits on everyone and then did a few buddy transfusions... of a sort (my blood was drawn, my blood was then given back to me.). As simple as that exercise sounds, I feel a lot more comfortable with the mechanics of the process than I had before. On a small team, knowing everyone’s blood type and carrying a couple of transfusion bags might not be the worst idea.
Another hard skill that was taught was fluid delivered via Inter-Osseous IV. Several different IO IVs were taught and two were demonstrated in class by students. Hats off to the Swiss medics for demoing the B.I.G. I don’t get paid enough for that.
“R” Respiration - Needle decompressions and chest tubes… don’t threaten me with a good time.
The “R” portion of the class focused on keeping air movement happening. Recognizing the signs of labored breathing and keeping the lungs functional enough to do their thing. The indications and procedures for needle decompressions and chest tubes were covered at length. Most students were able to practice both skills several times during the FTX.
“A” Airway – Back to basics.
The airway stuff is pretty simple. It’s a tube that needs to stay open for air to get into the lungs (for that whole respiration business). All else fails you can cut someone. The procedures for a surgical airway were discussed and were able to be practiced during the FTX. Throughout the class battlefield video was used to illustrate a point. One of the points that was reinforced for me, both from watching the videos and from the instruction is that a conscious casualty is usually going to know what position is best for their airway. There’s something about watching a soldier with half his face blown off being repeatedly forced onto his back that I found very frustrating. If the dude can breathe sitting up….
“M” Massive Hemorrhage - Nobody makes me bleed my own blood - nobody!
This portion of the class got into the science behind blood clotting and the use of Tranexamic Acid to assist the clotting process, in addition to all the usual stuff like TQ application and hemostatic agents. The science here was interesting but the hard skills are the same thing I’ve been taught for who knows how long (I can’t, for the life of me, remember when I was first exposed to MARCH).
Final Thoughts –
As a knuckle dragger, I thought for sure I was going to be in over my head when I got a handle on who else was in this class as students. Thankfully the folks at DMI have it broken down so that even when there is a lot of science, someone with a basic understanding of anatomy and their mother-fucker switched to receive can follow without any trouble. The enhanced understanding I gained about *why* I’m doing what I’m doing in addition to the skills that I was able to practice, either on other students in class or on the models at the FTX, left me with a much higher level of confidence in my abilities as a field medic…here’s hoping things are never bad enough that I actually find myself in that roll.
NOTE - I’ll say up front that I struggled with breaking this AAR down in a way that made sense. I would generally write it chronologically (T-day 1 through T-day 9) but I didn’t break my notes up that way. As such, I decided to just write the AAR as the class appears in my notes. I apologize if it’s hard to follow.
Instructors –
The course was taught by Dr. John Hagmann, Dr. James Goff(sp?), Mark D., Shorty and Mark A. Primary instruction during the lecture portions of the class was handled by Dr. Hagmann and Shorty.
Dr. Hagmann is a retired Army Doctor, sat on the TCCC committee for several (10?) years and is currently working as an emergency physician in WA.
Dr. Goff(sp?) is a Brit. Can’t make coffee to save his life and works out of Hereford with the military (may or may not know the color of the boat house. I didn’t ask.).
Mark D and Shorty are both former 18Ds. Shorty and I worked together in Basra for Triple Canopy seven or eight years ago so it was a surprise to see him again. Mark A. is a former SF soldier turned civilian paramedic with 20+ years of experience on the civilian side of emergency medicine.
Admin -
This class was made up of 22 students. Among them were 1 thoracic surgeon, 2 physicians, 4 Nurse Practitioners (all seven of the above were from DOS), 1 Army PA, 5 corpsmen from NSW, 1 AF medic, 2 medics from Switzerland, 2 medics from Latvia, 1 medic from Norway, 1 Canadian contractor (medic), another American contractor(18D) and myself.
On a personal note, my background in medicine is almost entirely window-licker level stuff. I attended an EMT-B course my senior year of high school. Combat Life Saver in the military and then the usual training that’s given to people carrying guns for a living (team training, medical training at requals, etc.). At no time have I been a professional medical provider in any capacity. Please keep that in mind reading this AAR. Some of the stuff that blew my hair back might be old hat to you.
Administratively the class was broken up into lecture in the morning and lab/prac-app in the afternoons. We trained Mon-Fri, half day Sat, Sun off, then Mon-Wed with an FTX the final two days. Training days were generally 0800 – 1700 with breaks about every hour and at mid-day for lunch.
POI -
The class was centered around the MARCH ON algorithm. Because so much attention in training is generally focused on the Massive bleeding and Airway skills, the algorithm was approached in reverse order to get some time on the lesser practiced/taught skills and information. This being the case, we started the class talking about “N” – No pain.
“N” No Pain – One good thing about music, when it hits you, you feel no pain…. Music and ketamine that is.
As a non-medic, this was largely new information to me. My pain management options in the military were a 10mg morphine auto injector. Since then it’s been “wait for the medic”.
Some of the studies cited were eye opening (fast pain mgmt leading to reduced cases of PTSD, better healing, etc.) and the skills were completely new. The lecture portion focused on the history (morphine ampules, morphine auto injectors, pill packs, etc), the science behind the drugs being used and why they’ve evolved to what they’re teaching now. Micro and macro dose ketamine was discussed and protocols explained, in addition to the pros and cons of each in a combat environment. The lab portion focused on nerve blocks in the extremities and we were able to practice them on each other as often as we could find another student to be our pin cushion.
“O” Open wounds. - Two Latvians cutting dead tissue out of a shotgun wound…. It was like watching Hostel in real life.
The lecture portion focused on longer term care for open wounds. Time lines and causes for infection, prevention of and treatment for infection, and debriding wounds. I’ll hang my head in shame and say that I’d put very little thought into the extended aspects of care before this class. If I’m working on someone my job is to keep the blood going round and round and the air going in and out. Then I give them to someone with magic machines and they make everything better (over the course of multiple surgeries). I’d rarely if ever considered what I should be doing if I can’t get the casualty to the higher standard of care in a reasonable amount of time (1-3 hrs). Casualty care at 6, 12, 24, 48hrs and beyond wasn’t really something I’d studied up on or planned for. This portion of the class was cold water to the face.
“H” Hypothermia/Head Injuries – Naked slumber parties and trying to restrict fluids.
As a climber I’ve been pretty well versed on treatment for hypothermia for quite a few years. The science behind why the treatments that work, work was really interesting to me, but I had a pretty good idea what I needed to be doing going into it (even if I didn’t know exactly why). Likewise the head injuries. The issues that closed head injuries raise with fluid management was a good take away for me from the science side, but my team medics have been preaching from that hymnal for quite a few years.
“C” Circulation – You want to put that needle where?!
This portion of the class focused on fluid management and shock. The science and studies on shock were some of the most interesting material in the class for me. First of all Dr. Hagmann made the distinction between massive hemorrhage (loss of all your blood volume leading to death) and shock (tissue hypoxia due to decreased effective cardiac output). Basically, to keep people from dying of shock, we need to keep the rest of their body getting oxygen.
The various fluid products on the market were discussed and ordered in least – most effective. It should be no surprise that the most effective fluid to give to wounded people is whole blood. For the lab portion we ran typing kits on everyone and then did a few buddy transfusions... of a sort (my blood was drawn, my blood was then given back to me.). As simple as that exercise sounds, I feel a lot more comfortable with the mechanics of the process than I had before. On a small team, knowing everyone’s blood type and carrying a couple of transfusion bags might not be the worst idea.
Another hard skill that was taught was fluid delivered via Inter-Osseous IV. Several different IO IVs were taught and two were demonstrated in class by students. Hats off to the Swiss medics for demoing the B.I.G. I don’t get paid enough for that.
“R” Respiration - Needle decompressions and chest tubes… don’t threaten me with a good time.
The “R” portion of the class focused on keeping air movement happening. Recognizing the signs of labored breathing and keeping the lungs functional enough to do their thing. The indications and procedures for needle decompressions and chest tubes were covered at length. Most students were able to practice both skills several times during the FTX.
“A” Airway – Back to basics.
The airway stuff is pretty simple. It’s a tube that needs to stay open for air to get into the lungs (for that whole respiration business). All else fails you can cut someone. The procedures for a surgical airway were discussed and were able to be practiced during the FTX. Throughout the class battlefield video was used to illustrate a point. One of the points that was reinforced for me, both from watching the videos and from the instruction is that a conscious casualty is usually going to know what position is best for their airway. There’s something about watching a soldier with half his face blown off being repeatedly forced onto his back that I found very frustrating. If the dude can breathe sitting up….
“M” Massive Hemorrhage - Nobody makes me bleed my own blood - nobody!
This portion of the class got into the science behind blood clotting and the use of Tranexamic Acid to assist the clotting process, in addition to all the usual stuff like TQ application and hemostatic agents. The science here was interesting but the hard skills are the same thing I’ve been taught for who knows how long (I can’t, for the life of me, remember when I was first exposed to MARCH).
Final Thoughts –
As a knuckle dragger, I thought for sure I was going to be in over my head when I got a handle on who else was in this class as students. Thankfully the folks at DMI have it broken down so that even when there is a lot of science, someone with a basic understanding of anatomy and their mother-fucker switched to receive can follow without any trouble. The enhanced understanding I gained about *why* I’m doing what I’m doing in addition to the skills that I was able to practice, either on other students in class or on the models at the FTX, left me with a much higher level of confidence in my abilities as a field medic…here’s hoping things are never bad enough that I actually find myself in that roll.