Author Disclaimer-This is an informational article for the general public. This is not to be taken as medical literature or used for any medical purposes. Not authorized for citation or reference.
Andrew D. Fisher MPAS, APA-C, was stationed at Fort Benning, GA and at the time this article was written was a Physician Assistant in the U.S. Army. He has no financial interest in any products mentioned, nor has any conflict of interested to disclose. These opinions are his own and are not endorsed by the U.S. Army or the Department of Defense. This article was first published in The Havok Journal on 12 June 2014.
No other unit in the last 13 years has made more improvements and contributions to Army medicine and combat casualty care than the 75th Ranger Regiment. For over a decade, the Regiment has influenced the Department of Defense (DoD), the Committee on Tactical Combat Casualty Care (CoTCCC), and the National Association of Emergency Medical Technicians (NAEMT), leading the way in developing groundbreaking tactics, techniques, and procedures (TTPs) that save lives in combat. Two of the Ranger Regiment’s TTPs that influenced the area of combat casualty care are the use of ketamine at the point of injury and the DoD casualty card.
20 years ago, when the CoTCCC published its recommendations for combat casualty care, the 75th Ranger Regiment took it to heart, embraced it and took it to new heights. The 75th Ranger Regiment took the concepts of CLS and TCCC and combined them to make the Ranger First Responder program (RFR). The RFR course is a two-day course that teaches identification and treatment of the most common causes of preventable causes of death on the battlefield: massive hemorrhage, tension pneumothorax, and airway obstruction. It also has instruction on hypothermia prevention, intravenous therapy, and other necessary lifesaving measures. In essence, the RFR course took the knowledge and skills required to dramatically decrease preventable combat deaths, and put it in the hands of every Ranger.
This does not quite explain why the 75th Ranger Regiment is so successful at combat casualty care. It is successful because of the command-directed Casualty Response System and a mastery of the basics through rehearsals, repetition, and conditioning.
In the Regiment, all Rangers and medical personnel are trained in TCCC with annual refresher training, casualty scenarios are integrated into small unit tactics, battle drills, and exercises, and the Pre-Hospital Trauma Registry (PHTR) is utilized for performance improvement and directed procurement.
Perhaps the most effective measurement of the RFR and the overall medical program inside the Regiment is the fact that there have been no preventable deaths in 13 years of combat. As mentioned above, a preventable death is someone who has died from massive extremity hemorrhage, a tension pneumothorax, and/or airway obstruction. This is no small feat for an infantry unit, let alone an infantry unit that has at a minimum 33% of its personnel deployed and in sustained combat since October 2001.
Now, the 75th Ranger Regiment is taking combat casualty care even further. The Advanced-RFR will be a specially selected non-medic, who has recently passed RFR and shows an inclination for medicine. This Advanced-RFR will be trauma focused, able to assist the Ranger Medic, and perform many difficult tasks and procedures. The Advanced-RFR course will be a minimum of 5 days/40 hours that will cover anatomy and physiology, trauma skill/procedures, and pharmacology.
Of course, saving lives on the battlefield goes beyond preventing what is currently considered preventable deaths; there is also a need to look to the future. Within the 75th Ranger Regiment, the driving force for future medical operations is identifying and implementing treatments to save the “potentially survivable.” Who are the potentially survivable? Potentially survivable casualties have non-compressible hemorrhage, nearly non-compressible hemorrhage, and junctional hemorrhage.
An example of this is a wound to the abdominal cavity that causes internal bleeding. There are very few interventions anyone can do at the point of injury. Without immediate surgery many die within one hour of injury. Even with the many advances in modern medicine, there have been very little advances to decrease the mortality rate of a truncal injury. This is the focus of the Regiment; it is leading the way, seeking a solution for the pre-hospital setting.
Surgeons and other healthcare providers improvising and attempting new techniques during war discover most of the advances made in the field of surgery and trauma care. Since 2001, there have been no shortages of opportunities for innovation.
At the 75th Ranger Regiment, instead of looking forward to find the newest treatments, it looked to World War I. Prior to ubiquitous isotonic intravenous fluids and blood components that become popular during the Vietnam War, whole blood was favored for treating blood loss. The data that relied on the recommendation to use isotonic fluid is flawed to say the least.
There has yet to be any conclusive evidence that isotonic fluids provide any life saving measures to traumatic injuries. There is an ample amount of data that supports the use of blood products in hypovolemic shock due to blood loss. Whole blood has all the lifesaving properties desired. Those lifesaving properties are: red blood cells that carry oxygen to the tissues; platelets and coagulation proteins that promote clotting; and other proteins that help maintain blood pressure. Why then, should pre-hospital healthcare providers, whether medics, paramedics, physician assistants, and/or physicians, rely on anything but the most identifiable lifesaving fluid there is?
Blood products and components come in a variety of types, including fresh whole blood (FWB), packed red blood cells (PRBCs), fresh frozen plasma (FFP), freeze-dried plasma (FDP), and platelets. While PRBCs is safe and effective, there are logistical issues with its use. PRBCs are stored cooled and have a relatively short shelf life. The packaging needed to carry them on missions is difficult and cumbersome. It requires special boxes that keep them at a certain temperatures. When there is a desire to use PRBCs, the unit must draw them from the local military blood bank, whether deployed or at home station. Both civilian and military healthcare systems use all but FDP on a regular basis throughout the United States. The French Military have used FDP, extensively since 1994 with outstanding effects. Yet, in the U.S. the FDA has not authorized it for use. FDP is currently under investigation by USASOC.
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