Tactical Combat Casualty Care in Special Operations

Transcription

1 Tactical Combat Casualty Care in Special Operations A supplement to M i l i t a r y M e d i c i n e by Captain Frank K. Butler, Jr., MC, USN L i e u t e n a n t C o l o n e l J o h n Haymann, MC, USA Ensign E. George Butler, MC, USN

2 MILITARY MEDICINE, 161, Suppl:3, 1996 Tactical Combat Casualty Care in Special Operations CAPT Frank K Butler, Jr., MC USN* L T C J o h n Hagmann, M C USAt U.S. military medical personnel are currently trained to care for combat casualties using the principles taught in the Advanced Trauma Life Support (ATLS) course. The appropriateness of many of the measures taught in ATLS for the combat setting is unproven. A l-year study to review this issue has been sponsored by the United States Special Operations Command. This paper presents the results of that study. We will review some of the factors that must be considered in caring for wounded patients on the battlefield with an emphasis on the Special Operations environment. A basic management protocol is proposed that organizes combat casualty care into three phases and suggests appropriate measures for each phase. A scenario-based approach is needed to plan in more detail for casualties on specific Special Operations missions, and several sample scenarios are presented and discussed. I n t r o d u c t i o n e d i c a l training for Special Operations forces (SOF) corpsmen and medics is currently based on the principles M taught in the Advanced Trauma Life Support (ATLS) c o u r s e. The ATLS guidelines provide a standardized, systematic approach to the management of trauma patients that has proven very successful when used in the setting of civilian hospital emergency departments, but the efficacy of at least s o m e o f t h e s e m e a s u r e s i n t h e p r e h o s p i t a l s e t t i n g h a s b e e n q u e s t i o n e d. 2-2 g E v e n l e s s c e r t a i n i s t h e a p p r o p r i a t e n e s s o f e x t r a p o l a t i n g A T L S guidelines without modification to the battlefield: some of the shortcomings of ATLS in the combat environment have been addressed by military medical authors.21*30-36 The prehospital phase of caring for combat casualties is critically important, since up to 90% of combat deaths occur on the battlefield before t h e c a s u a l t y e v e r r e a c h e s a m e d i c a l t r e a t m e n t f a c i l i t y (MTF).37 T h e i m p o r t a n c e o f t h i s i s s u e w a s r e c o g n i z e d b y t h e C o m m a n d e r of the Naval Special Warfare Command in 1993 when he called f o r a s t u d y o n c o m b a t c a s u a l t y c a r e t e c h n i q u e s i n S p e c i a l O p - e r a t i o n s. T h e n e e d f o r t h i s r e s e a r c h w a s v a l i d a t e d b y t h e U n i t e d S t a t e s S p e c i a l O p e r a t i o n s C o m m a n d ( U S S O C O M ). A a - y e a r s t u d y o f t h i s i s s u e w a s s u b s e q u e n t l y f u n d e d b y U S S O C O M a n d accomplished through literature reviews and multiple works h o p s w i t h S O F p h y s i c i a n s, c o r p s m e n, a n d m e d i c s. T h i s p a p e r presents the results of that study. A parallel and independent effort was found to be underway in the United Kingdom, where a moditied ATLS-type course is being developed for use by the British Special Air Service and Special Boat Squadron (personal *Naval Special Warfare Command, Detachment Pensacola, Naval Hospital, Pensacola, FL t Casualty Care Research Center, Uniformed Services University of the Health Sciences, Bethesda, MD t Uniformed Services University of the Health Sciences, Bethesda, MD The opinions expressed are those of the authors and should not be construed as representing the onlcial positions of the Departments of the Army or the Navy. This manuscript was received for review in September The revised manuscript was accepted for publication in March ENS E. George Butler, MC USN+ communication, Dr. John N a v e i n, former Senior Medical O f f I - cer, 22nd Special Air Service Regiment). F i g u r e s 1 t h r o u g h 4 d e s c r i b e s e v e r a l r e p r e s e n t a t i v e c a s u a l t y scenarios that might be encountered in the conduct of Special Operations and illustrate the complexity of the casualty care that must be rendered by SOF corpsmen and medics, The need to consider signtficant modifications to the principles of care taught in ATLS is obvious when considering the management of t h e s e s c e n a r i o s. F a c t o r s s u c h a s e n e m y f i r e, m e d i c a l e q u i p m e n t limitations, a widely variable evacuation time, tactical considerations, and the unique problems entailed in transporting cas u a l t i e s t h a t o c c u r i n S p e c i a l O p e r a t i o n s a l l m u s t b e a d d r e s s e d. In addition, greater emphasis needs to be placed on the mana g e m e n t o f p e n e t r a t i n g t r a u m a, s i n c e m o s t d e a t h s i n a c o m b a t s e t t i n g a r e c a u s e d b y p e n e t r a t i n g m i s s i l e wounds3 Although t h e D e p a r t m e n t o f D e f e n s e i s a g g r e s s i v e l y p u r s u i n g n e w t e c h - nologies that may result in improved management of combat trauma,38 the most important aspect of caring for trauma victims on the battlefield is well-thought-out planning for that environment and appropriate training of combat medical pers o n n e l. Initial training for SOF corpsmen and medics is currently c o n d u c t e d a t t h e 1 8 D e l t a M e d i c a l S e r g e a n t s C o u r s e t a u g h t a t Fort Sam Houston in San Antonio, Texas, although a move to the new Special Operations Medical Training Center in Fort Bragg, North Carolina, is planned for the near future. The 18 Delta course structures its trauma care around the principles taught in ATLS. These principles are supplemented by trauma care training in a field environment, but the departures from ATLS appropriate for the battlefield have not been systematic a l l y r e v i e w e d a n d p r e s e n t e d in the literature. In addition, many of the unique operating environments and missions encountered in Special Operations are not addressed. Another conside r a t i o n i s s k i l l s m a i n t e n a n c e. A f t e r c o m p l e t i o n o f t h e i r i n i t i a l training, SOF corpsmen and medics are generally assigned to s m a l l o p e r a t i o n a l u n i t s ( S E A L p l a t o o n s o r S p e c i a l F o r c e s A teams), which are required to conduct training in a wide variety of combat skills and to participate in numerous training exercises and operational deployments, Usually lacking from this intense training regimen is an ongoing exposure to victims of penetrating trauma, so the skills learned in their initial combat trauma care training are very infrequently utilized in the absence of armed conilicts. Some individuals attempt to supplement their unit training with rotations in a trauma center or by moonlighting as paramedics, but the intense operational tempo maintained in most SOF units has historically severely limited the effective use of either of these options. B e a r i n g t h e s e considerations in mind, this paper will begin by attempting to describe a basic casualty-management protocol that is appropriate for the battlefield. Necessary modifications to t h e b a s i c m a n a g e m e n t p r o t o c o l w i l l t h e n b e d i s c u s s e d f o r e a c h of the four scenarios mentioned previously. 3 Military Medicine, Vol. 16 1, Supplement 1

3 4 T a c t i c a l C o m b a t C a s u a l t y C a r e i n S p e c i a l O p e r a t i o n s S h i p a t t a c k o p e r a t i o n l a u n c h e d f r o m c o a s t a l p a t r o l c r a f t 1 2 m i l e s o u t One-hour transit i n two Zodiac rubber boats Seven swim pairs of SEALS Z o d i a c s g e t w l t h i n 1 m i l e of the harbor 7 8 F w a t e r ( d i v e r s w e a r i n g w e t s u i t s ) S u r f a c e s w i m f o r a h a l f - m i l e, t h e n b e g i n d i v e w i t h c l o s e d - c i r c u i t oxygen SCUBA One swimmer shot i n the chest by patrol boat as he surfaces to check his bearings in the harbor Wounded diver conscious Fig. 1. Scenario 1. Twelve-man Special Forces team Interdiction operation for weapons convoy Night parachute jump from a C- 130 aircraft Four-mile patrol over rocky terrain to the objective P l a n n e d h e l i c o p t e r e x t r a c t i o n n e a r t a r g e t One jumper sustains an open fracture of his left tibia and f I b u l a on landing pig. 2. Scenario 2. Stages of Care In making the transition from the standards of ATLS to the SOF tactical setting, it is useful to consider the management of c a s u a l t i e s t h a t o c c u r d u r i n g S O F m i s s i o n s a s b e i n g d i v i d e d i n t o t h r e e d i s t i n c t p h a s e s. 1. Care under fire is the care rendered by the medic or corpsman at the scene of the injury while he and the casualty are still under effective hostile fire. Available medical equipment is limited to that carried by the individual operator or by the c o r p s m a n o r m e d i c i n h i s m e d i c a l p a c k. 2. Tactical field care is the care rendered by the medic or c o r p s m a n o n c e h e a n d t h e c a s u a l t y a r e n o l o n g e r u n d e r e f f e c t i v e hostile fire. It also applies to situations in which an Injury has occurred on a mission but there has been no hostile fire. Availa b l e m e d i c a l e q u i p m e n t i s s t i l l l i m i t e d t o t h a t c a r r i e d i n t o t h e field by mission personnel. Time prior to evacuation to an MTF may vary considerably. 3. Combat casualty evacuation care is the care rendered o n c e t h e c a s u a l t y ( a n d usuaily the rest of the mission personnel) have been picked up by an aircraft, vehicle, or boat. Additional m e d i c a l p e r s o n n e l a n d e q u i p m e n t t h a t h a v e b e e n p r e - s t a g e d i n t h e s e a s s e t s s h o u l d b e a v a i l a b l e a t t h i s s t a g e o f c a s u a l t y m a n - agement. The term C A S E V A C! (for combat casualty evacuation) s h o u l d b e u s e d t o d e s c r i b e t h i s p h a s e i n s t e a d o f t h e c o m m o n l y used term MEDEVAC for reasons that will be explained below. Basic Tactical Combat Casualty Management Plan H a v i n g i d e n t i f i e d t h e t h r e e p h a s e s o f c a s u a l t y m a n a g e m e n t ln a t a c t i c a l s e t t i n g, t h e n e x t s t e p i s t o o u t l i n e i n a g e n e r a l w a y t h e c a r e t h a t i s a p p r o p r i a t e t o e a c h p h a s e. T h e b a s i c t a c t i c a l c a s u - a l t y m a n a g e m e n t p l a n d e s c r i b e d b e l o w i s p r e s e n t e d a s a g e n e r i c s e q u e n c e o f s t e p s t h a t w i l I probably require modification in s o m e w a y f o r a l m o s t a n y c a s u a l t y s c e n a r i o e n c o u n t e r e d i n S p e - c i a l O p e r a t i o n s. T h i s i s e x p e c t e d a n d n e c e s s a r y, b u t t h e b a s i c plan is important as a starting point from which development of specific management plans for the scenarios to be discussed later may begin. Care under Fire A more complete description of the SOF tactical setting will help provide a better understanding of the rationale for the recommendations made for this phase. Care under fire will typically be rendered during night operations and will take place in the middle of an active engagement with hostile forces. The corpsman will be hampered by severe visual limitations while caring for the casualty, since the use of a white light on the battlefield will identify his position to the enemy and is not generally recommended. Night-vision devices may provide some a s s i s t a n c e, b u t t h e y a r e n o t a l w a y s c a r r i e d o n n i g h t o p e r a t i o n s b e c a u s e o f w e i g h t a n d o t h e r c o n s i d e r a t i o n s. SOF medical personnel carry small arms with which to defend themselves in the field. In small-unit operations, the additional firepower p r o v i d e d b y t h e c o r p s m a n o r m e d i c m a y b e e s s e n t i a l in obtaining tactical fire superiority. The risk of injury to other patrol personnel and additional injury to the previously wounded operators will be reduced if immediate attention is directed to the suppression of hostile fire. The corpsman or medic may therefore initially need to assist in returning fire instead of stopping to care for the casualty. The best medicine on any battlefield is f h - e s u p e r i o r i t y. A s s o o n a s h e i s d i r e c t e d o r is able to render care, keeping the casualty from being wounded further is the first major objective. Wounded SOF operators who are unable to participate further in the engagement should lay flat and still if any ground cover is available or move as quickly as possible to nearby cover if able. If there is no cover and the casualty is unable to move himself to find cover, he should remain motionless on the ground so as not to draw more fire. There are typicaily only one or two corpsmen or medics present on small-unit SOF operations. If they sustain injuries, no other W e & y - f o u r - m a n Special Forces assault team Night assault operation on hostile position in dense jungle E s t i m a t e d h o s t i l e strength is 15 men with automatic weapons I n s e r t i o n f r o m rivertne c r a f t T h r e e - m i l e p a t r o l t o t a r g e t As patrol reaches objecttve area, a booby trap is tripped, resulting i n a dead point man and a patrol leader with massive t r a u m a t o o n e l e g H e a v y i n c o m i n g f i r e a s h o s t l l e s respond P l a n n e d e x t r a c t i o n i s b y b o a t a t a p o i n t o n t h e r i v e r a h a l f - m i l e f r o m t h e t a r g e t Fig. 3. Scenario 3. Sixteen-man SEAL patrol Planned interdiction operation in arid, mountainous Middle Eastern terrain Two t r u c k s w i t h S A M m i s s i l e s e x p e c t e d i n convoy E s t i m a t e d hostile strength is 10 men with automatic weapons in accompanying vehicle Helicopter insertion/extraction S i x - m i l e p a t r o l t o t a r g e t P l a n n e d e x t r a c t i o n c l o s e t o a m b u s h s i t e While patrol is in ambush position, one patrol member is bitten on the leg by an unidentified snake Over the next 5 minutes, the bitten SEAL becomes dizzy and c o n f u s e d Target convoy expected in approximately 1 hour Fig. 4. Scenario 4. M i l i t a r y Medicine, Vol. 161, Supplement 1

4 T a c t i c a l C o m b a t C a s u a l t y C a r e i n S p e c i a l O p e r a t i o n s medical personnel will be available until the time of extraction in t h e C A S E V A C p h a s e. W i t h t h e s e f a c t o r s i n m i n d, t h e p r o p o s e d m a n a g e m e n t o f c a s u a l t i e s in t h i s p h a s e i s c o n t a i n e d i n F i g u r e 5. No immediate management of the airway should be anticip a t e d a t t h i s t i m e b e c a u s e o f t h e n e e d t o m o v e t h e c a s u a l t y t o cover as quickly as possible. It is very important, however, to s t o p m a j o r b l e e d i n g a s q u i c k l y a s p o s s i b l e, s i n c e i n j u r y t o a major vessel may result in the very rapid onset of hypovolemic shock. The importance of this step requires emphasis in light of reports that hemorrhage from extremity wounds was the cause of death in more than 2,500 casualties in Vietnam who had no other injuries. 3g These are preventable deaths. If the casualty n e e d s t o b e m o v e d, a s i s u s u a l l y t h e c a s e, a t o u r n i q u e t i s t h e most reasonable initial choice to stop major bleeding. Although ATLS discourages the use of tourniquets, they are appropriate i n t h i s i n s t a n c e b e c a u s e d i r e c t p r e s s u r e i s h a r d t o m a i n t a i n during casualty transport under fire. Ischemic damage to the limb is rare if the tourniquet is left in place for less than 1 hour, and tourniquets are often left in place for several hours during surgical procedures. In any event, in the face of massive extremity hemorrhage it is better to accept the small risk of ischemic d a m a g e t o t h e l i m b t h a n t o l o s e a c a s u a l t y t o e x s a n g u i n a t i o n. Both the casualty and the corpsman or medic are in grave danger while a tourniquet is being applied in this phase, and non-life-threatening bleeding should be ignored until the tactic a l field care phase. The decision regarding the relative risk of further injury versus that of exsanguination must be made by the corpsman or medic rendering care. The need for Immediate a c c e s s t o a t o u r n i q u e t i n s u c h s i t u a t i o n s m a k e s i t c l e a r t h a t all SOF operators on combat missions should have a suitable tourniquet readily available at a standard location on their battle gear and be trained in its use. This may enable them to quickly p u t a t o u r n i q u e t o n t h e m s e l v e s i f n e c e s s a r y w i t h o u t s u s t a i n i n g further blood loss while waiting for medical assistance. Transport of the casualty will often be the most problematic aspect of providing tactical combat casualty care. Although the civilian standard of care is to immobilize the spinal column prior to moving a patient with injuries that might have resulted in damage to the spine, this practice needs to be re-evaluated in the combat setting. Arishita et al. examined the value of cervical spine immobilization in penetrating neck injuries in Vietnam and found that in only 1.4% of patients with penetrating neck injuries would immobilization of the cervical spine have been of p o s s i b l e benefit2 Since the time required to accomplish cervical spine immobilization was found to be 5.5 minutes, even when u s i n g e x p e r i e n c e d e m e r g e n c y m e d i c a l t e c h n i c i a n s, t h e a u t h o r s concluded that the potential hazards to both patient and provider outweighed the potential benefit of immobilization.2~21 Kennedy et al. similarly found no cervical spine injuries in 105 gunshot wound patients with injuries limited to the calvaria.40 Parachuting injuries, fast-roping injuries, falls, and other types R e t u r n f i r e a s d i r e c t e d o r r e q u i r e d Try to keep yourself from getting shot Try to keep the casualty from sustaining additional wounds Take the casualty with you when you leave p i g. 5. Basic tactical casualty management plan phase one: care under tire. of trauma resulting in neck pain or unconsciousness should still be treated with spinal immobilization unless the danger of hostile fire constitutes a greater risk in the judgment of the treating corpsman or medic. Standard litters for patient transport are not typically carried into the field on direct-action Special Operations missions because of their weight and bulk. Transport of the patient is currently accomplished with a shoulder carry or improvised litter. Since there will often be only 8 to 10 men on the operation, having additional operators engaged in transporting a wounded patient any significant distance presents a major problem. There should be no attempt to save the casualty s rucksack unless it contains items that are still critical to the mission. His w e a p o n s a n d a m m u n i t i o n s h o u l d b e t a k e n i f a t a l l p o s s i b l e. Tactical Field Care The proposed management plan for the tactical field care p h a s e i s d e s c r i b e d i n F i g u r e 6. T h i s p h a s e i s d i s t i n g u i s h e d f r o m the care under fire phase by more time with which to render care and a reduced level of hazard from hostile tire. The amount of time available to render care may be quite variable. In some cases, tactical field care will consist of rapid treatment of 1. Airway management C h i n - l i f t o r j a w - t h r u s t Unconscious casualty without airway obstruction: nasopharyngeal ah-way Unconscious casualty w i t h airway obstruction: cricothyroidotomy C e r v i c a l spine tmmobilization is not necessary for casualties w i t h penetrating head or neck trauma 2. Breathing Consider tension pneumothorax and decompress w i t h needle thoracostomy i f a casualty has unilateral penetrating chest trauma and progressive resptratory distress 3. Bleeding Control any remaining bleeding w i t h a tourniquet or direct pressure 4. N Start an 18-gauge N or saline lock 5. Fluid resuscitation Controlled hemorrhage without shock: no fluids necessary Controlled hemorrhage with shock: H e s p a n 1,000 cc Uncontrolled ( i n t r a - a b d o m i n a l or t h o r a c i c ) hemorrhage: no N fluid resuscitation 6. Inspect and dress wound 7. Check for additional wounds 8. Analgesia as necessary M o r p h i n e : 5 m g N, w a i t 1 0 m i n u t e s ; r e p e a t a s n e c e s s a r y 9. Splint fractures and recheck pulse 10. Antibiotics Cefoxittn: 2 g slow-n push (over 3-5 minutes) for penetrating abdominal trauma, massive soft-tissue damage, open fractures, grossly contaminated wounds, o r l o n g d e l a y s b e f o r e c a s u a l t y e v a c u a t i o n 11. Cardiopulmonary resuscitation R e s u s c i t a t i o n o n t h e b a t t l e f i e l d f o r v i c t i m s o f b l a s t o r penetrating trauma who have no pulse, no respirations, and no other signs of life wtll n o t b e s u c c e s s f u l a n d should not be attempted Fig. 6. Basic tactical casualty management plan phase t w o : tactical field care. 5 Military Medicine, Vol. 161, Supplement 1

5 6 Tactical Combat Casualty Care in Special Operations wounds with the expectation of a re-engagement with hostile forces at any moment. The need to avoid undertaking noness e n t i a l d i a g n o s t i c a n d t h e r a p e u t i c m e a s u r e s w i l l b e c r i t i c a l i n s u c h c a s e s. A t o t h e r t i m e s, c a r e m a y b e r e n d e r e d o n c e t h e p a t r o l has reached an anticipated extraction point without pursuing forces and is awaiting the arrival of a tactical SOF helicopter. In this circumstance, there may be ample time to render without h a s t e w h a t e v e r c a r e i s f e a s i b l e i n t h e f i e l d. T h e t i m e p r i o r t o extraction may range from half an hour or less to many hours. Another possibility is for the injury to occur before the presence of the patrol is known to the enemy, which would require that the mission commander make a decision about whether or not the operation should be continued and, if so, what to do with the casualty for the balance of the mission prior to CASEVAC. Although the patient and provider are now in a somewhat less h a z a r d o u s s e t t i n g, t h e t a c t i c a l held c a r e p h a s e i s s t i l l n o t t h e time or place for some of the procedures taught in ATLS, since the patrol will still typically be in the dark and operating in extremely non-sterile field conditions. Procedures such as diagn o s t i c p e r i t o n e a l l a v a g e a n d p e r i c a r d i o c e n t e s i s o b v i o u s l y h a v e no place in this environment. If a victim of blast or penetrating injury is found to be without pulse, respiration, or other signs of life, cardiopulmonary resuscitation on the battlefield will not be successful and should not b e a t t e m p t e d. A t t e m p t s t o r e s u s c i t a t e t r a u m a p a t i e n t s i n a r r e s t have been found to be futile even in the urban setting where the victim is in close proximity to trauma centers. One study rep o r t e d n o s u r v i v o r s o u t o f t r a u m a p a t i e n t s w h o s u f f e r e d a p r e h o s p i t a l c a r d i a c a r r e s t a n d i n w h o m r e s u s c i t a t i o n w a s attempted.41 The authors of that study recommended that trauma patients in cardiopulmonary arrest not be transported emerg e n t l y t o a t r a u m a c e n t e r e v e n i n a c i v i l i a n s e t t i n g b e c a u s e o f t h e large economic cost of treatment for these patients without a significant chance for survival. On the battlefield, the cost of attempting to perform cardiopulmonary resuscitation on casualties with what are inevitably fatal injuries will be measured in a d d i t i o n a l l i v e s l o s t a s c a r e i s w i t h h e l d f r o m p a t i e n t s w i t h l e s s s e v e r e i n j u r i e s a n d a s o p e r a t o r s a r e e x p o s e d t o a d d i t i o n a l h a z - ard from hostile fire because of their attempts. Only in the case of non-traumatic disorders such as hypothermia, near-drowning, or electrocution should cardiopulmonary resuscitation be considered prior to the CASEVAC phase. As taught in ATLS, attention is first directed to evaluation of airway, breathing, and circulation. There should be no attempt at airway intervention if the patient is conscious and breathing w e l l o n h i s o w n. I f t h e p a t i e n t i s u n c o n s c i o u s, t h e c a u s e w i l l most likely be hemorrhagic shock or penetrating head trauma. The airway should be opened with the chin-lift or jaw-thrust maneuver without worrying about cervical spine immobilization, as noted previously. If spontaneous respirations are p r e s e n t a n d t h e r e i s n o r e s p i r a t o r y d i s t r e s s, a n a d e q u a t e a i r w a y m a y b e m a i n t a i n e d i n a n u n c o n s c i o u s p a t i e n t in m o s t c a s e s b y the insertion of a nasopharyngeal airway. This device has the advantage of being better tolerated than an oropharyngeal airw a y s h o u l d t h e p a t i e n t s u b s e q u e n t l y r e g a i n c o n s c i o u s n e s s a n d b e i n g l e s s l i k e l y t o b e d i s l o d g e d d u r i n g p a t i e n t t r a n s p o r t. A suspected fracture of the cribriform plate might be a relative contraindication to the use of a nasopharyngeal airway, but this injury would be expected to be uncommon on the battlefield e x c e p t i n t h e c a s e o f m a s s i v e h e a d t r a u m a, w h i c h w o u l d m a k e survivd unlikely. Should an unconscious patient develop an airway obstruct i o n, t h e n a s o p h a r y n g e a l a i r w a y m a y n e e d t o b e r e p l a c e d w i t h a more deiinitive airway. Endotracheal intubation is the preferred airway technique in civilian emergency departments, and the ability of experienced paramedical personnel to master this skill h a s b e e n w e l l documented.4* A number of additional factors must be considered in the SOF battlefleld setting, however: (1) the authors could find no studies that documented the ability of well-trained but relatively inexperienced paramedical military intubationists to accomplish endotracheal intubation on the battlefield; (2) many SOF corpsmen and medics have never performed an intubation on a live patient or even a cadaver: (3) endotracheal intubation entails the use of the white light in the laryngoscope on the battlefield: (4) m a x i l l o f a c i a l i n j u r i e s t h a t result in blood and other obstructions in the airway would render endotracheal intubation extremely difficult and are probably best managed by cricothyroidotom$l; and ( 5 1 esophageal i n t u b a t i o n s w o u l d b e m u c h l e s s l i k e l y t o b e r e c o g n i z e d o n t h e battlefield and may result in fatalities. Endotracheal intubation may be difficult to accomplish even in the hands of more exper i e n c e d p a r a m e d i c a l p e r s o n n e l u n d e r l e s s a u s t e r e c o n d i t i o n s. 5 3 One study that examined first-time intubationists trained with manikin intubations alone noted an initial success rate of only 42% in the ideal confines of the operating room with paralyzed patients4 Most of the previously cited studies documenting the success of paramedical personnel in performing endotracheal intubation noted that cadaver training, operating room i n t u b a - tions, supervised initial intubations, or a combination of these methods were used in the training of paramedics. They also stressed the importance of continued practice of this skill in maintaining proficiency. Cricothyroidotomy is the other airway option. This procedure has been reported to be safe and effective in trauma v i c t i m ~. ~ ~ Although it would typically be attempted only after failed endotracheal intubation, in the hands of corpsmen or medics who do not intubate on a regular basis it is probably appropriate to c o n s i d e r t h i s a s t h e n e x t s t e p w h e n a n a s o p h a r y n g e a l a i r w a y i s not effective. It may be the only feasible alternative for any potential intubationist in cases of maxillofacial wounds in which blood or disrupted anatomy precludes visualization of the vocal cords.21*54 This procedure is not without c o m p l i c a t i o n s, but SOF corpsmen are all trained in this technique and a prepackaged SOF cricothyroidotomy kit that contains the equipment for an over-the-wire technique is currently under development. If blood or other obstructions are present in the oropharynx, they should be removed by hand or battery-powered suction. O x y g e n i s n o t u s u a l l y a p p r o p r i a t e f o r t h i s p h a s e o f c a r e b e c a u s e c y l i n d e r s o f c o m p r e s s e d g a s a n d t h e a s s o c i a t e d e q u i p m e n t f o r supplying the oxygen to the patient are too heavy to make their use in the field feasible on direct-action operations where they must be carried by the corpsman or medic. Attention should next be directed toward the patients breathi n g. P r o g r e s s i v e, s e v e r e r e s p i r a t o r y d i s t r e s s o n t h e b a t t l e f i e l d resulting from unilateral penetrating chest trauma should be considered to represent a tension pneumothorax and that hemi- Military M e d i c i n e, V o l , S u p p l e m e n t 1

6 T a c t i c a l C o m b a t C a s u a l t y C a r e i n S p e c i a l O p e r a t i o n s 7 t h o r a x d e c o m p r e s s e d with a g a u g e catheter. The diagnosis in t h i s s e t t i n g s h o u l d n o t r e l y o n s u c h t y p i c a l c l i n i c a l s i g n s a s breath sounds, tracheal shift, and h y p e r r e s o n a n c e o n p e r c u s - s i o n b e c a u s e t h e s e s i g n s m a y n o t a l w a y s b e p r e s e n t, 5 7 a n d e v e n if they are, they may be exceedingly difficult to appreciate on the battlefield. A patient with penetrating chest trauma will generally have some degree of hemo/pneumothorax as a result of his primary wound, and the additional trauma caused by a needle thoracostomy would not be expected to significantly worsen his condition should he not actually have a tension pneumothorax.51 A l l S p e c i a l O p e r a t i o n s c o r p s m e n a n d m e d i c s a r e t r a i n e d in this technique: it is technically easy to perform and may be lifesaving if the patient does in fact have a tension pneumothorax. Paramedics are authorized to perform needle thoracostomy in some civilian emergency medical services The decompression should be carried out with a needle and catheter so that the catheter may be taped in place to prevent recurrence of the tension pneumothorax. Chest tubes are not recommended i n t h i s p h a s e o f c a r e b e c a u s e ( 11 they are not needed to provide initial treatment for a tension pneumothorax; ( 2 1 they are more difficult and time-consuming for inexperienced medical personnel to perform, especially in the absence of adequate light: ( 3 1 they are more likely to cause additional tissue damage and subsequent infection than a less traumatic procedure; and (4) no documentation was found in the literature that demonstrated a benefit from tube thoracostomy performed by paramedical personnel on the battlefield. One Israeli study reported 1 6 p a t i e n t s i n w h o m c h e s t t u b e s w e r e p l a c e d b y p h y s i c i a n s i n the field. One patient suffered an iatrogenic pneumothorax, 3 p a t i e n t s r e c e i v e d c h e s t t u b e s t h a t w e r e c l e a r l y u n n e c e s s a r y, a n d 4 p a t i e n t s w e r e f o u n d t o h a v e h a d t h e i r c h e s t t u b e s i n s e r t e d s u b c u t a n e o u s l y. 5 * Tube thoracostomy is generally not part of t h e p a r a m e d i c s s c o p e o f c a r e e v e n i n l e s s a u s t e r e c i v i l i a n e m e r - g e n c y m e d i c a l s e r v i c e settings.46*51 Should the patient be found to have a major traumatic defect o f t h e c h e s t w a l l, t h e w o u n d s h o u l d b e c o v e r e d w i t h a p e t r o l a - t u r n g a u z e a n d a b a t t l e d r e s s i n g. I t i s n o t n e c e s s a r y t o v e n t o n e s i d e o f t h e w o u n d d r e s s i n g, s i n c e t h i s i s ditficult to do reliably in a c o m b a t s e t t i n g. I f t h e c a s u a l t y d e v e l o p s a t e n s i o n p n e u m o t h o - rax after treatment, it should be decompressed as described a b o v e. O t h e r w o u n d d r e s s i n g s s u c h a s a n A s h e r m a n v a l v e m a y b e r e a s o n a b l e a n d e a s y - t o - a p p l y a l t e r n a t i v e s. The corpsman or medic should now address any signiilcant bleeding sites not previously controlled. He should remove only the absolute minimum of clothing required to expose and treat injuries21 both because of time constraints and the need to continue to protect the patient against the environment. Signifi c a n t b l e e d i n g s h o u l d b e s t o p p e d a s q u i c k l y a s p o s s i b l e, u s i n g a tourniquet without hesitation as described previously to gain initial control of the bleeding. Once the p a t i e n t h a s b e e n t r a n s - ported to the site where extraction is anticipated, consideration should be given to loosening or removing the tourniquet and using direct pressure to control bleeding if this is feasible. Intravenous ( I V ) access should be obtained next. Although A T L S r e c o m m e n d s s t a r t i n g t w o l a r g e - b o r e ( 1 4 o r 1 6 g a u g e ) IVs, the use of an g a u g e catheter is preferred in the field setting because of the increased ease of starting. The larger catheters are needed to be able to administer large volumes of blood products rapidly. This is not a factor in the tactical setting, since blood products will not be available. One liter of lactated Ringer s solution can be administered through a 2-inch, g a u g e catheter in approximately 17 minutes without supplemental bag pressure compared to approximately 11 minutes with a 2-inch, g a u g e catheter.5g*60 Although larger-gauge IVs m a y then have to be started later on when the patient arrives at an MTF, it is common practice to discontinue prehospital IVs upon arrival at a definitive treatment facility because of concern about contamination of the IV siteu61 The corpsman or medic should ensure that the IV is not started on an extremity distal to a significant wound. Cleaning the skin before venipuncture is optional in the field. Subclavian and internal jugular venipunctures are not appropriate on the battlefleld because of the potential for complications from these p r o c e d u r e s. 31 Should I V access in an upp e r e x t r e m i t y b e a problem, an IV should be started in the saphenous or external jugular vein. If this also proves unsuccessful or infeasible, femoral venipuncture should be performed instead of trying to do a cutdown in the field. Heparin or saline lock-type access tubing should be used u n l e s s t h e p a t i e n t r e q u i r e s i m m e d i a t e f l u i d r e s u s c i t a t i o n a s d i s c u s s e d b e l o w. T h i s p r o v i d e s i n t r a v e n o u s a c c e s s f o r m e d i c a - tions and later fluid resuscitation ifrequired, but eliminates the logistical difficulties of managing the IV bag during transport and decreases the likelihood of the IV line becoming fouled and traumatically dislodged. Whenever a medication is given through a saline lock, the lock should be flushed with 5 cc of normal saline. Flushing the lock with normal saline approximately every 2 hours will usually suffice to keep it open without having to use heparinized solution. Despite its widespread use, the benefit of prehospital f l u i d r e s u s c i t a t i o n i n t r a u m a p a t i e n t s h a s n o t b e e n e s t a b l i s h e d ~ ,15,18.20,21~24-27,29,62 T h e beneficial e f f e c t from crystalloid and colloid fluid resuscitation in hemorrhagic shock has been demonstrated largely on animal models in which the volume of hemorrhage is controlled experimentally and resuscitation is initiated after the hemorrhage has been s t o p p e d. 20*22*25*63*64 The animal data from a variety of uncont r o l l e d h e m o r r h a g e m o d e l s h a s c l e a r l y e s t a b l i s h e d t h a t a g g r e s - s i v e f l u i d r e s u s c i t a t i o n i n t h e s e t t i n g o f a n u n r e p a i r e d v a s c u l a r injury is either of no benefit or results in an increase in blood loss and/or mortality when compared to no fluid resuscitation or hypotensive resuscitation.6~g~ ,26,27,65-6* H y p o t e n - sion has been postulated to be an important factor in thrombus formation in uncontrolled hemorrhage models6 The deleterio u s e f f e c t o f a g g r e s s i v e f l u i d r e s u s c i t a t i o n i n t h e s e m o d e l s m a y be due to interference with thrombus formation or other physi o l o g i c c o m p e n s a t o r y m e c h a n i s m s a s t h e b o d y a t t e m p t s t o a d - just to the loss of blood volume. Several studies noted that only after previously uncontrolled hemorrhage was stopped did fluid resuscitation prove to be of benefit.68970* Only two studies were found that suggested that fluid resuscitation may be of benefit in uncontrolled hemorrhage.72*73 Both used rat-tail amputation models. One study found that no fluid resuscitation, l a r g e - volume normal saline resuscitation, and a combination of hypertonic saline and large-volume normal saline resulted in mortalities of 22, 0, and ll%, r e s p e c t i v e l y. 7 2 The other found that the infusion of 80 ml/kg of lactated Ringer s solution decreased mortality from 73 to 53%.73 M i l i t a r y Medicine, Vol. 161, Supplement 1

7 8 T a c t i c a l C o m b a t C a s u a l t y C a r e i n S p e c i a l O p e r a t i o n s T h e r e h a v e b e e n s e v e r a l s t u d i e s t h a t a d d r e s s e d t h e i s s u e o f prehospital fluid resuscitation in humans. In his observations of combat trauma patients in World War I, Cannon concluded that initiating l V fluid replacement without first obtaining surgical hemostasis promoted further h e m o r r h a g e. 7 4 One large study of 6,855 trauma patients found that although hypotension was associated with a significantly higher mortality rate in trauma patients, the administration of prehospital l V fluids did not influence this rate.13 T h i s s t u d y d i d n o t s p e c i i l c a l l y a d d r e s s subgroups with controlled versus uncontrolled hemorrhage. A n o t h e r p a p e r d i s c u s s e d a r e t r o s p e c t i v e a n a l y s i s o f p a t i e n t s with ruptured abdominal aortic aneurysms and hypotension that showed a survival rate of 30% in patients who were treated with aggressive preoperative colloid fluid replacement; in contrast, the author reported a survival rate of 46% in 40 hypotensive patients with ruptured abdominal aortic aneurysms who were given only enough fluid to maintain a systolic blood pressure of 50 to 70 mm Hg until the time of operative repair.75 The author strongly recommends that aggressive fluid resuscit a t i o n b e w i t h h e l d u n t i l t h e t i m e o f s u r g e r y i n t h e s e p a t i e n t s. A large prospective trial examining this issue in 598 patients with penetrating torso trauma and htotension was recently published by Bickell and colleagues. They found that aggressive preoperative fluid resuscitation resulted in a survival rate of 62%. In those patients for whom aggressive fluid replacement was withheld until the time of operative intervention, the survival rate of 70% was significantly higher. The mean preoperative fluid volumes were 2,478 ml of Ringer s acetate for the immediate-resuscitation group and 375 ml for the delayed-resuscitation group. One consideration in applying the findings of this study to the battlefleld environment is that the mean transport times to the trauma center were only 12 minutes for the immediate-resuscitation group and 13 minutes for the delayedresuscitation group. Transport t i m e s from the battlefield to a medical treatment facility during an armed conflict would be expected to be much longer, and how this longer delay to operative intervention would affect the findings of the study is unknown. Some of the animal studies examining the value of fluid resuscitation on uncontrolled hemorrhagic shock, however, have had periods of observation after the induction of hemorrhage of 60 to 240 minutes and have still noted a beneficial effect from withholding fluid replacement in the setting of uncontrolled hemorrhage.8* 4~ 6~ 8-20~26s5s6 Although the tindings o f B i c k e l l a n d h i s c o l l e a g u e s a w a i t conih-mation by other prospective studies, the weight of evidence at this time favors withholding aggressive IV fluid resuscitation in patients with uncontrolled hemorrhage from penetrating thoracic or abdominal trauma until the time of surgical intervention. Immediate fluid resuscitation is still recommended for casualties on the battlefield whose hypovolemic shock is the result of bleeding from an extremity wound that has been controlled. Should the resuscitation fluid of choice for these patients still be lactated Ringer s or normal saline as taught in ATLS? T h e f i r s t c o n s i d e r a t i o n i n s e l e c t i n g a r e s u s c i t a t i o n f l u i d i s whether to use a crystalloid or a colloid. C r y s t a l l o i d s are fluids s u c h a s l a c t a t e d R i n g e r s a n d n o r m a l s a l i n e i n w h i c h s o d i u m i s the primary osmotically active solute. Since sodium eventually distributes throughout the entire extracellular space, most of the fluid in crystalloid solutions remains in the Intravascular space for only a very limited time. Colloids are solutions in which the primary osmotically active molecules are of greater molecular weight and do not readily pass though the capillary w a l l s i n t o t h e interstitium. These solutions are retained in the intravascular space for much longer periods of time than c r y s - talloids. The oncotic pressure of colloid solutions may result in an expansion of the blood volume that is greater than the amount of fluid infused. M o s t s t u d i e s h a v e s h o w n c r y s t a l l o i d s a n d c o l l o i d s t o b e a p - p r o x i m a t e l y e q u a l i n e f f i c a c y w h e n u s e d a s a n i n i t i a l r e s u s c i t a - tion fluid in hemorrhagic shock patients in the civilian trauma center setting.76v77 Given the lack of a demonstrated benefit from colloid solutions, the ATLS recommendation that fluid res u s c i t a t i o n b e i n i t i a t e d w i t h c r y s t a l l o i d s i s u n d e r s t a n d a b l e when one realizes that the estimated annual savings in the United States from using crystalloids is approximately $500 million.77 T h e c o s t o f 1 1 o f l a c t a t e d R i n g e r s t o a N a v a l H o s p i t a l i n J a n u a r y w a s 6 1 c e n t s a s o p p o s e d t o $ f o r c c of 25% albumin and $27.50 for 500 cc of 6% hetastarch (pers o n a l c o m m u n i c a t i o n, L C D R D o n C l e m e n s, P h a r m a c y D e p a r t - m e n t H e a d, N a v a l H o s p i t a l P e n s a c o l a ). When considering the prehospital environment in combat trauma, however, there is an additional consideration. In civilian settings, additional volume replacement therapy with blood components can be carried out shortly after the initial crystalloid therapy if necessary. Typical transport intervals for civilian a m b u l a n c e s y s t e m s a r e 1 5 m i n u t e s o r less.3*6-13 W i t h t h e s e v e r y short transport intervals, most of the infused crystalloid is stffl in the intravascular space at the time of arrival at the trauma center. Evacuation times for combat casualties are much longer. As recently as Operation Desert Storm, transport time to medical treatment facilities was found to range from 2 to 4 h o u r s. 7 8 The time interval between initial treatment and arrival at an MTF for c a s u a l t i e s i n S p e c i a l O p e r a t i o n s m a y b e m u c h l o n g e r t h a n t h i s. The fluid expansion from crystalloid therapy would not be sustained for these periods of time. Lactated Ringer s solution equilibrates rapidly throughout the extracellular space, and by 1 hour after administration only approximately 200 cc of an initial infused volume of 1,000 cc will remain in the intravascular s p a c e. 77z7gz80 In contrast, 500 cc of a colloid such as 6% hetastarch results in an intravascular volume expansion of almost 800 cc77 a n d t h i s e f f e c t i s s u s t a i n e d f o r a t l e a s t 8 h o u r s. I n d i s c u s s i n g r e s u s c i t a t i o n w i t h c o l l o i d s v e r s u s c r y s t a l l o i d s, o n e paper notes that the more sustained effects of the c o l l o i d - c o n - taining solutions would be of greatest value if a substantial time interval separated acute resuscitation from subsequent e f - forts.82 A review paper on fluid resuscitation in traumatic hemo r r h a g i c s h o c k s t a t e s t h a t t h e r e i s a l m o s t universal agreement that colloid-containing fluids act more efficiently than crystalloid fluids to restore hemodynamic s t a b i l i t y. 8 3 W h a t d o c r i t i c a l c a r e t e x t s s a y a b o u t c r y s t a l l o i d s v e r s u s colloids i n t h e r e s u s c i t a t i o n o f p a t i e n t s i n h y p o v o l e m i c s h o c k? O n e states that when rapid expansion of the intravascular volume is d e s i r e d, c o l l o i d s a r e t h e c l e a r choice. 77 A n o t h e r s t a t e s t h a t colloids should be used any time that more than a 30% loss of blood volume must be r e p l a c e d e 7 Even the ATLS manual states that crystalloids alone are insufficient for resuscitation of patients with blood loss of greater M i l i t a r y M e d i c i n e, V o l , Supplement 1

8 T a c t i c a l C o m b a t C a s u a l t y C a r e i n S p e c i a l O p e r a t i o n s 9 than 30% of their blood volume (1500 cc). Since this amount of blood loss is required for a drop in blood pressure to be seen (class-iii hemorrhage), another way to state this is that any patient who has a drop in blood pressure or altered sensorium due to hypovolemic shock will need more than crystalloid fluid therapy. Since it may be several hours or longer before blood component therapy can be initiated in combat trauma patients, it makes sense to use a blood volume expander whose effects will persist at least that long. Having determined that colloid therapy may be more desirable in the setting of battlefield trauma, the next question is which colloid to use. Albumin was the primary colloid used for volume expansion for many of the early comparative studies. As noted previously, albumin is much more expensive than c r y s - t a l l o i d s. T h e s y n t h e t i c c o l l o i d s s u c h a s 6 % h e t a s t a r c h ( H e s p a n ) a n d t h e d e x t r a n s w e r e d e v e l o p e d a s l e s s e x p e n s i v e a l t e r n a t i v e s to albumin.77,84 H e s p a n is composed of glucose polymers with an average molecular weight of 450,000. Although concerns have been voiced about coagulopathies associated with the use of H e s p a n, these effects are generally not clinically significant and are not seen with infusion volumes of less than 1,500 c c. 77*7g*83*87*88 An adverse effect of H e s p a n on immune function has been s u g g e s t e d, 8 g but H e s p a n w a s o b s e r v e d t o h a v e a b e n - eficial effect on m a c r o p h a g e function in another study, which examined its use as a resuscitation fluid in a mouse model of hemorrhagic s h o c k. g 0 Allergic reactions may occur, but are rare. T h e i n c i d e n c e o f s e v e r e r e a c t i o n s i s l e s s t h a n 1 i n 10,000.7g Serum amylase levels rise after hetastarch administration, but this is a normal response caused by the degradation of the hetastarch and is not an indication of pancreatitis.77*7g T h e d e x t r a n s a r e a l s o s y n t h e t i c g l u c o s e p o l y m e r s. T w o t y p e s of dextran are available: dextran 40, with an average molecular w e i g h t o f 4 0, 0 0 0, a n d d e x t r o s e 7 0, w i t h a n a v e r a g e m o l e c u l a r weight of 70,000. The dextrans have an intravascular volume expansion that is similar to that of h e t a s t a r c h 7 7 and are curr e n t l y l e s s e x p e n s i v e t h a n H e s p a n, costing approximately $15 per 500 cc. Side effects of the dextrans include acute renal failure, inhibition of platelet aggregation, aller$ic r e a c t i o n s, a n d interference with blood cross-matching.77.7g*8 A c u t e r e n a l f a i l - u r e i s s t a t e d t o b e m o r e l i k e l y i n p a t i e n t s w i t h d e c r e a s e d r e n a l perfusion,77~7g which trauma patients in hemorrhagic shock may be expected to have. The interference with cross-matching for blood products is also a problem in the combat setting, since most of the patients who require fluid resuscitation in the field may be expected to require transfusion upon arrival at an MTF. H y p e r t o n i c s a l i n e h a s b e e n s h o w n t o b e e f f e c t i v e a s a n i n i t i a l r e s u s c i t a t i o n fluid,7g*82,g1*g2 but since hypertonic saline is a crystalloid, its effects when used alone are very shortl i v e d. 77.7g.82 Studies examining the use of hypertonic saline have often combined it with a dextran to obtain a more prolonged effect, 1*7g9g3-g5 and this combination would then entail the same side effects mentioned previously for the dextrans. Shelf-life and storage requirements are important considerations for resuscitation fluids to be used in military operations and are similar for H e s p a n, t h e d e x t r a n s, a n d l a c t a t e d R i n g e r s. The shelf-life of all three products is 2 years, All three products are recommended to be protected from freezing and from e x p o - sures to temperatures above 104 F (sources: Abbott Laboratories for the dextrans and lactated Ringer s: DuPont Laboratories for H e s p a n ). One paper notes that the clotting abnormalities and allergic r e a c t i o n s s e e n w i t h t h e d e x t r a n s h a v e n o t b e e n a p r o b l e m w i t h Hespan. Another notes that H e s p a n is known to have the lowest rate of anaphylactoid complications when compared to the other colloids.go A third study states that dextran solutions are used for fluid resuscitation in Europe, but that H e s p a n i s the synthetic colloid more commonly used in the United S t a t e s. 8 2 In summary, then, the authors believe that hetastarch is the p r e f e r r e d f l u i d f o r i n i t i a l c o l l o i d r e s u s c i t a t i o n, s i n c e i t i s l e s s e x p e n s i v e t h a n a l b u m i n a n d h a s l e s s s i g n i f i c a n t s i d e e f f e c t s than the dextrans. Several papers have found H e s p a n to be a safe and effective alternative to lactated Ringer s solution in resuscitating patients with hemorrhagic hypovolemia.7g~83~g6- loo U s e o f t h i s f l u i d a s a p r e h o s p i t a l a l t e r n a t i v e t o l a c t a t e d Ringer s has been previously proposed in both the Army (personal communication, MAJ Lou Guzzi, Walter Reed Army Institute of Research) and the Air Force (personal communication, COL Dave Hammer, Air Force Special Operations Command). What will the operator in the field notice from using H e s p a n i n s t e a d o f l a c t a t e d R i n g e r s? A s s u m e t h a t o n e w i s h e s t o r e p l a c e a 1, c c blood loss on the battlefleld and have this effect be sustained for 4 hours or longer. By examining the distribution of t h e s e t w o f l u i d s d e s c r i b e d e a r l i e r, w e s e e t h a t t h i s d e g r e e o f volume expansion may be obtained with 1,000 cc of H e s p a n (2 pounds), but it would take approximately 8 1 of lactated Ringer s (almost 18 pounds) to achieve the same effect. This is a clinically significant weight reduction if one proposes to carry these fluids for long distances. How much fluid should be given to a patient in shock on the battlefield? Precise quantification of blood loss in this setting based on observation will be difficult, but at least 1,500 cc of blood loss is required to produce the signs and symptoms of hemorrhagic shock. In a patient with shock and controlled hemorrhage, 1,000 cc of H e s p a n should be administered initially. S u b s e q u e n t f l u i d a d m i n i s t r a t i o n s h o u l d b e t i t r a t e d t o a c h i e v e a good peripheral pulse and an improvement in sensorium rather than to normalize blood pressure. The amount of H e s p a n adm i n i s t e r e d s h o u l d g e n e r a l l y n o t e x c e e d 1, c c. Once fluid resuscitation has been initiated, the corpsman or medic should cover the major wounds with appropriate battle dressings to minimize further contamination and to promote hemostasis. A careful check for additional wounds should be made, since the high-velocity projectiles from assault rifles may tumble and take erratic courses when traveling through Ussue,lOi often leading to exit sites remote from the entry wound. I f t h e c a s u a l t y i s c o n s c i o u s a n d r e q u i r e s a n a l g e s i a, i t s h o u l d be achieved with morphine, administered intravenously if possible. This mode of administration allows for much more rapid onset of analgesia and for more effective titration of dosage than intramuscular administration. An initial dose of 5 mg is given and repeated at lo-minute intervals until adequate analgesia is achieved. The A J port nearest the site of the venipuncture s h o u l d b e u s e d a n d t h e lv opened for about 15 seconds after the m e d i c a t i o n i s i n j e c t e d o r, i f a s a l i n e l o c k i s u s e d, i t s h o u l d b e flushed with 5 cc of normal saline. Morphine may be a d m i n i s - Military Medicine, Vol. 161, Supplement 1