Innovation and Adaptation
Seasoning with SALTTBy James Savage May 13, 2019
The winning article from the EX HAMEL 18 writing competition provided an interesting update on the use of AME medics to retrieve casualties from hostile environments forward in the battlefield. For Shock Trauma Platoon (STP), as custodians of the Army’s only mobile forward damage control resuscitation and surgical team, the topic of casualty evacuation is just as relevant.
Due to the increased lethality of modern weapons, and the ability to acquire targets at longer ranges, tactical commanders have responded by dispersing their troops and relying on increased mobility to prevent destruction. One result of this is that in future conflicts we are likely to see the larger military hospitals further back in the echelon space than in previous wars. However, soldiers will still get injured on the front line and uncontrolled bleeding within the torso needs surgical intervention. The quicker the intervention the better chance of survival. Provision of a forward light surgical facility is one way the Army can mitigate against the increased distance/evacuation time to a Role 2E field hospital.
So let us return to our scenario from EX HAMEL:
HUSTLER (the Combat Recovery Aircraft callsign) has just collected the two gunshot wound (GSW) patients from the 7th Combat Brigade and is heading rearward towards the Role 2E hospital. Flight time will be 45 minutes. Three minutes into flight, one of the aeromedical evacuation (AME) Medics has identified a critically unstable patient that needs urgent surgery. This information is passed on to the pilots who in turn inform the Casualty Regulation Cell. It is noted that STP are located within five minutes flight time of HUSTLER’s current location.
Crackle, crackle. ‘LAZARUS (author’s suggested callsign for STP), this is HUSTLER we have one by Pri 1 casualty onboard. Requesting delivery to your location for damage control resuscitation.’
‘HUSTLER, LAZARUS acknowledges your one by Pri 1. The LZ is clear – bring them in.’
For this Shock Trauma Team the calm of the morning is shattered as the approaching MRH-90 lands with the typical downwash dust-storm. Before long a heavy breathing AME medic arrives at STP’s tent doors with the Pri 1 soldier. A quick hand over takes place from the delivering medic to the Emergency Medicine physician:
‘This patient needs immediate treatment. Mechanism of Injury: Gunshot wound from ambush. Injuries sustained: penetrating abdominal and chest injury. Signs and symptoms: airway - patent; breathing – ineffective, SpO2 89% on 15 litres of oxygen, respiratory rate 24; circulation - hypotensive BP 80/50, heart rate 160; GCS – 9. Treatment: oropharyngeal airway, 15 litres oxygen on non-rebreather, Sam-seal to chest, I have been unable to gain IV access’.
By now the injured soldier is already fully exposed and a resus team are conducting their own rapid assessment. Preparation for advanced airway measures are being put in place, intraosseous access is gained and blood is being delivered to this soldier. The general surgeon is observing and after ultrasound scans have shown a belly and lung space full of blood the decision is quickly made to transfer them to the operating theatre (located in the co-joined tent). 40 mins later surgery is finished and the bleeding is controlled. The soldier has a plastic tube in their windpipe and a mechanical ventilator is providing oxygen to keep them alive. An arterial blood pressure line has been inserted; and the anaesthetist uses syringe-drivers to deliver a careful mix of drugs into the soldier’s veins to maintain sedation and ensure blood pressure is high enough to oxygenate the brain. The surgeon steps back satisfied with his work – it is not definitive surgery – it is damage control. Enough to keep them alive for now but the soldier will need further surgery at the Role 2E hospital to ensure survival. This is an unwell patient that will need careful and expert monitoring on his evacuation.
And this is where the problem with the Army’s evacuation process lies. Under the current system this patient will be transferred rearward to the military hospital; most likely in a protected mobility vehicle - ambulance (PMV-A) or back into the helicopter that he was first delivery from. For all the good work done so far, the patient now faces their most dangerous journey where the potential for things to go wrong remains high and the ease of correcting them in a small and difficult working environment are low. In the civilian sector this task is carried out by a highly trained retrieval team; in the Army it is done by a medic. As well trained as our medics are, for a patient of this severity a medic is not sufficiently skilled to do this. This is not a criticism of our medics, this patient transfer would push most Army General Duties doctors out of their comfort zone.
A good casualty evacuation system ensures that a patient is taken to similar or progressively higher levels of medical care during their journey. STP’s surgical capability forward in the battle space has almost certainly saved this soldiers life, but its gains may have been futile if a complication occurs in the evacuation process and the attending clinician in unable to fix the problem.
So, what are the options? On HAMEL 2018 members of STP heard one proposal for how this could be improved. It is based on a project known as the Sea, Air, Land Treatment and Transport (SALTT) model: an Australian Defence Force (ADF) wide asset that provides the level of specialist doctors and equipment needed to perform these difficult patient transfers across all domains. It has similarities to UK’s MERT (Medical Emergency Response Team) but one that is shaped to fit with Australian capability and assets. Currently the SALTT is at proposal level.
At present the light surgical component of STP is itself not a recognised capability within the Army; nevertheless, STP is becoming better known within combat brigades and apparently has earnt its own map-marking symbol on brigade commanders' staff maps. This probably helps reassure leaders that they are meeting their 10-1-2 guidelines¹. However, despite STP’s potential life-saving capability there remains a life-threatening gap in the current evacuation process that is a detriment to the best medical care we can provide our soldiers. Could it be that SALTT is the missing ingredient from our casualty evacuation plan?