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Double Amputation done by Special Forces Medic!

Double Amputation done by Special Forces Medic!

What makes a Special Forces Medic (18D) different from conventional Army Medics (68W’s)?

It mostly comes down to prolonged field care—the ability to keep someone alive during a period of time where evacuation is not possible. While this may mean many things, such as being able to run your own lab and interpret the results, it primarily means the ability to manage significant wounds over a long period of time. This skill is learned during an extremely intense block of instruction in the Special Operations Medical Course (SOCM)/Special Forces Medical Sergeant (SFMS). This course covers anesthesia as well as surgery, to include amputation and subsequent wound care. This block of instruction is extraordinarily demanding, with long hours, significant documentation, and a justifiably rigorous examination of every decision you make during this critical phase of training by the instructors.

With the recent history of the U.S. military dominating the air space immediately and establishing significant evacuation capability, why is this skillset such an important part of the curriculum?

Think of the ongoing conflict between Russia and Ukraine, or the recent saber-rattling of China and Taiwan, or North Korea and their neighbors. If we enter into conflict with any of these countries, air dominance is hardly assured in the first few weeks, while SF and other SOCOM units are inevitably on the ground doing what they do best. This skillset is great in these hypothetical match ups, but when was the last time it was actually used? This brings us to the meat and potatoes of this article. It happened more recently than you might think.

A Special Forces Medic, who shall remain anonymous at his request, reached out to us and asked us to share his story of conducting a double above the knee amputation on an enemy combatant. He said he received permission to share the story from SOCOM Public Affairs Office, complete with pictures!

 In his words:

“We couldn’t evacuate an ISIS fighter who had surrendered to us. The injury supposedly happened about 10 days prior to him surrendering, and he was extremely septic. His core temperature was 104.7, and he had off-gassing on both injured legs. There was a traumatic amputation with exposed tibia on right leg, with everything distal to the distal head of the tibia gone. Open compound tibia-fibula fracture of the left leg, which was extremely infected. 

The ceiling was 50 feet due to intense fog, and evacuation was not possible. We turned an extremely austere clinic into a surgical suite as best as we could, and received permission from theater-command and our regional medical director to perform the life-saving intervention. The opportunity was everything the SOCM/SFMS course prepared me for.”

The following pictures are extremely graphic, but show the incredible work this 18D did!



This is extraordinary work, and perfectly demonstrates why the selection process and demands of Special Operations and especially Special Forces Medics is so high. 

Do you think you have what it takes to simultaneously run the intravenous anesthesia AND conduct this intensive surgery?

There is even a podcast about it, found here:

Read some of our other blogs posts for more information on what it takes to be an 18D, and the experiences we go through both on and off the battlefield!


Life on an SF ODA-sorta

Life on an SF ODA-sorta

The majority of the over 2000 responses to our Instagram poll requested we talk more about life on a team and team deployments. We’ll eventually hit all the topics, but wanted to start by writing about the most requested topic: Life on an ODA team.

What is life like on an Operational Detachment Alpha (ODA)? Well, it kind of depends.  I HATE that answer to most questions, but we’ll do our best to explain why it’s true in this instance in the paragraphs to follow, hopefully without rambling about nonsense. I haven't written this much before, so any misspellings, incoherent blabber, and non-sensical tangents are part of the process. 

I spent time on 2 different ODA’s in Group, the first being a Direct-Action (DA) team, and the second being a Maritime Operations team (MarOps). The teams and the dynamics of the two teams could not have been more different. I can tell you about my own experience, but it’s a small snapshot of the different personalities and team dynamics of many other teams. Each team takes on the personality of its members. Nevertheless, I am happy to share my day to day on these teams, and hope it brings some insight into what is otherwise a very hard topic to find elsewhere on the internet.

If you want to know what my first week in 1st Special Forces Group was like, you can find that on a post I previous wrote about HERE.

A typical SF Battalion is split into 3 companies. Each company has 6 ODA’s and an ODB (B-team). The B-team is generally stacked with the most senior guys in the company, including the Company Sergeant Major, the Major, and guys who basically have been around long enough to make training and deployments happen. There are occasions where junior guys end up on the B-team for various reasons, but despite the stigma, it’s not generally a bad thing to be on the B team.

The 6 ODA’s consist of a Direct-Action team, a Maritime Operations team, a Mountain team, a HALO team, a Dive team, and a Ruck team. All the teams have the same basic skillsets, but teams with the unique qualifications really stress what makes them unique. Being on the Direct-Action team, we focused heavily on all aspects of, you guessed it, shooting.

Now that the basics are out of the way, let’s get back to daily team life on my first ODA.

If we were actually at 1st Group (more about this later), our day generally started at 0600am at the 1st Group Gym. We worked with awesome personal trainers on the THOR3 (look it up) program, tailored to our specific mission sets. We worked out until 7:30, then hastily showered, ate, and got packed up to go to one of the various shooting ranges.

Ranges generally opened at 0900 and lasted until the sun went down or we ran out of ammo for the day. Rain or shine, we were usually shooting. It was entirely common for our team to start our day at 0600 and not leave until 1900 or 2000 on 3 or 4 nights per week. I would drive home, immediately fall asleep at 8:30pm, wake up at 4:45am, and do it all over again. I was new on a team, so I had no idea if this was normal or not, but I did notice when we returned to the team rooms at 1900, we were the only ones there. Hmmmmm suspicious.

We always threw in some cross-training for different MOS’s, and if there was any downtime on the range, everyone on the team knew they better be prepared to have a topic ready to teach. For example, we didn’t just push open doors to make entry into a shoot house. Our 18C’s taught us how to construct door charges, which we then used to blow doors before making entry. If someone screwed up, they became a ‘casualty’ and either myself or one of the other guys then had to treat them on the spot. Our team sergeant was a big fan of saying ‘good work, now do it again’ and throwing wrinkles into every iteration of training.

On Friday’s we tried to get caught up on paperwork, scheduled ranges for the future, or planned for upcoming deployments. Even with Friday’s being paperwork days, we still didn’t end up leaving until well after 5pm. The only difference was that at 1700 on Friday’s the ‘beer light’ was turned on. I can neither confirm nor deny paperwork got done quicker and more efficiently under the influence of a few beers. 

It wasn’t all ranges though. Something they don’t prepare you for AT ALL in the Q course is the amount of paperwork you have on the teams. As an 18D, I was in charge of the S-1 functions for my guys…aka making sure they were up-to-date on their pay. When you have a team full of guys getting paid at different levels for language, then throw in demo pay, airborne pay, etc. it gets complicated. We also were in charge of making sure everyone’s hearing, vaccinations, HALO/SCUBA physicals and yearly other appointments like dental were all good. You could get chosen to go to a school at the last minute, and god help you and your 18D if you weren’t able to go because you were late getting your teeth cleaned!

The day you sit down in the team room, guys will just come up with their paperwork and state ‘I’m not getting paid, fix it’. I was the only 18D on my team for the first year. I had no senior 18D, and I was fresh from the Q course. I didn’t know what the hell I was doing, but I wasn’t going to admit it to a senior guy on the team. I did the only thing I could think of, I ate humble pie and went and begged the E-3 in the battalion S-1 office to teach me how to do that part of the job. 

The 18E’s were always down in the commo office upgrading radios or learning new skills. The 18B’s were always in the armory inventorying their ammo and firearms and making sure they were properly maintained, and our 18C’s……oh lord our 18C’s. Those poor bastards had to keep track of every piece of gear that crossed the threshold of our team room door. You want to make an enemy out of your 18C, you start tossing gear around and saying phrases like ‘we’ll just get another one if this one breaks’.  

Okay-let’s see….what are some other typical things we did?

A few nights per month we scheduled training with 160th (SOAR), the Special Operations Aviation guys who flew helicopters like absolute bosses. The only downside is they primarily flew at night. We did significant training on fast-roping and conducting SPIES with their Blackhawks, and drove ATV’s and side-by-sides off their Chinook’s. On these nights we started our days later and usually ended around 0100 or 0200.

So far it sounds like we had a semblance of a routine throughout the year. Far from it. Our team leadership was all about finding realistic training missions, which means we were ALWAYS gone. Not only did we pick up multiple JCET’s (6-8 week trips to foreign countries to teach combat skills), but we had a plethora of out of state training exercises. On more than one occasion, our team would visit Yakima Training Center for a few weeks, then come back on a Friday afternoon, only to leave again Sunday afternoon for 4 weeks at another location.

Some of the training events included long range shooting and demolition in Yakima, high angle sniper training at 29 Palms, California, Osprey training at an Air Force Base in the southwest, and being the ground unit for the Air Force’s premier fighter pilot exercise out of Nellis AFB in Las Vegas two years in a row. This is on top of multiple trips to Thailand and the Philippines, and a 9-month deployment to Afghanistan. This didn’t include all the individual schools we were constantly going to-none of which ever seemed to local.

While the training we went to was an absolute blast, it struck me on more than one occasion how much we were away from home. As a single guy, I had no issues with being gone constantly, but married guys and those with kids were wearing down quickly. To put things in perspective, I signed a 1-year lease at an apartment complex in Tacoma, WA. From the day I moved in until my least expired, I spent a total of 47 nights in my apartment. This was NOT including our trip to Afghanistan. This was just a typical year of training and JCETs for us.

Team Dynamics: 

You don’t make it to an ODA without having a strong personality. This can be great in the sense of competition and pride in the work you do, but detrimental if you carry an ego. Whether we stated it verbally or not, every range day was a competition. We carried the Ricky Bobby philosophy of ‘If you’re not first, you’re last’. If you were last, you bought beer for the team as punishment. My first few months on the team, I was buying a LOT of beer. I don't know what i spent more time doing my first few months, learning how to do the most basic elements of my job, shooting a gun, or trying not to screw up. 

If you ever feel like SF guys are consummate professionals, you've never met me. Anyone else forget their PT gear on their first day of team workouts? What about standing at the firing line for the first time with his new team and realize you forgot all your loaded magazines back on the table? Walk in to a company training event 5 minutes late laughing and talking nonsense because you thought you were actually 25 minutes early, causing the entire room to go silent and stare at you? The list goes on, but for the sake of my dignity, i'll just reiterate that if someone like me made it to group and stayed, there is hope for all of you. I think my only saving grace was that I took my job as a medic extremely seriously. 

For the most part, we held each other accountable, but had a lot of fun. On training missions out of state, we always found time to visit the local town, went to shows, or just drank in local bars together. We had only one rule about going out. Make it back on time. If it took 3 of you hoisting your absurdly drunk teammate over your head and running him back to his room after he decided it was a good idea to slam dunk a ping pong ball into someone else’s beer pong game at a Vegas bar, you made it back. 

When we were at 1st Group, there were those random days we just watched tv in the team room all day, or it was implied we should ‘go on an errand’ after lunch and disappear….AKA go home and don’t get caught doing so.

Overall, we worked EXTREMELY hard, and developed a reputation as a very capable and competent team.

You always had to be careful on a team though. No matter how experienced you were or thought your position on the team was solidified, you never wanted to get too comfortable. Especially your first 6 months on a team, you were in constant fear you’d come in one morning and find all of your gear in the hallway, the ultimate F*ck You. It meant the team lost trust in you, and didn’t want you anymore. You had to lug your gear to the SGM’s office and explain yourself, while he had to figure out the next steps for you. If you royally screwed up, I.E. a DUI, domestic violence, or slept with the SGM’s daughter, you better just slink into the basement and hope you get a second chance after a year of doing every unenviable task imaginable.

We had a new, experienced 18F get assigned to us about 2 years into my team time. Seemed like a good dude, with no real personality issues we were concerned about. Some of the guys knew him to be a capable guy during his time in group. However, he had slacked on fitness, and resembled the Green Beret cliché of being overweight. One of his first days on our team we did a team ruck march. We hadn’t even made it a mile before he was falling out of it. We left him behind, completed our ruck, and threw all his stuff in the hallway before he returned. Last we saw of him he was reassigned to another company. Our Captain and Team Sergeant DESPISED physically weak people, and decided he wasn’t a good fit.

 After being on my first team for 3+ years and coming back from Afghanistan, we did a company shake up. I moved a whopping 10 feet next door to the MarOps ODA. This second team I went to was significantly different in a variety of ways. They took pride in going home every day by 4pm, and had only gone on 2 JCET’s and zero combat tours in the previous 3 years. Simple things, like programming radios and disassembling the weapons systems, was something most of the guys didn’t know how to do fluently.  As a Maritime team, we took the Zodiac boats out maybe 3 or 4 times the entire time I was there. It was clear from day one the majority of the guys on this team had no idea what they were doing on this ‘specialty’ team. While I had gone from the Q course to a very senior team, the majority of guys on this team were young and didn’t know any better. Myself and a few other guys were brought in to add some seniority to the team…sad considering I had just over 3 years in Group at the time. We eventually transitioned to a hard charging team, but still not nearly as gung-ho as I was accustomed to!

There is always going to be a tradeoff in which team you get on. Was it worth it to get on a team that was gone non-stop, trained like animals and got to do missions resembling recruiting videos? Depends on who you ask. When our team returned from Afghanistan, 5 guys on the team underwent divorces, and 3 more put in requests to leave the team and go to the teaching school in North Carolina in the hope for family stability. Those of us who were single stayed single. The trade-off could have been going to a team that went home early every day, but didn’t get to do half of the cool stuff we did.

I remember being at Nellis AFB near Vegas one year when the Electric Daisy Carnival was taking place at the Las Vegas Motor Speedway. We took off in 3 blacked out special operations helicopters at sunset, legs dangling off the side of the helo’s. We flew low and slow over the highway, only a few hundred feet above the row of cars going to EDC stretching all the way back to downtown Vegas. As we flew over the cars, looking down at the hundreds of faces looking back up at us, and then flying 2 hours into the heart of the desert before hitting a target., it felt worth it. Not entirely because I felt cool, but because I had fought so hard to get to a point in my career where I could do amazing missions like this. Will it be worth it for you? I hope so.

We have more blogs up about SF Selection, our time at Robin Sage, multiple case studies in wound care, and much more at our blog, found HERE

Mass Casualty Incident!!

Mass Casualty Incident!!

Responding to a Mass Casualty Incident

Awhile back, we had the massive explosion in Lebanon. More recently, we had the horrific explosion in Kabul that claimed the lives of 13 Americans and over 100 Afghans. 

The first few moments after the explosion are surreal. You don't necessarily know exactly what happened, but you know it's not good. Your brain is in a temporary fog and having difficulty understanding the magnitude of what you witnessed. Your ears are ringing. You check yourself to see if you're injured, and then know you need to help others. Casualties are everywhere. It's initially calm, but then people start screaming for help.  Your brain is having a million thoughts a second trying to assess, plan, process and help all at once. Everyone seems to be moving around, but no one is quite sure how to help. These are the realities of the moments after an IED blast. We know. We've been there before. This post will hopefully help those who have never experienced an incident like this gain a fundamental understanding of what to do should they encounter one (God forbid). 

We tend to think of Mass Casualty Incidents (MCI) as being due mainly to crazed shooters in the civilian sector and IED’s in the military sectors, and you'd be mostly correct. However, MCIs can also occur for a number of reasons, such as earthquakes, tornados, car accidents, and yes, industrial accidents.

The rules for military MCI/CCP’s and civilian CCP’s are inherently different, yet they share many of the same principles of care. Staying safe, rapid evaluation and prioritization of patients, and subsequent stabilization and evacuation.

This post is to help expand the understanding of EMS and First Responders, those with medical knowledge who are witness to MCI, and military medics who need refreshers on helpful tips and techniques.

What makes an MCI an MCI? By military definition, an MCI is when you have more casualties than you do medical resources to support their care.

In a civilian setting, this can also mean a resource constrained environment due to time, availability of services, or lack of nearby medical personnel.

A perfect example of this recently is the explosion in Kabul. The hospitals and EMS in the city were immediately overwhelmed, and hundreds of casualties wandered aimlessly seeking care. 

Rarely will a solitary medic/EMS response team have enough supplies to adequately care for large numbers of wounded simultaneously. We know that even a small delay in resources can have a major impact on the immediate need for care. Therefore, prioritization's must be made.

Step 1: Size the Scene Up

- Is what caused the incident under control? Are you at risk of becoming a casualty yourself? Taking the time to read this and wanting to help means you aren’t a coward. Scene Size Up means you being smart and taking a tactical pause to assess the situation to ensure you do not become another casualty before you’re able to help.

- Begin to assess what type of resources you’ll need. For example, in an explosion may see lots of amputations, burn injuries, head injuries, cuts from shrapnel etc., a shooting—puncture wounds, and in a car accident—blunt force trauma. Thinking about what injuries will most likely accompany an event will help you to immediately plan your response.

- Identify any onlookers who have medical training and /or are willing to help. Remember, people are more willing to help when directed. Saying “I need you to help me get this patient moved over here” is more effective than saying “who will help me?”.

If you are the bystander with no medical knowledge, take direction. Use available resources, and be proactive about reporting back to the medic with what you see. 

Step 2:  Identify a Casualty Collection Point (CCP)

- You’ve taken a second to recognize there will be multiple casualties requiring medical care. Rather than continuously running between each casualty over the entire casualty scene, it is necessary to get them all in the same area to render effective care. Identify a casualty collection point (CCP), preferably close to the patients but out of harm’s way. Must be accessible to emergency vehicles to begin accepting and transporting patients when they arrive. 


Step 3: Begin Initial Triage of Patients

  - A good way to begin is to yell out “If you are wounded and can walk, walk to the sound of my voice”. Those who may be less seriously injured and still conscious can identify themselves and begin assembling towards you. This will reduce your need to visit every patient and assess.

- Begin a systematic but expedient walk-through of patients. Identify injuries that need to be handled immediately, such as massive bleeding.

- Once you have identified a patient who needs immediate intervention, direct others to apply a tourniquet if they know how. If no one else knows how, apply a tourniquet, direct someone to hold pressure, or pack the wound yourself as quickly as possible. Have someone else hold packing in place once complete and move on to next patient. Remember, in this step, you are doing only immediate and life-threatening interventions only and moving on to more patients.

- Continue identifying all patients by order of seriousness of injury and have them moved to CCP and arranged accordingly.

Step 4: Take charge of Casualty Collection Point

The CCP is meant to assemble, continue triaging, stabilize and subsequently evacuate your casualties.

How you set up your CCP matters.

1) Organize patients by severity of wounds. Keep patients who will need greater attention together allows more rapid assessment, treatment and attention.  Try and keep the more severely wounded patients closest to where you expect them to be picked up by transport.

2) Economy of movement means being able to treat, direct treatment and move between patients as quickly and efficiently as possible. We recommend setting up your patients in the following ways to maximize efficiency. The lead medic establishing a presence in the center of the wounded allows for rapid evaluation and easy to direct patient care. 

Color BLACK: Expectant—Do not waste supplies on those who are dead or who would take up a sizable amount of resources with a small amount of survival.

-- Examples of Expectant injuries include: Exposed brain matter, agonal respirations, severe polytrauma.

-- A good rule of thumb is to separate the dead and expectant from the rest of those in your CCP, both for the sake of the living patients and to minimize confusion in a chaotic situation.  

Step 5: Begin systematically treating patients

As the lead medic, you will be responsible for directing care. As you move from patient to patient, assess rapidly through the MARCH algorithm.

1) Is the massive bleeding under control?

2) Is their airway open and patent?

3) Are their breathing/respirations adequate?

4) Is perfusion/circulation adequate?

5) Is this patient covered properly to prevent hypothermia?

Above diagram courtesy of @the_resusitationist
 - What we found to be effective was assigning a helper when available to each patient. The lead medic would rapidly assess MARCH for each patient. The helper would then be given instructions like “I need you to place your hand here and hold pressure, and don’t move until I get back” or “Keep the patient covered, and every 2 minutes I want you to count their respirations and pulse”. 

- If you were to work through the full MARCH algorithm yourself on each patient, it would delay vital assessments on other patients. Quickly understand what is happening to each patient, direct a helper to fix the issue, and move onto the next patient.

- We cannot stress this enough; In a mass casualty incident where you are responsible for multiple patients, your job is to DIRECT CARE as much as possible. You can direct others to place/check tourniquets, hold pressure on wounds, position people, cover them, etc.

- In a resource constrained environment, placing a hand on a chest wound may have to suffice instead of a chest seal. Putting pressure on a heavy bleeder with a shirt may have to take the place of a proper bandage. You as the medic know what supplies you have and which ones you do not. You must be smart about how and when you use them.

- If complicated procedures must take place, such as cricothyroidotomy, the medic would still be responsible for that.

Step 6: Continuously work to upgrade the status of your patients.

You’ve gone through your initial assessments. Starting with the most severely wounded, begin using what limited resources you have to upgrade when possible. Have an idea of who you want EMS or higher-level medical authorities to pick up first, and be prepared to give them proper vitals, treatments etc. when they arrive.

Final Thoughts

MCI’s and establishment of CCP’s are rare, but must be practiced. You can expect chaos, confusion, and a high-pressure environment. Don’t let the first time you experience it be a real-life event. 

If you are a medic, LEO, First Responder, etc. Please work an MCI, CCP etc. into your training. Even practicing it one time can have a significant impact on your ability to understand what is expected of you. It will also demonstrate how rapidly supplies are used, and can help you better assess and treat patients with alternative methods.

If you have experienced a Mass Casualty Incident, and want to share some feedback, please do so in the comments to continue the learning points!

If you want to help, but aren’t sure how, please check out our First on Scene Guides HERE. It will help walk you through the SMARCH algorithm of care, as well as how and where to place tourniquets, how to pack wounds, where to place chest seals, how to perform CPR, and more!

For military medics, we have an excellent guide for you HERE.

If you have or want to purchase a medical kit, but aren’t entirely sure how to use the contents within it, we have you covered with our Medical Kit Quick Reference Guide HERE

For all other medics…we have a full assortment of guides for you as well!

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