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First Week in Group--Expectations vs. Reality

First Week in Group--Expectations vs. Reality

Congrats! You have received your Green Beret! You are a lean, mean fighting machine and you are chomping at the bit to get to your Group. You brag to your friends that you think you’re going to either get a HALO team or get selected for the CIF. You can’t wait to show up to a military unit where you don’t get yelled at for stupid things, can grow your hair out longer and where common-sense rules all! You’ve made it!! Or so you think.

Let’s talk about my first week in group and how expectations don’t always meet reality.

One thing that you cannot escape from, despite being a so called ‘elite’ operator, is that you are still beholden to the big army system. While most of my fellow graduates received their orders and left for their units, myself and about 5 other unlucky souls waited for our orders to come….and waited….and waited. Even our out-processing cadre couldn’t figure out why we hadn’t received them. They didn’t even care if we showed up to formations anymore, and many of us just spend our days at Bragg working out and pushing the limits of not shaving while trying not to go stir crazy. What made it even worse was that some of my friends I graduated with had already arrived at 1st Special Forces Group (A) and were prepping for Afghanistan with their ODA’s.

I finally got my orders 7 weeks after I graduated, and drive my happy ass across the country from NC to WA state. I go through my first few days at JBLM in-processing the big army, and then get a further checklist of things to in-process for at 1st Group. I drive over to the compound for the first time, and am rightfully in awe. There are snowmobiles and ATV’s parked in the motor pool, the gym is world class, and there is a rubber pit where a team was practicing combative at what looked like an intense level. I park at Group HQ and begin to walk in, where I catch the eye of someone I hoped to never meet, 1st Group’s SGM. He sees my stack of folders and says

“Just getting to Group?”

Roger SGM….

”Cool, come with me”

…..uh oh…… and proceeds to walk me to all my in-processing stations within HQ, chatting with me like we’re buddies and life-long SF pals. Is this really happening? Is SF so chill that the 1st Group SGM is walking a lowly E-5 around and treating him like an equal? As he turns to leave he puts it all in perspective.

“Welcome to Group! Do good things!”

Then he gets really serious and I see that SGM hatred they are so well known for come out.

 “If I ever see you again, it’s probably because you royally fucked up, so I hope this is the last time we meet. Now get out of here.” Good to know some things never change. 

I get assigned to 4th BN, and begin the slog of paperwork all over again. I’m with 3 other new SF guys in-processing when we get told the 4th BN SGM wants to meet with us. Sigh—here we go again. We go into his office and there are 3 chairs lined up in front of his desk. We take our seats, and he launches into a 45-minute speech on the history of 1st Group, from our presence in Asia to our responsibilities in Afghanistan and Iraq and all the trips we take around the world for FID missions. He gets to the end of his speech and asks the guy seated in the last chair “how many missions did I say 1st Group was responsible for this year?” He couldn’t answer. Next guy, same thing. He gets to me and I remembered it. He pulls out his list of teams with openings for medics and says, what team do you want? Direct Action, Dive, or Mountain? I told him i'd like the DA team, and he says "okay..done..Alpha Company, DA team. Get out of here." "You two (referring to the two other guys) apparently can’t listen for shit, so until you do…you’re on the B team..also in A Co. Get out of here."

And then I made the dumbest mistake a new guy can make…. 

I went back to in-processing and then went home. I get a phone call at 8pm from a buddy of mine. “hey man, did you not go introduce yourself to your new team after SGM assigned you? I talked to your Team SGT today and he is PISSED.”

Well—FML. I’ve been in group for exactly one day and I’ve already potentially been kicked off my new team before I even arrived because I was too stupid to go introduce myself right away, thinking I needed to finish my paperwork first.

That night I got ZERO sleep. Instead, my sleep-deprived new guy brain thought it would be a brilliant idea to be outside my new team’s team room at 5:30am to show them how committed I was and start to make amends for my idiocy. Jokes on me, because that was a 9am formation morning for a 4-day weekend, and I sat outside like an absolute lunatic for 3 hours before anyone showed up.

 I finally meet my Team SGT, who had something crazy like 8 combat deployments over 12 years in group and is clearly a grizzled veteran. He and I had a heart to heart about expectations, which was 99% him telling me his expectations and me replying “Yes SGT” over and over. He left it with “We are too busy for me to babysit you. If you don’t keep up, do more than what is expected of you, and prove yourself every day, I’ll throw your shit in the hallway and you can find another team, understand?”

He walks me upstairs to the team room to show me my desk so I can start getting situated. I am nervous as hell at this point after the talking to I just got. Team SGT leaves, and the only other teammate in there at the time is hard at work on his computer. I sit in silence for at least an hour before I have to ask him something about passwords for the computer. “SGT….” And he spins around in his chair and goes “HEY DUDE! WHAT’S UP? First of all, I’m not SGT, I’m James, nice to meet you!” And that is how I met the man, the myth, the legend, SFC James Grissom, the senior 18C on the team. My team was a dichotomy of personalities. They were either super chill and personable towards the ‘new guy’ or they were ‘you will speak when spoken to’. I was the ONLY medic on the team for the first 9 months, and so they couldn’t ignore me or treat me like crap too long, thankfully.

The last thing I’ll leave you all with from this first experience in group comes from SFC James Grissom and is for all the medics out there. As we were leaving for the weekend, he takes me aside and says “You can be the greatest medic in the world, but if we’re at a range, and I need a Band-Aid and you don’t have one, I’ll pee in your cereal every morning for a month. Have a great weekend!” Best advice ever.

Burns

Burns

We noticed in our recent Instagram post (see it HERE) that there was a lot of incredible and earnest discussion about appropriate treatment for burns. We wanted to take a few minutes to expand on this subject a little bit and explain on some important topics.

As a point of clarification:

When we post on a topic, we are looking at it from the perspective of a First Responder, Civilian, or Military Medic in the field. We are not expecting the kind of resources, medications etc. that are available in a hospital. Think of it as what YOU could do on the ground with your aid bag for the patient BEFORE they arrive at a treatment facility.

Burns are extraordinarily difficult to treat, create long-term complications for hours and even months and years after initial injury, and depending on the severity, can fit anywhere in the MARCH algorithm of care. We will concentrate on the most severe injuries in this explanation.

Steps:

WE STILL FOLLOW SMARCH!!!!! This may be abbreviated, but the elements of it still apply!

Security/Scene Safety

-- Remove the patient from the situation that caused the burn. Do not try and treat the patient in a hazardous environment! PUT OUT THE FLAMES IMMEDIATELY.

Use common sense at this point to assess the appropriate next steps, some of which can be done simultaneously. Was this person just covered in flames or suffering flash burns from an explosion or IED, or is it something smaller like their leg suffering a bad burn?

Massive Hemorrhage: A quick inspection of wounds can determine if massive bleeding needs to be addressed. Stop all Massive Hemorrhage.

At this point-- STOP THE BURNING PROCESS. Just because you have put out the flames doesn’t mean the skin has returned to normal temperature. Just because you take a hamburger patty off the grill doesn’t mean its room temperature immediately. Actively work to cool the skin with water, hydrogel, burn blankets, or whatever you have available. Getting the skin back to normal temperature asap is important.

Go through the rest of your MARCH sequence quickly but efficiently. If no other life-threatening interventions are necessary-and burns is the primary injury, start thinking about the following.

1)  Facial Burns, especially those that occur in closed spaces, could be associated with inhalation injury. You must AGGRESSIVELY monitor airway status and O2 saturation.

- STRONGLY consider early surgical airway (Cric’ing).

- Once an airway has swelled up and shut, it is extremely difficult to open.

I have personally witnessed someone come into a hospital after receiving a flash burn to the face, talking and apologizing to the staff for how silly she felt letting it happen. They immediately RSI’d her and secured her airway—and it’s a good thing they did because not even an hour later her airway had completely swollen and closed off. If it were not for their immediate intervention that seemed unnecessary at first glance, this woman would have died.

From a field providers perspective and something I would do at my ability level—any suspected or confirmed inhalation injury (look for blackened nose hairs or singed eyebrows as possible sign) will get a pre-emptive lidocaine to the cricothyroid area in preparation for a cric. Any decrease in O2 sats or changes in breathing by the patient gets a surgical airway immediately. I’d rather get punched in the face later for a throat scar than let someone talk me out of it. Sorry not sorry.

2) Estimate the Total Body Surface Area (TBSA) to the nearest 10% using the Rule of 9’s.

3) Cover the burn area with dry, sterile dressings.

4) For extensive burns (over 20% BSA) I’d highly recommend a Heat-Reflective Shield or other LIGHT covering to try and retain the patients heat. Keep in mind that you will be dealing with damaged nerve endings, so while retaining patients body heat is important, putting heavy material on them must be balanced with appropriate pain management if that’s all you have.  

5) Fluid Resuscitation (Rule of 10’s)

   - We noticed a lot of people were still using the Parkland Burn Formula. This has been replaced with the Rule of 10’s.

Rule of 10’s:

  1. A) For Burns over 20% TBSA, start fluid resuscitation ASAP once IV/IO has been established.
  1. B) LR preferred, but NS or Hextend can also be used (no more than 1L of Hextend, but can be followed by LR and then NS)
  1. C) Initial fluid rate is calculated at %TBSA x 10ml/hr for adults weighing 40-80kg (88lbs-176lbs)
  1. D) For every 10kg ABOVE 80kg, increase initial rate by 100ml/hr.
  1. E) If hemorrhagic shock is present, resuscitation for hemorrhagic shock takes precedence over burn shock. Administer fluids for TCCC Fluid Challenge first in Hemorrhagic shock.

6) You can and SHOULD administer analgesic for pain if patient is conscious or drifting in and out of consciousness.  

--We had many people suggesting Fentanyl as an analgesic. While an effective method of pain control, in someone we anticipate having breathing complications, it is inadvisable to push opioids that depress respiratory drive. We strongly recommend Ketamine instead.

7) IF TRAINED—you can consider escharotomy for circumferential extremity burns with promised circulation and or/circumferential thoracic burns with compromised ventilation. LIMIT ESCHAROTOMY TO DEPTH OF BURN!

8) Splint burned hands and feet in position of function with dressings separating digits.

9) Consider AGGRESSIVE pain management in critical burn patients.

10) initiate AGGRESSIVE hypothermia management in extensive burn patients.

The more you are able to quickly stop the burning, get the skin back to room temperature, and manage their symptoms, the better their short AND long-term prospects for survival and recovery are. Burns are awful, but how you manage to treat at point of injury will be crucial. Hope this has helped!! Feel free to add comments below.

If you can’t remember the Rule of 10’s, the TCCC fluid resuscitation protocol, or what appropriate analgesia might be, we include it all in our Medic Quick Reference Guide and all narcotics information can be found in our Narcotics Quick Reference Guide!

 

 

Robin Sage: The Relapse..aka Part 3 aka The Stinkfest

Robin Sage: The Relapse..aka Part 3 aka The Stinkfest

As mentioned previously, I will try and keep certain instances general so as not to compromise the integrity or confidentiality of the exercise.

After our infil from the fiery pits of hell, treating some initial real-life medical situations, and then miraculously pulling off the luckiest mission save in my career, I am now about half way through the field exercise portion of Robin Sage.

Life at this point in the G camp consists of two phases. I’m either going on missions, or I’m doing my best to help out around the camp to improve the miserable living conditions. While I know you all would love to hear about additional missions, frankly, the missions weren’t that exciting from a medical perspective or from a participants perspective during those middle phases. Most of the missions were designed to evaluate different MOS’s and their ability to perform certain tasks, so my role as the medic on many of these missions was to simply support them. That being said, you’d be correct in assuming I didn’t take that for granted after that previously described mission in Robin Sage: The Encore.  They were more just ‘laying the groundwork’ type missions. The camp however, now there is a different story.

Where we ‘chose’ to set up camp was essentially a half-dried swamp….near a cow/pig farm…in NC…in August. While there undoubtedly was a very good reason that spot was chosen…i.e. no one in their right minds would even WANT to look there, it led to a miserable existence for us. The smell…ooooh the smell. When the wind blew just right you could literally taste the manure seeping through your nostrils and into your mouth, but don’t try and breath through your mouth because the massive swarm of gnats and mosquitos would immediately find their way into it.

When the wind was blowing in the opposite direction, you managed to get a whiff of our beloved outhouse. As you may have figured out, it’s not like we had permanent fixtures or a portapotty contract. Nope, we had a straight Little House on the Prairie outhouse that we had to dig ourselves and construct a makeshift privacy barrier around it using old pallets. We even carved an adorable little half-moon in the front door because we were fancy like that. Me being the medic, the unenviable task of making sure the outhouse was up to standard, and that everyone stayed healthy, was mine and mine alone. No easy task when everything around you is a dirty, smelly cesspool.

One of the ways we tried to reduce the stank was to pour lye on our ‘contributions’ to the outhouse after each visit. This helped reduce the smell, ward off flies, etc. However, despite the horrific stench, it quickly became apparent that people weren’t pouring the lye regularly.  The threat of their nose hairs spontaneously combusting wasn’t enough of a reason for them to do a SIMPLE TASK. After repeated attempts of reminding people, it was clear that the only way this would get done, is if I did it regularly. So at least twice a day, I would pick up a huge bag of lye and tip just enough in to cover what’s in there. Why am I describing this to you? Because on one of these days my foot broke through the floorboard and I half fell into that..uh…pile. There wasn’t enough soap in the world to get rid of that stench…so goodbye recently purchased pair of $180 hiking boots. Goodbye patience level. Month after month of tirelessly studying and being tested in the 18D course to do everything from trauma medicine to complete intravenous anesthesia and surgery, and the most medicine I’ve done since day 1 is pouring lye on human waste and nag them about hand washing. Now I’m sitting here covered in crap and wondering what life choices I’ve made that got me to this point. They don’t tell you about moments like this when you go through the course!

As Robin Sage is winding down, our team and G’s finally move out of that camp and into a real building. We are prepping for one last ‘battle’ that will decide if Pineland is free or not. Having kept my ear to the ground, I know this is where the mass casualty incident usually happens that tests the 18D’s, and I’m prepping like a madman. The other G’s give me the sorrowful look that indicates they know what’s about to happen, and one blatantly tells me ‘this is gonna suck for you’. Thanks dudes.

What I am not aware of at the time, is that an individual on my team has been struggling horribly in his mission planning, and this last mission is being designed around his ability to land nav and execute his plan for the team. Hint—this is the same individual who led us badly astray during our infil. So off we go on our mission….we do our thing to set it all up, and start to wait…and wait…and wait…and…wait a minute, are those the bad dudes driving by us in a truck waving a pirate flag and pointing at us? Needless to say the mission did not end in success, and despite us trying to chase these individuals around for an hour and trying to guess where they would be so we could ambush them, we returned to our building empty handed. Those who had been left behind ran out to our truck with litters, preparing to offload casualties, to find none, and our team in dead silence, knowing that something had gone horribly wrong, but not necessarily understanding what it was.

Wrapping it up….this last mission was designed for this one individual as a last gasp attempt. He failed and was dropped completely from the program. Having successfully passed a mass casualty exercise before the field portion started, and having treated the axe to the head injury early in the exercise, the cadre decided they wanted to focus on those who were struggling (or so I was told in my out-brief before we returned to Bragg). Sad for him..but the culmination mission was a bust for putting my skills to use.

Once it was all over, and we found out which one of us failed and which of us passed (4 failed, 12 passed), we were allowed to talk to the G’s as normal civilians.

They could break role and talk to us. As I mentioned in a previous post, all the G’s got to pick their own names during this exercise. Panther was my helper ‘medic’, etc. One of my absolute favorites, was a dude who came from out of state each exercise to help out. Dude was as country as they get. He went by the name Massey Ferguson. After the exercise I went up to him and thanked him for being an awesome role player, and for being enthusiastic and helpful in everything we asked him to do. When I asked him what his real name was, he said “what do you mean?” I explained that I know Massey Ferguson was clearly his Robin Sage name, but what was his real name. “It’s Massey Ferguson man”, he replied. He saw the look on my face and followed up with “My parents really like farming”. Trying to save face and not be an insensitive asshole, I asked him if there was anything I could help him out with before he left. He responded enthusiastically “could you get me a box of yellow chemlights? I love using them to go noodling with my kids!”. Of course I can Massey Ferguson, you pure country soul, of course I can.

There were so many variables, missions, scenarios and incredible stories that I can’t share with you all due to confidentiality rules, but I can honestly say that this UW mission was an incredible experience, and lessons taken from it applied in scarily accurate ways when my team conducted Village Stability Operations in Afghanistan, as well as anti-insurgency operations and FID in the Philippines (just to name a couple). The designers of this exercise and the participants from the community, as well as the role players, did a kickass job.