Home / Battlefield medicine case studies/SFAS tips

Blog - Battlefield medicine case studies/SFAS tips

MVA--couldn't breathe, where I messed up

MVA--couldn't breathe, where I messed up

Back Story: We were assured that no one ever went to this particular village without getting into a fight, so were determined to go and get our fair share that day. For hours and hours we maneuvered, repositioned, goaded them, and breeched homes we had intel on. After 4 hours of nothing, we were ready to call it a day and head out to another location to try our luck. Just then, my interpreter comes up and says "We have a casualty coming in". He doesn't know anything more. I don't know if the casualty has been shot, blown up, or even who the casualty is at this point. So up pulls a mid 1980's Toyota Corolla, and the driver quickly gets out, pops the trunk, and lifts a man out of it who is curled up in the fetal position. He carries him over to us, and sets him on the ground. What follows is a  mix of what I did correctly, what I missed in my assessment, and some very serious lessons learned. 

As he is being unloaded, I get the information that this was a local ALP (Afghan Local Police) member who had flipped his truck while patrolling nearby, and a local found him and hurried him over to us. 

All medics are taught to anticipate what injuries to look for based on how the wounds happened, right? So now knowing that this was a MVA (motor vehicle accident), I had a picture in my mind what could be wrong, but still needed to follow the SMARCH-RV formula. 

Presentation of patient: Semi-conscious, seemed to be having irregular respirations that almost appeared agonal while gasping for air. 

Security--We pushed teams out to secure the high ground, but we generally assessed our location to be secure. 

Massive Hemorrhage--No obvious bleeding, quick blood sweeps also turned up negative

Airway -- Nothing obvious. No facial deformity, teeth and tongue were intact with no blood or foreign bodies in the mouth. 

Respirations -- Patient was struggling to breathe. He was gasping for air and would suddenly have moments of clarity where he would reach for myself or a nearby Afghan helper and grab them in a panicked way. 

As his labored, gasping breathing was the only sign to that point of anything wrong, I handed off the further physical assessment to the 68W1 Civil Affairs medic we had with us that mission to conduct the remaining circulation sweep, including crepitus and grimace checks for broken bones. Concurrently, I did the following: 

1) Cut off his uniform to expose his chest

2) Placed a pulse oximeter on his finger. It gave us 84% when initially placed, indicating a serious problem. 

3) Laid him flat to see if there was bilateral rise and fall of the chest. There was. No unilateral rise and fall, and upon closer inspection of his now exposed chest, no penetrating wounds or anything to indicate a collapsed lung or damaged chest cavity by outward appearance. 

While this is taking place, the patient is still drifting in and out of consciousness, struggling with us, and his breathing is not getting any more regular. He seems to be panicking that he can't breathe. After conducting a quick roll to assess downside injuries and finding none, the 68W1 told me that the remaining checks, including for spinal deformities and step-offs, are negative. no ocular indications of severe brain injury, and that there doesn't appear to be any outward signs to indicate a reasoning for his labored breathing. I'm thinking that maybe I should just needle decompress him anyway to be safe. I mark the spot on his chest, but decide not do it at this time. Vitals at this point are Pulse 120, Respirations 10 and highly irregular, temp wasn't taken. BP wasn't taken because pulse was strong. 

At this point, I am thoroughly confused. I have found no physical indications as to why this patient is struggling to breathe, and as a medic, I am trained to find a problem and fix it....but I've been through all the steps and found nothing, while he still continues to gasp for air. At this point I'm thinking that I missed something. 

My next thought is that I'm going to have to calm this guy down in order to control his airway. I get out my field intubation kit and prepared everything in case the guy goes unconscious on me. So me and my brilliance (sarcasm) decide that I should give this guy a Fentanyl Lollipop to suck on to calm him down so I can start an IV, or at least get him relaxed enough to potentially bag him. After letting him suck on it for a bit, ...he simply looks at me with a 'what else you got?' look. 

I decide I've wasted enough time guessing, and take his arm to prep it for an IV...only to find strong evidence of heroin use. So much for pushing morphine, and also...no wonder he rolled his damn truck. 

My 68W1 volunteers that he has Ketamine. We draw up 50mg and push it DM. Within 2-3 minutes the patient calms down, his pulse ox reading goes from mid-80% to low 90%, and his breathing becomes more regular.  We package him up, and decide to evacuate him with us back to the base in our RG-33 and let our FST role 2 facility check him out. On the way back, thanks to my brilliant decision to use Fentanyl, he proceeds to vomit numerous times. 

The FST checks him out, and finds evidence of a bad concussion, and slightly cracked ribs, but not much else. The guy essentially had a severe case of having the wind knocked out of him, and coupled with the bad concussion, had a bizarre presentation of symptoms. He was discharged after 2 days with no memory of the incident whatsoever, but was fired for heroin use. Semi-happy ending. 

After Action Review:

Did well:

1) Focused on SMARCH-RV and didn't immediately go to the distractor wound (gasping for breath). 

2) Allowed for my 68W1 to offer suggestions, and that he could see what I could not. 

Did poorly: A lot. 

1) Didn't allow myself to think big picture about what other things could cause such labored breathing. 

2) The use of fentanyl was simply stupid. Not only is it probably the least effective narcotic to use on a population perpetually dehydrated (little absorption through membranes), but it is a respiratory depressant on a guy who was already struggling to breathe and had low O2 stats. Not to mention the fact he threw up, which only complicated his breathing efforts. Throw in the fact that he had a concussion, and needless to say I felt stupid for a long time after this one. 

3) I laid him down numerous times to try and get a better idea of what could be going wrong with him. One of the things we also do as medics is allow the person who is having trouble breathing be in a position most comfortable for them. Because of his semi-conscious behavior, I didn't know if he was sitting up because he was scared or because he couldn't breathe, but I should have defaulted to allowing him to sit up after my initial inspection. 

4) Not push Ketamine immediately. This was January/Feb of 2013, and I didn't feel as comfortable with Ketamine as I should have. From then on out I made sure it was my first-line drug. 

5) Didn't push any antiemetics to compensate for fentanyl once stabilized. 

What do you all think? Was there something I missed early that would have led you to diagnosis him quicker? Additional mistakes I made? 

Have any of you been in similar circumstances that you can offer insight on? 




Rucking tips for SFAS

Ah the ruck. Nothing feels quite as good as the phrase 'drop ruck', even if you know you'll inevitably have to pick it up and start moving with it again soon. Just like in life, there are people who are just naturally gifted at rucking. Other people (like me) had to work their asses off not to have their spine compressed and get even shorter under the crushing weight. I'm not here to claim I know everything about rucking. I don't. I still hate it, and no amount of training will ever help change that fact. It sucks. But it does get more manageable, and the weights do get more manageable if you practice. 

There are 2 kinds of ruck practice:

Basic Training/some regular army units method: Wear your helmet, keep your pants tucked into your boots, and put as much gear in your ruck as possible as you slog directly behind your fellow sufferer, rifle held across your chest. You justify it by thinking, I'll endure the suck now so that when I have to do it in selection, it will seem easier. 

-- This method is not recommended. If you are training for selection...immediately forget that this horrible method of human torture still exists. 

Selection Training: 

If you are starting from scratch--no worries. We were all there at one point. The point of practicing any exercise is to focus on building from a solid foundation, and then adding each week. I'm not here to layout a week by week plan for you. I'm going to tell you what your end goal should be, and give you some tips on how to get there. Chuck the helmet, un-blouse your pants, and when you carry your rifle, carry it however you want as long as you don't look like a jackass. Cool? 

First...your ruck.

- Pack your ruck evenly. Getting it right takes practice, but there is nothing worse than being a mile into the ruck and finding your ruck weight leans in one direction.

- Shoulder straps. There are some cool gel pads, extra padded shoulder straps, whatever. The important thing is that your shoulder straps are efficient, on correctly, and ride high on your shoulders. Caveat: Make sure you get one that the selection committee allows for selection. This may mean foregoing the high speed shoulder straps for the time being. 

- Back pad. Like shoulder straps, they have some high-speed ones nowadays. Find one that works for you, but don't expect even the most expensive one not to tear up your back after logging some serious miles. The trick is to find one that doesn't rub your belt line and cause you to chafe. Get one that the selection committee allows for selection.

- The ruck: Ask your friends, those who have gone to selection recently, or an SF recruiter about what ruck they are requiring at the current time. Try and match it. This goes too for the shoulder straps and back pad. Practice with what you will use in selection!! Years from now, when you make it through the Q course and end up on a team, you'll have about 6 different rucks to choose from. 

Okay--down to business. The ruck practice

Beginners Ruck:

Start with a 35lb. ruck, and go 2-3 miles at a 15 minute per mile clip. This will allow you to feel out how you have packed your rucksack, how the shoulder and back pad sits, and any adjustments you need to make. Once you can reliably do this distance and time, you'll move onto the intermediate ruck. 

Intermediate Ruck: 

Up your ruck weight to 40-45lbs. Your goal is to go 4-5 miles at a 13-14 minute pace. The first few miles may not seem that bad, but your shoulders and legs will undeniably start feeling the weight towards the end. You should reliably be able to hit the 5 mile distance at 13 minutes per mile before moving onto the Advanced Ruck. Both the Beginner's Ruck and Intermediate Ruck are meant to build up your leg muscles and your shoulder muscles, as well as get your mind mentally accustomed to going long distances with relatively heavy weights. 

Advanced Ruck:

Ruck weight between 50-60lbs. Your distance goal should be 6-8 miles, and your pace should be 11-13 minutes per mile. You won't achieve these times by brisk walking, especially if you're short like me.

--The best way to accomplish this is to alternate running and walking on the flat ground. Pick a spot in the distance and run to it. Pick another, preferably closer point, and power walk to it, then pick a distant point, run to it, etc. During selection in the backwoods of NC, a lot of the ruck marchers are conducted on dirt roads with nothing but trees and telephone poles. What I did was pick telephone poles as my bench marks. I would run to one telephone pole, power walk to the next, then repeat it over and over if it was flat ground. 

- Run the downhill portions. Use your momentum and gravity to gain time on the downhills.

- power walk the uphill portions. Don't run or even jog uphill. It drains your energy and you don't really gain any time doing it. 

If you start slow or get staggered time starts: Always set a goal on catching the person directly in front of you. Then repeat! 

I'm not claiming this is the ONLY way you can better yourself at rucking. You will still be sore, your shoulders will still ache, and your back will look like raw hamburger meat for awhile. But it does get better, and it works. Out of nearly 400 people in my selection class, I always noticed that I came in well ahead of the vast majority of other selection candidates.  

I hope this helps some of you!


Founder, Ready Warrior LLC


IED Blast-wound pattern--SMARCH-RV and reasons for EVAC

IED Blast-wound pattern--SMARCH-RV and reasons for EVAC


Thank you to everyone who commented about what they believed the appropriate course of action was for the injury shown on the IG page. Here is the COA I took as the medic. I welcome your feedback, criticisms, insight etc. 

Original story: A small element of our unit was hit by an IED from a mere 6 feet away after an ambush. Luckily, the IED was buried too deep to kill anyone, but it did do the following damage to one of my teammates, shown here. The questions posed were, How do you assess? What kind of treatment is required? Evac?

** I know I added the second picture for a more complete picture, but the answer doesn't change.

We operate on the SMARCH-RV Algorithm, but that doesn't mean lay the person down and make them hold still while you assess. Despite being knocked down by the IED and implications of spinal compromise, we were still in a hot zone, and I had to make my best judgement on C-Spine compromise. He had full range of motion in his neck, and his pupils were normal.

We were not actively engaged, but the threat was still present. Vehicles were moved to provide cover and patient was assessed there.

Massive Bleeding-Patient was knocked down by initial blast, but got up and moved to cover. Patient removed his body armor, helmet and combat top (expose the wound). Pants and boots stayed on, as visual and 'blood sweep' inspection showed no massive bleeding or penetrating blasts.

Airway -- Patient was talking when I got to him. Rules out the need for further airway check in the immediate assessment. Airway would need to be checked in follow on assessment for presence of soot-burns, etc and the potential need for upgraded airway.

Respiration -- Patient had numerous shrapnel injuries to the neck, back and side of the torso. Though I assessed them to be superficial, there was no way to be 100% sure. Because of the wide display of the shrapnel injuries, there was no way to Chest Seal that large area of an area. The largest shrapnel wounds found get a chest seal to be safe.

*** MIST report was initiated and sent up at this time while letting them know a 9-line would follow shortly--Information was passed by me, verbally, to a teammate who used a pre-printed M.I.S.T. card we had in our vehicles to record the information and pass it up via radio. Vitals were simply given as 'alert and stable at this time'. MIST would have been called up sooner, but we were re-positioning security.

*** 9-Line followed soon after, with patient category given as Routine. However, our Dustoff crew was amazing and didn't have another call at the time. They informed us they were coming asap, eta approximately 6 min. This changed my need to initiate IV antibiotics.

Circulation--No heavy bleeding. Numerous small bleeders associated with shrapnel injuries that you can see in the picture. Taking a rolled kerlex, I doused it in water to clean off the blood and any loose debris. Then I took another roll and did the same with Betadine to provide a layer of disinfectant, and the patient would be putting on his uniform and body armor again should we actively become engaged again. The neck was further cleaned to identify anything of significance that may lead to my placing additional restrictions on the casualty or the implementation of additional drugs.

Hypovolemia/hypothermia -- Dustoff had been called and was only 6 minutes out at this point. No IV was initiated, as we had radio chatter that the enemy could be regrouping, and so the security posture had to change.

Recovery Position and Vitals--No recovery position needed. A more complete set of Vitals was taken to pass along to Dustoff crew.

Patient insisted on walking himself to the helicopter so that the Taliban wouldn't get the satisfaction of seeing him on a stretcher. I went with him the Role 2 FST via Dustoff. He was placed under anesthesia while myself and a surgeon removed the shrapnel from his skin. He was also assessed to have suffered a concussion, and was flown to BAF to undergo further testing. He rejoined the team in 5 days, good to go.

2 things precipitated my decision that Medevac was recommended.

1) I couldn't get an accurate depiction on the exact depth of the shrapnel. Though you can see the outline of where the body armor was and where it wasn't based on the shrapnel pattern, I had no way of being sure that some of the fragments didn't penetrate and would lead to sudden respiratory compromise either due to a collapsed lung or small shrapnel getting in places it shouldn't be.

2) The proximity to the blast. The blast happened about 6 feet away (or less) from the patient. Though the adrenaline pushed him through it, I was worried about the possibility of cognitive deterioration over the course of the mission if not assessed.
--Had Medevac not arrived so quickly, I would have initiated a mini-mental status exam, and potentially a MACE report.
--We were operating out of a forward staging area at the time, which didn't have the same medical capabilities as the FST-Role 2 that he was EVAC'ed to. If we had waited to the end of the mission, he still wouldn't have received the care he needed.

Side note: I returned to the team the following day, where we went out to the same area and got into another fight, with two EKIA recorded. Boom.

Anything you would have done differently?