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?