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. Your feedback, criticisms, insight etc. are welcome for the benefit of the medical community. 

Original story: A small element of our unit was hit by an IED from approximately 4-6 feet away after an ambush. Luckily, the IED was buried too deep to kill anyone, but it did the following damage to one of my teammates, shown here. The questions posed: How do you assess? What kind of treatment is required? Evac?

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, and his pupils were normal.

We were not actively engaged, but the threat was still very present. Vehicles were positioned to provide cover and patient was moved behind the vehicles for assessment. 

Massive Bleeding-Patient was knocked down by initial blast, but got up and moved to cover. Once behind the vehicles, Patient removed his own body armor, helmet and combat top (expose the wound). Pants and boots stayed on, as visual and 'blood sweep' inspection showed no signs of massive or moderate bleeding, nor evidence of 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 burns 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 apply chest seals to that large of an area. The largest shrapnel area got a chest seal, but a judgement call was made not to use any additional. The fact we were still going to be potentially engaged also meant we had to think about resources.

*** MIST report was initiated and sent up after rapid first assessment.  Information was passed by me, verbally, to a teammate who wrote information down and passed 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. After completion of MIST, we included that the 9-line would follow shortly after. 

*** 9-Line was given with patient category given as Routine. However, the 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. (Afghan terrain is deceiving. A 4hr vehicle mission can be covered in 6-10 min via the air). No IV was started, as it was deemed unnecessary.

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 rode with him to the Role 2 FST (Junior 18D stayed with team). He was placed under anesthesia while myself and a surgeon removed the majority of 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, even if the wounds were perceived as 'moderate'.

1) My initial impression of the shrapnel wounds were that they were mostly superficial. However, there was no way to be sure without a closer exam, one we didn’t have time for when we were just hit by an IED after a small arms ambush. 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 respiratory compromise later in the mission. 

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.

There were plenty of resources we wish we had at the tip of our fingers this day in an easy to use and access format. It was one of the reasons we decided to write the Medic Quick Reference Guide, available HERE!

Anything you would have done differently? We highly encourage discussion for the benefit of all medics. 


Ready Warrior
Tagged: IED


Hindsight is always 20/20 so I am gonna say that the simplicity of your approach but at the same time a conscious understanding of your limitations resulted in a successful response.

— Leonel Uribe


Very good post. Strong info.
What about a combat pill pack? Instead of the IV? Giving the fast response of the medevac. No need for the pill pack (anaesthesia). Looking forward on your thoughts on this.


— Tom Staes
I like it. Talking without difficulty, good. Ambulatory and removed own vest and helmet is a pretty good spinal clearance for me. Maybe a quick pupil check and hearing check if practical due to proximity of the blast. I think you were on point with it all. Definitely agree with the unkown shrapnel issue. That needs imaging.
— Ed