Tactical Evacuation (TACEVAC) - This term refers to both CASEVAC and MEDEVAC.

When we were in Afghanistan, there was a particular mission where we had a strong suspicion that it was going to get ugly. Although we had driven 4 hours to get to our target, it was geographically only about 20 miles on the other side of a mountain range that separated our base and FST. We had pre-warned the base Dustoff crew that we were expecting contact, and they thanked us for the heads up, but we didn’t think much past it at that point. Sure enough, we take contact during our mission and one of my teammates is struck by an IED. We secure the site, I work on him and get him patched up, call in the MIST report and have a teammate relay the 9-line. We get the call from Dustoff—6 minutes out. Wait…what?

The Dustoff crew at the base had taken our warning very seriously, and had been monitoring our mission closely. The second they heard chatter about what had happened, they had the birds churning and warming up. They arrived so quickly that I had to scramble to get my teammate bandaged up appropriately and patient care card filled out. However, thankfully we were a full team that day, and because my junior 18D was still g2g, I was able to go with my teammate and the MEDEVAC crew back to base. (Teammate recovered fine and was back on team within a week, if you’re interested in the story, it’s one of the first blog posts).

Getting a patient prepped for transport can be an overlooked part of care. From the intensity of Care Under Fire to the scramble of Tactical Field Care to assess and treat all injury, Tactical Field Care seems like it would be the most relaxed stage of them all. As you can probably see where I’m headed with this, you’d be wrong to think that. Ideally, this stage means getting your patient properly packaged up for transport, checking all interventions again, relaying proper information about the patient’s condition, and ensuring all documentation necessary to pass off to TACEVAC crew is present and correct. While impossible to cover every single possible scenario, as with our coverage of the other phases of care, we hope this gets you to think about what kind of steps are necessary to better the outcome of your patient.

1) Tactical force should establish HLZ or evacuation point and maintain security. Tactical team can assist loading patient if situation permits.

2) Patient information should be communicated to the TACEVAC personnel if possible. The MINIMUM information required should be the following:

1. a) Stable or Unstable
2. b) Injuries Identified
3. c) Treatments provided

3) Triage patients as appropriate. Example: In the instance of mass casualty events and the use of a Chinook as your MEDEVAC platform, patients who are the most severely wounded need to be loaded LAST so that they are the first OFF the helo.

4) Go through MARCH again and consider the interventions you have done and whether they need to be upgraded for the trip.

M: Check all tourniquets and packed wounds. Will the vibrations of journey and the time during the trip shake your tourniquets and dressings loose? If so, add/tighten the tourniquet or add securing bandage to packed wounds.

A: Reassess patient’s airway. If patient is still struggling to breathe after basic airway intervention, and assessing the tactical situation and clinical skills of medic, consider upgrading patient’s airway to

1. i) Supraglottic intubation
2. ii) E.T. Tube

iii) Surgical Cricothyroidotomy (Use lidocaine if patient is conscious and you have the time…aka….don’t be a jerk)

R: Reassess chest seals and other interventions, check patient’s breathing. Continue to provide needle decompression if it remains effective.

1. i) Consider a chest tube if no improvement or long transport expected. If at high altitude or TBI, consider O2 if available.

Ii) If MEDEVAC will be at altitude, replace air in inflatable bulb of ET Tube or Cric with normal saline to ensure air pressure does not deflate bulb.

C: Reassess all interventions. Apply pelvic binder for ANY suspicion of suspected pelvic fracture if you have not already done so.

   Additional considerations:

1. i) Ensure IV is placed and still patent. Tubing needs to be appropriately wrapped. Rule of thumb is that someone should be able to literally throw the bag and the line will not come out. If you think I’m joking….that’s the test to make sure you wrapped it appropriately at SOCM.
2. ii) Check patient frequently for signs of shock.

H: Ensure patient is properly wrapped in either the HPMK or heat shell. Limit their exposure to elements.

1. i) Think patient safety and comfort during journey. Pad joints, keep them     covered, etc.

1. ii) If they are having continually decreased levels of consciousness, follow appropriate TBI and shock protocol.

5) You need to be constantly upgrading your patient’s condition. Delegate tasks if appropriate. YOU don’t need to be padding their limbs on the stretcher. YOU need to be filling in their patient care card.

6) The patient care card. Some helpful hints about filling this thing out:

1. a) Don’t worry about EXACT times for TQ’s. Was it 10:32am or 10:35am? No one cares.  10:30 or 10:40 is fine. Focus on the important stuff, like where the injuries are, what you’ve done for them, etc.
2. b) Don’t forget to mark what medications you’ve provided! It’s one thing to forget to mention you gave them their combat pill pack, but forgetting to mention you gave them narcotics will throw off the FST and likely cause serious repercussions if they administer more of it.
3. c) If your card isn’t complete, or you are frantically filling it out last minute…don’t bother making it look pretty. X marks the spot for injuries, make sure they know you gave narcotics. The FST will do a head to toe thorough assessment of the patient when they arrive, and your card will supplement what they have, but is not the only piece of info they need.

7) Make friends with your Dustoff crew. They are by far some of the most skilled and dedicated crews I’ve ever encountered, and I haven’t met a single one that I wouldn’t trust to work on me or my teammates. Even sometimes overlooked things, like pre-staging equipment or asking them to deliver a fully stocked aid bag to replace the depleted one you have now is entirely possible. Getting to know your Dustoff crew will help them think of that even if you’re too busy or stressed to consider it.

Many of these scenarios are just scratching the surface of the level of care that could be provided. Study, know your algorithms, and be prepared for worst case scenario.

Let no one say you could have done more.