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Immediate Care of the Wounded

Immediate Care of the Wounded

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Published by: MiodragDMilosevic on Mar 20, 2013
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 1
Immediate Care of the Wounded 
Clifford C. Cloonan, MD, FACEPCOL (ret) U.S. Army
 Associate Professor Department of Military & Emergency MedicineUniformed Services University of the Health Sciences
Introductory Thoughts
It will be tragic if medical historians can look back on the World War II periodand write of it as a time when so much was learned and so little remembered.”
Beecher H. Early Care of the Seriously Wounded Man.
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,
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It is highly desirable that anyone engaged in war surgery should keep his ideasfluid and so be ready to abandon methods which prove unsatisfactory in favour of others which, at first, may appear revolutionary and even not free from inherentdanger.”
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,
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Bailey H, ed. Surgery of Modern Warfare. 2nd ed.
Fight on, my men,” Sir Andrew says,A little Im hurt, but not yet slain;Ill but lie down and bleed awhile,And then Ill rise and fight again.”
Ballad of Sir Andrew Barton, author unknown, c. 1550
 
Immediate Care of the Wounded Introductory ThoughtsClifford C. Cloonan, MD
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Introduction
 This text represents a thirty year culmi-nation of my thoughts about pre-hospitalcombat casualty care.My earliest introduction to this topiccame in 1973 when I attended the 91ACombat Medic course in San Antonio Texas, a necessary pre-requisite before Icould attend the 300 F-1 Special ForcesMedic course. It was mostly poorlytaught and improperly focused and for-tunately I never had to take care of any-one in, or out of, a combat situation us-ing only the knowledge gained in thatcourse. It was run by nurses and theacademic focus of the course was onnursing care skills that were mostly ir-relevant to pre-hospital combat casualtycare, presumably the realm of the com-bat medic. Some of the combat skillsinstruction provided by veteran combatmedics with experience in the VietnamWar was a notable exception. The 300 F-1 Special Forces MedicCourse that followed was exactly theopposite; it remains to this date the bestand most intense medical instruction Ihave ever received. I learned more rele-vant medical information in the shortspan of that course than I would everagain learn in a similar time span. Uponcompletion of that course I was leftwondering why it took physicians fouryears of college, four years of medicalschool and several more years of intern-ship and residency training to learn whatI had learned in less than a year; I wasblessedly unencumbered with theknowledge of what I didn’t know andyouthfully confident in my skills andknowledge of combat casualty care. Iwas to never have the opportunity tolearn my shortcomings as a combatmedic since the Vietnam War wounddown faster than I completed my train-ing. It was this training and experienceas a Special Forces medic that sent meon the path to become a military physi-cian.What I learned in the ensuing years isthat most often:
 
 The simple answer is the right an-swer,
 
Well-performed basic techniquesare usually better for the patientthan more complicated and “so-phisticated” techniques,
 
Conscious inaction is better thanmindless action,
 
 Training is more important thanequipment, and
 
 The day I graduated from the Spe-cial Forces Medic Course I was“smarter” than I would ever beagain because mostly what Ilearned later was all the thingsthat I didn’t, and would never,know.What I also learned in my nearly thirtyyears in military medicine is that mostpeople believe that all relevant historybegan the day they were born and there-fore nothing much of use for the presentor the future can be learned from thepast.
Nothing could be further from
 
Immediate Care of the Wounded Introductory ThoughtsClifford C. Cloonan, MD
3
the truth
-- there is actually very littlethat is completely new in the realm of military medicine. If you are looking forthe solution to a problem the first placeto look is in the past because there is agood chance that someone else eitheralready solved the same or a similarproblem or at least was able to find outwhat didn’t work. Throughout my career in military medi-cine I spent a considerable amount of time as a trainer/educator; I observedhow people learn, what motivates themto learn, what they are likely to remem-ber, and what they are likely to forget. Ilearned that it is much better to createsystems (educational or otherwise) thattake into account and accommodateprobable human behavior than it is to tryto shape or modify human behavior.I also learned that much, if not most, of what is believed to be true has not beenproven true and further it is likely thatwithin my lifetime much of what I havebeen taught will be proven to be false this as certainly been the case over thepast thirty years. I discovered that al-most everything that is believed to betrue about pre-hospital combat casualtycare is completely unproven; this cer-tainly does not mean it is false, just thatit has not been, and will likely never be,proven true. The reason for this is be-cause, for obvious reasons, there are norandomized, double-blind, prospectivestudies of pre-hospital combat casualtycare; and there are remarkably few suchstudies of civilian pre-hospital care.What then is the basis for modern daypre-hospital combat casualty care? It is acomposite of battle proven, albeit anec-dotally supported, procedures and tech-niques combined with civilian EMSstandards of care (whether appropriateto combat casualty care or not), some of which are based upon well done studies,many of which are not. This text represents my best efforts toglean from the pages of military medicalhistory and from such civilian pre-hospital care and other relevant studiesas have been done the evidence, weakthough it may be, that supports or re-futes the performance of various proce-dures in a pre-hospital combat casualtycare environment.In the interest of full disclosure I admitto the reader certain biases that I haveacquired as a result of the observations,experiences, and education I have de-scribed above. One of these biases isagainst teaching pre-hospital combatcasualty care providers complex andpotentially hazardous medical proce-dures even when there is no alternative(e.g. cricothyrotomy); another is a biasin favor of better training over betterequipment. I also have a bias that some-times the most important thing is toknow what not to do and when not to doit.I independently observed that there isstrong psychological predisposition to-ward action over inaction among pre-hospital personnel, a predisposition thatis certainly characteristic of Special Op-erations medics/corpsmen. I had also

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