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M C2003000 1197 ACADEMY OF HEALTH SCIENCES, U.S.

ARMY AMEDD NONCOMMISSIONED OFFICER ACADEMY 91B TRACKING Patient Packaging in a Remote Environment (2 periods) COURSE PRESENTED TO: 6-8-C40 (91B), Basic Noncommissioned Officers Course (91B Tracking). PLACE: Classroom.

REFERENCES: FM 8-10-6, Medical Evacuation in a Theater of Operations. James Wilkerson, Medicine for Mountaineering. Merced. SKEDCO, Inc., SKED and Oregon Spine Splint manufacturers instructions on use. RELATED SOLDIERS MANUAL: None. STUDY ASSIGNMENT: Review M C2003000 prior to class. STUDENT UNIFORM AND EQUIPMENT: Uniform of the Day. TOOLS, EQUIPMENT, AND MATERIALS: Mimeo M C2003000 issued prior to class. PERSONNEL: One instructor (91B/91C), one assistant instructor (91B/91C). INSTRUCTIONAL AIDS: List of equipment (Annex A)

TROOP REQUIREMENTS: None. TRANSPORTATION REQUIREMENTS: RISK ASSESSMENT LEVEL: SAFETY REQUIREMENTS: Low. Insure that students use proper body mechanics when lifting patients. None.

METHOD OF INSTRUCTION: Demonstration 1.0 period and Practical Exercise 1.0 period. I. INTRODUCTION (5 minutes) 1. Opening Statement: As a Medic, you may find yourselves in situations that require treating casualties with little or no standard medical supplies and equipment. When confronted with this situation you must be able to improvise with whatever may be available and care for the casualty. A calm evaluation of the situation and an open mind to any alternative are the key factors in successful treatment and evacuation of the casualty. The only limitation to this process is the imagination of the medic on scene. Therefore, practice is key to success during this type of evacuation. The examples given in this class are by no means the only types of improvised litters that can be used. Objectives 1. Terminal Learning Objective: Given a scenario, a simulated patient and appropriate material, construct an improvised litter, package,

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M C2003000 1197 and evacuate the patient IAW cited references. 2. Enabling Learning Objectives: 1. b. 3. d. Given a list of statements, select the definition of patient packaging IAW cited references. Given a list of statements, select the principles of patient packaging IAW cited references. Given a list of statements, select the general principles of litter improvisation IAW cited references. Given a list of equipment, advantages and/or disadvantages and a list of improvised litters, match the equipment, advantages and/or disadvantages with the list of improvised litters IAW cited references. Given a patient trauma scenario in a remote environment, package a patient with the Oregon Spine Splint and the SKED IAW cited references.

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C. Class Procedures and Lesson Tie-in: This class will be one hour of discussion followed by one hour of demonstrations and will be related to evacuation of the patients treated in a remote field environment. II. EXPLANATION: (45 Min) OBJECTIVE 1: Given a list of statements, select the definition of patient packaging IAW cited references A. Patient packaging - Stabilizing a patient for transport is considered packaging. When injuries indicate that the patient must be carried, a litter is usually used. The litter serves as both a convenient vehicle for transport and as a full body splint. OBJECTIVE 2: Given a list of statements, select the principles of patient packaging IAW cited references. B. Principles of patient packaging. 1. Comfort and protection: a. b. c. 2. Head should be protected with a solid hood or blanket to prevent loss of body heat, as well as cspine control. Patient should be covered with dry warm blankets. Use waterproof material when possible.

Litter as a splint: a. Same immobilization principles as a backboard. b. c. Package spine injuries so that the spine is supported and is stable from head to toe. Avoid spine loading forces such as bumps, jarring, vertical descent, and vertical ascent.

M C2003000 1197 NOTE: Patients with spinal injuries should be raised and lowered over vertical obstacles in the horizontal position. 3. Terrain specific: a. 2. 3. 4. Consider the route to be traveled, steep inclines or declines would indicate that you should be able to stand the patient on end. Water obstacles - Litter should be water tight for floatation. Also ensure litter is tied in for possible rapid water crossing. Snow - Litter should slide smoothly and track well.

Packaging for cold environments: a. b. c. d. e. A vapor barrier to retain body heat. Insulation to prevent loss of body heat through conduction. A weather barrier to prevent water and wind from affecting the patient. Warm inspired air with hood, balaclava (scarf), or loose weave cloth. Litter should be constructed for easy carry by as few members as possible.

NOTE: Ensure patient remains dry during evacuation e.g. sweat, blood, and urination secondary to the vapor barrier. 5. General patient care while transporting: a. 2. c. 4. e. Monitor patients temperature by axillary or groin method, which is reasonably accurate with the vapor barrier system. Cut access flaps in the barrier and tape them closed when not in use. Keep all monitor gauges external. Keep external barrier closed as much as possible. Carry oxygen external to victim's vapor barrier.

NOTE: Oxygen is carried outside the vapor barrier to keep the body from having to heat the cylinder and to facilitate ease in changing the cylinder when it is empty. 6. g. Use absorbent material as diaper. Invert litter when the patient needs to relieve him/herself.

OBJECTIVE 3: Given a list of statements, select the general principles of litter improvisation IAW cited references. 3

M C2003000 1197 3. General principles that should be applied to improvisation are: 1. 2. 3. 4. 5. 6. Select material that is sturdy enough to support the weight of the patient. The extent of the wounds and the distance to be traveled are the major factors to consider when determining which type of litter is to be constructed and used. Protect C-Spine whenever possible. Pad all pressure points.(C-spine, lumbar, knees, ankles) Prevent further injury to the patient. Insure that the casualty is securely strapped to the litter.

OBJECTIVE 4: Given a list of equipment, advantages and/or disadvantages and a list of improvised litters, match the equipment, advantages and/or disadvantages with the list of improvised litters IAW cited references. 4. Improvised litters - litters made from available materials 1. Blanket and pole litter (Figure 1&2) a. b. c. d. One blanket two poles. Open blanket and lay one pole lengthwise across the center; then fold the blanket over the pole. Place the second pole across the center of the folded blanket (Figure 2). Fold the free edges of the blanket over the second pole and across the first pole. The weight of the patient will prevent slippage. Advantages: (1) Easy to assemble. f. 2. (2) It can be made from many different materials. Disadvantages - Offers no C-Spine control

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Cocoon litter (Figure 3). a. b. Also used as packaging in extreme cold weather. Sleeping bag, poles and rope.

M C2003000 1197 c. d. Place a non-slip loop in one end of the rope. Lay the rope on the ground next to the casualty in a zig-zag pattern that is approximately the width of the casualties outstretched arms from elbow to elbow. Pad the poles and lash them to the rope in a manner that prevents slipping. Place the patient in a sleeping bag and position him/her on the rope. Starting at the feet, lace each loop through the next higher loop, tie off the last loop high on the chest.

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NOTE: Can be utilized in a tactical environment for quick evacuation using just the rope or cords from splints or back packs. h. I. 3. Advantage - Excellent for vertical descents and ascents. Disadvantage - Patient care is difficult.

Rolled Blanket Litter - when there are no poles readily available, a blanket, poncho, shelter half, or tarpaulin may be used. (Figure 4) a. b. c. d. Place patient in the center of litter material. Roll both sides towards the patient. Use Roll as hand holds. Advantages: (1) Quick evacuation device. (2) Requires minimum resources. (3) Ideal for short distances when there are no spinal injuries. e. Disadvantages: (1) Provides no C-Spine support. (2) Requires six bearers.

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Jacket Litter. (Figure 5) a. b. Requires two jackets, two poles. Invert sleeves, button all buttons.

M C2003000 1197 c. d. e. f. Place jackets neck to neck and button collars together. Slide poles through sleeves. Ensure closures are away from patient or padded to prevent injury. Advantages: (1) Easy to assemble. (2) Materials are readily available. (3) Two man carry. g. Disadvantage - Little or no Spinal Support.

NOTE: Variations on this litter include using bed sheets (covers), Grain sacks, Etc... NOTE: Poles can be anything that is straight, and strong enough to support the weight of the patient. i.e. Ski poles, skis, tree limbs, tent poles, or camouflage support poles. 5. Ladder Stretcher. a. b. c. d. e. Requires a ladder and padding. Pad the ladder. Strap the patient securely to the ladder. Advantage - Easy to use. Disadvantages: (1) Cannot perform BLS. (2) Bulk (size) of the patient or equipment may preclude use. NOTE: Ensure that the ladder is sturdy enough to bear the weight of the patient. 6. External pack frame litter. a. b. c. d. Requires 2 pack frames, lashing ropes, padding, and poles. Lash frames together top to top. Use poles for rigidity. Pad pressure points.

M C2003000 1197 e. f. Strap patient securely to the litter. Advantages: (1) Provides some spinal support. (2) Materials readily available in most tactical operations. g. Disadvantages: (1) Cannot perform BLS. (2) Size of patient may preclude use. 7. Pall bearers carry. a. Requires three straps.

NOTE: Ropes can be used in place of straps. Straps or other wide material is preferred to minimize discomfort to the patient. b. c. d. f. Requires six bearers. Place straps at the shoulders, hips and calves. Strap is placed across bearers shoulders so that the weight of the patient is supported by the bearers shoulders. Advantages: (1) Can be used in conjunction with other litters, i.e. ladder, cocoon, pack frame, Etc... (2) Reduces fatigue of bearers. (3) Excellent for rough terrain and long distances. g. Disadvantages: (1) Provides no spinal support unless used in conjunction with other litters. (2) Requires six bearers. NOTE: The litters discussed above are just a few that can be improvised out of materials commonly found on the scene. OBJECTIVE 5: Given a patient trauma scenario in a remote environment, package a patient with the Oregon Spine Splint and the SKED IAW cited references. 1. 2. Instructor will demonstrate the usage of the Oregon Spine Splint and the SKED on a simulated patient in a remote environment. The reference for instructor standards concerning this demonstration will be the manufacturers written and 7

M C2003000 1197 video tape instruction that comes with both the Oregon Spine Splint and the SKED. III. Practical Exercise 1. Instructor Duties 1. 2. 3. 2. Gather all equipment IAW Annex A Separate improvised packaging material, Oregon Spine Splint and SKED among student work areas (4 students per station) Give students trauma manikin or simulated patient that requires packaging in a remote environment

Student Actions 1. 2. Students will package their simulated patient and move them 25 meters using each technique specified in this lesson. Students will ensure there is adequate immobilization of the patients spine without compromising respiratory function or access to specific wounds.

IV. SUMMARY (5 min) A. Review of main points. 1. 2. 3. 4. 3. Patient Packaging Principles of packaging General principles of litter improvisation Types of improvised litters. Package a patient with the Oregon Spine Splint and the SKED

B. Closing Statement: When faced with the situation of having to move a casualty from a remote tactical location with improvised litters you are limited only by the resources available and your imagination.

M C2003000 1197

ANNEX A Equipment List Name 1. 2. 3. 4. 5. 6. 7. 8. 9. Rope, Nylon Rope, sling Snap link, mountain piton Glove, leather, white work NSN 4020-00-931-8793 4020-00-931-8793 8465-00-360-0228 8415-00-268-7868 15 15 15 15 15 15 15 120 60 Quantity Required 15 15

Bag, deployment, extraction system 1670-00-168-5950 Litter folding rigid pole aluminum pole 6530-00-783-7905 Sleeping bag, intermediate cold weather 8465-01-049-0888 Jacket hot weather combat woodland pattern Poncho 8415-01-390-8544

8405-01-100-0976 6530-01-260-1222 6530-01-265-3583

10. SKED 11. Oregon Spine Splint

M C2003000 1197

Figure 230. Square knot. STEP 1. Holding one working end in each hand, place the working end in the right hand over the one in the left hand. STEP 2. Pull it under and back over the top of the rope in the left hand. STEP 3. Place the working end in the left hand over the one in the right hand and repeat STEP 2. STEP 4. Dress the knot down and secure it with an overhand knot on each side of the square knot. b. Checkpoints. There are two interlocking bights. The standing parts are on the same side and properly secured with overhand knots.

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SQUARE KNOT

The square knot is used to tie the ends of two ropes of equal diameter (see Figure 230). It is a joining knot. a. Tying the Knot. A-4

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M C2003000 1197

Figure 236. Round turn and two half hitches. This knot is used to tie the end of a rope to an anchor, and it must have constant tension (see Figure 236). It an anchor knot. 248 a. Tying the Knot. STEP 1. Route the rope around the anchor from right to left and wrap down (must have two wraps in the rear of the anchor, and one in the front). Run the loop around the object to provide 360degree contact, distributing the load over the anchor. STEP 2. Bring the working end of the rope left to right and over the standing part, forming a half hitch (first half hitch). STEP 3. Repeat STEP 2 (last half hitch has a 15cm (6inch pigtail) STEP 4. Dress the knot down. b. Checkpoints. (1) (2) A complete round turn should exist around the anchor with no Two half hitches should be held in place by a locking bar with no

crosses. less than a 15cm tail remaining.

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M C2003000 1197 (3) Look at the top of the half hitches; the rope should appear to be one continuous rope.

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