Standard disclosures, right? Nothing financial disclose. But the important one is these are my views on my views alone. Travis Deaton is talking to you today. I'm going to be very opinionated on my thoughts. And I'm looking for feedback. And I'm looking for people to have some some other thoughts and ideally some dissenting thoughts on where we're going here. I like to start off operational briefs with this slide right here. So the defense casualty analysis system, this is a public facing website, anybody can go on your smartphone right now. And you can look at this. And they will track our casualty statistics for not just the five named overseas contingency operations that you see up here. But you can go back and look at World War Two data, Vietnam data. Don't worry about all the numbers that are up there, draw your attention to this number in the bottom right hand corner, over 60,000 patients, 60,000 patients roughly 20 years, that's 10 patients a day, every single day, there were casualties coming back from overseas contingency operations for 20 years in a row, the collective we have a huge amount of experience, about what our patient dataset looks like. I'll be it from a different theater than what our next theater is likely going to look like, under different conditions. But this knowledge of 60,000 people was earned through blood, sweat and tears. We can't forget about that. So I think it's a good place to go look at every once in a while. I think it grounds us as to why we're here and why we're doing what we're doing. Obviously, when we talk a little bit about taking physicians or providers that are trained in a hospital, that's climate control, it's secure, it's got good lighting. We've got all sorts of backup staff that are helping us out on any given day. And when typically, when you ask for a piece of equipment, that piece of medical equipment or gear is usually readily available available as anybody actually dropped a wire from a central line on the ground ever before their careers. And then you turn and you say, give me another kid, right, another kid magically appears out of nowhere. That's the paradigm we've all been trained to work in and that we're comfortable working in. Now go back and remember the first time that you did an EMS ride along. I'm gonna watch about you, but mine was a total disaster. Right? We are not trained, nor do we practice working in low light conditions, moving conditions, places where you don't have backup, places where you're not necessarily secure. You'll see this in the hospital every day, right? If you respond to a code, especially if there's some junior residents, that's in a in a non traditional medical facility, where there's not a patient and a gown sit in the bed. So for example, you know, the fast food, the fast food joint, it's the to the hospital or, you know, the floor or the pharmacy, people get out of their loop right there, what they've trained to do, they don't know how to react that situation. There are all sorts of great civilian organizations that are out there that will help you with that problem set, right, I just listed a few these are just kind of representations that are out there. Obviously, the pre hospital trauma Life Support class is a great course that's tied very closely with the military as well. People can get a fellowship, right, we got I'm sure there's plenty of fellow train EMS folks in the room. But then there's also those folks that you know that if you want to go take care of somebody who's sailing on a ship out the middle of sea, or somebody on extended hike in the wilderness or in backcountry skiing, there's some fantastic organizations that will that'll help you through that. But that's not what we're gonna talk about today. We're gonna talk about this as an extreme example of what long range medicine is gonna look like for the Navy. So I'm sure there's there's plenty of folks in the room who are very familiar with distributed operations. We're gonna park here for a little bit, and we're going to try to try to shape this. So we all have a pretty good understanding of what this means going forward. This is an unclassified reef. This is an open source map chip that I pulled off, randomly pulled off the internet, specifically off the marines.mil public facing website. And it shows the anti access area that AI capability of a random country in this case, it's focused on Japan, or I'm sorry, on China. So what you're seeing are those range rings the project away from China, or cruise missiles, anti ship missiles, anti aircraft missiles, ballistic missiles, fighter aircraft, or fighter attack and bomber aircraft. This is how far out away from the coast of China they are able to project lethal munitions. There's a concept that Admiral Hancock refer to the first island chain. The first island chain stretches from Japan, South through the Ryukyu and Okinawa through Taiwan. Further south through the Philippines That's right. Those are the close island chains, you can see that those island chains are very well covered by the range rings, and are considered in the weapon zone, the West, those are inside of the West for a potential conflict. There's a second island chain a little further out, right stretches from northern Japan out to a why some might say all the way down to New Zealand, Australia even, that's a little further out that isn't quite as included in that that weapons Engagement Zone that danger zone. So let's let's what what you don't see depicted, here are a few things, you don't see the maritime naval assets that have individual range range with capabilities they can reach out and touch people with because they're moving around on a daily basis, right. But they're out there. You don't see the sensing capabilities. Right. So we talked about sensing capabilities, it's o'clock crossed the entire electromagnetic spectrum, this is going to be important specific stimuli for our long range medicine response. So we're going to talk about, but when I say sensing, that's everything from the mark one mod zero eyeball, right? Being able to look at something and say, Hey, I see something that is different that might not necessarily be here. And specifically, how many Chinese fishing vessels do you think are in this region? 1000s, right, all with eyeballs able to get on a VHF radio or cell phone and report back to say what they're seeing up to, you know, we talked about sensing capabilities, we're talking about 20 year old low tech, relatively satellites, that just have not even high resolution, so low resolution, visibility, all the way up to some insane sensing technologies that we're not gonna talk about in this particular space today. But I'll tell you are driven by AI to be able to sift through massive amounts of data that are looking very specifically at this region. The third thing you don't see on there are the electronic warfare capabilities. So we've been operating for the last 20 years in the overseas contingency operations. Under a very permissive communication environment, we were able to reach out and talk talk to people when we wanted to that being said, Who has ever struggled in the military, on radio, trying to talk to somebody that's 100% permissive environment we've been in. Now, what happens when we start degrading those capabilities? So keeping that in mind, I promise this is going somewhere. Let's look at the paradigm for let's just let's take a generic medium sized rule to capability that we brought into the Overseas Contingency Operations last 20 years. So what are we talking about talking about what 20 To 40 Medical packs somewhere in that range? About for medium to large sized tents, to generators, some communications equipment, but two or three field ambulances, you may be co located next to rotary wing aircraft that are parked alongside to help you get patients to and from your role to facility. Right. It's not just that the medical folks right we had to have attached security communicators, logisticians, cooks, maybe planners, all those folks needed a place to sleep, so we build extra tents for him. I'm sure I'm missing out like fuel, all the other sort of logistical supplies that are coming along with a roll to facility. Are you going to need a high fidelity high resolution satellite or ISR platform to see that footprint on this battlefield? Now? Mark, one mod zero eyeballs gonna tell you exactly where we put that medical capability. Now, our potential future enemies in a pacing enemy threat near peer conflict. They have the same Kill Chain issues that we do. So we talked about a kill chain. You got to find a target, assess the target and figure out if you want to execute that target. So my very simple Travis Deaton mind somebody's looking on a screen. Well, I found something that's got like 610s and a couple of vehicles. I only have so many missiles do I push the button or not? And I would argue that if you've got a footprint that big, that is a very juicy potential target. Right. So lesson number one, we got to get small. That's just a visual aspect. We like power, right? We'd like to run our lights and our medical equipment requires power. What what do you think happens every time we fire up one of those generators, they put out a whole lot of heat, right? From a sensing capability that he's gonna get found in a heartbeat when we call for patient transport, or where we receive a nine line request, assuming we can because we're a calm, degraded environment. What are we doing? We're giving away the position and potentially what we're doing and what we're moving. So we've got to stay light mobile, in stay off the EM spectrum. This has nothing to do with medicine. We're talking long range medicine. We haven't even touched on the medical piece yet. But these are important concepts and their key concepts. We talked a little bit about rule two, I'd like to go back and talk about rule one old paradigm. cooperations rule one medicine, you are good medic, and you're on the ground, you were already calling for that nine line chasm back. Before you were even finished on your initial assessment, right. So obviously, the gates effect looking at look at our time to get rotary wing aircraft on station. Realistically, when things were going well, you had under 30 minutes from the time you call that chasm back, the time there was a rotary wing on deck picking up your patient, typically, you didn't give it to make, make it through your entire assessment and get it packaged up for they're ready to take off your hands. In this environment, where we do not have air superiority, we've got to break that thought process, nobody's coming in 30 minutes to pick up your patient, the time distance is too great. And the fact that they can't safely get surface connectors, air connectors, ground connectors in, is going to severely limit our abilities to medevac folks out in a hurry. We'll talk about a little bit about planning factors, but I'm gonna throw out expect 72 plus hours, which are gonna be holding on to a patient. So as we wrap this up, we think about the problems that you got to be small, you don't want to get found you got to be able to move fast, you can't have a lot of gear and you can't emit anything on the EM spectrum. You're talking about small teams, not just medical teams, I'm talking small military teams, 2030 people ish Max, right, and one location that can move in a hurry, once they get sense, and they gotta gotta move to a different location. So what's your medical support for that? You got 20 or 30? warfighters? Out there non medical? How many medical folks do you put with them to take care of I don't know about you guys. But I have trained my entire career to be the best that I could possibly be. If somebody gets injured on the battlefield, I want to be standing next to him. That's what I've dedicated my life towards. The reality is, it's not going to be us. Reality is it's going to be a junior corpsman, or junior medic, who is going to be our center of influence, right? That's gonna be taking care of those folks. So we'll train we'll learn it. But at the end of the day, we have to learn how to man train and equip our forces going forward. Alright, so with that good news. This is how I look at things, right. So we put things on a spectrum of care. We heard animal Hancock talk about phase zero shaping operations, right. This is where nobody's shooting at this point. But the military actions that are happening in a competition phase, we've got folks deployed away from the continental United States. And we really got to focus on on the disease in that battle injury. So this is our non trauma skills in the emergency department. These are our sick call skills for folks who are in operational units. And we can't forget that there's a couple of kind of unique things right are tropical medicine, the mental health orthopedic injuries, obviously, the unique women's health issues that come up on deployment. I, in this spectrum, we're going to have to assume at some point, things are going to go kinetic. And that's what that little fake explosion of they're supposed to look like. When that happens, we tipped from phase zero to phase three operations were combat now. And you should expect to see more combat trauma, and a little bit less D MBI. Now, we've got some programs that are in place to help people work through this long range medicine because remember, you might not be able to call for help you got limited amount of equipment, limited on personnel, and you'd have to hold on to it for 72 plus hours. The way I look at it in my mind is we've got tactical combat casualty care, we got plenty of data that shows for the first 15 to 30 minutes well executed tactical combat casualty care will save lives. That's got to be the foundation of where we focus our efforts. So if everybody in this room does not feel like they are the absolute subject matter expert on tactical combat casualty care, I'd ask that we we go back and look that again, right, we need to be at the end of 30 minutes, you kind of run through your TC three protocols, and you're sort of stuck what I do now. And then we've also proven that whole blood saves lives. So what we've done, First Marine Division is instituted what we call a Valkyrie blood program, but it's nothing more than a low titer role, whole blood program that can be executed by medics with the assistance of Marines, with no medical officers present to be able to continue that resuscitation. What do I estimate cash that might be another 6090 minutes. And then what because helps still not come? This is when we went back and we looked at our prolong casualty care programs to really try to figure out how to train people for that 72 plus hours hold on to a patient before you can get somebody to come help pick you up. This is why I don't sleep at night, right? Trying to solve this problem set. Again, nobody has interrupted me and challenge me yet. Please do. We'll start a little bit with some tactical combat casualty care stuff. The kind of plug for the the image on the bottom right there. So deployed medicine. I love one of my favorite pastimes is complaining about DHA. I love it. But there is one thing that DHA got absolutely right. It's this app. And if it's not on your phone, you don't have it downloaded yet, I implore you beg you deployed health, it's free. That does a couple things for you. It's got all of the JTS killer clinical practice guidelines on it. Back in the days, I don't know, if you remember, we would deploy everything like hey, do you have the newest one? Or did you get the new one over email or kind of find the updated version, as soon as they're updated, they go up on this app, you can pull them down and download them if you need offline, you know, offline access to them. And not only that, it's got all of the training materials. So if you have to give an impromptu class for TC three, or prop two class for like any of your your your kind of roll to roll things up all those training materials are included on there makes it really easy this free app they actually did, right. So I'd ask you to please go take a look at I'm not going to insult anybody's intelligence. But I'm just going to briefly cover what the purpose behind the four different tiers of tactical combat casualty care where when they say tears, it's just target audience. Right. So the in the idea being, you know, teaching a paramedic, to do a bunch of interventions in tactical combat casualty care is gonna take a little bit of time and they come in with a little bit of of information and skill set beforehand. But the all service members like anybody that's that's working in a maybe administration or logistical position, they don't need a week and a half course, but they also don't need to know how to do high level procedures. So we've kind of tiered it out. So Tier one is your all service members. Tier Two, are your combat lifesavers. Tier three are your combat medics in your corpsman and then tier four is your paramedics your providers sir. Somebody saying Hey, hold on all tail officers you're asking? For medical school that's also an expectation. I don't know about you all, but I'm gonna run out a square hole. Admiral clearly agreed, right? When I want to go back to this this slide, right. What are we asking of our combat medics in our corpsman I want you to be a family care doc on the left side of this, right, with a little bit of OB experience and a little bit of mental health experience. And then I want you to be an ER doc and an ER nurse. And then I want you to be a transfusion assist. And then ultimately, I'm going to ask you to be a critical care nurse or critical care provider and an RT for a 20 to 21 year old target audience who hasn't been to medical school. This is a big ask the problems that we're looking at, and we didn't brief the casualty statistics or numbers, is it's a numbers game, there are not enough of us to tackle what the likely casualties of a near peer competitor gonna look like. So we've got to enable some of the skills for the folks that that are going to be their point well taken out and all that. It's a numbers issue that obviously we're concerned about as well. I will say just from an administrative perspective, tier one, tier two, tier three, all the training curriculum, all the videos are up on deployed medicine, the one that's still in works is tier four. So you can't get access to tier four yet. It's still being built out. Don't worry about this chart. Right. So this is just an organizational chart chart that looks at what you know who's in charge of JTS. And who does what for who don't worry about that. I want you to pay attention to what's on the bottom here. Right. This is not one of those situations where JTS the Defense Committee on trauma is an us versus them. JTS and Defense Committee on trauma is all of us, right? We are the ones that contribute to this body of work in this body of knowledge, the CPGs the curriculums that come out. This is the joint curriculum. This is the purple core curriculum. The medicine is purple. If you look for sample committee on T Triple C that puts out the guidelines both for TC three and PCC has 106 GP 106, or GP doc assigned to that particular person that's filling that billet right now is Captain Drew, who was also a command surgeon. Right? This is his collateral duty he does on the weekends. We as a community, are what make this up all the services, getting together, validating, doing the research, literature, literature search, looking at what our levels of recommendations are figuring out how to write the guidelines, update the guidelines, and How to Teach this to people. So this is a coalition of the willing from all services. And I would I would, I would challenge you, if you have an interest in this, and you're not engaged in this, let me know, come talk to me, we have more projects in more requirements than we have people to fill in, it's gonna be an extra job, right. But I also think it's one that that we can bind to JTS is not us versus them. We collectively are JTS. There's a couple people that keep the lights on for us on a day to day basis. I put this DoD up instruction up there. They came out early in 2022. That said a couple of things, but you know, cross cross the DOD. I'll read a couple things out here. So tactical combat casualty care is the standard of care. Right? It is the DoD standard of care cleared Clear, clear steps. And that all service members from all services should take this because it meets the J Robbins requirements that are out there. It also said that this is where we got to deploy medicine.com website saying that that's going to essentially be the repository to where we find these resources going forward. Luckily, we got some buy in right so after this came out as the DoD Instruction, the Air Force, were the first ones to the streets and yeah, understood. Um, you know, less than three weeks later, the Air Force says we in the Air Force will do the purple medicine, the joint medicine, a little bit later Department of Navy, about a month later came out and said, Alright, Air Force, Navy is gonna do the same thing. We'll practice the purple medicine took a little bit longer. But the Marines in the summer said we will practice the purple medicine as well. So what do you think next slide, Army, Space Force. haven't come on board yet. The DoD instructions but on the street for over a year haven't come on board yet formally as a service. Again, we as a community, these drivers. Gonna talk a little bit about the change payment process because this is what we do. Right, we go back and we revisit, we look at what new data what new information is out there are the recommendations and guidelines that we put out previously, are they still valid? Or do we need to change them around a little bit? If you looked at the fluid resuscitation for hemorrhagic shock recommendations, and TC three previously, it would walk through your blood options. But it would pay a little bit of respect to the fact that taking blood in the battlefield is hard. It's logistically difficult. And we left on two things. We left on the colloid Hexton. And we left the clear fluids, Plasma Light, and wholesale. Now, if you're a medical logistician trying to figure out well, I got a bunch of Cold Blood options, I got to figure out a source. Or I could just drop ship, some Hexton. And that's got a two or three year shelf life, which you're gonna choose. Excellent, for sure. Right? How easy is that done? Don't even think about it again. Who here has given Hexton for their primary traumatic research or resuscitation fluid of choice in a hospital? Right? We know, we know that that harms people and probably kills them. So we have to go back and look at these. I think this is a good one to look at, because it's new. When we look at what the current recommendations are for fluid officer for shock, coldstore, low titer Oh, whole blood. So these are coming out of our CONUS based military blood banks, right. These are screened, they're FDA compliant, and their universal blood products, whole blood products that can be given to anybody who comes to the door. They're great. But they're not easy to get a hold of and volume, right? There's not a whole lot of them out there. So they can work for submissions when you go overseas. We're still playing around a little bit with the additives. But right now we're looking at about 42 days, or what the current shelf life of these are. But again, they get dropped. That's when the data drawn, they get drawn into CONUS. Hospital, they have to go through the testing process that has to get reported, then they have to get shipped. So if you're sitting in Indo PAYCOM, or Africa, you're probably looking at about 25 Useful days of service life left on the cold stored level blood by the time it gets to you. So it is a solution. It's a safe solution. There's no harm involved in this but it is a logistically challenging solution. Second on the list, and these are these are an order of preference. By the way, it's like a whole list prescreen low titer, oil, fresh, whole blood. We're gonna hear a lot about this program later on today. We got some folks in the panelists, the panels gonna talk about maybe a little bit, yeah, right afterwards. So that's going to be kind of good talk about and this is where we we've named our Valkyrie program. But there's other programs that are out there. And we'll go into that a little bit. After that, obviously, plasma RBCs and platelets and One to One to One, knowing that you're not going to get platelets. Next, next on the list is just plasma RBCs and a one to one because platelets are so hard to find in overseas locations. And then at the bottom, if you can't get a one to one and just get plasma or give our red blood cells. Let's go through these just a little bit. Which of these require refrigeration? Is this one? Yes, this one. This one? Yes. Yes. Kind of Yes. But I mean, this is this is unicorn, right? If you can find it great. But the rest of it doesn't initially. But it's hard to get a hold of any sort of volume. But all the rest of these do. So what's really our only non refrigerated option. So if you are a ground force going forward, trying to figure out your blood solution. That's all you got, right? 2022. That's all Yeah. If you're looking for anything in volume. So we put this to the service, specifically to the Marine Corps and said, Look, we got a problem. We can't keep reinventing the wheel. So there's something called a universal needs statement, you can put up with the help of cabin dog. And we'll Hancock several other folks in this room, we were able to get the Marine Corps to sign this on as a program of record. And people that aren't familiar with program of record. You think this is where you get to go to the inside endzone and spike the football turns out it's not right. So you got to go through the entire.mil PF process to figure out funding and education and where it goes. We're getting there. We're close, we're much closer than we were. So it is now officially a program of record. And now we got to figure out all the details to make sure that we've got these access to low title Fresh, fresh, Old Blood programs going forward. This, this is a great article. This is a really good one to have has anybody. There's a couple of older folks in here. Has anybody tried to do anything with blood products and been told by a lab officer? Absolutely not. We're not doing low title. We're not doing cold storage. All right. So I just had that experience within the last couple of months. And so this came from a blood officer, have you met? And I said, Hey, you know, I hear what you're saying. I know you have some concerns, but you work for the armed services blood program, correct? Like that's essentially your your higher headquarters? Are you aware of a joint statement that came out between the joint trauma system and the senior author on the paper was our services blood program, and they say that we shouldn't be doing this though. The end of the end of the argument pretty quickly. This is a good good paper to have in your back pocket. Because there is a little bit of disconnect sometimes right? We are going to have to accept what I what I think is to be you know what, we're gonna take moderate risk by doing low tide roll buddy to buddy transfusions, we can mitigate that to low risk, but it's not no risk. And that's what this position paper is supposed to help people be able to go out to their commands. And say we understand that and everybody's on board with a low risk program like we have set up. Just couple storyboards. This is, you know, NSW is looking to formalize their programs. We were training some folks up with the seals to make sure that they were they understood how to use the Valkyrie program. This is the one I thought for sure I was gonna lose my job over and I didn't yet. We have some unique assets within First Marine Division with our force reconnaissance teams because they're small. And they asked if they could do send their Marines through with no corpsman. So this is a course that we held for some force connoisseurs Marines, there is no medical personnel that went through this course. And they scored higher on their practicals and their written exams than as an average than any other class that we've run through so far. So they're capable now great. These are these are kind of self selecting right. These are these are Marines who are pretty hard charging. But yeah, they're capable of it. Absolutely. And we took that information and we realized we may not want our, all of our Marines, transfusing, necessarily, but we can certainly teach them how to draw blood. And they can certainly run the administrative acts aspects of making sure that we've got, you know, people who are pre screened and identified and labeled appropriately. And so our Marines have been huge force force multipliers for us in our low Tyro, low blood programs. I'm not going to talk too much about these because I think he's going to come up a little bit later. But there's some folks in this room who did some excellent work, overseas training our partners on our best best practices for low titer oil programs. And those certainly, were used in some very real world circumstances that we're gonna talk about later on this conference as Well, just in your mouth stealing a thunder, am I? Okay, so this is a couple a couple of text messages back and forth with some folks on the ground. When you see the acronym CTM up there, and I'll read it for you. That's so CTM is our combat trauma management course that we run. It's nothing. So it sounds good. Yeah. time ago, it's tough to long. You got it, sir Gaby, all the way to the tactical combat here, the tactical combat care course, right? That is purple medicine. It's just medicine, medicine doesn't change, no matter what color uniform you're wearing, or where you're where you're working on how you apply that medicine to your platform, to your aircraft to your Bradley assault vehicle to your ship to your submarine. That's the platform application course the medicine doesn't change, or too too little different things. We got to look at them. So our platform application course, is our combat trauma management, our CTM course this is teaching ground force Marines how to work out of a backpack and the dirt while it's raining at night. That's how we apply our T Triple C. So the comments that came out of the HK attack right all of the corpsman except to have been to combat trauma management. Will irk the two didn't go we're working on that. All the Marines were CLS combat Lifesaver train. So our requirement is to have two per every corpsman, which would only give us about 120 Marines out of a battalion landing team. Instead, they trained up 1000 Right there are there was about 100 150 That didn't get chance to get that training, they turned 1000s dead. And the all of them that were involved were combat Lifesaver train before deployment. A handful from each platoon, Marines, sailors, Marines, rebel crew trained Marines as well to assist. I wasn't around for the blasts of the casualties, but the boys performed. They said if it wasn't for CTM and Valkyrie that they wouldn't have known what to do. We can teach this medicine in the hospitals. But if we're not working on the platform application stuff, we're not given people the confidence to use these skills forward. We're potentially set them up for failure. I'm gonna talk very briefly about prolonged Casualty Care for a couple of reasons. So first of all, prolonged field care.org. So Sean Keenan who used to come to these and still does occasionally, retired ER doc still works at JTS. He he was a visionary, right, he worked with a special forces, he realized, my situation might be a little different. I might be holding on to folks for an extended period of time. And we really don't know how to train people to do that the special forces. And he really along with some smart, smart folks, pushed this prolonged field care concept. This website, prolonged field care.org is a great resource for podcast for case studies for some training, documentation, all sorts stuff, it's really good to go take a look at. But I want you to notice something. His website he called prolonged field care, right. And I'm calling this prolonged casualty care what was a different term turns out, I'm gonna give you an example. If you're, if you're on a submarine submarines really rarely take physicians on they have an independent duty corpsman mission that submarine is to go and stay hidden. Right? Number one priority, stay hidden, do not come to the surface. You got a medical problem that you have to deal with and you can't come to service and you're in the middle of nowhere trying to hide? Is there a better definition of like prolonged casualty scenario, right that that is what submarines do. We took his program the surface fleet, we took it to the submarine fleet. We said, Hey, prolonged field care, we got to figure this out. And they said, we know we don't go to the field, or summary. We don't deploy to the field. Yeah, but you gotta understand there's a lot of parallels here. We don't go to the field. Would you consider it if we changed the name and called it prolong casualty care instead of yeah, we can go on board them. So even though there's still references to the prolonged field care, we're really trying to go in call it more prolonged casualty care, because, again, the medicine is purple. Doesn't matter what uniform you're wearing. So this, the initial CPGs just came out at the end of last year there again, on deployed medicine, if you want to pull up the newest version. They're not perfect. This is version one. They're good. They're not great. And we need smart people to look at this problem sets for people like folks in the room that are willing to come to JTS and help us with version two and version three. Is there a starting point? Now? What's what's not there? Initially comes the guidelines, and then the guidelines drive the curriculum. So we're in the process of writing the curriculum right now, again, folks that are interested in curriculum development. Excellent opportunity. That's a huge, huge beast that we're trying to tackle. I'm trying to figure out the prolong Casualty Care piece, but we're on timeline. I think when battle Hancock says that he's never just career felt like we were closer to this potential conflict than today. Do we need the help we need? We need folks that are smart here to help us through it. Let's talk about a couple cases. If I can make it short in time, someone's gonna weigh me. You give me my, um, we have to get comfortable with being uncomfortable. So I'll paint the situation here a little bit for you. This is a very small try service surgical team. You got a general surgeon, a ER doc a CRNA. And a PA. Same country with his partner forces got a call. They're about 150 miles away saying hey, we took a bunch of casualties bunch of gunshot wounds. That there's there's no medical resources there. Can you guys help out? That surgical team was engaged in a mission 150 miles away supporting us US service members? The answer is no, we can't come to you. But if you can, if you can get your patients to us, then we'll we'll do what we can do can't promise you anything. Good enough. So they loaded up half dozen patients G SW the chest, abdomen, pelvis. And then this gentleman who had a G SW to the left side of the brain, as you can see here. 150 miles in some countries coming down from mountainous terrain in an unimproved roads turns out to be an eight hour car ride. This patient had zero interventions for eight hours. This contract one of that shows up GCS of 10. Following commands with no rights moving on the right side of the body. And then obviously, the entry exit wound that you see up there. So let me ask you, what do you do? There's no there is no neurosurgeon in this country that that patient's never going to see a neurosurgeon. There is no neurocritical care bed in this country. You've got limited resources that you're there for a reason. What do you do with this robot for the quarter to die? Give it a shot. Is it easier if he came in with GCS of three that make the decision process a little easier? My mind it does a 10? What if this patient went from 10 follow commands and was compensated an eight hour car ride in the back of the truck through the mountains, they got to you, in front of your face goes from an eight or from a 10 to a seven to a six and the first 30 minutes to your assessment that change your calculus at all. There's no right answers, just some to think about. This team decided that they're gonna get to shop right. Like other folks that have either trepanation or craniums as a moderate as a regular part of their practice in this room, I kind of doubt No, but we, we all think about it, especially as military physicians. And I in my mind, like I had, like, this is what I'm going to do when this situation arises. And I think back to the pictures and the drawings and you know, go into the cadaver lab and we practices so the cadaver lab. And everything in the cadaver lab was pristine and out like the older but pristine anatomy in terms of an intact calvarium skin everything. Everything in the picture showed perfect anatomy before you start this procedure. And then you get your aha moment where you're like, Oh man, there's like bone fragments. Soft tissue disruption, and my plan didn't survive first contact going in to see this patient right. So you can see here, obviously, the scalpel station had to be modified to incorporate the wounds flaps raised. I'm gonna forget the name, the rainy clips, a little clips here rainy clips. Obviously we're not carrying any clips. So when you cut that scalp and start to bleed Whitesnake, well that's gonna take a half a minute to sit down and run some mock and sutures and try to get some hemorrhage control. And obviously, nobody nobody was available for for this case. We had a percentage gain we saw Roger elevator and of course, one of the first things that happens is this thing. You can't really see a therapist duct taped together because it didn't survive the initial initial procedure. bone fragments were removed to get to the gig we saw under the wound right the elevator used to free the dura devitalized brain tissue. We know what devitalized brain brain tissue looks like. Yeah, I don't either. Looks good. This doesn't stain something washed out and then without a bogey. We've never I've never seen any buddy publish a paper plate saying they put combat gauze inside a woman like this to try to get some hemostatic control but what are you gonna do? The Durva was there it was closed and the obviously a drain was placed in the skin was just stapled. So that patient was excavated about our six or seven somewhere in there. Did okay. That team got a call post op day to a retasked you got a critical mission. You're moving. What to do about this patient right. There were some folks that had zero medical training They're gonna be there. All right, we're gonna teach you about Cute, cute 24 hour antibiotics that are gonna go through that IV line. This is how you do it. Watch this once. Rest is on you feeding somebody for extended period of time. Wow. What are you do? You look around? Well, we got baby formula in the, in the village here and we got some protein, protein powder. We got some electrolytes and did some back of that napkin calculations and give it through an NG tube, right? It's not perfect. That's what we do. We figure things out in our community. 10 days later, Tim gets back takes a look at him, right. Obviously, he continues to be paralyzed on the right side, but he's eating, he's talking he's up to a wheelchair. Never get neurocritical care, rehab. He's living, right. These are hard. These are hard questions. We need to get uncomfortable or we need to get comfortable being uncomfortable. That's a I think that's what our next feature conflicts will look like. What does that mean trepanation trainees, limb amputations. I guarantee you the morbidity and mortality associated with me performing a limb amputation is going to be significantly higher than an orthopedic surgeon does it. But I can also guarantee at some point and a vascular necrotic limb is getting infected. That's going to have a higher morbidity mortality than me giving it a shot right? We need to get comfortable with being uncomfortable. That's Grotius fasciotomy. And for me, my worst feared procedure out there dental extractions right just hate to can't do but one of the most common things we're going to be called on to do. Alright, right. I'll make this quick. Just run through especially for the residents in here right think about your aim general team, your oral boards. Look at all those resources. You have em docks, trauma surgeon anesthesia, you got residents running around nurses, techs or T BloodBank security clerks. Look at all your resources right? IR suite CT surgical subspecialties blood banking, but took you forward and took those away. And I left you with that. This is the construct of the Navy's roll one shock trauma squad that goes out with the Marine Expeditionary units was what you got in pride are a PA emergency nursing and put a duty corpsman you're working with limited Class A portable ultrasound, portable monitor, portable ventilator, and I stat and maybe a cooler to take some blood products with you if you're lucky. We got to get comfortable being uncomfortable. Ibo to monitor right rolls off everybody's tongue in this room. Let's talk a little bit about ideas. John, anybody in this room know John, there's no doubt John is the one of the world's sneeze when it comes to IO. Io cannulation. Jonathan, I also own a fishing boat together in Southern California for offshore fishing. The problem is offshore fishing in Southern California, two to three hours to get up to the fishing grounds. Two to three hours of which I have to listen to IO stuff about which is great. I like them, but they're fast with a required training. It's the first skill set when we're tasked saturating a small team that we give to the medical the corpsman and you got to train for it. And they're temporary. I'll talk a little bit about cortices right so I think everybody's probably tracking first thing I do is I toss out all the triple lumen catheters on deployment stuff why you need triple lumen volume. Right good to get a quarter and you're gonna get a Cordis. Why do I say seven French? Why is that the only size I want? Rainbow right? It compatible. But you know, obviously you got to make sure that that seven French is gonna be compatible. If you're going to take Ribault that you bring this up in French where you didn't put it up there. But if you're gonna go for an AC line, like why not the ric? Why doesn't every AC line get followed up with a Rick more stable, less chance it's gonna blow on. Oxygen always is a hot issue. I love oxygen too. If you're talking about hanging on to a patient for 72 hours, it comes down to Cuban weight. And to a certain extent the fact that compressed highly compressed oxygen and a tank with a lot of hot lead flying around on the battlefield is typically not a great thing. But just the straight volume of what you need for for long range medicine. It is very challenging if you have it fantastic. But from planning factor, it's really challenging. If you've got young people with relatively good, good good physiology, pre pre injury, and we're talking just trauma, right? Just trauma. I look at fixed you know, we look at the equation for oxygen delivery. I can't change the variable on one side. The two that we really have to look at it the hemoglobin, oxygen, oxygen saturation, right? There are certain things I can do like put a chest tube in if there's if there's a lung problem to fit the saturation, but what can I fix the most out of that one compared to give him a little oxygen taken from 70 to maybe like low 90s I could fill them back up with hemoglobin. So I don't sweat not have access to oxygen i Of course I'd like it but it's not it's not a game changer for me. And finally, monitoring right? That's a nursing skill that we put in physician hands. Like everybody knows a watch, watch a resident go in a room patients go Going crazy the monitors going off. We know how to hit the silence button. I walk out to tell the nurse like I don't even know what's wrong with the monitor like without you look at the vital signs to see if there's a reason the monitors going off in the first place, right? But But it's more than just that right? It's not just Do you know how to do the button ology it's Do we know how to appropriately use the monitors, so we know how to use in tidal co2, we're doing stations or substations. And then I always probably put a plug in for low tech solutions. Very similar receive patients, you know, cut out that last situation, again, in a pickup truck coming from hours and hours away, the only intervention that they had done to him. And it was across the board, half dozen patients the only intervention, not wound wash out not splints, not tourniquets, or Foley catheter. Everybody had a Foley catheter. It took me a while to wrap my head around, like why did we take the time to drop six full length catheters throw these guys in the truck and get them to somebody else to take care of them? Because if you don't have a monitor, and you're in a country where you don't have access to a monitor, that's a pretty good monitor, right? What's the urine output look like over time. So useful? Well, other low tech solutions, pulse ox, right? If you're one except a little bit of, you know, potential infection control risk. You can carry the pulse ox around from patient to patient patient. Within 60 seconds, get a pretty good snapshot. Everybody poo poos the risk BP cuffs, right? And I'm gonna agree the values you get well documented in the literature are low fidelity numbers, what I love them for if you keep the patient in the same position every time you use it, you can follow your trends over time. That's what I care about. I don't care about the numbers much they care about the trend over time. All right, I'm out of time. Okay, let me tell a very brief story here. Iwo Jima has what is known, not called Eva Tau has a reunion with honors every year. They're actually wrapped because of COVID. They've they've finished this up now. But they would bring World War Two veterans from Japan and from United States, the small island, the very, very middle of the Pacific Ocean for a really, really important ceremony. It was right. And so of course, they asked for some medical medical folks to help out. Hey, can you bring your shock trauma platoon just to make sure nothing happens with these folks who are in their 90s that are coming out this island in the middle nowhere? Yeah, we'll support you but like I'm gonna I'm gonna need some medical equipment. We're going to just bring just bring it back back. It's fine people to pass and just use the backpack. No, no, no, no. We're gonna bring a big a small kit with real supplies, and I'm gonna need an aircraft on standby. Like you're telling me you need to see 130 state Yeah, I need to see 130 Standby on here. Okay. So we thought and thought and thought. We got there a couple days ahead of time. We set up all of our monitors. We plugged them in, we were ready to go. This gentleman who was at Mount Suribachi on Iwo Jima the first time was being driven there. There was a corporal that was driving the bus he said Stop the bus at the bottom of the hill. First time I was here, I walked up, but to walk up it again. Court was like, Okay, sir. They need mid 90 year old gentleman walked up to the top of Mount Suribachi to just find gotta ride back down. The ceremony was kind of at the base of the bottom the island. Halfway through the ceremony, he codes. Right. So we're cardiovert ng getting calls back. Grab all of our equipment, we go to the C 130. That we asked to be parked there. Within 10 minutes, the first monitor dies. We had that thing plugged in for two days, right? Nobody did better maintenance on the monitor center warehouse somewhere. That's okay, we got two more. Your second monitor we're gonna do crapped out. Third monitor. We are not 45 minutes off of this island trying to get someplace like Guam or Hawaii. Before we lost all monitoring capabilities on a Ross patient on multiple drips. We've got intubated, I'll see 130 So my risk BP cuff and my pulse ox they were money. Make fun of him if he wants to, but they were money. All right, we're gonna fly through a couple of these. So I'm gonna get to this one right here. So I get there too. I'm unapologetic about being emotional about these cases. Sergeant Vargas Andrew's 29 surgeries. This kid is doing great. Right? He is alive. Living at Walter Reed right now with his mom because of some heroes in this room right now that we're taking care of. When his mom calls me, and she does on a daily basis, right? This is a kid who lost vitals multiple times. He spent a whole lot of time on ECMO. He's got a long road recovery ahead of me. But she says, Thank you, for his second, and his third and his fourth chance at life. There's purpose in what we're doing here. And we have heroes in this room, who are responsible for this young man still being alive. And I'm on apologetic about caring about that. So on that note, one of my favorite pictures ever, some of our blood training on one of our Marines Blue Diamond as a seal for First Marine Division. Marines are a big deal to have on your arms. Apparently, this one, they kind of looked the other way when he got this tattoo. But I like it a lot. So any questions or concerns? I know I went a little bit over if I need to take them afterwards. I'm happy to do so. Okay, yeah, sir.Unknown:
Blue there. In a case, there needs to be logistics being pushed forward, because you're gonna run out of stuff that we think about trauma all the time, as much as trauma, every patient, right? Whatever it is. It's gonna be a bigger problem. For the juniors in the room moving forward, you've hit on it a couple of subtle, subtle moments, but I just wanna highlight it because I think it's not something in our forefront. It's not something that we train for often. The casualty estimates that you are looking at, you had a sign that showed 60,000, the last 20 years of war. If we go to war with China, we're talking 40,000 in two weeks. And with that comes prolonged field care and expectation management, we've come out of 20 years of war where our expectation is 99% of people who touch a physician are gonna make it home. That is not what's going to happen if we have 40,000 casualties in two weeks. So these medics are coming into it thinking I need to be a master because everybody will live if they can meet me. But that's not what's going to happen. So the mental health aspect of training your teams and debriefing afterwards. I love that text message because right above it, you said how are you mentally? And that is incredibly important. We don't ask those questions and we don't ask that of our medics. We don't ask that of our residents. We need toTravis Deaton:
be tastic alright, I talk to you long I apologize if there are any other questions please grab me during the conference and I was serious if there are folks that want to contribute to the joint mission right we are looking for people at T Triple C we're looking for people to PCC groups we need the help and we quite honestly we need fresh eyes young folks folks with different experiences to come in and give us handsome thank you again. Next yearLaura Tilley:
right, so that was like a 10 minute break and then 1345 We're back here for the panel discussion.