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Nursing care on the front line
Work in a Challenging environment
Some practices used in austere conditions may save a soldier's life on the front line. The principles of care do not change. The challenge is providing the best possible care with limited or no resources.
What the soldier has available in the field:
1-2 field dressings per soldier
2 canteens of water, possibly “camel-paks” (These may be used for fluid resuscitation or eye irrigation, know the field technique for making the irrigation system.)
In some units, each soldier may be carrying:
Intravenous fluid - 1 liter of Lactated Ringer’s (LR), Normal Saline (NS) or volume expander 2
Intravenous catheter kits
1-2 intravenous (iv) tube sets
You may have 2 liters of LR per squad, limited intravenous angiocatheters and intravenous tubing. This depends on what the medic is carrying and his proximity to you. If you do not have some of the items listed above, you may improvise:
- Your poncho can be used to prevent hypothermia or collect rainwater.
- MRE’s (provide calories and protein)
- Sugar packets are a source of calories
- Clean wipe napkins to clean or pack small wounds
- Matches to build a fire or to “sterilize”
- Table salt to make saline or oral resuscitation fluid
- MRE heaters to warm fluids
- Warm weather gear to prevent hypothermia
- Extra set of BDU’s, blankets, sleeping bags, poncho liners to prevent hypothermia and make rolls to elevate burned extremities
- Extra socks to keep the hands and feet warm (do not use if the hands and feet are burned
- Pocket knife (to cut dressings if you don’t have anything else)
- Boots filled with rocks or sand for C-spine immobilization
- Canteen cups for urine collection measurement or rainwater collection, as a drinking cut, etc. (more about that later)
- “Pogey” bait is a source of calories
- Rope for rescue and hanging bags
- Medics may carry Silvadene, extra bandages, volume expanders, intravenous catheters that can be used to give iv fluids, tracheal tubes and an ambu bag.
- Combat support hospitals have all of the above including additional medication, blood bank products, broad spectrum antibiotics, pain medication that can be administered intravenously, anxiolytics, ventilators, foley catheters, nasogastric tubes, laboratory support and support staff.
RESCUE:
If the casualty is not on fire, safety move them to cover and concealment.
If the casualty is on fire, role him/her on the ground or smoother the flames with a blanket or field jacket, ensure that you have cover and concealment, cautiously try to prevent further injuries.
If the source is electrical, use something nonconductive (wood stick, tree branch, rope) to move the casualty away from the electrical source to a dry safe area. Do NOT make direct contact with the casualty. Remember, the electrical casualty may need CPR if circumstances permit.
If the source is chemical, you must don MOPP gear before you approach and administer care to the casualty or you will become a casualty as well. If the casualty may have a neck or spine injury, avoid moving him/her. If you must move the individual, immobilize the neck and spine.
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< SITUATION:
1 Soldier (Buddy or Combat Lifesaver) and 1 or more casualties.
What do you do when you encounter a casualty?
Most likely cause of burns: flame, flash burn, hot liquid or steam, nuclear blast, chemical or explosion.
Field Assessment
Additional Information
Start with A, B, C, D, E
A: AIRWAY
“Are you okay?” If the answer is “yes” and the voice sounds normal, you have a patent airway, at least for now. Otherwise, intervene to ensure a patent airway. Always suspect inhalational injury.
B: BREATHING
Same as above, if the patient doesn’t appear short of breath, labored or have pain when breathing or talking. Needle decompression or tube thoracostomy may be indicated if the patient worsens – this is especially true of blast victims.
CAUTION
If the casualty is hoarse or if the voice sounds “different or strange”, there may be an inhalational injury. In other words, the airway may be burned. The burned airway can swell and close off within hours. Therefore, if you suspect a significant inhalation injury, you will intubate if you have been trained to perform this procedure. This may be done either through the mouth (orotracheal intubation, preferred) or nose (nasotracheal intubation. If intubation is not done, later you may have to perform an emergency cricothyroidotomy. CRICOTHYROIDOTOMY is a procedure done by making an opening in the cricothyroid membrane and directly inserting “a tube” (a smaller endotracheal tube) into the airway. This will be secured with ties, or tape. Make sure you know the field techniques for securing a tube if you do not have the items used at the field hospital.
C: CIRCULATION
Remember, if the casualty is talking to you and is coherent, blood is getting to the brain. This may be the only available assessment in an austere environment. Other tips: a palpable radial pulse suggest the patient’s systolic blood pressure is 80 or higher. A palpable femoral pulse, in the absence of a palpable radial pulse, suggest the patient’s systolic blood pressure is 60-70 mm Hg.
D: DISABILITY
A.V.P.U. - alert, voice, pain, unresponsive can be used as early sign to alert you to problems in austere conditions. It is not a substitute for the GCS scale and a complete neurological assessment.
E: EXPOSE
Expose the patient to determine the extent of the burns and identify other injuries. Maintain a warm environment. Keep the patient covered using dry sheets or blankets.
- AVOID HYPOTHERMIA How? Use warm intravenous fluids (37-40 C) Avoid debriding and cleaning large wounds until a heated environment is available Avoid covering wounds with saline soaked gauze, one common, it’s no longer done; this leads to hypothermia.
Since the burned patient is a trauma patient, cervical immobilization and spinal precautions should be maintained if the mechanism of injury suggests that there may be spinal injury.
F: FOLEY
Place a Foley urinary catheter
G: GASTRIC
Place a nasogastric tube (gastric ileus is not uncommon for burns over 20-30%)
Consider obtaining an ABG, EKG and critical x-rays; monitor vital signs and oxygen saturation.
**After performing the primary survey which has allowed you to identify and address most of the immediately life-threatening problems, PERFORM THE SECONDARY SURVEY.
WOUND CARE on the battlefield You may only have 1% Silvadene cream available in the field. If the patient has 2nd and 3rd degree burns and EVAC will be delayed more than 8 hours consider applying Silvadene 1%. Sulfamylon is used if you have 3rd degree burns. Creams are properly applied about 1/8 inch to 2nd and 3rd degree burns. It is removed and reapplied twice a day (every 12 hours). This offers significant protection against wound infection.
-If you are not in an appropriate environment, you will not debride; leave the blister intact. If you do not have topical antimicrobial creams in the field, cover (protect) the burns with a clean, dry blanket, T-shirt, or cravat.
PAIN MANAGEMENT on the battlefield Pain control is done by administration of small increments of intravenous morphine. Due to edema, intramuscular and subcutaneous injection of medication is not the preferred route of administration. Personnel who carry morphine should also carry Naloxone (Narcan) and be trained in its use.
EARLY PSYCHOLOGICAL SUPPORT on the battlefield Burn patients may experience depression and post-traumatic stress disorder very early after injury. Anger, fear, and guilt are common. Particularly vulnerable are those with loss of eyesight, burns of the face, hands, and burns that cause a perceived loss of masculinity i.e., perineal, or genital burns. In the short term, depression and the loss of the “will to survive” in these patients may manifest as patient being unwilling to talk, eat, participate in or cooperate with rehabilitative and physical therapy.
When is psychological screening normally done?
- In the first 24-72 hours, but circumstances and patient acuity dictate. Often, because of limited resources in the field and at the combat support hospital, mental health issues will not be addressed unless they are clearly indicated. As soon as a problem is brought to the attention of medical personnel, you must address the problem ASAP.
- Pick a time when you are not rushed.
- Pick a place where there are few distractions.
- Be prepared for any response: anger, refusal to talk
- Assure the soldier that the discussion is confidential
- Use open ended questions
- Keep question short, wait for an answer.
- Use verbal and non-verbal cues: sit, if possible, maintain eye contact.
- Show empathy: Try to demonstrate that that you want to understand how the soldier feels. Does the soldier feel changed or different after the injury? Is the soldier angry at himself or others? Does the soldier feel he should have died or wish he would have died? Is the soldier suicidal? You can ask this question directly your suspicion is high.
- Consider beginning by discussing a time proximal to the event to encourage the soldier to talk. Clarifying content sometimes will encourage discussion. Acknowledge that the soldier’s feelings are normal but that the distress should slowly resolve. Assure him or her that if the distress continues, help is available.
- Offer the soldier the opportunity to speak with someone that he trusts.
- Provide medications if indicated. Anxiety may be controlled (usually after pain is controlled) with an anxiolytic, such as Ativan (lorazepam) when indicated. The use of antidepressants, antipsychotics and sedatives are used in some cases bur they are usually prescribed at the discretion of a psychiatric clinical nurse specialist or psychiatric services.
*EVACUATION from the battlefield
If there is time, review the transfer sheet to make sure you have not forgotten anything. If you complete this sheet, place it in the right or left chest pocket for the receiving staff. You must understand the capabilities and limitations of the evacuation of procedures and have real-time and situational awareness. Transport time from the battlefield to definitive care may take several hours or days.
Learn More
< The Primary Survey and initial assessment
What are the key parts of the secondary survey?
How do you provide fluid resuscitation and wound care on the battlefield?