Hi Martin,
I have just completed my MIRA (Medicine In Remote Areas). On that we were taught DCABCDE
Danger
Catastrophic hemorrhage
Airway
Breathing (inc Flap Twelve)
Circulation
Disability
Environment
Apparently the main cause of death in Afghanistan now is blood loss from IED's, hence the change in priorities, I guess. But again as you said, in Civvy street, major bleeds are very rare and most of the time can be stopped with Direct/Indirect pressure (both) and elevation.
Ross
Sounds like a good course, some pretty advanced airway management there. One thing new for us is we're starting to use the i-gel LMA's ...big improvement over the old masks IMO. I've only used em on a doll to date, but they look superb.
Yeah, that military protocol change is what I was talking about - makes sense they'd teach it on your MIRA course too. Still ABCDE for us civvies though and unless we have a civil war or something, probably always will be.
I remember a few years back when quickclot started to gain popularity with the military, we had one of our "whats new in trauma management" training things. We are kept pretty up to date with this stuff, mainly I think because we have military doctors on attachment to us when they are not on a tour, so they can get continued training and exposure to trauma in a modern university hospital. We were always bumping into them over protocols, they were so cavalier - it was like "whoaaaa ..slow down Tex, this aint MASH, you have time and options".
Anyway, We were shown a series of videos produced by the makers of QC. They basically featured a series of anaesthetised pigs who had their femoral arteries surgically cut. The pigs were allowed to bleed out for a moment and then a packet of QC granules dumped into the wound. The haemorrhaging stopped almost immediately, it was very impressive. It was supposed to be though, as it was basically a QC advert. One thing they didnt show, was what happened to the pigs afterwards. I suspect they were all euthanased. Most of our docs were pretty sceptical about these vids. It was obvious that QC stopped bleeding, but at what cost? How did it affect the tissues? How did it affect the surgical repair of the site? What was the long term prognosis after use etc? None of these issues were addressed. They were selling it to the military on the basis of if they have a "black hawk down" scenario, what is there to loose. The cas will die anyway. That's well and good in theory and the military bought into it. I guess they saw the film too.
Problem is, the stuff does cause pretty horrible tissue damage, so your medic needs to be making the decision that the bleeding is too severe to stop with conventional methods and the cas will die without it. In practice, it started to get used too frequently. The hospitals started to see some pretty horrible tissue damage from it being used on wounds that could have been managed without it. Now they seem to have dumped QC, stopped using granules and switched to cellox impregnated sponges and bandages. Cellox certainly doesnt cause the same tissue damage and by using it on a sponge or bandage, it should be possible to remove the bulk of it later. So is cellox safe? The makers say it is - but the makers of QC said that was safe too. Cellox certainly should be safer, I think we can be sure of that, but there is still precious little long term data relating to things like DVT's, PE's strokes and wotnot. Does it cause the formation of micro emboli? We need more data and ideally a control group. At the moment, we are relying on anecdote and civvy medicine needs to be better than that. I'd agree that if someone is well trained, has the right skills and knows what they are doing, it's another tool in the bag. But as happened with QC, even then it can start being used inappropriately. My main worry is that civvies are buying it because it's cool ally kit that the soldiers use, without any training or medical knowledge watsoever. Personally, I think until we have some better data and have more certainty over it's efficacy and safety, it should not be sold to the public.
