Minor Nagging Knee Issues

The purpose of this post is to give stretches and other rehab exercises to address minor or chronic knee injury issues that did not result from trauma. My primary audience would be those who are deployed to austere environments whom are looking for ways to rehab their guys while awaiting a good time to see a provider or physical therapist. The secondary audience would be for those Soldiers, Sailors, Marines, or Airmen who have been diagnosed, but are unsure/forgot the exercises they need to perform.

As a disclaimer, knee issues can be more difficult to diagnose, and to treat. Any injury with trauma should be evaluated. Moreover, pain that occurs suddenly while in exercise should be evaluated. This post is not to address sudden or traumatic issues. I certainly am not pushing anyone to avoid a provider or a physical therapist.

Instead, use these stretches to “stay in the fight” or to start rehab until you can see a provider or therapist. There will be a download button also at the bottom to keep these for yourself. These documents were passed to me from a physical therapist, and obviously originated at Evans Army Community Hospital at Fort Carson.

KNEE STRETCHES, PAGE 1
KNEE STRETCHES PAGE 2

EXTRA CREDIT FOR NEXT LEVEL MEDICS

If You Enjoy This Content, Please Consider Sharing with Others to Help Them Learn Also

Click Here for “Doc Medic Shirt” sold on Amazon.Com with free prime shipping

All content is intended to be educational only. Medics should operate under the supervision of a medical provider and abide by all local laws while stateside. Medics should only practice at the level credentialed, and only at the level allowed. This content is not intended to treat or give a substitution for any credentialed provider. Content is intended to aid in a deployed prolonged care setting. Take guidance from your leaders. Utilize these posts as preparation and as a supplement to your provider’s direction and teaching.

Contact me by Email: admin@nextlevelmedic.com

Ankle Rehab

If you find yourself with an ankle sprain and it is situationally difficult to get to a physical therapist, try these ankle rehab exercises for the first few days.

I was fortunate to receive these cheat sheets from my physical therapy friends. I now give these sheets out to Soldiers when they get hurt over the weekend, or when I know they can’t make it to physical therapy any time soon. This would be awesome for when down-range.

Assessment of the injury is important. If Ottawa Ankle Rules are negative and the injury is minor, it may be appropriate to give out this handout for ankle sprain rehab.

PAGE 1 OF PHASE 1 ANKLE REHAB
PAGE 2 OF PHASE.1 ANKLE REHAB

DOWNLOAD THE ANKLE REHAB PROGRAMS HERE


  • If you want to read more on the subject, check out ORTHOBULLETS
  • More information on Lower Extremity Evaluation and Ottawa Ankle Rules

If You Enjoy This Content, Please Consider Sharing with Others to Help Them Learn Also

Click Here for “Doc Medic Shirt” sold on Amazon.Com with free prime shipping

All content is intended to be educational only. Medics should operate under the supervision of a medical provider and abide by all local laws while stateside. Medics should only practice at the level credentialed, and only at the level allowed. This content is not intended to treat or give a substitution for any credentialed provider. Content is intended to aid in a deployed prolonged care setting. Take guidance from your leaders. Utilize these posts as preparation and as a supplement to your provider’s direction and teaching.

Lower Extremity Evaluation

This post will include a PowerPoint lecture on “Lower Extremity Evaluation” taught by Dr. Anne Resty, DPT. She is a Physical Therapist that I have worked with and I highly respect. I greatly appreciate her assistance here. I recommend you also the watch videos further down on how to perform these special tests that she covers in her presentation (videos have already been posted to the blog covering knee exams-click here to go to this post). Additionally, the “When to get an Xray” video further down should be educational for any and all medics or corpsmen.

Lastly, there are a few links sprinkled in on this post that highlight products that I use for my patients, or have used in the past with success. There is a link to a cheaper version of the “Game Ready” ice compression machine, sold on Amazon. I’ve purchased this much cheaper alternative in the past, and it works. Patients love it. Additionally, I’ve linked to the ankle brace on Amazon.com that I give out to students – I call it the “Cadillac ankle brace” because it completely stabilizes the ankle and helps Soldiers continue on once we determine the injury is just a sprain. Soldiers can wear it under their boots or with their running shoe. I’m sharing the things that have worked for us.

Click Here for “Doc Medic Shirt” sold on Amazon.Com with free prime shipping

This video by Dr. Resty, DPT, will cover the following:

  • Ankle Exam
  • Knee Exam
  • When to get an X-ray for an Ankle Injury
  • When to get an X-ray for a Knee Injury
  • IT band Syndrome
Dr. Anne Resty, DPT

ANKLE SPECIAL TESTS


WHEN WE NEED TO GET AN XRAY

Click Here for “Doc Medic Shirt” sold on Amazon.Com with free prime shipping

Extra Credit for Next Level Medics

Link to “Ankle Sprain” Outline created by Orthopaedic Residents on “OrthoBullets” website. Gives Anatomy, Diagnosis criteria, Imaging, Surgical options, and Rehab Timelines.

All content is intended to be educational only. Medics should operate under the supervision of a medical provider and abide by all local laws while stateside. Medics should only practice at the level credentialed, and only at the level allowed. This content is not intended to treat or give a substitution for any credentialed provider. Content is intended to aid in a deployed prolonged care setting. Take guidance from your leaders. Utilize these posts as preparation and as a supplement to your provider’s direction and teaching.

This content is the author’s opinion alone and does not necessarily reflect the opinion, official position, or stance of the Department of Defense, or any other branch of the United States Military.

Forearm Injuries

When thinking about open wounds to the forearm or even open fractures, do you use Kerlix? Do you understand the risks of wrapping it circumferentially? Watch this video to learn more!

Not everything about this video is perfect, but the point is to not create more problems by creating a compartment syndrome. The secondary point is to cover the wounds of a suspected open fracture with guaze (with saline) as soon as possible. You can usually suspect (or rule out) an open fracture based on mechanism of injury.

All content is intended to be educational only. Medics should operate under the supervision of a medical provider and abide by all local laws while stateside. Medics should only practice at the level credentialed, and only at the level allowed. This content is not intended to treat or give a substitution for any credentialed provider. Content is intended to aid in a deployed prolonged care setting. Take guidance from your leaders. Utilize these posts as preparation and as a supplement to your provider’s direction and teaching.

New! Table 8 Training Aids

If you’re an Army Medic, then you are familiar with the TC 8-800 – the training guide for 68W Sustainment. It underwent an update a few years ago, and I’m a fan. The TC became more TCCC oriented, and it added some basic exam skills. It also did away with the CPR portion in Table 6 (already receiving it in BLS), and added “Force Protection.”

However, allotting training time for 68Ws remains a challenge. It’s hard to explain the training to line unit leaders; they don’t understand it. The medics are usually outnumbered and often lack an advocate to fight for their training time and resources. This problem is exacerbated more in units that only drill once a month, as time is further crunched.

That’s who can benefit the most from this, in my opinion -The National Guard units. Perhaps this would also benefit some active duty units and reserve units if the medic sections are small.

Everyone in the Army Lies

There was a paper written a few years ago that was entitled “Lying to Ourselves: Dishonesty in the Army Profession.” It detailed how everyone cuts corners and lies; they have to do so. The amount of hours required in training exceeds the amount of available time, and yet units report training is complete. Here is a link to the Army Times coverage of this paper. I read through the actual paper a while back, and I loved it. It showed in actual data what we all knew to be true. I wish we didn’t live in this world, but we do.

I’m not telling anyone to lie about their training. I’m not saying to cut corners and reduce your training time. Train as much as you can, and more than is required- if possible. Attending a formal (protected time) instructional program is probably best. However, if your team is already cutting corners, then this may be a way to bridge the gap and better meet the intent.

Use This as Periodic Refresher Training

Ideally, this material would only be used to conduct individual or collective periodic refresher training in between formal instructional periods. Medics can slowly refresh on a few videos during “sergeants time” or while sitting in a FLA pulling coverage somewhere. This is excellent for “filling holes” in training or deficiencies.

Check it out! I’ve completed Tables 1-6, and 7 will be posted soon. Here is the link. It’s also posted on the homepage and in the menu.

Please send me any feedback or recommendations for any changes. I’ll listen.

Contact me by Email: admin@nextlevelmedic.com

This content is the author’s opinion alone and does not necessarily reflect the opinion, official position, or stance of the Department of Defense, or any other branch of the United States Military.

Knee Exam

A good knee exam starts with obtaining a good history.

  • How did the pain begin? Sudden or gradual?
  • Did the patient feel a pop?
  • Did it occur while running? Twisting? When decelerating? Changing directions?
  • What hurts now? What actions make it better or worse?

Of course, if there is concern for infection then there are further questions to ask.

Click Here for Link to Detailed Info on History and Physical Exam of the Knee from Ortho Residents

My knee exam will be focused based on the history obtained, but I also tend to always perform most of the tests posted below every time. I develop a suspicion of the injury based on the history and mechanism of injury. Future posts will likely include more on this.

First observe the knee. Notice any clues like deformities or discoloration, and ask about severity of pain and/or any numbness. If these are present then the patient needs to be seen by a higher level of care for sure. Or, if the patient does not have full ROM then they need to be seen by a higher level of care. Do not miss a quad tendon tear or similar. Ensure the patient can fully extend the knee.

No, my intent is to help with the minor injuries in which no infection suspected, the pain is gradual, there has been no trauma, and the pain is not significant.

Below is a quick video on the basic anatomy of the knee.

Knee Anatomy Basics

Before we get into the academics of the knee, I think it is important to familiarize yourself on how to perform an adequate exam. Try to get a Doc, PA, Physical Therapist, PTA, or Athletic trainer to show you these also and allow you to practice. They can also go over the mechanisms of injury with you. In the meantime, you can obtain mental reps and save time by watching these videos.

Videos on the Special Tests for the Knee

Anterior Drawer Test to assess the ACL
Posterior Drawer for PCL Tear
Lackhman Test for ACL and PCL Tear
McMurray’s Test for Meniscus Tear
Looking for Patellofemoral dysfunction
Assessing the IT Band

Future posts will have more info. I am recruiting Physical Therapists and Athletic Trainers to assist me in this as well. Stay tuned.

All content is intended to be educational only. Medics should operate under the supervision of a medical provider and abide by all local laws while stateside. Medics should only practice at the level credentialed, and only at the level allowed. This content is not intended to treat or give a substitution for any credentialed provider. Content is intended to aid in a deployed prolonged care setting. Take guidance from your leaders. Utilize these posts as preparation and as a supplement to your provider’s direction and teaching.

Patellofemoral Syndrome

A Very Common Cause of Knee Pain

This is very common, and I believe that Medics can both diagnose and treat it. When Soldiers walk miles for Land Navigation in the dark on uneven terrain, ruck march 9-12 miles, and conduct patrols- they can definitely get some knee pain. This is one common reason why knee pain is seen so much in Ranger School, Pre-Ranger programs, and other exercise-intense courses. I think it is also why there is so much research into “exoskeleton” knee braces – a study is underway soon at Fort Benning.

Patellofemoral syndrome, of course, can only be diagnosed with a good knee exam. It is not a result of trauma, but usually a gradual onset. Therefore, a good history and a good knee exam is important before making this diagnosis. Future posts will detail more on knee history and exams.

A Quick 3 Minute Video from bellinhealth on Patellofemoral Syndrome

Patellofemoral Syndrome is one of the most common knee pain diagnoses that I see. I often treat it acutely with Ice packs (compressed with Ace wrap), NSAIDs, and an open patella knee brace to aid with patella tracking. And, if there is time, I send them to physical therapy to strengthen their quads.

Typically, physical therapists, physical therapy assistants, or athletic trainers will focus on quad stretching and isometric or other strengthening exercises. Some recommend foam rolling the quad also. In orthopedics, we would often prescribe short arc knee extension exercises, with little to no weight and with higher reps, if physical therapy was unaffordable. In short arc knee extension exercises, the knee only bends to approximately 30 degrees and then is extended fully on the knee extension machine. Or, alternatively, one can perform isometric quad strengthening exercises.

Below are a few videos describing some of these exercises. Again, this is posted to really get you the first few days of therapy until you followup. Or, if you are deployed to a remote location and have no other option. The last video is from Tom Brady’s body coaches detailing a good resistance band workout.

I think it is reasonable to eventually advance to functional exercises. I believe that this exercise below by TB12 is one that could build the endurance needed to sustain prolonged load bearing during increased and/or consecutive mileage. Ideally, Soldiers would complete these exercises in order to prevent injuries.

Once able to advance, Consider these exercises to improve quad function and/or prevent Patellofemoral Syndrome

I have future plans to enlist the help of some physical therapists and athletic trainers to help on these issues. Look for that info to come over the next few weeks.

All content is intended to be educational only. Medics should operate under the supervision of a medical provider and abide by all local laws while stateside. Medics should only practice at the level credentialed, and only at the level allowed. This content is not intended to treat or give a substitution for any credentialed provider. Content is intended to aid in a deployed prolonged care setting. Take guidance from your leaders. Utilize these posts as preparation and as a supplement to your provider’s direction and teaching.

This content is the author’s opinion alone and does not necessarily reflect the opinion, official position, or stance of the Department of Defense, or any other branch of the United States Military.

Contact me by Email: admin@nextlevelmedic.com

ACCIDENTAL HYPOTHERMIA

This post wasn’t an expected one for me. However, there have been a few hypothermia cases recently that motivated me to dig into this topic. This post will be a little more wordy, unfortunately. I admit that I completely nerded out on the reading and podcasts. But, I needed to find the most up-to-date info and answers. And I’ve posted it here for others to benefit as well

DEFINITIONS OF HYPOTHERMIA

  • Cold Stressed: 95-98.6 degrees (35-37 Celsius)
  • Mild hypothermia: 90-95 degrees F (32-35 Celsius)
  • Moderate hypothermia: 82-90 degrees F (28-32 Celsius)
  • Severe hypothermia: below 82 degrees F (28 Celsius)
  • (Some Sources) Profound Hypothermia: below 75 degrees F (24 Celsius)

Other sources will classify hypothermia in the Swiss system as Hypothermia (HT) 1, HT2, HT3, HT4, and HT5.  Either way, hypothermia is usually described based on core temperature.  However, this method may not be relevant or practical in assessment.

The American Heart Association defines hypothermia differently with different temperatures.  However, the takeaway is that the AHA does not believe that defibrillation is likely to succeed until the patient is warmed above 30 degrees Celsius.

This podcast (A podcast taught by Emergency Department Physicians) suggests describing the diagnosis in more of a symptoms-based approach instead.  This is in agreement with the overall direction and attitude of most of the recent articles that I reviewed.  This podcast is great because they break everything down in 20 minutes, and they describe a lot of the symptoms. This is a MUST LISTEN TO podcast, in my opinion.  You can read the show notes of the podcast also which are very helpful.

The degree of sluggishness and impairment is likely varied amongst individuals, so it is very difficult to diagnose.  However, a proper diagnosis does have practical implications because there are different recommendations based on severity of hypothermia.

Rectal temperatures are unreliable for the core temperature in hypothermia patients, and exposing the patient to the cold may worsen the problem.  Instead, we should probably focus more on symptoms and clinical picture more than the absolute measured temperature.

Current Recommendations and Protocols

The US Army has a Standard Medical Operating Guideline on Hypothermia for Flight paramedics. Mostly helpful. A good starting point.  Posted below:hypothermia-smog
(ABOVE) REBEL EM PODCAST ON ACCIDENTAL HYPOTHERMIA

The SMOG is pretty good, except that medics on the ground don’t usually have the ability to perform an EKG.  And being an algorithm, it is not full of details. Still, it’s a good starting point.

I also recommend this “COLD CARD” from the Wilderness Medicine Society. It is excellent and practical. Useful for assessment and treatment.  THIS IS A MUST HAVE. Download it for free here.

CONTROVERSIES REGARDING HYPOTHERMIA

There is some disagreement regarding the diagnosis of mild vs. moderate hypothermia, and how to approach this patient.  The controversy surrounds the idea of “Afterdrop.”

Afterdrop, the continued fall of deep body temperatures during rewarming after hypothermia, is thought to endanger the heart by further cooling from cold blood presumed to be returning from the periphery.

Webb, P. (1986). Afterdrop of body temperature during rewarming: an alternative explanation. Journal of Applied Physiology, 60(2), 385–390. doi: 10.1152/jappl.1986.60.2.385

The controversy is centered around the question: Is it safe to walk a mildly hypothermic patient?  The Clinical Practice Guidelines by the Wilderness Medicine Society suggest that a patient should rest in a sitting or prone position for 30 minutes while warming in order to minimize afterdrop.  However, some dispute this idea because it may be more important to move out of a dangerous situation and out of the elements.  Also, the effects of “Afterdrop” may be overstated. Still, the 2019 update to the Clinical Practice Guidelines by the Wilderness Medicine Society left this recommendation in place.

After reading, it appears that it may be wise to not move the extremities or walk the patient in mild hypothermia, if possible. If necessary to move due to danger to the patient, or further harm to the rescuers remaining in the elements, then the risk should be assumed.  Unfortunately, the studies are very limited and the data is lacking support. It is obviously unethical to perform studies by inducing hypothermia (harm) in controlled studies.

MANAGEMENT OF HYPOTHERMIA

THEY’RE NOT DEAD UNTIL THEY’RE WARM AND DEAD”

  1. COLD STRESSED
    1. Passive or active warming. Remove wet clothing. Provide a high-calorie food or drink. Move around and exercise to warm up.
  2. MILD HYPOTHERMIA
    1. Have patient lie down or sit for 30 minutes. Actively warm to head and trunk/chest. Use a vapor barrier, if possible. Can give warm PO high calorie fluids or food due to possible hypoglycemia. Evacuate if no improvement.
    2. If the patient is already walking, or if the scene is unsafe, proceed with movement out of the harsh elements to safety.
  3. MODERATE HYPOTHERMIA
    1. Be careful with movements of the patient. Keep the patient horizontal. No drink or food. Parenteral glucose in I/O or IV. Heat the trunk/head/chest. Use the vapor barrier. Give warmed IV fluids at 40-42 degrees Celsius (around 104 F). Must be evacuated.
  4. SEVERE HYPOTHERMIA
    1. Treat the same as moderate hypothermia, except that CPR may be needed. If there are no obvious signs of breathing or pulse, then begin CPR. An AED may be used to assist. The rhythm may not convert in less than 30 degrees Celsius (86 F), until warmed. Evacuate immediately. Be wary of complications and arrhythmias, most common is V-Fib.
    2. Maintain compressions for 5 minutes before moving, and then ensuring that the compressions resume within 5 minutes. Severe hypothermic may be able to tolerate interruptions due to lower metabolic requirements. However, this buffer will fade as the patient warms.

The above guidelines are a collaboration of the sources previously described or are cited below.  My main source, and the one article that everyone should read, is the Clinical Practice Guidelines from the Wilderness Medical Society.  As always, I would recommend reading through all of the sources in entirety. And keep in mind that the patient could have other reasons for collapse, V-Fib, or asystole besides hypothermia.

Who Needs to Be Evacuated?

Well, this is the big question.  And it depends on who you ask/read.  According to Dow et al:

” A shivering patient with impaired consciousness should be treated for moderate, not mild, hypothermia.”

Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update
Dow, Jennifer et al.
Wilderness & Environmental Medicine, Volume 30, Issue 4, S47 – S69

This is a bit murky because we already established that there are different levels of impaired consciousness, and that individuals respond differently.  Additionally, the same article describes mild hypothermia as “still shivering” in most cases. Therefore, I believe that it is prudent to err on the side of caution and refer a patient who has become sluggish and impaired/slowed to the Emergency Room for further evaluation and workup.

What Actions Should Be Taken Now?

I am definitely going to conduct some more training with my medics by asking them to read this information, the articles, and to listen to the podcast. We will also try to develop some hands-on training scenarios with a mannequin in a severe hypothermia situation.

I may also redesign some cold weather training for the non medical guys/cadre. I would recommend others do the same since the scenario, if encountered, may be complex.

We will ensure that we stock all of our vehicles with active external warming equipment. I’ll be looking to purchase more HYPOTHERMIA PREVENTION AND MANAGEMENT KITS (HPMK) from North American Rescue since it is most easily transportable. It provides 10 hours of active warming once activated by oxygen (Anyone can buy from the NAR website or from Amazon.com). And, I’m going to look at this low profile alternative to the thermal angels. It’s basically IV tubing warmed with coils from what appears to be a slimmer-profile battery (sold by North American Rescue).

JOURNAL REFERENCES

  1. Durrer, B., Brugger, H., Syme, D., and International Commission for Mountain Emergency Medicine. The medical on-site treatment of hypothermia: ICAR-MEDCOM recommendation. High Alt Med Biol. 2003;4: 99–103
  2. Soar, J., Perkins, G.D., Abbas, G., Alfonzo, A., Barelli, A., Bierens, J.J. et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation. 2010; 81: 1400–1433
  3. Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update. Dow, Jennifer et al.Wilderness & Environmental Medicine, Volume 30, Issue 4, S47 – S69
  4. Hypothermia Evidence, Afterdrop, and Practical Experience. Brown, Douglas et al. Wilderness & Environmental Medicine, Volume 26, Issue 3, 437 – 439
  5. Hypothermia Evidence, Afterdrop, and Guidelines. Zafren, Ken et al. Wilderness & Environmental Medicine, Volume 26, Issue 3, 439 – 441

All content is intended to be educational only. Medics should operate under the supervision of a medical provider and abide by all local laws while stateside. Medics should only practice at the level credentialed, and only at the level allowed. This content is not intended to treat or give a substitution for any credentialed provider. Content is intended to aid in a deployed prolonged care setting. Take guidance from your leaders. Utilize these posts as preparation and as a supplement to your provider’s direction and teaching.

 

How to Properly Screen a Ranger Physical

This post will momentarily take a different direction. It doesn’t have anything to do with improving your medical skills. But, it has everything to do with ensuring your Soldiers successfully get through medical in-processing and into Ranger School. That will make them happy, it will make your boss happy, and it will help you earn that Soldier’s trust.

Most Ranger Physicals are Not Performed Properly

It may seem like this post is not needed. I assure you that it is. My team screens more than 1000 Ranger physicals each year. Typically, 85-95 percent have a deficiency. It’s the same at Ranger School. And the result is that a lot of Soldiers get a game-day decision on their packet as to whether or not they can begin training. Don’t leave it up to chance. Soldiers get turned around and sent home all the time.

So, I recommend that you use this matrix to check the physical of the prospective Ranger Student in your unit before he/she goes. Or, give it to him/her to check on their own. The link for download is directly below. Ensure all of the labs are completed, and also that they are within limits.



Ensure The Soldier Does Not Require A Waiver

Next, ensure that the Soldier doesn’t have any disqualifying conditions. If the Soldier has never had any medical problems, has never taken any chronic medications, has no limitations, and has never had a hot or cold weather injury–> then they’re probably “good to go” and can stop here. Otherwise, you will want to reference a couple of regulations.

AR 40-501 details the requirements in Chapter 5 regarding Ranger Physicals. When chapter 5 references “accession standards,” it is referring to the DoDI 6303.03. This is the initial entry standards for all services. If they have any of these conditions, then you must submit for a waiver. See the two references below. These are also listed in the “Policies and Regulations” page of the site.



Medication Use While at Ranger School

Soldiers are not allowed to take any chronic medications at Ranger School (Only medicines prescribed at the Aid Stations while already in Ranger School are allowed). Daily medications are not allowed, or the condition has to be such that the Soldier can go without the medications during Ranger School (they probably require a waiver for that condition also).

Hot or Cold Weather Injury History

If the Soldier has had a hot or cold weather injury, then they cannot attend during the hot (April – October) or cold (October – April) months, respectively. The Ranger School website defines this on their page, for reference. They are very strict about this. This also often includes heat related rhabdomyolysis.

Find out information about how to submit for a waiver on their website.

Please share this page with your friends so we can help others, too. Too many physicals are wrong, and I’m looking to correct this.

Want to learn something I haven’t covered? Send me an email! I want to teach what you want to learn.

Email me at: admin@nextlevelmedic.com

Contact me by Email: admin@nextlevelmedic.com

This content is the author’s opinion alone and does not necessarily reflect the opinion, official position, or stance of the Department of Defense, or any other branch of the United States Military.

Heat Injuries (Final Thoughts for Now)

This will be my last post on this important topic until the next annual MCOE Heat Forum.

I get concerned about training each summer and the absence of knowledge and unit preparedness with regard to heat casualty prevention. Kids die each year on active duty training posts, but what about National Guard units that conduct training in un-manned areas? We read about these tragic stories all the time. Preparation is paramount.

The biggest challenges, in my opinion are:

  1. Ignorance on the issue
    1. Read these posts on Heat Injuries and share them with other medics. Volunteer to conduct a hot weather training class for the unit prior to the summer.
    2. Start trying to change the culture. This idea of “drink enough water to prevent heat injuries” is dying. Adequate and appropriate hydration is important, but the focus should be more about heat load and heat dumping. Over-hydration is killing Soldiers, too.
      1. Look at Drip Drop Packets for electrolyte supplementation during prolonged or consecutive hot training days. There are others, but this one is my favorite because it is nearly equal to an IV with regard to Sodium concentration, and it tastes really good. It’s also Class 8 now. You can even order DripDrop on Amazon, let your Soldiers try it, and then get your supply sergeant to buy it- that’s what I did. My unit used Drip Drop at JRTC and my BN Commander told me that he was convinced it prevented heat casualties (Who really knows?). Whether or not that is true, I do believe it is helpful for preventing hyponatremia and dehydration. Our Best Ranger Competitors use it during their training. Bottom line: Soldiers actually use it because it tastes good. There are several different brands to choose from to replace electrolytes, but Drip Drop is one of two approved by DOD and it tastes far superior to the other. See below for a graph on projected salt loss from the US Army Research Institute of Environmental Medicine.
    3. Get your “guys” to spend time outdoors as it starts getting closer to the training event. Acclimatization is key. Gradually increase exercise in the heat also.
    4. Spread around the cadre heat algorithm (added it below again). Ask your unit PA to review it and consider adding it to the OPORD for distribution. Make sure lowest level Soldiers know what to do. And send the 68W heat algorithm via text to all the medics so that they have it on their phone (they will forget it otherwise).
  2. Lack of Resources
    1. If you cannot prepare or pre-stage Ice Sheets in FLAs and/or Aid Stations, then find another solution.
      1. Ice Water Lavage- EMS on Ft. Benning now uses this as a primary option. They use sports bottles (like those that can be stored on a bicycle) to spray two bottles of water at a time on exposed skin to cool the patient. They typically carry a cooler of 16 bottles or so. If you don’t have a small cooler, then throw a couple ice water bottles in a few ruck sacks. Get creative.
      2. Dump canteens on a heat casualty if nothing else is available. I personally have been in a situation where we ran out of ice sheets and I had everyone line up to take turns dumping canteens of water on the patient. It is better than nothing.
      3. Make prior coordination with local EMS – I always talk to the local guys to let them know what we are going to be doing so they don’t redirect resources unknowingly. I’ve even called the local civilian Air Medevac twice in the last year because I was worried enough about response times.
Go to the Document Repository to access the PDF “Water Requirements and Soldier Hydration”
Example of Sports Bottle for Ice Water Lavage

These are my thoughts and suggestions. Ultimately, just make sure you are prepared and have a plan. I think it is worthwhile to follow algorithms (posted below) decided upon by a large group of medical professionals at the training post that sees the most heat injuries. However, your unit may elect a different or more cautionary approach. I’m just trying to provide more of a resource than what is currently available. Whatever you choose, recognize that this is becoming a more frequent problem and that it deserves your attention.

Algorithm for all Soldiers other than 68W or Medical Providers as proposed by the Maneuver Center of Excellence at Fort Benning, GA
Algorithm for 68Ws as proposed by the Maneuver Center of Excellence at Fort Benning, GA

All content is intended to be educational only. Medics should operate under the supervision of a medical provider and abide by all local laws while stateside. Medics should only practice at the level credentialed, and only at the level allowed. This content is not intended to treat or give a substitution for any credentialed provider. Content is intended to aid in a deployed prolonged care setting. Take guidance from your leaders. Utilize these posts as preparation and as a supplement to your provider’s direction and teaching.

This content is the author’s opinion alone and does not necessarily reflect the opinion, official position, or stance of the Department of Defense, or any other branch of the United States Military.

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