Kevin is a nurse anesthetist with more than a decade of bedside nursing. Dennis brings him on to talk about the part of prolonged field care that the CPG describes but does not time: nursing care.

The conversation starts with a practical definition. Life-saving interventions finish, and the patient is stabilized. That is when nursing begins. In a hospital, this is the handoff to the floor, PACU, or ICU. In the field, it is the moment after the tourniquet is converted, the amputation is complete, or the chest tube is in, and you are no longer chasing the next immediate threat.

From there, Kevin walks through what nurses actually do: continuous assessment and vital signs, documentation that keeps the provider from flying blind, pulmonary toileting, turning, skin care, dressing changes, medication administration, and monitoring every tube and line that has been placed. All of it is time-consuming.

Training advice is blunt. Mannequins do not show you the standard. Weekend ICU shifts do. You need to know what right looks like before the field degrades it. Evacuation remains the primary plan. Prolonged field care is the emergency option in the PACE plan, not the default. Kevin points to Desperate Surgery in the South Pacific and the simple observation that every platform that brought troops forward also brought them back. History already solved versions of the time problem. The risk is treating patients as expectant who are not, then letting the absence of basic nursing care finish them before they reach a surgeon.

PFC Podcast · prolongedfieldcare.org · @prolonged_field_care

Takeaways

1. Nursing starts when life-saving stops. Once the patient is stabilized and you are no longer performing immediate interventions, nursing care begins. That is the practical handoff point in the field.
2. Data gathering is the foundation. Assessment, vital signs, neuro checks, and documentation of every tube, dressing, and intervention are what let a provider manage the patient. Without it the provider is blind.
3. The majority of prolonged field care is nursing. Turning, pulmonary toileting, skin care, dressing changes, medication administration, and line care are the work. They are also the first things dropped when patient numbers rise.
4. Train against a known standard. Weekend ICU shifts show you what right looks like. Mannequins do not. You will degrade in the field; you need to know what you are degrading from.
5. Evacuation is still the primary plan. Treat prolonged field care as the E in the PACE plan. History (South Pacific, WWII) already solved versions of the time problem. Do not label patients expectant and withhold basic nursing care unless the injury is clearly unsurvivable.

Chapters

• 02:10 When does prolonged field care nursing start?
• 03:59 After life-saving interventions: the handoff point
• 04:29 What nurses actually do: assessment and data gathering
• 06:47 Interventions: turning, pulmonary toileting, skin care, lines
• 07:30 How to train it: know the standard before the field degrades it
• 08:17 Weekend ICU shifts beat mannequins
• 10:48 Prioritizing when you are solo
• 12:00 Assessment frequency and catching change early
• 24:00 Sedation, movement, and the unstable patient
• 28:00 IV and line care in the field
• 32:00 Cleaning and dressing sites with limited supplies
• 40:00 Calling the provider and the cost of interruptions
• 44:00 Perfusion and the trauma patient
• 54:40 Evacuation as the P in the PACE plan
• 55:08 The time math: one ICU nurse versus twenty patients
• 57:00 Prolonged field care as the emergency option
• 58:20 GWOT spoiled us on rapid evacuation
• 59:12 Desperate Surgery in the South Pacific
• 01:00:01 How they moved casualties without air superiority
• 01:02:35 Expectant category and not withholding nursing care
• 01:04:15 Low-titer whole blood and learning from history

We covered the new analgesia guidelines from TCCC, now lets talk about how to get it done.

Ryan Knight — emergency physician and Deep, Army anesthesiologist now at UNC, walk the new battlefield analgesia list.

Ryan’s views are his. Not the committee’s

What is on the card: acetaminophen, meloxicam, suzetrigine, ketamine, S-ketamine. Can you treat a combat wound with that? Both say yes — because ketamine is versatile and APAP plus a COX-2 actually work on traumatic pain. Suzetrigine is the unknown. Published data is bunionectomies and abdominoplasties. Onset is about two hours. Nobody in this room has used it on the X. Ketamine is the bridge.

Dennis asks the medic question: ketamine is almost harmless, so why not just repeat 25 mg IV or 100 mg IM until the pain stops? Deep’s answer is toxicology. The dose makes the toxin. Escalate and you lose the airway reflexes that made ketamine feel safe. Secretions plus an irritant is the laryngospasm pathway. Ketamine is a direct myocardial depressant; catechol-depleted, bleeding, hypoxic patients do not get the usual bump. Shock liver and hypothermia mean you metabolize less and clear norketamine slower — same milligrams, longer and harder effect. A stable high-pain patient may need stacked doses. A wrecked one may need 5–10 mg at a time.

Guidelines try to arm you at the edge of your skill and still survive a draw-up error. Training reps and real clinical time build better guardrails than a thinner formulary.

Top 5 takeaways

1. You can run analgesia on the new card — ketamine does the real work. APAP + a COX-2 cover some traumatic pain. Suzetrigine is unproven in combat and slow (~2 hours, elective-surgery data). Do not plan the first 30 minutes around it.
2. Ketamine is not a free refill. 25 mg IV / 100 mg IM is a start. Stacking in a stable, high-pain patient is expected. The same printed dose in hemorrhage, hypoxia, hypothermia, or shock lasts longer and hits harder.
3. High-dose ketamine loses the features that made it “safe.” Airway reflexes blunt. Secretions rise. Laryngospasm is uncommon, not imaginary. Direct myocardial depression shows up when catechol reserve is gone. Dysphoria used to have midazolam. That tool is off the guideline.
4. Opioids left more because of the market than a vote. OTFC and Dsuvia/sufentanil products went away. A lozenge is hard to 4×. A syringe is not. They remain the literature’s breakthrough-pain standard. Acute addiction is the director’s problem; respiratory depression is the medic’s.
5. Best care and safest care are both the job. Directors backstop with logistics (1 mg vs 5 mg hydromorphone) and fight for calendar time. Senior medics own reps. Deep: high-fidelity / real clinical time builds better guardrails than a protocol written by people who no longer push the drug.

Chapters

• 01:59 New analgesia card: suzetrigine, S-ketamine, more removed than added
• 02:46 Can you treat a combat wound with APAP, meloxicam, suzetrigine, ketamine, S-ketamine?

• 03:38 Suzetrigine: bunion/abdominoplasty data, ~2-hour onset
• 04:10 Deep: untested drugs, ketamine side-effect kit, midazolam gone
• 05:13 Opioids as context-specific adjunct, one-iteration concern

• 06:06 French prehospital RCT — ketamine non-inferior to morphine, less nausea

• 09:15 Stable high-pain vs bleeding/hypoxic — same printed dose, different patient

• 11:04 Norketamine, shock liver, hypothermia — same milligrams, longer hit
• 12:04 Ryan: the catastrophic effects are rare — context still matters

• 44:11 Breakthrough pain in the literature is still an opioid
• 45:18 Is addiction the medic’s problem on the X?

• 47:14 Side effects and hemodynamics, not just addiction
• 47:38 The market removed OTFC and Dsuvia

• 49:34 Are guidelines best care or safest care?
• 51:06 Ryan as 75th / XVIII Airborne medical director — arm them, backstop the mistake

• 53:21 Training reps beyond Table VIII / SOCM / 18D refreshers
• 54:33 Deep: guardrails come from training and real clinical time

Recorded live at SOMA 26

Dr. Sam, an orthopedic and surgical oncologist, shares hard-won lessons from humanitarian deployments in Syria, Ukraine, and Gaza. Operating in underground basements under airstrikes, he describes mass-casualty events that overwhelm capacity (hundreds arriving at once, patients dying on the doorstep), the deliberate targeting of marked hospitals and medical personnel, and the practical realities of war surgery when blood, space, evacuation, and supplies are exhausted. Core messages include leaving high-energy extremity wounds open, the decisive role of blood logistics over pure surgical skill, the impossibility of saving everyone in true MASCALs, and the long-term weight of moral injury for both patients and providers. Sponsored by the Special Operations Medical Association.

Takeaways

• Marked medical facilities and personnel are targets. Hospitals in Syria were driven underground; killing a medic or destroying an ambulance removes a community’s capacity for hope and future care.
• Leave war wounds open. High-energy blast and missile injuries continue to declare dead muscle for days; closing too early traps infection. Wait for a cleaner environment before definitive closure.
• Logistics (especially blood) save more lives than technical skill alone. Arbitrary quotas, unreliable cold chains, and no ability to escalate care render even correct triage useless.
• True MASCALs (dozens to a hundred patients) force binary decisions: choosing one patient means another dies. You cannot save everyone; the goal is to train so you do it wrong less often.
• War surgery is technically straightforward (debridement, amputation, fasciotomy, crash thoracotomy) but operationally and psychologically extreme: hostile environment, no gloves/gowns/evacuation, 20-hour days, and constant moral injury.
• Psychological resilience has no universal protocol. Many providers function while deployed and struggle afterward; moral injury (watching children die, body-bagging patients in cartoon pajamas, colleagues losing entire families) requires deliberate preparation and recovery.

Chapters

00:00 – Introduction and controlled vs. humanitarian environments
01:50 – Purpose of the talk: war does not discriminate
02:30 – Medical facilities as targets (Syria, Ukraine, Gaza)
04:00 – Underground hospitals and mass-casualty realities in East Aleppo
06:40 – War surgery is technically simple; the environment and psychology make it hard
07:10 – Leave war wounds open: case progression and rationale
08:30 – You cannot save everyone: triage under extreme resource limits
09:10 – Chaos of body bags and declaring the dead
10:00 – Blood protocols, logistics, and the limits of escalation
20:50 – Case examples: blood quotas, open fractures, and failed resuscitations
22:00 – Moral injury in the OR and among local staff
23:00 – Starvation, maggots, compartment syndrome, and unhealable psychic scars
24:30 – Providers as casualties: double-taps and personal losses
25:20 – Scenes from Gaza: resource decisions and morgue realities
27:20 – Final take-home points and psychological resilience
29:00 – Why the work matters and closing remarks

Listen / follow: podcast → prolongedfieldcare.org → @prolonged_field_care