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

A healthy person lying in the snow at -30 or -40 dies of hypothermia. Add a gunshot wound, wet clothes, and twenty minutes on the X while the team finishes the fight, and the cold competes with the bleeding.

Thomas spent nine years as a Danish Special Forces operator and medic. His view is that TCCC still applies, but the sequence does not survive contact with that climate unchanged.

Stripping a chest or abdomen to “do MARCH” on the snow makes the patient colder, more coagulopathic, and more acidotic. Massive hemorrhage still gets a tourniquet, over the clothing, because it is fast. Airway obstruction gets a roll to prone. Everything else waits for a semi-controlled heated shelter. That shelter is not a rock. It is a tent, a stove, and enough security to put both up.

Clothing changes the tools. A CAT may not reach a thigh under five layers. Mittens make the windlass clumsy, and taking them off at these temperatures is a frostbite problem in minutes. Train with the gloves you will wear. Inside the tent, two multi-fuel burners on a stable platform, a vapor barrier, and active heat come before a full secondary survey. Drugs he keeps close: ketamine, morphine, prefilled syringes rather than ampules, and an IV antibiotic. Plastic IV bags leak and contaminate when they thaw. Crystalloid and albumin in glass survive better. Blood products are still plastic. Freeze-dried plasma can work, but it needs fluid and time.

PFC Podcast · prolongedfieldcare.org · @prolonged_field_care

Takeaways

1. Hypothermia is a whole-team threat, and it outruns a lot of procedures. At these temperatures a down patient, especially a bleeding one, does not have a normal MARCH window on open snow.
2. Tourniquet over the clothing. Then get to heat. Do not strip chest or abdomen on the X. Airway obstruction gets prone positioning. Tactical field care starts in a heated, semi-controlled shelter, not behind a rock.
3. Gloves stay on. Test the tourniquet on the real clothing. Layer bulk can force a second tourniquet. Bare hands at minus forty are a frostbite injury in minutes. Practice the application you will actually do.
4. Cold kills the kit. Batteries die. Plastic IV bags leak when they thaw. Prefer glass vials and glass crystalloid. Freeze-dried plasma is possible if you have fluid and minutes. Prefilled syringes beat ampules with numb fingers.
5. The first shelter is a planning problem, not a terrain feature. You need time and security to pitch a tent and light a stove. Ten minutes down at minus twenty-five was enough to drop consciousness in a non-trauma patient. Wool, a stove you can start in mittens, and a tent you can pitch fast are medical equipment.

Chapters

• 00:19 Thomas — Danish SOF medic, anesthesiologist, Brightbird, Greenland
• 03:03 How extreme cold changes TCCC

• 06:08 Hypothermia plus injury, frozen fluids, dead batteries
• 06:43 Treatment on the snow makes him colder, coagulopathic, acidotic
• 07:55 Hypothermia is patient care and a team threat
• 08:16 Tactical field care waits for a heated shelter
• 08:48 MARCH on the X: hemorrhage first, clothing in the way

• 12:03 Do not start full MARCH until the environment is semi-controlled
• 14:01 Tourniquet over the clothing, prone if the airway is obstructed

• 22:00 Vapor barrier first, stop further heat loss
• 24:00 Tent up, stove running, then the secondary work
• 28:00 Warming drugs against the body
• 32:00 Cold drugs and product degradation
• 36:00 What cold does to the kit outside
• 37:27 Ketamine, morphine, prefilled syringes, IV antibiotics
• 38:11 Plastic IV bags leak on thaw. Glass crystalloid. Blood is still plastic.
• 38:46 Freeze-dried plasma: possible, needs fluid and time
• 39:26 How far to the first shelter
• 41:21 A tent needs security. Thirty minutes is already long.
• 43:07 Greenland expedition: ten minutes down, consciousness dropping, no new injury
• 45:39 Wool, tested gear, stoves you can light in gloves
• 49:11 Warm at all costs. Hemorrhage because it is fast.
• 49:38 Afghanistan heat versus minus forty

Medics add interventions easily. Prolonged field care is where those interventions start charging rent. Dave walks the unwind.

A cut endotracheal tube used as a cric can come out if the patient no longer needs it. Unhook the bag. Moving air through the tube, following commands, and a normal breathing pattern are good signs. Cuff down: if he cannot breathe around it, edema or a flap may be waiting, and pulling can lose the airway. Suction above the cuff first. Dress the site after. Do not pull the bookmark on a partial responder still in shock just to save narcotic. Uncomfortable and awake beats a lost airway.

Chest-tube logic is the same. Serous output and stable oxygen are a pull conversation. Blood, pus, or a leak plus climbing crepitus means the tube stays. Heimlich is enough for many. Suction, if used, is about 20 cm of water — a straw, not wall suction. No underwater seal is a sucking chest wound you created. A chest wall you cannot seal is bagged. A prophylactic fasciotomy without wound-care capacity can bleed and fluid-shift the patient you were trying to save.

PFC Podcast · prolongedfieldcare.org · @prolonged_field_care

Takeaways

1. A cric can come out if the patient no longer needs it. Positive pressure off, breathing through the tube, follows commands, normal pattern, cuff down and air moving around the tube. Fail that last test and you may be looking at edema or a flap.
2. Suction before you drop the cuff. Dress after you pull. Whatever is sitting on the balloon goes into the lungs. Occlude the site for cough and speech. If he obstructs again, adjuncts first, then back in.
3. Do not trade the airway bookmark for narcotic savings in a partial responder. Shock patients who drop their GCS after you pull are a different problem than the isolated femur you over-sedated. Uncomfortable and awake beats lost airway.
4. Chest tube suction is 20 cm of water, not wall suction. Heimlich is enough for many. Serous and stable oxygen is a pull conversation. Blood, pus, or a kazoo plus climbing crepitus means the tube stays. No seal equals a sucking chest wound you created.
5. Some interventions you should not start if you cannot finish them. An unsealable chest wall is bagged, not endlessly patched. A continuous leak with crepitus is surgical. A prophylactic fasciotomy without wound-care capacity can bleed and fluid-shift a patient you were trying to save.

Chapters

• 01:17 Adding interventions is easy. Unwinding them is the PFC problem.
• 02:17 The oversedated femur: ketamine, narcotic, snoring, cric
• 03:46 Same patient in a trauma bay — RSI, then do they still need the tube?
• 05:19 Yes, you can pull a cric — if the airway is not the problem you are about to recreate

• 06:29 Off the bag, follows commands, breathing pattern
• 07:10 Cuff down: can he breathe around it?

• 09:01 Suction above the cuff before you deflate
• 09:42 Ketamine no-man’s-land between analgesia and sedation
• 10:41 Fentanyl for the cuff, not another snow

• 14:05 If the airway is quiet, leave it until everything else is mitigated
• 14:16 Do not pull the bookmark in a partial responder

• 28:07 What is coming out — serous vs blood vs pus
• 28:30 Empyema tubes that stay for months
• 28:33 Air leak on a Heimlich: kazoo is fine, crepitus is not
• 29:02 SpO2, mental status, oxygen need before a pull
• 29:37 Heimlich vs three-bottle suction

• 30:51 Improvised single-bottle underwater seal
• 31:16 No seal, and you just made a sucking chest wound
• 33:34 Chest wall you cannot seal: positive pressure, or a cric
• 35:41 Finger thor converts tension to open. The tube is a valve and a measuring cup.
• 37:36 Continuous air leak and climbing crepitus — second tube, surgical problem
• 39:25 Sudden crepitus with an advanced airway: dislodged cric vs tracheobronchial injury
• 42:11 Fasciotomy: indication vs the wound you cannot dress

Medics add interventions easily. Prolonged field care is where those interventions start charging rent. Dave walks the unwind.

A cut endotracheal tube used as a cric can come out if the patient no longer needs it. Unhook the bag. Moving air through the tube, following commands, and a normal breathing pattern are good signs. Cuff down: if he cannot breathe around it, edema or a flap may be waiting, and pulling can lose the airway. Suction above the cuff first. Dress the site after. Do not pull the bookmark on a partial responder still in shock just to save narcotic. Uncomfortable and awake beats a lost airway.

Chest-tube logic is the same. Serous output and stable oxygen are a pull conversation. Blood, pus, or a leak plus climbing crepitus means the tube stays. Heimlich is enough for many. Suction, if used, is about 20 cm of water — a straw, not wall suction. No underwater seal is a sucking chest wound you created. A chest wall you cannot seal is bagged. A prophylactic fasciotomy without wound-care capacity can bleed and fluid-shift the patient you were trying to save.

PFC Podcast · prolongedfieldcare.org · @prolonged_field_care

Takeaways

1. A cric can come out if the patient no longer needs it. Positive pressure off, breathing through the tube, follows commands, normal pattern, cuff down and air moving around the tube. Fail that last test and you may be looking at edema or a flap.
2. Suction before you drop the cuff. Dress after you pull. Whatever is sitting on the balloon goes into the lungs. Occlude the site for cough and speech. If he obstructs again, adjuncts first, then back in.
3. Do not trade the airway bookmark for narcotic savings in a partial responder. Shock patients who drop their GCS after you pull are a different problem than the isolated femur you over-sedated. Uncomfortable and awake beats lost airway.
4. Chest tube suction is 20 cm of water, not wall suction. Heimlich is enough for many. Serous and stable oxygen is a pull conversation. Blood, pus, or a kazoo plus climbing crepitus means the tube stays. No seal equals a sucking chest wound you created.
5. Some interventions you should not start if you cannot finish them. An unsealable chest wall is bagged, not endlessly patched. A continuous leak with crepitus is surgical. A prophylactic fasciotomy without wound-care capacity can bleed and fluid-shift a patient you were trying to save.

Chapters

• 01:17 Adding interventions is easy. Unwinding them is the PFC problem.
• 02:17 The oversedated femur: ketamine, narcotic, snoring, cric
• 03:46 Same patient in a trauma bay — RSI, then do they still need the tube?
• 05:19 Yes, you can pull a cric — if the airway is not the problem you are about to recreate

• 06:29 Off the bag, follows commands, breathing pattern
• 07:10 Cuff down: can he breathe around it?

• 09:01 Suction above the cuff before you deflate
• 09:42 Ketamine no-man’s-land between analgesia and sedation
• 10:41 Fentanyl for the cuff, not another snow

• 14:05 If the airway is quiet, leave it until everything else is mitigated
• 14:16 Do not pull the bookmark in a partial responder

• 28:07 What is coming out — serous vs blood vs pus
• 28:30 Empyema tubes that stay for months
• 28:33 Air leak on a Heimlich: kazoo is fine, crepitus is not
• 29:02 SpO2, mental status, oxygen need before a pull
• 29:37 Heimlich vs three-bottle suction

• 30:51 Improvised single-bottle underwater seal
• 31:16 No seal, and you just made a sucking chest wound
• 33:34 Chest wall you cannot seal: positive pressure, or a cric
• 35:41 Finger thor converts tension to open. The tube is a valve and a measuring cup.
• 37:36 Continuous air leak and climbing crepitus — second tube, surgical problem
• 39:25 Sudden crepitus with an advanced airway: dislodged cric vs tracheobronchial injury
• 42:11 Fasciotomy: indication vs the wound you cannot dress

The internet will tell you how to “win” a VA claim. Almost none of it is how the exam is actually written.

Will spent 11 years Navy EOD, 9 as a SOF medic, and now sits as a National Guard battalion PA. In the middle he worked the other side of the table: third-party C&P exams. Meet the veteran. Fill the cookie-cutter form. Ship it to the VA actuaries. He never got Genesis. He got whatever dump the system decided was fit to send — problem lists, notes, radiology reports, and every PHA where you checked “no” to stay deployable.

What the examiner is hunting: a diagnosis, a nexus event, and a physical that matches the story. Range of motion. Special tests. Flare-ups. Work. ADLs. If they only asked questions and never touched you, that exam is incomplete. Say so.

SOF and aviation make this worse on purpose. Pipelines punish honesty. Team medics hand out diclofenac and toradol and skip the note so the guy keeps special duty pay. That is loyalty on Friday and a missing nexus on the way out.

Will’s practical kit: be honest on the late-career PHA. Print the DD-214s, V-device awards, schools, and the pages that prove exposure — because the current MOS on the screen may say PA while the tinnitus came from being an 18D. You have 10–15 minutes per condition. Do not make them scroll 2,000 pages.

Read 38 U.S.C. § 1155. Use VA.gov. Ask the teammates who already finished the process.

prolongedfieldcare.org | @prolonged_field_care | PFC Podcast

Top 5 takeaways

1. The examiner is not in your EHR. They get a curated PDF. If the note, x-ray report, or PHA is not in that dump, it does not exist that day unless you hand it to them.
2. Late-career PHAs are evidence. Battalion medicine may ignore them. The VA file does not. Stop auto-checking “no.”
3. Nexus plus diagnosis plus a matching physical. No in-service diagnosis makes the hill steeper. “Audio has to match the video” — a perfect straight-leg raise after a “debilitating” claim is a problem.
4. SOF culture writes the denial years early. Off-book gel and ketorolac keep people on the team and delete the paper trail. The C&P form cannot rate what was never documented.
5. Run the exam like a 15-minute hit. Tab DD-214s, awards, schools, and the pages for this appointment. Current MOS can hide prior blast and gunship time. C&P staff are QTC/Leidos contractors, not VA raters.

Chapters

• 00:21 Will: EOD, SOF medic, Guard battalion PA
• 01:03 Third-party VA examiner — what the job actually was
• 02:05 38 U.S.C. § 1155, Reddit, do the homework
• 03:03 Active duty TAP vs Guard/Reserve fog
• 03:33 Guard can file after first enlistment — and drill at 100% with offset
• 04:13 What the evaluator actually reads
• 04:40 No Genesis. You get the dump they send.
• 05:17 Those “no” PHAs are in the file
• 05:52 Cookie-cutter exams, history, nexus, physical
• 06:45 If they never laid hands on you, the exam is incomplete
• 07:30 Be your own advocate — diagnosis first
• 08:18 SOF and pilots under-report to stay in the pipeline
• 09:11 Off-book team medicine: gel, toradol, no note
• 10:00 Confirm the injury, grade the injury
• 10:34 Audio has to match the video
• 31:07 “I’m fine” is not the same as pre-service baseline
• 31:51 Examiner is not your enemy and not your lawyer
• 32:17 10–15 minutes per condition — they will leave value on the table
• 33:06 1,500–3,000 page PDF. Awards and 214s get buried.
• 33:44 Build the packet: 214s, V-device awards, schools, EIB
• 34:54 Print the pages for this exam so they stop scrolling
• 35:56 Current MOS can hide prior SOF noise and blast
• 37:27 Where to go: the Code, VA.gov — who to skip: paid mills
• 39:16 C&P is QTC / Leidos. They cannot reach into a record you do not bring.
• 40:45 Close: it matters for the family

Listen before you walk into the C&P

This is education from one former examiner, not legal advice and not a how-to for inflating a claim. Use VA.gov and a VSO for the filing itself.

Most of us were taught START, the sieve, RAMP, DIME, P1–P3. Andrew — EM physician on a small surgical team out of Fort Liberty — used none of it the night a helicopter went down with 22 people on board.

The rest of his medical team could not walk. Dust, firelight, yelling. Thirty-to-sixty seconds per patient on a linear algorithm is ten minutes before you reach number ten. People die of massive hemorrhage and lost airway in that window.

So he ran a binary pass: dying now or not. Blood sweep. “Take a deep breath.” Pulse. Ten to fifteen seconds. Keep a mental list of who leaves first. He got through about twelve before other medics arrived. He never reached the massive bleeder — a non-medic first responder did. That is the point.

Rick Hines puts the doctrine next to the wreckage. Triage is continuous, not a one-and-done sort. The most senior medical person is often the worst person to own the sort if they should be operating. Algorithms used after the first pass are training tools — studies put accuracy around or under 50 percent.

Training has to match that. Four casualties before twenty-two. Global endpoints, not a perfect score on every manikin. Delayed birds. Command decisions. Unit buy-in, not a tourniquet-and-check-the-block.

No perfect MASCAL. You were already behind when it started.

Listen: PFC Podcast · prolongedfieldcare.org · @prolonged_field_care

Top 5 takeaways

1. First contact is binary. Dying now / not dying now. Blood sweep, air movement, pulse. 10–15 seconds. Do not spend a minute running START on patient one while patient ten bleeds out.
2. Then deliberate triage. After LSIs and a move to the CCP: urgent / priority / routine (what TCCC/CoTCCC are leaning toward). Expectant exists when resources force it — not on the first pass.
3. Move, treat, transport. Rush’s three verbs beat a four-color card at the wreck. Get off the X, stop hemorrhage and airway loss, get them to the next level.
4. The senior clinician should not automatically own the sort. If they are the surgeon, someone else runs triage. Non-medic first responders are part of the system — Andrew never reached the massive hemorrhage; someone else did.
5. Train the real constraints. Nail four before you role-play twenty-two. Score the lane on whether life threats were found, blood got to shock, accountability held, and evac was prioritized — not whether every individual critical-action list was perfect. Delay the bird. Make the commander choose.

Chapters

• 00:00 Disclaimer and welcome
• 00:20 Andrew Shafrina intro — EM, small surgical team, Fort Liberty
• 01:23 Why most of us never actually practiced triage
• 02:14 Categories: START, sieve, NATO — four bins plus expectant
• 04:10 Why linear algorithms are too slow at the point of injury
• 04:32 The crash: 22 onboard, medical team down, one provider
• 05:39 The 10–15 second pass — blood sweep, deep breath, pulse
• 06:09 Rush, Shackelford, Remley, Hines — binary is what people actually do
• 06:50 Move, treat, transport
• 08:07 What “stable” meant that night — not P1/P2/P3
• 08:51 Twelve patients in five minutes — and he still missed the bleeder
• 10:01 Triage is continuous, not one-and-done
• 10:36 Do not burn the surgeon on the sort
• 11:11 MASCAL means you are already overwhelmed
• 12:06 Put non-medics to work
• 12:43 Evac categories vs who actually needs an OR
• 13:45 First-pass binary, then UPR at the CCP
• 14:14 Algorithms as training tools — accuracy ~50% or worse
• 47:06 Train to global endpoints, not perfect individual checklists
• 48:08 Can you handle four? Then scale.
• 49:09 Rick: six dead, seventeen wounded, no bird, they drove them out
• 52:23 King for a day: two-phase triage + basics
• 53:50 There is no right way — only best with what you have
• 54:18 Put MASCAL inside unit drills, not isolated medic lanes
• 55:22 Scare the staff honestly — risk, delayed evac, command decisions