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Hello, my name is Doctor David Lee GP Mountain Rescue and expedition doctor uh alongside faculty with Endeavor Medical. I'm going to take you through a short presentation on prolonged field care. The objectives for this session is for you to understand what prolonged field care includes and provide you with some tools in case you're ever in a position where you need to deploy them. So in case you've never heard of it, prolonged field care was born out of the US Special Forces sometimes called austere emergency care. It focuses on looking after casualties for extended periods of time whilst awaiting the next definitive step in the patient care pathway. Unfortunately, this is a growing problem, not just in the military but also in UK civilian practice with ambulance crews deploying these techniques when looking after patients outside of emergency departments. The specialized medical standards published in 2020 highlighted 10 key areas that needed to be managed during prolonged field care. The minimum better best framework included here on the slide has gained two additional categories, communication and logistics added for civilian use as they were inherent in military practice, but let obvious and frequently missed. We'll dive into each of these in turn. Now, here we have the first six of the core capabilities for prolonged field gap with the wilderness medicine. We are limited in our resources. And what we can achieve. The key principle is that whatever we do has to be effective and safe, good fundamentals are the key to good outcomes. And no amount of lightweight Gucci kit is gonna make up for poor levels of basic skills that are applied. Well, the second six capabilities include some of the wider expedition and activity planning. A thorough risk assessment will have determined what packaging and retrieval kit you decide to carry and what communication needs you have available and ask the question, what happens if they fail? What's your back up? Being aware of local rescue services, local hospitals and the transport links between them are imperative for any group venturing internationally. Under the British standards of 8848, we'll also be diving a little bit more into the nursing care shortly to remember those 12 capabilities is a bit unwieldly when you've just treated a casualty. So we're going to work through a few mnemonics starting with hit man. This was designed to give a more consistent structure to prolonged field care management. Following your primary survey, you'll naturally roll into your head to toe assessment or secondary survey. The longer the delay to definitive care, the more thorough this will become for infection. We're thinking about wounds all wounds should be washed out. Ideally with 2 L of potable, drinkable water. They then need dressing. Ideally with a noninherent dressing and reviewed every 12 hours to catch any infection, early tubes and tidy. Depend on what kit you're carrying, but act as a reminder to keep your workspace organized and the area. Clean medicines act as your drug ground. Any more analgesia required or any regular medication that the patient needs for chronic conditions. For example, epilepsy, meds require specific dosing to maintain their efficacy. So be aware and put it into your plan. Administration is a documentation and is typically quite poorly done. My preference is to put a note on my phone and dictate a summary as I go along to provide contemporary updates of my actions and treatments, then transcribe that to the formal documentation when the time allows as for nursing care, all it has its own pneumonic, all of its own. So for nursing care, we have the er very nice sheep vomit as our mnemonic. So we'll work through the 10 items here and give some advice on things that you can do to look after your casualty while awaiting that next step of care, starting with skin protection. So looking for any insect bites, any breaks in the skin, what we want to do is keep it healthy, avoid any ulcers, pressure sores, any damage that's going to cause another wound to develop. So even things like sunburn or becoming cold we need to look after, look after that skin uh as it is an effective barrier for keeping infections out and keeping fluid inside the body. The same with hypo and hyperthermia for casualties that are getting too hot or too cold. We again need to support that environment and use everything that we've learned in the heat illnesses module to look after our casualties and maintain a good temperature for them. One of the ees elevating the head, so we're looking to sit, the patient up. Patients should only be lying completely fat. If it's clinically necessary, it's much better for the morale. They'll feel better being able to talk to people, they'll get better chest movement and less likely to get chest infections. People are just happier and safer with them. Sat up also helps with head injuries by helping some of the drainage of the cerebral spinal fluid um to again improve some of the pressures and maintaining their airway much better with them upright. So if you can sit them, prop them up, we're aiming for a minimum of 30 degrees. Ok. Next day exercises. And we're thinking about every eight hours, we need to have moved every joint, hands, wrists, elbows, shoulders, neck, back, pelvis, knees, ankles, toes, getting everything moving every eight hours to stop anything seizing up and keeping the rest of the the healthy parts of the patient remaining healthy. And then last one is the pressure relief. It only takes about half an hour on a hard surface for some of the skin to break down to create ulcers, create wounds. So every two hours, we'd be encouraging the casualty to roll, to shift, to move everything that you will have done naturally while looking after them to help maintain that skin and stop anything from breaking down on to the second five, starting with the V vomit and the vital signs. So we'd be looking to record the patient's heart rate, respiratory rate. Any other observations that you can get every half an hour to an hour. This is a chance for us to recognize any deterioration and intervene early. There are structured charts that we use within hospitals and within ambulance services and based around the early warning scores. So the national early warning score two is the current one that's in use and gives sort of normal ranges for adult observations. They're vital signs and a useful thing for you to be keeping track of and record throughout your patient's care. The next step, thinking about the oral hygiene, people are at risk of mouth ulcers of their lips becoming sore and cracked. This in turn will impact their ability to eat and to drink and lower morale and lower mood. So protecting the lips with sort of Vaseline lip balm, keeping the mouth hydrated, but also brushing teeth and and yeah, looking, looking after that mouth area to stop anything deteriorating. The next step is massage. Following on from our kind of exercises that we were doing earlier. The massage is there focusing on the calves to stop any blood clots forming. When someone's unwell, their blood becomes much more sticky. And if it's stagnant with them out with them, not moving, then using massage to move that blood around will reduce the risk of them developing any clots and any consequences from that. The eye are the ins and outs, the hydration and the nutrition we wanna get about 30 mil per kilo for 24 hours into an individual to keep them nicely hydrated. They can do that orally and we will take in some salts, things like potassium and sodium alongside what they drink, but also within their food, within their food, aiming for a minimum of 50 to 100 g of glucose per 24 hours to make sure that they don't enter any starvation pattern. So encouraging food as you as you can to again, help with repair and help with their recovery. When it comes to passing urine, they might need help, might need sort of turns to help going to the toilet using bedpans or getting out the same using bottles to pass urine. We're expecting naught 0.5 to one ml per kilo per hour of urine output. If that's less, it's likely that they need to drink more to match the environment that they're in. The last t is turn to what we really mean is again, shifting position, encouraging deep breaths and encouraging coughing. Ideally, if you can build this into a routine where they're doing these exercises 10 times every hour, giving themselves purpose, giving themselves motivation and the focus on recovery and getting help, then we'll get better outcomes in the long run. What I've taken a picture of here is one of the um, booklets that I take with me when I go on expedition to record these. So in a prolonged field care situation has the sort of the pneumonics that we've discussed already alongside a sheet for me to be able to record the details of my care of the casualties as they go through just the importance of good administration to record the details. So that when you pass on that to the to the definitive care, one example that I was involved in was in the um sort of the caves around Brecon beacons in which it's taken over 60 hours for over 200 sort of rescuers to extricate a gentleman out of the cave, the level of administration and details that needed to be recorded to support the handover of care between professionals during that sort of three days. Evacuation just shows the importance of starting well, so that people can follow on and know exactly what's been happening. So that's the end of the prolonged field care talk. Um If you have any questions or want any further information, then please get in touch with endeavor medical. Um We look forward to, to helping you with your studies and look forward to seeing you on the course. Again, here are the references. If there's anything that's caught your eye that you want to look more into, then there's a couple of references there from sort of military medicine practice and the sort of origins of prolonged field care alongside a podcast by recess room um caring in the broken system that explore um O Kelly's article on prolonged field care in paramedic practice. All visiting that hit man and sheep vomit, pneumonics. Bye for now.