Legacy Advanced Medical & TCCC (A3 KAT)

Squad Medic Responsibilities;

Conduct rapid and efficient assessments of casualties and triage.
Address any emergent conditions in the field.
Manage the supply of medical equipment for your fireteams of responsibility

This document will address these responsibilities and ensure familiarity with the concepts of ACE advanced medical as it has been adapted to Coalition™ gameplay.

Example Medical Treatment Step-By-Step

Reference

Part 1: Assessment

Assess the patient. Easy way to remember is the acronym "ABC" for "Airway", "Breathing", and "Circulation".

Medic: Attach a Pulse Oximeter or AED X-series to monitor vitals.
- Generic AED does NOT have vitals monitoring
- Must be attached to a body part that will not be tourniqueted.

Assess Airway

Assessed with Head > Check Airway
- Airway may be Clear, Occluded, Obstructed, or both Occluded and Obstructed.

Assess Breathing

Assessed with Head > Check Cyanosis
- Cyanosis may be None, Slight, Mild, or Severe
  - Medics and vitals-monitoring equipment can obtain a specific oxygen saturation reading.
    - Ideal SpO2 level is 100%.
    - Minimum SpO2 level for recovery is 85%
    - SpO2 level leading to unconsciousness is 75%
    - SpO2 level leading to death is 65%

Assess Circulation

Assess Bleeding, Pulse, and Blood Pressure.
- Bleeding
  - Select a Body Part to assess physical injuries.
  - Identify presence of a Pneumothorax or Hemothorax injury on the Chest
- Pulse
  - Assessed with Body Part > Check Pulse
  - Medics and vitals-monitoring equipment can obtain a specific heart rate reading:
    - No Heart Rate is 0 bpm
    - Low Heart Rate is 40 bpm and below
    - Ideal Heart Rate is 80 bpm
    - High Heart Rate is 120 bpm and above
- Blood Pressure
  - Assessed with Body Part > Check Blood Pressure
  - Medics and vitals-monitoring equipment can obtain a specific blood pressure reading (systolic/diastolic):
    - No Blood Pressure is 20/0 mmHg
    - Low Blood Pressure is below 90/60 mmHg
    - Ideal Blood Pressure is 120/80 mmHg
    - High Blood Pressure is above 140/90 mmHg

Part 2: Treatment

Treat the patient in the order of "CAB", or "Circulation", then "Airways", then "Breathing".

Treat Circulation

Stop Bleeding
- If all injuries are equal, prioritize Head/Chest injuries over limb injuries
- Tourniquet limbs with multiple injuries
- General guideline to injury bleed rate:
  - Average/Fast Bleeding: Avulsions, Cuts, Velocity Wounds
  - Slow Bleeding: Abrasions, Bruises, Crushes, Lacerations, Puncture Wounds
  - No Bleeding: Bruises, Fractures
  - Large injuries bleed faster than medium injuries which bleed faster than small injuries
- If assessment found a Pneumothorax or Hemothorax injury:
  - Call for a Medic if you are not one.
  - Medic:
    - Pneumothorax: Apply chest seal
    - Hemothorax: Apply chest seal and drain fluid
Blood Transfusion if Necessary
- If a "fatal amount of blood was lost" (more than 2400mL lost):
  - Call for a Medic if you are not one.
  - Medic: Administer 1000mL of blood or plasma to a non-tourniqueted body part.
    - Need to reach "lost a lot of blood" (less than 2400mL lost) to be able to re-establish heart rate
Reestablish Heart Rate
- If no pulse was found during assessment (Patient is in cardiac arrest):
  - Perform CPR until heart rate found.
    - Medic: If in possession of an AED, check rhythm between steps to determine if shock advised.
  - Ensure you are checking the pulse on a non-tourniqueted body part.
- If only a low heart rate was found, monitor the Patient's pulse in case they enter cardiac arrest
If assessment found no immediate Airway Occlusion/Obstruction and no Cyanosis/Low SpO2 level:
- Bandage any wounds remaining on tourniqueted limbs, then remove tourniquets
- Blood pressure may change as tourniquets are removed
- Splint broken bones
- Continue to administer blood until "Lost Some Blood" (less than 900mL lost) status reached

Treat Airway:

Re-assess airways if some time has passed since initial assessment.
If Airway is Occluded:
- Perform head turning (Head > Head Turning) until occulusion is mitigated.
  - Medic: Can instead use the Accuvac to mitigate occlusion.
If Airway is Obstructed:
- Perform head hyperextension (Head > Hyperextension Head) to clear obstruction.
- Must physically stay near patient to maintain hyperextension.
If Airways were/are now clear:
- Medic: Can use the King LT (prevents further obstructions and occlusions) or the Guedal Tube (prevents further obstructions).
  - King LTs and Guedal Tubes are single-use only, and are not required to use provided regular monitoring of the Patient's airways.

Treat Breathing:

Re-assess breathing if some time has passed since initial assessment.
If Cyanosis is present (or SpO2 levels below 90%):
- Check if airways became occluded or obstructed again.
- Check for presence of Pneumothorax or Hemothorax injury on the chest.
- If no problem can be found, monitor patient oxygen saturation levels to ensure they are rising
- SpO2 levels will have decreased temporarily if the heart rate fell below 20bpm

Part 3: Post Treatment:

Continue to monitor patient to ensure pulse continues to be present.
Put Patient in Recovery Position if no King LT or Guedal Tube was inserted.
- Recovery Position prevents further occlusions and obstructions.
- Recovery Position prevents CPR/chest seal application/AEDs/fluid draining so ensure those are done beforehand
- Patients with only the Guedal Tube need to be monitored for occlusion reoccuring
Medic Magic:
- Medics have a suite of more advanced medication to speed up a patient's recovery
  - Goal is to reach "Ideal" vital levels (80 bpm, 120/80 mmHg) through medication affecting heart rate, blood pressure, and pain.
  - Different medics will have their own "flavor" in how they treat their patients.
  - Improper use of medication may result in worsening a patient's condition.
  - Special Medication Effects:
    - Pain Suppressors: Morphine, Painkillers, Ketamine, Fentanyl, Nalbuphine, Etomidate
    - Medication Affecting Wake-Up/Recovery:
      - Epinephrine increases wake-up chances.
      - Ammonium Carbonate forces a wake-up attempt.
    - Medication Affecting Circulation:
      - Norepinephrine slows down bleeding but also slows down transfusions.
      - Phenylephrine slows down bleeding/transfusions even more than Norepinephrine.
      - Nitroglycerin speeds up transfusions but also speeds up bleeding.
    - Pain Suppressors Reducing Both Heart Rate and Blood Pressure:
      - Fentanyl suppresses pain better than Morphine.
      - Nalbuphine suppresses pain worse than Morphine.
      - Morphine lasts twice as long in the body compared to Fentanyl/Nalbuphine.
      - Fentanyl can only be used twice before overdose; Morphine/Nalbuphine can be used four times.
      - Naloxone can treat a Morphine/Fentanyl/Nalbuphine overdose, clears their effects in a 1:1 dose ratio.
    - Surgery-Related Medication (Surgery isn't enabled in our modpack):
      - Lorazepam instantly forces a patient into unconsciousness, may cause sudden heart rate drop/cardiac arrest.
      - Atropine can counter the sudden heart rate drop.
      - Etomidate suppresses the pain during surgery.
      - Flumazenil removes Lorazepam from the patient.
  - General table of Medication and their effects (bold are common medications) can be found in the below table.

	Increases HR	Decreases HR	No HR Effect
Increases BP	Epinephrine, Norepinephrine, Ketamine	Phenylephrine
Decreases BP	Nitroglycerin, Painkillers	Morphine, Adenosine, Fentanyl, Nalbuphine	Lorazepam
No BP Effect	Ammonium Carbonate, Atropine	Etomidate

Further detail on why/how/what is going on when doing the above steps, can be found below.

Patient Presentation & Assessment

General terminology

Hypotensive - Low blood pressure, defined as a systolic pressure less than 90mmHg and/or a diastolic pressure less than 60mmHg.
Normotensive - Normal blood pressure (around 120/80mmHg).
Hypertensive - High blood pressure, defined as a systolic pressure greater than 140mmHg and/or a diastolic pressure greater than 90mmHg.
Bradycardia - Low pulse, threshold is generally 60bpm but becomes symptomatic in arma in the 30-40bpm range.
Tachycardia - High pulse, threshold is generally 100bpm but becomes symptomatic in arma in the 150bpm range.
Vasodilation - The widening of blood vessels to decrease blood-pressure.
Vasoconstriction - The narrowing of blood vessels to increase blood-pressure

In its present condition the ACE medical system we have adapted provides for a singular "normal" patient presentation. This comprises a pulse of around 80bpm and a blood-pressure of 120/80mmHg. These metrics will fluctuate with increased activity and injury. While pulse fluctuation is straightforward there is reason to outline blood-pressure here.

Pulse & Blood Pressure

Blood Pressure is read as the top number (the numerator) over the bottom number (the denominator), that is around one-hundred and twenty over eighty normally. These are your systolic and diastolic pressures respectively. Systolic pressure, as the name implies, is the arterial pressure of blood in the body as it is circulated by the contraction of the heart. Diastolic refers to the pressure between contractions of the heart. Thus as "beats per minute" increase (again normal is 80bpm in Arma) the pressure will hover around 120/80 millimetres of mercury (mmHg). This is important in rectifying blood loss and in considering morphine administration. As the casualty's injury exsanguinates, or bleeds, the pressure will drop - although if the pulse is high enough it may fluctuate upwards, this features when considering the administration of epinephrine.

Essentially think of the heart as a pump, because it is, and the pressures measured as changing with the increased or decreased volume of fluid in the system as it relates to the contractility of the heart pump. So following the Frank-Starling Law as we increase volume with fluids administered in the field, we increase blood pressure, but as we decrease heart rate (pulse) we lose blood-pressure.

Symptoms

As is to be expected, wounds accelerate the loss of blood and fluctuation in those circulatory metrics can affect the player's health. In-game, as pulse rises into tachycardic ranges or blood-pressure enters hypertensive ranges the player will begin to hear a fast heartbeat in their ears. Likewise, as the pulse decreases to bradycardic ranges or the blood-pressure drops into hypotensive ranges the heart-rate sound in the player's ears will drop in intensity and tempo. In the former's case this is more of an annoyance, but in the latter case it can be the undoing of the player. In the event another wound is sustained by the bradycardic or hypotensive patient they are more likely to be knocked unconscious or to die outright. Further, in hypotensive ranges the screen will grey and colour will drain from the game-world for the player.

Broken limbs similarly hinder the player. Broken arms will affect recoil management and weapon manipulation. Broken legs will near incapacitate the player's movement requiring prompt splinting. Splinting is not reliant on the bandaging of the limb and may be delayed until the more acute injuries are addressed.

Lastly, pain is often a side-affect of injury. The pain effects of ACE medical are either a pulsing blur of cinematic aberration or a white flashing at the peripheries of the screen. This can be modulated in a player's settings.

Interventions

Tools of the Trade

15x elastic bandages best used for avulsions, lacerations and crushed tissues. See figure X
15x packing bandages best used for penetrating injuries. See figure X
10x splints for broken bones. See figure X
2x tourniquets for stemming the flow of blood. See figure X
12x epinephrine doses for increasing heart-rate and "coding" patients. See figure X
12x morphine doses for analgesia and in a pinch hypertension correction. See figure X
5x body-bags for the management of the deceased See figure X

In this section we'll assume an understanding of the applications of elastic and packing bandages covered in Basic Medical Information/TCCC. As such we cover primarily pharmacological interventions available in ACE medical starting with the things you're generally issued and terminating with the items found in Casualty Collection MASH tents and Field Hospitals.

||Note, Tourniquets will occlude the administration of any of the following. You must administer fluids or drugs peripherally (via limbs) that are not occluded.

Epinephrine is a vasoconstrictor. In-game epi should be employed if the pulse drops into or below the 70bpm range or systolic blood-pressure falls below 90mmHg and symptoms are present. In the same vein unconscious patients, covered in "Acute Care & Resuscitation" section below require epinephrine to increase the contractility of the heart.

Morphine in-game has rather exacerbated vasodilatory effects and is used primarily for analgesia. Though it is often requested by the general infantry one must be careful. There is no naloxone to reverse its affects. My rule of thumb is a systolic pressure greater than or equal to 100mmHg in an otherwise stable patient. Anything less than that and I tell them I'm not comfortable doing so. If the player's wounds have been addressed and their pain is compromising their ability to function, and they meet the systolic pressure threshold, morphine as indicated for pain may be administered without concern. Else they need their pressure increased. In a pinch you can give epi and morphine together although I'd still monitor them.

Atropine was likely added to the game for potential NBC activities because it really doesnt feature elsewhere in the game. In terms of ACLS it is indicated for bradycardia, although not everyone responds to it in real life. I am unsure as to how effective it is in Arma as that discrepancy is likely not modelled - so in cases of bradycardia epinephrine is preferable but atropine is an alternative.

Adenosine is indicated for narrow PSVT/SVT and wide QRS tachycardia, adenosine in-game appears to have been added for their stamina system. It is not used by Coalition, not least of all because we've no NS flushes and second because we're not converting irregular rhythms as we would with adenosine.

Fluids such as Plasma, Blood and Saline ("Normal Saline" or "NS", a 0.9% NaCl solution) are available for volume replacement. Lactated Ringers is, for some ungodly reason, not an available crystalloid. Unfortunately ACE medical doesnt really model the clotting cascade so all fluids are technically the same. They are provided in 250mL, 500mL (known as a "unit" of fluid), and 1000mL volumes. A good rule of thumb is to infuse 2L in anyone with a systolic pressure less than 70mmHg and has sustained significant injuries. There have been times, in acute care situations, I have hung a litre while another individual bandages so as to begin fluid resuscitation as soon as possible. Ultimately, you're replacing fluids lost with the goal of reaching a systolic over 100mmHg or as close to 120/80mmHg as possible.

Acute Care & Resuscitation

The most interesting moments you receive as a medic in Coalition Arma are critical casualties. These are essentially a "code blue" in civilian medicine. Someone on the field of battle has sustained injuries so extreme that they are unconscious. This could be due to incredible pain, it could be due to significant fluid loss, but it's your job to respond to and manage that situation.

First, secure the scene. If applicable snag an adjacent squad-mate to begin chest compressions (CPR). Else snag someone to pull security depending on where the casualty is being treated. You dont want enemy walking up on you mid treatment.
- When in cardiac arrest a timer will begin. When it runs down the patient will die. When one completes a round of CPR however it will reset the timer, buying the intervening medical personnel time.
Tourniquetting wounds is often faster than bandaging multiple injuries. This will buy time, although if it's merely a singular wound to be addressed it may be best to do that first. Remember tourniquets will impeded drug and fluid administration.
Bandage from chest and head wounds to the extremities.
Pulse check. These should be completed every 30-60seconds in-game as the time is rather accelerated compared to real life. Remember the vitals numbers you're seeking to return to (80bpm, 120/80mmHg blood-pressure).
- Note tourniquets will also render a "No Heart Rate Found" message, see figure XYZ
Begin epinephrine as you've most or all wounds bandaged. It will take time to take effect but will rapidly increase the rate of the patient's recovery.
Begin fluid replacement depending on the blood-pressure reading you got previously.
Lastly, consider shock and pain.
- ACE Medical will add a degree of shock for high levels of pain. It may be that the patient is unconscious because of this and morphine will thus be indicated, but as noted above this will affect pulse and blood-pressure. Epinephrine and fluids may be indicated to resist the side-affects of morphine.