By Hospital Corpsman 2nd Class (FMF) Justin P. Schneider, Naval Expeditionary Medical Training Institute
One of the greatest opportunities I have had in my naval career has been to serve as a hospital corpsman assigned with Marines as a company line corpsman. I am trusted to treat and care for Marines on a daily basis.
From a training evolution, to combat operations treating wounded service members from gunshot wounds, to traumatic brain injuries (TBI) caused by explosive blast, the demands are tremendous as is the responsibility to provide the best care in potential life or death situations.
In direct support of this responsibility, I experienced one of my greatest opportunities – attending the Tactical Combat Casualty Care Course (TCCC), and ultimately became a TCCC instructor at Naval Expeditionary Medical Training Institute (NEMTI) at Camp Pendleton, Calif.
TCCC helps provide the knowledge and skills to provide medical care in a combat environment. TCCC is taught in three phases. During the first phase – care under fire, treatment is administered under hostile fire or at the site of an accident, known as the “X,” while still completing the mission.
During the second phase – tactical field care, a provider administers the bulk of the interventions to treat a patient’s injuries in a safer environment.
In the last phase – tactical evacuation, a patient is transported to the next echelon of care while additional medical and tactical assets may assist.
At NEMTI, we also teach full head-to-toe assessment using the patient/provider safety, massive hemorrhage, airway, respirations, circulation, head/hypothermia, and pain management (P-MARCH-P) algorithm. The algorithm addresses major life-threatening injuries first, and puts the steps in an easy to remember system that can be used by the most junior corpsmen or medics, up to the most experienced trauma surgeon.
Using P-MARCH-P algorithm, the signs and symptoms of Traumatic Brain Injuries (TBI) are identified during the head assessment. The medical provider assesses and evaluates the patient’s skull and facial bones. We teach students to go through the basic deformities, contusions, abrasions, punctures, burns, tenderness, lacerations, and swelling (DCAP-BTLS) followed by a thorough inspections of the eyes. The eyes are inspected for pupils equal round reactive to light plus accommodation (PERRL+A) and extra-ocular muscle intact (EOMI) tests. Any abnormal findings are indications of a possible traumatic brain injury.
The ears are inspected for signs of bleeding. If any blood is identified, the field expedient “halo” test is performed. A positive halo test, when the cerebral spinal fluid separates from the blood, indicates the presence of cerebral spinal fluid, an indication of head trauma, and a possible TBI. Swelling behind the ears, called battle signs, or bruising around the eyes, known as raccoon eyes, indicates possible skull fracture and may suggest underlying brain trauma.
All signs and symptoms a provider looks for during the head assessment are to identify possible traumatic brain injuries, and while the corpsman on the ground cannot diagnose and further treat the injury, there are a few precautions that can be taken. For example, TCCC teaches that if a TBI is suspected, the provider must be extremely aware of the fluids being administered. Students are taught to get the patient’s systolic blood pressure to 80/P then titrate or stop fluids to reduce the chances of increasing intracranial pressure. We also mention that a dosage of 100cc of a hypertonic solution administered intravenously can possibly help with decreasing ICP.
The best thing a provider can do for patients who exhibit signs and symptoms of a TBI is to evacuate them immediately. If supplemental oxygen is available, it is highly recommended to begin therapy and monitor their oxygen levels. Also, a suspected TBI can limit the types of medications a patient can receive without causing further damage. Such examples are ketamine, fentanyl citrate, and morphine. These medications can change mental status and suppress cardiovascular and respiratory rate.
Providers are taught to look for “red flags” such as witnessed loss of consciousness, altered mental status, headaches or vomiting. Ultimately the goal we teach is for providers to identify signs and symptoms of a TBI and evacuate their patients as quickly and efficiently as possible to the next echelon of care.
I am truly grateful that TCCC gave me the ability to learn, apply and ultimately teach others how to recognize the signs and symptoms of TBI.
I’m Hospital Corpsman 2nd Class Justin Schneider. I am Navy Medicine.