Prolonged Field Care Podcast

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

Dennis sits down with Max to walk through hemorrhagic shock the way it actually behaves in young, healthy military-age casualties—not the tidy textbook ladder of Class I–IV. They start with the only split that matters: compensated versus uncompensated. Class I–II means the body is still delivering oxygen to organs. Class III–IV means it is not, and the damage is no longer a simple volume problem.

Max breaks compensation into “gears”: venous reserve first (no vital-sign change), then heart rate, pulse-pressure narrowing from arterial squeeze, contractility, and work of breathing. He stresses why a 40-year-old operator with a resting HR of 50 who hits 80 is already tachycardic, why a diastolic climbing toward 100 is a warning, and why scene blood volume—“How much blood was on the ground?”—is often the most important sentence in the handoff.

They cover why fit casualties can look like Class II, then skip Class III and drop into unconscious Class IV in minutes (Ranger Campbell and similar “walking dead” cases). Decision-making is reduced to two tenets: Is bleeding stopped? What is the trend? Guidelines that wait for SBP <100 will be late in this population. Short pearls close the episode on peds (small volumes, parental mental-status baseline), pregnant patients (left-side IVC, massive reserve then sudden collapse), and elderly (they follow the book but cannot tolerate Class III).

Top 5 takeaways

1. Draw the line between compensated and uncompensated, not between the four classes. Once end-organ perfusion fails, you are not just replacing lost volume—you are treating ischemia, cytokines, electrolyte leak, and reperfusion.
2. Trauma tachycardia is hemorrhage until proven otherwise. Pain, exertion, and combat stress are real, but you do not get to invoke them until you have ruled out bleeding.
3. Pulse pressure and diastolic BP are early windows into how hard the patient is squeezing. A young casualty at 120/100 with a climbing HR and changing affect is already near the cliff even if SBP is still “fine.”
4. Fit operators can stay in Class II on exam until they have lost a lethal volume, then skip Class III. Reassess constantly. Scene blood volume and expanding hematomas matter more than a single SBP number.
5. Two questions drive transfusion in resource-limited care: Do I have hemorrhage control? Is the patient trending the wrong way on two or more data points (HR, pulse pressure, breathing quality, mental status, hematoma size)? One number on a guideline is not a plan.

Chapters

• 00:00 — Intro and disclaimer
• 00:20 — What we’re covering: hemorrhagic shock and when to resuscitate
• 01:12 — Traditional Class I–IV and why textbooks fail in the field
• 03:00 — Compensated vs uncompensated: the only line that matters
• 04:50 — Class I: venous reserve, no vital-sign change
• 08:30 — How much blood was on scene? The handoff question that predicts danger
• 11:15 — Tennis-score memory aid (15 / 30 / 40) and Class I exam
• 16:20 — Operator baselines: HR 80 can already be tachycardia
• 20:00 — Golden rule: trauma tachycardia is bleeding until proven otherwise
• 22:00 — Pulse locations as a crude MAP map (carotid / femoral / radial)
• 27:00 — Why SBP stays normal in compensated shock
• 29:00 — Pulse pressure explained: diastolic rise, not “falling BP”
• 36:00 — Compensation gears: reserve → HR → squeeze → contractility → breathing
• 39:00 — Orthostasis, cap refill, urine output, and mental status as red flags
• 47:00 — Altered mental status: “drunk” from blood loss until proven otherwise
• 51:00 — Class II: all gears on, BP still held
• 59:00 — Class III–IV and why healthy patients blast through Class III
• 1:06:50 — Ranger Campbell and other “walking dead” cases
• 1:11:48 — When to give blood if SBP is still over 100
• 1:13:50 — Tenet 1: Is bleeding stopped? Five spaces that hide volume
• 1:20:40 — Tenet 2: Trend, not a single trigger
• 1:27:50 — Don’t hang a life on one guideline number
• 1:32:40 — Pearls: pediatrics, pregnancy (left side / IVC), elderly

Ben walks Dennis through a six-month plan that became a jungle course for about 200 unpaid resistance volunteers. Vic built the curriculum from TCCC, the Ranger Medic Handbook, and what that force actually needed — then wrote it to their education level, culture, and organization. Supplies moved through the existing network. The first four days were not student training. They were instructor train-up. Then the locals taught. Interpreters shrank. Force multiplication went up. Chiefs owned the schedule because they knew the logistics better than the foreigners.

The five-day basic block — Ranger First Responder flavor, ~150 students, three languages — ran cleaner than the ten-day advanced course. Around day six, the instructors sat in a hut wondering if anyone could action the material. The FTX answered it: recovery mission, collect, treat, triage, evacuate. When words failed, Ben inserted himself into the lane. Watch me. Do as I do.

Then the punchline he brought home to NATO partners in four and a half days: stop making this more complicated than the environment allows. Basics save lives. Teaching is a hard skill and a soft skill. Ego gets you ignored — or worse. Likability moves supplies. Medics still have to influence commanders so casualties do not bog down the assault.

Listen, then steal the method. Not the ego.

⁠prolongedfieldcare.org⁠ | ⁠@prolonged_field_care⁠ | PFC Podcast

Top 5 takeaways:

1. Build a local instructor cadre first. Four days of train-the-trainer, then hand the blocks to them. Less interpreter drag. Real force multiplication.
2. Write the course to the force in front of you. TCCC + Ranger Medic Handbook as the spine. Education level, culture, and org constraints as the cut line. Chiefs own the schedule.
3. Basics scale. Abstraction does not. The 5-day / 150-student / 3-language block worked because it was see-do-act. The 10-day advanced block created the “do they actually get this?” crisis.
4. When comprehension is in doubt, stop talking and enter the lane. Insert yourself. Narrate while you do the work. Show shock. Do not lecture shock.
5. Teaching is an act of love plus influence. Humble competence beats the alpha brief. Medics still owe commanders a clear recommendation — even if the answer is “we’re doing it anyway, figure it out.”

Chapters:

• 00:00 Cold open + why this trip
• 01:08 Six months of planning — you do not show up on a whim
• 01:59 Vic Nigo’s curriculum: TCCC, Ranger Medic Handbook, culture, org
• 02:51 Supply network for ~200 students
• 03:20 Plan vs jungle reality
• 04:01 Four-day instructor train-up and handing the class off
• 04:56 Volunteers, buy-in, and a culture that does not like quitters
• 06:24 Motivation that costs a patch and a thumbs-up
• 07:29 Ukraine militia hunger vs professional-military spoiling
• 08:26 Why train-the-trainer beats you plus an interpreter
• 09:00 What actually broke: hours, land nav, competing requirements
• 09:54 5-day basic / ~150 / 3 languages — the block that worked
• 10:53 10-day advanced — day 6 doubt in the hut
• 11:41 The FTX: recover, collect, treat, triage, evacuate
• 12:30 Teaching tactic: insert yourself, watch me, do as I do
• 13:14 Show them shock. Do not define it.
• 14:13 SOCM lesson: you do not know the job until you see the job
• 34:54 The course continues — Vic takes it deeper / SOCM Light
• 35:37 The West overcomplicates TCCC
• 36:10 Basics save lives
• 37:11 NATO partners in 4.5 days: trenches, physical exam, pain, cheat cards
• 39:17 Advice for the first overseas class
• 40:06 Know the audience — products change with the culture
• 40:39 Ego is a teaching failure and a survival failure
• 41:24 All teaching is an act of love
• 42:03 Likability as a core attribute
• 43:09 The medic as SME: influence, battlefield clearance, buy-in
• 44:56 Be ready for the unexpected — and try to enjoy it

Mike Weisman — 25 years as a Navy Corpsman and SARC, 27 years on a busy Vegas fire department, now clinical education at Celox — does not sell magic dust. He sells a hydraulic problem.

A femoral-rate bleed can dump on the order of 500 mL a minute. The clotting cascade is a 14-step masterpiece built for arterioles, not that jet. Early platelet plug gets blown off the vessel wall unless something holds equal pressure against it. Tourniquet, packed gauze, or packed hemostatic gauze: all of them are pressure tools. The chemistry is the advantage on top.

Two families, two jobs. Kaolin (Combat Gauze class) is a clay mineral that lights up Factor XII and accelerates your cascade — which means it still needs time and a body that can clot.

Chitosan / cellulose dressings work off the cascade. They absorb fluid, grab red cells by charge, and build a viscous mucoadhesive plug. Granules and sprays exist. Mike’s line stays the same: if you do not back them with pressure, you bought a show booth.

Then the part schoolhouses skip. The product has to touch the bleeding vessel, not the pool in the hole. Three to six minutes of hold time on a kaolin dressing feels short on the pouch and endless on a screaming casualty. Hemorrhage control is not a monkey skill. Blood programs without packing reps are the cart in front of the horse. Read mechanisms, not company PDFs. Deployed Medicine and independent retrospectives beat the booth.

Listen, then pack something that bleeds.
prolongedfieldcare.org | @prolonged_field_care | PFC Podcast

Top 5 takeaways

1. It is a hydraulic problem. Fight pressure with pressure. Chemistry cannot replace a packed tract or a tourniquet.
2. Know the two mechanisms. Kaolin accelerates Factor XII / your cascade. Chitosan-type polysaccharides work independently and form a mucoadhesive plug.
3. Contact the vessel or you wasted the dressing. Clot in a basin of blood is not hemostasis. Anatomy and packing skill are the product.
4. Hold the clock. Kaolin-class products typically need on the order of 3–6 minutes of continuous pressure. The pouch lie is that this is short.
5. Unconscious competence beats the brand. Schoolhouse reps expire. Blood on the truck does not save the casualty if the medic cannot pack. Understand the mechanism, then pick what your system will actually issue.

Chapters

• 00:00 Cold open
• 00:19 Dennis + Mike (SARC, Vegas FD, Celox education)
• 01:25 Why not just pressure and plain gauze?
• 02:16 Hydraulic problem: cascade vs femoral-rate bleed
• 03:42 What a hemostatic actually adds
• 03:54 Kaolin: Factor XII, still gauze, still pressure
• 04:54 Chitosan / cellulose: cascade-independent mucoadhesive plug
• 06:03 Charge, RBCs, dual action with the gauze
• 07:07 Granules, sprays, “hummus” pastes — still need pressure
• 08:20 No good hemorrhage control without pressure. Period.
• 08:47 Does it have to touch the vessel? Yes.
• 09:34 Anatomy, packing method, skill — not the brand
• 10:07 Why the 3–5 minute hold feels like an hour
• 10:42 Kaolin activation window (~3–6 min)
• 28:57 Know every item in the bag the way you know a drug
• 29:26 You can spot a professional by the pouch
• 30:11 Hemorrhage control is not a monkey skill
• 31:04 Unconscious competence: pack it blind
• 31:56 Blood programs without packing reps
• 33:04 Schoolhouse months do not last a career
• 34:32 How to read studies that are not the company PDF
• 35:37 Deployed Medicine, JTS workload, mechanisms over marketing
• 37:48 Close: keep getting the reps

OTFC is gone. That was not a small supply hiccup. It punched a hole in the old TCCC pain plan.

George Barbee, a PA and co-author of TCCC Guideline Change 25-03, walks Dennis through why the committee rebuilt battlefield analgesia instead of patching the old triple-option chart.

They screened 56 analgesics. They built an objective matrix. They landed on suzetrigine: non-opioid, mentation-sparing, slow onset, long duration — a drug that can keep a still-fighting casualty in the fight and then carry them into prolonged care.

The bigger shift is the fork in the road. Not “mild / moderate / severe” as four overlapping options. Can they stay in the fight, or not? Functioning casualties get a non-sedating pack. Non-functioning casualties get a shock-agnostic pathway so you are not stacking drugs blindly down the continuum.

Ketamine is still the drug you reach for when you have almost no information. Nystagmus is not the goal. It is the “you gave too much, back off” line. Option 4 sedation is being pulled out of TCCC and written into PCC, where it belongs.

If you still teach OTFC, still dose to shaking eyes, or still treat every casualty like they need a narcotic, this episode is the update.

Read the change paper @ ⁠www.prolongedfieldcare.org⁠

or ⁠https://jsomonline.org/⁠

Follow @prolonged_field_care

Top 5 takeaways

1. The change was forced. OTFC disappeared, GWOT safety data said the old plan was too loose, and LSCO needs mission-capable pain control plus a safer path for people who cannot stay in the fight.
2. Suzetrigine is the new stay-in-the-fight drug. Non-opioid. Cognition and blood pressure mostly spared. About a 2-hour onset, long duration. Pair it with meloxicam and acetaminophen for the functioning casualty. Muscle spasm in 1–10% is not a seizure and does not get benzos.
3. Stop using four overlapping “options.” Define pain with the Defense and Veterans Pain Rating Scale. Rough cut: 1–6 can often still function and self-declare. 9–10, polytrauma, multi-amp — they are out of the fight. Medics already know this on sight. The guideline finally says it.
4. Ketamine stays, but the endpoint is not nystagmus. If you have almost no information, ketamine is still the safest narcotic start. Reduction of pain means the casualty and the medic can both manage the situation. Nystagmus means you crossed the line. Fixed-dose ketamine in a bleeding patient can get weird as volume drops — not usually lethal, still a problem.
5. Option 4 is leaving TCCC. Heavy sedation and procedural endpoints are being moved into the PCC update. TCCC keeps the systematic, stack-aware, evidence-based path so the next provider is not surprised by what you already gave.

Chapters

00:00 — Disclaimer and open

00:23 — Dennis and George: who wrote the change

02:10 — If it ain’t broke, why touch analgesia?

02:56 — We lost OTFC

03:11 — Safety, LSCO, and early pain vs PTSD

04:27 — Mission-capable control and a shock-agnostic path

05:48 — How suzetrigine beat 56 other drugs

09:38 — Why this non-opioid survived the matrix

11:33 — Spasm vs seizure: do not reach for benzos

13:33 — Stay in the fight vs cannot

14:20 — The old “triple option” was actually four

15:06 — Defining pain with the DVPRS

16:10 — The stay-in-the-fight pack: suzetrigine, meloxicam, Tylenol

17:20 — What “reduction of pain” actually means

18:15 — Esketamine: more analgesia, fewer side effects

27:38 — If you only get one narcotic, start ketamine

28:56 — Esketamine, IN 28 mg, and the 4PANE study

30:15 — IV, IO, IM, IN: why they kept the nose

33:07 — Pain control vs nystagmus

35:26 — Option 4 is moving to PCC

36:41 — Chest tubes, crics, and the sedation gap

37:54 — Next: backing the PCC analgesia update

38:48 — Read JSOM Change 25-03 and close