In this powerful episode of the Prolonged Field Care Podcast, Dennis sits down with Viktoriia, Chief Medical Officer, responsible for medical care across more than 150 kilometers of active front line. A former OB/GYN who served as a combat medic in 2014–2015 and later on Medevac, Viktoriia shares the raw, real-time evolution of Ukrainian military medicine from outdated Soviet-era training to a battle-hardened system built for drone-saturated battlefields, prolonged evacuations, and extreme resource constraints.

They dive deep into how Ukraine rapidly expanded medic scope of practice, trained every infantryman to Combat Lifesaver (CLS) level, pushed aggressive hypothermia management, and achieved a groundbreaking policy change allowing combat medics to deliver low-titer group O whole blood and dry plasma at the point of injury after a specialized 32-hour course.

This podcast was recorded in partnership with Leleka Foundation, an American-Ukrainian charitable initiative committed to helping frontline medics in Ukraine save lives. This project creates a vital platform for Ukrainian frontline medics to share firsthand trauma care experience from the battlefield with their American counterparts, strengthening knowledge exchange. Key Takeaways:

• Train everyone to CLS level — it’s the only scalable solution to medic shortages and the targeting of medical personnel.
• “Prolonged Field Care under fire” is the new reality: limited interventions, maximum security, and ruthless prioritization because the battlefield is completely transparent.
• Aggressive hypothermia management and intraosseous access have become frontline skills for regular infantry due to hours-to-weeks-long evacuations in freezing trenches.
• Decision-making under fire is the most critical (and trainable) skill — technical abilities mean nothing without the judgment of when to act.
• Other militaries should stop preparing for the last war. Use Ukraine’s “lessons identified” now, while you still have time to adapt training proactively.

Whether you’re a combat medic, unit leader, medical educator, or just obsessed with what actually works when everything goes wrong, this episode delivers hard-won wisdom you won’t find in any textbook.

Chapters

• 00:00 — Welcome & Introduction to Viktoriia Kovach, Chief Medical Officer
• 02:03 — The Core Lesson of the War: Radical Adaptability to Save Lives
• 03:11 — Pre-2014 Medical Training: Soviet-Era Foundations & “Grandfather’s Bandages”
• 06:36 — The 2014 Shift: NATO Cross-Training Lands in Ukraine
• 09:38 — Expanding Medic Scope of Practice: Blood, IO Access & Advanced Interventions
• 11:14 — The Modern Training Pipeline: 55-Day Basic General Military Training + Adaptive Period
• 16:01 — Combat Lifesaver (CLS) for Every Infantryman — The Scalable Solution
• 19:39 — Solving the Combat Medic Shortage: Positioning, Internal Instructors & CLS Emphasis
• 23:52 — Drone Warfare Reality: Training Rapid Decision-Making Under Constant Aerial Threat
• 29:07 — Prolonged Field Care Under Fire: Hypothermia Priority, Wound Care & Limited Interventions
• 31:49 — The Blood Transfusion Revolution: 32-Hour Course, Low-Titer O Whole Blood & Dry Plasma
• 36:23 — Lessons Identified: Advice for Commanders Preparing for the Next War
• 39:39 — Closing & Resources

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In this episode of the Prolonged Field Care Podcast, Dennis sits down with Jeff to tackle one of the most time-sensitive and under-appreciated threats in tactical and austere medicine: anoxic brain injury. They break down exactly what it is, how fast it can progress from unnoticed hypoxia to devastating outcomes, and why the MARCH algorithm plus aggressive prevention of secondary injury are your most powerful tools when oxygen and resources are limited.

Key Takeaways:

• Anoxic brain injury exists on a spectrum — brief drops in SpO2 can cause real damage, and recovery (when it happens) can take days, weeks, months, or even years of rehab.
• The landmark Arizona pre-post TBI study showed hypoxia and hypotension each increase mortality 2–3×; combined they increase it 5–6×. Updated analysis reveals harm begins at SpO2 <96–97%. In the field resuscitation phase, the goal is 100% whenever possible.
• Prevention starts with MARCH: control hemorrhage first (no blood = no oxygen delivery), then airway and breathing. Give whatever oxygen you have — even 1 L/min is better than nothing. Keep patients warm to avoid coagulopathy.
• Airway escalation trigger: consistent SpO2 <94% despite maximal non-invasive oxygen → move to supraglottic or definitive airway based on your proficiency, scenario, and time to definitive care. In tactical environments, the fastest reliable airway often beats the “gold standard.”
• Once anoxic injury is suspected, focus shifts entirely to preventing secondary and tertiary brain injury: avoid re-hypoxia, hypotension, hyperthermia, hypoglycemia, pain/agitation (which raises ICP and oxygen demand), and seizures.
• Resuscitation targets: SBP 120–140 mmHg (or MAP 65–85) — avoid the U-shaped mortality curve on both ends. ETCO2/PaCO2 35–45 mmHg. Normoglycemia and normothermia (avoid fever). Consider higher sodium for cerebral edema under neurocritical care guidance.
• Basics win: Even non-medics can save brains by controlling bleeding, positioning airways, and keeping patients warm. Time will tell on recovery — keep working at it.

Whether you’re a combat medic, flight medic, wilderness provider, or anyone operating in resource-limited environments, this episode delivers practical, evidence-based strategies to protect the brain when every molecule of oxygen counts.

Check out free resources and downloads at www.prolongedfieldcare.org. Grab a bag of fresh-roasted PFC coffee (link in the description) and stay on the bleeding edge of combat and austere medicine.

Podcast Chapters (approximate timestamps)

• 00:00 — Introduction & What Is Anoxic Brain Injury?
• 03:15 — The Spectrum of Anoxic Injury & Recovery Potential
• 07:00 — Prevention: MARCH Algorithm & Limited Resource Strategies
• 11:45 — The Arizona TBI Study: Why Hypoxia & Hypotension Are So Deadly
• 16:30 — SpO2 Targets: 100% Goal & When Harm Really Begins
• 21:00 — Airway Decision-Making: Triggers, Escalation & Skill-Based Choices
• 26:30 — When Anoxia Has Occurred: Shifting to Secondary Injury Prevention
• 31:15 — Resuscitation Targets: BP, MAP, ETCO2 & Avoiding the U-Shaped Curve
• 35:45 — Neuroprotection Extras: Pain, Agitation, Seizures, Glucose & Temperature
• 40:00 — Key Takeaways: Basics Save Brains (Even for Non-Medics)

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In this episode of the Prolonged Field Care Podcast, Dennis sits down with Dr. Mike Falk — pediatric ICU physician with multiple deployments to Iraq, Gaza, and Ukraine — for a raw, practical, deep dive into pediatric care when you’re the only asset and evacuation is denied.

Most combat medics carry 99% adult gear. Kids still show up. Dr. Falk breaks down the absolute minimalist kit that actually works in austere and combat environments: canine tourniquets for toddlers, the single blue IO you really need, simplified airway choices, push-pull resuscitation with a syringe and stopcock, and a field-expedient needle cric setup.

Then he walks through three real cases that expose the brutal decision-making required in prolonged field care:

• A 4-year-old pulled from rubble with a head injury who decompensates from rising ICP
• An 8-year-old with a penetrating chest wound and tension pneumothorax at the thoracoabdominal junction
• A 4-year-old with an infected blast wound fracture who develops septic shock days later in a denied environment

You’ll learn weight-based dosing that actually works in the field, why kids decompensate differently, how to mix and run an epinephrine drip with limited supplies, the realities of black-tagging children in mass casualty events, and why these cases stay with providers long after the mission.

Key Takeaways:

• The truly minimalist pediatric kit that won’t break your weight limit
• Practical field management of rising ICP when you have no CT or neurosurgery
• Push-pull volume resuscitation and epinephrine drip mixing for pediatric shock
• Why penetrating trauma at the 6th–7th rib level is often thoracoabdominal
• The emotional and ethical weight of black-tagging kids — and why you must train it
• Malnutrition’s hidden impact on wound healing and sepsis in prolonged scenarios

Chapters

00:00 - Welcome & Why Most Medics Are Unprepared for Pediatric Patients

00:57 - The Bare Essential Pediatric Combat Medic Bag

02:25 - Canine Tourniquet for Under-2s & Minimalist Hemorrhage Control

02:25 - Vascular Access: Why the Blue IO is Usually All You Need

03:22 - Simplified Airway: OPAs, NPAs & i-gel Sizes That Actually Matter

03:22 - ET Tubes: Why Only 4.0, 5.0 & 6.0 Cuffed Are Necessary

04:24 - Push-Pull Resuscitation Technique (Syringe + Stopcock)

04:56 - Needle Cricothyrotomy Setup & Critical I:E Ratio Warning

07:09 - Case 1 Begins: 4-Year-Old Blast Victim Pulled from Rubble

08:47 - Initial Assessment, C-Spine Considerations in Kids & Access

12:16 - GCS 11, Pain Control & Why Fluids Make Sense Early

14:17 - Hours Later: Decompensation & Rising ICP

18:17 - Positioning, Hypertonic Saline Dosing (5 mL/kg) & Decision to Intubate

23:13 - Ketamine-Only Intubation, Permissive Hyperventilation & Realities

27:51 - The Emotional Toll: Black Tagging Kids in MCI

29:44 - Case 2: 8-Year-Old with Right Chest GSW & Tension Pneumothorax

31:36 - Chest Seal + Needle Decompression (Anterior Approach Preference)

34:23 - Blood Resuscitation (10 mL/kg) & Why Location Matters (Diaphragm Level)

40:20 - Case 3: 4-Year-Old with Infected Blast Wound Fracture – Septic Shock

42:51 - Broad-Spectrum Antibiotics & Source Control in Denied Environments

45:26 - Push-Pull Boluses, Epinephrine Drip Mixing & Permissive Hypotension

51:09 - Malnutrition’s Impact on Healing & Infection in Prolonged Care

56:49 - Final Lessons: Training Black Tags, Calling for Help & Provider PTSD

57:32 - Outro & Where to Find More PFC Content

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In this deep-dive episode of the Prolonged Field Care Podcast, Dennis sits down with trauma and critical care surgeon Dr. John McClellan ( University of North Carolina) to cut through the noise on tranexamic acid (TXA) in trauma.

They cover the mechanism, who actually needs it, why the dosing shifted from 1g + drip to 2g upfront, pre-hospital decision-making when bleeding is controlled, redosing in ongoing hemorrhage, IM/IO options, seizure and hypotension concerns, the critical 3-hour window, and practical advice for the medic who is truly alone and afraid.

Whether you’re a combat medic, flight medic, or trauma provider, this conversation delivers actionable clarity on one of the most studied — and sometimes misunderstood — tools in hemorrhagic shock resuscitation.

Key Takeaways:

• TXA is a lysine analog that reversibly (and at higher doses irreversibly) binds plasminogen, preventing its conversion to plasmin and stabilizing clots. It is one of the most evidence-backed hemorrhage adjuncts available.
• The ideal candidate is any patient you suspect will trigger (or has triggered) a massive transfusion protocol — not just obvious amputations. Err on the side of giving it early in pre-hospital/austere settings to avoid missing occult bleeding.
• Modern trauma practice favors 2g IV push upfront over the older CRASH-2 regimen of 1g bolus + 8-hour drip because traumatic bleeding is an acute event that needs rapid high plasma levels. The 8-hour drip was designed for elective surgical cases with ongoing bleeding over hours.
• Overall safety is excellent. Large meta-analyses have not shown a clear increase in thrombotic events attributable to TXA. The bigger practical risks are seizures with doses significantly above 2g and accidental double-dosing due to poor handoff between pre-hospital and hospital teams.
• Transient hypotension can occur with rapid push, but causality is murky — it is often impossible to separate from the patient’s underlying shock state.
• Redosing is reasonable (another 1–2g) if significant re-bleeding causes hemodynamic instability. Roughly 25% of active TXA can be lost in major hemorrhage/transfusion models.
• Give TXA within 3 hours of injury for maximum benefit. After 3 hours efficacy drops sharply and some data suggest potential increased bleeding risk.
• For the solo medic: Preload if your protocol allows. Make TXA automatic once you have access (alongside calcium and blood products). Prioritize rapid transport. TCCC supports IM if no IV/IO is possible, though delivering the full 2g volume can be challenging.
• Documentation and clear handoff are non-negotiable when pre-hospital TXA is given.

Chapters:

00:00 – Welcome & Podcast Disclaimer00:25 – Guest Introduction: Dr. John McClellan, Trauma Surgeon01:52 – What is TXA and How Does It Actually Work?03:28 – Who Should Get TXA? The Massive Transfusion Patient04:16 – Pre-Hospital TXA: Bleed Control First or TXA First?07:06 – Safety Concerns: Thrombosis, Seizures & Double Dosing Risks09:54 – Dosing Evolution: CRASH-2, 1g + Drip vs 2g Push in Trauma13:33 – Does TXA Cause Hypotension? Unpacking the Evidence19:12 – IO & IM TXA: Practical Routes When IV Access Is Tough21:46 – Redosing TXA in Ongoing Bleeding or Transport29:37 – Advice for the Medic Who Is Truly “Alone and Afraid”32:21 – The 3-Hour Rule: Why Timing Matters and What Happens After34:14 – Final Thoughts & Practical Takeaways from Dr. McClellan

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In this episode of the PFC Podcast, Dennis sits down with David Plaster — former U.S. Army combat nurse, medic, and 68 Delta who has lived and worked in Ukraine since 2012, long before the full-scale invasion. David pulls back the curtain on one of the most remarkable stories in modern tactical medicine: how Ukraine built resilient, dispersed, underground manufacturing networks for hemostatic gauze and tourniquets when conventional supply chains collapsed or became targets.

From the very first improvised IFACs in 2014 (duct-tape chest seals and all) to scaling production of Krovin Goss / Hemostat gauze at roughly $1 per meter and developing a functional “cat-style” tourniquet that Ukrainian and U.S. SOF tested and trusted, David shares the real mechanics of wartime medical logistics. He explains pre-planned basement factories, compartmentalized production across multiple hidden sites, the shift from volunteers to paid war widows and veterans’ families, rigorous quality control, and the constant fight against opportunists, “carpet baggers,” and adversarial intelligence collection.

This is far more than a war story — it’s a masterclass in austere medical manufacturing, supply-chain resilience, and why training and knowledge will always outperform gear alone.

Key Takeaways:

• Pre-war planning and deep personal networks (built years earlier) are the real force multipliers when supply chains get bombed or corrupted.
• Highly motivated local workforces — especially people with direct skin in the game (war widows, veterans’ families) — can deliver exceptional quality and output even in dispersed, low-tech underground conditions.
• Dramatic cost advantages ($1/m hemostatic gauze vs. $10+ imported) free up resources to buy more of everything else and keep production sustainable.
• Dispersed, multi-site manufacturing with compartmentalized components dramatically increases survivability and operational security.
• Functional analogs that are properly tested (double-blind SOF trials included) can serve as effective bridges when premium Western gear is unavailable or too expensive.
• The biggest failure point in tactical medicine is almost never the gear — it’s implementation and mastery of the basics by everyone, not just medics. Tourniquet application, conversion/repositioning, and preventive medicine thinking belong at the squad-leader level.
• Medics must operate as advisors and educators. Command emphasis on these skills across the force (not just in the aid bag) is what actually moves the needle on survival.

Chapters:

• 00:00 – Introduction & David Plaster’s Background (U.S. Army combat nurse in Ukraine since 2012)
• 02:30 – Early Days: 2014 Improvisation, First IFACs, and the Complete Absence of Western TCCC
• 06:00 – The Krovin Goss / Hemostat Gauze Story: Chemistry, Corruption, and the Pivot Underground
• 11:30 – Going Underground: Pre-Planned Basements, Plan B/C/D, and Dispersed Manufacturing Strategy
• 16:00 – Why the Tourniquet Project Started: Fake Chinese Gear, Expensive CATs, and Local Demand

• 23:30 – The Manufacturing Model: Volunteers to Paid Staff, War-Affected Workers, and Quality Control
• 27:00 – Security Realities: Protecting Sites from “Carpet Baggers,” Visitors, and Adversarial Interest
• 30:00 – Bigger Lessons: Training Failures, ASM/Tourniquet Conversion Changes, and Why Knowledge > Gear
• 36:00 – Preventive Medicine Mindset, Medics as Advisors, and Building Systems That Actually Work

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In this episode of the Prolonged Field Care Podcast, Dennis sits down with trauma surgeon Mark Shapiro for a no-BS masterclass on wound ballistics. They break down why understanding the physics of penetrating and blast trauma matters in austere and combat environments — even when experience makes you cynical. From high-velocity rifle rounds and their massive temporary cavities to the infectious nightmare of shotgun wounds and the four phases of blast injury, Mark shares hard-won lessons from civilian Level I trauma centers and years training special operations medics and ground surgical teams.

They tackle the myths around entry/exit wounds, when (and when not) to explore right upper quadrant gunshot wounds downrange, why you should almost never pack the abdomen or chest from the outside, how to assess neurovascular status in blast-injured extremities, and why bizarre bullet paths and “stable” patients with signs of life can still surprise you.

Key Takeaways:

• Kinetic energy (½mv²) means velocity is king — high-velocity rifle rounds create devastating temporary cavities and fragmentation that can turn one projectile into many.
• Jacketed rounds still fragment at rifle speeds; never assume a clean through-and-through. Bone fragments act like secondary missiles and can create wounds up to 3x the size of the fragment.
• For stable patients with right upper quadrant GSWs in resource-limited settings, expectant management can be reasonable — but you must have a plan, know your limits, and be ready to move if things change.
• Never pack the abdomen or chest from the outside in most cases. It risks pushing debris deeper and worsening injuries. Cover exposed organs if needed, but don’t shove gauze into body cavities.
• Shotgun wounds (especially buckshot/birdshot) are “mobile IEDs” — massive tissue destruction, heavy debris inoculation, and extremely high risk of infection, fistula, and devascularized tissue requiring serial debridement.

• In extremity blast trauma, assess vascular status (pulses, Doppler signals, color, warmth, capillary refill) and neurologic function. The ~6-hour window to revascularization is critical, but the decision point comes earlier.

• Training + common sense + adaptability beat rigid protocols when resources are limited. Sometimes the best move is observation.

Chapters

• 04:15 – Why Wound Ballistics Knowledge Still Matters (even when you’re cynical)
• 08:30 – High-Energy Rifle Wounds: Muzzle Velocity, Kinetic Energy & Spitzer Bullets
• 13:45 – Fragmentation, Tumbling & Secondary Missiles (bone shards & unpredictable paths)
• 18:20 – Clinical Reality: Multiple Injuries & Why “Small Entrance, Big Exit” Is a Myth
• 22:50 – Entry vs. Exit Wounds: When Trajectory Actually Matters (and when it doesn’t)
• 26:40 – Right Upper Quadrant GSWs: Explore, Observe, or Expectant Management Downrange?
• 31:10 – The Dangers of Packing Abdominal & Chest Wounds from the Outside
• 34:55 – Low-Energy Pistol Wounds: How They Differ (or Don’t) from Rifles
• 37:20 – Shotgun Wounds: Close-Range Carnage, Debris & Infectious Nightmares
• 42:40 – IEDs & Modern Explosives: Blast Physics, Ukraine Patterns & Hard-Ground Effects
• 48:15 – Primary, Secondary, Tertiary & Quaternary Blast Injuries Explained
• 52:30 – Neurovascular Assessment in Blast-Injured Extremities (Conscious & Unconscious Patients)
• 56:45 – Lessons from the Trauma Bay: Common Sense, Training & Knowing When to Deviate from Protocol

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In this high-signal PFC Podcast episode, Dennis sits down with Dr. John Wightman — former 24th Special Operations Wing Surgeon, emergency physician, and one of the world’s leading experts on blast injuries. Drawing from decades of clinical, combat, and academic experience (including co-authoring a seminal paper on blast injuries just before 9/11 and multiple combat deployments), Dr. Wightman breaks down the unique pathophysiology, recognition, and prolonged field care management of blast lung injury — the often-hidden threat that can kill even when penetrating trauma doesn’t.

From the physics of the supersonic pressure wave to practical field decisions on tension pneumothorax, ventilation strategies, fluid management, and avoiding air embolism, this is essential listening for medics, operators, and anyone preparing for large-scale combat operations, urban warfare, or confined-space blasts.

Key Takeaways:

• Primary blast lung injury is caused by the blast wave itself — not fragments or being thrown — and creates unique pulmonary contusions, air leaks, and arterial air emboli risks.
• Most significant blast lung develops within the first 1–6 hours; subtle dyspnea on exertion can be an early warning.
• MARCH priorities still rule — aggressively rule out (or treat) tension pneumothorax, even bilaterally, before assuming blast lung.
• Positive pressure ventilation can worsen outcomes (especially air embolism risk) — use judiciously; CPAP or PEEP may be better bridges when possible.
• PAO₂/FiO₂ ratio (or SpO₂ on room air) helps stratify severity and predict need for advanced support.
• Tympanic membrane rupture proves blast exposure but is not required for blast lung.
• Fluid management must be careful — permissive hypotension may be dangerous in blast lung + shock.
• Don’t forget occult blast bowel injury — delayed perforation is real (up to 8 days).

Whether you're running a team in Ukraine-style trench warfare, preparing for mass casualty events, or just want to stay on the bleeding edge of combat medicine, this episode delivers critical, actionable knowledge.

Chapters:

• 00:43 - John Wightman Introduction: 32 Years as Air Force EM Physician & Blast Injury Expert
• 02:54 - What Is Blast Lung? Defining Primary vs Secondary, Tertiary, Quaternary & Collateral Injuries
• 05:23 - The Physics of the Blast Wave: Overpressure, Stress Waves & Alveolar Damage
• 09:50 - Pathophysiology: Pulmonary Contusion, Pneumothorax, Air Embolism & Traumatic Pseudocysts
• 12:30 - Timelines: When Does Blast Lung Declare Itself? (Israeli & Combat Data)
• 15:56 - Epidemiology: Confined Spaces, Buses, Buildings vs Open-Air Blasts
• 23:12 - Field Diagnosis & MARCH Priorities — Tension Pneumothorax First
• 28:30 - Advanced Assessment: P/F Ratio, Ultrasound Findings, SpO₂ Guidance
• 35:55 - Ventilation Strategies: When to Intubate, CPAP/PEEP, Lung Protective Settings
• 41:18 - Oxygenation Goals, Fluid Management & Permissive Hypotension Risks
• 52:16 - Air Embolism Management & Patient Positioning
• 56:12 - Other Critical Considerations: Blast Bowel Injury, TM Rupture, Resource Triage
• 01:04:36 - Final Thoughts & Key Advice for Deploying Medics

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In this episode, Dennis sits down with Reagan Lyon, an Emergency Medicine physician and 17-year Air Force veteran who spent the majority of her career in special operations, including time on Special Operations Surgical Teams. While at the Naval Postgraduate School, Reagan wrote a thesis on one of the hardest problems in military medicine: how do you actually build and sustain indigenous medical networks in unconventional warfare and denied environments?

Drawing from the Yugoslav Partisan guerrilla hospitals of WWII, modern lessons out of Ukraine, and the harsh realities of occupied territory medicine (including Iran’s protest crackdowns), Reagan breaks down why our current Role 1–4 doctrine collapses in these scenarios. She introduces a treatment-goal-based framework instead of capability-based tiers, uses systems dynamics modeling to expose the real chokepoints (training pipelines, blood, patient movement, and capacity), and makes a compelling case for radical cognitive agility and “MacGyver medicine” when the supply chain disappears.

Key Takeaways:

• Why proximity to the fight is both your biggest advantage and fastest way to get compromised
• How to shift from “what gear do we have?” to “what treatment goals can we actually achieve?”
• The hidden choke points that will kill your casualty care system long before you run out of bullets
• Why forcing the “American way” on partner nations is arrogant and usually counterproductive
• The power (and ethical case) for open-source knowledge to enable a true whole-of-society medical response
• What needs to change in training, authorities, and interoperability before the next fight

If you’re a medic, planner, SOF leader, or anyone thinking seriously about large-scale combat operations or unconventional warfare medicine, this conversation is essential. Reagan doesn’t just diagnose the problem — she gives a clear path forward.

Chapters

• 00:00 – Introduction & Reagan Lyon’s Background (Special Operations Surgical Teams to Naval Postgraduate School)
• 05:15 – Why Tackle an “Unanswerable” Problem? (Avoiding Pat-on-the-Back Academia)
• 09:30 – Historical Context: WWII Guerrilla Hospitals & the Yugoslav Partisans
• 15:45 – The Core Trade-off: Proximity to the Fight vs. Security & Sustainability
• 19:45 – Modern Parallels: Iran Protests, Telemedicine Risks & Ukraine’s Brutal Validation
• 24:00 – Why Traditional Role 1–4 Doctrine Breaks in Denied/Unconventional Environments
• 29:30 – A Better Framework: Treatment Goals Over Capability Tiers (Preventable Death Categories)
• 33:45 – Systems Dynamics Modeling: Finding the Real Chokepoints in Casualty Flow
• 38:45 – Model Validation with Ukraine + Limitations of Current Planning Tools
• 42:45 – The Supply Nightmare: Caches, MacGyvering & Building Cognitive Agility
• 49:30 – Partner Nation Engagement: Humility, Coordination & Avoiding the “American Way” Trap
• 56:00 – Whole of Society Medicine: Empowering Civilians Through Open Source (Without Creating Liability)
• 1:02:15 – Reagan’s “King for a Day” Recommendations (Training, Interoperability & Authorities)
• 1:07:30 – Closing Thoughts & Where This Work Needs to Go Next

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In this raw and unflinching episode of the Prolonged Field Care Podcast, Dennis sits down with Thad Snyder (physician, former medic, and brigade surgeon) to tackle one of the most uncomfortable topics in combat medicine: what happens when resources run out, evacuation timelines collapse, and “doing everything” is no longer possible.

Drawing from a 72-page crisis standards of care memo (originally written for flu and updated for COVID), Thad explains the shift from standard → contingency → crisis care, the ethical duty to plan for no-win scenarios, and why medics, teams, and leaders must have real conversations about capabilities, limitations, and what “living” actually means after catastrophic injury. They explore palliative/comfort care in austere environments, the emotional weight of those decisions, and practical ways to share the burden so the medic isn’t left carrying it alone.

Essential listening for medics, operators, team leaders, and anyone preparing for large-scale combat or prolonged operations where the next casualty might not get a bird out for days or weeks.

Key Takeaways

• There is a duty to plan for crisis standards of care before you’re in the middle of it.
• Leaders and teams must understand the real capabilities and limitations of their medics—not the 437-task training list.
• Pre-mission conversations about quality of life, advanced directives, and unacceptable outcomes give medics a moral framework when they have to make the hardest calls.
• Palliative/comfort care is already happening in modern conflicts (Ukraine, etc.) even if no one wants to talk about it.
• The emotional and moral burden of end-of-life decisions cannot fall solely on the medic—teams and leaders must share ownership.
• Staying busy to “do something” can sometimes cause more harm than shifting to dignity-focused comfort care.

Chapters

00:00 – Intro & Pulling the Crisis Standards Memo from the Closet

00:56 – Standard, Contingency, and Crisis Care: What Changes When Resources Vanish

02:51 – The Duty to Plan: Preparing for No-Win Scenarios

04:55 – Why Commanders Need Brutally Honest Briefs on Medic Capabilities

06:20 – Surgical Team Limitations, Non-Survivable Injuries, and Realistic Expectations

08:40 – Advanced Directives, Quality of Life, and “Living vs. Being Alive”

11:36 – Palliative Care in Large-Scale Combat (Ukraine, Future Conflicts)

13:15 – How (and When) to Have These Conversations with Your Team

14:38 – The Emotional Reality: Holding Someone’s Hand While They Die Is Harder Than Any Procedure

20:33 – Real Hospital Examples of Hard End-of-Life Discussions

25:58 – What Outcomes Actually Matter to Warriors? (Walking, talking, independence)

32:00 – Using Patient Values as a Moral Framework in Crisis

35:04 – Offloading the Burden: Team Ownership of Comfort Care Decisions

40:43 – Shared Responsibility, Rituals, and Preventing Moral Injury

43:14 – Final Thoughts + Where to Get the Crisis Standards Document

This episode is heavy, honest, and desperately needed. Share it with your team.

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In this powerful episode of the Prolonged Field Care Podcast, Special Forces Detachment Commander Nate shares his journey from medical novice to building a highly effective team clinic SOP. With only one 18D on the team, Nate realized that top cover and systems thinking were critical for success in austere environments. He discusses creating, testing, and refining a practical clinic layout, the "Care Chain" concept, realistic PFC training under fatigue, honest medical risk assessment for commanders, and breaking down the mystique of medicine for the entire team.

Key Takeaways:

• Why commanders must dive into medical capabilities and challenge assumptions instead of leaving it solely to the medic.
• How to design an efficient SOF clinic using systems thinking and proxemics to reduce friction during prolonged care.
• The critical importance of testing medical plans with full rehearsals and pushing to realistic limits (fatigue, resource constraints).
• Treating prolonged field care like any other battle drill: train to standard, not convenience.
• Strategies for communicating medical limitations honestly to higher command and building a culture of openness.
• Expanding medical knowledge across the entire ODA to increase team resilience.
• 
  

Whether you're a commander, medic, or operator preparing for austere operations, this episode delivers practical, battle-tested insights on turning medical readiness into a true force multiplier.

Podcast Chapters:

• 00:00 - Introduction & Guest WelcomeHost Dennis introduces Nate, SF Detachment Commander, and sets the stage.
• 00:00 - Nate's Medical Journey & First PFC ExerciseHow a failed 24-hour PFC exercise exposed gaps in equipment familiarity, charting, and leadership involvement.
• 03:30 - The Suffolk Experience & Understanding 18D CapabilitiesKey training that gave Nate better appreciation for medics and his own limitations.
• 06:00 - Why Create a Team Clinic SOP?The first overseas deployment, poor rehearsal results, and the lack of existing doctrine for ODA-level clinics.
• 09:00 - Designing the Ideal SOF ClinicSystems-based approach, "Care Chain" concept, layout, storage, vampire kits, proxemics, and reducing friction.
• 13:30 - Testing & Iterating the SOPMoving the entire clinic, rehearsals, learning from failures, and refining based on real feedback.
• 17:00 - Training to Standard vs. Training to ConvenienceComparing medical training to breaching, CQB, and other skills. Why PFC needs to be treated as a battle drill.
• 21:00 - The Power of Realistic, Fatigue-Based TrainingLessons from Suffolk, Rangers' approach, and pushing teams to their actual limits.
• 25:30 - Planning Challenges & Honest Risk AssessmentCommon failures in CONOPs, evac planning, the "death of the golden hour," and testing medical capabilities early.
• 29:00 - Convincing Command & Building a Culture of HonestyCommunicating limitations, resource requirements, and fostering intellectual openness.
• 33:00 - Expanding Medical Knowledge Across the TeamDemystifying medicine, operator-level training, and treating it like ballistics or demolitions.
• 36:30 - Final Thoughts & Call for FeedbackNate's request for community input on the clinic SOP and closing remarks.

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