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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What happens when a sharp-eyed cruise ship doctor spots a hantavirus amid a sea of hangovers and flu symptoms? In this high-stakes episode of the Prolonged Field Care Podcast, Dennis sits down with Dr. Ryan Maves — combat-experienced infectious disease expert and military medicine veteran — to break down the shocking recent Andes virus outbreak.

Far from the next global pandemic, hantaviruses are a real, rodent-borne threat that has hit soldiers before (Korean War, anyone?) and can strike deployed units in austere environments. Ryan delivers hard-hitting insights on rapid diagnosis, the “off-script” decompensation that screams hantavirus, supportive care when there’s no magic antiviral, and — most importantly — prevention strategies that actually work in the field.

If you operate in rodent-infested buildings, set up in abandoned structures, or just want to trust your gut when a patient goes south fast, this episode is required listening. Real talk from the A-team who are currently managing these patients stateside.

Key Takeaways

• Classic presentation: Flu-like prodrome (fever, fatigue, myalgias, GI upset) for a few days followed by sudden shock, respiratory failure, and decompensation.
• Bedside diagnostic gold: Thrombocytopenia (low platelets) + hemoconcentration (elevated hematocrit) in a previously healthy patient = major red flag.
• Treatment reality: Purely supportive — fluids, pressors, oxygen, renal support. No silver-bullet antiviral; ribavirin has limited data at best.
• Prevention beats everything: Humans are dead-end hosts. Avoid aerosolizing rodent urine/feces/droppings (no dry sweeping!). Use bleach, N95 (or equivalent), gloves, and gown.
• Human-to-human spread: Extremely rare except with Andes virus (this outbreak strain). Still, treat unknowns with respect.
• Military relevance: Endemic in deployment zones worldwide; occupying previously rat-infested buildings is a classic risk. History tied directly to U.S. troops in Korea.
• Mindset: When things go “off script,” trust your clinical instincts over machines. The best tool in the field is still an experienced medic’s gut.

Chapters00:00 – Welcome back to the PFC Podcast00:26 – Introducing Dr. Ryan Maves & the cruise ship outbreak00:55 – Why this isn’t the next pandemic… but still matters03:04 – Military relevance: hantaviruses in deployment zones03:51 – How the cruise ship doc nailed the diagnosis05:27 – Clinical syndrome & the “virus-y” prodrome07:04 – Key labs: thrombocytopenia + hemoconcentration explained09:42 – Disease progression and why young healthy people can still crash10:50 – History of hantaviruses (Korean War → Sin Nombre → Andes)12:21 – Who actually dies and why14:50 – Biocontainment units and the military experts on the case17:35 – Treatment in the field: supportive care only19:35 – Shock management: distributive + capillary leak20:55 – Prevention is king: rodent control & PPE tactics24:22 – Human-to-human transmission (Andes virus exception)27:31 – Infection control, differential diagnosis, and real-world precautions30:08 – Final thoughts: clinical acumen, zoonoses, and trusting your instincts32:32 – Closing & where to find more PFC content

Grab your N95 and hit play

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In this hard-hitting episode of the PFC Podcast, Dennis sits down with Doug, a cardiothoracic ICU physician, for a no-fluff deep dive into ACLS with a heavy focus on pulseless VT and VFib in austere, military, and prolonged field care environments.

From deciding when CPR is worth it under fire or in a mass casualty scenario, to running a lean team code with minimal personnel, nailing high-quality BLS, working the H’s and T’s under chaos, post-ROSC pitfalls, antiarrhythmics, and the gut-wrenching decision of when to call it — this conversation delivers practical, experience-based wisdom you won’t find in standard ACLS class.

Whether you’re a medic, PA, physician, or team leader operating far from a hospital, this episode gives you the mental framework and tactical edge to give your teammate the best possible shot at survival.

Key Takeaways:

• Scene safety and triage realities — when not to start CPR
• How one knowledgeable person can effectively run an entire code by delegating roles (CPR rotations, timer, airway, meds, defibrillator)
• Prioritizing actions in resource-limited environments: early high-quality CPR + epi > everything else
• When and how to practically apply the H’s and T’s (especially hypovolemia, acidosis, hypoxia, and tension pneumo)
• Post-ROSC critical care: preventing rearrest, airway management, sedation, and treating the “two patients” (heart + brain)
• Amiodarone vs Lidocaine — when to use what
• Realistic termination of resuscitation guidelines, the difference between witnessed vs unwitnessed arrest, and the value of objective outside input (telemedicine)
• The power of bringing the team in for closure when the fight is over

Chapters

• 00:00 – Intro & Welcome
• 00:57 – Can you really do CPR in the field? Safety, triage, and mass casualty realities
• 02:57 – Running a code with minimal trained personnel – how one leader directs chaos
• 06:02 – Essential team roles: CPR rotation, AED/pads, airway, access, and early epi
• 09:08 – Making the H’s and T’s actually useful (hypovolemia, acidosis, hypoxia, tension physiology)
• 16:53 – Post-ROSC care: Preventing rearrest, airway security, sedation, and neuroprotection
• 20:41 – Antiarrhythmics – Amiodarone vs Lidocaine, dosing, and post-arrest infusions
• 22:53 – The hard call: When to terminate resuscitation (witnessed vs unwitnessed, resources, hypothermia exception)
• 28:19 – Emotional reality of coding teammates and giving families/teammates closure
• 33:21 – Final pearls: Telemedicine, ultrasound/video for handoff, STEMI considerations, and medevac prep
• 36:03 – Closing thoughts & resources

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In this no-fluff, high-stakes episode of the PFC Podcast, Dennis sits down with Patrick Liebel - trauma/ICU surgeon to tackle the injury that makes every medic’s stomach drop: penetrating abdominal trauma.

When the golden hour stretches into days, evacuation is delayed, and your patient’s belly is a black box of bleeding, contamination, and impending sepsis, what do you actually do? Patrick delivers hard-earned, practical wisdom on hemorrhage control, evisceration management, permissive hypotension, antibiotics, nutrition, peritonitis, and abdominal compartment syndrome — all tailored for the austere, resource-limited prolonged field care environment.

If you carry a medic bag and might one day face a guy with his guts hanging out and no surgeon in sight, this episode is required listening. Real talk, real decisions, real consequences.

Key Takeaways (Actionable Gold for Every Medic):

• Mesenteric torsion = widespread ischemia → never spin the bowel for hemorrhage control. Clamp or ligate targeted vessels instead.
• Clamping is fine in the heat of the moment — revise to ligation later when safe. Remember: every vessel has two ends.
• Eviscerated bowel is happier inside the abdomen. Tuck it back if you can (keep it wet, protect it). Only widen the defect if ischemia is imminent and you’re in a controlled setting.
• Solid organ (liver/spleen) bleeding → permissive hypotension is your only friend. Titrate to mental status + palpable radial pulse. Track trends, not single numbers.
• Assume hollow viscus injury until proven otherwise. Hit it hard and early with antibiotics (Ceftriaxone + Flagyl is the practical winner most teams actually carry).
• Nutrition: If they’re hungry, stable, soft abdomen, and no peritonitis after 1–2 days → feed them. Start slow, listen to the patient.
• Peritonitis = bad news. You’ve done everything possible with antibiotics and resuscitation — now you’re buying time for definitive surgery.
• Abdominal compartment syndrome is rare with whole blood resuscitation but lethal if it develops. Watch for progressive distension + organ dysfunction (urine output drop + respiratory failure).
• Document everything. Trends in vitals, urine output, mental status, and abdominal exam are your lifeline in PFC.

Chapters:

• 00:00 – 01:30 Welcome & Patrick Liebel Introduction
• 01:30 – 08:00 Hemorrhage Control: Clamping, Ligating, and Why You Should Never Spin the Bowel
• 08:00 – 14:30 Evisceration Management — Tuck It, Widen It, or Leave It?
• 14:30 – 25:00 Solid Organ Injuries & Permissive Hypotension in PFC
• 25:00 – 35:00 Prolonged Critical Care Monitoring, Urine Output, and Trend Analysis
• 35:00 – 42:00 Contamination Control, Antibiotics, and Hollow Viscus Injuries
• 42:00 – 49:00 Nutrition, Ileus, and When to Feed
• 49:00 – 57:00 Peritonitis, Sepsis, and Abdominal Compartment Syndrome
• 57:00 – End Final Pearls, Nursing Care, and Closing Thoughts

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In this episode of the PFC Podcast, Dennis sits down with Kevin — a Nurse Anesthetist (CRNA) with deep experience in hospice/oncology floors, Level I trauma ICUs and ERs, military nursing, and years in austere environments, including a Role III in Baghdad. Kevin delivers straight talk on the most overlooked, time-consuming, and life-saving phase of Prolonged Field Care: nursing care.

He answers the exact question every medic wants to know: When does nursing actually start? Then he walks through the full reality of what “nursing” means in the field — from relentless data gathering and charting, to turning patients, pulmonary toileting, skin care, oral care, managing the mess (yes, including bowel movements on litters), and preventing the downstream killers like pressure ulcers, ventilator-associated pneumonia, and sepsis that can undo even perfect damage-control surgery.

You’ll get practical austere hacks (including Kevin’s legendary Barbasol shaving cream trick), training advice that actually works, how to know when the patient is truly stable, when to escalate to a provider, and why evacuation must remain the primary plan — not prolonged field care.

Key Takeaways:

• PFC nursing starts the moment life-saving interventions (hemorrhage control, surgery, cric, chest tubes, etc.) are complete and the patient is stabilized — not during the gunfight or initial resuscitation.

• Skin care and turning patients prevents deadly complications — pressure ulcers, infections, and sepsis can kill a patient with otherwise survivable injuries.
• Austere game-changer: Barbasol shaving cream + washcloths cuts through blood, stool, grease, and debris without drying out skin. Bring cheap bottles.

• First hour priorities: frequent vitals/assessments, confirm stability, get fluids/sedation/maintenance running, then move to the full nursing checklist.
• Set clear “left and right limits” / parameters for teammates or non-nurses so you can actually rest, rearm, or plan the next mission.
• Best training: Work real ICU/floor shifts (especially weekends when staffing is thin) — mannequins and sims don’t teach the time sink or the “why.”
• Mindset shift: Move from high-speed, high-adrenaline interventions to the “boring but essential” maintenance phase. If it feels boring, you’re probably doing it right.
• Strategic reality: Evacuation (Medevac or CasEvac) should stay the P in your PACE plan. Prolonged field care with high casualty volumes and limited resources is an enormous time and math problem — history (WWII South Pacific, etc.) proves it.

Chapters:

• 01:50 – When Does Prolonged Field Care Nursing Actually Start?
• 04:39 – The Foundation: Data Gathering, Assessments & Charting
• 07:03 – The Full Laundry List of Bedside Nursing Interventions
• 09:26 – How to Train Real Nursing Care (ICU Shifts Beat Mannequins)
• 11:46 – The Critical First Hour: Settling In & Confirming Stability
• 14:04 – Head-to-Toe Assessment, Pulmonary Toileting, Oral Care & Eye Care
• 16:16 – Real Talk: Skin Care, Turning Patients, Bowel Movements & Preventing Ulcers/Sepsis
• 20:50 – How Long Until the Patient Is Truly Stable? (The Pregnant Pause)
• 34:49 – Patient Changes: When to Call the Provider & Setting Left/Right Limits
• 41:34 – Common Pitfalls Medics & Teams Make in PFC Nursing
• 48:59 – Nursing Care Plans, Early Ambulation & Broader Patient Needs
• 54:26 – PACE Plan Reality Check: Why Evacuation Must Stay Priority #1

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In this high-yield, no-fluff episode, Dennis is joined by Dr. Michael Falk, a pediatric emergency medicine physician, former academic, and combat-experienced relief worker who has run airways in Haiti post-earthquake, Mosul during the ISIS fight, Ukraine, and Gaza. They break down exactly why pediatric airways are a completely different beast in prolonged field care and give you field-proven tactics that actually work when you’re the only one there with a BVM and a prayer.

Key Takeaways You Can Use Tomorrow

• Positioning is everything: One to two inches under the shoulders (or whole body) prevents automatic obstruction from the massive occiput.
• Adjuncts > early tube: NPA or OPA + side-lying (gravity is your friend) can keep you from tubing in the field.
• Tube sizing rule: Child’s pinky ≈ ET tube diameter. Depth = 3× tube size. Always go smaller — you can ventilate, you can’t un-damage a ripped airway.
• Intubation mindset: Kid airway is more anterior and cephalad. Slow down, work your way in, or you’ll be in the esophagus.
• GCS decision: <8–9 = tube. GCS 9+ with good positioning/NPA? Buy time and move.
• Sedation: Ketamine 0.5–1 mg/kg IV (post-tube). Longer acting, hemodynamically friendly.
• Ventilation: 20–30 breaths/min (one every 2–3 seconds). CO₂ buildup kills faster than low O₂.
• Fluids: 20 mL/kg NS/LR bolus, then 10 mL/kg blood. Push-pull technique with stopcock = fast.
• Shock recognition: Tachycardia + skin/mottling/mental status changes — they compensate until they don’t.
• Resource mindset: Permissive hypotension (>70 mmHg), conservative management, and don’t burn your whole blood bank on one patient.

Chapters

• 01:57 – Why kids crash so damn fast (high metabolic demand + tiny reserves)
• 03:00 – The big-head/tiny-neck problem: Why laying a kid flat kills the airway
• 05:10 – Shoulder elevation hack (T-shirt, plate carrier, demo pouch — anything works)
• 06:59 – Gear reality check: What peds equipment should you actually carry?
• 09:31 – Dosing apps that save lives (EM Stat / Stadia) + pinky rule for ET tubes
• 12:01 – Go smaller, never bigger — and why
• 13:12 – Croup physiology, floppy epiglottis, and dynamic airway collapse in trauma
• 14:56 – The intubation trap: Your adult muscle memory will kill the kid
• 17:12 – When to avoid intubation (GCS 9+ and supraglottic airways buy time)
• 19:23 – Decision-making: Positioning → NPA/OPA → side-lying → tube
• 22:32 – Oxygen vs. ventilation: CO₂ kills faster than hypoxia in kids
• 25:35 – Supraglottic airways, King/Combi, and why cric is off-limits under ~10–12
• 29:09 – Post-intubation sedation: Ketamine is king (0.5–1 mg/kg)
• 32:28 – Ventilation goals, rates, and the “automatic BVM” vent limitations
• 35:27 – Hypertonic saline hack for ICP and avoiding the tube
• 39:42 – Circulation: Kids hide shock like pros (20 mL/kg crystalloid, 10 mL/kg blood)
• 44:16 – Hypothermia, tourniquets (don’t fit), packing over tourniquets, and permissive hypotension
• 48:50 – Monitoring traps: Adult cuffs lie, go analog (skin, pulses, cap refill, mental status)
• 50:12 – Other peds trauma pearls (liver/spleen below ribs, no rib fractures = still bad chest injury)
• 52:37 – Wrap-up & future deep-dive tease (peds chest trauma cases)

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In this high-value episode of the PFC Podcast, Dennis reconnects with Brad for a no-fluff, combat-medic-focused breakdown of fentanyl—the fast, predictable, cardiovascularly stable synthetic opioid that belongs at the front of every aid bag. From its 1950s Belgian lab origins to real-world battlefield use, Brad shares hard-earned lessons on why fentanyl beats morphine and Dilaudid in trauma, how to titrate it safely in the dirt, and why it’s the perfect partner for procedural sedation. Whether you’re pushing IV doses, deploying lollipops, or wondering why patches are a bad idea, this is the practical, experience-packed guide every prolonged field care provider needs.

Key Takeaways

• Fentanyl is your new “run-home-to-mama” opioid—faster, more predictable, and more stable than morphine in trauma.
• Titrate aggressively but smartly: 50 mcg IV bumps every few minutes guided by respiratory rate; cut to 25 mcg if hypotensive.
• Perfect for both analgesia AND procedures—pair with Versed for synergy and ketamine for deeper sedation without burning through your supply.
• Lollipops work great when used correctly (800 mcg is the money dose); add Zofran for the second one and wet the mouth if dry.
• Ditch the patches for acute care—they’re slow, unpredictable, and risky in the field.
• Protect your supply: Prefer vials over ampules and store smart—fentanyl is too valuable to lose to breakage.
• Bottom line: Understand the drug, respect the respiratory depression, and you’ll have one of the most powerful, titratable tools in modern combat medicine.

Chapters00:00 – Welcome back to the PFC Podcast01:20 – History of fentanyl: Developed in Belgium to beat morphine & Demerol03:35 – Why fentanyl was engineered as the ideal titratable opioid (onset, peak, duration)05:52 – Pharmacology advantages: 100× potency of morphine, 50 mcg = 1 cc, CV stability, no histamine release08:12 – Side effects, respiratory depression, and debunking “wooden chest syndrome” in field doses11:39 – Real-world IV titration: Start at 50 mcg, titrate to respiratory rate in the dirt16:13 – Fentanyl for pain control vs. procedural sedation (Versed + fentanyl + ketamine combos)19:01 – Strategy debate: Versed first or fentanyl first?23:27 – Best patients for fentanyl (and who to skip it on)26:47 – Why fentanyl is the trauma opioid of choice27:29 – Routes: IV is king, IM works but…27:48 – Fentanyl lollipops (Actiq): 800 mcg sweet spot, proper technique, “poor man’s PCA,” Zofran hack36:42 – Fentanyl patches: Why they’re a terrible idea in acute/trauma settings44:08 – Final pearls: Vials vs. ampules, protecting your supply, and why you need this drug47:53 – Wrap-up and outro

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In this must-listen episode, Dennis sits down with Dr. Jon Andrews—former 5th and 20th Group Special Forces medic turned Duke-trained anesthesiologist (pediatric & cardiac fellowships)—to tackle one of the biggest headaches in austere medicine: you have a tiny box of opioids and ketamine, a long mission, and a patient who needs to stay alive AND comfortable.

They break down exactly how to stretch every milligram using real OR strategies adapted for prolonged field care: patient-specific planning, smart titration, multimodal synergy, regional blocks, ketamine myths, and when (and how) to layer non-narcotics without crashing your patient or your supply.

Why this episode matters: Acute pain becomes chronic pain. Chronic pain leads to opioid dependence, PTSD, and worse outcomes. In the field, your choices today shape your patient’s tomorrow—and whether you still have meds left when the next casualty shows up.

Key Takeaways

• Start low, titrate smart. Cut your first dose in half on sick or unstable patients. You can always give more—never the other way around.
• Multimodal is mission-critical. Hit pain from every angle (blocks + ketamine + acetaminophen + judicious NSAIDs) to dramatically reduce opioid requirements and prevent chronic pain pathways.
• Ketamine IS an analgesic. It’s not just dissociation—it’s an NMDA antagonist that blunts central sensitization and has proven opioid-sparing effects.
• Schedule your non-opioids. Acetaminophen (1 g IV/PO/PR q6h) and longer-acting adjuncts form your baseline; use fentanyl or morphine only for breakthrough.
• Blocks beat everything—if you can do them. Pre-emptive regional anesthesia (when feasible) is the single highest-yield move before surgical stimulus hits.
• Monitor like your life depends on it. Heart rate, blood pressure, and respiratory rate are your best pain score when the patient can’t talk.
• Plan for worst-case evacuation. Bring more than you think you’ll need and dose for the opioid-naïve or opioid-tolerant reality in front of you.

• Why treating hypertension in the OR (or field) almost always starts with fixing pain first
• The “start low, see response, add more” mantra every austere provider needs
• Why Tylenol often performs as well as morphine in blinded ED studies (and why your patients still doubt it)
• Real talk on ultrasound-guided blocks in 2011 vs. today—and why proficiency still matters
• The dangerous synergy of opioids + benzos + ketamine on respiratory drive
• Why you must get comfortable decreasing doses, not just ramping them up

Chapters

• 01:55 – The austere reality: limited narcotics and why your favorite med won’t last forever
• 03:37 – OR planning vs. field reality: opioid-naïve vs. chronic users
• 05:57 – Multimodal analgesia explained (blocks, ketamine, Tylenol, NSAIDs, dexmedetomidine)
• 08:28 – Patient & mission factors that should drive your loadout
• 12:23 – Golden rule: start low, titrate to effect, monitor vitals
• 15:05 – Sick-patient hack: cut your mental dose in half
• 16:01 – Is ketamine actually an analgesic? (NMDA, opioid-sparing, PTSD data)
• 19:12 – Extending your supply: bolus vs. infusion, redosing strategy
• 24:27 – First-line multimodal choices in the field
• 27:43 – Juggling multiple agents: timing, scheduling, and longer-acting blocks
• 30:15 – Regional anesthesia timing—pre-emptive is king (post-injury limitations)
• 32:48 – Ultrasound & blocks in the current PFC world
• 35:08 – Safety considerations for adjuncts (liver, kidneys, bleeding, alcohol)
• 36:59 – Bang-for-buck data on Tylenol vs. morphine
• 38:55 – Practical integration: layering Tylenol/ketamine with fentanyl titration
• 41:54 – Getting comfortable titrating down (and why pain scores can lie)
• 42:53 – Final wisdom: use everything you’re comfortable with.

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This was my Favorite Presentation from SOMSA '25. Check back for the latest updates from SOMSA '26.

In this episode of the PFC Podcast, Victor, a former Ranger medic, shares his experiences and lessons learned from a mass casualty event during a humanitarian mission in Burma. He discusses the historical context of the conflict, the challenges faced in providing medical support, and the innovative solutions developed in a denied environment. The conversation emphasizes the importance of training, adaptability, and building sustainable medical practices to empower local medics in future conflicts.

Takeaways

Victor shares his experiences as a former Ranger medic.

The humanitarian mission in Burma faced severe challenges.

The conflict in Burma has historical roots dating back to World War II.

Training focused on hemorrhage control and casualty extraction techniques.

Two casualty collection points were established during the operation.

The team had to adapt to carrying casualties over long distances.

Blood transfusions were successfully conducted in the field for the first time.

Building sustainable medical practices is crucial for future operations.

Empowering local medics is essential for effective care.

The mission was guided by a sense of love and purpose.

Chapter

00:00 Introduction to the Humanitarian Mission

02:54 The Conflict in Burma: Historical Context

05:52 Training the Rangers: Preparing for Combat

08:55 The Medical Support Operation: Initial Challenges

11:49 Casualty Management: Triage and Evacuation

14:55 Adapting to the Battlefield: Lessons Learned

17:54 Blood Transfusions in the Field: A New Capability

20:45 Building Sustainable Medical Practices

23:48 Empowering Local Medics: The Future of Care

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