Letters to the Editor

Military Medicine, Mar 2008 by Baker, Michael S, Thornsvard, Charles T, Gaydos, Joel C, Chretien, Jean-Paul, Tomich, Nancy, Cox, Kenneth, Erickson, Ralph L, Kelley, Patrick W, Casscells, S Ward

To the Editor

Captain Butler and his Tactical Combat Casualty Care (TCCC) team are to be congratulated on this new set of guidelines designed to ensure both the medical care and the missions are successful. TCCC has once again have provided a well thought out and succinct approach to melding best medical care practices with the realities of casualty care on the battlefield. This tactical approach to medical care is essential both in military medicine and will also apply to certain civilian casualty events, and has utility in pre-hospital life support programs.

The clear advantage and proper use of tourniquets, recommendations for battlefield analgesia, antibiotics, recognition of hypothermia risk, and proper fluid resuscitation are critically important tools which our providers need at the tip of their fingers. In the last paragraph there is a teaser about the challenge in finding better battlefield analgesia and moving forward in other areas.

I challenge the TCCC group to consider one more difficult scenario that I find daunting even in our stable civilian setting. Patients with traumatic brain injury, hypoxia, psychiatric decompensation, drug use, or alcohol intoxication often have an agitated or altered mental status. The combative and disoriented patient is a danger to himself, to the medical providers, and to the mission. Rarely can they be reasoned with, physical restraint may well be impractical, and further constructive action is sometimes impossible.

Guidelines for the handling and control of the disoriented, agitated, or combative patient would be of great value to medical personnel, their line commanders, and also to many in civilian practice. It is a major threat to good patient care, to successful mission completion, and to the safety of the team members. TCCC efforts have been instrumental in providing recognition of the tactical setting as it relates to the care of casualties. This is another branch in the stalwart tree of work they have started.

Michael S. Baker, MD, FACS

Rear Admiral, MC, USN (ret)

Dear Editor.

I was a rodeo doctor once. Can you imagine an internist as a rodeo doctor? That was the problem. I could. I could imagine the back injury, the neck injury - all those injuries that I was so poorly qualified to treat. But it was a Saturday. I was an Army doc in Germany - and any "doc" would do. It was the soldier rodeo! Yea!

Bull riding was the big event. Soon making his way to my tent was a young soldier. His foot had been stepped on by a bull. I carefully removed his boot - every one of his toes seemed broken - his foot swollen and blue. But, the pulse was OK. We lay him down on a cot, packed his foot in ice and prepared to take him to the clinic for X-rays. Meanwhile, I resumed my duties, praying fervently that every bull would be a blooper (a dud) and its rider bail out without incident. I was the only one that day hoping for a truly boring rodeo.

After a while as I made my rounds, I spied that same soldier with the crushed foot standing at the rodeo ring, his booted injured foot on the rail.

"What are you doing?" I asked.

"Cowboying it out,"

"Ah, yes, of course," I thought. How could I have been so foolish not to have known this ancient principle? I marveled. How could he stand it, how did he get that boot back on?

"You need to get off that foot and get ice back on it."

"Aw, doc, it'll be alright."

I left him there, never to see him again, imagining what happened to that blue, crushed foot, now better able to conform to those pointytoed boots.

That evening I recounted the day's events for my family and the story of the soldier who "cowboyed it out." Over the years this became our mantra when injuries or life's vicissitudes required "a certain" toughness. If the kids got scraped or cut - "you need to cowboy it out." A bad headache: "cowboy it out." Post op pain: "cowboy it out." You get the idea.

Of course cowboy it out is an ages old concept, as old as the Stoic philosophers. It is particularly apt for a soldier - or a cowboy: 'Take the pain." It encourages fortitude, quiet suffering, eliminating emotion and passion - thus allowing coolness of reason. As physicians we see different ways people react to pain - from wailing and writhing to a quiet acceptance.

One day not long ago a patient arrived. A middle-aged man, short and thin of stature, who of late had switched his look from preppy to cowboy, sporting a big hat, big buckle, levis, and western style shirt. My nurse Norma asked him why. "I got horses," he said.

Four days before, he had been thrown by a horse. He had struck his left back. It was still hurting. His physical exam disclosed a little tenderness and mild swelling over the paraspinous muscles of his back in the left lumbar region. There was no bruising. My impression was a mild contusion. He wanted an X-ray, which we obtained. It was late in the afternoon. I pulled up the images on our digital station and studied the axial spine carefully. No fracture. He did not want narcotics. I advised rest and Ibuprofen.