Prolonged Field Care Podcast

Recorded live at SOMA 26Dr. 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.TakeawaysMarked 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.Chapters00:00 – Introduction and controlled vs. humanitarian environments01:50 – Purpose of the talk: war does not discriminate02:30 – Medical facilities as targets (Syria, Ukraine, Gaza)04:00 – Underground hospitals and mass-casualty realities in East Aleppo06:40 – War surgery is technically simple; the environment and psychology make it hard07:10 – Leave war wounds open: case progression and rationale08:30 – You cannot save everyone: triage under extreme resource limits09:10 – Chaos of body bags and declaring the dead10:00 – Blood protocols, logistics, and the limits of escalation20:50 – Case examples: blood quotas, open fractures, and failed resuscitations22:00 – Moral injury in the OR and among local staff23:00 – Starvation, maggots, compartment syndrome, and unhealable psychic scars24:30 – Providers as casualties: double-taps and personal losses25:20 – Scenes from Gaza: resource decisions and morgue realities27:20 – Final take-home points and psychological resilience29:00 – Why the work matters and closing remarksListen / 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_careTakeawaysHypothermia 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.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.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.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.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.Chapters00:19 Thomas — Danish SOF medic, anesthesiologist, Brightbird, Greenland03:03 How extreme cold changes TCCC06:08 Hypothermia plus injury, frozen fluids, dead batteries06:43 Treatment on the snow makes him colder, coagulopathic, acidotic07:55 Hypothermia is patient care and a team threat08:16 Tactical field care waits for a heated shelter08:48 MARCH on the X: hemorrhage first, clothing in the way12:03 Do not start full MARCH until the environment is semi-controlled14:01 Tourniquet over the clothing, prone if the airway is obstructed22:00 Vapor barrier first, stop further heat loss24:00 Tent up, stove running, then the secondary work28:00 Warming drugs against the body32:00 Cold drugs and product degradation36:00 What cold does to the kit outside37:27 Ketamine, morphine, prefilled syringes, IV antibiotics38:11 Plastic IV bags leak on thaw. Glass crystalloid. Blood is still plastic.38:46 Freeze-dried plasma: possible, needs fluid and time39:26 How far to the first shelter41:21 A tent needs security. Thirty minutes is already long.43:07 Greenland expedition: ten minutes down, consciousness dropping, no new injury45:39 Wool, tested gear, stoves you can light in gloves49:11 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_careTakeawaysA 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.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.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.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.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.Chapters01:17 Adding interventions is easy. Unwinding them is the PFC problem.02:17 The oversedated femur: ketamine, narcotic, snoring, cric03:46 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 recreate06:29 Off the bag, follows commands, breathing pattern07:10 Cuff down: can he breathe around it?09:01 Suction above the cuff before you deflate09:42 Ketamine no-man’s-land between analgesia and sedation10:41 Fentanyl for the cuff, not another snow14:05 If the airway is quiet, leave it until everything else is mitigated14:16 Do not pull the bookmark in a partial responder28:07 What is coming out — serous vs blood vs pus28:30 Empyema tubes that stay for months28:33 Air leak on a Heimlich: kazoo is fine, crepitus is not29:02 SpO2, mental status, oxygen need before a pull29:37 Heimlich vs three-bottle suction30:51 Improvised single-bottle underwater seal31:16 No seal, and you just made a sucking chest wound33:34 Chest wall you cannot seal: positive pressure, or a cric35:41 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 problem39:25 Sudden crepitus with an advanced airway: dislodged cric vs tracheobronchial injury42:11 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_careTakeawaysA 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.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.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.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.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.Chapters01:17 Adding interventions is easy. Unwinding them is the PFC problem.02:17 The oversedated femur: ketamine, narcotic, snoring, cric03:46 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 recreate06:29 Off the bag, follows commands, breathing pattern07:10 Cuff down: can he breathe around it?09:01 Suction above the cuff before you deflate09:42 Ketamine no-man’s-land between analgesia and sedation10:41 Fentanyl for the cuff, not another snow14:05 If the airway is quiet, leave it until everything else is mitigated14:16 Do not pull the bookmark in a partial responder28:07 What is coming out — serous vs blood vs pus28:30 Empyema tubes that stay for months28:33 Air leak on a Heimlich: kazoo is fine, crepitus is not29:02 SpO2, mental status, oxygen need before a pull29:37 Heimlich vs three-bottle suction30:51 Improvised single-bottle underwater seal31:16 No seal, and you just made a sucking chest wound33:34 Chest wall you cannot seal: positive pressure, or a cric35:41 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 problem39:25 Sudden crepitus with an advanced airway: dislodged cric vs tracheobronchial injury42:11 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 PodcastTop 5 takeawaysThe 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.Late-career PHAs are evidence. Battalion medicine may ignore them. The VA file does not. Stop auto-checking “no.”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.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.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.Chapters00:21 Will: EOD, SOF medic, Guard battalion PA01:03 Third-party VA examiner — what the job actually was02:05 38 U.S.C. § 1155, Reddit, do the homework03:03 Active duty TAP vs Guard/Reserve fog03:33 Guard can file after first enlistment — and drill at 100% with offset04:13 What the evaluator actually reads04:40 No Genesis. You get the dump they send.05:17 Those “no” PHAs are in the file05:52 Cookie-cutter exams, history, nexus, physical06:45 If they never laid hands on you, the exam is incomplete07:30 Be your own advocate — diagnosis first08:18 SOF and pilots under-report to stay in the pipeline09:11 Off-book team medicine: gel, toradol, no note10:00 Confirm the injury, grade the injury10:34 Audio has to match the video31:07 “I’m fine” is not the same as pre-service baseline31:51 Examiner is not your enemy and not your lawyer32:17 10–15 minutes per condition — they will leave value on the table33:06 1,500–3,000 page PDF. Awards and 214s get buried.33:44 Build the packet: 214s, V-device awards, schools, EIB34:54 Print the pages for this exam so they stop scrolling35:56 Current MOS can hide prior SOF noise and blast37:27 Where to go: the Code, VA.gov — who to skip: paid mills39:16 C&P is QTC / Leidos. They cannot reach into a record you do not bring.40:45 Close: it matters for the familyListen 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.