Prolonged Field Care Podcast

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 PodcastTop 5 takeawaysIt is a hydraulic problem. Fight pressure with pressure. Chemistry cannot replace a packed tract or a tourniquet.Know the two mechanisms. Kaolin accelerates Factor XII / your cascade. Chitosan-type polysaccharides work independently and form a mucoadhesive plug.Contact the vessel or you wasted the dressing. Clot in a basin of blood is not hemostasis. Anatomy and packing skill are the product.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.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.Chapters00:00 Cold open00:19 Dennis + Mike (SARC, Vegas FD, Celox education)01:25 Why not just pressure and plain gauze?02:16 Hydraulic problem: cascade vs femoral-rate bleed03:42 What a hemostatic actually adds03:54 Kaolin: Factor XII, still gauze, still pressure04:54 Chitosan / cellulose: cascade-independent mucoadhesive plug06:03 Charge, RBCs, dual action with the gauze07:07 Granules, sprays, “hummus” pastes — still need pressure08:20 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 brand10:07 Why the 3–5 minute hold feels like an hour10:42 Kaolin activation window (~3–6 min)28:57 Know every item in the bag the way you know a drug29:26 You can spot a professional by the pouch30:11 Hemorrhage control is not a monkey skill31:04 Unconscious competence: pack it blind31:56 Blood programs without packing reps33:04 Schoolhouse months do not last a career34:32 How to read studies that are not the company PDF35:37 Deployed Medicine, JTS workload, mechanisms over marketing37:48 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.org⁠or ⁠https://jsomonline.org/⁠Follow @prolonged_field_careTop 5 takeawaysThe 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.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.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.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.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.Chapters00:00 — Disclaimer and open00:23 — Dennis and George: who wrote the change02:10 — If it ain’t broke, why touch analgesia?02:56 — We lost OTFC03:11 — Safety, LSCO, and early pain vs PTSD04:27 — Mission-capable control and a shock-agnostic path05:48 — How suzetrigine beat 56 other drugs09:38 — Why this non-opioid survived the matrix11:33 — Spasm vs seizure: do not reach for benzos13:33 — Stay in the fight vs cannot14:20 — The old “triple option” was actually four15:06 — Defining pain with the DVPRS16:10 — The stay-in-the-fight pack: suzetrigine, meloxicam, Tylenol17:20 — What “reduction of pain” actually means18:15 — Esketamine: more analgesia, fewer side effects27:38 — If you only get one narcotic, start ketamine28:56 — Esketamine, IN 28 mg, and the 4PANE study30:15 — IV, IO, IM, IN: why they kept the nose33:07 — Pain control vs nystagmus35:26 — Option 4 is moving to PCC36:41 — Chest tubes, crics, and the sedation gap37:54 — Next: backing the PCC analgesia update38:48 — Read JSOM Change 25-03 and close

Recorded live at SOMA 26In a near-peer MASCAL, one medic and one junior medic may face twenty penetrating torso casualties, one unit of blood, and no time to empirically needle or finger-decompress every chest. This SOMA presentation argues that formal triage algorithms are already giving way to intuitive, intervention-first decisions—and that point-of-care ultrasound can make that second pass objective. The proposed two-pass model keeps MARCH as a fast first pass (urgent vs non-urgent), then uses a three-view POCUS exam—parasternal or subxiphoid cardiac motion, pericardial effusion, and bilateral lung apices—completed in under 30 seconds to decide who gets blood, who needs targeted decompression, who needs a surgical airway to thoracotomy or pericardiocentesis, and who is unsurvivable cardiac standstill. Speakers review trauma-arrest survival data, needle-decompression overuse, SOF medic training at Henry Ford (RUSH exam and the abbreviated 30-second protocol), and civilian paramedic programs showing that short courses can produce usable scans that change management. Sponsored by the Special Operations Medical Association.Key TakeawaysEmpiric bilateral chest decompression and “treat everybody” TCCC habits will not scale in large MASCALs when blood, time, and procedural capacity are scarce.Formal algorithms are often unused in real events; medics already default to intuitive triage. The missing piece is an objective tool that separates salvageable from unsurvivable casualties.Published decompression data show low response rates, high practice variation, and procedures performed on patients who did not meet criteria—driven by subjective breath sounds.Cardiac motion on ultrasound is the strongest practical field marker of salvageability in pulseless trauma; standstill without tamponade is associated with essentially no survival and should conserve blood and procedures.A three-view exam (cardiac motion, pericardial effusion, pneumothorax) can be completed in ~25–30 seconds. SOF medics approached expert performance after focused training; civilian paramedics have shown usable accuracy after 4–8 hour courses.Positive findings should drive action: motion → consider blood; effusion + access to thoracotomy/pericardiocentesis → prioritize evacuation/intervention; no lung slide → targeted decompression rather than bilateral empiric procedures.Chapters00:00 – Introduction, disclosures, and the MASCAL problem01:00 – Case: 20 casualties, one unit of blood, empiric procedures02:40 – Intuitive triage vs formal algorithms03:20 – Why empiric needle/finger decompression falls short05:10 – Scarce blood and the need for a modified LSCO triage approach05:50 – Two-pass model: MARCH first, POCUS second07:20 – Three-view exam: motion, tamponade, pneumothorax08:00 – Pulseless trauma survival: civilian and military data11:00 – Cardiac views and what “salvageable” looks like15:20 – Field case: ultrasound guiding thoracotomy and blood use16:00 – Can medics do this? SOF RUSH pathway since 201717:30 – Abbreviated 30-second protocol: retrospective and prospective times19:30 – Civilian 4-hour training and New Orleans scan performance22:40 – Putting it together in MASCAL: salvage the survivable24:00 – Resource rules: motion vs standstill vs tamponade25:30 – Questions and closeListen / follow: podcast → ⁠prolongedfieldcare.org⁠ → ⁠@prolonged_field_care⁠

Medical logistics was an afterthought for a lot of us in GWOT. You submitted a request, something showed up, and everyone joked that the warehouse never read the order. That model does not survive large-scale combat operations.In this episode, Dennis sits down with Jesse Bashel, a medical logistician and acquisitionist, to walk through how SOF medical supply is supposed to work—pre-deployment, on deployment, and after the first 15 days. They cover NSNs versus product names, automatic in-lieu substitutions, Theater Lead Agents for Medical Materiel (T-LAM), the shift from OCO “easy button” money to MFP-2 vs MFP-11 rules, statements of requirement, and why most medical items are service-common (GCC problem) while a tiny slice of SOF-peculiar items stay on MFP-11.The conversation then turns practical: MedLog personnel usually have zero clinical training. How do you teach them why a 6.0 tube matters for a surgical airway instead of an 8.5 ET tube? How do you get logisticians into Ridge Healer, unit training, and field exercises so they stop treating the property book as the mission? And why, in LSCO, logistics itself starts looking like a combat MOS—because the side that can feed, fuel, and bandage longer usually wins.If you are an 18 Delta, flight medic, battalion PA, group surgeon, this one is for you.Key takeawaysOrder by NSN (or full product name + manufacturer), not the nickname you use in the aid bag. Vendors should put NSN placards on tables at SOMA.The system will auto-accept “in-lieu” substitutes unless the logistician blocks it. That is how you get Halo chest seals when you wanted HyFin.SOF units are required to deploy with 15 days of supply. After that, the Geographic Combatant Command (usually MFP-2 / service-common) is supposed to resource the rest; SOCOM MFP-11 covers only SOF-peculiar items (certain CASVAC sets, freeze-dried plasma in some cases, specific antivenoms, etc.).A Statement of Requirements (class I–IX) should be built jointly by the team and the TSOC 180–270 days out when possible, validated by surgeon + J4, then sent to the GCC for a service lead to resource.Most medical products are MFP-2. Do not default everything to “SOCOM will pay.”Close the gap: five-minute education sessions when medics hit the cage, bring logisticians forward on training events, and treat enablers like part of the team instead of a battle squire.In LSCO, supply lines will be targeted. Logistics personnel need to be trained and treated as if they will be on the battlefield—not just in an office.Visit prolongedfieldcare.org, follow @prolonged_field_care, and subscribe so you stay on the bleeding edge of combat medicine.Chapters02:02 – Pre-deployment ordering done right: NSNs vs product names and why you get the wrong chest seal04:24 – In-lieu / substitute items and how to stop the system from auto-accepting them05:24 – Theater Lead Agent for Medical Materiel (T-LAM) catalogs and how they get built07:09 – MFP-2 (service common / common user) vs MFP-11 (SOF peculiar)08:27 – Joint pub requirement: SOF deploys with 15 days of supply10:07 – Who pays for days 16–60? GCC vs US SOCOM headquarters12:10 – Statement of Requirements process: team + TSOC + GCC J4 validation15:58 – MedLog has no medical training—how to educate them before they send the wrong tube21:17 – Closing the operator–logistician distance; policy is not always law26:00 – Retaining SOF-enabler talent instead of rotating everyone back to conventional force28:22 – SUBACUS lessons and why enablers must not be a liability forward30:29 – Two LSCO paradigm shifts: SOF as supporting force + logistics as a combat MOS32:08 – Positional warfare, endurance, and targeting supply lines (bullets, batteries, bandages)32:50 – Where to do the work: put a logistician on the DTS for Ridge Healer and big exercises34:25 – Flip side: teach operators the fiscal and appropriation reality so they can advocate overseas

Ukrainian orthopedic and reconstructive surgeon describes what prolonged field care actually looks like when evacuation from the front line to Role 2 takes three to four days, and sometimes longer. After years of Role 1, Role 2, and evacuation-stage work, he focuses on a problem that now drives limb outcomes: tourniquet syndrome. TCCC made rapid tourniquet application routine; the neglected next step is conversion, replacement, and complication prevention when the casualty remains in the field for hours to days. He shares a three-week Role 1 case series, frontline protocols for resuscitation, antibiotics, and multimodal analgesia, and why communication between echelons is no longer optional. Sponsored by the Special Operations Medical Association.Key TakeawaysCombat has outpaced doctrine: drones, delayed evacuation, and shifting surgical capability forward mean medics now make high-stakes decisions that used to wait for the hospital.In summer–autumn 2025, movement from the front line to Role 2 commonly took three to four days. Complications of prolonged tourniquet time develop during that window, not after arrival.Forces have become highly proficient at rapid tourniquet application for hemorrhage control. Far less attention has been paid to when, how, and under what conditions to convert or remove a tourniquet during extended delayed evacuation.Incorrect application, delayed conversion, and early reperfusion errors at Role 1 create complications that later echelons often cannot fully reverse. Prevention at the first capable point is easier than correction later.Over three weeks at one Role 1, the team reviewed 27 tourniquet cases: 18 already removed before arrival, 5 converted on site, 4 replaced, and 8 presenting with established tourniquet syndrome.A tourniquet left on too long can function as a venous tourniquet. In one ~12-hour case, conversion and wound care were possible; the patient still spent a full day at Role 1 because evacuation remained unsafe.Role 1 care in this environment combines hemostatic resuscitation, Ukrainian MoH / JTS-aligned antibiotic prophylaxis, and multimodal analgesia to reduce opioid dependence while waiting for movement.Drones, shelling, and remote mining remain constant threats to both casualties and medical teams. High-quality Role 1 care still depends on continuous risk assessment and tactical awareness.Continuous case review, data capture, and closed-loop communication from prehospital to hospital are essential so frontline observations can change tactics in real time.Chapters00:00 – Introduction and speaker background 01:50 – Evolving war, prolonged field care, and higher medic responsibility 04:10 – Why tourniquet syndrome now dominates limb outcomes 05:30 – TCCC taught application; the neglected next step is conversion 06:20 – Drones, delayed evacuation, and care shifting pre-evacuation 07:40 – 3–4 day timelines from front line to Role 2 in 2025 08:30 – Role 1 errors that later hospitals cannot fully fix 09:10 – Role 1.5 mission: assess, convert, prevent, stabilize11:50 – Resuscitation, antibiotic, and multimodal analgesia approach 13:10 – Three-week tourniquet case series (27 TQs, 8 syndromes) 15:00 – Case example: 12-hour venous-effect tourniquet conversion 16:20 – When conversion is no longer possible 17:40 – Ongoing battlefield threats to evacuation and medics 18:30 – Continuous learning and echelon-to-echelon feedbackFor more content, go to ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠www.prolongedfieldcare.org⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠