Medical SOP

This document is broken into two parts, the first of which being the proper determination of when to render medical services, and the second being how to render those medical services. This SOP will apply to all Bravo 3 members, not just medical staff as all members of Bravo 3 are to be cross trained in numerous roles.

## Part 1. Assessment

The most important thing to do before rendering any sort of medical aid whether to oneself or others is to make a proper assessment of the situation before rendering aid.

* The cause of wounds should be identified and if still threatening eliminated, whether by force or evasion.

* Medical aid should not be rendered until the cause of wounds is identified, and all identified imminent threats are eliminated or evaded (imminent threats being defined as anything that can cause further wounds to the recipient or provider of care within the next two minutes).

After assessment of the situation, assessment of the patient should follow.

* There are five levels of triage with corollary levels of stability and mobility(stability and mobility referring to how long a patient can go without care and how far/long a patient can be moved)
	+ These five levels while color coded are not to be confused with the color system we use for Ace Reports

* Triage Level Blue
	+ The patient is conscious
		- Only render aid if there is no more pressing tasking or the patient is unable to render self aid due to current tasking or lack of medical supplies

* Triage Level Green
	+ An unconscious patient with a heart rate, no bleeding, moderately high blood pressure (110/70 or Lost some blood), and low pain is a triage level green
		- This patient is highly stable and highly mobile and is expected to become conscious at any moment

* Triage Level Yellow
	+ An unconscious patient with no heart rate, no to low bleeding, moderately high blood pressure to low blood pressure(110/70-70/40 or Lost some blood to Lost a lot of blood), and low pain is a triage level yellow
		- This patient is of moderate to low stability and moderate mobility based on when cpr was last rendered.
		- This patient should not go more than 4 minutes between rounds of cpr, but is mobile between rounds of cpr

* An unconscious patient with a heart rate, no bleeding, moderately low blood pressure(100/70-80/50 or Lost a lot of blood), and any level of pain is a triage level yellow
	+ This patient is highly stable and highly mobile but is not expected to become conscious without medical attention

* Triage Level Orange
	+ An unconscious patient with any heart rate, moderate bleeding, high to moderately low(120/80-90/60 or Lost some blood to Lost a large amount of blood), and any level of pain is a triage level orange
		- This patient is of moderate to low stability and moderate to low mobility based on current blood pressure

* Triage Level Red
	+ An unconscious patient with any heart rate, heavy bleeding, any blood pressure, and any level of pain is a triage level red
		- This patient is of low stability and low mobility as a heavy bleed will result in crashing vitals and rapid death

* Note: Any patient with an active bleed is at risk of deteriorating to a more severe triage level

Triage level determination is useful for providing information about the combat effectiveness of the group, the mobility of the group, and the priority of care. Priority of care is used when there are two or more patients. Once the situation and patients have been assessed, care can be administered in the following priority.

* Role Based Priority
	+ Any patient with role based priority should be brought to triage level green before moving to patients without role based priority so that they may resume fulfilling their role asap

* Chain of Command
	+ While all members of the unit are valued, restoring the chain of command and thereby the chain of communication is most important to ensure continuation of the mission.
* FACs
	+ When FACs are in use they take priority after members of the chain in command in order to reestablish communication with other UNSC forces operating in the AO
* Medics
	+ Since all members of the unit are to be cross trained in medical, medics are not the highest priority as any unit member should be capable of providing care to patients.
	+ Medics still should be prioritized over regular unit members as they carry more medical supplies then other unit members and can therefore render aid to more patients before requiring resupply
* Everyone Else
	+ There are no further priorities given based on role or rank after the previously stated

* Condition Based Priority
	+ When there are multiple patients within the same role care should be administered based on condition
		- Patients below triage level yellow should be prioritized first as patients at or above triage level yellow can be kept alive with little to no care
			* Triage Level Orange is take first priority
				+ These patients can quickly and reliable be brought to triage level yellow compared to patients in Triage Level Red
			* Triage Level Red takes next priority
				+ These patients can be quite volatile and easily lost, as such it is often recommended for two people to administer care to them when possible
					- No more than two people should ever be rendering medical care to an individual patient
		- Triage Level Yellow patients can be brought to triage level green once all patients are at least triage level yellow
		- Triage Level Green and Blue patients should only be cared for if there is no more pressing tasking

## Part 2. Treatment

This section will cover the proper treatment of patients in order to stabilize and restore consciousness in the most efficient manner.

The first condition to treat is bleeding.

* Limbs
	+ Arms and Legs are the fastest body parts to treat for bleeding to due the implementation of tourniquets
	+ Any limb with more than one bleeding wound should be tourniqueted
		- Note: In our current settings an elastic bandage takes 6s, a biofoam canister 8s, and a tourniquet 7s. Therefore a tourniquet is faster than bandaging two or more wounds by at least 5s and faster than biofoaming any number of wounds by at least 1s.
		- In situations of massive hemorrhaging (at least 15 open wounds) and low blood pressure(90/60 or less/Lost a large amount of blood or worse) the least injured limb should NOT be tourniqueted so blood can be transfused. In the event that all limbs are similarly wounded the patient’s right leg should be NOT be tourniqueted
* After bleeding in the limbs has been halted treat bleeding in the head and torso
	+ If both the head and torso have similar amount of bleeding wounds the head torso should be prioritized

After bleeding is stopped, the patient should have any bandaged wounds stitched to prevent wounds from reopening

After bleeding is stopped and any bandaged wounds are stitched, blood loss should be reversed

* Blood loss is prioritized over heart rate in Arma because a low blood pressure can prevent a heart from restarting
* Blood transfusions also occur passively over time after the active administration meaning other treatments can be provided during the transfusion such as cpr, splints, or further care of open wounds on tourniqueted limbs
	+ This is also why running a blood transfusion on a massively hemorrhaging patient works before bleeding has stopped because the passive transfusion results in a lower rate of total blood loss then just bandaging open wounds
* Blood transfusions should be administered until the patient has at least a moderately high blood pressure(at least 110/70 or lost some blood)
	+ A quick way to determine how much blood a patient needs is to look at the quick message related to blood loss
		- Lost some blood is <0.9L of blood
		- Lost a lot of blood is 0.9L to 1.8L of blood
		- Lost a large amount of blood is 1.8L to 2.4L of blood
		- Lost a fatal amount of blood is 2.4L to 3.0L of blood
			* If a patient loses more than 3.0L of blood they die
* Note: Blood pressure can not be accurately measured through a tourniqueted limb

Once bleeding is stopped and blood level is at or approaching 110/70 or Lost some blood the patient’s heart can be restarted

* Note: It is possible to restart a heart at 100/60 or Lost a lot of blood, but it is less likely
* The heart rate of a patient can be detected through the torso, or any non tourniqueted limb
	+ The heart rate of a patient will be incorrectly measured if taken while someone is performing cpr
* If the patient has a heart rate of 80 it is considered normal and no heart related treatment is needed at that time
	+ If the patient has a heart rate other than 80, cpr is not needed at that time but occasional monitoring is necessary to ensure cardiac arrest does not occur before the heart rate normalizes
* If the patient does not have a heart rate administer a single dose of epinephrine and begin administering cpr, checking heart rate every three cycles of cpr
	+ Epinephrine temporarily raises the blood pressure of the patient and increases the likelihood of cpr restarting the heart by roughly 20% while the epinephrine is in the patient’s system
		- Only one dose of epinephrine should be administered per heart stoppage to prevent overdoses which can cause a loss of consciousness and even death in severe cases

Once a patient’s bleeding has stopped, blood loss reversed, and heart started they are considered fully stable.

* Fully stable patients should wake up without further care unless their pain level is too high
	+ Pain may be being caused by broken bones, applied tourniquets, or the previous wounds sustained
		- Once wounds are treated, broken bones splinted, and tourniquets removed pain will decrease over time
		- Morphine can be administered to patients who are only unconscious due to pain or conscious patients who are about to fall unconscious due to pain
			* Morphine should be used sparingly as it causes a temporary drop in blood pressure which can result in unconsciousness for patients with low blood pressure, it can also be overdosed on like epinephrine causing similar symptoms