Combat Medic Vs Combat Paramedic

[u/codyfire226]

I have the Deployed medicine app on my phone and I was wondering if someone from the military could tell me about whats makes someone a Combat Medic vs A Combat Paramedic?

I looked at the skills list and both roles are very similar with the exception that a Combat paramedic can intubate and a Combat Medic can't not, I am a civilian Paramedic with a heavy interest in Combat medicine, I have taken TECC with plans to take the TP-C once I complete my Associates degree

[u/thedesperaterun]

look again, under TBI.

[u/[deleted] → u/thedesperaterun]

I’m looking at the 2024 guidelines right now. The verbiage is “consider a definitive airway”. Unless you’re referring to the JTS CPGs, which are not the TCCC guidelines.

[u/thedesperaterun → u/[deleted]]

so you're looking right at it and arguing that it's not there?

*finishes beer*

I'm out.

[u/[deleted] → u/thedesperaterun]

Are you looking to have a discussion or see how many sarcastic remarks we can throw at each other to get internet points? There is one line in the 2024 guidelines about intubations in lieu of cric during tacevac only. If you see anything else in the 2024 tccc guidelines about utilizing paralytics and intubations we must be looking at a different document.

[u/beefy_whale → u/[deleted]]

This is where tier 4 clearly differs from the other tiers though. As a Combat Paramedic or Provider the guidelines clearly state indications, limitations, and contraindications of ETI. You’re right that the guidelines only “recommend” it in the Tacevac phase specifically. But the verbage and guidelines clearly state that, if trained, you can intubate and it is up to your clinical judgment of when and how. There is a lot of autonomy in Tier 4 as a Tactical Provider.

But, ETI in this setting is NOT “recommended” by TCCC in a lot of scenarios and for a lot of reasons. But, it is still taught in Tier 4 and you are still able to do it if warranted and if trained.

Also you mentioned paralytics before, just wanted to clarify that you’re 100% right about paralytics not being utilized in TCCC, there’s no recommendations for it and it is not taught. If you want more info on this you can look into the “Prolonged Field Care” sections where they mention not recommending paralytics due to the risk, however still stating that if its in your scope, and you are trained AND its stated in your protocols then go for it.

I think the problem a lot of people have is seeing TCCC training and guidelines as the end all be all. These are just guidelines and training built for people of different levels of skill and knowledge, meant to make things more standardized and easy in the combat environment

[u/SFCEBM → u/beefy_whale]

I don’t remember putting paralytics in the analgesia and sedation CPG. But it’s been a few years. Possibly in the airway, but didn’t write that one.

[u/[deleted] → u/beefy_whale]

I get what you’re saying, but everyone falls under the same guidelines. Nowhere in the 2024 guidelines are intubations even talked about except for that one line at the end of tacevac. I’m a paramedic and there are literally 0 situations where I’d feel comfortable doing an RSI in CUF/TFC.

I agree it’s important to adjust the guidelines to specific scopes of practice, but keep in mind they are worded and developed very intentionally. If you want to adjust your approach that’s a conversation to have with your seniors/medical chain of command.

Also full disclosure, I have never been to the official tier 4 class/course

[u/thedesperaterun → u/[deleted]]

I don’t understand what the discussion would be. You said it’s not in TCCC. I pointed out that getting a definitive airway is absolutely mentioned in TCCC under TBI. You agree it’s there, but now you’re wording it as paralytics AND intubation as if they always have to go hand in hand when they don’t. A definitive airway can be accomplished without paralytics. Use Ketamine. You’re also stating you don’t feel comfortable with RSI in Care under Fire or TFC. Well I would hope so. No one is suggesting you do that.

[u/[deleted] → u/thedesperaterun]

It is implied that a definitive airway is a cric, hence the note about intubation in lieu of cric in tacevac. Curious, would you feel comfortable sedating and intubating in CUF or TFC?

Also the comment I was originally replying to mentioned RSI, which is why I made a comment about paralytics not being in TCCC guidelines, which you then told me it was under the TBI section.

[u/thedesperaterun → u/[deleted]]

ABSOLUTELY NOT. you’re not just cric-ing your TBI, and that is NOT what’s ‘implied’. Especially with you being a paramedic. Come on, man.

And what you seem to be missing here is the latitude available to you to use your own clinical judgement. No situation is the same; all are unique. That’s why TCCC are GUIDELINES. So you asking me would I feel comfortable here or there… it’s all situation dependent. I can tell you if the casualty needs an airway, they’ll be getting one as soon as I can make it happen given what’s going on in THAT situation. And that should be your perspective as well.

[u/[deleted] → u/thedesperaterun]

Actually, you absolutely are. That is what is taught in a majority of all SOF medical courses, socm refresher, and by numerous EM and trauma surgery physicians that have taught on TBI injuries in TCCC, so maybe chill on the caps lock.

That is my perspective, however it doesn’t change the fact that intubation is not a recommended intervention in TCCC. If you don’t believe me you can read the comment from a member of CoTCCC that said exactly that on this post. If you and your medical chain of command feel comfortable doing so that’s okay, but those aren’t the guidelines.

[u/thedesperaterun → u/[deleted]]

TCCC doesn’t “imply”. They’re either clear or are leaving up to your clinical judgment. And you said you’d never been to Tier 4 training, but now you’re familiar with SOF curriculum.

If an 18D or Trauma Surgeon comes in and says he is performing a cric on a hypertensive TBI patient that needs an airway because it is now the standard in a situation where you don’t have paralytics, I’ll believe it, because it does make sense. But I have NEVER heard that as an indication for cric.

[u/[deleted] → u/thedesperaterun]

Brother, I’m familiar with the SOF curriculum because I’m a SOF medic. We are tier 4 credentialed through socm/SFMS. I just consider that kind of grandfathered in compared to going to a formal tier 4 course.

But yes as an 18D grad I can tell you that is what is taught as the standard currently.

[u/CamelProof1941 → u/thedesperaterun]

I wouldn’t throw a tube in patient’s mouth unless I could guarantee paralysis in pt’s with head injuries.

With Ketamine-only intubations their gag reflex is still intact. Stimulating CN IX and X in a patient with sTBI can significantly elevate their ICP and worsen their outcome.

I would in fact far prefer a cric in sTBI if you absolutely had to get an airway onboard. I would consider the cric to be neuroprotective in this case, which is entirely the point of managing a sTBI in an austere environment.

But I’m just a socm without NRP (old guy). I could be wrong.

[u/[deleted] → u/CamelProof1941]

Bingo. And hey I might have my NRP but I missed out on the bachelors degree 🥲

[u/thedesperaterun → u/CamelProof1941]

RSRL, yes. And I get your thinking, but I have never heard or read it recommended to cric a TBI patient unless at the tail-end of a failed airway algorithm (apart from the other obvious indications). Without a paralytic, you’ll have a harder time getting that tube, exacerbating stimulation on those supraglottic reflexes and possibly worsening ICP (which is more of a concern now that the Ketamine itself, which is considered safe for use in TBI). I follow, I do, but I’ve just never seen a cric be recommended FOR this case. They don’t even find it worthwhile to use pharmacologic adjuncts to attenuate that hemodynamic response anymore (used to be either esmolol, fentanyl, or lidocaine). You can argue for it, but to say that it is what is being implied here is a leap, especially in a TBI pt with hypotension (and hemodynamic status here isn’t specified).