Recorded live at SOMA 26

Dr. Emily Johnston (Cascadia Mountain Institute) and SFC Ezequiel Mendoza (Arctic Dustoff, Fairbanks) deliver a hard-hitting, field-validated look at how standard tactical medical gear and medications actually perform—and fail—in true Arctic and extreme cold conditions. Drawing from cold-soak testing, simulated combat exercises, and real operational experience, they break down battery and fluid-warmer failures, rapid freezing of IV tubing and blood sets, medication storage realities, tourniquet performance, and the critical need for early frostbite interventions like ibuprofen and iloprost far forward. Practical fieldcraft solutions, insulation strategies, and clear calls for better-designed cold-weather medical systems are front and center.

Key Takeaways

• No electronic or mechanical medical device (IV pumps, Buddy Lite warmers, etc.) can be trusted to operate unprotected in Arctic conditions—insulate everything, including fluids and tubing.
• Fluids and tubing freeze extremely quickly and become brittle; passive warming solutions using insulated containers + chemical heat packs can keep fluids viable for many hours even at –20°F to –30°F.
• Body heat (base-layer transport systems worn against the skin) is the only reliably consistent way to prevent medication freezing during multi-day cold operations; outer pockets, med boxes, and sling packs routinely fail.
• Current blood administration sets create major clotting and failure points in the cold; shorter, fully insulated, or redesigned kits are needed.
• Most common tourniquets performed adequately after freeze-thaw cycles; metal windlasses held up better than plastic ones under extreme cold.
• Reperfusion injury is the dominant mechanism of tissue loss in frostbite. Early NSAID (ibuprofen) loading and rapid iloprost administration dramatically improve outcomes, yet cold-chain and far-forward delivery of iloprost remain unsolved problems.
• Manufacturer claims about extreme-cold performance often do not match real-world Arctic testing. Independent field validation is essential before relying on any device or medication in these environments.

Chapters00:00 – Introduction & Arctic strategic context

04:45 – Operational realities: long evacuation times and limited cold-weather experience

06:00 – Battery and device cold-soak testing (IV pump & Buddy Lite)

09:20 – Functional testing: frozen pumps, ruptured warmer cartridges, and fluid output

11:40 – Practical insulation and pre-warming techniques for fluids

13:40 – Medication transport failures vs. base-layer body-heat solutions

18:50 – Blood product challenges and call for redesigned cold-weather kits

20:20 – Tourniquet performance after freeze-thaw cycles

21:15 – Frostbite pathophysiology and the critical role of early ibuprofen + iloprost

27:20 – Path forward: needed research, device redesign, and medication stability after freezing

29:40 – Closing remarks and Q&A discussion

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In this essential episode of the Prolonged Field Care Podcast, Dennis sits down with pediatric intensivist Dr. Sara Bibbens to tackle one of the most challenging and anxiety-inducing scenarios in austere medicine: pediatric burns. From initial trauma assessment using MARCH/ABCDE to nuanced airway decisions in small children, burn resuscitation formulas, fluid management pitfalls, hypothermia prevention, wound care, and safe pain/sedation strategies, this conversation delivers practical, downrange-applicable guidance every combat medic, flight medic, and austere provider needs.

Key Takeaways:

• Stick to MARCH/ABCDE — don’t get distracted by dramatic burns; treat life threats first.
• Pediatric airways swell faster — early intubation considerations (GCS <8, large TBSA, stridor, facial burns, soot).
• Initial fluid resuscitation rates by age + precise TBSA calculation using the Consensus Formula (3 mL × kg × %TBSA).
• Add maintenance D5 fluids in kids <30 kg and titrate everything to urine output goals (1 mL/kg/hr under 30 kg; 0.5 mL/kg/hr over 30 kg).
• Plasma-based resuscitation is preferred when available.
• Hypothermia prevention is more critical in children due to higher BSA-to-mass ratio.
• Pain management: Start low with opioids (morphine preferred), ketamine for dissociation/procedural sedation; watch for respiratory depression when combining meds.
• Avoid routine prophylactic antibiotics; focus on source control and dry dressings.

Whether you’re operating in contested environments, remote settings, or supporting pediatric casualties, this episode arms you with the knowledge to avoid common pitfalls like fluid creep and over-resuscitation while delivering life-saving care.

Website: ⁠www.prolongedfieldcare.org⁠

Follow @prolonged_field_care on Instagram for carousels, reels, and more austere medicine content.

Subscribe and stay on the bleeding edge of combat casualty care.

• Episode Chapters00:00 - Introduction & Welcome

• 00:46 - Guest Introduction: Dr. Sara Bibbens, Pediatric Intensivist
• 01:04 - Initial Assessment: MARCH/ABCDE in Burned Pediatric Patients
• 02:43 - Prioritizing Life Threats Over Dramatic Burns
• 03:37 - Airway Management in Children: When to Intubate?
• 06:11 - Surgical Airway Limitations & Head Positioning in Pediatrics
• 07:42 - Burn Resuscitation: Initial Fluids & Rule of Tens Limitations
• 08:04 - Pediatric Lund-Browder Chart, TBSA Estimation & Consensus Formula
• 11:46 - Maintenance Fluids (D5) + 4-2-1 Rule in Kids <30 kg
• 13:26 - Glucose Goals & Dextrose Fluid Mixing in Austere Settings
• 14:14 - Urine Output Goals & Endpoints for Resuscitation
• 16:15 - Avoiding Fluid Overload & Fluid Creep in Pediatrics
• 19:00 - Plasma Resuscitation (Vanderbilt Protocol) in Burns
• 20:25 - Titration Strategy: Urine Output Over Fixed Formulas
• 21:52 - Creative Urine Output Measurement (Diaper Weights)
• 22:59 - Hypothermia Prevention in Children (Large Head, High BSA:Mass)
• 24:26 - Wound Care & Why to Avoid Prophylactic Antibiotics
• 25:37 - Pain & Sedation Management: Opioids, Ketamine Dosing & Monitoring
• 28:46 - Common Pitfalls: Fluid Over-Resuscitation
• 29:48 - Managing Fluid Overload & Closing Thoughts

In this presentation, we take a deep dive into the 300-year history of mobile surgery supporting land campaigns — from Dominique Larrey’s ambulance volantes through the Letterman system, Arnhem, the Falklands, Mali, and the current Russia-Ukraine war. Drawing on rare surgical memoirs, battle maps, and personal accounts, the discussion extracts the recurring problems that technology has never fully solved: logistics drag, extended timelines, signature management, and the tension between mobility and capability.

We then turn to the horizon. In an era of mosaic warfare and large-scale combat operations, medicine cannot remain a drag factor. The talk explores contractile and expandable surgical systems, single-surgeon reach, austere armored resuscitation teams, underground and containerized facilities, emissions control, and how we expand the surgical workforce under resource constraints while still doing the most for the most.

Whether you are preparing for LSCO, SOF support, or prolonged field care in denied environments, the hard-won lessons of the past remain the best preparation for the fight ahead.

Key Takeaways

• Mobile surgery is not new — Larrey, Guthrie, Pirogov, and Letterman already solved (and documented) many of the mobility and triage problems we still face.
• Institutional memory fades fast. Rare single-edition war surgery texts must be digitized and pushed into training pipelines before the lessons are watered down.
• In mosaic warfare the linear Role 1–4 model is insufficient. Surgical capability must become a mesh: dispersed, diggable, low-signature, and able to expand or contract with the fight.
• Big fixed facilities and large tented Role 2/3s become high-value targets. Single-surgeon or small polyvalent teams, pre-dug containers, underground sites, and armored austere teams offer greater survivability and shorter wounding-to-surgery times.
• Blood, sterilizing capacity, anesthetic volume, and outflow remain the greatest logistic constraints. Expectation management and robust triage (including expectant) will be non-negotiable.
• Capability can be extended by bringing registrars, ODPs/CRNA-equivalents, and well-trained medics further forward earlier — but this requires deliberate peacetime training and wartime derogations.
• Command and control, decision-making loops, and the ability to cache or hand off casualties must be rehearsed now, not improvised under fire.

Chapters

00:00 – Introduction & Scope: 300 Years of Mobile Surgery02:00 – Institutional Memory, Rare Texts & the Risk of Forgetting05:25 – Dominique Larrey & the Birth of the Ambulance Volante07:00 – Guthrie, Napoleonic Lessons & Early British Mobility07:40 – Crimea, Pirogov’s Forward Teams & Brunel’s Prefabs08:15 – The Letterman System & the American Civil War08:50 – World War I: Auto-Chir, Operating Cars & the Limits of Static Warfare11:15 – Spanish Civil War: Civilian Surgeons & Fluid Fronts12:00 – World War II Desert, SAS & the Reality of Extreme Isolation13:40 – Arnhem, Market Garden & Improvised Care Under Fire16:00 – Varsity, Chindits & the Logistics Drag of Jungle Warfare18:00 – Falklands, Gulf War, Mali & Modern Mobility Challenges19:50 – Ukraine: Extended Timelines, Targeting of Medical Assets & Aged Injuries20:50 – Horizon Scan: Mosaic Warfare & Contractile Surgical Systems22:00 – Dispersion, Digging In, Underground Facilities & Signature Management24:00 – Capability Extenders, Team Composition & Decision-Making Under Constraint25:30 – Logistics, Blood, Sterilization & the Middle Ground Between Fixed and Tiny Teams27:00 – Closing Thoughts & Questions

Follow @prolonged_field_care and visit prolongedfieldcare.org for more austere and prolonged field care education.