Most of us were taught START, the sieve, RAMP, DIME, P1–P3. Andrew — EM physician on a small surgical team out of Fort Liberty — used none of it the night a helicopter went down with 22 people on board.

The rest of his medical team could not walk. Dust, firelight, yelling. Thirty-to-sixty seconds per patient on a linear algorithm is ten minutes before you reach number ten. People die of massive hemorrhage and lost airway in that window.

So he ran a binary pass: dying now or not. Blood sweep. “Take a deep breath.” Pulse. Ten to fifteen seconds. Keep a mental list of who leaves first. He got through about twelve before other medics arrived. He never reached the massive bleeder — a non-medic first responder did. That is the point.

Rick Hines puts the doctrine next to the wreckage. Triage is continuous, not a one-and-done sort. The most senior medical person is often the worst person to own the sort if they should be operating. Algorithms used after the first pass are training tools — studies put accuracy around or under 50 percent.

Training has to match that. Four casualties before twenty-two. Global endpoints, not a perfect score on every manikin. Delayed birds. Command decisions. Unit buy-in, not a tourniquet-and-check-the-block.

No perfect MASCAL. You were already behind when it started.

Listen: PFC Podcast · prolongedfieldcare.org · @prolonged_field_care

Top 5 takeaways

1. First contact is binary. Dying now / not dying now. Blood sweep, air movement, pulse. 10–15 seconds. Do not spend a minute running START on patient one while patient ten bleeds out.
2. Then deliberate triage. After LSIs and a move to the CCP: urgent / priority / routine (what TCCC/CoTCCC are leaning toward). Expectant exists when resources force it — not on the first pass.
3. Move, treat, transport. Rush’s three verbs beat a four-color card at the wreck. Get off the X, stop hemorrhage and airway loss, get them to the next level.
4. The senior clinician should not automatically own the sort. If they are the surgeon, someone else runs triage. Non-medic first responders are part of the system — Andrew never reached the massive hemorrhage; someone else did.
5. Train the real constraints. Nail four before you role-play twenty-two. Score the lane on whether life threats were found, blood got to shock, accountability held, and evac was prioritized — not whether every individual critical-action list was perfect. Delay the bird. Make the commander choose.

Chapters

• 00:00 Disclaimer and welcome
• 00:20 Andrew Shafrina intro — EM, small surgical team, Fort Liberty
• 01:23 Why most of us never actually practiced triage
• 02:14 Categories: START, sieve, NATO — four bins plus expectant
• 04:10 Why linear algorithms are too slow at the point of injury
• 04:32 The crash: 22 onboard, medical team down, one provider
• 05:39 The 10–15 second pass — blood sweep, deep breath, pulse
• 06:09 Rush, Shackelford, Remley, Hines — binary is what people actually do
• 06:50 Move, treat, transport
• 08:07 What “stable” meant that night — not P1/P2/P3
• 08:51 Twelve patients in five minutes — and he still missed the bleeder
• 10:01 Triage is continuous, not one-and-done
• 10:36 Do not burn the surgeon on the sort
• 11:11 MASCAL means you are already overwhelmed
• 12:06 Put non-medics to work
• 12:43 Evac categories vs who actually needs an OR
• 13:45 First-pass binary, then UPR at the CCP
• 14:14 Algorithms as training tools — accuracy ~50% or worse
• 47:06 Train to global endpoints, not perfect individual checklists
• 48:08 Can you handle four? Then scale.
• 49:09 Rick: six dead, seventeen wounded, no bird, they drove them out
• 52:23 King for a day: two-phase triage + basics
• 53:50 There is no right way — only best with what you have
• 54:18 Put MASCAL inside unit drills, not isolated medic lanes
• 55:22 Scare the staff honestly — risk, delayed evac, command decisions

Dennis sits down with Max to walk through hemorrhagic shock the way it actually behaves in young, healthy military-age casualties—not the tidy textbook ladder of Class I–IV. They start with the only split that matters: compensated versus uncompensated. Class I–II means the body is still delivering oxygen to organs. Class III–IV means it is not, and the damage is no longer a simple volume problem.

Max breaks compensation into “gears”: venous reserve first (no vital-sign change), then heart rate, pulse-pressure narrowing from arterial squeeze, contractility, and work of breathing. He stresses why a 40-year-old operator with a resting HR of 50 who hits 80 is already tachycardic, why a diastolic climbing toward 100 is a warning, and why scene blood volume—“How much blood was on the ground?”—is often the most important sentence in the handoff.

They cover why fit casualties can look like Class II, then skip Class III and drop into unconscious Class IV in minutes (Ranger Campbell and similar “walking dead” cases). Decision-making is reduced to two tenets: Is bleeding stopped? What is the trend? Guidelines that wait for SBP <100 will be late in this population. Short pearls close the episode on peds (small volumes, parental mental-status baseline), pregnant patients (left-side IVC, massive reserve then sudden collapse), and elderly (they follow the book but cannot tolerate Class III).

Top 5 takeaways

1. Draw the line between compensated and uncompensated, not between the four classes. Once end-organ perfusion fails, you are not just replacing lost volume—you are treating ischemia, cytokines, electrolyte leak, and reperfusion.
2. Trauma tachycardia is hemorrhage until proven otherwise. Pain, exertion, and combat stress are real, but you do not get to invoke them until you have ruled out bleeding.
3. Pulse pressure and diastolic BP are early windows into how hard the patient is squeezing. A young casualty at 120/100 with a climbing HR and changing affect is already near the cliff even if SBP is still “fine.”
4. Fit operators can stay in Class II on exam until they have lost a lethal volume, then skip Class III. Reassess constantly. Scene blood volume and expanding hematomas matter more than a single SBP number.
5. Two questions drive transfusion in resource-limited care: Do I have hemorrhage control? Is the patient trending the wrong way on two or more data points (HR, pulse pressure, breathing quality, mental status, hematoma size)? One number on a guideline is not a plan.

Chapters

• 00:00 — Intro and disclaimer
• 00:20 — What we’re covering: hemorrhagic shock and when to resuscitate
• 01:12 — Traditional Class I–IV and why textbooks fail in the field
• 03:00 — Compensated vs uncompensated: the only line that matters
• 04:50 — Class I: venous reserve, no vital-sign change
• 08:30 — How much blood was on scene? The handoff question that predicts danger
• 11:15 — Tennis-score memory aid (15 / 30 / 40) and Class I exam
• 16:20 — Operator baselines: HR 80 can already be tachycardia
• 20:00 — Golden rule: trauma tachycardia is bleeding until proven otherwise
• 22:00 — Pulse locations as a crude MAP map (carotid / femoral / radial)
• 27:00 — Why SBP stays normal in compensated shock
• 29:00 — Pulse pressure explained: diastolic rise, not “falling BP”
• 36:00 — Compensation gears: reserve → HR → squeeze → contractility → breathing
• 39:00 — Orthostasis, cap refill, urine output, and mental status as red flags
• 47:00 — Altered mental status: “drunk” from blood loss until proven otherwise
• 51:00 — Class II: all gears on, BP still held
• 59:00 — Class III–IV and why healthy patients blast through Class III
• 1:06:50 — Ranger Campbell and other “walking dead” cases
• 1:11:48 — When to give blood if SBP is still over 100
• 1:13:50 — Tenet 1: Is bleeding stopped? Five spaces that hide volume
• 1:20:40 — Tenet 2: Trend, not a single trigger
• 1:27:50 — Don’t hang a life on one guideline number
• 1:32:40 — Pearls: pediatrics, pregnancy (left side / IVC), elderly

Ben walks Dennis through a six-month plan that became a jungle course for about 200 unpaid resistance volunteers. Vic built the curriculum from TCCC, the Ranger Medic Handbook, and what that force actually needed — then wrote it to their education level, culture, and organization. Supplies moved through the existing network. The first four days were not student training. They were instructor train-up. Then the locals taught. Interpreters shrank. Force multiplication went up. Chiefs owned the schedule because they knew the logistics better than the foreigners.

The five-day basic block — Ranger First Responder flavor, ~150 students, three languages — ran cleaner than the ten-day advanced course. Around day six, the instructors sat in a hut wondering if anyone could action the material. The FTX answered it: recovery mission, collect, treat, triage, evacuate. When words failed, Ben inserted himself into the lane. Watch me. Do as I do.

Then the punchline he brought home to NATO partners in four and a half days: stop making this more complicated than the environment allows. Basics save lives. Teaching is a hard skill and a soft skill. Ego gets you ignored — or worse. Likability moves supplies. Medics still have to influence commanders so casualties do not bog down the assault.

Listen, then steal the method. Not the ego.

⁠prolongedfieldcare.org⁠ | ⁠@prolonged_field_care⁠ | PFC Podcast

Top 5 takeaways:

1. Build a local instructor cadre first. Four days of train-the-trainer, then hand the blocks to them. Less interpreter drag. Real force multiplication.
2. Write the course to the force in front of you. TCCC + Ranger Medic Handbook as the spine. Education level, culture, and org constraints as the cut line. Chiefs own the schedule.
3. Basics scale. Abstraction does not. The 5-day / 150-student / 3-language block worked because it was see-do-act. The 10-day advanced block created the “do they actually get this?” crisis.
4. When comprehension is in doubt, stop talking and enter the lane. Insert yourself. Narrate while you do the work. Show shock. Do not lecture shock.
5. Teaching is an act of love plus influence. Humble competence beats the alpha brief. Medics still owe commanders a clear recommendation — even if the answer is “we’re doing it anyway, figure it out.”

Chapters:

• 00:00 Cold open + why this trip
• 01:08 Six months of planning — you do not show up on a whim
• 01:59 Vic Nigo’s curriculum: TCCC, Ranger Medic Handbook, culture, org
• 02:51 Supply network for ~200 students
• 03:20 Plan vs jungle reality
• 04:01 Four-day instructor train-up and handing the class off
• 04:56 Volunteers, buy-in, and a culture that does not like quitters
• 06:24 Motivation that costs a patch and a thumbs-up
• 07:29 Ukraine militia hunger vs professional-military spoiling
• 08:26 Why train-the-trainer beats you plus an interpreter
• 09:00 What actually broke: hours, land nav, competing requirements
• 09:54 5-day basic / ~150 / 3 languages — the block that worked
• 10:53 10-day advanced — day 6 doubt in the hut
• 11:41 The FTX: recover, collect, treat, triage, evacuate
• 12:30 Teaching tactic: insert yourself, watch me, do as I do
• 13:14 Show them shock. Do not define it.
• 14:13 SOCM lesson: you do not know the job until you see the job
• 34:54 The course continues — Vic takes it deeper / SOCM Light
• 35:37 The West overcomplicates TCCC
• 36:10 Basics save lives
• 37:11 NATO partners in 4.5 days: trenches, physical exam, pain, cheat cards
• 39:17 Advice for the first overseas class
• 40:06 Know the audience — products change with the culture
• 40:39 Ego is a teaching failure and a survival failure
• 41:24 All teaching is an act of love
• 42:03 Likability as a core attribute
• 43:09 The medic as SME: influence, battlefield clearance, buy-in
• 44:56 Be ready for the unexpected — and try to enjoy it