Recorded live at SOMA 26

In 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 Takeaways

• Empiric 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.

Chapters

00:00 – 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 close

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