Prolonged Field Care (PFC) is a concept, a practice, a specific kind of austere, remote, yet cutting edge medicine. The concept of PFC is as old as medicine itself, but only recently was it systematized and protocolized. In 2012, as the DOD transitioned from the matured, kinetic combat environments of Iraq and Afghanistan into new, low intensity conflicts smoldering around the globe, medical personnel realized that the old way of practicing combat medicine downrange was incompatible with emerging threats and battlefields. Change was crucial.
Why Prolonged Field Care?
The two main stimuli for this evolution were (1) the tyranny of distance, and (2) the anticipation of future conflicts with peer and near-pear nations. In Iraq and Afghanistan, after Secretary of Defense Robert Gates mandated adherence to the Golden Hour, the battlefield was medically matured. Development required that medical capabilities be distributed within close distances of ongoing missions or operations, or alternately, mobile medical teams be forward deployed close to the battlefield to receive and resuscitate the injured rapidly. This mandate also restricted operational planning to maintain missions within sixty minutes MEDEVAC flight time for critically injured.
While Gates’ mandate functioned fine in Iraq and Afghanistan, special operations units deployed elsewhere to much larger and less developed battlefields soon realized that this idea was inactionable and required modification. Africa is a prime example of the tyranny of distance. We have DOD units deployed all over Africa with limited medical capabilities, and Africa is huge. SOF medics often find themselves managing critically injured patients far beyond the Golden Hour just because of the massivity of the continent and the inability to MEDEVAC immediately.
The second compelling reason to develop PFC concepts and capabilities is the high likelihood of conflicts with near peer and peer nations in the future. In these conflicts, we may exercise only limited air superiority or even no air superiority, in which case air MEDEVAC may be impossible or significantly delayed. Examples include conflicts with Russia, China, Iran, North Korea, etc. This dynamic may require SOF and conventional medics to “babysit” critically injured or sick patients for extended periods without next level of care available. The tyranny of distance and the threat of near peer adversary conflicts forced evolution in the concepts of medical care downrange.
“In the future, we will be working in permissive, semi-permissive, and some non-permissive environments. We may have no authority to operate in certain countries without that government’s or the ambassador’s approval. We will not have the same robust infrastructure available, but battlefield commanders will still expect the same medical capability as past wars. It is our job as medical providers/planners to inform them, and their job to understand this dynamic and mitigate operational risks.”Jim Czarnik, Army Colonel, Emergency Medicine Physician. PFC Podcast 27.
Prolonged Field Care Origins
In 2014, during the first PFC podcast, Dr. Sean Keenan, emergency medicine physician and command surgeon of the 10th Special Forces Group at that time described the origin of Prolonged Field Care concepts and practice in the US military. In 2013, as multiple groups began to recognize the need for training in “extended care” beyond the Tactical Combat Casualty Care (TCCC) algorithm and the Golden Hour, the Prolonged Field Care Working Group (PFCWG) was created at the annual Special Operations Medical Scientific Assembly (SOMSA). Members of the working group began brainstorming and working through the concepts, training, and practices and established the initial form of PFC. Over the years these concepts and practices were evolved and refined into what PFC is today.
In 2015, the PFCWG published two position papers in the Journal of Special Operations Medicine. The first position paper detailed the ten requisite skills for PFC practitioners in austere environments. This position paper purposefully focused on specific skill development in a “good, better, best” format, rather than emphasizing specific equipment usage. The ten original skills included monitoring, resuscitation, ventilation/oxygenation, airway, sedation/pain control, physical exam/diagnostics, nursing/hygiene/comfort, surgical interventions, use of telemedicine, and preparation for flight.
The second position paper introduced a concept of medical operational planning. Previously, medics practicing TCCC divided stages of medical care into Care Under Fire (CUF), Tactical Field Care (TFC), and Tactical Evacuation Care (TACEVAC). The PFCWG proposed the concept of dividing stages of care into a generalizable system codified as RUCK, TRUCK, HOUSE, and PLANE (RTHP). This is a universal approach to planning, and the wording recommends a concept, not necessarily a specific location. Generally, the capabilities and equipment increase in complexity as the medic progresses from RUCK to PLANE.
Over the last decade, the concepts and practice of Prolonged Field Care have evolved tremendously: from hosting its own website at https://prolongedfieldcare.org/, to also hosting its own podcast to disseminate PFC information and practice guidelines. Thirteen different PFC specific Clinical Practice Guidelines (CPGs) have been developed during this time and can be found on the Joint Trauma System (JTS) website. During the last few years, the Committee on Prolonged Casualty Care was created to translate PFC across all services and further professionally codify PFC, or what is now referred to as Prolonged Casualty Care (PCC).
Prolonged Casualty Care Clinical Practice Guideline!
In December of 2021, the Joint Trauma System released the exhaustive Prolonged Casualty Care Guidelines, a “consolidated list of casualty-centric knowledge, skills, and best practices intended to serve as the DoD baseline clinical practice guidance to guide casualty management over a prolonged amount of time in austere, remote, or expeditionary settings, and/or during long-distance movements.” The new PCC CPG can be found below for reference. Much has changed since the beginning of PFC, but the core tenets remain the same. PFC is still “field medical care, applied beyond ‘doctrinal planning time-lines,’… that utilizes limited resources, and is sustained until the patient arrives at an appropriate level of care.”
Understanding the concepts and practices of Prolonged Casualty Care is a requirement of all military medical providers going forward. The warfare that is waged in the future will be very different than the past. We will be required to accomplish much more with much less, and will often be alone for extended periods of time while managing the critically ill and injured. We cannot become comfortable with our current practice of first world medicine and expect the same dynamic in the future operational environment.
“Remember, the primary goal in PCC is to get out of PCC!!!”https://prolongedfieldcare.org/2022/01/07/prolonged-casualty-care-for-all/
- Mohr CJ, Keenan S. Prolonged Field Care Working Group Position Paper: Operational Context for Prolonged Field Care. J Spec Oper Med. 2015 Fall;15(3):78-80. PMID: 26360359.
- Ball JA, Keenan S. Prolonged Field Care Working Group Position Paper: Prolonged Field Care Capabilities. J Spec Oper Med. 2015 Fall;15(3):76-7. PMID: 26360358.
- Warner, Rocky. The Death of the Golden Hour and the Return of the Future Guerrilla Hospital. JSOU 2017. Free E-book.
- Kotwal RS, Howard JT, Orman JA, Tarpey BW, Bailey JA, Champion HR, Mabry RL, Holcomb JB, Gross KR. The Effect of a Golden Hour Policy on the Morbidity and Mortality of Combat Casualties. JAMA Surg. 2016 Jan;151(1):15-24. doi: 10.1001/jamasurg.2015.3104. PMID: 26422778.
- Keenan S, Riesberg JC. Prolonged Field Care: Beyond the “Golden Hour”. Wilderness Environ Med. 2017 Jun;28(2S):S135-S139. doi: 10.1016/j.wem.2017.02.001. PMID: 28601206.
- Prolonged Field Care Podcast 1. What’s this PFC stuff anyway and why should I care?
- Prolonged Field Care Podcast 11. Beyond the Golden Hour: Austere Critical Care in Future Operating Environments.
- Prolonged Field Care Podcast 27. Winning in a Complex World.