Medic (KAT)

BBB 3b’s

March can be simplified in to the Following for ARMA purposes Bleeding, Breathing, Beating,

Bleeding

Simplified is the Patient Bleeding.

Breathing

Include breathing and Oxygen saturation

Beating

Includes pulse and blood volume 

The advanced medical system provides a more complex and detailed medical simulation and is based off the CSE CMS. It focuses on a more realistic model for injuries and treatments, thus resulting in a more important and prominent role for combat medics, and a bigger incentive to avoid getting shot.

The system behind advanced medical is designed to attempt to mimic important parts of the human body, as well as react to any injuries sustained and treatments applied in a realistic manner. 

THE BASICS

In ACE the human body is represented as 6 distinct areas that can receive damage. Some of these areas have special abilities such as applying a tourniquet or using a variety of IV solutions.

Each living person in the battlespace has Four key metrics which define their state of health. Every action you take will be to maintain or restore one of these metrics:

• Blood Volume

• Pulse

• Oxygen saturation

• Responsive State (Are they conscious? )

Besides the 4 elements introduced by basic medical, advanced (w/KAT) introduces the following:

• More detailed wound system.

• Accurate blood loss based upon sustained injuries.

• Vitals, including heart rate and blood pressure.

• Cardiac Arrest.

• Airway Management

• Breathing

• Circulation 

• Various treatment methods such as CPR, different kinds of IVs and a working tourniquet.

REVIVE SYSTEM

The revive system lets you bring downed units back up. Upon receiving a deadly amount of damage, a unit will fall unconscious. In that time a medic will need to treat them to bring them back up.

Death And Unconscious

Unconsciousness happens when one of the following is met:

• Pain threshold is reached

• Low Blood pressure

• Cardiac Arrest.

• Oxygen saturation below 90%

Someone cannot recover from unconsciousness till the underlying factor has been resolved  

Death happens if one of the following happens.

• The Cardiac Arrest timer runs out, the base timer is 300seconds (5 minutes), this can be extended to a max of 3600 seconds (60 minutes) with CPR each usage will extend the timer by 120 seconds. 

AI

The AI are able to go unconscious, and can be revived

ACE 3 is a matrix of complicated 3D menus and contrived custom keys. 

Changing the Medical Menu to a 2D interface:

1. Go to the ACE OPTIONS menu in the top left-hand corner of your in-game options menu.

2. Navigate to the “Medical Menu” option

3. Enable the Medical Menu

After enabling the medical menu, you should be able to ACE interact and find the “Medical Menu” under interactions - this is in contrast to the usual 3D “Medical” setting that would be there. This allows you to access the 2D medical menu and access time critical information faster.

 Overview Window

Red - Open wounds, severe bleeding

Orange -Open wounds, intermediate bleeding

Yellow -Open wounds, minor bleeding

Light blue -Bruised

Dark blue -Fully bandaged

Blue belt -The limb is tourniquet'ed

Red bone -The limb is fractured

Blue bone -The limb is splinted

There are four types of Auto Injector for injecting drugs. Drugs are used to manipulate the pulse and to reduce pain levels.

The first and most common autoinjector is Morphine which reduces the pain experienced by the patient. It also has side effects of reducing the patient’s blood pressure and heart rate, reducing it by around 20 BPM. There is a potential of overdosing, (3+ with in 10 minutes)

The second autoinjector is Epinephrine - more commonly known as Adrenaline. This drug solely affects the patient’s pulse raising it by around 20 BPM.

The third autoinjector is Atropine - a muscle relaxant - which lowers the heart rate of the patient by approximately 20 BPM.

The fourth is Adenosine, it lowers the heart rate.

-Flow Rate System: The movement of fluids such as saline, blood, and plasma into the body are now determined by a flow rate variable. This variable changes based on the size of established IVs and IOs, which smallest to largest are 20g IV, 16g IV, and 45mm IO. This variable also changes based on the heart rate of a patient as lower heart rates will mean a slower intake of fluids and in cardiac arrest, will stop entirely. 

However, this only applies to the 20g and 16g IV, meaning that the flow rate of the 45mm IO is not dependent on heart rate and can be used to still push fluids into a body while in cardiac arrest. (This decision is based on gameplay considerations as to give players a reason to pick different sized IVs and IOs. Very subject to change in the near future).

Naloxone - Sold under the brand name NARCAN, Naloxone is built to combat opioid overdoses. Naloxone acts as an opioid antagonist, essentially booting opioids from their respective receptors and rendering them harmless in the body. In KAT Pharmacy, Naloxone is primarily used to combat morphine overdoses through the simple elimination of morphine from a player’s medication array. This is done one at a time so if someone has two morphines in their array, it would take two Naloxone nasal sprays to fully eliminate morphine from the player’s system. Note that any pain that is being suppressed by the morphines will return once said morphines are removed.

Amiodarone - Amiodarone is a Class III Antiarrhythmic used most commonly for treating ventricular tachycardia. In KAT Pharmacy, Amiodarone’s primary function is to increase the success chance of a patient under shockable cardiac arrest. When compared to the other antiarrhythmics in Pharmacy, it is the most effective and can give a 20 point increase to a patient’s wakeup chance, however there is a downside to this as Amiodarone has a 1-in-3 chance of giving the patient bradycardia, which can decrease the standing heart rate by 15-20 points. Considering this, it is not recommended to give more than a single Amiodarone dose to a patient.

Lidocaine - Although more commonly known for its use as an anesthetic, Lidocaine has long been used as an antiarrhythmic drug for treating patients in VF/VT. In KAT Pharmacy, Lidocaine increases the success chance of a patient in shockable cardiac arrest with less risk of bradycardia when compared to Amiodarone and in turn gives less of a boost to said success chance, standing at around 10-12 point increase. When Amiodarone fails to resuscitate a patient on the first try, Lidocaine should be the second drug a medic reaches for.

Epinephrine - Good old Epinephrine, a mainstay of the ACE Medical System and the most commonly used drug to treat ALL forms of cardiac arrest regardless of rhythm. Quick application of epinephrine in an arrest scenario is critical to the survival of any patient. In KAT Pharmacy, Epinephrine has no risk of application and while it only increases the success chance of a patient by 5 points, it offers other benefits as it stacks over time, increasing its effectiveness as the cardiac cycle goes on. Epinephrine is also the only drug that can be used to increase the success chance of a patient in non-shockable cardiac arrest.

Atropine - Atropine is known primarily for two primary actions, the first is the treatment of nerve agents and certain poisons and the second is the treatment of bradycardia. In KAT Pharmacy, Atropine may not be able to treat nerve agents (yet) but it is able to treat bradycardia created by Amiodarone and Lidocaine. Currently this medication acts like Naloxone where it simply locates the bradycardia effect in the player’s medical array and removes it, however this will become more involved over time. 

Ammonium Carbonate - Ammonium Carbonate or “smelling salts” were at one point used to recover individuals who fainted by triggering an inhalation reflex. While not currently used or recommended in any sort of medical practice, they serve a gameplay purpose as ACE Medical has a nasty tendency of knocking people out for remarkably minor wounds. Rather than rely on the wakeup chance with Epinephrine, Ammonium Carbonate goes right to the wakeup script and will wake players up as long as they are within the stable vital threshold. This is pure gameplay and players will be given an addon option to disable this medication entirely in their missions if they dislike how gamey this medication can appear.

TXA - Tranexamic Acid (TXA) is a lysine substitute that binds to lysine receptors sites, inhibiting the breakdown of clots. Used primarily for patients who have experienced severe hemorrhaging and trauma, it is recommended by the TCCC to be used on individuals who will need significant blood transfusions in the near future. In KAT Pharmacy, TXA should be administered as quickly as possible as it will clot open wounds and assist medics in the bandaging process. Currently this medication has no contraindications and is recommended for all unconscious patients regardless of status.

Ondansetron - Commonly known as Zofran, Ondansetron is commonly used to discourage vomiting and nausea in patients. It is recommended by the TCCC to be used to counter the vomiting that can come with the administration of certain pain management medications. In KAT Pharmacy, Ondansetron will prevent a patient from vomiting and should be used if an airway cannot be properly established. Be advised that it will not clear any vomit currently present in the patient, just prevent additional vomit from being generated.

Norepinephrine - The first-line drug used in cases of septic shock, Norepinephrine is a vasopressor which acts on both the Alpha-1 and Beta-1/2 receptors to help with vasoconstriction and increasing cardiac output and in turn, increasing overall blood pressure. Norepinephrine will quickly increase blood pressure by 15% in a patient and will stay in a patient’s system for two minutes before clearing. 

Phenylephrine - While Norepinephrine acts on both Alpha and Beta receptors, Phenylephrine is pure Alpha, focusing specifically on vasoconstriction which means its more effective at actually increasing blood pressure compared to Norepinephrine and will do so by 30%. However, the downside with this drug is that the pure alpha focus causes reflexive bradycardia in a patient meaning that while blood pressure may increase, pulse will simultaneously fall by 5-15 points while Phenylephrine is in the patient’s system.

Nitroglycerin - While Phenylephrine and Norepinephrine are focused on vasoconstriction, Nitroglycerin is instead focused on vasodilation which dilate a patient’s blood vessels and decrease their blood pressure by 15%. 

Quick Chart (needs updated)

INJURY TYPE

Each limb on the body can receive different types of injury. Each injury has a different level of pain and bleeding that it will inflict. Each injury type also has a set of treatment procedures that are best suited for it - these will be laid out in the subsequent chapter about rendering aid.

ABRASIONS

An Abrasion is a wound caused by friction. Examples include Vehicle Crashes and Rope Burn. This wound type has a low pain effect and an extremely slow bleed rate.

AVULSIONS

An Avulsion is when an entire structure is separated from the body. Examples include lost teeth or an ear lobe. These are caused by explosions, shrapnel and any other situation which could sever a body part.

Avulsions have an extremely high pain effect with an extremely fast bleed rate.

CONTUSIONS

Contusions, commonly known as Bruises are caused by trauma that injures an internal structure without breaking the skin. Blunt blows to areas such as the chest or head can cause contusions.

LACERATIONS

Lacerations are wounds with ragged edges. They are produced by large forces exerted on the body.

Lacerations have a slight pain effect with a slow bleed rate.

VELOCITY WOUND

A Velocity wound is caused by objects entering the body at speed, such as shrapnel or bullets.

Velocity wounds have an extremely high pain effect with a medium bleed rate.

PUNCTURE WOUNDS

A puncture wound is a narrow wound produced by a sharp object such as a knife.

Puncture wounds have a slight pain effect with a slow bleed rate.

Treatment Order 

1. Avulsion 

2. Velocity Wound

3. Laceration

4. Cut Wound

5. Puncture

6. Crush Wound

7. Abrasion

8. Contusion

• Efficiency: Bandage efficiency, higher is better.

• Reopening chance: Reopening chance when advanced wounds are enabled, lower is better.

Bandages are used to pack ounds to reduce bleeding and provide a surface for blood to clot against. Bandages are temporary solutions and wounds will require stitching to repair permanently.

Breathing is the second most important thing, if the blood is not carrying oxygen this is service no purpose.

CHECK AIRWAYS

To check the patient’s airways, you must open the medical menu and select the head, here we get an option to “check airways” in the section of “examine patient”.

To check the patient’s airways, you must open the medical menu and select the head, here we get an option to “check airways” in the section of “examine patient”. 

In this case the patient needs no airway management so the normal treatment procedures can be followed. In the case where airway management is needed it will say “airway management needed”.

AIRWAY MANAGEMENT 

is the process of ensuring that:

• there is an open pathway between a patient’s lungs and the outside world, and

• the lungs are safe from aspiration

HEAD TURNING

In the case of an occluded airway (symptoms of puking) you must either use an Accuvac or use the Head Turning treatment. The Head Turning has a smaller chance of success (35%) compared to the Accuvacs 100%.

HEAD OVERSTRETCH

In the case of a collapsed airway/lung you should use a NPA (King LT or Guedel Tube) however if you are lacking any of the tubes you should overstretch the head. This treatment, if successful, will increase the blood oxygen saturation (SPO2)

BLOOD OXYGEN SATURATION

Blood Oxygen Saturation is measured in SP02 values, they signify from a 100 to 0 from the patients’ values. 

If the airway is secured either by overstretching the head or insertion of a NPA the value of the blood oxygen saturation should increase.

• • • •  Minimal saturation (default settings): 65% -> Less results in death 

      • Minimal saturation to get someone up (default settings): 85%

PNEUMOTHORAX

Pneumothorax is a medical event where the lung is damaged and leaks air into the chest cavity damaging lungs over a prolonged time.

In order to treat Pneumothorax medics will have an option to use a chest seal under the chest section in the ace medical menu. It can be spotted by seeing the blood oxygen saturation levels dropping quickly, it is also worth noting that using an NPA on a patient will not work if Pneumothorax is diagnosed (this is how you can tell if a patient has it). 

TENSION PNEUMOTHORAX

A tension pneumothorax is a life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary function.

In order to treat tension pneumothorax medics will have an option to use an AAT Kit under the chest section in the ace medical menu.

Hemothorax

The accumulation of blood in the pleural cavity (the space between the lungs and the walls of the chest) In order to treat a Hemothorax medics will have an option to use an AAT Kit under the chest section in the ace medical menu.

Bradycardia 

Bradycardia is a heart rate that's too slow. What's considered too slow can depend on your age and physical condition. Elderly people, for example, are more prone to bradycardia. In general, for adults, a resting heart rate of fewer than 60 beats per minute (BPM) qualifies as bradycardia. But there are exceptions.

Ventricular tachycardia 

Ventricular tachycardia (VT or V-tach) is a type of abnormal heart rhythm, or arrhythmia. It occurs when the lower chamber of the heart beats too fast to pump well and the body doesn't receive enough oxygenated blood.

VITALS

BLOOD PRESSURE

Your blood pressure is recorded as two numbers:

Systolic blood pressure (the first number) – indicates how much pressure your blood is exerting against your artery walls when the heart beats.

Diastolic blood pressure (the second number) – indicates how much pressure your blood is exerting against your artery walls while the heart is resting between beats.

Blood pressure is affected by the amount of blood lost as well as IVs and medication.

• Nonexistent: 0 - 20 systolic.

• Low: 20 - 100 systolic.

• Normal: 100 - 160 systolic.

• High: 160 and above systolic.

HEART RATE

The heart rate (pulse) is affected by the amount of blood lost and medications.

• Low: 45 and below

• Normal: between 46 and 119

• High: 120 and above

• Minimal HR to get someone up: 40

CARDIAC ARREST

A patient will enter cardiac arrest when:

• The heart rate is below 20.

• The heart rate is above 200.

• The systolic blood pressure is above 260.

• The diastolic blood pressure is below 40 and the heart rate is above 190.

• The systolic blood pressure is above 145 and the heart rate is above 150.

 4 different heart rhythms can be present while unconscious. They are hereby listed in the order at which they occur: 

The KAT adds the coagulation factor - a feature which expands the system of wounds clotting. A script is run each 8 seconds to check for the player's condition, namely: HR and bleeding wounds. If the HR of at least 20 BPM is present and there is at least one bleeding wound, clots (treated by the game as “Unstable Clot” bandage) start appearing on wounds. Each player starts with 10 factors - they are used for clotting wounds (one factor per one wound) and restored by administering blood and plasma . Max 30 factors can be available at the same time.

TXA

• • If coagulation is enabled, pushing TXA causes the clotting system to apply a more durable packing bandage instead of “unstable clot” on bleeding wounds - TXA does not cause wound clotting on its own but makes the clots stronger.

  • If coagulation is disabled, TXA applies the equivalent of a packing bandage every 6 seconds to all parts of the body for 120 seconds. 

You should not attempt to render aid to a casualty until the friendly force has obtained fire superiority.

Failure to ensure that the friendly force holds fire superiority can lead to a multiplication of casualties as first responders become injured.

CARE UNDER FIRE

Care under Fire is the actions undertaken by the squamates of the injured personnel when a casualty is first injured. This phase revolves solely around bleeding control.

TRIAGE

Triage will be performed at all levels. Traditional categories of triage are immediate, delayed, minimal, and expectant. To easily remember the order of the categories, use the acronym IDME. No significant treatment should occur in the triage area. Casualties should be rapidly sent to the appropriate treatment area for care. 

TIMERS

• Revive Timer:600 seconds 

• Breathing timer: 600 seconds

PRIORITY

In general, the treatment priority is as follows (from most-urgent to least-urgent):

IMMEDIATE

• Bleeding and unconscious. These soldiers may bleed to death if not treated. The soldier administering the treatment may even often call for help in bandaging the patient, to make sure that the bleeding stops before the patient bleeds out.

• Life-threatening Bleeding. A conscious but bleeding soldier could pass out or die if not treated. Therefore, anyone bleeding severely is a high priority for treatment.

• Not breathing. A soldier has 300 seconds before death if not breathing,

DELAYED

• Unconscious but not bleeding. Unconsciousness is somewhat dangerous in and of itself and needs to be treated with some haste. Death from unconsciousness, however, is rarer. Furthermore, once the unconscious soldier is revived, he may be able to provide cover for the medic during the rest of the treatment.

• Severe Pain. A soldier in severe pain may pass out, requiring more treatment. Therefore, it may be necessary to administer Morphine to them before that can happen.

MINIMAL

• Minor Bleeding. Minor bleeding can worsen over time and even lead to unconsciousness and death, but it is not immediately life-threatening. Soldiers with minor bleeding may even be able to treat themselves.

• Crippled Legs. Soldiers with crippled legs have a bare minimum of mobility. Leaving them in this state could cause them to fall behind if the unit needs to leave the area, and should be treated sooner rather than later.

• Crippled Arms. Soldiers with crippled arms are not very combat effective. Treatment of this injury will restore one soldier - and his gun - back to effectiveness.

• Mild Pain. Mild pain in itself is not life-threatening and reduces a soldier's effectiveness only mildly. Furthermore, Morphine is in short supply, and medics may choose not to treat Mild Pain at all in order to conserve it for more serious cases.

EXPECTANT

• Multiple bleeding wounds, not breathing, cardiac arrest 

If there are more than one wounded, treating the Expectant may cause the death of other wounded, a decision to not treat may be necessary.

 Do Not Resuscitate Guidelines

Do NOT resuscitate (DNR) casualties under the following circumstances:

1. Combat (direct fire) situations:

   • Patient with no pulse, regardless of cause.

   • Patient with a pulse but no respirations, who cannot be resuscitated without endangering the lives of caregivers and/or rescuers.

NOTE: The decision not to initiate resuscitation IS NOT a legal declaration of death, unless a qualified physician declares the patient dead.

2. In a combat situation, body recovery should be attempted unless the attempt exposes the rescue team to undue danger. If the body cannot be safely recovered, the location should be noted as accurately as possible (GPS coordinates preferred) for later recovery efforts.   If the body has a set of ID tags that can be safely recovered, one should be left with the body, and one should be secured.

3. In non-combat situations, attempt body recovery only if it can be accomplished with a minimum of risk to   the rescue team. If there is any suspicion of CBRN the body and the area around it should be undisturbed, until personnel with proper equipment are present.

STEP 1: IS THE PATIENT RESPONSIVE?

Yes: Ask him if he has wounds / he is in pain.

No: Go to step 2.

STEP 2: IS THE PATIENT BLEEDING?

Yes: Administer TXA , Treat the wounds and go to step 3.

No: Skip this step.

STEP 3: IS THE PATIENT BREATHING?

Yes: Go to step 4.

No:  Clear the airway

STEP 4: IS THE BLOOD OXYGEN SATURATION GOOD?

Yes: Go to step 5.

No:  check for a Pneumothorax and treat if needed

STEP 5: DOES THE PATIENT HAVE A PULSE?

Yes: Go to step 6.

No: Perform CPR, or use an AED (do not touch the Patient when using the AED)

STEP 6: DID THE PATIENT LOSE A LOT OF BLOOD?

Yes: Give fluids.

No: Go to step 7.

STEP 7: IS THE PATIENT IN PAIN?

Yes, and a stable pulse: Give him morphine.

Yes, and unstable heart rate: Stabilize the heart rate before administering morphine.

No: Go to step 8.

STEP 8: IS THE PATIENT AWAKE NOW?

Yes: You’re done.

No: Go to Step 1, 

(If you have completed the process two times already, evac the patient)