RESPONSIVE

Within the context of a catastrophic, non-survivable brain injury, if the patient responds to initial resuscitation and treatment and achieves clinical stability, transport to the next higher role of care should be considered. In these circumstances, aggressive effort should be made to re-unite the service member with family at the Role 4 facility. As a secondary priority to be considered only in these otherwise futile situations, service members may also be evaluated for potential organ donation at the Role 4 facility.

NON RESPONSIVE

Within the context of a catastrophic, non-survivable brain injury, if the patient does not respond to initial aggressive resuscitation, continued further efforts should be guided by a combination of clinical judgment and battlefield effects, including: resources available at the current role of care facility (critical care personnel, equipment, and supply resources), other critically injured patients requiring immediate attention, potential for further casualties from active troop contact, and availability and capacity of evacuation to next higher role of care.

The medical evacuation clinical and operational leadership should be engaged early in these circumstances. Clinical discussion and decisions regarding stability for transport should occur between the trauma team and the flight team. The clinical team should also inform medical operations leadership who will be able to provide information about evolving battlefield effects affecting the availability and capacity of transport.

If the patient cannot be clinically stabilized or battlefield effects otherwise preclude transport, no further efforts should be pursued and withdrawal of support with dignity and with comfort measures is the most respectful and appropriate course of action. Providers presented with these patients are always encouraged to discuss patient care with colleagues and medical leadership at their location to achieve a clinical consensus in these very difficult situations. When available and appropriate, they are also encouraged to communicate with trauma providers at the next higher role of care to achieve consensus on the plan to transport or not to transport. These situations are fortunately not common, but constitute the most challenging of clinical and ethical management dilemmas that one can face while deployed.