Why HITMAN for PFC

When I was on the BATLS faculty in the MoD fifteen years ago, we used the mnemonic HITMAN for Prolonged Field Care. The SAS lads from Hereford were the first group to use that on their documentation. Before that, they used AFITARSE. I first heard about Prolonged Field Care whilst teaching for Deployment Medicine International in 2006. DMI used TRI-AEIOU.

As my experience in Prolonged Casualty Care progressed through the years, I have worked within all three mnemonics. I have seen how quickly students pick up each of the three ways of remembering the PFC concepts. The UK military medics, nurses and doctors I taught were heading to Afghanistan, and many used the training and principles the BATLS faculty taught them. I heard back from more than a few after their deployment, and I got an AAR from their experiences on the BATLS course and how well they remembered the PFC concepts. The feedback was that they used the HITMAN mnemonic in anger and could recall all PFC concepts within that keyword.

Whilst working for DMI, I was able to see how well they remembered the TRI-AEIOU mnemonic during the nine-day Operational and Emergency Medical Skills course. After seven years of teaching OEMS, I found that few could use that mnemonic effectively.

Currently, the Prolonged Field Care Working Group is using RAVINE as a memory tool for PFC. HITMAN can also be found on their website, although they use it as a nursing tool.

AFITARSE the origins of the PFC mnemonic

As an academic, I find utilising a mnemonic like this more challenging. We need to be civil and cognisant of the use of crass words. The BATLS faculty felt the same way and never really embraced this option. They moved on to the better choice, which was HITMAN.

·????? Ask the casualty how they are. You have already finished your casualty exam. Now, talk to your patient.

·????? Fluids. Monitor urine output and improvise a way to let the casualty void. Hydrate your casualty.

·????? Infection. Keep wounds clean and treat with antibiotics if trained. You have a six-hour window before your wounds will become infected.

·????? Tubes. Ensure your cannulation lines, ET tubes, IV sites, and Foley Catheters are clean and blockage-free.

·????? Analgesia. Think about pain management for your casualty.

·????? Records. Document your patient assessment and reassessment.

·????? Sanitation. Keep the casualty clean. This means baths if they are sweaty or dirty. This means that you need to think about their voiding.

·????? Environment. In a remote setting, you must deal with the casualty being too hot or cold. More often than not, they will be too cold.

TRI-AEIOU

This mnemonic never took off, and there is a reason for that. It is chunky and doesn’t address many topics that must be covered. I don’t know if DMI still teaches this, but they have moved on to either RAVINES or HITMAN.

·????? Tubes. Functioning, clean and secure

·????? Record and Reassess. Flow sheet repeated vital signs, and MIST report

·????? Infection. Antibiotics, wound care

·????? Analgesia. Pain control, splint fractures, release TQs if possible

·????? Environment. Heat, cold and insects

·????? Intake. Fluids, electrolytes, food.

·????? Output. Urine, drainage and stool

·????? Ulcers. Pressure sores, tubes, eyes and gastric

HITMAN

Once the Special Air Service published this option, it took off like wildfire. It hit both sides of the pond but remained more influential here in Europe. I started using it during BATLS and have integrated it into all parts of the College of Remote and Offshore Medicine Foundation. Since we use the CABCEDEFG patient assessment mnemonic, it made perfect sense to put the HITMAN at the end of our assessment. It means that our students learn to stabilise the casualty using the CABC approach and then automatically roll over into PFC without a pause. We have moved our secondary assessment into HITMAN.

The College modified the original SAS HITMAN mnemonic. The original concept had H for Hydration, A for Analgesia and N for Nutrition. I felt we could do better, and I changed those three paragraphs to what you can see below. The largest change is the Nursing point, which Jason Jarvis and I again modified to incorporate the entire SHEEP VOMIT under Nursing care. I have been teaching this modified HITMAN for ten years now and found students can retain the information.

Head-to-toe exam, hydration and hygiene

Infection. Wound Care, Irrigation (3L or more), Debridement, Wet to Dry dressings, Antibiotics, Reduce Tourniquets to pressure dressings

Tubes & Tidy. Secure, functioning, flush with 10mg NS every 20min, clean all tubes, transition to water if flying, secure all wires and tubes

Medications: Whole blood, IV fluids, analgesic, anaesthetic, sedation drip if RSI, antiemetic, antiulcer, antibiotic, antipyretic, anxiolytic, TXA.

Administration Documentation, planning for evacuation, replenishment, and recuperation

Nursing. This is a vast topic. Nurses train for three years. As medics, we are just not going ever to be as good as they are. But we must improve our capabilities. Jason and I were teaching four Remote Paramedic courses in 2015 and found that students were profoundly improved once they started using SHEEP VOMIT.

• Skin protection (sunscreen, insects, wet clothing), Hypo/Hyperthermia
• Elevate head
• Exercises (passive ROM)
• Pad stretcher and Pressure points
• Vital signs
• Oral hygiene (dirty teeth lead to pneumonia)
• Massage (DVT prophylaxis)
• Ins and outs (diet and fluid management/records)
• Turn/cough/deep breath/cupping

The Bottom Line: Be cognisant of the history of HITMAN. Make sure that you are using the best evidence-based medicine.