Tactical Medicine in the Civilian Setting – Part 3

The third and final instalment of this series has been a while coming. Nothing to do with being tactical just because “reasons”. Here’s Mel Brown following from part 1 and part 2 with, yes you guessed it because of precedent and it was written at the top there, part 3. 

In part one of this series we looked at what tactical medicine is, some of the history of tactical medicine (both military and civilian) and the three preventable causes of death within the tactical environment. In part two we looked at some of the models of infiltration for medical teams, specifically the “whos, hows and whats” of this topic. Now in part three we will look at the three phases of care as set out by the Committee for Tactical Emergency Casualty Care (C-TECC).

Not just “what” but “when”

Medical intervention is vital to saving lives in the tactical environment as 90% of tactical deaths occur prior to the casualty reaching a medical treatment facility. However, these interventions must be performed at a tactically appropriate time otherwise more injuries may be sustained and potentially more lives potentially lost. This is why the three phases of care (as set out by C-TECC) guide when certain interventions should be attempted.

Conventional EMS protocols don’t account for unsecure or high threat scenes and are solely patient focused without any acknowledgement of the surrounding operational or tactical constraints other than to assess for danger during the primary survey. This is why the C-TECC guidelines were developed; they guide patient care whilst taking into account the operational requirements of a high threat environment.

C-TECC guidelines should be seen as “guiding principles”; they are not rigid or inflexible like some current civilian EMS protocols. The three phases of tactical care are dynamic, often overlap and rarely work in a linear or isolated fashion. This is why it is so important to have a clear understanding of each phase so that fluid movement between phases is possible.

The Three Phases 

There are three distinct phase of care within the tactical environment that guide which treatment should be applied when. The three phase of care are:

  • Direct Threat Care
  • Indirect Threat Care
  • Evacuation Care

For those of you with a military background you may be used to these three phases being called:

  • Care under Fire
  • Tactical Field Care
  • Combat Casualty Evacuation Care

C-TECC changed the titles of each phase to ensure that they could be easily used in all high threat situations within the civilian setting. A high threat situation is not just the kinetic one (active shooter, blast) but includes building collapse, multi-vehicle accidents, natural disasters or even the rapid advancement of fire.

Let’s dive in a little deeper.

1. Direct Threat Care

The direct threat care phase exists whilst there is a continued threat directed towards both casualties and other personnel and the risk of further injuries and / or deaths is very high. Treatment during this phase is focussed on minimising further harm, accomplishing the mission, neutralising the threat and stopping catastrophic haemorrhage. There are minimal medical interventions delivered to the casualty in this phase. This is a foreign concept to most medical personnel.

The medical care provided in this phase is limited to controlling extremity haemorrhage and removing the casualty from the point of injury. This care can either be delivered via self-aid or buddy-aid. If the casualty is able to self administer first-aid then this should be encouraged so that the medical responder can care for the casualties that are unable to treat themselves.

A big part of the care in this phase may be simply assisting the casualty to a point of cover; after all, the casualty should never (look maybe that should be in capitals because never, never, never) be treated in an exposed area. Don’t treat on the street.  It is important to think about the choice of cover….good concealment doesn’t always equal good cover.

concealment

Early haemorrhage control is critical in tactical medicine as it accounts for the largest statistical group of preventable deaths. The C-TECC guidelines recommend rapidly controlling extremity haemorrhage in this phase and this usually defaults to the application of an arterial tourniquet. It is important to remember that any medical interventions in this environment need to be balanced with operational risk. This means that sometimes we can’t provide all the care we would to our patient it we were in a non-tactical environment.

Applying a windlass arterial tourniquet can rapidly, easily and effectively treat extremity haemorrhage. There are two such arterial tourniquets widely used in Australia and approved by the TGA – the SOFFT-W and CAT (and remember that first post in the series had a bit on tourniquets). Be aware that the latest CAT is a generation 7 and has some differences to the generation 6 – equipment familiarity is a must.

The arterial tourniquet must be applied as high as possible on the limb and over clothing as it is tactically unsound and time consuming to remove clothing to look for all wounds on the extremity within the direct threat care phase. The aim of treatment within this phase is to keep the blood where it needs to be! In simple terms if you don’t keep the red stuff on the inside then you may as well not bother with anything else as the best blood for the casualty is their own. Don’t forget to mark your casualty’s forehead with the universal sign for an arterial tourniquet, that being a “T” and the time.

Direct pressure should be considered if the environment allows it or if the casualty can apply direct pressure by him or herself. Applying effective direct pressure is time consuming and reduces the medic’s ability to treat multiple casualties. Haemostatic dressings are not considered in this phase and are deferred to the indirect threat care phase, as they require time to work (3 – 5mins of continuous pressure). This is why arterial tourniquets are seen as the most effective and rapid intervention for extremity haemorrhage within the direct threat care phase of the tactical environment.

The only other brief consideration in this phase is to airway. Put simply, this means that you may place the casualty in the recovery position when moving them to a safer position but only if it is tactically appropriate to do so and can be rapidly achieved (this is not a formal assessment of airway – it is simply positioning).

2. Indirect Threat Care Phase

The indirect threat care phase evolves once the responder and the casualty / casualties have moved to an area of relative safety. This relative safety may be provided by structures such as a wall, building, car etc. or by the presence of a tactical security force. Either way the tactical medic must maintain situational awareness whilst treating the casualty / casualties as the environment is dynamic and can change back into a direct threat situation rapidly and at no notice. Always be prepared to move instantly…..this means do not open all of your pack up and spread it out!

In some situations consideration must be given to the disarming of casualties, both friend and foe. If the casualty is unable to sufficiently control or secure his or her own weapon then the medic needs to render the weapon safe and remove it from the casualty. This action is paramount if the casualty is showing signs of altered mental status or head injury. This helps ensure the safety of you, other personnel and the casualties.

If there are multiple casualties then the tactical medic needs to complete a rapid triage that will sort the casualties into three simple groups:

  • Uninjured and / or capable of self-extraction
  • Deceased / expectant
  • All others

The uninjured or capable of self-extrication group should be encouraged to self-aid. This group (if able) may also assist in applying first-aid to other injured casualties. The deceased / expectant group should (if tactically appropriate) be placed away from the core group of casualties that are receiving care.

The “all others” group should be assessed using the C-ABC acronym (Catastrophic haemorrhage – Airway, Breathing & Circulation). The casualty / casualties need(s) to be reassessed to ensure that all interventions performed in the direct threat phase are still effective and needed as well as assessing for any unrecognised haemorrhage.

Removal of clothing and protective equipment should be kept to a minimum. However, the tactical medic needs to ensure that life-threatening injuries are not missed. Therefore, they must check under clothing, body armour etc. and ensure they inspect the casualty’s back.

Because body armour and clothing should not be completely removed (it is required in order to provide continued protection for your casualty) the casualty should be assessed for further injuries by firmly raking the whole body. When assessing under body armour only unclip one side of the armour and lift up (don’t completely undo or remove). Raking allows for identification of unseen wounds as the fingers will fall into divots due to the firm pressure being applied.

Haemorrhage control within this phase may include:

  • Direct pressure methods (an emergency bandage is useful for this);
  • Tourniquets for undiagnosed extremity haemorrhage; and,
  • Haemostatic dressings for non-compressible haemorrhage.

The emergency bandage is a useful tool within the high threat environment as it can be applied rapidly and ensures direct pressure is applied to compressible haemorrhage (See the picture below). The combine found within the bandage has a rumoured capacity of 400mL (note: our experience is closer to 250mL – which is still a lot!) and the pressure device can apply up to 13.6kg (30lbs) of pressure onto a wound.

emergency-bandage
Probably a pretty effective way of soaking up spills around the house too.

If you don’t have such a device available or you run out of resources it is extremely simple to improvise this device by following the four steps below:

4-steps

For further information on direct pressure methods you could link at the post that is totally on that right here.

Haemostatic dressings are an effective method of controlling non-compressible haemorrhage, compressible haemorrhage not amenable to tourniquet use or as an adjunct to tourniquet removal (if evacuation times are anticipated to be prolonged). Currently there is only one haemostatic dressing approved by the TGA for use in Australia, this is called QuikClot Combat Gauze.

QuikClot Combat Gauze is impregnated with kaolin, an inert mineral found in some clay, specifically clays from tropical areas. Kaolin is a potent activator of contact (intrinsic) clotting pathways that accelerates the initial onset and speed of clot formation. Further information on QuikClot and its use will be available on the Collective as part of a future post of the ongoing series titled “I Wish I Knew Then What I Know Now!” If you want information sooner our Education team would be happy to share its one page handout – contact them by leaving a response to this blog.

What about the Airway?

Airway management in the high threat environment must be high yield and take minimal time to implement. That means the intervention might be as simple as applying a jaw-thrust or positioning the casualty to open the airway. The position chosen for the casualty (recovery or seated position) will depend on a few things, some of which include:

  • The current tactical situation (this has a massive impact on what position may be used for anyone as it may not be safe to sit your patient upright).
  • The conscious level of your casualty (unconscious vs conscious but with airway concerns).

The only piece of plastic that is considered in the high threat environment is a nasopharyngeal airway (NPA). NPA no longer has the contraindication of basal skull fracture…..believe it or not. It is now considered a relative consideration when basal skull fractures are suspected (or known). I put to you that the reason why one or two have been caught on CT or x-ray in the wrong spot is purely and simply due to poor technique. The best tip I can give you here is aim in the direction of the ears NOT the eyes!!!

NPAs are far more useful than Oropharyngeal Airways (OPA) in an overwhelming situation where you are unlikely to remain solely with one casualty. NPAs allow for airway support through all stages of unconsciousness to consciousness, unlike the OPA that will be spat out by the casualty as soon as their gag reflex returns (but not always with a return of complete airway control by the casualty).

And getting on to breathing …

Assessment of breathing cannot always (actually put it in the “rarely” category) be done through the traditional means most healthcare professionals are used to in the hospital setting. The ability to listen to breath sounds is diminished considerably due to noise, protective gear (body armour, clothing) etc. and the fact that an ongoing tactical situation is likely to be noisy. Therefore, it is important to remember to use your observation skills and sense of touch. Assess the quality of the chest wall movement – is it equal, does the left side look the same as the right side, is it moving as you would expect?

It is important to assess the casualty’s chest and back thoroughly. This is the only way you can be sure that there are no open chest wounds or obvious chest injuries. So make sure you lift up body armour then look, feel and rake firmly to ensure you don’t miss any injuries!

If during your assessment you find an open chest wound it is important to cover the wound with an occlusive dressing. The general rule of thumb is any wound between the umbilicus and the shoulder should be covered with an occlusive dressing. There are many commercially made chest seals on the market (e.g. Ashermans, Halo, Russel etc.) or you can used improvised ones – one improvised seal that is usually readily available is defibrillator pads. No matter what you use, just make sure it sticks and that you have cover both the entry and the exit (if there is one) wounds.

An important point to remember is that even if you use a vented seal, it is likely to clog up with blood or fluid quickly. This means it will lose its ability to allow air to escape from the casualty’s chest. Therefore, it is a useful to get into the habit of checking for signs of an increasing pneumothorax regularly even if you use a vented seal. If the casualty starts to display signs of an increasing pneumothorax it will be necessary to “burp” the biggest chest wound. This is achieved by manually forcing air out of the chest by compressing the rib cage (with the seal removed enough to expose the wound). Once the air has been manually expelled replace the seal whilst the downwards pressure is still being applied.

The only invasive intervention considered here for a breathing problem is that of needle thoracocentecis (or decompression). There is no time nor should there be any consideration given to more advanced interventions (e.g. finger / tube thoracostomy). Always remember the indirect threat phase can quickly and without warning return to a direct threat phase.

Casualties who fall victim to penetrating or blast injuries that do not exhibit signs of life are most likely to have exsanguinated, or “bled out”. In these cases commencing CPR is unlikely to revive the casualty as the most likely cause of their cardiac arrest is insufficient circulating blood volume – compressing the heart will not circulate blood if there is no blood left.

This is not a hard and fast rule though – if this casualty is your only casualty and the tactical environment permits then it may be in the best interests of your team and bystanders to be seen to be doing something for the casualty. Furthermore, if your medical team is immediately available and possesses appropriate resuscitative equipment (such as the ability to “plug the hole” and perform a blood transfusion) then the commencement of CPR may be warranted. Again, C-TECC produce guidelines, not rules.

Always remember to reassess your casualties as frequently as possible. It is important to rapidly acknowledge the deteriorating casualty and to ensure that all interventions performed remain both effective and necessary. Once the environment starts to settle it is important to consider documentation (this may be as simple as writing on the casualty in permanent marker) and packaging the casualty as they will require moving to an evacuation point at some stage.

Some Notes on Triage and Organisation

Triage in these overwhelming situations needs to be simple and understood. You will not have the cognitive ability to follow complicated processes in this environment. There are many systems of triage in existence. In the presence of a mass casualty situation the CareFlight triage system has been assessed as being a simple yet effective method (as it effectively triages both adults and children). This system has been adopted by many agencies around the world including certain militaries (who shall remain unnamed, you’ll just have to trust me there).

The CareFlight Triage system is a simple system that can be used by people with minimal training to determine whom should be treated when.  If casualties are able to walk (this is walk, hop or crawl) then it can be assumed their ABCs are all satisfactory (at least for the time being) and they can wait or even be transported in groups by simple means (e.g. bus) to a staging area / hospital. To put it bluntly, if you can walk then you have reasonable perfusion, irrespective of your injuries.

Casualties who do not obey commands and don’t breathe when their airway is opened are deemed unsalvageable in this setting.  However, remember that this only applies when resources are overwhelmed; if you have a single casualty then you may consider continuing full active treatment.

If the casualty is requiring airway manoeuvres for them to breathe or have no radial pulse, suggesting poor perfusion, then they have the highest priority for treatment (i.e. immediate). The other group of casualties that cannot walk, but can obey commands and have a radial pulse should be treated as soon as possible (i.e. urgent). See below for the CareFlight Triage – Mass Casualty Card.

triage

Experienced TEMS personnel have found that a lot of time is being spent on the re-triage of deceased casualties. Some injuries in the light of reflection are easily seen to be non-consistent with life, yet in the tactical environment people will re-triage these casualties many times. Therefore it is important to consider positioning the deceased casualty in a respectful yet distinctive position (that all personnel know as the sign for deceased) to indicate they have been assessed and are considered deceased.

The position recommended by Threat Suppression in the USA is to place the casualty on their back, legs crossed at the ankles, arms straight up (above head) with wrists crossed. This will help ensure the casualties that require treatment and that we can potentially save are assessed as quickly as possible.

If you are involved in setting up a Casualty Collection Point (CCP) then it is important to keep your casualties and equipment together. This minimises time wastage and allows for easy access to both the casualties and resources. It is important to ensure that you think about setting up in a protected area which gives you easy egress (escape) points as well as allowing you to maintain a good visual of any threat entry point. Here are two set-up examples:

setup-1

setup-2
There’s not a single solution but the principles stay the same

3. Evacuation Care Phase

This phase of care takes place in a safe location removed from the tactical environment. In theory, once the casualty is loaded onto the evacuation asset or moved to the pre-staged evacuation point they should be departing the scene of any threat.

Prior to commencing the evacuation all previously performed interventions should be reassessed and, where required, bolstered. Good packaging of the casualty here is vital to ensure all interventions remain insitu.

Spinal immobilisation is becoming more and more controversial as more reviews of the literature come out. Some services no longer place cervical collars as they don’t immobilise the neck effectively and make airway control difficult. However, consideration of spinal injuries should still occur and the casualty should be packaged appropriately (in accordance with local practice) for these injuries.

More resources should become available during this phase. There should be an increase in:

  • Personnel (medical, logistical, tactical)
  • Equipment
  • Medical supplies

Other considerations include: large bore venous access or intraosseous access; further assessment and administration of analgesia and fluid replacement; and if prolonged holding or transport times are expected then consideration may be given to the administration of antibiotics.

It is important to remember in this phase that only interventions that are needed should be performed. If the casualty does not need a chest tube then they should not receive one just in case. These unnecessary interventions will lead to a choke point within the flow of care and will delay casualties getting to where they need to go – the hospital!

The Summary

In broad terms, casualties in a tactical environment will fall into three categories:

  1. Casualties who will live regardless,
  2. Casualties who will die regardless, and
  3. Casualties who will die from preventable deaths unless proper life-saving steps are taken immediately.

The guiding principles of Tactical Emergency Casualty Care exist for the purpose of eliminating preventable deaths. Remember never “treat on the street” and that the right procedure performed at the wrong time or place might result in further casualties, injuries and death. If all we can do is treat extremity haemorrhage (tourniquets) and tension pneumothorax then up to 94% of preventable deaths may be avoided.

Notes and References:

Here’s a few of the more useful references you’ll find out there.

Tactical Emergency Casulaty Care (TECC): Guidelines for the Provision of Prehospital Trauma Care in High Threat Environments, 2011, Callaway DW et al, Journal of Special Operations Medicine, vol. 11, Edition 3.

How to Develop Tactical EMS Protocols, 2014, Carhart E

Afghanistan Casualties: Military Forces and Civilians, Chesser SG, Congressional Research Service, 2012

Death on the battlefield (2001 – 2011): Implications for the future of combat casualty care, 2012, Eastridge BJ et al, Journal of Trauma Acute Care Surgery, vol. 73, no. 6

A Guide to U.S. Military Casualty Statistics: Operation Inherent Resolve, Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom, Fischer H, Congressional Research Service, 2014

Combat Casualty Care, 2010,Katoch BR. Medical Journal Armed Forces India, Vol. 66, no. 4

Introduction to Tactical Emergency Casualty Care, NAEMT.org

Resident Involvement in Civilian Tactical Emergency Medicine,2010, Ramirez ML et al, Journal of Emergency Medicine, vol. 39, no 1

A New Response supporting paradigm change in EMS’ operational medical response to active shooter events, December 2013, Smith ER (Jr) & Delaney JB, Journal of Emergency Medical Services

Lessons learnt and battlefield innovations from the Middle East Area of Operations, Stephenson J. 2008, Journal of Military and Veterans’ Health, vol. 16, no. 4

Learning from tragedy: Preventing officer deaths with medical interventions. Sztajnkrycer MD. 2010, The Tactical Edge, Winter 2010

Tactical Combat Casualty Care Handbook, Center for Army Lessons Learned Supporting the Warfighter.

And if you were interested enough to get this far, maybe it’s time to fill in your details so you’ll get an email update whenever there’s a new post.

 

Unexpected at 24,000 Feet

Contributors Dr Toby Shipway and Flight Nurse Jodie Martin return with a little about something that would make any retrievalist sweat – delivering babies in the air. 

A call came into the Logistics Coordination centre from a nurse in a remote health centre, worried about new contractions in a pregnant woman who was 31 weeks pregnant. We decided to take a full retrieval team for the ‘just in case’ scenario.  Afraid of getting caught out, we had a big discussion to make sure we had all the right gear on board the aircraft and what our plan of action would be should we be faced with the rare event of an inflight birth. Why worry though? They’re rare, right?

We retrieved the woman from a remote airstrip and it became evident just after takeoff that she was in established labour. Even after tocolytic therapy, the preterm baby was born at the start of descent into Darwin. No one on the plane will forget the midwife examining the patient, looking up wide-eyed and shouting calmly down the plane ‘its coming out now’.  Never has a pilot descended at such a pace. After initial resuscitation of the baby, both mum and baby did well and were transferred safely to the hospital. Phew.

After this, we started researching how many in-flight births had been registered during CareFlight’s tenure in the Northern Territory (NT). This became the basis for a recent case series publication in the Airmedical Journal.

img_4028
The sort of view you don’t get to enjoy when it starts getting imminent.

The Big and Little Numbers

Four cases were found on searching through the database over a four-year period from 2011 to 2015. Over that four-year period there were 1311 retrievals associated with Obstetrics and Gynecology, out of a total number of 15967 retrievals in the NT. This means obstetric and gynecology related retrievals account for approximately 8.2% in our aeromedical retrieval service.

Looking at the obstetric retrievals in more detail, there were 436 cases associated with pre-term labour of which 4 progressed to in-flight births. This equates to an incidence of 0.92% of all women transferred in preterm labour. It is not a common clinical situation.

These numbers are similar to a paper from Ontario, Canada1, which showed an incidence of 2.25% (11 in-flight births from 488 pre-term labour patients over a 5 year period). A paper from RFDS in Western Australia from 20122 showed no in-flight births over a 26-month period, with 500 cases of women at risk of pre-term birth included. Our four cases aren’t the only ones happening in Australia though. There was a preterm birth on an aeromedical aircraft over the Bass Strait recently.

What About Those Cases Then?

Here’s a brief description of each of those 4 cases.

Case one was a 37 year old woman of gestational age 36+5 weeks, gravida 5 para 2. The retrieval was tasked in the early hours at 0010. Take off was at 0050 and contact was made with the patient at 0145 at the airstrip. She was contracting 3:10 at this point. Tocolytics had been administered according to protocol, which was 3 separate doses of nifedipine 20 mg initially, at 30 mins and at 1 hour.  Return takeoff was at 0210 with progression to spontaneous vaginal delivery of the baby at 0245. 10 unit of syntocinon was administered intramuscularly with approximately 300 mL of blood loss measured with delivery of the placenta. Apgars of 61 and 95 were recorded. Both baby and mother were discharged at 3 days from hospital with routine follow-up from the community nurse.

Case two was a 25 year old woman of 31week’s gestation, G2P1 – this was the case from the top.  Again this was an early morning flight, tasking was at 0052 and take off was 0128.  Patient contact was made at 0250, where the patient walked onto the plane contracting 1:10. The clinic team had given nifedipine as per protocol. Return takeoff was at 0300 with progression to spontaneous vaginal delivery at 0400. Apgars were 61 and 85 with the baby needing some supportive ventilation. Mother and baby were transferred to hospital where on assessment in the neonatal unit positive pressure ventilation was stopped. Length of stay for this little one with intrauterine growth retardation was 22 days; there were no complications with the mother.

Case three was a 31 year old woman of 22 week’s gestation, G6P2. This one came up in a previous post as it involved a complicated resuscitation of mother and baby. The midwife was en-route back to home base on another task when the referral call to divert to this case was made. This again was in the early morning with the re-tasking occurring at 0330. On assessment at 0450 the patient was contracting 3:10, and the clinic reported a large clot was passed in clinic. Return takeoff was at 0500, with progression to spontaneous vaginal delivery at 0522. Apgars were recorded as 61 55 510 as neonatal resuscitation was ongoing. The mother delivered the placenta at 0548, which was accompanied by a PPH of 1 L dropping maternal BP to 42/38. Fundal massage and a blood transfusion were started. On landing the retrieval team was met by a ground crew – the neonate was transferred in a separate ambulance with ongoing resuscitation by the Medical Retrieval Consultant and a flight nurse. On reaching the Emergency Department the multi-disciplinary team decided to cease resuscitation of the baby at 0645. The mother received further blood products and stayed in hospital for 4 days.

Case four was a 26 year old woman of 28+5 week’s gestation, G2P1. This was the only retrieval in daytime hours with tasking at 1040 and take off recorded as 1135. The retrieval team went into clinic on arrival, making contact at 1245. On assessment the patient was contracting 1:10. Return takeoff was at 1345 and patient passed a large blood clot at 1410 with rapid progress to spontaneous vaginal delivery at 1418. Apgars recorded were 61 95 and some respiratory support with nasal high-flow was given. The placenta was passed at 1425 and the total blood loss was estimated to be 250 mL. The patient had no documented cardiovascular instability. The patient and baby were transferred to hospital with no further issues. However the baby stayed in hospital for 66 days needing long-term respiratory and feeding support. It was diagnosed with a dilated cardiomyopathy and on follow-up review was listed for a heart transplant.

 

What About the Treatment?

All women received the recommended preterm labour treatment, being intravenous antibiotics and steroid therapy. Three out of four patients received tocolysis – the fourth case did not as the blood clot passed in clinic was deemed a contraindication. It was reported vaginal examinations upon referral were conducted in 3 out of 4 of these cases. Interestingly, the reports of those examinations found the cervix to be closed or an undetermined dilation.  It goes to show that despite our best estimates from a physical examination we need to be prepared that inflight birth may in fact occur, even though it is a rare occurrence.

In transferring women in pre-term labour, the aim is to keep the baby in utero, as the evidence relevant to our setting indicates that in utero transfer is associated with much improved maternal and neonatal outcomes. The NT has a particularly high proportion (10.6%) of preterm births prior to hospital arrival and although multifactorial the large distances are likely to play a significant role.  Prompt retrieval and the involvement of a team with the right skill mix to make a detailed obstetric/midwifery risk assessment would hopefully lessen the chances of inflight birth. But very rare still doesn’t mean never.

Notes:

Here are those other papers again:

McCubbin K, Moore S, MacDonald R. Medical transfer of patients in preterm

labor: treatment and tocolytics. Prehosp Emerg Care. 2015;19:103e109.

and

Akl N, Coghlan EA, Nathan EA, Langford SA, Newnham JP. Aeromedical transfer

of women at risk of preterm delivery in remote and ruralWestern Australia: why

are there no births in flight? Aust N Z J Obstet Gynaecol. 2012;52:327e333.

and of course the trigger paper from our NT experience is here:

Shipway T, Johnson E, Bell S, Martin J, Clark P. A Case Review: In-Flight Births Over a 4-Year Period in the Northern Territory, Australia. Air Med Journal. 2016;315:317-20. 

 

 

 

 

I Wish I Knew Then What I Know Now (Edition 1 – Direct and Indirect Pressure)

Sometimes the really basic stuff needs better coverage. This series will probably start popping up a bit because sometimes it’s good to get people to share the stuff they wish someone said at the start. Here’s Greg Brown with simple techniques that could make all the difference that we should definitely do well. 

Here are two sayings you hear all the time:

  • “Simple measures are lifesaving”;
  • “I thought it was common knowledge”.

More and more we are discovering that only one of these sayings is true. Yes, some of the simplest clinical interventions are the highest yield, but there is nothing common about knowledge. Why is it then we don’t often talk about or pass on these lifesaving skills and knowledge? A lot of the time we all put it down to “if I know then everyone knows”.

So it is about time that we all started talking about these simple and or basic interventions that save lives (or at least minimise the mess we have to clean up at a later stage).

In this the first of an indefinite series titled “I wish I knew then what I know now” we will be looking at the simple yet effective tips and tricks that either:

  • We wish somebody had taught us at Uni / college;
  • Didn’t exist then but do now; or, (c)
  • We are at risk of forgetting due to an abundance of modern technology.

So quieten the voice inside your head that is saying “I am a senior doctor / nurse / paramedic / rescue guru – what could I possibly learn about the basics?” and take up the challenge to continue reading and see if you know our little tips and tricks. Or maybe you’ll have some tips and tricks to send back our way. With any luck these posts will generate some healthy continuous improvement and discussions all about the patient. We might all be surprised what we’ll learn along the way.

Controlling the Red Tide

This is not a post about quelling a Communist insurgency. Basic haemorrhage control appears to be a dying art (no pun intended). The skill of haemorrhage control is used across all areas of healthcare whether you work as an immediate responder in the pre-hospital environment, as a paramedic or professional pre-hospital care provider, within an emergency department, ICU or wards of a hospital or simply as a relative or friend after hours.

However, our observations of many of the health care professionals and volunteers that we work with (or teach) indicate that the basics are not known and rarely taught these days. So let’s look at some  – direct pressure and indirect pressure.

Direct Pressure

Direct pressure….it sounds simple enough, but how do you achieve this? Let’s use a simple laceration to a limb with venous bleeding as an example.

The standard approach to applying direct pressure will see many people reaching for a flat combine (or other blood soaky-uppy type device), placing that directly onto the wound and bandage away. What about when that bleeds through? Simple – repeat step 1 by applying a second combine on top and bandage away. What about when it bleeds through again? Easy – repeat as above. Right? Well, maybe not so much.

The problem with this process (that we have all been taught at some point) is that at no stage are you actually applying direct pressure to what is bleeding. This is not a criticism of the individual – rather, it’s a firm clue that perhaps there is an issue with the teaching.

To explain what is going wrong we ask you to consider a leaking garden hose. If your hose has a small leak in it, what happens if you place the palm of your hand down on the leak? The water oozes out underneath your hand – this is just like the flat combine being placed onto a bleeding wound (i.e. the blood leaks out the side).

Now, what if you were to walk up to your leaking garden hose and place a single finger on the hole – what would happen? Well, assuming that there is not massive pressure behind the leak then the leaking water would cease.

This is direct pressure in action. One needs to think about what it is you are actually trying to achieve with your bandaging technique – flat on flat with distributive pressure is different to direct pressure. You need to add a pressure device, and a simple solution is to add a small rolled up bandage on top of the first combine – placed directly over the source of bleeding – then bandage over that.

These images describe this as simply as we can (it’s much easier to demonstrate than describe):

direct-pressure

So simple to achieve when you think about it, and also very cost-effective.

Now, there are also various commercially made bandages out there that achieve the same thing. Two that are widely used across our planet (well, certainly in Australia…) are “The Emergency Bandage” (aka Israeli Dressing, made by FirstCare) and the OLEAS Modular Bandage (made by Tactical Medical Solutions). If you have the ability to have these as part of your kit then these are great additions – they also do a lot more than just apply direct pressure, but that is a story for another day.

oleas

Remember though, big and flashy is not always needed to be effective. The main thing to remember with direct pressure is that smaller in this case is better. By this we mean that if you only need finger point pressure to stop the bleeding don’t use a combine as your patient will bleed more than they should; and let’s face it – once the blood has left the body it is damn hard to put it back.

Story Time

Many years ago I was working in a small(ish) country hospital when an elderly gentleman was brought in by ambulance. This gent had slipped on a wet pavement and unfortunately hit his head on the sidewalk whereupon he commenced bleeding from a nasty scalp wound.

A first aider from a nearby shop applied standard level treatment – flat combine and a crepe bandage. The ambulance team arrived shortly thereafter and, noting that the first layer was soaked through with blood, applied a second combine and crepe bandage then commenced transport to hospital. Believe it or not, the process was again repeated when the second layer had bled through – that’s three combines and three crepe bandages.

head
And yes, I’ve previously got clearance to use these photos.

In the hospital the man’s dressings were removed and he was still bleeding from the wound. A single gloved finger was used to apply direct pressure and, lo and behold, three minutes later he had stopped bleeding.

One of the hospital staff then weighed the combined soiled dressings – the clot, combines and bandages weighed in at just under 800g. That is a LOT of blood what would have been better served remaining in the gentleman’s circulatory system.

Indirect Pressure

Indirect pressure is a great intervention that will stop (or at least slow) bleeding while we implement effective wound treatment. By this we mean you need to stop the blood spilling onto the ground while you apply the arterial tourniquet or pack the wound.

Indirect pressure is achieved by applying a compressive force proximal to the damaged artery until the bleeding stops (or is at least slowed down). There are in essence two methods of achieving this:

  1. Use of manual indirect pressure (e.g. a knee to the groin (femoral artery) or fist / knee to the elbow (brachial artery)); and
  2. Arterial tourniquets.

This Collective entry will only deal with the former; we’re keeping arterial tourniquets up our sleeve. Or somewhere.

So, manual indirect pressure.…again, it sounds simple enough. But how do you achieve this?

Many people are taught to simply apply some form of pressure to an artery above the wound. But, given that many first aid courses no longer teach the taking of pulses (for the international readers, within Australia a few years ago “first aid” seemed to become very cardiac arrest oriented, and we all know the presence or absence of a pulse no longer forms part of the CPR ritual for many people…) how can a first responder be relied upon to locate a brachial or femoral pulse in an exsanguinating patient when they’ve never been taught?

It is not just the first responders who are at risk here. As healthcare professionals we need to be able to act reliably and instinctively in the presence of life threatening haemorrhage. None us were born with ultrasound-guided vision (patent still pending so back off), and if you are reaching for your favourite POCUS device to find that vessel then you are doing your patient a great disservice.

The money shot is to go for the joint – at least here the pulses tend to be more superficial – and apply pressure there. How much pressure? Lots, in fact as much as you physically can! Manual indirect pressure requires a lot of force. To be most effective one needs to use as much of their own body weight as possible. Don’t stop here though – there is a vitally important extra step to this technique that is not widely known.

If all you do is apply a compressive force to the area in which the artery lays you stand a very good chance of missing your target’s location and sitting either left or right of where the artery actually lies. To ensure that the artery is compressed we recommend adding a twist of the knee or fist after compressing in order to kink off all vasculature under where the compressive force has been applied. We call this technique a “Z Lock”. This helps ensure that you are going to stop (or at least slow down) the bleeding and buy yourself time to treat the actual wound or apply an arterial tourniquet (if warranted).

Press and twist. It makes a difference. Also those are the instructions for that ultrasound-guided vision device. Damn. Shouldn’t have mentioned that.

Summary

Direct and indirect pressure are powerful interventions that help minimise a patient’s blood loss. They are however often forgotten about during both teaching and application stages as we become more and more task fixated. So we challenge you to make these steps part of your training regimes when talking about haemorrhage control. Practice them or, as one of our former instructors used to say, “don’t just be good at the basics – be awesome at them!”.

The Remote Bad Stuff

Last time Jodie Martin, Flight Nurse extraordinaire dropped by she shared one of our most popular posts ever. Jodie returns with a little on the Top End experience of sepsis. 

Time for a look at some remote medicine again.

CareFlight provides the aeromedical service for the top half of the Northern Territory (NT) in Australia.  The area covered by the service is the same size as France but has only 160,000 people.  And less vineyards.

As 115,000 of this population are in Darwin which is serviced by road ambulance services this leaves CareFlight to provide services to about 45,000 people in very remote and widely scattered centres, most of which are small Indigenous communities.  The catchment area has only two rural hospitals which are non-referral centres with care otherwise provided in remote health clinics. Even then not everyone lives close to a rural hospital or remote health clinic. Some rural folk still have to drive several hours or even a few days to any level of health care. Access to health care is a real challenge when someone becomes sick.

The Top End of the Northern Territory may be sparsely populated with 0.2 persons per square km, but it has the highest incidence of sepsis in Australia and five times higher rates than those recorded in the US and Europe 1,2. It has been suggested that one of the reasons for the high incidence of sepsis is related to the higher Indigenous population in the Top End 2. The incidence of sepsis requiring ICU admission in the Top End of the NT for Indigenous people is reported to be 4.7 per 1,000. In the non-Indigenous population there are 1.3 admissions per 1000 people. When compared to the rest of Australia, the rate of admission to an ICU for sepsis is 0.77 per 1,000 2  with national 28 day mortality rates of 32.4% 1.

The Top End – Not Just Popular with People

Human-invading bacteria and viruses love the warmth and moisture of the tropics. To make things even harder, the Top End has the highest rate in the world of melioidosis, a very nasty pathogen found in the wet tropics of Australia.  Melioidosis has been classified as a Type B bioterrorism agent by the Centre for Disease Control in the US and kills up to 40% of infected patients often from rapidly fulminant disease.  However most sepsis is of the more common garden variety, but still causes severe, life threatening illness.

jurgen-otto
A quick editorial note that we have done another story from the Top End and still it’s not about crocodiles. We apologise but it turns out there are other things up there trying to kill you.

When you add the challenges of distance and retrieval times, meeting targets for sepsis treatment which are time-based would seem an impossible task. Given this, we were keen to review the retrieval of septic shock patients in our service to see what the outcomes are like and whether we could improve the process.  The results have just been published in the Air Medical Journal which you can find here.

The patients were sick.  A third of patients required intubation and 89% required inotropes.  Median mission time however was 6 hours and the longest case took 12 hours.  Given the remoteness and time delays inherent in retrieval over such distances with a population known to have worse health outcomes, you would expect mortality to be high.  Surprisingly however the 30 day mortality in this group of 69 patients, which are predominately Indigenous, was only 13%.  This is lower than previous rates described for both sepsis in Australian Indigenous populations and for patients in Australian and New Zealand intensive care units.

That’s Excellent, But Why?

It is interesting to speculate on the possible reasons for such good outcomes.  Reasons might include:

  • The relatively young age of the patients compared with many series. Perhaps the better physiological reserves of younger patients are still a key factor despite the higher rates of co-morbidities.
  • Early antibiotics – these are almost always given by the end of the referral call. Good clinical coordination has a role to play in this too.
  • Early aggressive fluid resuscitation – the median volume of crystalloid administered was 3L during the retrieval process.
  • Inotropes administered following fluid resuscitation occurred in the vast majority of patients.
  • Early referral – recognising when a patient is sick. This is something we’d like to gather more data on. We didn’t record how long a patient was in a remote health centre before a referral call was made, but we have a suspicion early referral might have played a part here.

It is also interesting to note the good outcomes that were achieved without invasive monitoring in approximately half the patients retrieved.  Perhaps there are shades of the findings of the ARISE study here where fancy haemodynamic monitoring really did not seem to make much difference either – what matters in the retrieval context is early antibiotics, aggressive fluid resuscitation and early intubation when indicated.

We did not randomise patients to invasive versus non-invasive monitoring and it is possible that the sicker patients and those with longer transport times received the invasive version.  But it is also possible that we get too hung up on this stuff and it is the basics that really matter whether you are in the city or a really remote health clinic.

The Wrap

The Australian Indigenous population have poorer health outcomes than the general community. Outcomes are even worse for those residing in remote areas than those in urban areas. In our small study it is pleasing to see such good outcomes despite remoteness and long retrieval times. Our young patient cohort recovered well considering how sick they were but what would be even better is preventing sepsis in the first instance. The incidence and burden of sepsis in young Indigenous people requires preventative strategies and appropriate and timely health care resources. Improving access to health care, improved housing and decreasing overcrowding, decreasing co-morbidities and decreasing rates of alcohol and tobacco use are hopefully just some of ways we can possibly decrease the incidence of sepsis and contribute to closing the gap.

Notes:

That croc with almost enough teeth came from flickr’s Creative Commons area and is unchanged from Jurgen Otto’s original post.

Here’s the link to the paper that’s just been published:

Joynes EL, Martin J, Ross M. Management of Septic Shock in the Remote Prehospital Setting. Air Med Journal. 2016;35:235-8. 

The two references with the actual superscript numbers above are here:

  1. Finfer S, Bellomo R, Lipman, J, et al. Adult population incidence of severe sepsis in Australian and New Zealand intensive care units. Intensive Care Med. 2004; 30: 589-596.
  2. Davis J, Cheng A, Humphrey A, Stephens D, Anstey N. Sepsis in the tropical Top End of Australia’s Northern Territory: Disease burden and impact on Indigenous Australians. Med J Aust. 2011; 194: 519-524.

Here’s a bit on melioidosis from the CDC website and here’s a review in the NEJM.

If you want to look more at the government’s Closing the Gap stuff, you could go here.

The Rest of Their Lives

At the recent Student Paramedics Australasia International Conference 2016 held in Sydney, Dr Andrew Weatherall was given the topic of “things paramedics can do to produce better long-term outcomes after traumatic brain injury”. This is a version of that talk modified for the blog. 

This topic, that someone else came up with, gets it.

So much of the time in prehospital medicine we focus on things we measure in the first hour or so. The stuff we do before we hit the doors of the hospital. That fairly bogus ‘golden hour’.

Those things matter. But the big picture of trauma care isn’t the first hour. It’s the rest of the patient’s life.

Everything we do in the prehospital setting is really about whether they get back to what they were dreaming of doing. It’s not up to us what those dreams are. Your patient might dream of playing big time sport. They might dream of creating the world’s great collection of corn chips that look like ex-Prime Ministers. They might want to fly on the first trip to Mars (and almost certainly die of cancer because everyone seems to be forgetting about deep space radiation). When we care for them we sort of have to want their dream to happen for them.

So on the days when I get to hang out with paramedics instead of getting paid by the government to wear pyjamas and give drugs to kids, this is the aim. And traumatic brain injury is worth looking after well.

We could dive into traumatic brain injury by starting with a bunch of graphs from a physiology text. Let’s dive into something to make it relevant.

The Scene

crash-copy-2

This is the scene we’ll be going to. You’ll end up looking mostly at the patient who was driving the SUV. It looks like they had an initial collision, rolled over and then nudged up against the hatch that was veering off the road. Emergency services have been called by a passing pharmacy student who has done a First Aid course. They tried shaking and shouting and got no response. They thought about feeling for a pulse and they’ve found one. 

This patient is clearly one who might have a traumatic brain injury (TBI). They could end up as one of the patients with moderate or severe TBI who lead to a cost to the system of around $8.6 billion each year. That comes from a report prepared for the Victorian Neurotrauma Initiative released in 2009. It estimated that for 2008 Australia would have around 1400 in the moderate TBI group and 1000 in the severely injured group.

And each one of those people doesn’t get back to their planned life. Some of them end up needing help with simple things for their whole life.

So this is the job and the clock started 5 minutes ago. What should we focus on? Is it all about RSI? Is it about early TXA? Is about the sort of stuff you need an advanced medical team for?

Well that could be the basis of discussion but we should start with a reality check.

If you look at the NSW Institute of Trauma and Injury Management report of the 2014 trauma database stats, there were 3458 severely injured trauma patients. 66% of the patients had an injury to the head. 3 of the top 5 severe injuries were subdivisions of subdural haematomas.

Of those arriving straight to a trauma centre, 80.4% arrived in an ambulance (vs 12.6% in a helicopter).

Even allowing for some of those ambulances having an accompanying advanced prehospital team, I think this grouping of numbers says something pretty significant: the vast majority of “big” trauma patients will get their care from paramedics.

This also means that if we want to save the most brain cells we should focus on making sure the patients getting those transports have the possible care that those paramedics’ training can make happen. That’s more important across the population than the advanced team’s contribution.

There is a separate chat to have some day about trying to get advanced teams to the jobs where they might really help or the best way to do pointy end stuff. That’s just not the focus for this particular bit.

It does brings us to the first key thing that trained paramedics can do to improve long-term neurological outcomes – be there.

The nature of their training and their ability to focus on getting the vital things done and get moving means that paramedics will invariably lift the standard of care of the patient when they turn up and do their job.

Now exactly what they should do we’ll get onto in a bit but there will only ever be a small number of meaningful interventions to do for the patient so it makes sense to get it done as efficiently as possible and get moving. And of course while neurosurgery is mostly not an urgent requirement, about 1 in 5 patients will need some form of early head-cutter work. That 20% of patients really want professionals who are trained to make things move.

So it might seem like there’s not much meat on just saying “be there”, but I think it’s worth noting as we go that the standard way professional paramedics go about their business represents a step up compared to what was managed in the past.

Now that you’re there …

Back to the patient. When you get there, the patient looks to be in their mid-30s, is making breathing efforts and there is some air moving but it is fairly noisy respiration. Initial peripheral saturations read at 85% and the measured blood pressure of 95 mmHg is somewhere near what you would have guessed by palpating the radial pulse. The patient’s GCS is 7, the pupils are equal and reactive. A quick glance suggests the right femur looks like it’s adopting a more meandering course than usual on the way down to the knee. 

So what should our aim be for these patients? What targets do we have that are the best evidence-based ones available?

Somewhat disappointingly we don’t have that much evidence for discrete targets. What evidence there is hasn’t really shifted much over the last couple of decades. Most of the stuff we do leans heavily on a general understanding of physiology as much as firm numbers.

But let’s focus on the numbers we do have. They’re based mostly on retrospective looks at info from big data banks. And the number to remember is 90. That’s the breakpoint because:

  • 90% saturations is around 60 mmHg pO2 and we know that patients who have a reading below that value have worse long-term neurological outcomes.
  • 90 mmHg is the magic BP number for adults – a measurement below this is associated with worse outcomes.

So we want to stay above 90 on both counts. That’s what we can all target right now.

And these markers kind of make sense. We often think about the primary injury already having happened when we get to the patient and focus on avoiding secondary injuries which we view as discrete and separate extra insults. Add new injuries and you make the outcome worse.

It’s probably more accurate to say that the primary injury evolves over a number of hours. In that traumatised brain there will be excitatory neurotransmitters looking to party way too much for the cells to recover. There will be inappropriate triggering of cell death. Calcium will be getting places it shouldn’t and generally grabbing onto cell elements it should leave alone. Each secondary injury ramps up processes like these as they continue to evolve. It’s one of those times all evidence-based practitioners need to try and stop evolution from being a thing.

There are a few other things worth keeping in mind:

  • The brain is pretty simple in its demands. It wants oxygen and nutrients delivered.
  • Things that make blood flow decrease aren’t good (remember that the injury itself is quite likely to drop blood flow well below normal).
  • Intracranial pressure that is high isn’t great. It compromises blood flow.

Oh, and it’s also worth mentioning that there aren’t many things inside the head that we influence the volume of prehospitally:

  • There’s the brain tissue (and the associated fluid that goes with it).
  • There’s blood. Blood can be inside vessels which gives us some scope to manipulate how much flow is occurring. Occasionally it will be outside vessels and the vast majority of times that patient will get their definitive care at the hands of a neurosurgeon.
  • There’s CSF (which we have less influence over).

So if our aims are basic do we have to wait for advanced techniques to try and reach this target? Of course not.

This brings us to the second important “thing that we can do right now” – be basic.

Consistent delivery of basic measures has the potential to save huge numbers of brain cells. It’s more meaningful than waiting to try and develop the infrastructure and expertise to get more people doing advanced things like RSI.

The perfect example is impact brain apnoea. This has really only been described in any detail fairly recently by Wilson et al but there are accounts throughout medical history and the animal literature that describes a phenomenon of subjects forgetting that whole breathing malarkey in the immediate aftermath of trauma.

The suggested treatment? Open the airway and support ventilation. Those simple steps are meaningful.

They’re meaningful for all patients with TBI too. Which is why it’s worth getting back to the simple message of “A-B-C” which some sage once told us was as easy as “1-2-3”. Simpler than the transition to adulthood from child stardom if you were that individual anyway.

So let’s work through those simple little letters.

1. How’s your “A” game?

a-luca-rossato
Well, is it anarchy? 

Failure to do the basic bit of airway well is one of the commonest issues we see when welcome people training at the kids’ hospital. It’s such an important foundation though. So ask yourself whether you do the basic version of “A” well. Is your jaw thrust good enough to get those bottom teeth in front of the top teeth? Do you reach for adjuncts like oropharyngeal or nasopharyngeal airways as an aid? Are you quick enough to move to a two hand technique?

Most importantly do you make sure that you create a good seal with your mask? The value of a good seal is actually highlighted by work looking at pre oxygenation techniques. A colleague from CareFlight, Dr Chris Groombridge, did a nifty study with volunteers evaluating the maximum expired oxygen level you could achieve with different techniques. Anaesthetic circuit vs bag-valve mask (either alone or with nasal cannulae or PEEP valve or both) vs non-rebreather mask (with and without nasal cannulae).

And at the end of 3 minutes you still couldn’t beat either the anaesthetic circuit or the bag-valve mask with a well-maintained seal.

Hayes-Bradley et al did some work with a slightly different focus, evaluating the impact of nasal cannulae on pre-oxygenation with a bag-valve mask set-up or non-rebreather. Nasal cannulae helped only where there was a deliberately created leak in the seal.

Now you could take the line that it’s just pragmatic to assume you’ll end up with a leak. But why should we accept doing the technique anyway other than perfectly? Let’s focus on getting the seal right.

We’ve really taken that to heart at work, making the effort to maintain that seal throughout pre-oxygenation. It’s all part of ensuring that our focus on is on the main game – maximising oxygenation throughout the RSI rather than pushing on to the laryngoscopy and intubation step without optimising things up front. The brain wants oxygen more than it wants laryngoscopy.

That some prioritisation of the basic step of managing “A” well – perfect performance of basic airway manoeuvres, suction and use of adjuncts – can apply to all of us, whether we intubate or not. It’s the first step to delivering on our first aim – get those peripheral saturations above 90.

It also feeds seamlessly onto …

“How good are your “B” moves?”

b-nadege
Is it carnival material?

What about those patients who need support for the breathing part of the equation. That might be via that bag-valve mask set-up or you might have supraglottic airways as an option you’ve been trained to use.

The question here is not just how well do you do it but do you take steps to make sure you’re using that skill set in the best interests of the patient?

So if you think a supraglottic airway might be appropriate for a patient do you quickly assess if they’re ready for it with a firm jaw thrust and a deep suction before placing it? Do you check what the seal is like once it’s in?

And how do you measure your effort with the bag you hook up to that SGA? Because it’s easy to puff away like your hand is a talking sock puppet. We should really all be hooking up capnography wherever we can (for bag-valve mask work too). It might not provide a trace like the intubated patient but it will be more accurate than a guesstimate. And without having a sense of where you’re at with the CO2, how do you know if you’re not creating hypocapnoea when hypocapnoea is associated with reduced cerebral blood flow (and of course hypercapnoea could cause raised ICP)?

Doing the “basics” well requires a bit of attention. Who knew?

But you might well say, what about RSI? Shouldn’t we be figuring out how to train people to do that? Well while there is a probable role for RSI it is really hard to demonstrate the positive benefit. That is probably partly because prospective research in prehospital medicine is very hard. But the evolution of the research that’s out there suggests that getting that high stakes procedure done well enough to have the benefit outweigh the potential complications will take a very long and concerted effort.

Take for example just 3 studies:

  • The San Diego RSI paper – this suggested worse outcomes but subsequent analysis revealed performance of the procedure with significant periods of hypoxia (57% of those analysed had a desaturation with an average time of 160 seconds and a median fall in saturations of 22%).
  • HIRT – which took long enough in recruitment that the system changed all around it, rendering it very difficult to keep arms of the study in their planned arms. Those that received the advanced interventions team as intended did have a 14% reduction in mortality but it’s not robust enough to bank your house on.
  • The Victorian paramedic RSI paper – this showed benefit but there were more patients in the control group lost to follow-up and you’d think that those who did better would be the ones you’d lose. Just one different outcome in the control group would have made the findings insignificant. So it’s not robust enough but for different reasons.

So RSI makes physiological sense and most would still say it has a role. But it’s hard to make it pay off. We can all do the basics right every day from today.

What should we see when people are doing “C”?

c-karyn-christner

It’s not like there’s some study out there saying “this particular prehospital intervention related to circulation and haemorrhage leads to better TBI outcomes” but we can focus on maintaining that blood pressure above 90 mmHg. So things that cause catastrophic hypotension (say, pneumothorax with haemodynamic consequences) need treatment with whatever the provider is trained for.

If there is external haemorrhage that has to be controlled so we can focus on doing that particularly excellently. If you’re putting on a tourniquet, think about providing proximal occlusion of flow first with your whole weight (e.g. a knee not just into the groin but leaning in and twisting a bit to really slow down flow before the tourniquet goes on). Really  provide pressure to stop bleeding if pressure is the treatment you’ve chosen. Splint that femoral fracture to reduce loss of blood volume.

At the same time it’s worth noting that some of the evidence base for things we do is less strong than we might assume. As covered by Dr Alan Garner in the series starting here, the evidence base for pelvic splints improving haemodynamics isn’t based on huge reams of work.

Other options will probably come through for lots of practitioners soon. Haemostatic dressings or granules are likely to make a difference for some patients. With a little more evidence TXA might roll out across the land. And while there are very interesting concepts like prehospital REBOA out there to be wielded by a select few, something like the Abdominal Aortic Junctional Tourniquet might be a far more significant option on a population level. Judicious use in the exsanguinating patient with due regard to the potential downsides (particularly if it might take a while to get to somewhere else) could be an option for an awful lot more practitioners.

The Other Simple Things

That’s not the end of the simple things of course. Think about whether you can sit your patient up to drop the ICP. Is there a better way to maintain C-spine stability then a rigid collar? Is there anything constricting the neck?

Add a lot of simple steps together and you have pretty comprehensive efforts for those brain cells that just want blood to flow and nutrients to turn up.

The Group Who Doesn’t Get the Simple Things

And while we’re at it, there is one group who tend to get much less of all of the things, including the basics.

Kids.

Which is not great if you’re trying to think about how to provide better long-term outcomes. Their long-term is even more long-term.

Bankole et al provide just one example of a study demonstrating this. They looked at prehospital care around a New Jersey centre and compared the care received by kids with TBI to that received by adults. The numbers are pretty stark (though some of the headline items relate to interventions like intubation).

69.2% of the kids intubated had complications at intubation. 20% of kids with a GCS under 8 had no attempt at intubation. Failed intubation rates were 29.03% (vs 2.27% in adults). Kids also had higher rates of the dislodgement, oesophageal intubation, wrong size of tube choice and a requirement for multiple attempts.

Even intravenous access was placed less (adults had a prehospital cannula 85.9% of the time whereas in kids with the same spectrum of pretty severe injuries it was 65.7%).

More recently advanced practitioners in Switzerland published around the topic of advanced airway management in kids and while they did well initially, wrong tube sizes and wrong depth of the tube turned up again.

There are lots of reasons we do less well with kids. We see them less for a start and there can be additional scene distractions. But ultimately we need to recognise this and figure out a way to make sure we step up to the mark.

Back to the Scene

The patient has been making respiratory efforts but you can see the chest see-sawing a bit with diaphragmatic effort with an added breathing buzzsaw soundtrack. You jaw thrust and the airway improves. A suction improves the airway still further. You add a bag-mask set-up and really focus on a great seal. The saturations rise above 95%. The femur looks like it’s taking a meandering the scenic route towards the knee but it’s soon splinted and a big wound in the calf gets pressure to slow the bleeding. You’re on your way…

Now that sounds pretty easy. When you’re in a lecture theatre or reading a lesser known blog it sounds even easier. But we all know that the scene isn’t actually that easy. We’re assailed by all sorts of things and there is plenty of work in simulation sessions (like here) showing that when faced with high stress situations we tend to omit things we ordinarily wouldn’t, do things we’d normally not contemplate and remember all of it less.

This touches on the next thing prehospital practitioners have to do to provide better care for the brain – be the same with your care, everywhere. (The astute reader will notice that not only did I match the formatting to the other “be” statements, I made it internally rhyme. I’m really trying to make it seem meaningful.)

Beyond starting by acknowledging the risks of a deterioration in performance depending on the day or the job or the other stuff in our lives, we have to figure out how to be consistently excellent with our care. That’s what the patient expects. Their brain cells aren’t very interested in your back story or your motivation. They’d like you to do your job.

The strategies to try and make sure you always step up are way too many to go in right here, so it’s worth looking around. But use the team, communicate well, share your plans with those around you, use checklists or practice tactical breathing or other focus techniques or whatever it is that works for your good self.

Just don’t accept that you have to be a hostage to all those other factors.

And part of not accepting the status quo is striving to always provide better than we can do right now. That requires all of us to be a leader.

If we want to be able to provide capnography for all those patients whose A and B we’re managing then we might need to advocate for that. If we want to be able to look back in detail at how well we did, then monitors that only store information every 2 minutes (which is so often the case with prehospital monitors) aren’t up to scratch and we need to lead those demands. We need to provide leadership in governance and education to keep our standards constantly improving. We might even need to advocate solutions to issues in other areas of health that would free up paramedics to be out on the roads so they can work on that being there bit.

Future Dreams

brett-burton-future

While this topic is mostly about what we can do right now we obviously have to keep an eye out for what comes next. And I could well be wrong but my guess is that the thing that comes next that makes a big difference across the population to those who suffer a TBI won’t be one of the magic bullets being tried like progesterone, or EPO, or even TXA.

What would be really great is to actually know what the brain wants right now. Is the blood pressure of 100 mmHg actually adequate for this person’s brain or are they usually hypertensive and critical cerebral ischaemia is being added to your mix?

Does this patient actually need their CO2 a little higher than you might have thought because blood flow isn’t so great?  Is their evidence of haematoma developing on one side that hasn’t shown up clinically?

That’s part of why we’re researching tech like near-infrared spectroscopy tissue oximetry. Now I’m not convinced that particular technology will provide that information reliably enough, but I do think that the most meaningful thing we could add to prehospital TBI care is more info about what this patient’s individual brain would like, rather than being stuck with population-based gross numbers.

And if we find that device the ultimate result will probably be that it tells us how to do the basics just that little bit better for this particular patient.

Because they might have big plans for corn chips that look like ex-Prime Ministers.

 

Notes:

OK, this was a really long post, but when you put a talk into post form it can be like that.

Here are just a few things from along the way you might like to go and look at.

Here’s a link to that Access Economics report with the alarming costs stuff.

Here’s the 2014 Trauma Registry report from ITIM in NSW.

The “90” numbers are part of the prehospital TBI guidelines.

Badjatia N, Carney N, Crocco TJ, et al. Guidelines for Prehospital Management of Traumatic Brain Injury 2nd Edition. Prehosp Emerg Care. 2007;sup1. S1-S53.

The first of the “seal” papers:

Groombridge C, Chin CW, Hanrahan B, Holdgate A. Assessment of Common Preoxygenation Strategies Outside of the Operating Room Environment. 2016;23:342-6. 

and the other one …

Hayes-Bradley C, Lewis A, Burns B, Miller M. Efficacy of Nasal Cannula Oxygen as a Preoxygenation Adjunct in Emergency Airway Management. Ann Emerg Med. 2016;68:174-80.

The San Diego paper:

Davis DP, Hoyt DB, Ochs M, et al. The effect of paramedic rapid sequence intubation on outcome in patients with severe traumatic brain injury. J Trauma. 2003;53:444-53. 

HIRT:
Garner AA, Mann KP, Fearnside M, et al. The Head Injury Retrieval Trial (HIRT): a single-centre randomised controlled trial of physician prehospital management of severe blunt head injury compared with management by paramedics only. Emerge Med J. 2015;32:869-75. 

The Victorian paper:

Bernard SA, Nguyen V, Cameron P, et al. Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomised controlled trial. Ann. Sure. 2010;252:959-65. 

Here’s the start of Dr Alan Garner’s series on pelvic binders here. The AAJT also scores a mention in post 4 in that series.

That Bankole thing:

Bankole S, Asuncion A, Ross S, et al. First responder performance in pediatric trauma: A comparison with an adult cohort. Pediatr Crit Care Med. 2011;12:366-170. 

That sim paper:

Leblanc VR, Regehr C, Tavares W, et al. The impact of stress on paramedic performance during simulated critical events. Prehosp Disaster Med. 2012;27:369-74. 

Oh, and I put stuff over on the blog site at www.songsorstories.com relating to kids anaesthesia. If you look at the categories “airway” and “tips and tricks” and “cannulation” you’ll find some basic tips for working on things.

All the images here are from flickr creative commons and unaltered.

Did you scroll this far? Well you will inherit the earth that is constructed where scrolling is rewarded. Here, have this porcupine reviewing pumpkins as payback.

 

Physiology in the Winch

Dr Alan Garner has a blog post in the context of a report just published. A catastrophe during a winching operation highlights the physiological challenges we sometimes add in the work we do. 

The death of a patient during a winching incident in Victoria in 2013 was distressing for everyone concerned.  I was asked by the Victorian Coroner’s Office to provide an expert opinion on the death based on some previous research I had conducted with one of our registrars, Dave Murphy, looking at the effects on respiratory function of various methods of helicopter rescue.  I’m pretty sure at the time we were the only group in Australia who had published in this area so I guess we were the obvious choice.

As part of trying to avoid a similar incident the coroner’s office agreed to us publishing the case in an appropriate scientific journal so that operators worldwide would benefit from the lessons learned rather than just the industry in Australia.  That report has just been published in Aerospace Medicine and Human Performance and can be found here.

The details of the case are now on the public record in both the coronial inquest and the ATSB investigation.  Our case report focuses more on the physiology of hoisting than either of these forums needed.

For those not aware of the case the brief version is that a man of approximately 60 years of age and BMI of 45 with borderline cardiac failure injured his ankle whilst on a hunting trip in Victoria about a kilometre from the nearest road.  Carrying him was considered risky for the rescuers (the terrain was steep) and a hoist extrication by helicopter was organised.  An accompanied single sling technique was utilised.

Unfortunately as they approached the aircraft skid the patient became combative and then unconscious.  He slipped from the strop despite the best efforts of the paramedic and crewman and fell to his death.  I can only imagine the distress of the crew when this occurred.

The actions of the crew on the day were consistent with their company/Ambulance Victoria procedures and were within the specifications of the equipment utilised. They were just doing their best to provide their best care as they’d been trained. Neither was any of the equipment found to be faulty.  The obvious question then is why did the fall happen?

What happens when you put someone in that hoist?

You need to go looking in the climbing literature to find the physiological effects of suspension with chest compression which is what happens when you are in a single strop.  As you would expect, there is a constrictive effect upon respiration but there is also a considerable decrease in cardiac output resulting from the decreased venous return with raised intrathoracic pressure.  The decrease in cardiac output has been demonstrated to be as much as a third in fit young climbers.  The decrease in respiratory function parameters is similar (in both the Murphy paper and the one referenced in the link in the previous sentence).

HMS Montrose conducts Rapid Roping and Winch Training
When you think through what’s involved, the physiology makes sense.

Given that the chest compression associated with hoist rescue is of short duration it is generally adequately tolerated long enough to complete the rescue in fit young people.  Having said that one of the best studies of the physiological effects of suspension in a chest harness was precipitated by the death of a 25 year old soldier who was left suspended in a single strop for just 6 minutes.  Cardiovascular collapse can occur surprisingly rapidly.  The man in the Victorian incident with his significant comorbidities was however not able to tolerate even a short period of thoracic compression and rapidly became unconscious.

The effects of single strop rescue in people who have been immersed even where they are otherwise fit and young is perhaps better known and the second sling under the knees (or hypostrop as it is often called) is in widespread use in this situation.  For winches of non-immersed persons it seems that the physiological consequences of various rescue techniques are not well known in the industry however.

Subsequent actions by Ambulance Victoria, the helicopter operator, the Victorian Coroner, CASA and the Australian Transportation Safety Bureau (ATSB) all rightly concentrated on determining how a repeat of the incident could be avoided by better educating both clinical and operational crews about the physiological implications of hoisting techniques.

What are the options?

We have previously published on the use of the Coast Guard Rescue Basket due to its benign effect on physiology compared with other techniques (Murphy).  It remains a surprise to us that this device is not in more widespread use.  Ambulance Victoria has now introduced a sit type harness which is definitely to be preferred in hoists over land.  The Rescue Basket can be used in winches out of water as well and we think is the more flexible option.

jim-howard
You can see that this sort of option would be easier on the physiology.

Should the single strop technique be banned entirely?  We don’t believe so. Every rescue is a balance of risks and sometimes the risk to either the patient, aircraft or both means that an immediate single sling extrication may be the safest option overall.  We certainly have not banned its use within CareFlight.  Knowing about the physiological downsides we have discouraged its use for many years and encouraged use of the rescue basket.  We have not removed it from the armamentarium however.  If a crew elect to use it they have to provide a report in writing to the chief pilot about why they chose that technique.  Knowing that there is that little bit of extra documentation required is enough to make teams make sure they’ve covered their options and risks carefully before they go ahead, but the option remains on the table.

Hoisting is risky for lots of reasons. We train for a range of safety considerations. And equally we have to make sure we’re aware of the physiological changes we might inflict on our all important patients.

Conflict of Interest Statement:

Neither I, nor either of my employers have any interest, financial or otherwise, in the manufacturer or distribution of the Coast Guard Rescue Basket.

Notes:

The first image here is from the Royal Navy Media Archive while the second was posted by Jim Howard, both to the Creative Commons area of flickr. Both are unchanged.

And now those references.

First is the paper derived from this case:

Biles J, Garner AA. Loss of Consciousness During Single Sling Helicopter Hoist Rescue Resulting in a Fatal Fall. Aerospace Medicine and Human Performance. 2016;87:821-4.

Next is the paper written with Dave Murphy:

Murphy D, Garner A, Bishop R. Respiratory function in Hoist Rescue: Comparing Slings, Stretcher and Rescue Basket. Aviat Space Environ Med 2011; 82(2):123-27

And the first of the climbing things:

Roeggla M, Brunner M, Michalek A, Gamper G, Marschall I, Hirschl MM, et al. Cardiorespiratory response to free suspension simulating the situation between fall and rescue in a rock climbing accident. Wild Environ Med 1996;7(2):109-14

And the next one:

Madsen P, Svendsen L B, Jørgensen L G, Matzen S, Jansen E, Secher N H. Tolerance to head-up tilt and suspension with elevated legs. Aviat Space Environ Med 1998; 69(8):781-4

And you can find the ATSB report here.

Brighter Lights for Darker Nights (or How and Why to Set up Trauma Workshops for Your Local Volunteers)

Greg Brown, the person with the job of coordinating education at CareFlight on things anyone with a bit of background can do to help make the wide, brown land feel a little less remote. 

It is a dark and stormy night. It had been a long day at work and you are now driving home from a nearby town where you have been holding fort at what is loosely termed a “hospital”. Your mind drifts to all that is warm, dry and welcoming – family, a comfortable lounge, re-runs of your favourite show (obviously it’s Helicopter Heroes…) – only 40km to go…

These were your last conscious thoughts before you hit a kangaroo, lost control of your Tesla (okay, maybe a Camry) and crash into a tree.

A passer-by calls emergency services. They are on their way – but it’s a dark and stormy night and you don’t live in NSW (that’s Newcastle, Sydney or Wollongong) and the response will be made up of volunteer emergency services.

Meanwhile, a page goes out back in your hometown. Members from various volunteer agencies drop their food and head to their respective depots, don their respective protective uniforms (usually coloured yellow, orange or white), jump in their respective response vehicles and head to the scene where you are now cold, wet and sore.

You are still in your car – you cannot get out because the dashboard has collapsed into your lap. The passer-by tells you that the first response vehicle has arrived. You twist your head to see who it is – Police, Fire or Ambulance? It’s none of those – you don’t live in NSW (again, that’s Newcastle, Sydney or Wollongong) and the response is made up of volunteer emergency services: State (or Territory) Emergency Service, the volunteer bush fire brigade and some others that you didn’t even know existed.

“Where’s the ambulance?” you ask – but the nearest ambulance is at least another half an hour away – maybe more! They tried calling the local doctor but it turns out that was you.

Damn those “dark and stormy nights” you sigh……

Reds Mando Gomez
The other kangaroo probably looks even less impressed.

The Problem

If this scenario sounds far fetched then I encourage you to head out of the big smoke and go bush for a while. Situations such as this are not only real – they are an almost daily occurrence in Australia and many other parts of the world. Conservative estimates reveal that volunteer emergency services personnel outnumber their paid (professional) compatriots by a ratio of 20:1 in Australia with similar comparisons reported abroad.

But all is far from lost. The reality is that the vast majority of emergency services volunteers in Australia are highly capable, appropriately resourced and widely respected for the unpaid yet vital roles that they perform in serving their communities in times of need.

But (yes, there is always a but) those roles rarely include the provision of medical first response unless they are trained community first responders or volunteer ambulance officers. As such, it is also a reality that in non-metropolitan Australia the victim of trauma (vehicle, industrial or other) is likely to be treated initially by a volunteer with nothing but a generic first aid kit and some non-specific training – good if you need a splint or sling, not so good if you are seriously injured. What’s more, many of these volunteers lack the confidence to engage in the provision of medical first response.

The Challenge

Whilst it would be nice if an expertly trained and equipped pre-hospital care team was available in every postcode every hour of the day, we all recognise that this is simply not possible. But (yes, another but) we can do something to help the volunteers that are out there in regional and remote areas. It’s called training.

In the mid 2000’s a small group of “greybeards” at CareFlight were discussing the ways of the world over a few decaf-soy-mochaccinos (probably more likely double macchiatos…) and collectively voiced that if only those volunteers in regional and rural Australia felt appropriately trained and empowered to do a few extra small things for their casualties then they could make even more of a difference to the survivability of the people that they treat. Thus, the concept of the Trauma Care Workshop (formerly termed the Volunteer Trauma Course) was born. With this concept came a list of expectations. These included:

  • The training was to augment the participants’ current training content and systems, not replace them;
  • It needed to bridge the gap between high quality first aid and the care provided by professional medical responders;
  • The educators providing the training needed to be expert clinicians that were clinically current – credibility was going to be important;
  • The training needed to occur in the locations where the responders live – not in Sydney; and
  • Since the participants were likely to comprise mainly volunteers, the training had to be for free (or at least at no charge to the individuals).

Nothing like a good challenge to get the neurons firing…

The Role of AeroMed in Regional Trauma Training

There is little doubt that the sound of an aeromedical flight (helicopter or fixed wing) provides reassurance to both the injured patient and their carers, especially in regional and remote areas. The very sound of an inbound flight conjures up images of advanced medical care, expert clinical decision makers and the opportunity to whisk the patient away to a shiny hospital filled with white lab coats and machines that go “ping”.

The reality is that most trauma patients do not get better at the place their injury happens; they get better in hospitals. So the presence of an aeromedical retrieval team on scene does not in and of itself guarantee survival for the patient – but it can help. So too can that group of volunteer emergency services personnel – if they are trained and empowered to do so.

Herein lies the opportunity. Aeromedical providers owe it to the volunteers that they support to build local capacity and resilience within the regional and remote areas that they service. After all, at some point we all must recognise that we all exist for the same purpose – that is to save lives, speed recovery and serve the community. It is not about the colour of your uniform, nor is it about the company that pays you – it’s about people.

The same is true for clinicians working in regional and remote areas but not associated with an aeromedical provider. Clinic staff are often the second line of defence in the battle against trauma related morbidity and mortality. Supporting the local emergency response team in many ways makes your job easier, and who doesn’t want that?

So what can we offer? To me, we can offer three things: time, knowledge and support.

1. Time

Never underestimate the power of offering your time. I know you are busy – heck, we are all busy. But finding the time to head bush and conduct clinical teaching for those who are rarely exposed to it is one of the most powerful gifts that you can offer.

Emergency services personnel, particularly those of the volunteer varieties, want to know what you are thinking when you are presented with a casualty – any casualty. For you it may be a simple, run of the mill, seen it a thousand times before type of patient; but for the local volunteer emergency services personnel it will likely be new, difficult, unexpected, or perhaps all three! What are YOU thinking when you fly overhead? What goes through YOUR mind when you step onto the pre-hospital scene? How does YOUR clinical assessment process differ from that of a first aider? They can never learn from you if you don’t ever find the time to visit their locations and teach them. Your time is important – to both you and them.

2. Knowledge

Most readers of this article will have at some point in their careers been subjected to a training session delivered by an individual who knows their content but nothing more. This is all-too-often the case in first aid. The reality is that the process for teaching accredited first aid in Australia is highly regulated within the AQTF (that’s the Australian Quality Training Framework – if you’re having trouble sleeping you could look right about here). To pretend you can change or ignore this is perilous.

So aeromedical providers need to embrace the fact that the emergency services personnel that they work with already hold first aid skills and therefore seek to deliver complimentary training. In other words, fill the gaps but eliminate duplication.

What are the elements of casualty care that are easy to perform by a non-clinician yet not covered by the majority of first aid courses? Consider topics such as arterial tourniquets, the difference between crush injury and release syndrome, and the elements of aeromedical evacuation that they need to know (e.g. like not using flares when you’re flying on night vision goggles).

3. Support

The need to build resilience amongst emergency services personnel in Australia is well publicised (if you don’t believe me check out this or this or this).

Building this resilience is a long and involved process, but simple things can and do make a difference in the lives of emergency services personnel. It can be as simple as: acknowledging effort; involving them in decisions; asking them their opinions; and explaining what you are doing / thinking. But you can build resilience during training by offering your time to answer questions or “fill in the blanks”.

For example, in 2015 I taught a bunch of volunteer and professional emergency response personnel at a resort in an extremely remote part of Australia (note: details kept purposely vague). Whilst there we heard of a horrendous job that the local team attended which involved the death of a tourist. In 2016 our team taught a different bunch of response personnel in a different part of Australia and had the opportunity to informally debrief an individual who was effected particularly badly by the aforementioned incident – essentially, this individual volunteered to accompany and protect the deceased tourist overnight in the bottom of a canyon until a repatriation team could fly from the nearest urban centre.

This is an extreme example, but every time I teach I am afforded the privilege of hearing these personal stories. I like to think that every time an individual vents their job related emotions to me that “black dog” is pushed ever so slightly out of the picture.

CareFlight’s Trauma Care Workshop

As previously mentioned, the Trauma Care Workshop (TCW) concept was born out of numerous conversations had by the “greybeards” of CareFlight. It took a few years to secure the funding, purchase the equipment and, of course, write the content, but between January 2011 and June 2016 a total of 174 TCW’s were delivered to a total of 2711 emergency services and first response personnel across Australia – at no cost to the individual attendees.

Everywhere copy
Trauma Care Workshop Locations 2011-2016

The TCW is an eight hour interactive workshop that is delivered either as a single day session or over two consecutive nights. Utilising the principles of adult learning (look up andragogy or Knowles’ principles of adult learning – or just go here) the content is delivered by professional pre-hospital care providers, many of whom also hold post-graduate or vocational qualifications in clinical education, training or assessment.

Any contemporary medical training that is worth the paper it is written on is interdisciplinary in nature. Therefore, the TCW works best when members from different services (e.g. state emergency services, bush fire brigades, rescue agencies, police, park rangers etc) all attend. After all, when was the last time you attended a pre-hospital scene and saw only one colour uniform?

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Park Rangers and Volunteer Ambulance Officers training together on Kangaroo Island, South Australia

The reality is that pre-hospital scenes are like an open bag of Skittles – every colour under the rainbow all mixed in together. But this goes for the Educators too. Where possible, the three Educators on any given TCW will come from diverse clinical backgrounds – critical care doctors, specialist flight / emergency nurses and professional paramedics.

Importantly, all content is evidence based and research centred. The content itself is delivered through a combination of pre-readings, didactic lessons, interactive skill sessions and immersive scenarios which cover the essentials of pre-hospital trauma care:

  • Patient assessment techniques;
  • Haemorrhage control;
  • Basic airway management;
  • Mass casualty triage;
  • Extrication;
  • Burns management;
  • Teamwork and communication strategies (including the need for a shared mental model); and,
  • The essentials of aeromedical evacuation.

But what the TCW does NOT do is change anybody’s scope of practice; the TCW is designed to augment previous training, not replace it. We are not there to take over the world or supersede anyone’s service – it’s about the patient, not the uniform.

If individuals who complete a TCW wish to see their scope of practice altered in light of their newfound knowledge and skills then the responsibility for achieving these changes rests with them (although we are always happy to provide the evidence to back up their case).

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Police and local mine rescue staff often form the frontline in emergency response in outback areas (photo from a course in Kalgoorlie, Western Australia).

But what about you?

Whilst at CareFlight we love delivering high quality evidence based training in locations that are off the beaten track the reality is that we cannot be everywhere. But if you are living and working as a clinician in regional areas then you can help.

Head down to the depot of your local volunteer emergency services agency and introduce yourself. Whilst there, ask them how you can help. They will most likely be looking for more volunteers but the purpose of this article is not to recruit those (although that would be a welcome side effect); instead ask them what medical-based training they’ve been looking for and seek to fill the gaps.

You may find this to be a challenge, especially if pre-hospital care is not your forte. However, the benefits for the community – you, the volunteers and the constituents alike – will be huge. You will need to conduct research, refresh some long forgotten knowledge and perhaps step outside of your comfort zone – all great professional development benefits.

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Park rangers, resort staff, volunteer emergency services and local cattle station workers all training together at a Trauma Care Workshop in the Northern Territory

The volunteers will benefit from the networking and the opportunity to expand their base of knowledge via education delivered by a local healthcare professional.  This will lead to increased confidence within the volunteer group and therefore positively affect their willingness to commence appropriate clinical treatment (even when their primary role is not a medical one). The community will benefit by having local emergency responders who are better trained, more empowered and have increased resilience.

In the words of Mr Dylan Campher (from Queensland Health’s Clinical Skills Development Service), “Economy of scale is produced by having a single agreed model and adapting that to the local needs”. In other words, training and working together makes sense. There are some caveats though:

  1. Don’t expect to change the world overnight – believe me when I say that the wheels of change turn slowly in highly regulated environments.
  2. Don’t attempt to teach something that you have no credibility in – differentiate between what you know (based on experience, training and research) versus what you think.
  3. And perhaps most importantly, don’t ever discredit their previous training. Is it perfect? Probably not. But has it helped serve the community prior to your arrival? Absolutely!

Remember: fill the gaps, eliminate duplication.

That dark and stormy night …

All is not lost. It turns out that the volunteers in their various coloured suits have trained for this very incident – in fact, judging by their shared mental model, it appears that they have trained together!

They rapidly assess the scene and make it safe then apply a “zero survey” to you. This “zero survey” has allowed them to sort any oxygenation issues and expedite your extrication from the car using appropriate spinal precautions. They then applied all the relevant clinical interventions within their scopes of practice including binding your pelvis and protecting you from the elements; all you need now is for the volunteer ambulance crew to arrive on scene so that you can be taken back to work (no re-runs of Helicopter Heroes for you tonight).

You gaze up at the volunteer in the yellow / orange / white uniform and ask “Who are you people, and where did you learn to do all of that?” Her response? “We are just the local volunteers – and your predecessor taught us.”

 

The Post Script:

If you want to know more about the CareFlight Trauma Care Workshop then go here.

If you would like to know about the other clinical education delivered by CareFlight then check out this spot.

If you would like to keep up with where we are and what we are doing then consider following us on Twitter where we travel under @MyCareFlight_Ed

The image of the kangaroos was posted by Mando Gomez under Creative Commons and is unchanged from the original post. All those appearing in the other photos have given previous permission.

 

Getting to the Start Line

We can debate the value of this advanced team model vs that advanced team model. We can debate videolaryngoscopy vs direct laryngoscopy for days. People do. Its all chump change compared to the real challenge. Getting that team where they need to be. Dr Alan Garner and Dr Andrew Weatherall have a bit reviewing a paper they’ve just had published trying to add to this discussion. 

You may just have noticed that there are things happening in Brazil. They are called Olympics and they are a curious mix of inspiring feats of athleticism and cynical marketing exercise inflicted upon cities that can probably barely afford them and which will be scarred for a generation afterwards. I’d hashtag that but it turns out the IOC will take you on if you mess with their precious sponsor money.

Now, you might think the obvious segue from a mention of the Olympics at the start there would be to mention drugs. The sort of drugs that enhance performance. It’s just that this feels too obvious. We’d rather make a very tangential link to kids. In particular, let’s talk about kids who are very, very injured.

 

The Teams

One of the bits of the Olympics that is a bit fascinating is the logistics of getting highly specialised teams into the right place at the right time in the sorts of cities that don’t usually get anything to the right place at the right time.

Maybe this is unfair but I don’t immediately think “super efficient transport infrastructure” when I think of Rio de Janeiro. And when I’m on a commute in the early hours of a Sydney workday, the fact that anyone was able to get a rowing team out of the stacking rack and to a patch of water in the hillock-shaded nirvana of Penrith during our local Olympics is astounding.

That’s kind of central to the whole circus though. Everyone is getting their right team to the right start line at the right time. It would probably be more entertaining if you dropped the table tennis team at the volleyball court but that’s not how it works when you’re trying to get the best of the best doing what they are built for.

Which is the cue to make this lumbering patchwork monster lurch back to the segue.

 

Right Place, Right Time

Advanced EMS needs to achieve the same goals of right place and right time. (Never said it would be a pretty link, but there it is.) Whatever your model of staff might be for delivering advanced prehospital care (paramedic/physician, paramedics across the board, St Bernard with an alcohol supply) there would be no one who doubts that the key to the whole thing is to get them to the right jobs at a time when those advanced skills have a role in making a difference.

You might be able to put one of those snorkels in the airway hanging upside down while drilling an intraosseous with particularly agile toes but if you’re back at base that’s not going to help the patient out there who is injured.

For a while now we’ve been really exercised by that problem. How do we make the tasking process better? Because tasking is not about the team at base. It’s not about which location the vehicle comes from. Tasking is always about the patient waiting for the care they need. They’re just wishing you’d been waiting there already, not still somewhere else.

The latest in a suite of papers which are ultimately about this question has gone online pretty recently. With the catchy title of “Physician staffed helicopter emergency medical service case identification – a before and after study in children” it builds a little bit from an earlier paper where two parallel tasking systems for sending advanced EMS (in this case physician staffed HEMS) to injured kids was compared.

That paper suggested that when you had a team actually delivering HEMS involved in identifying and tasking of cases, they were far more likely to identify cases where their skills might help (meaning they were more likely to identify cases of severely injured kids from the initial emergency call information in the system) than a single non-HEMS tasker working away in the office.

The involvement of the HEMS team got removed though, so it seemed timely to revisit this area to look at the time before the changes where the two systems worked together and the subsequent time period where it was just left to that one paramedic in the office.

Kids and the NSW System

It is going to help you to know a bit of background here. For a while now in New South Wales, there has been a stated goal in the trauma system to get kids straight to a paediatric trauma centre (PTC). Interest in this first came about because of overseas evidence that maybe this was the best option for kids. This was later followed by local work. This established that kids who went to other centres before the PTC tended to wait a long time in the first place they went to. Like 5 hours in that initial hospital before there was any movement.

Another study also suggested that kids who went to an adult trauma centre first had 3 to 6 times the risk of a bad outcome. And by bad outcome I mean a dying sort of outcome. Now, there are issues with being too firm on those numbers, particularly as not many kids die from traumatic injuries over any measured time period in our system so one or two kids surviving in the adult centre would make a big difference to those stats. But these were the sort of figures that made people keen to get kids straight to the specialist kids centres.

So the system is supposed to be designed to get kids to the kids’ hospitals as a priority. Do not pass go, do pass the adult centre.

Around the same time as that was becoming a talking point, the Head Injury Retrieval Trial was getting moving. As part of that trial, there was an agreed setup for the HEMS crew (including the aviators) to have access to the emergency call info on the ambulance computer screens on about a 90 second delay from when it hit the ambulance system.

For the trial (only adults), you’d look at the highest urgency trauma cases and look for specific trigger mechanisms which would lead to a protocolised response – either an immediate decision to randomize or a callback and interrogation step.

For kids, a different request was made. The request was just to respond to severely injured kids (where it seemed like the severity matched the initial call info or the mechanism was a super bad one; something like “kid vs train” for example). No randomisation as they were not in the trial; we just went.

So the crew screened for paediatric cases too, as requested. And went to paediatric cases. There was some real learning in that too, as the HEMS crews started making it to a much higher proportion of severe paeds trauma (and drowning) than had historically been the case.  This was partly due to the higher rate of recognition of cases, and partly due to the fact that the HEMS team was really fast getting to the patient, arriving before the road paramedics had already moved on.   You can read more about the kind of time intervals the HEMS team achieved here.  As far as we are aware from the published literature the whole end-to-end process was the fastest ever reported for a physician staffed HEMS system, while still offering the full range of interventions when indicated.

Mirror, Mirror

A third of the way through the HIRT thing happening, the ambulance service introduced a role within ambulance which hadn’t been there before. The Rapid Launch Trauma Coordinator. Their role? To look at the screens as jobs came in and try to identify cases where advanced EMS might help.

As it turned out they elected to include the trial area as well as other areas in the state in the roving brief for this paramedic sitting in at the control centre. While that was an issue for the trial, for kids it was just a bonus, right? Another set of eyes trying to find kids who might need help sounded perfect.

The bonus in kids was that there was no need to try and have the person doing the RLTC work blinded to whether the case had been randomised or not, so if the HIRT crew in their screening saw a case with a kid, they’d call quickly and see if the RLTC knew of a reason they shouldn’t go. It was a nice collegial cross-check.

This also ensured that only one advanced team went unless they thought there were multiple casualties (in the trial double tasking was common due to the blinding of the RLTC to the randomization allocation).  So the cross-check avoided double ups and maximized use of resources too.

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Well how close to being the same are they then?

It was in this context of the systems for screening cases operating alongside each other that the first bit of research was done [2]. Over a two year period cases with severely injured kids occurring while the HEMS was available were reviewed to see if either screening process picked them up.

There were 44 kids fitting that bill (again, the numbers are low in the Sydney metro area). 21 weren’t picked up by anyone. 20 were picked up by that HIRT crew and 3 were picked up by that person working on their lonesome in central control.

When you looked more broadly at times the HIRT system wasn’t available compared to those it was, the proportion of patients directly transferred to the PTC was much lower. This fits with other stuff showing that advanced EMS teams tend to be more comfortable bypassing other sites to make it to a PTC, while also performing more interventions.

Another thing this research threw up was to do with time of a different kind: when HIRT was available the median time to reach the PTC was 92 minutes, compared to 296 (nearly 5 hours again) when they weren’t available.

So on that first round of research the message seemed to be that there was something about that case screening process that picked the severely injured kids more often. Maybe it was the extra eyes and regular rotation. Maybe it was better familiarity with the nature of the operational work for advanced EMS on the ground. Either way that screening process seemed to support the goals of the trauma system pretty well.

Things You Take Away

Come March 2011, the screens were taken away from the HIRT set-up as the trial wrapped up. No more screening by the actual HEMS crew. Back to centralised control screening back in the office.

As the HIRT screening process seemed to have such a dramatic effect on the trauma system in Sydney we wanted to keep it going as did the trauma people in the Children’s Hospital at Westmead.  They had particularly noted the change as by virtue of geography they are the closest kids centre to most of the Sydney basin.  The increase in kids arriving straight to the ED even led them to revise their internal trauma systems. But away the screens went.

So the question for this subsequent bit of research was really pretty simple: did we lose anything going back to the centralised process alone? More crucially, do the patients lose anything?

Comparisons

This time the comparison wasn’t the two screening processes working alongside each other. It was before and after. What didn’t change was the sort of paeds patients being looked for. It was any kid with severe trauma. This might include head injury, trunk trauma, limb injuries, penetrating injuries, near drownings, burns and multi-casualty incidents with kids involved.

So in the ‘before’ epoch there were 71 cases of severely injured kids (covering 34 months) that fitted the bill. For the ‘after’ epoch there were 126 cases (over 54 months).

In the ‘before’ epoch with the systems working alongside each other, 62% of severely injured kids were picked up and had an advanced EMS team sent.

In the ‘after’ phase? It fell. To 31%.

And while the identification rate halved it also took kids longer to reach the PTC going from 69 to 97 mins. 28 minutes might seem small but then most of us have probably seen how much can change in a severely injured patient in less time than an episode of Playschool runs for.

Things that didn’t change? Well the overtriage rate for the CareFlight crew was pretty much the same. And whether advanced EMS teams or paramedic only teams reached the kids, their respective rates of transfer direct to PTC were pretty much the same as in the ‘before’ time. It seems that once crews get tasked they treat the patients much the same as their training sets them up to do.

It certainly seems that the right team in our system is a physician/paramedic crew (in NSW the doctor/paramedic mix is the advanced EMS set-up used across the board) as the kids get much more intensively treated at the scene and then get transported directly to a kids centre.  In other words faster access to advanced interventions and much faster access to the specialist kids trauma people.  Right team to the right patient at the right time.

 

The Washup

So we’re left with a few things to consider. There is an acceptance locally that severely injured kids are more likely to get time critical interventions if an advanced EMS team is sent (and advanced EMS teams could come from different backgrounds in different places, it just happens to be physician/paramedic here). There is a belief that those who’ve had that extra training and exposure will feel more comfortable with kids, who can be challenging.

The system has set a goal of getting those advanced teams to severely injured patients, and in this case we’re talking about kids. These two papers suggest that a model where those who are directly involved in advanced EMS are part of the screening process will identify more severely injured kids and get more of them straight to the PTC and definitive care.

Should this be a surprise? As the paper mentions this isn’t the only example of a model where clinicians who do advanced EMS work being part of the screening process seems to be a success above and beyond those who specialise in screening all calls. It may be that knowing the lay of the land when it comes to service capability counts for a whole lot. There is also work suggesting that telephone interrogation of the emergency caller by a flight paramedic is accurate when compared to assessment by on-ground ambulance crews when trying to figure out whether advanced care might help.

This was the experience with the HIRT screening process too, where structured callback was part of the game. The HIRT system also had some unique features.  It is the only one we have heard of where the crew sitting next to the helicopter identified the cases they responded to.  This seemed to create added benefits in shortening the time to getting airborne because parallel activities come to the fore (see the paper for more).  A very consistent six minutes from the beginning of the triple zero call (emergency call from the public) to airborne is pretty quick.

Does this have any implications for adults too?  Back in 2007 when the RLTC was introduced the local ambulance admin made the decision that sending advanced EMS teams to severely injured patients was the standard in Sydney and the RLTCs job was to make that happen.  From the time the RLTC started till the screens were removed in March 2011 the HIRT system identified 499 severely injured adults.  The RLTC also spotted 82 of these, or 16%.  So the HIRT spotting system appears to be even more effective for adults than in kids.

Right now there are a bunch of different advanced EMS teams in Sydney, all wanting to get to that right patient and offer top notch care. Those patients would be very happy to have teams with the full range of skills coming. And all those teams have the skills to add the sort of screening that involves protocols that operated during HIRT. They’re sitting waiting for someone else to look their way.

So let’s work it through again.

Let’s say you were trying to meet that thorny challenge of right team, right place, right time. Let’s say you had ended up trying out a screening system similar to some others around the world but with some tweaks that made it even better, particularly for local conditions.

Let’s say that system hugely improved the way that severely injured kids were cared for.  Let’s say that system was also even better at spotting severely injured adults too.  Let’s say that system was part of the fastest end-to-end physician HEMS system yet described in the world literature.

Let’s say when you moved away from that screening system you didn’t pick up as many of the severely injured kids as you wanted to so they missed out on early advanced care, the kids didn’t get to your preferred destination first up as often and they took longer to get there.

You might ask why such a hugely effective system was discontinued in the first place.

You might ask why it has not been reinstated given the subsequent evidence.

And they would be very good questions.

 

Notes:

The image of Charlie in his guises was on the Creative Commons area of flickr and posted by Kevin O’Mara. It’s unchanged here.

The papers mentioned again are:

Garner AA, Lee A, Weatherall A, Langcake M, Balogh ZJ. Physician staffed helicopter emergency medical service case identification – a before and after study in children. Scand J Trauma Resusc Emerg Med. 2016;24:92.

Garner AA, Lee A, Weatherall A. Physician staffed helicopter emergency medical service dispatch via centralised control or directly by crew – case identification rates and effect on the Sydney paediatric trauma system. Scand J Trauma, Resusc Emerg Med. 2012;20:82. 

Soundappan SVS, Holland AJA, Fahy F, et al. Transfer of Pediatric Trauma Patients to a Tertiary Pediatric Trauma Centre: Appropriateness and Timeliness. J. trauma. 2007;62:1229-33.

Mitchell RJ, Curtis K, Chong S, et al. Comparative analysis of trends in paediatric trauma outcomes in New South Wales, Australia. Injury. 2013;44:97-103.

Garner AA, Mann KP, Fearnside M, et al. The Head Injury Retrieval Trial (HIRT): a single-centre randomised controlled trial of physician prehospital management of severe brain injury compared with management by paramedics only. Emerg Med J. 2015;32:869-75.

Garner AA, Mann KP, Poynter E, et al. Prehospital response model and time to CT scan in blunt trauma patients; an exploratory analysis of data from the head injury retrieval trial. Scand J Trauma Resusc Emerg Med. 2015;23:28. 

Garner AA, Fearnside M, Gebski V. The study protocol for the Head Injury Retrieval Trial (HIRT): a single centre randomised controlled trial of physician prehospital management of severe blunt head injury compared with management by paramedics. Scand J Trauma Resusc Emerg Med. 2013;21:69. 

Wilmer I, Chalk G, Davies GE, et al. Air ambulance tasking: mechanism of injury, telephone interrogation or ambulance crew assessment? Emerg Med J. 2015;32:813-6. 

Did you check all of those out? Why not take a break from all of that and watch these French kids rock a club track?

 

 

Tactical Medicine in the Civilian Setting – The Second Bit

We’re back with the second post in a series on tactical medicine in the civilian setting, written again by one of our CNCs Mel Brown. We’re going back to back with these ones (you can find part one here) though you might have to wait a little for part three. 

The tactical environment is dynamic and can change in an instant. That is why it is imperative that everyone involved in such an incident knows and thoroughly understands both the tactical and medical processes along with the mental model that will be used within this environment. The first time you work together should not be once the incident has occurred. More bad things happen if agencies don’t train together prior to a high threat incident happening.

In part one of this series we looked at what tactical medicine is, some of the history of tactical medicine (both military and civilian) and the three preventable causes of death within the tactical environment. In part two we look at some of the models of infiltration for medical teams, specifically the “whos, hows and whats” of this topic. I had thought I’d get straight onto the phases as part of this post but once I got into it I realised there’s quite a bit to cover when talking about people and teams. People, huh? So deep.

So what is the current thinking? Questions worth considering include:

  • Who should make up tactical medical teams?
  • When should they enter the tactical environment?
  • In what style of team should they enter?
  • Should they be armed or unarmed?

I am sure there have been (and will continue to be) some very robust discussions and even some controversy about these questions. But, let’s look at some of the current thinking both in Australia and internationally.

Current Tactical Team Models

Generally speaking there seems to be three core models of how the tactical medical team may be setup and inserted within the civilian setting. Each one of these team models comes with their own set of advantages and disadvantages. The most important thing with any of these models is that all local agencies must know, understand and have practiced as a multiagency team within the chosen framework to be used in these incidents. Any model that isn’t known and tried will fail within such a high stress, high threat environment and more injuries and death will occur as a result (Levy MJ et al, 2016).

Option one – Primary Officer with a Secondary Role:

The first model we will look at is the law enforcement officer embedded within the response team that has a secondary role as the team medic. This is the most commonly used model within Australia. Generally speaking in this model the medic’s primary role is to complete the mission (neutralise the threat) as part of the tactical team. His or her secondary role is to treat his / her team members (if they are injured). Once the tactical environment allows then the medic may treat civilian casualties.

The difficulty with this model is that the primary role of the medic is not to treat civilian casualties. Therefore, this may lead to extended time delays until the civilian casualties receive medical treatment if the tactical / mission phase is prolonged. This prolonged time between point of injury and treatment may lead to increased deaths amongst the casualty group.

Option two – Dedicated Rescue Task Force (into the Hot Zone)

The second model that is used is that of the rescue task force which is made up of 2 – 4 law enforcement officers with 1 – 2 professional (medical) first responders (EMT or fire). In this model the professional first responder is inserted into the “hot” zone (direct threat care phase) or “warm” zone (indirect threat phase) with the protective support of designated law enforcement officers. In this case the professional first responder’s primary responsibility is the treatment of casualties (both civilian and law enforcement). The professional first responders do not carry weapons; rather the law enforcement officers provide force protection for them.

This model allows for rapid assessment and treatment of all casualties which helps minimise the total number of deaths. This decrease in deaths is due to there being minimal delay between the point of injury and medical treatment for casualties.

One point to consider with this model is that there will be an increased risk to the medical first responders as part of the rescue task force as they are entering the high threat environment whilst the direct threat still exists. This is one of the reasons why there is often four law enforcement officers instead of only two. This allows for two law enforcement officers to “drop off” to pursue and neutralise any threat, whilst the remaining two law enforcement officers continue providing force protection for the professional first responders within their team.

Option three – Rescue Task Force, Warm Zone Only

The third model is that of two or more professional first responders that have law enforcement support and only enter the “warm” zone (indirect threat phase) to treat casualties with a view to removing them further from the area of engagement. In this model the professional first responder doesn’t progress through the scene to clear other casualties. These are usually strategic insertions with plans for rapid extrication of the casualty and professional first responders to a safe zone or pre-staged evacuation area. These medics do not carry weapons as their primary role is the treatment of casualties whilst under the force protection of law enforcement.

 

Let’s Discuss This a Bit …

Do these models suit all high threat environments? How do these current law enforcement focused models work when there are either multiple active shooter / IED / hostage incidents or if the high threat environment is a building collapse or advancing fire line? Sometimes we become so focused on the single active shooter / IED / hostage scenario that we forget about all of the other high threat environments that need us to use the same tactical mindset for assessing and treating the casualties. Currently the focus seems to be on the “kinetic” and not on the “routine” high threat environment.

This is why it is imperative that all emergency services (police, fire and ambulance) are provided with C-TECC training. For example if you look at the Paris attacks in November 2015 it was the fire department that lead a lot of the tactical medical response for the multiple attacks. Law enforcement officers are potentially going to be targeted as they respond to such incidents. As such they need to know how to treat themselves and their teammates if harm comes their way. Furthermore if law enforcement agencies become overwhelmed with multiple scenes to secure it may become necessary for other emergency agencies to step up and take over the casualty care side of things.

It is also time for Australia to think about teaching potential “lay” first responders (bystanders) the life saving skills of catastrophic haemorrhage control (arterial tourniquets [commercial and improvised] and pressure dressings etc) and airway management. According to the fourth Hartford Consensus these lifesaving skills should be commonplace, just as community CPR programs are becoming.

We should be collaborating with our international counterparts and learning from what they have experienced. Paris and North America are already running numerous public education sessions on haemorrhage control (arterial tourniquets & haemostatic dressings) and CPR (which may not help in the traumatically injured casualty, but is beneficial to society all the same as out of hospital cardiac arrest is still one of the leading causes of death in adults). In these moments of horror whether terrorism or natural disaster related all emergency care providers are going to be absolutely overwhelmed and may not be able to immediately access the casualties. We need the public to help us treat the casualties as soon as possible after the injuries occur, as this will decrease the death rate amongst the casualty group.

The current thinking within tactical medicine is that we should be striving for the “platinum 10” and not paying too much attention to the good old “golden hour”.

Dave Owl
Yes this owl is also not that used to the ‘Platinum 10’ thing but it’s coming, relax.

“What’s the platinum 10?” I hear you electronically asking. Well, the patterns of injury and the potential for extended time before receiving definitive care means that it is a struggle to get the casualties to hospital within the “golden hour”.

In tactical medicine a better gold standard might be that casualties need to receive initial care within 10 minutes of injury (hence the term “Platinum 10” because that 10 minutes is even more valuable than gold and diamonds just make no sense). Bystanders play a major role in ensuring this “platinum” standard can be met.

 

Who should make up the tactical medical team?

The tactical environment is an interesting one from the medical point of view as all medical interventions must be high yield but require a limited time investment to complete. The right intervention must also be performed at the right time within the tactical flow of the mission. After all if the right medical intervention is done at the wrong time more injuries and potentially deaths will occur to either the casualty or the responder. This is the essence of tactical medicine.

If you look at the medical interventions recommended by C-TECC they are simple but very effective interventions that require minimal time to implement. There are also clear guidelines as to when these interventions should be performed (there will be more on the phases of care in part three).

If you remember back to part one of this series, the medical interventions recommended are simple (but lifesaving) ones aimed at treating the three causes of preventable death (extremity haemorrhage, airway, tension pneumothorax). These simple interventions include:

  • Arterial tourniquets
  • Nasopharyngeal airways (NPA)
  • Chest seals
  • Needle thoracocentesis
  • Haemostatic dressings
  • Effective bandaging techniques (direct pressure)

 

Direct and indirect threat phases

If we keep in mind what medical interventions need to be applied in this situation it is easy to see what personnel are needed within the medical aspect of the tactical environment. Within the direct threat and indirect threat phase the skills needed by the professional first responder lend themselves to either the paramedic’s or even nurse’s skill set (yes….I just went there….a nurse).

The extra skills a doctor would bring cannot be implemented within such a high threat dynamic environment; the continued threat level and the dynamic nature of this environment makes it impossible to setup for and complete higher-level interventions. Therefore, I am a firm believer that doctors should not enter the initial tactical medical space (direct threat or indirect threat phases) unless they are specifically trained and possess the right (minimalist) mindset.

 

Evacuation care phase

As for the evacuation care phase, who should make up the medical teams within this stage of the tactical environment? I think this decision is less black and white and has many influencing factors on the day. The most important thing to remember here when deciding who should make up the medical team in the evacuation area is that this area exists to facilitate the patient being transported to the appropriate hospital.

This means that casualties should only stop here if the medical system (hospitals, transport) is so overwhelmed that transport is not an option or if the casualty needs a lifesaving intervention now. An example of this is the casualty with chest injuries requiring repeated needle decompression. They should have a chest tube placed prior to transport (if such medical skills are available).

The patient should not stop here if the medical interventions are not necessary as this leads to a “choke point” within the flow of casualties and will blowout casualty transport times to definitive care. This will lead to further casualty deaths. It is important to remember we can’t make the casualty “better” on the “road side”, we’re aiming to make sure the immediately threatening situations don’t get worse.

The forgotten resource

One team of medical assistants that has not been mentioned and is often forgotten about is that of the “bystander”. The Hartford Consensus III & IV recommend that community training is put in place the ensure that “bystanders”, or as the Hartford Consensus calls them Immediate Responders, can recognise catastrophic haemorrhage and stop (or at least slow) the flow of bleeding as well as recognising and treating airway problems. Learning such skills will empower immediate responders to help casualties, will build community resilience and will save countless lives at the point of injury.

This group of non-professional immediate responders are often a forgotten resource vital in the fight to save lives within these high threat environments. Let’s return to Paris and the Bataclan theatre to consider just one example of the delay in help for casualties by professional first responders.

It took over 160 minutes from the time of the first shot to when professional first responders were able to reach the casualties inside the venue. This is too long between the point of injury and treatment being received (but is an indication of the level of planning that went into the attack).

Because of such experiences America and Paris have already implemented community-based courses that equip civilians (immediate responders) with the skills necessary to save lives. As a result they have seen countless lives saved by these personnel; such as in the aftermath of the Boston Marathon bombings, active shooter events, French attacks, but also in the aftermath of hurricanes, industrial accidents or everyday incidents (e.g. motor vehicle accidents).

It is imperative that Australia also starts tapping into this large resource that can make a huge difference to the survivability of casualties within a high threat environment. It will take time for professional medical help to arrive and start treating casualties, especially under Australia’s current model.

Time of entry of the tactical medical team

This topic is one that is rather controversial and both sides of the discussion are very passionate about their beliefs. I guess all we can do is look at both arguments and encourage the departmental bodies making these decisions to weigh up all of the advantages and disadvantages. We should also learn from our international colleagues. They’ve been there a lot more often. So let’s look at those two sides….

The Front Side

The first side we will look at is that of the “no medical personnel will enter the direct threat phase and will preferably never enter the indirect threat phase” group. This is the current stance taken by most organisations within Australia at present, except for tactical police that have one member within their teams that has a secondary role as the team medic (to primarily treat his / her team members).

There are some advantages to this thought process, the main one being safety. This model ensures that only highly trained law enforcement officers enter the direct threat phase and minimises the entry of medical personnel into the indirect threat phase. It is rarely seen in Australia that medical teams are even inserted into the indirect threat phase. This minimises the risk of harm or death to medical personnel.

Some disadvantages of this model are that there will be extended timeframes until casualties receive medical attention, as seen at the nightclub shootings in Orlando. This extended time until treatment will lead to higher death rates amongst the casualty group.

The Flip Side

The second side in this discussion says that medical personnel should be at least inserted into the indirect threat phase (with law enforcement protection) and potentially into the direct threat phase (this is due to the possibility of a new threat arising or the old threat returning).

In general terms a clearing team (law enforcement only) will advance into the scene first with a rescue task force (law enforcement officers and medical personnel) following shortly after to clear rooms of casualties and to treat them for the life threatening conditions as soon as tactically possible. These casualties may then be moved to a pre-arranged casualty collection point if tactically feasible to do so. Through reviewing the literature and in discussions with experts this appears to be the leading model of choice in USA.

Some of the advantages of this model are that professional medical responders can be inserted early to ensure casualties receive medical care as soon as possible. This in turn leads to less preventable deaths occurring within the casualty group. The medical personnel are afforded a high level of protection from the law enforcement officers ensuring that the threat to their lives is minimised.

The main disadvantage to this model is that there will be some increased risk of injury or death to the professional medical responders simply by the fact they are entering a high threat environment. There is also an increase in responsibility on the law enforcement officers that are charged with the safety of the professional medical personnel, as they now have a group of people (most likely unarmed) that they now need to provide protection for. In Australia where we have limited law enforcement resources (when compared to the USA for example) this allocation of force protection will further decrease the law enforcement officer numbers available to pursue and neutralise the threat. Herein lies the problem – what takes precedence, the law enforcement officer’s responsibility to protect the profession medical personnel and casualties or neutralising the threat and thereby eliminating the risk of additional casualties?

No matter what model is used there needs to be more interdepartmental training so that all emergency personnel share the same mental model, whether they are ambulance, fire, police or medical. This means that everyone involved in the incident will have an understanding of each group’s capabilities, strengths and weaknesses. This in turn allows everyone to effectively support each other no matter what the situation presents. This can only benefit the casualties and the emergency service personnel.

Should the tactical medical team be armed?

This is yet another controversial topic within the tactical space. This is a very difficult question to answer and once again there are two very distinct groups within this argument. One side is furiously opposed and one is furiously in favour of professional first responders carrying weapons. All we can do once again is look at the current thinking and their associated advantages and disadvantages.

In the ideal world we would all like to think that not even the “bad guys” would hurt or kill the person who is just trying to save lives. However, we don’t live in that ideal world and even though humans are meant to be one of the cleverest of the animal kingdom we see more and more that we certainly can be the most inhumane to our own kind.

Unfortunately we see the “bad guys” killing any emergency response personnel so that they can’t stop them or fix the people they have hurt. I guess this is where the first group sits and as such they believe that all professional first responders should be armed to protect themselves and the casualties they are treating. Think about the Geneva Conventions – military medical personnel are allowed to bear arms for the purpose of self protection (and the protection of their casualties) in combat.

The main advantage of professional first responders carrying weapons seems to come simply down to their safety and the safety of their casualties. There seems to be the belief that a weapon would simply be another tool in their bag to help treat their patient’s safely. I must admit I am not yet convinced it is as simple as that, and the reader of this blog from military backgrounds would understand this well.

One of the disadvantages associated with this argument is the question where does the professional first responder’s responsibility end? Imagine they are at the local coffee shop (whilst on duty) and there is an armed robbery. What is their responsibility then? Do they simply try and call it in or do they try and overpower the offender with their weapon? It becomes very cloudy very quickly.

Carrying a weapon also requires a lot of extra skill acquisition and effort to keep current. It is not as simple as just carrying a weapon and doing a once off course. There are many responsibilities that come with carrying such a tool; it requires a huge commitment by the professional first responder. To be skilled in weapons handling requires hours of practice both in a range to develop target accuracy but also in scenario based training working in the teams and environments that you may find yourself. Safety is also a major concern; no one wants to accidentally discharge his or her weapon and harm an innocent bystander or lose control of their weapon to the “bay guys”.

Another point to consider if professional first responders carry weapons is what does their primary focus become: casualty treatment or neutralising the threat? This may become a disadvantage if the professional first responder becomes more focused on their weapon than they are on their casualties. Brigadier Boutinaud had some very good advice (I think) during his presentation in Sydney on the Paris attacks in May. This was that if professional first responders carry weapons then they will lose sight of what their primary role is…….to treat the casualties.

Please don’t get me wrong; I am a firm believer that all professional first responders need to be kept safe. However, I feel that this can more often than not be achieved by wearing the appropriate protective clothing (body armour, helmet) and by only entering the direct or indirect threat phase as part of a rescue task force (law enforcement officers and professional first responders). I guess this is where the second group sits when they firmly believe that professional first responders should not carry weapons.

Some of the advantages to this argument are that the core business of the professional first responder (treating casualties) stays their core business. It also minimises the chance of first responders entering environments that they shouldn’t as they will need to wait for law enforcement to arrive and provide them with force protection. As such the professional first responder will need to maintain situational awareness within the tactical environment, but the responsibility of true tactical awareness remains the responsibility of the law enforcement officers.

The main disadvantage in my mind is that the professional first responder may feel less empowered and safe as they have a perceived limitation in the control of their own safety. Another disadvantage may include that there could be a delay in casualties receiving treatment if law enforcement takes some time to respond to the same incident.

I think this argument is quite a difficult one to solve. The arguments often appear fairly even and as the tactical environment becomes more and more prevalent within society the argument for professional first responders to carry weapons seems to gain favour.

 

What does all this all mean?

If nothing else comes out of this series on the CareFlight Collective I hope that it facilitates open discussion about this topic within Australia and abroad. Australia, thus far, has been lucky in the terrorism stakes. However, we do experience many other high threat incidents (bush fires to name one). It is time that all emergency services work together for what is important…….best possible patient outcomes and that “we” the professional first responders (EMT or fire) or law enforcement officers get to go home to our families at the end of every shift.

 

A Bit More Reading:

Here are a bunch of relevant things to read you might find interesting.

A Descriptive Analysis of US Prehospital Care Response to Law Enforcement Tactical Incidents, 2015, Aberle SA et al, Journal of Special Operations Medicine, vol. 15, Edition 2 / Summer.

Is it time we armed EMS providers? Givot D, EMS1.com, April 2013.

Fighting Terrorism with Tourniquets. Horn H, The Atlantic, Nov 2015.

The Hartford Consensus IV: A Call for Increased National Resilience. Jacobs LM et al. The Bulletin, March 2016.

The Hartford Consensus III: Implementation of Bleeding Control. Jacobs et al. July 2015, The Bulletin, v. 100, no. 7

A Threat-Based, Statewide EMS Protocol to Address Lifesving Interventions in Potentially Volatile Environments. Levy MJ et al, Journal of Special Operations Medicine, Spring 2016.

A New Response supporting paradigm change in EMS’ operational medical response to active shooter events, December 2013, Smith ER (Jr) & Delaney JB, Journal of Emergency Medical Services.

The image was from the Creative Commons bit of flickr and was posted by “Dave”. We didn’t alter it.

Thinking Tactically – Part 1

With events such Dallas and its ongoing grief, it is a little timely to introduce a new series on tactical medicine in the civilian setting. We also welcome a new contributor to the site: Melanie Brown. As one of CareFlight’s Clinical Nurse Consultants for Medical Education and with a background as an Emergency Nurse and independent practitioner in various high risk prehospital environments Mel is passionate about ensuring the “right” patients get the “right” treatment at the “right” time.

Civilian tactical medicine is a rapidly  evolving area within Australia. And while you may think “surely it’s not that much different, you just have to keep your wits about you more” here’s the  thing: the injuries seen and the environment involved are very different to the “normal” civilian trauma setting. In fact, 94% of the preventable causes of death rely on appropriate haemorrhage control and appropriate recognition and management of tension pneumothorax.

But how many of us are trained to function well in this situation and deliver that care? There is a distinct knowledge gap between prehospital trauma training and civilian trauma training

In response to this gap CareFlight Education has drawn on many years of experience in conducting the pre-deployment medical training for the Australian Defence Force and the individual experiences of our educators in tactical environments to develop a course that is designed to bridge the gap between “normal” civilian trauma and the tactical trauma casualty. This real life experience in conjunction with our agreement with the Committee for Tactical Emergency Casualty Care (C-TECC) has lead to CareFlight Education developing the Tactical and Hostile Response, Emergency Access and Treatment (THREAT) course. It’s a subject we’re a bit passionate about so we thought we’d take the chance to share a few thoughts here as well.

As this topic is quite large I’m going to break this into two instalments. Part one will look at what tactical medicine is, some of its history of (both military and civilian) and the three preventable causes of death within the tactical environment. Part two will look at the three phases of care within the tactical environment (direct threat care, indirect threat care and evacuation care). So, let’s get started on part one…..

What do we mean by “tactical medicine”?

When most people are asked what they think tactical medicine is they jump to improvised explosive devices (IED), terrorist attacks, hostage situations or active shooter incidents. However, these examples are only a small representation of the civilian tactical / high threat environment.

Within the civilian setting a high threat situation that requires a tactical medicine mindset is of course all of the situations mentioned above (IED & active shooter etc.) but it may also include incidents such as advancing fire lines, building collapse or civil unrest (the sort of protests / riots that go beyond folk guitar protest songs). All of these situations require a different mindset and / or approach to what “we” are used to in the medical profession.

Australia as a whole has certainly been lucky thus far in the terrorism stakes when compared to many other countries. Many believe that the mantra now is “when and not if” there will be a terrorist attack on Australian soil. This change in thinking, the international experience and the continuing threat of incidents such as bush fires means that Australia needs to get on board with the tactical emergency medicine way of thinking

Comparison of civilian and military trauma

When most people are asked what they think tactical medicine is they jump to improvised explosive devices (IED), terrorist attacks, hostage situations or active shooter incidents. However, these examples are only a small representation of the civilian tactical / high threat environment.

Within the civilian setting a high threat situation that requires a tactical medicine mindset is of course all of the situations mentioned above (IED & active shooter etc.) but it may also include incidents such as advancing fire lines, building collapse or civil unrest (the sort of protests / riots that go beyond folk guitar protest songs). All of these situations require a different mindset and / or approach to what “we” are used to in the medical profession.

Australia as a whole has certainly been lucky thus far in the terrorism stakes when compared to many other countries. Many believe that the mantra now is “when and not if” there will be a terrorist attack on Australian soil. This change in thinking, the international experience and the continuing threat of incidents such as bush fires mean that Australia needs to get on board with the tactical emergency medicine way of thinking.

What can we learn from others?

It is important to look upon some of the lessons learnt by our defence and overseas law enforcement colleagues when trying to understand how tactical medicine fits into the Australian civilian setting. After all we shouldn’t just go making a new wheel. Let’s learn from experts.

We learn a lot both tactically and medically from these groups as their personnel are exposed to these high stress situations (and the MOIs that come with these environments) far more frequently than the average civilian emergency medical provider.

Perhaps some numbers can help make this clear. Studies in America suggest that once an active shooter incident commences 1 casualty is shot every 15 seconds. That’s 4 casualties per minute.

The average active shooter incident lasts 1 – 12 minutes with the average response time of the first officer on scene being 3 minutes. 60% of active shooter incidents end before police arrive. 30% of officers that enter as solo operators are shot. Stop and consider how many casualties have already occurred before reinforcements even arrive.

These studies conducted in America found that these tactical incidents occur in public environments; the list of locations includes businesses, schools,  universities, government buildings, open spaces, homes, hospitals and even places of worship (FBI, 2013 and Aberle et al, 2015). Unfortunately these incidents (especially active shooter) are increasing. In fact the FBI reports in their study from 2000 – 2013 on active shooter incidents a large increase. In the first 7 years of the study the USA averaged 6.4 active shooter incidents per year. However, in the last 7 years of the study they averaged 16.4 active shooter incidents per year.

The Journal of Special Operations Medicine published a study by Aberle et al in 2015 which found that USA Emergency Medical Services (EMS) average 11 responses in support of law enforcement tactical operations per day. Unfortunately Australian statistics are difficult to find in relation to civilian tactical incidents. However, in a 5 year period from 2005 until 2010 police report that they were injured 6, 423 times (APJ, 2015). This statistic does not include public injuries or assailant injuries and not all injuries were serious. However, this number easily demonstrates the need for law enforcement agencies to have a full understanding of tactical medicine guidelines, knowledge and skills.

As for our Australian Defence Force colleagues, they have found that the average combat casualty has 2.4 life threatening injuries. However fatality rates amongst wounded soldiers have dropped from 20 – 30% pre Vietnam to just 8.8% during the Middle East Area Operations.

This decrease in the fatality rate can be attributed to many factors some of these being:

  • Tactical Combat Casualty Care (TCCC) / Care of the Battle Casualty (CBC) training (note: this is the military version of TECC)
  • Advances in body armour
  • Availability and training in life saving equipment (arterial tourniquets, haemostatic dressings, bandaging techniques etc.)
  • Deployed trauma systems
  • Introduction of antibiotics and hypotensive resuscitation.

What does this mean to us?Just as we should learn from others’ experiences it is important to understand the factors that influence the care that we can give within the tactical environment. Those of us that have ever worked in the pre-hospital setting know how different this working environment is when compared to the hospital setting. The tactical medicine setting introduces another unique set of challenges. Some of these include:

  • Presence of a direct and continued threat
  • Environment
    • Darkness / light / uncontrolled surroundings
    • Heat / cold
  • Limited medical equipment – the equipment that you can carry is limited by the need to be highly mobile (i.e. huge packs)
  • Length of evacuation times
  • Mission intent / tactical flow
  • Preparedness of medical providers

C-TECC is the leading international body on civilian tactical medicine and they work closely with the Committee of Tactical Combat Casualty Care (Co-TCCC), the international military focused tactical medicine body. C-TECC presented at the recent Special Operations Medical Associations (SOMA) Scientific Assembly held in Charlotte, North Carolina in May with the overarching message regarding civilian tactical medicine continuing to be the three goals of tactical emergency casualty care (TECC). These three goals are:

  • Save preventable deaths
  • Prevent additional casualties / injuries
  • Complete the mission.

But how do we meet these three goals?

Let’s look at these three goals in more detail, firstly saving preventable deaths. There are three preventable causes of death within the tactical environment, these being:

  • Extremity haemorrhage
  • Tension pneumothorax
  • Airway obstruction

With a little training these causes of preventable deaths can be very easily recognised and treated.  Treatments provided within the tactical space are designed to be high yield without being time intensive or resource heavy.  Tactical medics do not enjoy the luxury of working within a safe and secure environment and as such they must be able to complete any interventions rapidly so that if the need to move arises due to renewed threat, they can move themselves (and the casualty) quickly and efficiently.

Extremity Haemorrhage

Extremity haemorrhage, which makes up 61% of preventable causes of death in the tactical environment, can be rapidly treated with the application of an arterial tourniquet. The Combat Application Tourniquet (CAT) is the most widely used arterial tourniquet within the tactical environment and is closely followed by the Special Operations Tactical Tourniquet – Wide (SOFT T – W).

CAT copy 2
Combat Application Tourniquet (CAT) 6th Generation

Both of these tourniquets have limiting factors. However, when used correctly they have been proven to save countless lives both here in Australia and internationally. The Therapeutic Goods Administration (TGA) has approved both the CAT and the SOFTT – W for use in Australia.

SOFTT copy
Special Operations Tactical Tourniquet – Wide (SOFTT-W)

Tension Pneumthorax

Tension pneumothorax accounts for 33% of preventable causes of death in the tactical environment. It is paramount to the survivability of the casualty that tension pneumothoraces are recognised and treated early. If you need a refresher then check out this post with a podcast from a little while back.

In the tactical environment, once a tension has been recognised treatment is as “simple” as conducting a needle thoracocentesis. This is an intervention that takes very little time and can be life saving in this environment – but remember, it is a temporising measure and not definitive treatment. However, working in the tactical environment requires a constant awareness that the threat to all personnel is likely to be high and ongoing. This strongly influences the choice of treatment and in this setting training and experience suggests the “simple” option of needle thoracocentesis – you don’t have time to consider more technical and time intensive interventions (e.g. tube thoracostomies); besides, you won’t have the necessary equipment with you anyway.

Airway Obstruction

Airway obstruction is the final preventable cause of death within the tactical environment and accounts for 6% of the overall numbers. Simple measures such as opening the airway, inserting an nasopharyngeal (NPA) or allowing a patient with extensive facial injuries to sit up and forward can be life saving. Once again there is no time within this environment to consider more technical and time intensive interventions (e.g. intubation).

The second goal of TECC is to prevent further injuries or casualties. This is an important concept and dictates how and when a casualty should be treated within the tactical environment. A good mantra to abide by is “never treat the casualty on the street” (or “on the X”). If the casualty is able, get them to move themselves (this is preferred). If they can’t move they can be moved by someone else to a place of relative safety prior to being treated. If you treat where the casualty was injured there is a higher chance that you yourself will be injured compared to moving to a place of relative safety.

When moving the patient to an area of relative safety you must consider both concealment and cover from the continued threat. It is important to think about what you choose as your cover as not all choices are equal. Just because an object provides good concealment, it may not provide good cover (e.g. corrugated iron provides very little protection from high velocity projectiles or fire, but it may stop you being seen).

Another concept that needs to be considered along with not treating on the street is that the correct intervention needs to occur at the correct time in the continuum of tactical care. The flipside of this is that a medically correct intervention performed at the incorrect time in the incident may lead to further casualties or deaths. The tactical environment is highly dynamic and it may change at any time. Therefore, tactical medics (be they paramedics, nurses or doctors) must always keep situational awareness and take this into account prior to commencing any medical intervention.

The third and final goal of TECC is completing the mission. This is very foreign to most civilian medical providers, as our focus has always been on treating the casualty first and foremost.  However, in the tactical environment the completion of the mission and the maintenance of situational awareness must take precedence over caring for casualties as this helps minimise casualties, injuries and loss of life. Highly trained law enforcement officers will provide the advice for this side of tactical medicine and as the medical providers we must follow their instructions.

There are varying models and thoughts of how we should integrate medical response into these high threat environments. The biggest recommendation in this area really is that no matter what model is followed there must be interagency preplanning, understanding of processes and these methods must be practiced (Levy et al, 2016). It is imperative that Australian and international agencies support each other so that we may learn from one another in order to give our casualties and ourselves the best chance at surviving such an incident.

To that end posts like this aren’t designed to be a one way conversation. We’ve come up with a course that we really like but that doesn’t mean we don’t want to learn from any others with experience or knowledge in this area. So please, speak up and let us all share the wisdom.

Then we’ll come back with a few more of our own thoughts on the three phases of care in these challenging situations.

 

Notes and Extra Reading:

Are you after a bit of reading on this topic? Well here you go …

Aberle SA et al. A Descriptive Analysis of US Prehospital Care Response to Law Enforcement Tactical Incidents. Journal of Special Operations Medicine, 2015;15 (2). 117-122. 

Calloway DW et al. Tactical Emergency Casualty Care (TECC): Guidelines for the Provision of Prehospital Trauma Care in High Threat Environments . Journal of Special Operations Medicine. 2011;11:104-22  

Tactical Medicine in Domestic Policing, 2015, Cantrick A, Australian Journal Police Journal.

Carhart E. How to Develop Tactical EMS Protocols, 2014. 

Champion HR, Bellamy RF, Roberts Col P, et al. A Profile of Combat Injury. J Trauma Inj Inf Crit Care. 2003; 54:5:S13-S19. 

Afghanistan Casualties: Military Forces and Civilians, Chesser SG, Congressional Research Service, 2012.  www.crs.gov

Eastridge BJ, Mabry RL, Sequin P, et al. Death on the battlefield (2001 – 2011): Implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;63(6 Suppl 5):S431-7.

A Study of Active Shooter Incidents in the United States Between 2000 and 2013, Federal Bureau of Investigation (FBI), September 2013

A Guide to U.S. Military Casualty Statistics: Operation Inherent Resolve, Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom, Fischer H, Congressional Research Service, 2014,

Katoch BR. Combat Casualty Care. Medical Journal Armed Forces India. 2010;66:302-3. 

Levy MJ, Straight K, Marino MJ et al. A Threat-Based, Statewide EMS Protocol to Address Lifesaving Interventions in Potentially Volatile Environments. Journal of Special Operations Medicine. 2016; 16:98-102. 

Introduction to Tactical Combat Casualty Care, NAEMT.org.

Ramirez ML, Slovis CM. Resident Involvement in Civilian Tactical Emergency Medicine, 2010;39:49-56.  

Smith ER Jr, Delaney JB. A New EMS response: supporting paradigm change in EMS operational medical response to active shooter events. JEMS. 2013;38:48-55. 

Learning from tragedy: Preventing officer deaths with medical interventions, 2010, The Tactical Edge, Winter 2010