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

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