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.

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