OK it’s a few weeks back, but here’s Greg Brown with the lowdown on a conference about tactical matters.
Conferences: a formal meeting of people with a shared interest, typically one that takes place over several days; the means by which professionals from around the globe congregate with a view to learning from each other. Sometimes also referred to as junkets, jollies, paid holidays and tax write-offs.
But in all honesty, oftentimes the only way one can be afforded the chance to be surrounded by like-minded professionals with a view to learning from the experience of others, benchmarking your intellectual property against that of other organisations operating in the same “space” and refining your knowledge thanks to the latest in international research is to travel to the other side of the world and attend a conference. So, as one of the few non-government providers of tactical medicine training in Australia, that’s precisely what we did.
In mid-October 2017 two of CareFlight Education’s staff travelled to sunny (well, we assume there was sun above the pouring rain) Sundsvall, Sweden, to attend the inaugural Tactical Trauma conference. If you are on Twitter, you can search for it using #TacT17. If you are not on Twitter, then join Twitter and search for it using #TacT17….
This post provides a summary of what we found, what we liked, what we didn’t like and some takeaway points.
This was truly an international event. Presenters came from across Europe (with a strong Scandinavian presence, as expected), North America, the Middle East and even Australia. Participants included both hospital and pre-hospital doctors, nurses, paramedics, police medics, retrieval (road and air) clinicians and military folk.
The Stuff to Chew On
As the name “Tactical Trauma” suggests, the conference was focussed on the medical management of trauma with a tactical twist. It should be noted that discussions regarding any tactical imperatives were limited by the realities of operational security. For obvious reasons, nobody wished to describe their unit’s tactics in great detail. They were enough to paint the scene though.
Therefore, if you were looking to learn how to become the next big thing in SWAT team medicine then this conference probably wasn’t for you – and there certainly were no skill sessions on how to kick in doors, breach a terrorist stronghold or fast rope from a helicopter (although these might be popular sessions next time).
Rather, focus was placed on the provision of “good medicine in bad places”. There were sessions by military doctors discussing what worked (and what didn’t) on recent deployments (including topics such as blast injuries, penetrating chest injuries and rates of injuries in dynamic events), the usefulness (or otherwise) of helicopter emergency medical services in hostile mass casualty events, comparisons of contemporary haemostatic agents versus conventional bandages in wound packing, the perils of acute traumatic coagulopathy, discussions on vascular access options, and the progress over the years in the application of clinical management strategies. It is also worth noting that since this is in fact 2017 no medical conference would be complete without at least one presentation on POCUS (that’s Point Of Care UltraSound – and yes, it is very useful) and one on REBOA (or Resuscitative Endovascular Balloon Occlusion of the Aorta – and no, there is not enough evidence to definitively support it); these were dutifully attended to.
Case studies are always useful; in this instance we were treated to reviews by the Finnish and Norwegians of their tactical emergency medical support systems, the Israelis and their medical response to contemporary domestic contingencies and both the French and Swedish on their responses to recent mass casualty events. There were also a few “closed door” sessions for police medics regarding recent mass casualty events in the USA.
But finally, as most of us already appreciate, being outstanding at your trade is only part of the job; the ability to communicate effectively with your team members whilst managing your own stress levels are also vital in providing optimal patient care. As such, sessions on crew resource management skills, the cognitive revolution, tips for centring one’s self prior to and during a job, and how to get the rollout of good ideas actually rolling were welcome additions to the program.
Things We Liked
Firstly, whilst it is obvious that military experiences inform civilian practices, we appreciated the fact that this conference was focussed on civilian (not military) practice. Other conferences of the type claim to do this yet the majority of the auditorium is filled with uniforms of various militaries.
Secondly, sessions were kept at a length that were short enough to retain audience attention but long enough to cover the required level of detail for the given topic. If a topic was not floating your boat, a new topic would commence in 20 minutes.
Thirdly, at no point did we hear “you must do it this way – if not, you are wrong”. The overall feel of the conference was that no single entity had all the answers but that through collaboration we can all improve. Participants were encouraged to seek out presenters (who were all easy to find) and undertake collaboration.
Finally, the focus was on “good medicine in bad places” and not cool Velcro patches, the latest fashion in tactical gear (which would obviously only come in black and be stamped with a label consisting only of numbers) and the liberal application of mutual back-slapping.
Things That Were Not the Business For Us
Despite the fact that the conference was aimed at civilian practice, the majority of presenters referred to TCCC (Tactical Combat Casualty Care) and not TECC (Tactical Emergency Casualty Care). It is possible that the presenters were using the term TCCC out of habit, but when one considers that the latest review of TCCC by the Committee has lead to their terms coming closer into line with that of TECC (and not vice versa), it is time that the world started embracing the correct terminology.
Having a single track makes it hard to keep everybody interested, and at times we felt sorry for certain members in the room. These folks included frontline police officers who have a secondary role of medical response – whilst the clinicians were riveted by the maps of clotting cascades and stories of roadside REBOA, the Police Medics just wanted to know (a) how best to plug the hole, and (b) how fast to drive.
[Note: we got the impression that the conference convenors were victims of their own success – we are not sure they realised just how popular it might be when they originally floated the idea on social media. We are confident that this issue will be alleviated next time.]
If you had to sum up the content of a jam-packed two-day conference in just a handful of points then these would be them [note: these are more paraphrases than quotes]:
“Learn from the experiences of others. Recognise that no single agency has all the answers, so work with and not against each other.” Matt Libby, flight paramedic with Boston Med Flight, USA
“In resuscitation, the most effective therapies are those that can be applied quickly. Time is blood.” Dr Richard Dutton, trauma anaesthetist, USA
“You can possess all the best haemorrhage control devices in the world, but if you are not using them properly then they are worthless. Training is key.” Dr Mark Forrest, medical director of ATACC, UK
“Battlefield medicine is like plumbing: if it’s blocked, clear it; if it’s leaking, plug it.” Gary Grossman, CSAR paramedic, Israel
“In a high risk or major incident, it makes sense to have all rescue agencies working together under a common SOP that has been tested prior.” Dr Stephen Sollid, medical director and retrievalist, Norway
“REBOA has a place in pre-hospital care; we are just not quite sure what that place is. Blood will still be lost from backflow.” Dr Tal Hörer, vascular surgeon, Sweden
“Medics in the hot zone should focus on not getting themselves killed and not endangering the mission. Cross training is vital.” Dr (LTCOL) Ishay Ostfeld, IDF and cardiothoracic surgeon, Israel
“In a critical patient, performance of life saving interventions should take precedence over applying rigid protocols around immobilisation.” Dr Thomas Dolven, intensivist and retrievalist, Norway
“People only improve if they actually want to. You cannot force improvement.” Michael Lauria, former USAF PJ and current medical student, USA
“When it comes to vascular access, there should not be different hospital standards and prehospital standards. There should just be standards.” Dr Knut Taxbro, anaesthetist and retrievalist, Sweden.
So I guess the big question that remains for everyone is “was 50+ hours of travel from Australia to central Sweden for a 17 hour conference really worth it?” Given that we were able to assess the content of our training against that which other like-minded organisations from around the world provide in an open and non-threatening forum, tweak our content in line with the latest evidence, build contacts with groups and individuals that have the same struggles as we do in Australia, and provide some guidance to participants who were looking to develop their own tactical medicine training – the answer is obvious.
Wait, I almost forgot the really vital lessons
The Swedish love speed cameras. I mean, seriously, they are everywhere!
Reindeer is actually quite tasty.
Moose is a bit, well, meh….
When it comes to rivalries, Norway is to Sweden what New Zealand is to Australia.
The Australian TV shows “Prisoner” and “Flying Doctors” are compulsory viewing for Swedes.
And 50+ hours of travel by air is in fact a very long way – but it beats driving.
Hey, are you interested in this stuff?
Well you could choose to read our previous posts about TECC here, here, or here. If you do you’ll find heaps of references and further reading on all things tactical.
CareFlight does have courses on that sort of stuff (it’s one of the bits you can find here) so you might find a bit of interest in that or, [looks shy, kicks dirt] y’know, do whatever. If you were interested (but no pressure) it runs pretty regularly (like in 2018 it’s happening on 12 February, 26 May, 20 August and 24 November).
Meanwhile if you like the stuff on the site you could always share it around. Or even sign up to get the emails whenever things hit.
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
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.
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
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.
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:
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.
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:
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)
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!
In broad terms, casualties in a tactical environment will fall into three categories:
Casualties who will live regardless,
Casualties who will die regardless, and
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.
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”.
“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:
Nasopharyngeal airways (NPA)
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.