Triage & Initial Treatment at the Active Shooter incident: Do you SALT your MCI?

DWK Fraser, CD, BA, PCP @DWKF
Views are my own, and do not represent my employers in any way.

Triage of any MCI is one of those infrequently practiced skills that have massive implications for patient outcomes, and when it’s done “wrong” it leads to wasted resources and potentially deaths.  It also has virtually no science to back it up. It wasn’t until recently that we even recognized the gap between what we knew and what we assumed about MCI Triage.  

In fact, current ALTS-based physician-directed triage training doesn’t seem to make a difference in triage outcomes!

In 2008 this gap was acknowledged, and a “new” method of triage was developed based on the limited information available and compliant with the American College of Surgeons best-practices guidelines.   This new method, using the mnemonic SALT, takes into account (in fact, relies on) developments in tactical medical care such as the modern tourniquet, almost universal NPA use, specific antidotes for chemical agent exposure.  It also allows for genuine clinical acumen and incorporates resource availability into final decision making.

More importantly, SALT is far more compatible with Hartford Consensus III which sums up the recommended response to the active shooter with the acronym THREAT:

Threat suppression
Hemorrhage Control
Rapid Evacuation from the hot zone
Assessment by medical providers
Transport to care

In an active shooter situation the first people through the door are there for job 1, threat suppression and mitigation, and this frequently (28.1%) results in an exchange of fire between the perpetrator and the responding members. Where officers engaged the perpetrator, in 46% of the events an officer was injured or killed.

But once the threat has been suppressed it’s time for the rest of the THREAT mnemonic to kick in, and that’s where SALT can play a role.

SALT stands for Sort, Assess, Life Saving Treatment, Transport.

Sorting is conducted as a “Walk, wave, still” where the the walking are directed to a safe area (to be cleared by LEO in an active shooter) unmoving are assessed first, and the waving are checked after the unmoving.

Tac Responder KitThe SALT Assessment is conducted concurrently with limited treatment, and is even simpler than START. Obvious life-threatening injuries get treated! Tourniqueting major bleeds, opening airways with positioning, NPA or ESA, decompress tension pneumothorax (and seal obvious open pneumothorax) and administer 2PAM or other antidote as required are all reasonable and appropriate, depending on resources available.

In the Tactical Medical world, this limited treatment is what’s run out of the medic’s leg bag. The jump kit doesn’t get opened outside the casualty collection point (CCP) until the treatment areas are being established.

Simple SALT Algorithm

 

The critical difference between the Active Shooter MCI and the other MCI is the speed with which providers must act.  An Active Shooter is frequently an ongoing, open incident that will continue until the shooter is contained, killed, or surrenders.  The initial RTF medics must continue to push forward with the security element, providing appropriate hemcon and other interventions with the equipment on hand and leaving follow on personnel the job of further treatment and evacuation to the cold zone.

Consider adding some SALT to your MCI!  Simple, limited life-saving interventions performed at point of injury are the norm in tactical medicine, reducing the cognitive load is essential in performing at our finest. Add these life-saving steps to your Active Shooter and MCI training!

 

Check out the full SALT Online Training package courtesy of the National Disaster Life Support Foundation

How have we gotten here?

DWK Fraser, CD, BA, PCP @DWKF
Views are my own, and do not represent my employers in any way.

65% of US States lacked specific guidelines on how and when to use a tourniquet!

Blow Out Kit for HemCon

Blow Out Kit for HemCon

After almost a decade and a half of continuous warfare, after achieving the best trauma outcomes in the history of medicine, after the formation of both the Committee for Tactical Emergency Casualty Care  and the Committee on Tactical Combat Casualty Care, even when the most recent best practices are available free online, we still can’t come up with a coherent extremity hemorrhage control strategy!

Ladies and gentlemen, the evidence is there, most of the tools are there, and the techniques are well developed;  There is no longer any excuse for any patient in prehospital care to die from exsanguinating extremity hemorrhage.

Know how to use a tourniquet! Put them on your ambulances, on your belt, in your pockets.  Have a primary, an alternate, a contingency, and know how to make a emergency tourniquet one.

See our post here for the evidence supporting their use.

 

What do we owe our patients?

DWK Fraser, CD, BA, PCP @DWKF
Views are my own, and do not represent my employers in any way.

No, not like that, although we’ve all encountered patients or other members of society with a, shall we say, heightened sense of entitlement.  But what is our duty of care as prehospital professionals?  When can we leave a patient and when must we stay with them to definitive care?

Duty to Act

There isn’t a huge amount of information available in Canadian law that applies to this subject with regards to Paramedics and other prehospital providers, but there are some basic principles at play and some guidance from some EMS authors, the BC EMA Licensing Board and the Royal College of Physicians and Surgeons of Canada. The Royal College outlines four fundamental obligations of a physician to their patient:

  • The obligation to obtain informed consent.
  • The obligation to provide prudent and diligent care.
  • The obligation not to abandon the patient.
  • The obligation to preserve confidentiality.

While Paramedics and other prehospital providers are not bound by regulations of the Royal College, it seems prudent and reasonable to look to our physician’s guiding documents, and note that there is absolute overlap between the duties of physicians and the duties of paramedics in the other three areas mentioned. The Emergency Licensing Board of British Columbia Schedule 3 Code of Ethics writes, in part:

(a) consider, above all, the well-being of the patient in the exercise of their duties and responsibilities;

(c) protect and maintain the patient’s safety and dignity, regardless of the patient’s race, colour, ancestry, place of origin, religion, marital status, family status, physical or mental disability, sex or sexual orientation;

(d) preserve the confidence of patient information consistent with the duty to act at all times for the patient’s well-being;

(g) carry out professional responsibilities with integrity and in accordance with the highest standards of professional competence;

One key question that must be answered if any fault is to be found is “Did the Paramedic have a duty to act?”  In the prehospital setting, it is reasonable to say that a Paramedic or other public safety member who is responding in a professional capacity to a call for service, whether this comes from a flag-down on the street or a 911 call, has an established duty to act in the best interests of the calling party (if they and the patient are the same individual), or, with consent, any person found in medical distress at the location.

What is abandonment?

Nancy Caroline, the author of Emergency Care in the Streets very succinctly wrote “Abandonment can occur anytime Paramedics turn over their patients inappropriately or to a level of care lesser than themselves or if they leave a patient without ensuring the patient had the mental capacity to refuse treatment or transport.”

If you have established a relationship with a patient, by assessing, treating, or otherwise offering aid to a person in distress, and then you leave them without handing them off to a person capable of providing care to an equal or higher level you have abandoned your patient. You have breached your duty of care to that person, and can be held liable.

In the EMALB code of ethics, (c) protect and maintain the patient’s safety, would imply that Paramedics must protect the patient against reasonably foreseeable complications and risks.  While untested, this could include occult injuries at a MVC scene or the resuscitated narcotic overdose patient refusing care.

“In other words, after care of any kind is administered, the physician must “provide the medical follow-up required by the patient’s condition” unless the physician has ensured that a colleague or another competent professional will do so.36 Where a physician wishes to refer the patient to a colleague, he/she remains responsible for the patient until the new physician takes up the patient’s care.37″

You can read more in this article from EMS 1

 

I’m not a lawyer, and this shouldn’t be taken to construe legal advice.  I didn’t even stay at a Holiday Inn last night.  Comments? You can find me on Twitter @DWKF

How sick is he?

DWK Fraser, CD, BA, PCP @DWKF
Views are my own, and do not represent my employers in any way.

I recently attended to a retired gentleman who had been picking up some work around the holidays.  He’d been an electrician for 25 years, and had retired the year before.  When his first grandchild was on the way right before Christmas he decided to pick up some work to get his daughter and son-in-law something special, and to help set up the nursery for them.NSR Pelvic Binding

He fell off a 12 foot ladder, and suffered a basal skull and sinus fracture, along with an obviously displaced fracture of his arm.  He was briefly unconscious and had some aspiration before we got there, but was awake and alert upon initial exam with a chief complaint of arm pain and a headache. His teeth were intact, he had no Battle’s sign or Raccoon Eyes, no epistaxis or discharge.

He “usually” took pills for his blood pressure, his angina, his afib, and a few others which he also couldn’t name, but he knew it was important to tell people he was on blood thinners.  He was mildly tachycardic and normotensive.  He didn’t look unwell.

How can you predict the degree of injury in this patient?  He’s medicated in such a way that his body’s response is blunted.  He’s at risk of increased ICP and Cushing’s, and of bleeding in general, but how to judge his vital signs?

There’s a great tool which allows you to predict otherwise difficult to detect shock states, the Shock Index.  There’s evidence to back it up in helping to differentiate major from minor injuries, and it’s even validated for use in geriatric patients, even when neither HR and SBP were useful on their own.

TXASI = HR / SBP.  The faster the heart rate the greater the degree of compensation, and the BP is indicating how well the body is achieving perfusion.  A normal range is 0.5-0.75 ( HR60 BPM / 120SBP = SI of 0.5, HR90 / 120SBP = SI 0.75, HR 120 / 120SBP = SI 1).

A Shock Index greater than 0.9 should be assumed to be actively bleeding!

 

10 Principles of Leadership

DWK Fraser, CD, BA, PCP @DWKF
Views are my own, and do not represent my employers in any way.

From the Canadian Armed Forces, these 10 principles of leadership are a great starting point for evaluating your performance as a leader.  Keep in mind, just because you don’t have bars on your shoulders or pips on your slip on doesn’t mean you don’t have a leadership role in your organization!

 

1. Achieve professional competence.

2. Appreciate your own strengths and limitations and pursue self-improvement.

3. Seek and accept responsibility.

4. Lead by example.

5. Make sure that your followers know your meaning and intent, then lead them to the accomplishment of the mission.

6. Know your followers and promote their welfare.

7. Develop the leadership potential of your followers.

8. Make sound and timely decisions.

9. Train your followers as a team and employ them up to their capabilities.

10. Keep your followers informed of the mission, the changing situation and the overall picture.

More on public access hemorrhage control

DWK Fraser, CD, BA, PCP @DWKF
Views are my own, and do not represent my employers in any way.

There is ample evidence that tourniquets work in controlling hemorrhage from extremities, and now various public bodies, including the White House, are adding their voices to a push for public access hemorrhage control:

“…make tourniquets as commonplace as heart defibrillators in U.S. schools, stadiums, airports, malls and other public places, to reduce fatalities from mass shootings and terror bombings.”

Department of Homeland Security and NAEMT have all added their voices to the call for public access hemcon and public training in hemcon techniques.

If you don’t know how to use a tourniquet, if you can’t apply one to yourself quickly, efficiently, and effectively, you are exposed to an easily controlled risk.  It’s not just hybrid targeted violence of the sort we’ve seen in Paris, Mali, Kenya, London, Madrid, but any exposure to a traumatic injury that warrants no-fail hemorrhage control measures!

More (well, some!) evidence to back up hemostatic dressings.

Unlike tourniquets and TXA, both of which have  a robust and growing body of literature to support their use, hemostatic dressings such as Quickclot, Combat Gauze, WoundStat etc have had limited published field experience to support their use.
EMS1 on Hemostatics

Blowout Kit

Blowout Kit

 

In US DoD studies, Combat Gauze was chosen as the agent of choice, but that decision was largely based on animal models, which are great, but provide limited value and don’t always translate well to clinical practice. Some suggest they are about 30% more effective than good wound packing with regular materials.

But here’s a study from Israel that supports their effectiveness in the field about 90% of the time!  Keep in mind that this is a small study, but it’s pretty reflective of this authors experience with hemostatics in the military setting, includes extremity and junctional injuries, and acknowledges where there are gaps in the data.

Hemostatic agents in their current form seem to be a potent addition to the hemorrhage control arsenal, and have lots of cheerleaders in the military health care community, but are not a silver bullet that will stop every source of bleeding.  Here’s hoping one of the many gels, foams, CO2 delivered TXA interventions is THE answer to the bleeding patient!

Big Box vs Small Box EMS Education

DWK Fraser, CD, BA, PCP @DWKF
V
iews are my own, and do not represent my employers in any way.

I’ve been working on this post for a couple of weeks, and then along comes LUTL and Chris Kaiser who posts on pretty much the same topic, and does a better job of it, but I’m going to post it anyway. Here’s a link to Chris Kaiser’s article.

I was off for almost two months with a bum shoulder, and my inner EMS geek came out in full force.  I’d been following the Social Media and Critical Care Conference (SMACCUS) online for a couple of days, and it was both a positive and negative experience.  On the on one hand, it became completely apparent to me that we’re not providing the most cutting edge care that we can. On the other hand, it’s easier than ever for Paramedics around the world to provide that cutting edge evidence based medicine. Sea Can

 

Among my peers, there are two competing theories of EMS education, what my partner and I refer to as the “small box vs big box debate”.  The small box theory of EMS is the system that many of us come from.  In order to be a PCP I need to know how to perform the following procedures….I need to know the indications, contraindications, dosages and routes for the following medications…I need to know how to recognize, diagnose, test for, and treat the following conditions… And the reason we think that way is that’s the system that we come from, that’s the way EMS programs are designed, especially in light of Canada’s NOCPs. Crich

The big box theory states that I need to know all that, and lots more.  I’m a better paramedic who delivers more effectively treated patients to the hospital because I also know about things OUTSIDE my scope of practice.  I read up on ECMO, ROTEM, REBOA, blood products, rehab, and indications for procedures I can’t perform. Why? Because prehospital and retrieval medicine needs to be a team sport, and I can best support my ALS colleagues, the nursing team and Emergency Physician in the ED, the Trauma Surgeon in the MTC, the RTs and allied health care providers if I can anticipate their needs.  In the past two weeks I’ve approached my ALS colleagues with some neat things that I’ve seen thanks to @Ketaminh on Twitter, and in both cases they’ve been positively received.  An ETT setup that allows you to suction through the tube during VL or DL? Awesome!  A new use for the venerable Stiffneck? Hilarious, but great.

20150718_213034Let’s look at a “simple” skill, common across the full spectrum of practitioner levels: As the Paramedic Association of Canada describes it “Perform ventilation using a manual positive pressure device” which means everyone from First Responder and Occupational First Aid to EMR to CCP needs to know how to use a manual resuscitator (BVM) to assist or provide breaths to a patient. We all need to know it because we may all need to do it. We teach all sorts of people how to do it.  Poorly.  And we KNOW that using it poorly is potentially devastating to all sorts of patients!  Life-saving, yes.  Benign, no.

I’d been in EMS for almost a decade before an anesthesiologist showed me how to use a BVM properly, who took the time to explain what it was doing behind the scenes, on a physiologic basis.  It’s been over a decade since then, and despite the trickle-down effect of knowledge translation, it’s still a tool that’s used improperly by many Paramedics.  Paramedics with months in the classroom and hundreds of hours in practice still use it improperly, because the foundation their practice is built on is less than solid.

In his book Outliers Malcolm Gladwell says that expertise takes 10,000 hours. I was let loose on patients with 10 minutes of actual instruction and less than 10 hours of practicing bad habits, and it took me almost 10 years to realize it. Now I’m happy to say that AIME is one of the four-letter-acronym courses that I help deliver for BCEHS Learning, to every BC Ambulance Service Paramedic.  We talk about endotracheal intubation to people who don’t do it because it makes them better assistants. We show extraglottic airway placement to people who don’t place them because it makes them better assistants and helps them make that “call for help” decision.  In ITLS, our CME trauma course, we discuss and demo intraosseus infusion and needle decompression to people who don’t do it because it makes them better assistants.Facepump!

Our BLS crews are being dragged into the “big box” world, which is a relief for those who have been working in that larger medical world as their practice. We’ve moved from protocols to Treatment Guidelines, and our prehospital practitioners are free to pursue treatment goals versus applying treatment protocols.

CPAP in ClassThis puts a huge amount of responsibility onto the individual Paramedics, and none more so than the Primary Care Paramedics who staff the bulk of ambulances across British Columbia.  Over the past several years we’ve seen major leaps in PCP practice in BC.  We’ve added TXA, EGA, CPAP, PEEP, NPA, NODESAT and dimenhydrinate. We’ve added a pediatrics module to AIME, ITLS, and Cardiac Arrest Management to complete our ongoing “4-pillars” 20150726_192314training regime.  Our crews in the Lower Mainland are involved in the FRONTIER study.  The ROC TXA in TBI trial starts soon. An MCI update is in the works.  The scope of practice is advancing, and the knowledge base required to differentiate, to diagnose, to treat our patients is deeper than ever before.

There is a movement to bring “upstairs care downstairs,” to bring ICU level care to the Emergency Departments of the world.  As this movement gains momentum, Paramedics need to be prepared to bring that same level of care to the prehospital setting.  The key to doing this is to take a “big box” view of EMS education from the moment we set foot in the classroom, commit to career-long learning, and be prepared to up our game continuously.

Clinical Decision Making in a Team Context

Have you ever had one of those partners? The one you didn’t even need to speak to during the arrests, the profoundly collapsed CHF call, the multisystem trauma call? The one who had everything you needed in their hands as you felt your sphincter tighten and your heart rate increase? You turn and ask for an 16g in a big vein and they’re already doing it?  You mumble “maybe a NRFM?” and they’re already inflating the reservoir?  There’s a beauty to EMS when it runs like that, a precision and finesse that makes it look effortless.

For that call, and hopefully for many more, you were working with a shared mental model of what was wrong with the patient, what courses of action you had open to you, and how best to move the call forward to a good outcome.

You may have worked with that person a dozen years, or it could be your first call together.  You don’t need to be experienced to have that shared mental model.  Two brand new medics just out of school working on a classic EMS call are working from the same place of (over) confidence and unrecognized pitfalls, but from the same playbook of classic presentation and conservative treatment.

There are things you can do to enhance this, and improve your individual performance as well as that of your team, especially for uncommon procedures.  For those who don’t do thoracotomy or surgical airways, replace that with triage or childbirth. And it really works.

Classic cases are classic cases because they’re classic….

Rescue Task Force Skill. Tourniquets: Where the science stands

DWK Fraser, CD, BA, PCP @DWKF
Views are my own, and do not represent my employers in any way.

If you asked any researcher to name some prehospital interventions that truly proved their worth during the recent conflicts in Iraq and Afghanistan they would, almost universally, include  tourniquets and TXA on their list.  Yet there is still, despite a huge volume of well documented research, widespread resistance and misinformation  about these two interventions.

During an EMA Licensing Exam I recently watched someone take a tourniquet off a complete amputation.   He looked at his watch, said “Ten minutes, time to loosen the tourniquet”, and proceeded to remove it from his patient.  Looking at me he asked “Is it bleeding again?” “Of course it’s bleeding again!” was my reply.

I looked at his instructor, and I was floored.  This is what the first aid groups are teaching people about tourniquets? Something very important has been lost in the knowledge translation.

Here are several published studies which look at tourniquet use in the modern context.

The first one we’ll look at was conducted at a US Army Combat Support Hospital (CSH) outside Baghdad over a 7 month period in 2006.  232 patients had 428 tourniquets applied on 309 injured limbs.  194 patients had tourniquets applied in the prehospital setting.  The remainder had them applied in the CSH.  “The 5 casualties indicated for tourniquets but had none used had a survival rate of 0% versus 87% for those casualties with tourniquets used.” The most common complication (less than 2% of patient) suffered a transient nerve palsy. Let me say that again.  Less than 2% of patients had complications, and the most common one was that their limb hurt or felt funny from the tourniquet compressing a nerve. And it went away.  There were no amputations associated with tourniquet use in this study.  

While this study isn’t without some problems, most glaringly the use of the quality & presence or absence of a radial pulse as the determinant of shock, it is very noteworthy that early tourniquet placement was associated with a better outcome and such a low complication rate makes it THE prehospital intervention for hemorrhage that can be tourniqueted.

LEO Applied TK

Law Enforcement Applied Tk to upper extremity due to arterial bleeding post stabbing. This required an additional full rotation of torsion bar to achieve hemorrhage control by EMS

The second is a follow up to the first, and when we add another 267 patients we get virtually identical data: an overall 87% survival rate, higher in those who received tourniquets early and lower in those who didn’t receive one at all or until the CSH, with a <2% complication rate and no amputations.

This is not to say that any intervention is without risk.  The use of improvised tourniquets and prolonged application times are associated with worse outcomes, and there are some documented cases, with improvised tourniquets, that DID result in amputations after long (17 hour) application.

It is critical that medical providers train with their tourniquet of choice under all potential conditions.  Application effectiveness does not improve under real world conditions! Lower extremity application continues to have the highest failure rate, likely due to the higher occlusion pressures needed (300mmHg!).

The inherent efficacy of tourniquet products contributes to high failure rates under combat conditions, pointing to the need for superior tourniquets and for rigorous deployment preparation training

What is the objective to loosening a tourniquet? To prevent loss of limb? To decrease complications like transient nerve palsies?  If those are your objectives, relax, the tourniquets have this one. Put it on, and don’t take it off.  We’ve got the EMS evidence to back this up.