Far from the front: the role of trauma systems in IED/Active Shooter Events

HMMVW Amb on the flight line, KAFWith the recent release of the US DHS Guidance for IED and Active Shooter document, we’re taking a look at some of the key concepts within that document.  This week we’re looking at the Trauma Systems roles in preparing for and responding to these events.

To some extent we are lucky.  We’re lucky because there are probably few tertiary care trauma centers that don’t have a veteran of Afghanistan or Iraq on their surgical, ICU or resuscitation service.  Experience counts, and team leadership is essential in MCI, no matter where they happen. Many hospitals have regular MCI drills, and at the facility level it really doesn’t matter what the incident is.  Plane crash? Bus Crash? IED? Unless you move the MCI to the hospital during transport, or the incident targets a health care facility, MCI in hospitals (should be) are very different from the chaos of responding to the incident scene.

“EMS must rapidly and accurately triage casualties at the incident site and expeditiously transport those identified for “immediate care” into an appropriate hospital setting.”

All facilities, not just those designated trauma receiving facilities, need to be ready for an influx of patients.  Experience shows that in major events many casualties self-report to the nearest treatment facility if they are capable of doing so.  These facilities need to have triage systems in place and EMS needs to stage transport units at these facilities to effect secondary transport.  In a major event, secondary transport may include out of region and even out of province transfers.  We need to keep in mind that our health care system is currently operating with a very limited surge capacity.

Damage control resuscitation and surgery (DCR/DCS) is the name of the game.  Prevent hypothermia, treat with blood products not salt water, and stop ongoing hemorrhage.

DCR is based on the balanced administration of thawed plasma, pRBCs, and platelets in severely injured patients instead of solutions such as normal saline and lactated ringers.9 10 11 12 DCR also includes avoidance of hypothermia and pursuit of other measures to maximize oxygenation and reduce injurious factors in the blast-injured patient.

However, all the surgeons in all the OR’s aren’t much help if you can’t get the patient to them in the right sequence.  Triage is one of the most critical elements of any MCI response, and MCI triage is not what you’ve experienced in the Emergency Room during a normal visit.  Triage also can’t happen once.  Triage should happen at each stage of evacuation, again on arrival at the hospital, and again among the priority patients for surgical priority.

Behind the scenes of any surgery are the hidden experts, radiology, lab techs, blood bank, and all the others without whom a modern OR can’t function, and they each have a job to do. This job will take a finite amount of time, and have a finite amount of stores on hand.

One area where significant efficiencies can be found is the role of the blood bank in trauma resuscitation, particularly development and implementation of Massive Transfusion (MT) Protocols.  Fascinating research in MT is ongoing, and developments like rotational thromboelastometry (ROTEM) are offering exciting developments

Any patient who may require MT should have already received TXA, preferably during tactical field care or casevac care. Despite best efforts, none of the prehospital blood replacements (or even Normal Saline for that matter!) show much benefit in hemorrhagic shock.  With that in mind, resuscitation with blood products is the gold standard.  Everything infused should be warm, it should be under pressure, and it should either help promote clotting or carry oxygen.

And let’s not forget that when these patients come out of resus and are off to the OR or ICU there is a finite amount of resources available for them even if they’ve made it this far.  We know that care of the traumatized patient is a long-term problem that will persist long after the event.

Trauma bays fullThe provider on scene is only the tip of what must be a vast concerted effort of allied health care providers working together towards a common goal:  Best care for the patients under less than ideal circumstances.

 

 

 

For more on Boston listen to this BBC Broadcast

To see what the New Yorker had to say about the hospital response to the Boston Marathon Bombing 

To learn more about Damage Control Surgery we recommend this #SMACC presentation.

“Non-traditional EMS and Fire roles”: A look at the Rescue Task Force concept

With the recent release of the US DHS Guidance for IED and Active Shooter document, we’re taking a look at some of the key concepts within that document.  This week we’re looking at the concept of the Rescue Task Force, a specialized team trained and equipped to operate within the warm, sometimes hot, zones of these high-risk unstable incidents.  

 

Last weeks link

When we talk about traditional EMS and Fire Department tasks at a major incident we are talking about the day to day activities. EMS has the job of triaging, caring for, the treatment and transport of the injured from the point of injury to different levels of care.  Fire’s job is risk mitigation, hazard containment, and access and extrication.  Law enforcement is usually there in a support and advise role during non-criminal/ terrorism  events.

In a IED/Dynamic Threat environment guess who’s in charge? Law enforcement.  Guess who’s doing the threat mitigation and hazard containment? Law enforcement.  Guess who’s getting other agencies in and out safely? Law enforcement.

Everyone becomes subordinate to the police.  They have a play book (IRD) to follow, and paramedics and firefighters rushing in and complicating things isn’t part of it.

These incidents may, but not necessarily will, result in mass casualties. Their very nature and the incredibly high risk requires that we respond prepared for significant numbers of casualties with significant injuries.  Some jurisdictions have developed the Rescue Task Force, a (sometimes) multi-agency team that is trained and equipped to operate within the operational warm zone.

Treatment by these RTF’s should be limited.  TECC and TCCC guidelines should be followed to maximize survival. Skills like wound packing, IO initiation, pelvic binding and needle decompression should be second nature for all members.  They need to be expert in the direct and indirect threat care phases of TECC, especially skilled in the art of triage.

“First responders should incorporate tourniquets and hemostatic agents as part of treatment for severe bleeding…First responders should adopt, develop training for, and operationalize the evidence-based guidelines of TECC. Training should be conducted in conjunction with EMS, fire, law enforcement, and medical community personnel to improve interoperability during IED and/or active shooter events.”

TECC 1dDuring almost any MCI debrief, two obstacles to patient care come up.  Communication and patient transport.  Communications is a systemic problem, and an ongoing one at that. The implementation of tac channels for some agencies has helped, but encrypted digital all-agency systems are still problematic (See CREST in Victoria).

Moving patients is hard.  Very hard.  In the absence of modern patient transporters it is even harder.  Add broken ground, terrain features or obstacles, constrained evacuation routes and it will quickly become one of the most labour intensive tasks for EMS and Fire. Teams must be familiar with all patient transport devices, and often underutilized tools like the Ferno Manta Mat and KED find a niche.

“First responders should develop inter-domain (EMS, fire, and law enforcement) TTPs—including use of ballistic vests, better situational awareness, and application of concealment and cover concepts— and train first responders on proper use of the TTPs.”

The RTF’s need to be properly equipped to operate within the warm zone, with protective equipment including helmets, CBRNE equipment, level IV vests, (and perhaps current generation NVG).  They need to train in and practice tactical awareness on scene, utilizing cover and concealment, remaining alert to the potential for both direct or IED attack during rescue operations. These aren’t pieces of equipment that you handle once and then hang up at the station. They need to become so familiar to the members that they operate fluidly and unhindered by them. These TTPs need regular thorough rehearsal between all agencies, using the same language, on the same radio frequencies.

Deploying in small (4-5 person) teams, RTF are comprised usually of a designated security element and a designated treatment element. Medics move forward into warm or even hot zones under direct cover of police to perform limited casualty care as far forward as possible and initiate evacuation out of the danger zone to more definitive care away from the scene.

“Rendering life-saving care in warm zones (by EMS, fire, and/or law enforcement) is a relatively new paradigm that is supported by data. Historically, when EMS and fire personnel waited up to several hours before being permitted to enter scenes and render life-saving care, very few critical victims survived. The passage of that time resulted in the likely preventable loss of life for victims.”

TECC recognized educational content

 Link to the full DHS Report

Link

Tac Responder KitThere are  virtually no reasons not to use a tourniquet to stop hemorrhage that is amenable to one.  It’s not unreasonable to make one attempt at controlling bleeding with direct pressure, directly on the bleeding site (pinpoint pressure, not pillow pressure!) but while your using one hand to do that, the other hand should be reaching for a tourniquet.  Maybe your knee should be pressing down on the femoral or brachial artery too, depending on the injury.

The key to success in using a tourniquet, like many procedures in EMS, is making the decision to commit to it.  Once you’ve applied that device, it should not be coming off except in very specific circumstances, and very rarely in the civilian EMS setting.

The biggest pitfalls with using a tourniquet are:

  1. Not using one when indicated.  Delays in tourniquet application allow unacceptable hemorrhage.  There is no acceptable amount of blood loss!
  2. Using one for minimal bleeding.  Significant venous or arterial bleeding only!
  3. Taking it off!  If it’s working, leave it!  If it isn’t working, add another!
  4. Not making it tight enough.  Tourniquet slack is a killer.
  5. Not using a second (or third) tourniquet when needed.
  6. Periodically loosening it.  You’re not killing distal tissue with it, so you don’t need to worry about it in the short term!  Surgeons use 300mmHg on a femoral tourniquet in the OR regularly!

If you’re carrying one, you need to be proficient in it’s use, and it needs to be close to hand.  There is nothing worse than needing that one piece of kit that’s buried at the bottom of your duty bag or jump kit.

Law Officer.com on LEO TK Use

Interesting TK

New First Responder Guidance on IED/Active Shooter Incidents

TECC recognized educational content“…there is no single model for providing care during law enforcement operations and that TEMS basic principles should be considered core law enforcement skills relevant to all police operations, as NTOA “supports the efforts of the Committee for Tactical Emergency Casualty Care (C-TECC) and others to foster the development of standardized taxonomy and evidence based clinical practice guidelines tailored to the law enforcement mission.”

The US Department of Homeland has released their latest guidance for planning for and responding to IED and Active Shooter events. This paper reinforces our core belief that civilian trauma response can be greatly improved by the rapid adoption of the lessons which we have learned in decades of military operations and research.

This report looks at the role police, fire, and EMS should play in planning for and responding to deliberate mass casualty events; it identifies critical areas of coordination, Tactics, Techniques, and Procedures for hemorrhage control, damage control surgery, hemostatic agents etc.

Unified command must be established, and will always be under law enforcement command while the event remains active.  LEO will move as quickly as possible to engage and stop the shooter, contain the incident from unauthorized ingress, and prevent escape.  Casualty care will come later.  EMS and Fire must orient their resources for rapid access and anticipated tasks which focus on triage, rapid hemorrhage control, limited airway management, and rapid transport out of the warm zone.

“The protocols and procedures should also address non-traditional roles of EMS and fire personnel. These roles include the use of properly trained, armored (not armed) medical personnel who are accompanied by law enforcement into areas of mitigated risk (warm zones). In these roles, life-saving care (i.e., hemorrhage control and airway management) and evacuation of the injured from the warm zone may help improve survivability of victims.”

Police will have their hands full in dealing with policing duties, but that doesn’t mean they don’t have a role to play in casualty care.   “…the National Tactical Officers Association (NTOA) states that there is a need for all police officers to have basic Tactical Emergency Medical Support (TEMS) medical training in order to potentially save the lives of victims, bystanders, police officers, and suspects in the event they are wounded.”

Over the next few weeks we’ll take a look at more elements of the DHS guidelines, and some of the scenarios they include in it!

 

Leg work done. Let’s get training!

It’s been a while since we’ve posted here!  It’s been a busy month or three at PEMT.  The big news is that we hosted our International Trauma Life Support International BOD Site Visit, the imagepaperwork’s been done, the t’s crossed and i’s dotted, and we’re officially a ITLS Training Center!  The board signed off on this at their last meeting, and we’re good to go.

 

Some of us have been involved in ITLS for over 2 decades. Some of us are more recent converts to the faith.  Either way, we’re incredibly proud that we’ve been able obtain the rights to teach ITLS in British Columbia.  This puts us among a very small pool of training providers who have proven to international organizations that we’re up to the standard!

TECC recognized educational contentAnd speaking of being up to international standards, we’ve also taken the steps necessary to accredit with the Committee for Tactical Emergency Casualty Care after our successful first TECC LE/EMS course. Held at the VPD Tactical Training Centre in March, this course confirmed our course content, instructional techniques, facility and faculty all meet the standards expected from a TECC Course.

 

While we’re fielding calls from various organizations, some old partners and some new, planning our next 6 months of delivering high quality training, we’re also working on developing our public access courses, bringing the world-class standards of TECC and ITLS to the public, because while saving a life by using a tourniquet properly isn’t rocket science, it does take training and practice!

 

Tac Responder Kit

Tactical Emergency Casualty Care for Law Enforcement and EMS Class #1

We just wrapped up our first tactical EMS class.  A fellow Kandahar medic and I put 6 paramedics through 16 hours of lectures and drills, case studies and scenarios.  All the feedback so far has been great!TECC 1f

It did expose some gaps.  We’re used to working with prehospital professionals for EMS education.  We’re used to working with soldiers when it comes to tactical medicine.  But teaching EMS professionals things that soldiers take for granted, things like tactical movement, hand signals, light and noise discipline threw us for a bit of a loop at times.

We’re continuously striving to improve the courses we deliver, and we’re already working on new sims, a new tactical skills module for our EMS providers, and on our intermediate course for those who had such a good time this time around!

 

Tac Tool Tuesday! IFAK!

This week let’s take a look at IFAKs.  What do you carry on your belt?   What’s going to be immediately at hand when something catastrophic happens?

DSC_1103

A tourniquet? Where is it?  Can you get to it with your dumb hand? When was the last time you drilled with your preferred model?

You see pictures of combat medics festooned with tourniquets, and that’s a good place to start.  At least one easily accessible TK rigged for application to yourself with one hand.

Anything else?  Here’s the thing about an IFAK.  It’s all about you!  There’s a reason it’s an “Individual” First Aid Kit.  YOU use it on YOURSELF under bad conditions.  Worst case, someone else uses it on you because you’re so immobilized you can’t even get a TK on your own arm.

There are some great products on the market, some innovative designs that fit in a plate carrier or a hydration pocket on a small pack, a cargo pocket on your pants, or the slash pocket on a duty vest. It needs to be small enough that you’ll carry it everywhere.  Don’t keep it in a jacket pocket, you probably leave your jacket in your car some days.

Or you can build your own.  Must haves? Think of it like your ten essentials for a backcountry trip.  What must I be able to do? What would I like to be able to do? How much can I carry? How much can I spend?

About 60% of combat fatalities come from extremity bleeding.  Some come from tension pneumothorax.  Few come from airway obstruction.

What do you need to do with your IFAK? You need to stop bleeding.  Tourniquets. Pressure dressings. Wound packing. Hemostatic agents. You need to open an airway. A size 28 NPA is a good device for that. Needling a chest would be great.  14g x 3.5″ needle.

There are lots of kits on the market.  North American Rescue makes their Individual Patrol Officer Kit available with chitosan, combat gauze, or celox hemostatics to customize your kit for your needs based on your best assessment. It only comes with one tourniquet, but hang a second on your belt if you’ve got space and you’re good to go in that department.

As importantly or more, you and your peers, the guy on your left and the woman on your right flank need to know what to do with it.

 

 

Tac Tool Tuesday! Junctional Compression!

The AAT is now the AAJT! This device has been shown to reduce hemorrhage in junctional trauma with lower tissue pressures than other devices.

AAJT

Exciting emerging applications for this device include it’s prospective use in pelvic fractures! Rather than worry about stopping multiple fracture sources of blood loss, just stop blood flow to the affected area altogether until timely surgical repair or embolization.

Here’s a link to the abstract from the research at Madigan Army Medical Centre

Tac TechniqueTuesday! Casualty Movement

We’ve looked at airways, we’ve looked at hemcon.  Let’s take a look at casualty movement skills & decision making for this week Tac Technique Tuesday.

There are a number of ways to drag and or carry a casualty and to determine which one is the most effective for any given situation you need to start with a task assessment.

A two person drag can be sustained for distance and can cover even clear ground quickly.

A two person drag can be sustained for distance and can cover even clear ground quickly.

Answer the following questions about the situation:

How far am I moving him?
How quickly do I need to move him?
Have we won the firefight or mitigated the threat?
Is there cover and/or concealment where I can stage on route?
From where can I be observed? Are those spots covered by friendlies?
From where can I be engaged? Are those spots covered by friendlies?
Do I have a device to assist with this task?

Now that you appreciate the task at hand, think about the options open to you.  Are you on your own with your partner down in the open?  Do you have an ERT poised to take the target building? Can you quickly get a set of eyes on that vital ground? Do you have air assets, drones, or other means in play?

4 moves you need to know!Cradle Drop Drag

Self evacuation via the leopard crawl
2 Person Drag
1 Person Drag
Hawes Carry

Tac Technique Tuesday!

We’ve recently looked at wound packing as one of the more effective methods to control hemorrhage.  This week let’s look at surgical crichoidthyrotomy as an airway option in tactical environments.

Surgical airways are recommended by both C-TECC and CoTCCC relatively early in the airway management flowchart, below NPA and positioning and above placement of an ET tube.  Unlike the civilian setting where equipment is readily available and one monitor/patient is the norm, the Tactical Field Care (TCCC) and Indirect Threat Care (TECC) phase recommendations recognize that time and equipment constraints may not allow us to use tools like ETCO2 waveform capnography to confirm tube placement, or even Direct Laryngoscopy or Video Laryngoscopy to place a tube.  In those settings, a scalpel-bougie crich may be your best bet for definitive tactical airway management.Crich

Watch this video of Dr Dennis Kim demonstrating a very deliberate surgical method on a cadaver, and think about doing this in a dust-storm in Iraq (or a blizzard in the BC Alpine), or in the pitch black with IR illumination and NVG’s while balancing the equipment on the cleanest surface you can find, your jumpkit or your lap.

https://www.youtube.com/watch?v=Kg14kdIycDE

If they are done quickly and smoothly out of prepared stripped-down kits they are significantly easier and safer than ETT placement.  There is no technology to depend upon.  No Laryngoscope, no waveform capnography to confirm placement.

Equipment is simple: A scalpel, a bougie, and a cut down #6 ETT with 10 ml syringe attached.

If necessary, make a vertical incision to mark your midline.  Cut the skin laterally across the neck to expose the crichoid membrane.  Pierce the membrane, extend the incision and do not remove the scalpel.  Insert the bougie over top of the scalpel blade into the tracheal lumen. Remove the scalpel and pass the tube over the bougie.

The technique starts at 2:30 in this video!

https://www.youtube.com/watch?v=BT7KsQN6ANc

If you compare the two techniques, you’ll see that the scalpel-bougie Crich is the easier, safer method.  By keeping the surgical tract open continuously, via scalpel, then bougie, then tube, there is a major reduction in the chance of losing the tract.  Losing the tract in the dark, in the dust, in the snow, isn’t an option. This is your last ditch airway procedure.  It must work!