Tag Archives: British Columbia

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!

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!

 

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 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

One Step Closer to our Tactical Emergency Casualty Care Course

For the past several days I’ve been working the phone lines and email tree trying to nail down a venue for our next course offering, and I think we’ve found it.  I’ll be stopping by tomorrow to ensure that it meets our needs and is cost effective for our clientele.

Our Tactical Emergency Casualty Care Course is open to paramedics, law enforcement, and Canadian Armed Forces members.  TCCC and TECC teach the same material, but to different target audiences, in a slightly different format.  While sending the 9-Liner CasEvacReq is an essential skill for a deployed soldier, there isn’t much need to teach it to a street level paramedic or police member.

What each of them does have to know is how to handle themselves if they’re injured; how to apply a tourniquet to themselves, their patient, or their partner quickly and efficiently and get back to the job at hand.  How to control hemorrhage with wound packing, direct pressure, and with a variety of bandages.  How to place an airway, on the floor, in the dark, by touch. How to move someone by themselves over smooth terrain, over rough terrain.

Tomorrow, at 1300, I find out if we’ve got our venue!

Tactical & Medical Decision Making

Not all tactical tools are tangible, some are cognitive.

This runs to 20 pages including bibliography, but it describes several essential skills that any emergency medical provider needs to have.

The OODA loop is something that we use in the classroom in order to give students a model of constant reevaluation of the patient condition, the conditions they’re operating under, the courses of action open to them, and the most efficient treatment, movement, or evac options.

To truly master Emergency Medicine, much less the tactical environment, you need to understand the OODA Loop. Yours should be tight and fast. But sometimes you need a far quicker response, and only training and simulation can build instant RPD through what this author calls tactical decision games (TDG) or decision making exercises (DME).

This is the core of current EMS education.

Simulation creates an experiential learning environment where the students can develop that mental database of Action : Response for everything from snoring respiration : jaw thrust or massive extremity bleed : tourniquet intuitively, not just academically. Where they can find themselves suddenly on the ground applying a tourniquet to their own leg intuitively knowing that placing the tourniquet chasis This way instead of that way will give them a better initial pull on the strap.  The same repetition that has someone doing a tap, rack, and engage on one stoppage but a reload just from the feel of the recoil.  That’s recognition primed decision making.

Klein says “…Their experience let them identify a reasonable reaction as the first one they
considered, so they did not bother thinking of others. They were not being perverse. They
were being skillful. We now call this strategy recognition-primed decision making.”2

Sometimes the best care isn’t enough

Tonight, the RCMP announced that Cst David Wynn is unlikely to survive the GSW head injury he suffered yesterday morning in a Edmonton area casino. He’s in an Edmonton hospital receiving the best possible care, but sometimes, far too often, that isn’t enough.

The results of a gun shot wound to the brain are devastating.  Tonight we’re thinking of the families of Cst Wynn, both natural and regimental. We’re praying for the speedy and complete recovery of Aux Cst Bond (unarmed at the time of the shooting, being an Auxiliary), who suffered a grievous limb injury and faces a long difficult recovery ahead of himself.

We have seen one bloody police shooting after another in this country.  We have buried far too many Canadians in red serge and navy blue.

It is time Canada’s police services have access, across the board, top to bottom and coast to coast, to hard armour and suitable patrol carbines.  It will cost more, both in terms of training time, training ammunition, capital expenses to buy the things, but it is worth it.  Time and money spent on training is almost always money well spent.

Always with the paperwork, or get a textbook early if you’re taking ITLS!

We’ve wrapped our NSR ITLS Provider Course, and it’s all over even the paperwork.  ITLS is a great organization to work with, and they try hard to make the administration pretty seamless.

I sent it off yesterday morning, got a reply yesterday afternoon, and someone at Int’l is hard at work in the CMS getting our cards ready for printing a distribution to our friends at North Shore Rescue.

There’s the course roster, which we try hard to get done before hand.  The practical evaluation results, the student info forms, and the written “celebration of learning” answer forms all get scanned, and all the data goes into ITLS Course Management System.  We also keep copies of every course feedback form in our database; it’s nice to make sure we’re not making the same mistake three or four times!

The number one comment that we get is some variation on “I wish I’d gotten the textbook sooner!” and this has been consistent throughout the 15 years I’ve been teaching ITLS.  There’s a huge amount of info crammed into a 2-day provider course, and the more thoroughly you do a pre-read, the better your experience in the course will be!

Yesterday was a good day

Devon, Ian and I spent the day with 10 NSR members working our way through day one of ITLS.  We covered the ITLS Primary Survey and Ongoing Exam. Airway management, hemorrhage control, chest and abdominal injuries.

One of the best things we do in ITLS is almost insidious.  We get people talking the same language.  We take students with qualifications ranging from Wilderness First Aid through to EMR (in this case) who have been trained by the Red Cross, St John’s, JIBC, AET and other training providers, and we get them all using the same terminology.  This means that when teams are communicating and collaborating on scene, the transfer of information is fast, efficient, and leads to shorter scene times and better care.

North Shore Rescue 2 TK

We also try to introduce new equipment, procedures, and techniques to our classes. Comfortable with a CAT? Let’s look at a SOFT too.  Use the SAM Pelvic Sling? Have you looked at the TPOD for your agency?  Asherman Seals work, but how about Hyfin?

We don’t expect our clientele to stay on top of the latest science behind EMS.  That’s what we do.

Our second NSR course!

Tomorrow we start our second contract course, another ITLS for North Shore Rescue.  We’d originally planned this to be our ITLS Site Visit for sign-off as a ITLS Training Centre, but due to scheduling conflicts we won’t be getting our visit done this time around.

Ian’s packing up a his jumpbags, AV kit, and airway mannequins. I’ve got a briefcase full of admin and paperwork, and I’m answering questions from students already. Devon’s looking over his material.

Faculty at the CF SAR School in Comox, BC practice ITLS Rapid Trauma Surveys.

Faculty at the CF SAR School in Comox, BC practice ITLS Rapid Trauma Surveys.

Working with SAR groups is always a bit different than working with EMS or other health care providers.  Medicine is only a small part of the mission, whether you’re a CF SARTECH or a community volunteer, and amidst all of the other critical skills that they work hard to keep sharp, the more difficult it can be to keep the finer nuances of patient care.

Regular review of the material is great, but team based training helps to ensure that the collective knowledge of the team is maintained.  Not every team member needs to be an expert prehospital care provider; every team member does need to know what the goals and fundamentals of care are. That’s what makes a team efficient and effective, that they’re all working towards the same greater goal.

One of the great things about ITLS is it’s focus on a team based approach to caring for the HMMVW Amb on the flight line, KAFinjured.  Concurrent activity and clearly defined and communicated goals keeps scene times to a minimum and allows for superb care even under very austere conditions.