Tag Archives: Care Under Fire

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.

 

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!

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.

“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

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

Our TECC Venue

We’ve got it.  We’ve booked one of British Columbia’s premier tactical training facilities for our March TECC Course!  The Vancouver Police Department Tactical Training Center will be hosting us on the 14th and 15th of March for our inaugural Tactical Emergency Casualty Care for Law Enforcement & EMS course.  What this means is access to simulation rooms and equipment through the full use of force spectrum.

We’re firm believers in the principle of “train as you fight”.

The facility motto is “train as you work”, clearly someone in City Hall didn’t like the violent overtones of the original statement, but considering the facility includes multiple firearms ranges, redman suits and training batons, firearms and OC Spray, we’ll stick with original intention of the statement.

Train as you fight.  We’re good with that.