Tag Archives: Emergency Operations Planning

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

“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