Tag Archives: EMS

“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

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!

 

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.

ITLS site visit

We’re at T-7 days until our second ITLS course for North Shore Rescue.  This course will also mark our site visit for our sign-off as an ITLS Training Centre.  Ian, Devon, and I are all divying up tasks and figuring out a teaching schedules.

We’ve done this before, there have been years where I’ve taught more than one course per week, but the added pressure of our certification as an ITLS Training Centre is putting a certain stress on us.  North Shore Rescue is always a great group to work with!