Tag Archives: Hemcon

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

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!

More (well, some!) evidence to back up hemostatic dressings.

Unlike tourniquets and TXA, both of which have  a robust and growing body of literature to support their use, hemostatic dressings such as Quickclot, Combat Gauze, WoundStat etc have had limited published field experience to support their use.
EMS1 on Hemostatics

Blowout Kit

Blowout Kit

 

In US DoD studies, Combat Gauze was chosen as the agent of choice, but that decision was largely based on animal models, which are great, but provide limited value and don’t always translate well to clinical practice. Some suggest they are about 30% more effective than good wound packing with regular materials.

But here’s a study from Israel that supports their effectiveness in the field about 90% of the time!  Keep in mind that this is a small study, but it’s pretty reflective of this authors experience with hemostatics in the military setting, includes extremity and junctional injuries, and acknowledges where there are gaps in the data.

Hemostatic agents in their current form seem to be a potent addition to the hemorrhage control arsenal, and have lots of cheerleaders in the military health care community, but are not a silver bullet that will stop every source of bleeding.  Here’s hoping one of the many gels, foams, CO2 delivered TXA interventions is THE answer to the bleeding patient!

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.

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

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.

 

 

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!