Tag Archives: Tactical Field Care

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

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!

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.

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

Wound packing & Hemcon

Direct pressure is the mainstay of hemcon, but it’s one that isn’t necessarily well applied.

One of our local ERP used to accuse paramedics of using “pillow pressure” versus “pinpoint pressure.”

The difference, as the names imply, is one of location.  Pillow pressure is the tendency of responders to take a large dressing, abd pad, etc. and apply it over top of the wound, using something to hold it in place against the skin.  Pinpoint pressure, on the other hand, is to directly visualize the site of the bleeding and put pressure directly on the bleeding vessel.

Bodies don’t just spontaneously bleed.  Blood vessels are damaged or severed due to a mechanism, and bleed from the site of that damage. Putting pressure on the site of the bleeding is the way to stop it.  Putting pressure in the general vicinity of the bleed doesn’t really do much to stop the hemorrhage.

TCCC and TECC advocate the use of hemostatic dressings, but we need an understanding that the dressings (and the hemostatic agent) need to get down to the actual site of the bleeding in order for them to be effective.  Simply filling a hole with gauze isn’t going to do much.  Filling a hole with gauze that applies pressure to the vessel is going to be far more effective than a poorly placed hemostatic agent.

There is a huge amount of information on the internet about TCCC/TECC, some accurate, some not.  There are a million companies lining up to sell you a blowout kit.  There is no point in carrying a pouch stuffed full of things you don’t know how to use, especially if misuse can worsen your patients condition.

Wound packing is a simple skill, easily learned, quickly applied, and incredibly effective.  A skill everyone who may have to control hemorrhage should have.

www.PacificEmergencyMedicalTraining.com