Tag Archives: TECC

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.


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!


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!


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

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.

A terrifying trend in law enforcement

Yesterday, two NYPD officers were shot while sitting in their patrol cars, the suspect fled before shooting himself.  In France a man walked into a police station , drew a knife and attacked several officers before he was shot and killed. In Florida an officer was killed in Tarpon Springs, details are still pending as I type this, one male in custody. Mayerthorpe. Moncton.

People have asked me why I didn’t teach tactical medicine.  I spend a lot of my time teaching neophytes how to practice and teaching good paramedics how to be better paramedics, why don’t I teach this?  At the time I answered “when people start blowing shit up on Canadian streets, I’ll start teaching it.”

Then Boston happened. And then firefighters and paramedics were ambushed in Texas. And then it happened again in the North East.  And then Ottawa.  And now.  Again and again and again our emergency responders are being targeted by the deranged, by the mentally ill, and by the radicalized. And it’s time we recognize that this isn’t some flash in the pan activity.  This isn’t fueled by media coverage and a few copycats.  This is a real course of action by a small but significant portion of the population. And that’s a terrifying trend.  Be safe.  Be diligent. Watch your arcs.


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.



We’ve just received a reply from the EMA Licensing Board for our Tactical Emergency Casualty Care for EMS course!  We couldn’t have asked for better news; 16 credits for our two day course that covers situational awareness, hemcon, fracture immobilization, tactical airway management, triage, casevac, and many more subjects in both lecture and simulation formats.

We’ve put a lot of thought into how to bridge TCCC into the civilian environment, and TECC certainly covers that gap nicely, which is why we’ve adopted their guideline for our training.