Tag Archives: Vancouver EMS Training

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.

 

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.

“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 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.

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

Always with the paperwork, or get a textbook early if you’re taking ITLS!

We’ve wrapped our NSR ITLS Provider Course, and it’s all over even the paperwork.  ITLS is a great organization to work with, and they try hard to make the administration pretty seamless.

I sent it off yesterday morning, got a reply yesterday afternoon, and someone at Int’l is hard at work in the CMS getting our cards ready for printing a distribution to our friends at North Shore Rescue.

There’s the course roster, which we try hard to get done before hand.  The practical evaluation results, the student info forms, and the written “celebration of learning” answer forms all get scanned, and all the data goes into ITLS Course Management System.  We also keep copies of every course feedback form in our database; it’s nice to make sure we’re not making the same mistake three or four times!

The number one comment that we get is some variation on “I wish I’d gotten the textbook sooner!” and this has been consistent throughout the 15 years I’ve been teaching ITLS.  There’s a huge amount of info crammed into a 2-day provider course, and the more thoroughly you do a pre-read, the better your experience in the course will be!

Yesterday was a good day

Devon, Ian and I spent the day with 10 NSR members working our way through day one of ITLS.  We covered the ITLS Primary Survey and Ongoing Exam. Airway management, hemorrhage control, chest and abdominal injuries.

One of the best things we do in ITLS is almost insidious.  We get people talking the same language.  We take students with qualifications ranging from Wilderness First Aid through to EMR (in this case) who have been trained by the Red Cross, St John’s, JIBC, AET and other training providers, and we get them all using the same terminology.  This means that when teams are communicating and collaborating on scene, the transfer of information is fast, efficient, and leads to shorter scene times and better care.

North Shore Rescue 2 TK

We also try to introduce new equipment, procedures, and techniques to our classes. Comfortable with a CAT? Let’s look at a SOFT too.  Use the SAM Pelvic Sling? Have you looked at the TPOD for your agency?  Asherman Seals work, but how about Hyfin?

We don’t expect our clientele to stay on top of the latest science behind EMS.  That’s what we do.

Our second NSR course!

Tomorrow we start our second contract course, another ITLS for North Shore Rescue.  We’d originally planned this to be our ITLS Site Visit for sign-off as a ITLS Training Centre, but due to scheduling conflicts we won’t be getting our visit done this time around.

Ian’s packing up a his jumpbags, AV kit, and airway mannequins. I’ve got a briefcase full of admin and paperwork, and I’m answering questions from students already. Devon’s looking over his material.

Faculty at the CF SAR School in Comox, BC practice ITLS Rapid Trauma Surveys.

Faculty at the CF SAR School in Comox, BC practice ITLS Rapid Trauma Surveys.

Working with SAR groups is always a bit different than working with EMS or other health care providers.  Medicine is only a small part of the mission, whether you’re a CF SARTECH or a community volunteer, and amidst all of the other critical skills that they work hard to keep sharp, the more difficult it can be to keep the finer nuances of patient care.

Regular review of the material is great, but team based training helps to ensure that the collective knowledge of the team is maintained.  Not every team member needs to be an expert prehospital care provider; every team member does need to know what the goals and fundamentals of care are. That’s what makes a team efficient and effective, that they’re all working towards the same greater goal.

One of the great things about ITLS is it’s focus on a team based approach to caring for the HMMVW Amb on the flight line, KAFinjured.  Concurrent activity and clearly defined and communicated goals keeps scene times to a minimum and allows for superb care even under very austere conditions.