Tactical Combat Casualty Care (TCCC) has become the standard for medical care within DOD. It is slowly being adopted by law enforcement throughout the USA as more departments are embracing the fact that the first line of medical care after a felonious assault rests with the officer. The transition in the mindset over the last 10 years is remarkable. Initially, most LEOs thought of medicine as the domain of EMS, whereas departments are currently attempting to integrate military TCCC into their protocols. For instance, use of tourniquets as a first option for extremity wounds has been accepted as a priority in civilian medicine. However, all of the lessons learned during GWOT regarding TCCC do not neatly transition to the the civilian sector. Although extremity bleeding is the most common cause of preventable death on the battlefield, chest injuries are the leading cause of preventable death for LEOs. So why do so many officers only focus on hemorrhage control when deciding what to carry in Individual First-Aid Kits (IFAKS)? It is due to the dearth of research in the field of LEO medicine and a full adoption of the research from the battlefield.

One of the first studies to address this issue was published in Prehospital and Disaster Medicine in 2009 titled “Tactical Medical Skills Requirements for Law Enforcement Officers: A 10-Year Analysis of Line-of-Duty Deaths” by Matthew D. Sztajnkrycer, MD. He concluded that “…current emphasis of TCCC on control of exsanguinating extremity hemorrhage may not meet the needs of law enforcement personnel in an environment with expedited access to -well developed trauma systems. Further study is needed to better examine the causes of preventable deaths in law enforcement officers, as well as the most appropriate tactical medical set and treatment priorities.”

It is clear that more work needs to be done, but we will explore the issue more in the following posts.

TCCC_Sztajnkrycer

Multiple casualties in the tactical environment or a disaster area that exceed both human and materiel resources require rescuers to triage rapidly, so the limited resources may be used for the most critical casualties. In the tactical environment, one may have to do so under fire, thereby increasing the chance of sustaining injury. In disaster zone, precious time may be wasted by attempting to access and treat vocal casualties, while delaying treatment for higher priority patients. Nonetheless, current methods for triage require rescuers to assess casualties one-on-one, delaying further the time to locate, triage and treat the most critical. A recent article in The Army Department Medical Journal succinctly captured the crux of problem noting:

Physiologic status assessment in casualties can be problematic in the military setting, where physical access to the injured individual may be complicated by terrain, weather and hostile action. Likewise, some civil sector settings may challenge first responders, particularly when victims are located remotely. The lack of a remote triage capability may therefore result in the medic attending to either a) a Soldier who is uninjured but caught in the vicinity of combat; or b) a Soldier under severe fire who has an injury that is deemed unsalvageable. Indeed, a combat medic may place himself in harm’s way to assist a Soldier who may not even be injured or may be unsalvageable. Data collected during the Vietnam War indicate that the fatality rate of US Army medics was double that seen in infantrymen.1

There is an initiative to remedy this situation within the Departments of Defense and Homeland Security. DHS, in cooperation with Boeing and Washington’s School of Medicine in St. Louise, developed a “Standoff Patient Triage Tool” in 2009 that allows a rescuer to assess pulse, body temperature and respiration. As the article from Science Daily notes, “The magic behind SPTT is a technology known as Laser Doppler Vibrometry, which has been used in aircraft and automotive components, acoustic speakers, radar technology, and landmine detection. When connected to a camera, the vibrometer can measure the velocity and displacement of vibrating objects. An algorithm then converts those data points into measurements emergency medical responders can use in their rapid assessment of a patient’s critical medical conditions.”2 Although the technology is not yet available, it is an interesting approach.

In addition to the above-mentioned, the US Army is currently seeking technologies that will allow them to have stand-off monitoring capabilities. Researchers seek to assemble a system that is functional from a human factors perspective (i.e., Soldiers will wear it and it will not hindered the mission) and useful with regard to discerning physiological signs of hemorrhage from normal combat stress. For instance, mental status and blood pressure, while useful, are unreliable indicators of hemo-dynamic stability.1 Moreover, they take time to gather. Researchers have therefor sought other “markers” that one can use to discern hemorrhage from stress. To this end, they investigated ECG readings, which can be attained remotely. Unfortunately, the readings are not sensitive enough. Another alternative is using “energy monitors” and algorithms that can detect physiological changes. The challenges are many, however. Location of monitors, for example, require Soldiers to have an uninjured limb. In the age of IEDs, this may be difficult, though researches found that in all but 6% of reported casualties an arm was viable for monitoring.

While technological challenges remain, the ability to quickly triage casualties in a tactical or civil disaster scenario is becoming more likely. Although these futuristic Star Trek device or Soldier-worn monitors lack feasibility currently, researchers are getting closer.

Article:Triage Tech
References:

1. Ryan K, Rickards C, et al. Advanced Technology Development for Remote Triage Applications in Bleeding Combat Casualties. The Army Medical Department Journal. 2011;4/5/6:61-71.

2. Department of Homeland Security. “Triage Technology With A Star Trek Twist: Tricorder-like Device.” ScienceDaily, 1 Jun. 2009. Web. 8 Nov. 2012.

The SOF Tactical Tourniquet has always been TCCC approved, but until recently, it has been overlooked when it comes to official TCCC instructions and guides. Here is the link to the most recent Care Under Fire PowerPoint produced by the TCCC board that outline the instructions. Furthermore, the second link below has many other training aides for all phases of tactical medicine.

CUF Link

General TCCC Links

A principal learning objective taught in many tactical medical training programs is self-application of tourniquets. Although reports from current battlefields estimate the frequency of one-handed application at less 1/10 of 1% (o.oo1), it is still a valuable drill for those working alone (i.e., law enforcement officers). Unfortunately, the technique taught is often incorrect, as most disregard the fact that if one is applying a tourniquet to one’s limb, the limb is probably injured. Therefore, as the video demonstrates, one ought to train for real-world application.

In a recent article published in the Journal of Trauma Injury, Infection, and Critical Care, the authors analyzed the effect of life-saving interventions (LSI) performed by combat medics and other forward providers. The medical practitioners in the study were arranged in an EMS style hierarchy under a medical director, with the majority of medics trained to the EMT-B level, in addition to supplemental training in TCCC-approved LSI procedures. Additionally, they analyzed outcomes with an eye toward the applicability of more advanced care in the form of Remote Damage Resuscitation protocols. As summarized below, they found that forward deployment of blood products would be beneficial if the logistical and scope-of-practice concerns could be addressed. In the limitations section of the study, they concede that certain biases might have affected the outcome. They note, for instance, “[t]he differential impact of transport time from point-of-injury to surgical facility arrival is worth considering.” Time from injury to point-of-injury treatment, time between request for evacuation to arrival of transportation, and time from extraction to the study facility all affected the outcomes, some of which were unknown in retrospect.

Although the authors did acknowledge in the conclusion that LSI need to be performed sooner, they unfortunately continued to argue that their notional blood protocol would have been beneficial. This is despite the fact that the majority of LSI were preformed by PA-level practitioners or higher, which is the major concern, because that indicates that urgent and priority patients were evacuated without LSI. It is difficult to surmise why LSI were not performed sooner, due to the nature of record keeping and retrospective studies. Perhaps tactical considerations dictated transport before treatment, or casualties deteriorated during evacuation. Nonetheless, early treatment is paramount, so training might possibly the more important to allocate resources to than blood protocols. Technology is an exceptional adjunct to the basics, but medics must have a foundation upon which to build.

Background: To analyze casualties from the Camp Eagle Study, focusing on
life-saving interventions (LSI) and potentially survivable deaths.

Methods: Retrospective cohort of battle casualties from a forward base engaged in urban combat in Central Iraq. Medical support included emergency medicine practitioners and combat medics with advanced training and protocols. LSI were defined as advanced airway, needle or tube thoracostomy, tourniquet, and hypotensive resuscitation with Hetastarch. Cases were assessed retrospectively for notional application of a Remote Damage Control Resuscitation protocol using blood products.

Results: Three hundred eighteen subjects were included. The case fatality rate was 7%. “Urgent” (55) or “priority” (88) medical evacuation was required for 45% of casualties. Sixty-one LSI were performed, in most cases by the physician or PA, with 80% on “urgent” and 9% on “priority” casualties, respectively. Among survivors requiring LSI, the percentage actually performed were airway 100%; thoracostomy 100%; tourniquet 100%; hetastarch 100%. Among nonsurvivors, these percentages were 78%, 50%, 100%, and 56%, respectively. Proximate causes of potentially survivable death were delays in airway placement and ventilation (40%), no thoracostomy (20%), and delayed evacuation
resulting in hemorrhagic shock (60%). The notional Remote Damage Control Resuscitation protocol would have been appropriate in 15% of “urgent” survivors
and in 26% of nonsurvivors.

Conclusion: LSI were required by most urgent casualties, and a lack or delay in their performance was associated with increased mortality. Forward deployment of blood components may represent the next addition to LSI if logistical and scope-of-practice issues can be overcome.

(J Trauma. 2011;71: S109–S113)

Rethinking Tension Pneumothorax

An interesting article in the Emergency Medicine Journal, “Tension Pneumothorax–Time for a Re-think?,” questions the traditional signs and symptoms of tension pneumothorax (TPT). The authors independently compiled and analyzed previous research dating from 1966 to 2003 determine if “classic” signs of TPT exist, and, if so, the rate of diagnosis. Essentially, the survey found that the majority of TPT cases do not present with classical signs, which necessitates a rethinking of how TPT recognition is taught (see Box 1). The authors also address the poor outcomes associated with needle decompression.

The article established that one must divide patients into two groups: 1) spontaneous breathing; 2) ventilated. This is important due to the ability of spontaneously breathing patients to compensate, thereby presenting differently. Group one displayed the ability to compensate during respiration with tension building (for a more detailed list of compensatory mechanisms, see Box 2). Up until time of death, cardiac output was reserved due to progressive tachycardia, incomplete transmission of positive IPP to the mediastinum (see Box 3 for group 1 signs and symptoms). Group two, however, presented differently due to not being able to compensate (see Box 4 and Table 1). Familiarity with the unique presentation of group 2 is obviously important because your patient may need to be ventilated en-route to a higher echelon of care.

The most intriguing findings were the poor correlation of TPT to mediastinal shift and tracheal deviation, two classic signs. The former is an inconsistent finding, except in children, due to mobility of their mediastinum. Moreover, tracheal displacement is also a poor indicator of mediastinal shift. In fact, in the this study, “it was absent in all 108 cases of suspected TPTs treated by paramedics with needle decompression and present in only 1 percent of those receiving needle decompression by flight nurses…. Even when present, the odds of experienced physicians diagnosing it are 50:50—that is, the same as tossing a coin.” Essentially, tracheal deviation is not diagnostic of TPT.

The authors also question the use of needle decompression as a diagnostic tool, due to associated morbidity (Box 8). For instance, “of 106 patients treated with tube thoracostomy by pre-hospital flight nurses, 38% had been attributable to failure of clinical improvement with needle decompression.” Furthermore, the authors are concerned with the use of needle decompression as a “rule-out” procedure, for no studies exist showing it as a sensitive test. Despite this, it is a therapeutic treatment and reduces time on scene when compared to chest tubes, which is important in the tactical environment. However, their research shows it is often used when no TPT is present, but that is an easier assessment after the fact. It should be highlighted that flutter valves, which are popular in the pre-hospital environment may cause re-tension according to their findings, so be vigilant in construction and re-assessment.

Overall, this is a detailed article that deserves consideration. It is worth your time to download the full version and prudently reassess your training and adjust accordingly.

References and tables from:
S Leigh-Smith and T Harris, “Tension Pneumothorax–Time for a Re-think?.” Emerg Med J 2005 22: 8-16.

Rubber band tourniquets (RBT) have gained popularity in the law enforcement community over the past 24 months. The compact size and nominal cost make them attractive to cash-strapped, and over loaded with respect to equipment, LEOs. Furthermore, as LEO commanders seek to outfit their personnel with live saving equipment while grappling with budget constraints, RBTs seem like a viable option. However, upon further consideration, they may not be the BEST choice due to inherit dangers of RBTs with regard to function and application.

The function of RBTs is simple: one applies it proximal to the injury, wrapping it around the limb until hemorrhage control is achieved, using the elasticity of the rubber to create greater circumferential pressure with each wrap. Initially, this seems easy and straight forward. However, due to the nature of elastic wraps one must be cautious when using one as a tourniquet, due to the difficulty in controlling the applied pressure. As noted in the Journal of Medicine and Biomedical Research, “[t]he pressure induced by the rubber bandage increases at a rate of 3 to 4 times the initial pressure when the bandage is stretched after each wrap.”(1)(3) This is dangerous due to the shearing effect generated on the underling tissues, specifically the nerves. In fact, Graham et al found that at above 300mm Hg shearing forces increased exponentially.(2)(3) With RBTs this is concerning as “[t]he pressure applied to the limb could easily exceed the safe limits and put the limb at risk of complications because the rubber bandage is capable of generating pressures in excess of 1000mmHg beneath it.” “At such extremely high pressure,” Ogbemudia continues, “neurovascular damage becomes likely and makes the use of the RBT relatively unsafe.”(1)(3) He does explain how, in a controlled environment such as a surgical suite, a RBT can be made safe by placing a BP cuff under to monitor pressure. Obviously, this is not optimal in the tactical environment.

There are also difficulties faced when applying a RBT with respect to generating adequate circumferential pressure to stop arterial hemorrhage. Applying a RBT to an extremity, especially an upper limb, mobility is required in order to wrap it around the limb a sufficient number of times. If there has been any bone involvement, this may be an excruciating affair. Furthermore, if, due to pain associated with application, the casualty does not achieve hemorrhage control, he must then un-wrap the RBT multiple times, then re-wrap it in the hopes of achieving enough pressure. Unfortunately, the reverse is true. In an attempt to generate enough pressure, one may generate too much unknowingly. Compared to a windlass-style tourniquet, for instance, one must only turn the windlass an additional 180 degrees, thereby tightening it to achieve more tension. Tourniquets issued within DOD, unlike RBTs, are difficult to over tighten when used one-handed and according to the manufacturers’ directions due to the nature of the webbing and knot interface.

Finally, when compared to standard tourniquets used by the majority of DOD and many state and local LEOs, a RBT has multiple variables that must be considered that relate to the pressure generated. In this case, variables are defined as inconsistencies between casualties and application each time a tourniquets is used. They are compared as follows:

Windlass style tourniquets have 2 variables:
1) limb circumference;
2) degrees rotated.

RBT tourniquets have 4 variables:
1) the percentage of stretch applied with each turn (composition and elasticity of the material, which affect the restoring force of the polymers);
2) the number of layers of the RBT;
3) the degree of overlap;
4) the circumference of the limb.

In the end, a RBT can be used as a field tourniquet. However, it is not the best option for LEOs. The benefits of cost savings do not outweigh the potential problems and risks associated with rubber band tourniquets.

References
[1] Ogbemudia A et al. Adaptation of the rubber bandage for the safe use as tourniquet. Journal of Medicine and biomedical Research 2006; Vol. 5 No. 2 pp-69-74.
[2] Graham B et al. Perinerual pressures under the pneumatic tourniquet in the upper and lower extremity. Journal of Hand Surgery 1992: 17B: 262-6.
[3] McEwen J. A. and Casey V. Measurement of hazardous pressure levels and gradients produced on human limbs by non-pneumatic tourniquets. Accessd at
http://www.tourniquets.org/pdf/CMBEC%2032%20McEwen%20and%20Casey%20Tourniquet%20Paper.pdf

Here is a link to reviews of tactical medical literature. None are current, but if one is interested in peer-reviewed articles, these are a good start.

Review of the Tactical Medical Literature

By: Tripp Winslow, MD MPH

In the medical literature, there is a paucity of peer-reviewed articles regarding Tactical Emergency Medical Services (TEMS). The majority of TEMS based articles are reviews of extrapolated EMS, Trauma, or Emergency Medicine literature. While these review articles are informative and promote awareness of TEMS as a specialty, it is evident that a greater effort must be made to advance the science and evidence based literature available for use in the field. In this journal scan identifying existing TEMS literature, I have summarized a few review articles and presented several original research papers as well. This review was carried out on PubMed. The bibliographies of all articles were reviewed for additional relevant articles.

LINK

A large discrepancy between civilian and military medicine exists with respect to the importance placed upon spinal injury management. In the past, most combat injuries have been secondary to penetrating trauma. Therefore, during the initial phases of treatment, moving the casualty to cover would be the only concern, without taking the time to immobilize c-spine as a civilian medic would. However, new injury patterns are emerging. As Dr. Keith Gates noted in the Spring 2010 issue of The Journal of Special Operations Medicine (JSOM), blunt trauma is emerging more often as an mechanism of injury secondary to the increase in number of IED attacks. According unpublished data, 39% of casualties had mechanism of injuries secondary to blunt trauma. Additionally, according to JSOM, between June and December 2009, of the 119 casualties with blunt force trauma spinal fractures, 14 had spinal cord injuries. Thus, an increasing number of casualties are presenting with thoracic and cervical injuries on the modern battlefield.

This trend has not gone unnoticed. A working group was commissioned to address this issue, out of which a new technique for spinal protection emerged, called Spinal Motion Restriction (SMR). Essentially, the rescuer would use the casualty’s IBA to protect the thoracic spine, while taking care to not unnecessarily manipulating the c-spine during movement. The suggested changes to the TCCC protocol are as follows:

Care Under Fire:
3. Direct casualty to move to cover and apply self-aid if able. If casualty requires assistance, move him to cover. If mechanism of injury included blunt trauma (such as riding in a vehicle which was struck by and Improvised Explosive Device), minimize spinal movement while extracting him from the vehicle and moving him to cover. The casualty should be moved along his long spinal axis if at all possible while attempting to stabilize the head and neck.

Tactical Field Care and TACEVAC Care Insert new #2:
Use Spinal Motion Restriction techniques as defined below for casualties whose mechanism of injury included blunt trauma IF: a) they are unconscious; b) they are conscious and have mid-line cervical spine tenderness or mid-line back pain; or c) they are conscious but demonstrate neurological injury such as inability to move their arms and/or legs, sensory deficits, or parenthesis. For these casualties, leave the IBA in place and secure to protect the thoracic spine. The cervical spine may be protected by using a cervical stabilization device in conjunction with the casualty’s IBA or by an additional first responder holding the casualty’s head to maintain alignment with the back. Long or short spine boards should be used in addition to these measures when available (JSOM, Spring 10, pg. 60).

Unfortunately, initial findings from a pilot study conducted at USAISR found that if one keeps the IBA in place, in a supine position, without the helmet, the c-spine is put in extension. More problems surfaced during later discussions: 1) pouches commonly worn on the IBA could further injuries in the supine position; 2) IBAs obstruct evaluation and treatment, thus they are often removed; 3) SMR may not be protective.

In the end, more research needs to be done in light of the recent trends in wounds. As more soldiers and LEO officers are exposed to blunt trauma, medics need to be conscious of the potentiality injuries secondary to it. While Spinal Motion Restriction is unsatisfactory, it continues the conversation regarding treatment.

What are your thoughts and experiences?

Rhabdomyolysis (Rhabdo for short) secondary to a combination over exertion and dehydration is gaining attention in exercise circles due to documented cases recently with the increasingly popular high-intensity workout regimens. The threat of Rhabdo is not only confined to the the gym. It ought to be planned for and considered in the tactical environment as well. It is not a concern in the Care Under Fire stage of care, but, as Schwartz, et. al. note in Tactical Emergency Medicine, it ought to be addressed during tactical en route care. In addition to being caused by exertion and dehydration, Rhabdo and the subsequent renal failure my be secondary to a crush injury in the tactical environment. However, this brief essay assumes that crush injuries will tip-off care providers to included Rhabdo in their differential diagnosis. Rhabdo due to exertion may not, however, be as apparent.

Essentially, Rhabdomyolysis is the release of myoglobin into the blood stream, which damages the kidneys in two ways: 1) physically blocking the nerphrons with myoglobin; 2) chemotoxic toxification. While this can only be definitively determined by a lab test at a higher echelon of care, it is beneficial to keep this in mind. For instance, in a disaster situation or MCI, an operator may exert himself and present with acute muscle pain and local edema. It has been shown that the level or exertion required for the Rhabdo is dependent on individual fitness. In fact, as little as 50 sit-ups a day for 5 consecutive days led to a case. Studies of NYC Firemen have shown that there is an inverse relation between risk or Rhabado and fitness level. Therefore, risk is difficult to determine as a group and needs to be considered with patient history in mind.

In addition to exertion, non-exercise risk factors can combine to increase the chance of occurrence. For instance, metabolic myopathies and Malignant Hyperthermia, both of which can be inherited, may increase risk when combined with nominal exertion. Furthermore, viral illness such as Epstien-Barr, herpes simplex, and parainfluenze may increase risks. Finally, the US Army has shown a 200-fold increase in risk in those with sickle cell traits.

While medics in the tactical environment may not have the capabilities to diagnose Rhbado, they can manage it if the patient’s exam leads one to believe it is an issue. However, only 50% of patients present with the classic signs of myalgias, tenderness or swelling of muscles, dark urine. Therefore, if a medic suspects Rhabdo, s/he needs to treat the acute risk of damage to renal tubes. To do so, it is suggested that one needs to use a saline infusion producing an ideal urine output of 200 ml/h. Of course, drugs and buffering with alkalization is optimal, but that is beyond the scope of most medics, and it is probably not needed for support during transport to higher medical care.

The best treatment is, as always, prevention in the tactical environment where resources are precious and limited. Risk ought to be mitigated by ensuring members of your team are in good shape. If they posses any of the listed non-exertional risks, they need to be instructed to use caution when performing tasks and operations.

For more detailed information, see this paper: Rhabdo_Military_Pers.