Below is an excerpt from a lessons learned compilation titled “First to Cut: Trauma Lessons Learned in the Combat Zone.” Though it is geared toward FST surgeons and forward medical providers, some of the lessons are applicable to tactical medics and mountain rescue. The larger take-away point is that the physiology occurring distally to a tourniquet applied for a long duration needs to be considered when changing or loosening, especially in environments where medical care may be limited (e.g., Third World).

“Four Hours of Tourniquet Time”

“26 y.o. male with foot traumatic amputation and
multiple frag wounds to the right leg with a high thigh
field tourniquet in place. Arrived to the CSH with SBP of
100 HR of 120. we had no report on duration of the
tourniquet. We took down the tourniquet and he promptly
coded. We put the tourniquet back up, intubated him and
gave him fluid and bicarb and he came back. We found
out later that the tourniquet had been in place for over 4
hours….”

The use of tourniquets – while rare in civilian trauma is
very common in combat injuries. Tourniquets are the
number 1 instrument that a medic can employ to lower the
KIA numbers. The use of tourniquet with application until
the absence of a distal pulse by default causes distal
ischemia. Release of a functioning tourniquet after several
hours can result in the release of acidic fluid and potassium.
The patient intubated and without a head injury can be
briefly hyperventilated. Before taking down a long
duration tourniquet make sure the patient is well hydrated,
resuscitated, adding an ampule of sodium bicarbonate or
THAM can prophylax against the release of “bad humors”,
lactic acid, and potassium. Also release the tourniquet
slowly – if the rare arrhythmia arises re–employ the
tourniquet and retry after further bicarb and fluid. If the leg
is necrotic remember “life before limb” and perform an
amputation.

Lessons Learned:
–Prolonged tourniquet times can result in the release
of acidotic fluid and hyperkalemia
–Perform 4 compartment fasciotomy with all lower
extremities with significant tourniquet times

(more…)

As noted in the Tactical K-9 Care: Part 1, a tactical medic may be the only care provider able to assist a working dog that has been injured. The goal of the following article is introduce medics to common trauma associated with working dogs in a tactical environment. As previously suggested, medics ought to find a veterinarian that has experience with working dogs and work with them to become more familiar with anatomy and what is “normal” for canines, as well as become comfortable working with them.

The following article is from the Journal of Special Operations Medicine, vol. 9, edition 2, pg 14-21.

Care of the Military Working Dog Part 2

When planning for a mission, a medic must pack relevant equipment that reflects the highest percentages of injuries he could face (e.g, splinting material for air ops) . More important, medics must pack in accordance with the priority of treatment. That is to say, medics ought to pack their gear in three levels.

Level 1:
Level 1 equipment is needed for life threatening injuries. It ought to be carried on your person. For example, tourniquets, bandages, NPAs, etc, are needed to prevent death from the high-percentage killers. These items ought to be carried in IFAKs (your personal as well as your operators’), in leg-rigs, or on your vest. Accessibility is key, especially if you are going to use the equipment in the CUF phase. Also, medics must train to use the casualty’s equipment first, so he does not exhaust his equipment too rapidly. This requires operators to carry their own gear, not rely on the medic to carry it for them. Finally, do not use your personal first-aid kit unless absolutely necessary.

What do you carry in your Level 1 Gear?

Levels 2 and 3 will be covered in future posts.

This post is geared toward TEMS Medics. We will be posting a video in two weeks detailing medical equipment improvisation techniques for the field. Dr. Schwartz recently published a book that examines TEMS programs in greater detail. There is a link to it in the right margin of the page, under the heading Recommended Readings.

By Joshua S. Vayer, BA; Richard B. Schwartz, MD, FACEP

The development of a tactical emergency support (TEMS) program is an involved process. Multiple TEMS models effectively function and there is no “best model” for every agency. This article summarizes common components that must be considered in the development of a TEMS program. Components discussed include: goals of TEMS program, structure of the TEMS element, training for TEMS providers, law enforcement status, TEMS provider skill level, arming of TEMS providers, operating location, liability issues, insurance issues, and equipment for TEMS units. The proper development of a TEMS program will meet the primary goal of enhancing the tactical unit’s mission accomplishment. Key words: CASEVAC, explosive ordinance disposal, hostage rescue team, special weapons and tactics, special response team, tactical combat casualty care, tactical emergency medical support, tactical medicine.

TEMS ARTICLE

The important changes are highlighted.

2008 TCCC Guidelines

In the last few years the topic of tactical rescue/high threat extraction has become increasingly popular. New techniques and products enter the field almost weekly. While some of the techniques have merit, some do not. Some of these are presented as a panacea, but have extremely limited application in the tactical or combat arena.
When performing a tactical rescue the most important component is the employment of proper tactics. Failing to have a well rehearsed tactically sound plan for varying terrain, building structures and locations (e.g., hallways, stairwells, rooms etc. ) within that structure will seriously hamper your efforts. We will not cover how to conduct a rescue due to the open nature of this blog, but we will cover several things to consider when developing your plan and selecting techniques.

Fitness levels/size
Keep in mind you will be moving a significant amount of weight when using a drag-device. For example, have your smallest operator move your largest operator and see how effective they are.

Terrain/surface
A technique that works well on a buffed tile-floor may not work well on a concrete walkway leading to the front of a house, or in the middle of a road in Baghdad. Increased levels of friction will seriously hamper your movement out of the danger area. If the surface is slick enough to facilitate casualty movement it also increases the risk of a rescuer losing their footing due to pooling blood or other bodily fluids.

Size of the rescue team
Find the balance between efficiency and clutter. A larger team brings more guns, but it is also a big target. A four-man rescue team can rapidly turn into a four-man team in need of rescue. Minimize the amount of human assets you place in harm’s way whenever possible, especially if they can more effectively engage from another position.

Who will provide security?
Will the rescuer provide their own security? How effective are they with their weapon when pulling the heaviest member of your team? Generally, they are not effective at all. If the rescuer is the only person available to provide security, it may make more sense to delay the rescue. All other options should be considered before this is chosen. It makes more sense for a security element to establish an over-watch position from a position of cover to provide security than to expose itself to an adversary that has the advantage of cover and deciding whether to engage or not. In a military setting this is less of a concern if suppressive fire can be placed on the enemy position during the rescue attempt.
Do I have a ballistic shield? How can I employ it into my rescue plan?

Determined enemy vs. just a bad guy
All bad guys are not created equal. A truly determined enemy will take risks and make sacrifices far beyond what you would see in a “regular” bad guy. This also holds true for the mentally ill or chemically impaired. Suppressive fire from a crew-served weapon may not deter some enemy combatants; do you think a lone soldier or officer firing his M-4 one-handed from the hip will? Most likely not. If your enemy is determined to kill you he will not be scared of a few rounds. You need to be in a position to make those rounds count, not just wildly spray a doorway or wall.

Abort criteria
At what point does this not make sense anymore? Set your limits and stick to them if possible. These limits should be set before emotions get involved. Don’t wait until it’s time to do it for real.

There is an old saying, “speed is security,” and this is a scenario where it holds true. The primary focus of the rescue team should be rapid movement out of the danger area. You cannot perform every task of a tactical rescue by yourself, while performing those tasks to standard. You cannot move casualties and effectively engage hostile personnel at the same time. It briefs well, but it does not go much farther than that. Instead of practicing 50 ways to use tubular nylon, pick 5, and then spend the rest of the day working as a team to save a friend’s life.

Below you will find copies of the two reports addressing the Virginia Tech Shootings, and the Police and EMS response to them. The first report gives an overview of the event, followed by “Key Findings” and “Recommendations”. The second report covers the EMS response more in-depth.

Unfortunately, active-shooter scenarios are events for which one must prepare. In doing so, one should study past occurrences to garner lessons-learned, so as to implement them in your response scenarios. Doing so allows one to examine one’s protocols against real-world occurrences, which may expose flaws.

How might you have done things differently?

Post answers to the comments section.

VA Tech EMS Report

VA Tech After-Action 1

The 9-line format for casualty evacuations is a standard format.  Due to the uniqueness of situations and different medics’ needs, I will only discuss generic considerations regarding its implementation.  During pre-mission planning, you should be aware of the following:

1.  Enemy Situation(e.g, barricade, Meth-lab, etc.)

2. Severity of wounds/injuries (e.g., understand MOI, and injuries you may encounter)

3. Number of casualties (e.g., number of assaulters on the objective, suspects, etc.)

4. Response time (i.e., are you close to a Trauma Center, what is the response time of air)

5. Platforms available (e.g., horse cart, truck, and helicopter)

6. Level of care on Platforms available (i.e., is there a PA onboard, EMT, medic)

7. Travel time to next level of care

Obviously the above-mentioned will be in constant flux.  Also, you will not know all of these beforehand (e.g., severity of wounds).  However, you can assess the types of injuries you may encounter due to the type of mission, then plan accordingly with the type of gear you carry and your prepositioned equipment on a dedicated evacuation platform.  For example, if conducting an assault and inserting via fast-rope, then you may encounter long-bone fractures.  You would not carry a splint in your assault bag.  Instead, leave it on the evac-platform in your level 3 kit.  Another example would be a suspected meth-lab.  You may encounter inhalation injuries.  Therefore, you would have the requisite equipment for treatment on the evac-platform.  

Once you have initiated an evacuation, you should consider the following when prepping a casualty for hand-over:

1. Remove Load bearing equipment

2. Mission Essential Eqt stays in the field (e.g., ammunition, radios, weapons, etc.)

3. Bag and tag all other effects (laundry bags or 4-mil heavy-duty trash bags work well)

4. Lay out in priority – most critical will probably be loaded last

5. Ensure casualties are marked appropriately with casualty card and glow-sticks (if at night)

6. Protect your casualty: hypothermia prevention (blanket), Eye Pro, Ear Pro, strap them to the litter, secure IV lines

Hypothermia is of concern in hot climates as well.   Studies from Iraq indicate that in temperatures over 120 F, casualties are arriving at surgical units hypothermic.   You do not need to use external heat sources (e.g., heatpacks) if you PREVENT heat loss at the point of injury.  You must prevent so you do not have to rewarm.

Providing care under fire is a mentally daunting task. Few other phases have so little to do with medicine and so much to do with your surroundings. Even with a sizable piece of cover, it is easy to make mistakes and expose yourself during treatment when focused on patient care.

In the video you can see the medic doing a decent job of maintaining a low profile during treatment, then, while shifting from the casualty’s leg to his head, he elevates his body during movement. This action briefly exposes his head to enemy fire. An analogy we like to use to explain the atmosphere you are operating in when providing true “care under fire” is that it can be equated to working in confined space. The difference is that instead of bumping your head or elbow on a concrete slab, the concrete slab is replaced by incoming fire. It is generally best for everyone if the medic avoids bumping parts of his body into bullets.

The effort to maintain your position of cover is exponentially more difficult in urban areas or areas with varying points of elevation. You should regularly reassess the effectiveness of you position as the fight progresses. If the enemy force has moved to an elevated position, or possibly to the second or third story of a surrounding structure, you just lost about 50% of your position. Now you must either be more cautious when moving to provide treatment or you need to shift to maximize the use of the position you are in. If in a structure with external windows and “plunging fire” from surrounding buildings, the safest position is on an external wall, in the corners, away from windows. However, remember to consider the type of materials used to construct the building before selecting this position. This position is not recommended if in a vinyl-sided home or a 3rd world type structure.

Failure to practice working in tight quarters behind cover can lead to potentially fatal mistakes in combat. Incorporate these situations into your training and use them to increase the effectiveness of your equipment (e.g., how and where you store or pack it) and how to asses your positions.

Here are some tips for operating in this phase of tactical medicine:
-Keep items required for Care Under Fire or buddy-aid easily accessible.
-Reposition casualties to minimize their level of exposure and yours.
-Don’t lose touch with your surroundings, regularly reassess the enemy’s position.
-Don’t be afraid to move to a new position if the tactical situation allows.
-If in a structure, be mindful of interior and exterior threats.
-Keep your treatments as simple as possible then get back on your gun!