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 below abstract is from Resuscitation, Volume 82, available at Science Direct. It provides a detailed examination of out-of-hospital airway management, success rates, and complicating factors. The crux of the article for tactical medics is the need to maintain skills through training, because the low ratio of calls to the need for invasive airway interventions, even in the EMS sector, suggests that real-world practice is not sufficient. It points to the low success rate of reported advanced interventions as proof, claiming that the rate might be high due to one not wanting to report failures. Finally, in addition to skill fade, failure is also attributed to vomit, blood, and mucus, all hindrances faced in the tactical environment, as a factors leading to failed advanced airway management. In the end, tactical medics may not manage enough advanced airways to maintain their skills, thus they need to find appropriate training models if live-tissue training is not available. Unfortunately, this article does not provide many alternatives.

A b s t r a c t
Objective: Prior studies describe airway management by single EMS agencies, regions or states.We sought
to characterize out-of-hospital airway management interventions, outcomes and complications across
the United States.

Methods: Using the 2008 National Emergency Medical Services Information System (NEMSIS) Public-Release Data Set containing data from 16 states, we identified patients receiving advanced airway management, including endotracheal intubation (ETI), alternate airways (Combitube, Laryngeal Mask Airway (LMA), King LT, Esophageal-Obturator Airway (EOA)), and cricothyroidotomy (needle and open). We examined airway management success and complications in the full cohort and in key subsets (cardiacarrest, non-arrest medical, non-arrest injury, children <10 and 10–19 years, rapid-sequence intubation (RSI), population setting and US census region). We analyzed the data using descriptive statistics.

Results:Among4,383,768EMSactivations, there were 10,356 ETI, 2246 alternate airways, and 88 cricothyroidotomies.
ETI success rates were: overall 6482/8418 (77.0%; 95% CI: 76.1–77.9%), cardiac arrest 3494/4482 (78.0%), non-arrest medical 616/846 (72.8%), non-arrest injury 417/505 (82.6%), children<10 years 295/397 (74.3%), children 10–19 years 228/289 (78.9%), adult 5829/7552 (77.2%), and rapidsequence
intubation 289/355 (81.4%). ETI success was success was lowest in the South US census region. Alternate airway success was 1564/1794 (87.2%). Major complications included: bleeding 84 (7.0 per 1000 interventions), vomiting 80 (6.7 per 1000) and esophageal intubation 12 (1.0 per 1000).

Conclusions: In this study characterizing out-of-hospital airway management across the United States, we observed low out-of-hospital ETI success rates. These data may guide national efforts to improve the quality of out-of-hospital airway management.

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