intro to tactical medicine

Introduction to Tactical Medicine

Alexander Berk, MDAssistant Clinical Professor

Department of Emergency MedicineUniversity of Florida College of Medicine - Jacksonville

Obligatory Disclaimer

• I have no association personally or financially with any product or courses referenced in this talk

• Unfortunately….

Objectives

• History and current use of tactical emergency medical support (TEMS)

• Epidemiology of injury in combat/tactical situations

• Phases of Tactical Combat Causality Care• Care Under Fire (Hot Zone)• Tactical Field Care (Warm Zone)• CausaltyEvacuation (Cool Zone)

TEMS• Tactical Emergency Medical Support

• Out of hospital system of care dedicated to enhancing the probability of special operations law enforcement mission success and promoting public safety

• Non-military EMS services that have been modified for the tactical environment

• TEMS Goals• Mission accomplishment• Overall team health• Care under fire• Protection of team members, victims/hostages,

bystanders and perpetrators

EMS vs. TEMS

• Rescuer Safety• Scene Safety• Ambulanced based• BLS• ALS• PHTLS• Rapid transport• Golden hour

• Mission success• Team safety• Zones of care• TCCC• Preventative medicine• Health maintenance• Delayed transport• Golden 5 minutes

Unique Challenges to TEMS

• Image of the medical provider• Providing care in hostile environments• Limited resources• No national standards of training• Ethics

Is it needed?

• Per 1,000 SWAT missions• 3.8 officers injured• 21.9 perpetrators injured• 7.2 bystanders injured

• Over 100 Tactical Emergency Medical Support units throughout the US and the world

Introduction to Tactical Combat Casualty Care

Why are we here?“90% of combat deaths occur on the

battlefield before the casualty ever reaches a medical treatment facility.”

This can be extrapolated to the urban tactical environment

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Introduction to Tactical Combat Casualty Care

ConclusionImperative need to focus on

battlefield/tactical medical care during the first 30 minutes after

incident.

Specialize training ofcombat lifesavers andEMT/paramedicsin Tactical

Combat Casualty Care

Epidemiology of Injury

• Preventable causes of death• Exsanguination from extremity wounds – 66%• Tension pneumothorax – 30%• Airway obstruction – 4%

• Blast injuries becoming increasingly more common

• Basically the biggest bang for your tactical buck

Tactical Combat Casualty Care

• In the past, Special Operations combat medical personnel as well as city/county based EMTs and paramedics were trained to manage combat trauma based on the principles of care taught in the ATLS (Advanced Traumatic Life Support)

Overview

PROBLEM: ATLS is not designed to be used in the combat environment.• Not intended for combat medics• Assumes hospital diagnostic and therapeutic

equipment is readily available• No tactical context

Overview

• What are some tactical considerations?• Incoming fire• Darkness• Environmental factors (cold, heat, rain, sand)• Casualty transportation problems• Delays to definitive care• Command decisions

Overview

• ATLS• CPR• C-spine immobilization• Primary survey• Definitive airway• Tourniquets discouraged• Two large bore IVs• Fluid resuscitation• Monitoring (EKG, pulse ox, BP, HR)• Completely expose the patient• Secondary survey

• Does anybody see a problem with doing all of those things in the middle of a firefight?

Overview

Solution: Tactical Combat Casualty Care (TCCC) – An evolving set of principles guiding trauma in the combat/tactical environment

• Good medicine can sometimes be bad tactics• Bad tactics can get everyone killed and/or cause the

mission to fail• The best possible outcome for both the personnel and the

mission• The right things to do AND the right TIME to do them

Where did TCCC come from?

• 2001: USSOCOM initiated CoTCCC• Physicians (trauma, ER, FP, CC), medics (Rangers, Recon, SEALS, PJs), civilian EMS reps

• 2004: BUMED • Coordinated through Naval Operational Medical Institute• Continues to evaluate the effectiveness of the TCCC guidelines

• Civilian care under fire is still care under fire• Published in the 5th edition of the PHTLS manual

Who is using TCCC

• US Navy Corpsmen• SEAL Junior Officer Course• US Army Rangers• USAF PJ School• C4 Course (DMRTI)• JSOC Medical Readiness

Course• Over 100 Civilian Law

Enforcement Organizations• Israeli Defense Forces, British

SAS, Canadian Counterterrorism Unit, Belgium, Sweden, Norway, NATO

• Endorsed by:

• American College of Surgeons

• National Association of EMTs

• Included in the PHTLS course curriculum

Phases of Tactical Combat Care

Different phases of combat care requires different priorities and different skill sets

and equipment1. Care under Fire (Hot Zone)2. Tactical Field Care (Warm Zone)3. Casualty Evacuation (CASEVAC)

Care (Cold Zone)

Care Under Fire

• “The care rendered by corpsman or buddy at the scene of the injury, while he and the casualty are still under effective hostile fire. The risk of additional injuries being sustained at any moment is extremely high for both casualty and rescuer. Available medical equipment is limited to that carried by the individual operator or corpsman/medic in his medical pack”

• Tactical Combat Casualty Care in Special Operations, Military Medicine, Volume 101, August 1996

• Think beach scene from Saving Private Ryan

Overview

• Keep in mind the environment• Night operations

• No white lights• +/- Night vision goggles

• Active firefight• Try to keep from getting shot• Try to keep casualty from

sustaining more wounds

• Additional firepower provided by the operator may be imperative for fire superiority

• First rule of care under fire is to return fire

• Limited personnel• May have only one trained

medic

Phase 1Care Under Fire

Overview

Traditionally• A – Airway• B – Breathing• C – Circulation

Care Under Fire• A – Assess• B – Bleeding• C – Carry / Cover


AssessBleeding

Carry / Cover

Phase 1 - Care Under Fire

Assessment

• Assess the tactical situation. • Can I treat the casualty or do I need to be putting rounds down

range?• Assess the patient

• What happened here?• Is he injured / bleeding?• Is he conscious, semiconscious, or unconscious?

• Can he safely maintain his weapon? • Can I position the casualty so he can get back in the fight or

position him for safety?• No immediate management of the airway should be

anticipated due to the need to quickly move the patient


Assessment

• Alert and Oriented? • Is it safe for them to hold a weapon? If not, DISARM!

• Check for a pulse (Carotid, Radial, Femoral)• Yes / No• Normal Rate (70-100 bpm)• Quick BP Check

• Carotid (>60), Brachial (>70), Radial (>80)

• Check respirations (Yes / No – Labored?)• Normal Rate (12-16 per min)

• Is there active bleeding noted?• Can they be put back in the fight?


AssessBleeding

Carry / Cover


Bleeding

• Exsanguination from extremity wounds is the #1 cause of preventable death on the battlefield

• Hemorrhage was the cause of death in more than 2,500 casualties in Vietnam who had no other injuries

• Control of hemorrhage is the TOP PRIORITY


Bleeding• Hemorrhage Control Agents

• Direct Pressure• (Immediate, requires constant attention)

• Tourniquet • (<20 sec, minimal attention, periodic reassessment)

• Wound Packing / Pressure Dressing• (1-3 minutes, requires close observation/reassessment)

• Fibrin Dressing / QuikClot• (1-3 minutes, requires close observation)

• Often times, a combination of these measures is used• Direct Pressure Tourniquet + Pressure Dressing

• Depending on the tactical situation, more time consuming measures will have to wait until Phase 2 – Tactical Field Care.


The Tourniquet

• Discouraged by ATLS

• Tactical Combat Casualty Care: It is the most reasonable choice to stop potentially life-threatening bleeding while giving care under fire

• It is immediate and definitive

Historical FactApril 1862 – The Battle of Shiloh

• General Albert Sidney Johnson was one of Robert E. Lee’s senior commanders

• Dr. David Yandell, Command Surgeon for Johnson’s Corps, directed all troops to carry a tourniquet into battle

• General Johnson suffered damage to his popliteal artery; an injury that can be controlled by a tourniquet

• Forgetting that he had one, General Johnson bled to death with the tourniquet in his pocket.

The Facts About Tourniquets

• Damage is rare if on for < 1 hour• Some orthopedic operations place them for hours

• If massive extremity hemorrhage, better to risk ischemic damage to limb than bleeding out

• Non-life threatening bleeding should not receive a tourniquet

• Apply as close to bleeding site as possible• Time should be noted• Remove when feasible

Special ForcesOne-HandedTourniquet

Ranger Ratchet Tourniquet

Tourniquets for Hemorrhage Control on the Battlefield: A 4-Year Accumulated Experience.

Journal of Trauma-Injury Infection & Critical Care. 54(5) Supplement:S221-S225, May 2003.Lakstein, Dror MD; Blumenfeld, Amir MD; Sokolov, Tali MD; Lin, Guy MD; Bssorai, Roni MD; Lynn,

Mauricio MD; Abraham, Ron Ben- MD

• 550 soldiers of the IDF were treated in prehospital setting. • Tourniquets were applied to 91 (16%) of patients in less

than 15 minutes. • 78% of applications were effective with higher success

rates for upper limbs (94%) as compared to lower limbs (71%).

• Neurologic complications in seven limbs of five patients. Ischemic time ranged between 109 and 187 minutes.

• Not a single case of death resulting from uncontrolled limb hemorrhage was recorded during the four years.

That was then, this is now…

Black Hawk Down

• Mogadishu, Somalia• Task Force Ranger member Corporal

Jamie Smith suffers a severed femoral artery during combat operations

• U.S. Army Medic Kurt Schmidt and other Rangers present try repeatedly to stop the bleeding using direct pressure and attempts at reaching inside Smith's wound to pinch the artery shut with their fingers

• Despite the heroic efforts by his fellow Rangers, Corporal Smith succumbs to the wound

• One of 18 service members lost during fierce fighting between 3 and 4 October 1993.

QuikClot

• Provides a hemo-concentration effect in blood that is exiting a wound

• Accelerates the body’s natural clotting process by increasing the concentration of platelets and clotting factors at the wound site

• FDA approved for external use only

How it works

• The main component material is called Zeolite• Derivative of volcanic rock with many pores

• Acts as an adsorbent or molecular sieve• Captures and holds the water molecules in blood • The ability to attract and hold the water molecules is

due to electrostatic forces • Clotting factors, proteins, and cellular components

of the blood are neither attracted nor held• They are simply too large to fit in the pore structure

Product FAQs

• Allergies?• Physical reaction, not

chemical or biologic• No biological or

botanical substances• No danger of allergic

reaction

• Side Effects?• Exothermic reaction• 85-90 degrees Celsius

possible• In vivo studies 37-42

degrees Celsius• Only FDA approved

for external use

Hemorrhage Control: QuikClot Directions

• Attempt to control bleeding with pressure dressing.• If moderate to severe bleeding continues after 90 seconds, hold

QuikClot package away from face and tear open tabs • Package down wind

• Remove dressings to expose wound and wipe away as much excess blood and water as possible

• Immediately begin a gradual pour of QuikClot in a back-and-forth motion onto the source of bleeding

• Try to keep QuikClot in wound ONLY.

• QuikClot changes from its dry light beige color to a dark color as it absorbs moisture and induces clotting.

• Stop pouring promptly when you see a dry layer of QuikClot on wound surface

• IMMEDIATELY REAPPLY direct pressure or pressure dressing.


Hemorrhage Control: QuikClot Precautions

• Do not use material in the face, eyes, chest or abdomen• Do not ingest or inhale QuikClot

• If ingested, drink 2+ glasses of water and seek medical attention immediately

• If inhaled, move to well-ventilated space• Do not use bare hands to apply pressure immediately

following application of QuikClot• If QuikClot causes heat discomfort to skin, brush excess

granules away or flush gently with water• Discard contents once open – DO NOT REUSE


Hemorrhage Control: QuikClotPhase 1

Care Under Fire

Comparative Analysis of Hemostatic Agents in a Swine Model of Lethal Groin Injury.

J Trauma. 2003;54:1077–1082 Alam, Hasan, Uy, Gemma, Miller, Dana, Koustova, Elena, Hancock, Timothy, Inocencio,

Ryan, Anderson, Daniel, Llorente, Orlando, Rhee, Peter, MD, MPH

• 30 Yorkshire swine (42–55 kg) used to produce uncontrolled hemorrhage.

• The injury included semitransection of the proximal thigh and complete division of the femoral artery and vein

• Randomized to (n = 6 animals per group) no dressing (ND), standard dressing (SD), SD and Rapid Deployment Hemostat (RDH) bandage, SD and QuikClot hemostatic agent (QC), or SD and TraumaDEX (TDEX).

• After 5 minutes, treatment was provided and limited volume 0.9% saline (1,000 mL over 30 minutes) resuscitation was started

• Blood loss, early mortality (180 minutes), and physiologic markers of hemorrhagic shock (e.g., cardiac output, blood pressure, hemoglobin, metabolic acidosis) were recorded.

Comparative Analysis of Hemostatic Agents in a Swine Model of Lethal Groin Injury.

J Trauma. 2003;54:1077–1082 Alam, Hasan, Uy, Gemma, Miller, Dana, Koustova, Elena, Hancock, Timothy, Inocencio,

Ryan, Anderson, Daniel, Llorente, Orlando, Rhee, Peter, MD, MPH

• Before the application of dressing (first 5 minutes), there were no differences in blood loss between the groups

• After application of wound dressing, decreased mortality was only statistically significant (p< 0.05) for the QuikClot hemostatic agent group (0% mortality)

• After application of dressings, the QC group had the lowest blood loss (4.4 ± 1.4 mL/kg).

Hemorrhage ControlDressings


Hemorrhage ControlIFAK

Pressure Dressings

Tourniquet

Burn Dressing

Bulky GauzeDressing

Band-Aids

WoundDisinfectant

IodineTablets

QuikClot


Hemorrhage Control Review

• Both the casualty and the corpsman/medic are in grave danger while a tourniquet/dressing is being applied during the Care under Fire phase.

• Non-life threatening bleeding should be ignored until the Tactical Field Care phase.

• Tourniquet is the best, fastest, first line of defense• More definitive treatment like pressure dressings and/or

QuikClot may be applied given the tactical situation• The decision regarding the relative risk of further injury

versus that of exsanguination must be made by the operator rendering care.


AssessBleeding

Carry / Cover


CarryCervical Immobilization

• C-spine immobilization (CSI) only needed for high velocity impacts (airborne, fast-roping, MVC, significant blast injuries)

• Only 1.4% of patients with penetrating neck injuries would benefit from CSI.

• Time to accomplish CSI was found to be 5.5 minutes, even with experienced EMTs

• Conclusion: The potential hazards to both patient and provider outweighed the potential benefit of CSI in penetrating neck trauma.

Phase 1Care Under

Fire

CarryCervical Immobilization

• Treat parachuting injuries, fast-roping injuries, falls, and other types of trauma resulting in midline neck pain OR unconsciousness with CSI unless the danger of hostile fire constitutes a greater risk

• Fireman carry SHOULD NOT be used if c-spine injury is suspected.

Phase 1Care Under

Fire

Casualty MovementPhase 1

Care Under Fire

Casualty Movement Options

• Firefighter’s carry• One-person drag• Two-person drag• Two-person fore-and-aft carry• Two-person rifle carry• Poncho drag• Stokes basket drag• Litter Carry (2 man / 4 man)

Phase 1Care Under

Fire

Casualty Movement

Fireman’s Carry

Phase 1Care Under

Fire

Casualty Movement

One-Person Drag

Phase 1Care Under

Fire

Casualty Movement

Two-Person Drag

Phase 1Care Under

Fire

Casualty Movement

Two-Person Fore-and-Aft Carry

Phase 1Care Under

Fire

Casualty Movement

Two-Person Rifle or Pack Carry

Phase 1Care Under

Fire

Casualty Movement

Poncho Drag

Phase 1Care Under

Fire

Casualty Movement

Stoke’s Basket Drag

Phase 1Care Under

Fire

Casualty Movement

• Situation dictates method• No need to lift casualty• No extra gear required• Side position from casualty allows for

better run/walk • Rescuers facing forward to identify threats• No need to leave packs or weapons

Phase 1Care Under

Fire

Review

• TEMS: Advanced medical care in areas unsuitable for conventional EMS• Get involved

• International Tactical EMS Society (ITEMS): http://www.tems.org

• International School of Tactical Medicine: http://www.tacticalmedicine.com

• C.O.N.T.O.M.S.: http://www.casualtycareresearchcenter.org

• EMT Tactical:http://www.tacticalmedic.us/Course_info.htm

Phase 1Care Under

Fire

http://www.tems.org/

http://www.tacticalmedicine.com/

http://www.tacticalmedicine.com/

http://www.casualtycareresearchcenter.org/

http://www.casualtycareresearchcenter.org/

http://www.tacticalmedic.us/Course_info.htm

http://www.tacticalmedic.us/Course_info.htm

ReviewSituation - actively engaged • Assess, Bleeding, Carry/Cover• Expect casualty to stay engaged if possible• Return fire as directed/required• Airway management is generally best deferred until the

Tactical Field Care Phase• Stop any life-threatening external hemorrhage

• Tourniquet, pressure dressing, QuikClot• Try to keep yourself and casualty from sustaining

additional injuries

Phase 1Care Under

Fire

Review Treatment Algorithm

• Rapid Assessment• Assess• Bleeding (Control)• Carry/Cover

• Trauma Assessment• Airway• Breathing • Circulation• Disability• Exposure

• Phase 2: Tactical Field Care (stay tuned)

Phase 1Care Under

Fire

Questions?

Acknowledgements

• Tactical Combat Casualty Care in Special Operations. CAPT Frank Butler, MC(UMO/SEAL), USN.

• Tactical Combat Casualty Care – Update 2003. Stephen D. Gieber, MD, MPH. Journal of Special Operations Medicine. Fall 2003

• Battlefield Trauma Course. HM2(FMF/DV/PJ) Walker, HM1(DV/FPJ) Tague.

• Patterns of Injury and Effects on Delay of Treatment. Howard Champion, MD, FACS. SOMA 2003.

• Explosions, Explosive Devices, and Blast Injuries. Albert J. Romanosky, MD, PhD. SOMA 2003.

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