Rounding out the Warriors Arsenal

Rounding out the Warrior’s Arsenal: Part 1

By: Sean McKay, EMT-P / T and Alex Eastman, Tactical M.D.
This is part 1 of a 3 part series

INTRODUCTION

The arsenal of today’s warrior changes daily. Not only must they continually cross train and hone multiple skill sets, but also each day they don’t fight, they have to try to learn a new technique, a new tactic or something to improve them. This drive to improve is part of the true warrior’s creed. While historically, this drive has been focused on fitness, weapons and overall readiness, we now must also include those skills intended to save lives—whether that be our own or our partner’s. Today’s asymmetric threats leave us no choice but to prepare accordingly.

Unfortunately, the Hollywood paradigm for conducting casualty care during tactical operations falls far short of achieving legitimate, effective self-aid/buddy aid (SABA). The shot rings out, the vaunted character falls wounded, some well-intentioned teammate yells “Medic!” and the valiant life-saver heroically charges through a barrage of fire to reach the downed warrior to provide immediate medical care just in time to save his life. While such scenes are entertaining, these fantasies are about as relevant for modeling appropriate real-world tactical casualty care as the “Die Hard” series of action movies is for modeling counter-terrorist tactics. Whether you face an armored combat patrol in Afghanistan or a “routine” traffic stop that is met with an un-anticipated deadly force escalation, the threat from an armed adversary intent on inflicting harm upon the modern warrior is present. And while we train and fight for ultimate success, the potential for an untoward outcome or injury should force the warrior to supplement his other training with enough SABA training designed to sustain his life, or the life of his fellow warriors, in the event of serious injury.

The intent of this article is to introduce the concepts of the most basic tactical medicine program. Tactical medicine, as it is discussed here, is not synonymous with SWAT medicine, or any of its other names. It is a vital set of skills that any warrior headed into harm’s way should master. A robust tactical medicine program requires a critical analysis of several factors.

- Impact on ongoing tactical operations
- Medical resource capability and availability
- Evacuation capabilities, and environmental factors – to include continuing hostilities – all impact the tactical commander’s decision-making process.
- How can we best achieve our desired end state – optimizing tactical success while simultaneously providing the best medical outcome for a wounded warrior?

TCCC: A Closer Look
The interventions described in this article were not devised on the fly or by the uninitiated. Tactical medicine interventions are based on scientific recommendations—sounds medicine that has been proven and tested on the battlefield. Following tactical operations in Somalia in 1993, the U.S. Special Operations Command identified a void in tactical casualty management. Under the direction of the Naval Special Warfare Command, CAPT Frank Butler began the Tactical Combat Casualty Care (TCCC) project with the desired end-state of developing a set of tactically appropriate battlefield trauma care guidelines. Maintaining the tenet that “good medicine can sometimes be bad tactics, and bad tactics can create additional casualties or cause the mission to fail,” the TCCC project’s principle mandate was the critical execution of the right medical interventions at the right time and place. Butler et al published these guidelines in a special supplement to Military Medicine in 1996. Subsequently, a standing committee, the Committee on Tactical Combat Casualty Care, was formed to continually review and update these guidelines. This committee is a multi-disciplinary entity comprised of physicians, physician assistants, and combat medics from all components of the Department of Defense (DoD) as well as other Government organizations and civilian agencies.

The TCCC recommendations were “somewhat at odds” with civilian pre-hospital guidelines being taught at that time, but the advantages of having battlefield trauma guidelines customized for the tactical environment was quickly acknowledged. Since the first course in 1996, TCCC is now standardized DoD-wide from the warfighter/operator to the physician. Many civilian law enforcement and EMS agencies, including the National Tactical Officer’s Association (NTOA) and the National Association of EMT’s (NAEMT) have adopted these guidelines for conducting operations in austere environments where the risk from penetrating trauma is a reality. With the DoD implementation of TCCC guidelines, US forces have achieved the lowest percentage of Killed in Action and Case Fatality Rate in recent recordable history (1945-present).

It is a common misconception from the civilian sector that the TCCC guidelines are only applicable in a 360° military battle space similar to that seen in Blackhawk Down, or in the middle of the streets of Ramadi, Iraq. The reality is that TCCC addresses optimal casualty care within a hostile environment when there is an unknown or variable evacuation time or potential delay in casualty transport. The average transport time to a medical treatment facility (MTF) in Iraq can be less than one hour, which is not unlike situations that may be encountered here in the United States. Weather, traffic, rural response, mass casualty, and ongoing tactical operations against active threats can contribute to longer transport times to definitive care in the civilian environment. Many also question the relevance of these guidelines due to the epidemiology of “battlefield” injuries compared to injuries likely to be encountered during civilian tactical operations. While military forces face a higher incidence of explosion and fragmentation injuries, penetrating trauma remains the predominant cause of injury and death. A gunshot wound that severs a police officer’s femoral artery is just as likely to cause death from blood loss as a shrapnel wound that severs a soldier’s femoral artery, and both are equally amenable to immediate life-saving treatment.

Reviewing historical tactical operations in which a operator was wounded or killed, regardless if the injury occurred during a full-scale military combat operation or within the contemporary civilian law enforcement realm, we see that injuries fall into one of three main categories. The first category is the “catastrophic” injury. This injury results in immediate death or is so severe that the wounded casualty will die despite all available medical care resources. The second category is the “minimally wounded.” These casualties will not only survive their injuries; they will recover well regardless of the medical attention they receive. The third category is the “critical” injury. Casualties with these injuries are likely to die, or have their health deteriorate to such a condition that they are likely to suffer permanent disability if appropriate medical interventions are not rapidly accomplished. Since we cannot save the “catastrophic” casualty, and the “minimal” casualty requires no dedicated medical care, we should focus our efforts on identifying and treating the “critical” casualty.

A study published in Pre-hospital Disaster Medicine (August 2007) entitled Police Officer Response to the Injured Officer: A Survey-Based Analysis of Medical Care Decisions assessed the responding law enforcement personnel's capability to appropriately address medical emergencies while under an “active threat” condition. The authors’ conclusions were that our law enforcement personnel's tactical medical decision-making training is sub-optimal, resulting in disruption to the on-going tactical mission, unnecessary deaths, or both. Given recent threats against us, there has never been a greater need to incorporate TCCC concepts on a wide-scale, equipping every warrior and law enforcement officer with these essential skills.

KEY TCCC CONCEPTS

Based on extensive and quantifiable research of wounding patterns in the tactical environment, the three major causes of potentially preventable tactical deaths are Extremity Hemorrhage, Tension Pneumothorax, and Airway Obstruction. (Preventable death is always caveated with “potentially” within the tactical environment simply because an on-going threat may prevent a rescuer from reaching the casualty.) TCCC is the only medical guideline specifically developed for the tactical environment to receive the dual endorsement of the American College of Surgeons Committee on Trauma and the National Association of Emergency Medical Technicians. The TCCC guidelines have been included in the Pre-Hospital Life Support (PHTLS) Manual since the fourth edition in 1999.

“In the last decade there has been a strong emphasis from organized medicine to develop “best practices” based on evidence based medicine (EBM). Simply stated this is to question why we do what we do and to validate our practices by subjecting all we do to objective scientific scrutiny. Keep in mind that best practices is a dynamic concept, that is, change is expected as technology and the fund of knowledge increases. What is a best practice today may not be when re-evaluated in the future.”
Dr. Richard Carmona, Former United States Surgeon General

When we identify a requirement – in this case, conducting appropriate trauma care within the tactical environment - we must critically analyze the skills and equipment we select to accomplish the mission. Incorporating an assessment and validation process for skills and equipment is a mandatory aspect of training that is often ignored. The question must be asked, “why should I learn this skill and who says it is effective?”

The answer lies in integrating an appropriate Casualty Management System (CMS) for any organization operating within the tactical environment. A CMS is far more than a simple set of individual skills. An appropriate CMS takes a general set of principles common to all operations within a tactical environment, and tailors the program to the specific needs of an individual organization. See Box 1 for principles that a CMS should address. The CMS enables tactical leaders to more effectively understand the risk that a single casualty poses to their operation, and more importantly, how to mitigate that risk.

The S.P.A.R.T.A.N. Training System™ utilizes a 3E methodology. This training methodology was developed with the assistance of Bruce K. Siddle and Lt. Col. Dave Grossman, with the purpose of developing executable high threat rescue and casualty care capabilities in non-linear conflict. This methodology imposes a three-stage stop gate system. If a skill or piece of equipment fails any of the stop gates it is removed from the system and reviewed or re-engineered. This validation process is designed for specific skills, equipment selection and product development; however for the purposes of this section it will be focused on skill validation and equipment selection. The 3E methodology consists of the following;

Effective – Is the skill or equipment effective in accomplishing the desired result. Through an aggressive preliminary testing does it perform as advertised? Can we exploit its strengths and/or weaknesses?

Efficient – Is this skill or equipment efficient in the area of operation (AO) of its intended use? Based on the specific AO, a skill and/or equipment requirement list should be performed. A list of characteristics pertinent to the environment where the skill and/or equipment will be utilized must be compiled. I.e. Low / no light, temperature extremes, Personal Protective Equipment that will be utilized, altitude extremes, threat level, etc.

Executable – Having the capability of accurately predicting the physiological and psychological effects of survival stress in the specific AO, will the rescuer even have the capability of performing the skills or utilizing the equipment suggested? This is a two-step process; first identify predictable stress levels during application based on AO and/or phase of care. Second, utilize the above information to determine technique / equipment /skill selection. Utilization of the Inverted U Law and Thom’s Catastrophe Theory will assist in selecting the appropriate motor skill capability. Compatibility of skill selection to the AO and subsequent sympathetic nervous system response (SNS) is critical. The situational paradox we are maneuvering within innately activates SNS response; integral understanding of the body’s response and capabilities will drive the Rescue Human Factors™ Engineering Process.

We first need to recognize and admit that we are not going to utilize a tactical combat casualty care skill set under optimal conditions. If we are in a position to apply life-saving self-aid/buddy-aid skills, our situational report is suboptimal. Our reality is that once this situation has occurred, our sympathetic nervous system will probably be in full swing. What does this mean? We will no longer be smart, precise, and deliberate, but rather, fast, strong, and probably dumb. The implications of SNS dominance are catastrophic to the vision, cognitive processing, as well as fine and/or complex motor skill performance. How does this correlate to the AO, phase of care, and/or skill sets we expect to employ? On the surface, at large, we need to be capable of choosing techniques and equipment that can be employed mainly with gross motor operation (extremely difficult considering most of these skills require precision). For those skills and equipment that are absolutely vital or our only options, we must focus our training at specific neuro-muscular programming under the replicated stress of the situation.

CONCLUSIONS

Today’s violent tactical environment demands an unconventional approach to rescue and medicine to address the current asymmetric threats. We must define a Casualty Management System that is effective, efficient (in our specific Area of Operation), executable (under survival stress), evidence-based, and combat proven. The medic-centric model of tactical medicine must go by the wayside, and an improved focused training at the operator level must be implemented. Enhanced self-aid / buddy-aid (E-SABA) must be instituted for any warrior when the potential for penetrating injuries exist.

While tactical medics remain an invaluable asset, it is impossible and un-realistic for any organization to field a 1:1 ratio of medics to operators. There are certain life-threatening injuries the operator must be prepared to treat in order to prevent death before a trained medical provider can reach the fallen warrior. A tiered casualty management system adequately addresses medical care that begins at the point of wounding with the operator and proceeds through the tactical medic along the continuum of care to a medical treatment facility. This casualty management system must also address evacuating the casualty from the tactical scene and moving them to a treatment center. Since adequate casualty care cannot be rendered until the casualty has been moved to cover, incorporating a specific High Threat Extraction process enables more efficient and expedient care. The topic of High Threat Extraction will be covered next in Part 2 of this series. Stay safe, brothers.

TABLE 1: Essential Elements of a Casualty Management System
Casualty Response System components
Education
How people die in tactical operations
Other medical threats
Basic Medical principles and skills
Tactical Combat Casualty Care
Tactical Environment limitations
Resource availability
- Personal Protection Equipment
- Individual Medical Equipment
- Team Medical Equipment
- Tactical Medic capabilities
- Other local medical resources

Training
Individual Medical Skills
Individual skills assessment/validation
Unit casualty drills
Casualty movement techniques
Rescue/extraction techniques/equipment
Scenario-Based Training events

Mission Planning
Resource availability
Evacuation procedures
Local medical facility capability
Treatment capability/location of medical assets by phase of the mission
Resupply
Communications

Related Article: The Relevance of Tactical Combat Casualty Care (TCCC) Guidelines to Civilian Law Enforcement Operations
The National Tactical Officers Association (NTOA) endorses and supports the
incorporation of a well-trained and equipped Tactical Emergency Medical Support
(TEMS) element into all tactical teams. TEMS is the provision of preventative, urgent
and emergent medical care during high-risk, extended duration and mission-driven law
enforcement special operations.

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I have been providing anesthesia as a nurse anesthetist since 1994. In 2005, I decided to switch gears and become a Flight Nurse for CALSTAR (California Shock Trauma Air Transport). It didn’t take long for me to become very impressed with nearly every prehospital provider, nurse or medic, that I came into contact with.

Related Article: Review of Basics of Forensic Consideration for Gunshot Wounds
We are often confronted with an array of both forensic and clinical/medical issues involving trauma - both blunt and penetrating. As in all injuries, evaluation and treatment should begin as soon as possible by the EMS system. This paper will present issues associated with gunshot wounds but is not intended to create the impression that all wounds fit neatly into categories. Each injury is unique and must be evaluated singly. A wound from a .22 cal rifle can be as dangerous as from a high velocity hunting or military rifle. Clinical and timely evaluation by trained physicians and a medical team is the key issue.

Related Article: Altered Mental Status: A Review
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Related Article: Why Evidence Based EMS?
Evidence-based medicine (EBM) refers to making medical decisions based on evidence gained from the scientific method. While that may seem to be common sense, it may come as a surprise that EBM has only really come into practice since the late-twentieth century.

Related Article: A Matter of Time
Let's face it: For many of our calls, time is not an issue when it comes to clinical importance. Sure, the public expects that EMS will respond in a timely manner, and we configure our systems so that performance standards can be met. But from the perspective of improving patient outcomes, there's not a lot of data to support the notion that time is critical.

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