Our Clinical Governance Day on 15 June 2016 was an introductory discussion about the why, who, and how of tactical medicine. Out of this came a recognition of the importance of this knowledge base and skill set not only for the next Lindt Cafe Siege or other high threat event, but also for our daily trauma practice. This is a summary of the highlights as well as some additional key concepts.
THE #1 RULE OF TACTICAL MEDICINE IS… 1st WIN THE GUN FIGHT!
Obviously our medical teams don’t shoot their way into jobs; however, ensuring a scene is safe and secure before commencing patient care is essential. This is true on any mission, but you must be extra vigilant when responding to a GSW, stabbing, fire, explosion, building collapse, and the like. Check on scene safety en route to the job, if possible, and then confirm with the police or scene commander on arrival.
Don’t forget that scene safety is relative and dynamic: an assailant may return to the scene later, a distant fire may spread, secondary devices may have been placed to target responders. Keep your eyes and ears open.
TACTICAL EMERGENCY CASUALTY CARE (TECC) is the name of the game
Inspired by the military’s Tactical Combat Casualty Care (TCCC), TECC is an increasingly evidence-based, standardized approach for addressing preventable death in civilian trauma. Although geared towards the logistics and special needs of a tactical situation, the tenets apply to many of the scenes we encounter in prehospital medicine. At the core of TECC is a laser focus on what kills this patient population first, and how to treat it.
So your standard ABCs of ATLS/EMST fame become MARCH, ensuring massive hemorrhage is assessed and treated immediately. No sense putting that ET tube in if your patient bleeds out while you do the kit dump. This model of primary assessment also specifically calls out attention to head injury and the threat of hypothermia.
THINK ABOUT WHAT KIT YOU WILL NEED
With these priorities in mind, consider what kit you really need when responding to a high threat job, especially if a tactical situation is in progress (such as a standoff), or if there are multiple casualties (shooting, explosion). Do you really need two heavy trauma packs, a monitor, and an unwieldy stretcher as you enter a scene, or would you be better served to commandeer a cache of tourniquets, pressure bandages, hemostatic gauze, nasal/oral airways, and thoracostomy supplies? Keep in mind that many of these events are not static, and may require you to be mobile as the scene evolves.
BE AN EXPERT AT TOURNIQUET APPLICATION
During our practical workshops, it was clear that although we all understand how to use a tourniquet in theory, the actual mechanical application (particularly under stress, or with a patient on the ground) can be quite slow and fiddly. As any other kit we use infrequently in high stakes scenarios, we should become intimately familiar with the tourniquet and practice using it.
Two pro tips: 1) If you can’t immediately identify the source of major limb bleeding, place the tourniquet as proximal on the affected extremity as possible. 2) If bleeding continues despite your tourniquet, place a second one adjacent to the first.
Here’s a good overview video as a refresher.
CONSIDER OTHER POTENTIAL SOURCES OF INJURY
When evaluating a patient brought to you from a tactical scene, keep your mind that there are numerous ways someone can be injured: fragmentation (grenades, explosives), burns (flash bangs), chemical (pepper spray or hazmat), lacerations from broken glass, blunt trauma (restraint, impact weapons, falls), taser barbs, heat/cold illness, dehydration.
OUR JOB IS NOT TO KICK DOWN DOORS
Lastly, as mentioned during this CGD, nothing in our training or ongoing discussion of these tactical medicine issues prepares us to throw on body armor and go into the so-called “hot zone” with the police/tactical unit. This primary operational tactical medicine role is the responsibility of a dedicated group of specially trained SOT/SCAT paramedics who “provide medical support to Police tactical operations, in urban and remote settings, with specialist vehicles, uniforms and equipment available to ensure integration into high risk operations. Initial training on cover and concealment, tactical movement and awareness of tactical considerations is covered, with ongoing interagency training.”
THAT SAID: BE USEFUL
Much like the Ingleburn shooting, we may be on a scene with nothing medically happening for hours (if at all). Try to be as useful as possible. Start making sure the command structure knows there is a doctor-paramedic team on scene. Begin pre-planning your casualty collection point, how you will get additional supplies, where patients will be transported and how (easy when in MTC-rich Sydney, much harder in a bush town). Make sure everyone is drinking water. Help create shelters from the heat or cold. Be available to support the SOT/SCAT tactical paramedics, and provide advice and care for minor medical issues.
Sometimes the best thing you can do for the success of a prolonged mission is to just get people to wash their hands before eating.
CC0 Public Domain- pixabay.com
OTHER RESOURCES
Committee on Tactical Emergency Casualty Care – guidelines, rationale, and evidence
Comprehensive compendium of information from American College of Surgeons and the Hartford Consensus.
Greater Sydney Area HEMS 