Introduction to Tactical Medicine

Alexander Berk, MD Assistant Clinical Professor Department of Emergency Medicine University 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

US Army Combat Deaths Data

100 90 80 70 60 50 40 30 20 10 0 Battlefield 1st & 2nd Echeons

World War Korea Vietnam

U.S. Army Combat Deaths

Surg & Gen Hosp Evac & CONUS Hospitals

PERCENTAGE OF TOTAL DEATHS

10 15 20 25 30 35 40 45 0 Imm ediate <5m 5 to < 30m 30m to <2h 5

Time to Death Time to Death

TIME TO DEATH

KILLED IN ACTION

DIED OF Wound

2 to < 6h 6h to <1d 1d to <1w 1w or >

Introduction to Tactical Combat Casualty Care

Conclusion Imperative 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 equipment

1. 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

Phase 1 Care Under Fire

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 1 Care Under Fire

Overview
Care Under Fire
A Assess B Bleeding C Carry / Cover

Traditionally
A Airway B Breathing C Circulation

Phase 1 - Care Under Fire

Assess Bleeding 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

Phase 1 Care Under Fire

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?

Phase 1 - Care Under Fire

Assess Bleeding Carry / Cover

Phase 1 Care Under Fire

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

Phase 1 Care Under Fire

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 Fact
April 1862 The Battle of Shiloh

General Albert Sidney Johnson was one of Robert E. Lees senior commanders Dr. David Yandell, Command Surgeon for Johnsons 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 Forces One-Handed Tourniquet

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 hemoconcentration effect in blood that is exiting a wound Accelerates the bodys 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

Side Effects?
Exothermic reaction 85-90 degrees Celsius possible In vivo studies 37-42 degrees Celsius

No danger of allergic reaction

Only FDA approved for external use

Phase 1 Care Under Fire

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.

Phase 1Hemorrhage Control: QuikClot Care Under Fire 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

Phase 1 Care Under Fire

Hemorrhage Control: QuikClot

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

J Trauma. 2003;54:10771082 Alam, Hasan, Uy, Gemma, Miller, Dana, Koustova, Elena, Hancock, Timothy, Inocencio, Ryan, Anderson, Daniel, Llorente, Orlando, Rhee, Peter, MD, MPH

30 Yorkshire swine (4255 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;54:10771082 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).

Phase 1 Care Under Fire

Hemorrhage Control Dressings

Phase 1 Care Under Fire

Hemorrhage Control IFAK

Bulky Gauze Dressing Pressure Dressings Tourniquet Burn Dressing Band-Aids Wound Disinfectant Iodine Tablets QuikClot

Phase 1 Care Under Fire

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.

Phase 1 - Care Under Fire

Assess Bleeding Carry / Cover

Phase 1 Care Under Fire

Carry
Cervical 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 1 Care Under Fire

Carry
Cervical 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 cspine injury is suspected.

Phase 1 Care Under Fire

Casualty Movement

Phase 1 Care Under Fire

Casualty Movement Options

Firefighters 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 1 Care Under Fire

Casualty Movement

Firemans Carry

Phase 1 Care Under Fire

Casualty Movement

One-Person Drag

Phase 1 Care Under Fire

Casualty Movement

Two-Person Drag

Phase 1 Care Under Fire

Casualty Movement

Two-Person Fore-and-Aft Carry

Phase 1 Care Under Fire

Casualty Movement

Two-Person Rifle or Pack Carry

Phase 1 Care Under Fire

Casualty Movement

Poncho Drag

Phase 1 Care Under Fire

Casualty Movement

Stokes Basket Drag

Phase 1 Care 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 1 Care 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.c om C.O.N.T.O.M.S.: http://www.casualtycareresear chcenter.org EMT Tactical:http://www.tacticalm edic.us/Course_info.htm

Phase 1 Care Under Fire

Review

Situation - 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 1 Care Under Fire

Review Treatment Algorithm

Trauma Assessment
Airway Breathing Circulation Disability Exposure

Rapid Assessment
Assess Bleeding (Control) Carry/Cover

Phase 2: Tactical Field Care (stay tuned)

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.