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)

victims/hostages.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. 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 .

9 perpetrators injured ‡ 7.000 SWAT missions ‡ 3.Is it needed? ‡ Per 1.2 bystanders injured ‡ Over 100 Tactical Emergency Medical Support units throughout the US and the world .8 officers injured ‡ 21.

´ This can be extrapolated to the urban tactical environment .Introduction to Tactical Combat Casualty Care Why are we here? ³90% of combat deaths occur on the battlefield before the casualty ever reaches a medical treatment facility.

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. Army Combat Deaths Surg & Gen Hosp Evac & CONUS Hospitals .S.

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) .

‡ Not intended for combat medics ‡ Assumes hospital diagnostic and therapeutic equipment is readily available ‡ No tactical context .Overview PROBLEM: ATLS is not designed to be used in the combat environment.

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

HR) Completely expose the patient Secondary survey ‡ Does anybody see a problem with doing all of those things in the middle of a firefight? . pulse ox. BP.Overview ‡ ATLS ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ CPR C-spine immobilization Primary survey Definitive airway Tourniquets discouraged Two large bore IVs Fluid resuscitation Monitoring (EKG.

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 ‡ ³The care rendered by corpsman or buddy at the scene of the injury. August 1996 ‡ Think beach scene from Saving Private Ryan . The risk of additional injuries being sustained at any moment is extremely high for both casualty and rescuer. Volume 101. 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. while he and the casualty are still under effective hostile fire. Military Medicine.

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 ‡ Keep in mind the environment ‡ Night operations ‡ No white lights ‡ +/.

Phase 1 Care Under Fire Overview Care Under Fire ‡ A ± Assess ‡ B ± Bleeding ‡ C ± Carry / Cover Traditionally ‡ A ± Airway ‡ B ± Breathing ‡ C ± Circulation .

Care Under Fire Assess Bleeding Carry / Cover .Phase 1 .

‡ 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 ‡ Assess the tactical situation.

Phase 1 Care Under Fire Assessment ‡ Alert and Oriented? ‡ Is it safe for them to hold a weapon? If not. 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? . DISARM! ‡ Check for a pulse (Carotid. Radial. Femoral) ‡ Yes / No ‡ Normal Rate (70-100 bpm) ‡ Quick BP Check ‡ Carotid (>60). Brachial (>70).

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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. . a combination of these measures is used ‡ Direct Pressure Tourniquet + Pressure Dressing ‡ Depending on the tactical situation. requires close observation) ‡ Often times. minimal attention. requires constant attention) ‡ Tourniquet ‡ (<20 sec. periodic reassessment) ‡ Wound Packing / Pressure Dressing ‡ (1-3 minutes. requires close observation/reassessment) ‡ Fibrin Dressing / QuikClot ‡ (1-3 minutes. 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 .

General Johnson bled to death with the tourniquet in his pocket. Lee¶s senior commanders ‡ Dr. David Yandell. Command Surgeon for Johnson¶s Corps. an injury that can be controlled by a tourniquet ‡ Forgetting that he had one. . directed all troops to carry a tourniquet into battle ‡ General Johnson suffered damage to his popliteal artery.Historical Fact April 1862 ± The Battle of Shiloh ‡ General Albert Sidney Johnson was one of Robert E.

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 .The Facts About Tourniquets ‡ Damage is rare if on for < 1 hour ‡ Some orthopedic operations place them for hours ‡ If massive extremity hemorrhage.

Special Forces One-Handed Tourniquet .

Ranger Ratchet Tourniquet .

Lakstein. ‡ Not a single case of death resulting from uncontrolled limb hemorrhage was recorded during the four years. ‡ 78% of applications were effective with higher success rates for upper limbs (94%) as compared to lower limbs (71%). Abraham. Ischemic time ranged between 109 and 187 minutes. Sokolov.Tourniquets for Hemorrhage Control on the Battlefield: A 4-Year Accumulated Experience. Guy MD. 54(5) Supplement:S221-S225. Tali MD. Lynn. ‡ Neurologic complications in seven limbs of five patients. Ron Ben.MD ‡ 550 soldiers of the IDF were treated in prehospital setting. Lin. Roni MD. . May 2003. Mauricio MD. Blumenfeld. Journal of Trauma-Injury Infection & Critical Care. Amir MD. Bssorai. Dror MD. ‡ Tourniquets were applied to 91 (16%) of patients in less than 15 minutes.

this is now« .That was then.

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Somalia ‡ Task Force Ranger member Corporal Jamie Smith suffers a severed femoral artery during combat operations ‡ U.S.Black Hawk Down ‡ Mogadishu. . Corporal Smith succumbs to the wound ‡ One of 18 service members lost during fierce fighting between 3 and 4 October 1993. 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.

QuikClot ‡ Provides a hemoconcentration 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 .

and cellular components of the blood are neither attracted nor held ‡ They are simply too large to fit in the pore structure . proteins.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.

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 .Product FAQs ‡ Allergies? ‡ Physical reaction.

‡ QuikClot changes from its dry light beige color to a dark color as it absorbs moisture and induces clotting. ‡ If moderate to severe bleeding continues after 90 seconds.Phase 1 Care Under Fire Hemorrhage Control: QuikClot Directions ‡ Attempt to control bleeding with pressure dressing. . 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. ‡ Stop pouring promptly when you see a dry layer of QuikClot on wound surface ‡ IMMEDIATELY REAPPLY direct pressure or pressure dressing.

eyes.Phase 1Hemorrhage Control: QuikClot Care Under Fire Precautions ‡ Do not use material in the face. 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. chest or abdomen ‡ Do not ingest or inhale QuikClot ‡ If ingested. drink 2+ glasses of water and seek medical attention immediately ‡ If inhaled. brush excess granules away or flush gently with water ‡ Discard contents once open ± DO NOT REUSE .

Phase 1 Care Under Fire Hemorrhage Control: QuikClot .

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Elena. Ryan. MPH ‡ 30 Yorkshire swine (42±55 kg) used to produce uncontrolled hemorrhage. Orlando. ‡ After 5 minutes.. Gemma. and physiologic markers of hemorrhagic shock (e. SD and QuikClot hemostatic agent (QC). Anderson. cardiac output. .Comparative Analysis of Hemostatic Agents in a Swine Model of Lethal Groin Injury. Rhee. Uy. Miller. ‡ 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). metabolic acidosis) were recorded. SD and Rapid Deployment Hemostat (RDH) bandage.54:1077±1082 Alam. Hasan. Dana. J Trauma. Hancock. treatment was provided and limited volume 0.000 mL over 30 minutes) resuscitation was started ‡ Blood loss. Koustova. Timothy. Daniel. MD. 2003. standard dressing (SD). Llorente. hemoglobin. blood pressure. Peter.9% saline (1. Inocencio. early mortality (180 minutes). or SD and TraumaDEX (TDEX).g.

Daniel. Hancock. MPH ‡ Before the application of dressing (first 5 minutes). Inocencio. Elena.54:1077±1082 Alam. the QC group had the lowest blood loss (4. MD. Koustova. Miller. there were no differences in blood loss between the groups ‡ After application of wound dressing. Anderson. Rhee.05) for the QuikClot hemostatic agent group (0% mortality) ‡ After application of dressings. Uy. Ryan.4 mL/kg). Llorente. decreased mortality was only statistically significant (p< 0. Peter. Dana.4 1. Hasan. Orlando. Timothy. . Gemma. 2003.Comparative Analysis of Hemostatic Agents in a Swine Model of Lethal Groin Injury. J Trauma.

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 .

. ‡ Tourniquet is the best. ‡ Non-life threatening bleeding should be ignored until the Tactical Field Care phase.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. 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. fastest.

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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.5 minutes.4% of patients with penetrating neck injuries would benefit from CSI. MVC. . ‡ Time to accomplish CSI was found to be 5. significant blast injuries) ‡ Only 1. fast-roping. even with experienced EMTs ‡ Conclusion: The potential hazards to both patient and provider outweighed the potential benefit of CSI in penetrating neck trauma.

fast-roping injuries.Phase 1 Care Under Fire Carry Cervical Immobilization ‡ Treat parachuting 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 ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ 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 1 Care Under Fire Casualty Movement Fireman¶s 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 Stoke¶s 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 ‡ ‡ ‡ ‡ .

c om ‡ C.tems.M.us/Course_info.: http://www.htm .tacticalm edic.O.N.S.T.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.casualtycareresear chcenter.O.org ‡ International School of Tactical Medicine: http://www.tacticalmedicine.org ‡ EMT Tactical:http://www.

Bleeding.actively engaged Assess. 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. QuikClot ‡ Try to keep yourself and casualty from sustaining additional injuries . pressure dressing.Phase 1 Care Under Fire Review Situation .

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? .

Gieber. Explosive Devices. MD. SOMA 2003. Albert J. . ‡ Tactical Combat Casualty Care ± Update 2003. HM2(FMF/DV/PJ) Walker. MD. MPH. SOMA 2003. HM1(DV/FPJ) Tague. Journal of Special Operations Medicine. PhD. USN. Fall 2003 ‡ Battlefield Trauma Course. CAPT Frank Butler. Romanosky. ‡ Patterns of Injury and Effects on Delay of Treatment. MC(UMO/SEAL).Acknowledgements ‡ Tactical Combat Casualty Care in Special Operations. and Blast Injuries. Howard Champion. MD. FACS. Stephen D. ‡ Explosions.

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