With all the things we have added to these curriculums, I am surprised to see that tactical medicine, is usually not on the course curriculum. This prompts the question of our responder readiness. Are our students or our senior responders adequately prepared to provide the care necessary in an active shooter or hostile type incident? I will venture to say, we are typically not. In this article we will discuss the many differences between typical street EMS versus EMS at an active shooter or hostile type of incident.
It’s two in the morning and you get the tones for a gun shot victim in your first due response area. You arrive to find a single victim with multiple gun-shot wounds (GSW) laying in the street surrounded by a large group of Police Officers urging you to move faster. You scoop and run, strip them, flip them, plug holes and start IV’s. This is bread and butter EMS, but does your proficiency and knowledge in street trauma transfer to the hostile environment? Unfortunately, not as well as some responders and administrators may like to think. The good news is that tactical EMS skills build on good base-hospital skill-sets. However, the first step forward is knowing what we don’t know, and looking for who has the answers. More good news, we don’t have to look any farther than our brothers and sisters in the Military to find exactly what civilian EMS has been without for far too long — battle tested trauma care guidelines.
Let’s take a step back about three decades and discuss where these excellent tactical care guidelines came from. In the mid 1990s the majority of military treatment guidelines and training was derived from civilian EMS. Even the elite of our military providers were getting trained with civilian EMS models. It was at this point that Navy Seal Dr. Frank Butler identified what was working in civilian EMS, was not working in the theatre of combat. Dr. Butler set forth to identify what were preventable battlefield deaths, and what were the treatment modalities that would prevent these deaths. What Dr. Butler found was that there were three major areas of preventable death; exsanguinating hemorrhage, loss of patent airway and loss of ventilation. Dr. Butler termed his new program Tactical Combat Casualty Care. In the last decade NAEMT has adopted this curriculum and also created sister curriculums called Tactical Emergency Medical Care (civilian program), and the Law Enforcement First Responder Tactical Casualty Care Course. Through the evolution of this program, the acronym MARCH has been developed. We are going to break down each letter and discuss how to address these injuries in the tactical environment. Keeping in mind that this is written snap-shot of an in-depth 16 hour or longer course.
The first thing that must be highlighted, is that having two to four responders huddled around one GSW patient, is completely different than two providers treating 10 or 20 plus victims. To be prepared to adapt to the scope of tactical care, we need the right training and the right equipment. Depending on your response program guidelines, how you triage, treat and move, may be different. I whole heartedly believe that the first in Rescue Task Force should be treating and moving, trying to stop the bleeding and keep as many patients breathing, as fast as tactically possible. Once this is under way, other individuals can perform extraction and re-assessment of treatments.
The first priority of the MARCH algorithm is M-Massive Bleeding. We know that arterial hemorrhagic bleeding can be fatal in three to five minutes. We address massive bleeding through two treatment modalities, tourniquets and wound packing. Tourniquets (TQs) have thankfully become vogue again after the military proved their necessity and safety in Operations Iraqi Freedom and Enduring Freedom. Tourniquets should be applied above any massive limb bleeding above the joint on the single bone appendage, IE Humoral and Femoral bone placement. Placing the TQ below the joint makes gaining successful tamponade over two bones far less efficient. Safety is of minimal concern in pre-hospital EMS now that tourniquets have been utilized for up to 16 hours, with no long-term damage (Kragh, Journal of Trauma. 2008). If massive bleeding is not amendable to TQ use, it is likely from a junctional injury. A junctional injury is an injury of the pelvis, shoulder, or neck. Junctional injuries are defined as those not amenable to a Tourniquet, this could also be a very high thigh or groin wound. Wound packing has been practiced in the military for well over 20 years. As products have improved and effectiveness tracked, it is not un-common for this to be a basic life support treatment in various places around the United States.
Once massive bleeding has been addressed, responders should next address A-Airway. When trauma victims begin to lose consciousness, they begin to lose the ability to protect their airway. In the back of an ambulance these patients usually get intubated to establish a patent airway. In the tactical setting, intubation is not an option. However, the very basic insertion of a nasopharyngeal airway is a surprisingly great replacement. This cheap and small device can be the difference of your victim maintaining their airway or occluding it and going into respiratory collapse.
Now that we have stopped the bleeding and kept them breathing, we need to make sure they stay breathing. Next in algorithm is R-Respiratory. One of the biggest challenges of tactical medicine, is a departure from utilizing complete clinical picture diagnosis. For example, we probably wouldn’t treat a tension pneumothorax in an ambulance unless the patient had shortness of breath, decreasing oxygen saturations and loss of lung sounds. In the tactical environment we lack the equipment and time to make such accurate diagnosis. What this means for treating respiratory concerns, is that you may be treating the injury and likely injury progression, not necessarily the symptoms. If a patient has a GSW to any part of the thoracic region, we should have a high index of suspicion for a developing sucking chest wound. Since there are no negative effects of placing a non-occlusive chest seal, this should be done in almost every circumstance. The challenge becomes deciding if the patient needs to have a thoracic needle decompression performed. There is no clear-cut answer when to do this in the tactical environment. If the patient is clearly presenting like they have a tension pneumothorax, they likely need to have a needle decompression performed. The patient who hasn’t progressed to that point but may not see further care for a substantial amount of time, becomes the difficult one to decide to treat. In general, when a patient has a GSW to the chest, they have a very high likelihood of developing a tension pneumothorax, even after the non-occlusive dressing is placed.
The MAR components of the MARCH algorithm will really be the extent of treatment performed in a warm zone or hostile environment. The equipment needed to stop the progression of these injuries can be carried in large quantities on one or two providers. These also make up the treatment modalities that will be necessary to keep patients from rapid decline and death. Once patients are moved to Casualty Collection Points, Ambulance Exchange Points, or placed in ambulances, is when providers should address the C and H of the MARCH algorithm.
The C-circulation should be addressed once the patient is in a place where advanced care kits exist. In paramedic school it was branded on our brains that every trauma patient got two large bore IVs and two bags of fluids. Shortly after finishing medic school I had the pleasure of working on a SWAT team under the legendary Dr. Joe Bobovsky. He assured me that I didn’t need to pack a liter of Lactated Ringers around on my tactical vest. I had a hard time buying in on the theory of “permissive hypotension.” Now 13 years later, this is a well-studied practice that should be utilized in all pre-hospital trauma scenarios. It is not in the scope of this article to adequality describe the why and the how of permissive hypotension, but if it is currently not in your guidelines, it is something worth researching.
Lastly, the H-Hypothermia treatment. One of the most damaging things we do to field trauma EMS patients; is strip them, flip them and take them into the ER cold. According to a 2014 Jems article by Dr. Ryan Gerecht, a study of 71 trauma victims, with a core temperature less than 32 degrees Celsius, was associated with 100 percent mortality independent of the presence of shock, injury severity or volume of fluid resuscitation. Following the onset of hypothermia in a trauma patient is the “lethal trauma triad.” This consists of hypothermia, acidosis and coagulopathy problems. While understanding the triad can be complex, its treatment is easy; put your trauma patients in one of the many commercially offered pre-hospital space blankets and keep them warm.
As mentioned earlier, the complexities associated with tactical medicine are something that are best covered in an in-depth two to five-day course. The purpose of this article is to bring to light that someone who has not been trained in tactical medicine may find themselves very overwhelmed and under pre-paired in the hostile environment. It is however equally as important to remember that the majority of hostile incident care is in the scope of a BLS provider, who is appropriately trained and appropriately equipped. If you find yourself working in the hostile environment and your training or experience have fallen short, just remember the basics;
- Stop the bleeding,
- Keep them breathing,
- Keep them warm.