Beyond the First 5 Minutes

I have attended and been involved in a number of trainings where the medic’s role has been diluted to a shooter with bandages. This has unfortunately overflowed into much of the available training based on popular demand. It makes sense as a student. I’d love to go to a class and shoot for a week.

With that thought in mind there are two questions that must be asked. Number one, why am I here? Secondly, when I get back to the team, what was I supposed to learn, and what role will I be filling?

These two questions can very clearly help determine the efficacy and relevance of the training. It’s like hiring a plumber that’s primary role is roofing. He may have taken one class on plumbing, but hasn’t done it in five years. Is this the guy you want to hire to fix your pipes?

While that analogy may not be an exact parallel, it illustrates the misconception that has clouded the lines on the tactical team. Please don’t confuse this with me saying, “the medic is not responsible for care directly after injury.” Yet, the medic in most cases is not responsible for threat suppression, or “engagement” outside of a self-defense role. This varies in some situations, but for the majority the medic has a mainly supportive role to the team.

The Real Role

Without offending too many, let me back up the statements above. The role of the medic extends far beyond the first five minutes of care. While this is the bread and butter of medicine in the tactical setting, the “medic” is responsible for significantly more than that. “Force Preservation” should ultimately be the driving force of the medic on the team. Regardless of the situation, whether it be training or operational, the medic should be able to attend to conditions that can reduce the operational force. This means that placing a tourniquet is incredibly important, but so is knowing how to assess and treat a sprain, as well as having Tylenol or other over the counter (OTC) medications available. While much of this sounds similar to a street paramedic there are significant variations in methods as well as population. From the street side you meet a patient that has called, assess them, load them into the ambulance and treat en-route to the hospital. In most cases you are treating the immediate life threats or symptoms that are severe enough to treat, with the anticipation that you will be at definitive care shortly.

Conversely, in the tactical setting ailments are expected to be treated quickly so team members can return to training or working a call-out. The military follows a similar yet much more established and robust system of pre-hospital primary care. Specifically, the special operations community has what is called the Tactical Medical Emergency Protocols or TMEPs. This set of protocols covers acute dental pain to urinary tract infections. The military has learned over time that the medic must go beyond trauma care. “Doc” has long time been the go to guy for just about anything. The military has realized that they must prepare and train these guys to assess and treat just about anything that comes through the door. The TMEPs have added a pharmacology section that covers 68 medications that extend far beyond the traditional loadout of a medic. The box pictured is one of military origin. This being said, there is always a lag in transfer of best practice from the military to the civilian side. We, inclusive of the tactical medicine community, as a whole are trying to decrease that lag.

The Transition of Knowledge and Practice

How are we achieving the transition of knowledge? It’s an incredibly loaded question with answers that vary depending on who you talk to. The big picture is that we have begun to implement an approach much like the military’s. Training anyone and everyone to be able to do something in those first few minutes after injury. OIF/OF data shows that 24 percent of casualties passed before reaching a treatment facility. This number has significantly decreased with the implementation of proper equipment in training. Yet, in rural America the likelihood of passing before reaching a facility is 36 percent. You are 12 percent more likely to die from injuries in rural America, than you are in a declared area of conflict1.  That being said, the need has risen to implement these programs in the United States. Mr. Caulder cited the 75th Ranger Regiment in a previous article; they are the poster child of effective implementation of care. The 75th Ranger Regiment has an incredibly well developed and implemented medical program. They have lead the way with respect to reducing preventable death from trauma in combat. In a review done of fatalities within regiment, there was a fascinating determination made. Of 32 fatalities sustained by the regiment, only one passed. The death occurred in the hospital and not in the field. None of the fatalities sustained passed from preventable injuries or infection2. This shows there is an absolute need for training and equipping the masses. With the increase in incidence of mass violence as well as better-armed suspects, the implementation of an effective trauma treatment system domestically is a requirement. The Committee on Tactical Emergency Casualty Care or C-TECC, has been deeply ingrained in the implementation of such a process domestically. Training school teachers and church leaders as well as tactical medics and physicians will only improve the survivability of Americans.

Back to the Big Picture

With all of that said, it helps reiterate the fact that the face of trauma care and tactical medicine is changing. With that, the tactical medic needs to be better prepared to take care of the team. Primary care and sports medicine is quite possibly one of the best ways to “conserve the fighting force.” This can be accomplished by taking care of team members; understanding more advanced assessment practices as well as treatment. By being proficient at the administration of OTC medications, and making sure that team members with pre-existing conditions are properly prepared or medicated. By knowing that Tylenol and Mobic are the choice for mild pain versus ibuprofen or aspirin. Being able to assess and wrap an ankle. All of these things fall outside of the traditional paramedic scope of practice, however they are necessary skillsets for the tactical medic.

The advantage of being able to cross train between the military and the civilian side has been the ability to see the changes occurring the military real time and to translate these to the civilian side. Trauma treatment has been worked down to a science. With the changes now, we are learning that an otoscope and ophthalmoscope does much to conserve the force. The kit pictured is being issued to many of the Special Operations Forces (SOF) medics now, and has its place in the civilian setting with the right training. I see its place specifically when attached to teams that do energetic breaching or bomb/EOD teams. These tools allow you to assess for ruptured tympanic membranes (ear drum), retinal hemorrhage, and many other conditions, both traumatic and medical. Teaching medics basic assessment techniques, as well as basic treatment, is going to help in the long run. Making our team medics truly subject matter experts and aware of their mission within the team is a lofty goal. It is achievable. If you are currently a medic on a team I urge you to expand your clinical knowledge into the not so exciting, but incredibly important world of primary care and sports medicine. These conversations can be had with medical directors to allow for an expanded scope that is an easy sell. The caveat is if you don’t have formal training, don’t pick up these tools and begin to assess or treat without knowledge of use.

References:

1 Eastridge et al, Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma 2011

2 Kotwal et al, Eliminating preventable death on the battlefield.J Surgery 2011