TRAINING Tactical Medics

     In military environments, fast evacuation of casualties is imperative. Ninety percent of combat deaths occur before patients reach medical treatment facilities; some 15%-20% of these are probably preventable, coming from causes like bleeding extremities, collapsing lungs and airway obstructions.

     Many of the wounding patterns seen in recent military conflicts are also seen in the civilian tactical arena. Medical providers supporting tactical law enforcement operations are now developing, implementing and utilizing casualty-response tactics, techniques and procedures based on concepts of tactical combat casualty care (TCCC)-utilizing the appropriate equipment at the appropriate time.

Casualty Response Training Course
     In the world of policing, the goal of tactical (SWAT) teams is to contain, control, communicate and try to bring about a peaceful resolution. Yet sometimes police actions do not end peacefully. Trying to fit conventional civilian medical methodologies into a police tactical environment can feel like trying to provide care at arm's length: Time, blood and hope are lost as ambulance crews wait in a safe place until the situation, the bad guys and their weapons are under control and the scene is safe.

     Learning from the military's experiences, enlightened tactical teams increasingly operate accompanied by unconventional tactical medics. These medics work up front, in close proximity to entry teams, where they might be urgently needed to deal with injuries.

     Recently, 90 participants and instructors took part in a new casualty response training course sponsored by the National Tactical Officers Association (NTOA), Greenville County (SC) Sheriff's Office SWAT Team and North American Rescue Products, Inc. The driving force behind it was North American Rescue Products CEO Robert Castellani, a former Air Force tactical medic and pararescuer. Castellani wanted to combine the knowledge and resources of leading academic institutions, culturally like-minded companies and experts in asymmetric warfare to generate innovative combat casualty care solutions. Accordingly, course organizers brought in a broad cadre of instructors to provide solid and well-referenced training.

     Participants similarly brought their day-to-day experiences to the program. While most were fire and rescue medics, they also included doctors with special-operations backgrounds and tactical operators including medics, SWAT operators, military special-ops personnel, federal agents, state troopers, sheriffs' deputies and police officers.

     Course objectives were to enhance mission successes and reduce legal liabilities by conducting practical exercises for students.

Lectures, Hands-On and Scenarios
     The conference began with lectures, then progressed to task-orientated hands-on training, and finally to show-what-you-now-know scenarios.

Lectures
     Lecture topics covered such areas as the evolution and future of TCCC, lessons learned from special forces, TCCC for civilian applications, perimeter tactics and movements, high-threat extraction and the physiology of self-preservation.

     One lecture, on medical threat assessment, imparted basic wisdom such as the need to know the type of mission being conducted, if there are any animals or hazardous-material concerns, and how to evaluate a targeted structure. Medics should also have extraction and treatment plans, know the medical and health issues of fellow team members, be aware of local medical resources and have transportation and evacuation available, both ground and air.

     Class members were provided with combat casualty response kits that included tourniquets, nasopharyngeal airways and other mission-critical products needed to address the three most preventable causes of death in the tactical environment. These kits were utilized for the scenarios and hands-on training.

Hands-on Training
     Hands-on training took place in a vacant warehouse. Participants were divided into groups that met with their instructors at five different skill stations.

     At one station an Army Ranger doctor and member of the military's Committee on Tactical Combat Casualty Care discussed and demonstrated several products, which included the Combat Application Tourniquet (CAT), which was developed for hemorrhage control in combat situations. In addition, Hemostatic HemCon, CELOX and QuikClot bandages, tapes and powders were reviewed, and common myths associated with their use were addressed. Wounds were packed with gauze to minimize bleeding, and the various hemostatic agents were introduced. For immediate lifesaving control in a patient with hemorrhage not amenable to conventional methods of hemostasis, wounds were packed to the bone and the gauze and hemostatic agent left in. Medics often sprinkle hemostatic powder on; instead, it should be used heavily, with a pressure dressing applied for five minutes. If a patient is moved too soon, rebleeding may occur. (In this case, the "patient" was constructed from large-diameter PVC pipe covered with padding and black tape at each end. Slits represented penetrating wounds.)

     Down the hall, nasopharyngeal airways and the King LT Supraglottic Airway were reviewed, with a warning that laryngoscopes with white lights are detectable in tactical environments. Another station covered use of the Hyfin chest seal and the need to cover sucking chest wounds. The instructor demonstrated needle chest decompression on a manikin filled with air, and the medics practiced what they'd learned.

     In the darkness of the back of the warehouse, medics responded to a barricaded drug lab subject scenario. It was night, the team was inside, gunshots had been heard, and the medics were called in to find the wounded officer, assess him by touch and take him out of the room. The small room was dimly lit and filled with chemical smoke. A manikin patient with a moulage arm wound lay on the concrete in a pool of blood. Assessment techniques involved searching for a gun (there was one), verbalizing so that the team leader and medics knew when they were searching for a weapon and when it was found, locating the wound and applying a tourniquet in the correct location. The medics dragged their patient to safety, after which their work was critiqued and decontamination procedures discussed.

     After morning classes on the third day, the hands-on applications involved methods of getting an individual to safety. These included various ways of using specialized webbing, moving an unresponsive person in an urban environment and other methods of dragging. Emphasis was placed on adding high-threat extraction to the medics' repertoire of care.

     Late in the day, conference participants went to a nearby area of abandoned houses and practiced entering the buildings and searching them, at first rapidly, then slowly, thinking out moves before attempting them. TCCC lessons were combined with use of ballistic shields, door breachers, entry and room-clearing techniques, and taking down doors. Rescuing a patient by breaking through walls (as in a series of motel rooms) rather than by approaching directly (e.g., down the outside hallway) was discussed, and participants practiced going through walls of the houses, as well as making a passageway through a specially constructed cinderblock wall.

Final Scenarios
     The final scenarios were force-on-force, with protective gear, paintball guns, role players and rules of engagement. This was intended to give participants a better understanding of police tactics, as well as their role in rescuing individuals.

     The four final events took place in the long, bowling alley-like halls, classrooms and gym of a closed 1960s-era elementary school, and the playground outside. At the fifth station, participants took a written examination to gauge their knowledge of TCCC.

     The medics and officers were split into tactical teams, each with a team leader. Those playing the bad guys did not shoot medics/officers if they were doing the correct things.

     Scenarios were tightly controlled. The bad guys could give up, but if one was "shot" in the scenario, he would also have to be rescued. All the force-on-force scenarios involved stress factors, tactics, bringing patients to safe zones, gaining ground and extricating patients quickly. There were problems that required solving; incorrect tactics might place a team member in a kill spot.

     One scenario included an active shooter at the end of a deep hallway near role players and a manikin patient. Another involved the use of a police armored rescue vehicle. Shots were fired, and a downed person needed to be extricated. The shooter and his location were unknown to the responders. The team was dropped off along one side of the school, near a chain-link fence line and trees. A woman role player, running across the playground to meet the arriving tactical team, was shot in the leg. The armored rescue vehicle was "stuck" in traffic, so the team had to formulate a plan. They extricated the downed woman by dragging her out of fire and assessed her. When the ARV finally responded, team members used it for cover and placed her inside. The original injured person-this time a manikin-was also taken to the safety of the ARV. Inside the medics performed the needed medical procedures as the ARV drove them away.

Conclusion
     Tactical combat casualty care is based upon proven, practical knowledge, experience and lessons drawn from the military. However, tactical emergency medical support (TEMS) needs to be more widely implemented and a blueprint for its wider dissemination put in place.

Jim Weiss and Mickey Davis are writers specializing in safety-forces issues and technology, and have had more than 100 articles published in law enforcement and emergency services magazines. Weiss is a retired lieutenant from the Brook Park, OH, Police Department and a former investigator for the state of Florida. Davis is a Florida-based writer and author of an award-winning novel.