Setting the (Tactical) Scene

When tactical medics encounter a sudden, life-threatening situation-also referred to as a high threat stimulus -their body's sympathetic nervous system (SNS) is likely to automatically engage, making them unable to function in the manner in which they were trained. Such a triggering crisis might be a barricaded suspect, a hostage situation, an active shooter or accompanying a SWAT team serving a high-risk warrant.

     Some people react better than others to fearful or threatening situations. Tactical medic trainers understand this and often use building-block training to give students the physical and psychological tools they will need to handle these incidents. This type of training begins at slower speeds, working into faster appropriate responses and building up the tactical medic's ability to effectively respond to violent crisis situations. In martial arts, this is known as "hardening," and this is what tactical medic scenario training is all about.

Hormonal-Induced Tachycardia
     The sympathetic nervous system is responsible for the massive discharge of catecholamine that leads to our fight-or-flight reaction when our mind perceives imminent danger. Unfortunately, this can result in catastrophic performance deterioration.

     During hormonal-induced tachycardia, the body can reach its peak of strength and energy within 10 seconds. Within this minimal amount of time, heart rates can spike well into the mid 200 beats per minute (bpm) range. Depending on the person's training, physical fitness and exertion, the midbrain (mammilian) will take over when heart rates climb above approximately 175 bpm.

     The midbrain is typically responsible for four lifesaving or life-preserving tasks: fight, flight, feeding and breeding. Unfortunately, the midbrain will not know how to react appropriately unless it is trained through hours and hours of repetitive conditioning. The body will also sensory-gait, deleting sensory skills it does not deem useful for survival. The goal to overcoming the catastrophic events that this SNS reaction can cause is to force the body to return to the way it was trained.

     When hormonal-induced tachycardia occurs, a scramble of events takes place within the human mind and body. According to tactical medic Sean McKay of Clearwater (FL) Fire and Rescue, increased heart rate is an indication of survival stress reaction. Normal heart rate is 60-100 beats per minute. At 115 beats per minute, most people begin to lose fine motor skills: finger dexterity, eye/hand coordination and the ability to multitask. At 145 bpm and above, most people lose their complex motor skills-the ability of three or more motor skills to work in unison. But between 115-145 bpm, survival performance is at its highest in regard to better complex motor skills, reaction time and cognitive reaction time. Therefore, if a medic is at a high level of bpm, he needs to get his heart rate down to do skills like inserting an IV, intubating or decompressing a chest. However, the higher heart rate may be appropriate when extracting a victim.

     Finally, when fear and shock force the heart rate to 175 bpm and above, there is a catastrophic breakdown in a person's ability to effectively respond, leading to freezing, irrational fight or flight, submissive behavior, voiding of the bladder, etc. The higher the beats per minute, the more a person's perception of a situation and his ability to cognitively process response options will be affected.

     That is not all the biochemistry that takes place. Near vision and the ability to focus close up are also lost, leading to tunnel vision.

     According to McKay, tactical medic trainers try to reproduce in their scenarios the collection of psychological and physiological effects that are likely to happen in real life. The more stress induced in training, the less stress is experienced in real-life situations. The key is creating "hyper-realistic" scenario training, thereby providing students with stress inoculation and stimulus-response situations.

Survival Stress

Reaction Scenario Training Active Shooter Scenario #1
     In this scenario, rescues and bad guy suppression had to be conducted while bad guys were still firing weapons and creating a threat. Casualties needed to be evacuated. These casualties might be medics or responding officers shot while doing their rescue or suppression work. To heighten the levels of stress in the scenarios, sirens were sounded and responding medics and police officers were shot at with paintballs or Simunition training munitions. This scenario also included stress inoculation under low-light conditions.

     Issues teams needed to consider were tactical planning, diversion, officer-down situations, shots fired, tactical retreats, rally points and safe areas, multiple victims, egress and evacuation. Some patients were dragged to cover and evacuated on a half Sked. Students were required to engage both existing and potential threats, and assess, triage, treat and extract any casualties. This event mirrored day-to-day special operations high-risk entries by achieving quick, aggressive control of a house or building. The threats in this scenario were unknown, and multiple victims needed to be kept alive until they could be treated further. Patients and downed team members were extracted and taken to cover.

     Problems encountered by medics during the scenario were arterial hemorrhaging of extremities, chest wounds and confirmed dead. The medics had to determine who was dead and who was not by remote assessment from behind cover without exposing themselves.

Active Shooter Scenario #2-Tourniquet
     This low-light scenario was conducted within a dark training house normally used for gas mask drills. The medics, working in two-medic elements, were tasked with locating a casualty, conducting any required tactical combat casualty care, and evacuating a wounded person to a waiting SWAT van.

     In this scenario, the bad guy was not inside the dark house, but the building needed to be searched. The use of a flashlight or any other lighting device was not an option. Officers, in the form of the police element of the SWAT team, provided security, thereby preventing the bad guy from entering the dark house and endangering the two medics and any patients. During this threat, the bad guy was not eliminated.

     Upon entering the dark house, the two medics crawled along the walls until they located their patient. They did not talk or make any noise while they searched for him. Once found, the patient had to be treated. His symptoms were slow breathing and bleeding out from a moulage leg wound, which the medics could find by feel. The medics had to apply a zero-lighting tourniquet and intubate their patient. They could not use a scope to intubate because, in the real world, the white light from a scope would give away their location. According to McKay, in Israel, two medics using a laryngoscope's light were killed by a sniper when first one medic and then the other turned on the light. The message was clear-no lights in this sort of tactical environment. In the tactical training scenario, the two medics had to use either a blind insertion airway device, such as a Combitube, or digitally intubate the patient.

     After the patient was treated and a tourniquet applied, the injured role-player was moved from the dark house and into a waiting SWAT van. Once inside the van, the patient was replaced by a manikin. A 12-minute ride in the van was simulated by turning on the van's siren. Inside the van, there were some variations as different medic teams treated the patient. A basic treatment was for airway management-utilization of airway adjunct devices, NPA, etc.-to be assisted by the use of a bag-valve mask and IV administration. Preventable blood loss was the most important concern.

     A follow-up critique also addressed any weaknesses.

Conclusion
     This survival stress reaction training works. Not only have Clearwater Fire and Rescue tactical medics placed first or second in the International Tactical EMS Conference and Competition for the last three years-the only years they entered-but this training will carry over to their jobs on the streets, saving their lives and the lives of their patients.

     For further information, McKay recommends reading On Combat by Lt. Col. Dave Grossman, who is a leading authority on the psychological and physiological reactions of the body during deadly conflicts. McKay's scenario training is modeled after Grossman's invaluable research. Sean McKay can be contacted at tacticalrescue@tampabay.rr.com.

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. Jim is a retired lieutenant from the Brook Park, OH, Police Department and a former state of Florida investigator. Mickey is a Florida-based writer and author of an award-winning novel.