Tuesday, November 8, 2011

Tactical Emergency Medicine for Operations

This past weekend saw the first TEMO course run for the Irish Defence Forces. The course ran over three days and offered Tactical Combat Casualty Care curriculum for the troops. The TCCC was designed by Dr. John Hagmann and the US military in the mid ninety's. 
   Ireland's jump into the TCCC arena is a welcome event. Most of the countries around the world have adapted this programme into their combat medical training. The United Kingdom has been running their Battlefield Advanced Trauma Life Support (BATLS) course for over ten years. The United States has been running TCCC courses for even longer than that.
   Deployment Medicine International (DMI) was the first civilian company on the market to offer the new TCCC principles for the civilian market. DMI was founded by Dr. John Hagmann who was part of the original team who designed the TCCC curriculum. DMI runs the Operational and Emergency Medical Skills (OEMS) for medics and the Deployment Medicine Operator's Course for non medics. 
   The basics of TCCC are:
     1. Traditional EMS approach gets people killed on the battlefield
     2. The ABC protocol needs to be changed to CABC
     3. Most of the combat deaths occur within the first hour after injury
     4. Most of those deaths are preventable by stopping catastrophic haemorrhage 

   Therefore the TCCC guidelines changed the normal Airway-Breathing-Circulation algorithm into Catastrophic Haemorrhage-Airway-Breathing-Circulation algorithm. This change alone has saved many lives in the past ten years of warfare in the middle east. 

   Another major change in the way that tactical medicine is practised is to split down the treatment that the casualties will receive while the bullets are still firing. This is called Care Under Fire (CUF). Once the firefight is over or temporarily paused, the TCCC medic can move the casualty into a safer place and provide Tactical Field Care (TFC). 

   Basically it looks like this:

Return effective fire and take cover.
Direct casualty to continue to provide effective fire if possible.
Direct casualty to move to cover and apply self-aid if able.
Keep the casualty from sustaining additional wounds.
Casualties should be extricated from burning vehicles or buildings and moved to places of relative safety.
Once the medic has safely reached the casualty only two procedures are allocated: Stop massive bleeding, and stabilize the airway.

Casualties with an altered mental status or who are combative should be disarmed immediately.
Catastrophic Haemorrhage
   Casualties are reassessed whenever they are rolled or moved. Their massive bleeding should have been stopped during Care Under Fire.

Airway Management
a. Pain or Unresponsive casualties in the AVPU scale:
- Chin lift or jaw thrust maneuver
- Nasopharyngeal airway
- Place casualty in the recovery position
b. Casualty with airway obstruction or impending airway obstruction:
- Chin lift or jaw thrust maneuver
- Nasopharyngeal airway
- Allow casualty to assume any position that best protects the airway
- Place unconscious casualty in the recovery position.
- If previous measures unsuccessful:
- Surgical cricothyroidotomy

a. Consider a tension pneumothorax and decompress the chest on the side of the injury with a 14-gauge needle catheter inserted in the intercostal space at the mid axillary line one hands width below the axilla. Aim 1 cm anterior in order to miss the long thoracic artery. 
b. All open and/or sucking chest wounds should be treated by immediately applying an occlusive material to cover the defect and securing it in place. Monitor the casualty for the potential development of a subsequent tension pneumothorax.

a. Assess for unrecognized haemorrhage and control all sources of bleeding. 
b. Reassess prior tourniquet application. Expose wound and determine if tourniquet is needed. If a tourniquet is not needed, use other techniques to control bleeding such as Celox gauze. 
d. When time and the tactical situation permit, a distal pulse check should be accomplished. If a distal pulse is present then no resuscitation hydration is provided for the first hour. This is called Hypotensive Resuscitation.
e. Expose and clearly mark all tourniquet sites with the time of tourniquet application. 
Intravenous (IV) access
- Start an 18-gauge IV or heparin lock on ALL casualties. One never knows when the viens will disappear.
- If resuscitation is required and IV access is not obtainable, use the intraosseous (IO) route, preferably with the FAST-1 device.
Fluid resuscitation
Assess for haemorrhagic shock; altered mental status (in the absence of head injury) and weak or absent peripheral pulses are the best field indicators of shock.
a. If not in shock:
- No IV fluids necessary
- PO fluids permissible if conscious and can swallow
b. If in shock:
- Hextend, 250-mL IV bolus. Use Hartmann's Solution as a second option.
- Repeat once after 30 minutes if still in shock.
- No more than 1000 mL of Hextend
-Continue to give fluids until a radial pulse is felt.
c. Continued efforts to resuscitate must be weighed against logistical and tactical considerations and the risk of incurring further casualties.

a. Determine an AVPU, PERRLA and A&O assessment
b. Splint and package any extremity or other orthopaedic injury

a. Minimize casualty’s exposure to the elements. Keep protective gear on or with the casualty if feasible.
b. Replace wet clothing with dry if possible. Get the casualty onto an insulated wrap.
c. When gear is not available, use dry blankets, poncho liners, sleeping bags, or anything that will retain heat and keep the casualty dry.
f. Warm fluids are preferred if IV fluids are required.

Full set of Vital Signs
Pulse oximetry is an important assessment tool often forgotten in tactical medicine.
Find and continue to monitor vital signs. Long term observations are critical for the Tactical Medic. A lot of medical assessments can be determined from long term vital sign monitoring.

Get Documentation
The ATMIST Report has been used here in Ireland and the UK for several years. It is still finding resistance at the highest levels by those who find change challenging.
A- Age of casualty
T- Time of incident
M- Mechanism of Injury
I- Injuries sustained
S- Signs and symptoms
T- Treatment

TEMO Medics hot loading an A139 helicopter

Operational Emergency Medical Skills Course Manual, LTC (Ret) J. Hagmann, M.D., 2004
Tactical Combat Casualty Care, Committee on Tactical Combat Casualty Care, Government Printing Agency, Feb 2003
Tactical Combat Casualty Care in Special Operations, CPT Frank Butler, Jr., MC, USN; LTC John Hagmann, MC, USA; ENS George Butler, MC, USN, Military Medicine, Vol. 161, Supp 1, 1996

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