TacticalTactical EmergencyEmergency MedicineMedicine (TEMS)(TEMS)

DavidDavid W.W. Callaway,Callaway, MDMD Resident, Emergency Medicine Harvard Affiliated Emergency Medicine Residency 25 FEB 2006 TEMSTEMS OverviewOverview

! WhatWhat isis TEMSTEMS ?? ! TheThe NeedNeed forfor TEMSTEMS ! TheThe OriginOrigin ofof TEMSTEMS ! TEMSTEMS ChallengesChallenges ! ManagementManagement GuidelinesGuidelines ! EquipmentEquipment TacticalTactical EmergencyEmergency MedicalMedical SupportSupport (TEMS)(TEMS)

! TEMSTEMS isis anan outout--ofof--hospitalhospital systemsystem ofof carecare dedicateddedicated toto enhancingenhancing thethe probabilityprobability ofof specialspecial operationsoperations lawlaw enforcementenforcement missionmission successsuccess andand promotingpromoting publicpublic safetysafety TEMSTEMS GoalsGoals

! Mission accomplishment

! Overall team health

! “Step into the fray”

! Protection of: 1. Team Members 2. Victims/ hostages 3. Bystanders 4. Perpetrators TheThe NeedNeed forfor TEMSTEMS

“People sleep peaceably in their beds at night only because rough men stand ready to do violence on their behalf”.

- George Orwell BriefBrief HistoryHistory ofof TacticalTactical MedicineMedicine

! HippocratesHippocrates ! BarronBarron dede LarreyLarrey ! HawkeyeHawkeye PiercePierce ! VietnamVietnam ! LAPDLAPD SWATSWAT ! SpecialSpecial OperationsOperations ! IncreasedIncreased NeedNeed OriginOrigin ofof TEMSTEMS

! SpecialSpecial OperationsOperations ! US Army 18D ! US Navy Hospital Corpsmen ! S.W.A.T.S.W.A.T. ! Origin ! Evolution of Tactical Emergency Medical Support ! TheThe lastlast 22 yearsyears ! Committee on Tactical Combat Casualty Care ! PHTLS ! Private Organizations

UniqueUnique TEMSTEMS ChallengesChallenges

! ImageImage ofof thethe medicalmedical providerprovider ! ProvisionProvision ofof carecare inin hostilehostile oror austereaustere environmentsenvironments ! LimitedLimited resourcesresources ! NoNo nationalnational standardstandard ofof trainingtraining ! EthicsEthics TEMSTEMS ––vv-- ConventionalConventional EMSEMS

EMSEMS TEMSTEMS ! RescuerRescuer safetysafety ! MissionMission successsuccess ! SceneScene safetysafety ! TeamTeam safetysafety ! AmbulanceAmbulance basedbased ! ZonesZones ofof CareCare ! BLSBLS ! ManMan packpack ! ALSALS ! TacticalTactical constraintsconstraints ! CPRCPR ! PreventivePreventive medicinemedicine ! HealthHealth maintenancemaintenance ! TraumaTrauma carecare DocsDocs withwith GlocksGlocks??

! TacticalTactical MedicsMedics ! Sworn or not ! Armed or not ! MedicalMedical RegulationRegulation ! CommunityCommunity ImpressionsImpressions ! Cowboy’s ! Hippocratic Oath TheThe workingworking environmentenvironment

! SpecialSpecial equipmentequipment ! TheThe SixSix “P’s”“P’s” ! “Man“Man Pack”Pack” ! PlanPlan forfor thethe worst,worst, hopehope forfor thethe bestbest ! You can’t go to the supply room in the ED ! DifficultDifficult toto workwork inin thethe HotHot ZoneZone Limitation of Resources TEMSTEMS GuidelinesGuidelines

! DevelopmentDevelopment hashas beenbeen adad hochoc ! ZonesZones ofof CareCare ! HotHot ! WarmWarm ! CoolCool ! NoNo nationalnational standardizedstandardized guidelinesguidelines ! TacticalTactical CombatCombat CasualtyCasualty CareCare TEMSTEMS ProviderProvider MustMust UnderstandUnderstand

! Chemical Munitions and deployment techniques ! Distraction devices and effects ! Booby Traps and unconventional weapons ! Weapons Systems and management ! Active countermeasures ! Dynamic Clearing and movement ! Stealth Movement ! Medical advisor to the mission commander TEMSTEMS TrainingTraining

! TEMS providers are trained to work in a tactical environment ! Tactical Training ! Evidence preservation ! Weapons trained ! Law enforcement training ! Medical Training ! Provide care that Officers CANNOT ! Tactical Combat Casualty Care CommitteeCommittee onon TacticalTactical CombatCombat CasualtyCasualty CareCare ((CoTCCCCoTCCC)) 2004:2004: USSOCOMUSSOCOM toto BUMEDBUMED

! 2001:2001: USSOCOMUSSOCOM initiatedinitiated thethe CoTCCCCoTCCC

! 2004:2004: BUMEDBUMED assumedassumed sponsorshipsponsorship ofof TCCCTCCC

! FormalizedFormalized CommitteeCommittee onon TCCCTCCC

! CoordinatedCoordinated throughthrough NavalNaval OperationalOperational MedicineMedicine InstituteInstitute (NOMI)(NOMI) CommitteeCommittee onon TCCCTCCC ((CoTCCCCoTCCC))

! Responsibilities:Responsibilities: ! DraftDraft andand updateupdate TCCCTCCC guidelinesguidelines forfor thethe PHTLSPHTLS ManualManual ! ProvideProvide recommendationsrecommendations onon TCCCTCCC implementationimplementation toto componentcomponent servicesservices ! EvaluateEvaluate effectivenesseffectiveness ofof TCCCTCCC guidelinesguidelines inin combatcombat CommitteeCommittee onon TCCCTCCC ((CoTCCCCoTCCC))

! Membership:Membership: ! Chairman:Chairman: Dr.Dr. SteveSteve GiebnerGiebner ! Medics:Medics: 18D,18D, PJ,PJ, Rangers,Rangers, USMC,USMC, SEALSSEALS ! Physicians:Physicians: TraumaTrauma surgeons,surgeons, ER,ER, FP,FP, CriticalCritical CareCare andand OperationalOperational MedMed ! MilitaryMilitary andand civiliancivilian representationrepresentation ! Voting:Voting: ! AA votevote isis aa votevote (equal(equal representation)representation) CommitteeCommittee onon TCCCTCCC ((CoTCCCCoTCCC))

TheThe CoTCCCCoTCCC doesdoes NOTNOT mandatemandate medicalmedical trainingtraining oror carecare policy…policy…

WeWe provideprovide recommendationsrecommendations forfor aa basicbasic combatcombat traumatrauma managementmanagement planplan SoSoSo whatwhatwhat isisis there?there?there?

1996:1996: PublicationPublication ofof GuidelinesGuidelines Tactical Combat Casualty Care in Special Operations

Military Medicine Supplement August 96 TCCCTCCC SummarySummary

1. AnAn evolvingevolving setset ofof PrinciplesPrinciples guidingguiding traumatrauma responseresponse inin thethe combatcombat environment:environment: ! Care Under Fire (Hot Zone) ! Tactical Field Care (Warm Zone) ! CASEVAC Care (Cool Zone) 2. TeachesTeaches operatorsoperators andand medicalmedical personnelpersonnel toto managemanage appropriatelyappropriately thethe toptop 33 causescauses ofof preventablepreventable deathdeath onon thethe battlefieldbattlefield withinwithin eacheach phasephase ofof care:care: ! Exsanguination from extremityextremity woundwound ! Tension pneumothorax ! Airway obstruction TCCCTCCC SummarySummary

! TCCCTCCC guidelinesguidelines areare tacticallytactically andand medicallymedically soundsound

! TCCCTCCC guidelinesguidelines areare relevantrelevant inin ITEMSITEMS curriculumcurriculum designdesign andand operationaloperational executionexecution CivilianCivilian ApplicationsApplications ““CareCare UnderUnder Fire”Fire” isis CareCare UnderUnder FireFire CivilianCivilian ApplicationsApplications

! TCCCTCCC isis notnot “anti”“anti”-- ATLSATLS ! IncreasedIncreased tacticaltactical medicalmedical trainingtraining forfor “non“non medicalmedical personnel”personnel” ! EmphasisEmphasis onon “Medical”“Medical” involvementinvolvement inin operationaloperational planningplanning ! CASEVACCASEVAC ! VehicleVehicle staging/Gearstaging/Gear ! IncreasedIncreased acceptanceacceptance ofof tourniquetstourniquets TCCCTCCC RevisionRevision 20032003

! First version in 1999

! Published in Revised 5th Edition of PHTLS Manual

! Per Recommendations of CoTCCC TTCCCCCC TransitionTransition PHTLSPHTLS ManualManual ! RecommendationsRecommendations endorsedendorsed byby AmericanAmerican CollegeCollege ofof SurgeonsSurgeons

! RecommendationsRecommendations endorsedendorsed byby NationalNational AssociationAssociation EMTsEMTs

! TheThe TCCCTCCC guidelinesguidelines areare thethe combatcombat traumatrauma carecare guidelinesguidelines everever toto havehave obtainedobtained thisthis dualdual endorsementendorsement onlyonly setset ofof SoSo whatwhat doesdoes TEMSTEMS reallyreally do?do?

PrePre-- MissionMission

Mission/OperationMission/Operation

PostPost-- MissionMission PrePre-- MissionMission

! OperationalOperational PlanningPlanning ! Local Resources ! Agency coordination ! Operations Order ! ReconRecon MissionMission ! MedicalMedical IntelligenceIntelligence ! Prediction of medical problems of suspects and hostages ! Improves public opinion ! Reduces Liability ! TeamTeam andand personalpersonal education/trainingeducation/training MissionMission

! OperatorOperator ! ProvisionsProvisions forfor transporttransport ! EvidenceEvidence PreservationPreservation ! BarricadeBarricade medicinemedicine ! RemoteRemote physicalphysical assessmentassessment ! ExtricationExtrication andand evacuationevacuation ! CanineCanine firstfirst aidaid MissionMission

! SituationSituation ! Location ! Suspects ! Number of suspects ! Physical description ! Dogs ! MissionMission ! Warrants ! Barricaides MissionMission ExecutionExecution

! 66 “P’s”“P’s” ! ClearClear RolesRoles ! CommunicationCommunication ! FlexibilityFlexibility ! AlternativeAlternative plansplans ! ConfidenceConfidence ! TrustTrust BasicBasic TraumaTrauma GuidelinesGuidelines

! Hot Zone (Care Under Fire) ! Scoop and run ! Life threatening bleeding ! Safe and quick exit to warm zone ! Warm Zone (Tactical Field Care) ! ABC’s ! C-Spine ! Cool Zone ! Relative safety ! Staging area ! Rarely a need to rush into a situation TEMSTEMS TraumaTrauma FactsFacts SameSame Care,Care, yetyet notnot thethe samesame

! 90%90% ofof victimsvictims inin warwar diedie onon thethe battlefieldbattlefield ! 2,5002,500 dieddied fromfrom aa simplesimple extremityextremity hemorrhagehemorrhage inin VietnamVietnam ! GoldenGolden HourHour –– mostmost diedie inin 3030 minutesminutes ofof injuriesinjuries thatthat requirerequire simplesimple interventionsinterventions ! PenetratingPenetrating injuryinjury requiresrequires differentdifferent carecare fromfrom bluntblunt traumatrauma ! Boarded and collared? ! Forget collar under fire ! Board and Collar in the Warm Zone ! Scoop and run? CareCare inin thethe HotHot zonezone

! Fire superiority ! Stop life threatening bleeding ! Protect yourself ! Protect the casualty ! Scoop and Go CareCare inin thethe WarmWarm ZoneZone

! Airway Management ! No airway obstruction ! Chin Lift or Jaw thrust ! Nasal Airway ! ETT or Esophageal airway ! LMA ! Breathing

! O2 ! Ventilate ! Needle Thoracostomy ! Chest Tube Insertion ! Circulation ! IV Access/ Intraosseous ! Control Hemorrhage ! Hespan TacticalTactical MovementMovement ofof CasualtiesCasualties (CASEVAC)(CASEVAC)

! Monitoring Vitals ! Inspect and dress all wounds ! Analgesia ! Splint fractures and establish neurovascular integrity ! Antibiotics ! Open Fractures ! Penetrating abdominal Trauma ! CPR ! Evacuation and Transport InjuryInjury PriorityPriority

! LifeLife threateningthreatening bleedsbleeds ! BreathingBreathing ! BleedingBleeding WoundsWounds ! BrokenBroken bonesbones ! BurnsBurns CoolCool ZoneZone

! StagingStaging areaarea ! RelativelyRelatively safesafe ! MustMust staystay alertalert

Texas,Texas, AugustAugust 1st,1st, 1966…1966… CharlesCharles WhitmanWhitman

! TexasTexas TowerTower SniperSniper ! 9090 minutesminutes ! 1414 deaddead ! ScoresScores injuredinjured TheThe ToysToys-- II meanmean EquipmentEquipment MedicalMedical GearGear

! Hemorrhage control pack ! Airway kit ! Ambu Bag ! Mechanical Airway ! Chest tubes ! IV’s ! Trauma Supplies ! Surgical Kits ! Suture Material ! Burn Supplies ! Personal protective equipment ! Light source ! Drugs TacticalTactical GearGear

! Body Armor ! Side Arm - Long Gun ! Spare magazines/ammunition ! Flash Bangs ! Helmet ! Goggles ! Gloves ! Knee and elbow pads ! Tactical Load Bearing vest or pack ! Protective Shield ! Mirror or Breaching Equipment OnOn thethe HorizonHorizon HemorrhageHemorrhage ControlControl OneOne Option:Option: CombatCombat ApplicationApplication TourniquetTourniquet (CAT)(CAT) ChitosanChitosan HemostaticHemostatic DressingDressing

! Hold dressing by the non-absorbable polyester backing and discard the foil over-pouch. Hands must be dry to prevent dressing from sticking to hands. QuikClotQuikClot

! AcceptedAccepted byby USMCUSMC ! IFAKIFAK (Individual(Individual FirstFirst AidAid Kits)Kits) ! WipeWipe bloodblood andand excessexcess waterwater fromfrom woundwound ! SprinkleSprinkle inin powderpowder ! Caution:Caution: GetsGets veryvery HOTHOT FutureFuture PainPain ControlControl FentanylFentanyl LozengeLozenge

Fentanyl Transmucosal Lozenge FentanylFentanyl LozengeLozenge

! ComesComes inin threethree strengths:strengths: ! 400mcg400mcg ! 800mcg800mcg ! 1600mcg1600mcg ! 400mcg400mcg hashas shownshown anan effecteffect equivalentequivalent toto morphinemorphine injectioninjection ! DoesDoes notnot requirerequire anan IVIV lineline ! Simple,Simple, easy,easy, andand effectiveeffective IntranasalIntranasal KetamineKetamine

• Easy to use

• No drowsiness (unlike narcotics)

• Side effects: • Dizziness •Nausea • Fatigue • Increased secretions • Hallucinations on withdrawal SummarySummary

! TEMSTEMS isis cool,cool, butbut itit ain’tain’t easyeasy

! TCCCTCCC isis solidsolid

! TrainingTraining isis availableavailable So… GetGet InvolvedInvolved

! International Tactical EMS Society (ITEMS) ! http://www.tems.org/ ! International School of Tactical Medicine ! http://www.tacticalmedicine.com ! C.O.N.T.O.M.S. ! http://www.casualtycareresearchcenter.org/ ! Disaster Medicine David E. Hogan and Jonathan L. Burstein Philadelphia, PA: Lippincott Williams & Wilkins, 2002, 2006 US Questions?Questions? ThanksThanks toto allall ofof ourour menmen andand womenwomen inin uniformuniform ThanksThanks forfor youryour timetime

DavidDavid CallawayCallaway [email protected]@bidmc.harvard.edu