Tactical Emergency Care
An Introduction for Physicians
Robert A. De Lorenzo, MD, FACEP
Major, Medical Corps, US Army
Disaster 2000 Conference, Orlando, FL
April 2000
Objectives
Describe the tactical environment and the impact it has on emergency care.
Understand the role of the physician & EMS provider in the tactical environment.
Discuss the approaches and techniques unique to tactical care to include the 3 stages of tactical care
Bibliography
1. De Lorenzo RA, Porter RS: Tactical Emergency Care. Brady (Prentice Hall), Upper Saddle River, NJ, 1999
2. Butler FK, Hagmann J, Butler EJ: Tactical combat casualty care in special operations. Military Medicine 1996; 161, Suppl: 3-15
3. De Lorenzo RA: Improving combat casualty care and field medicine: Focus on the military medic. Military Medicine 1997
4. De Lorenzo RA: Military and Civilian Emergency Aeromedical Services: Achieving Common Goals with Different Approaches. Aviation, Space and Environmental Medicine 1997; 68(1): 56-60
5. Bowen TE, Bellamy RF: Emergency War Surgery, 2nd Ed, US Government Printing Office, Washington, DC, 1988
6. Weiner SL, et al: Trauma Management fro Civilian and Military Physicians. WB Saunders, Philadelphia, 1986
7. Bellamy RF: Combat Trauma Overview, in Zajtchuk R, Bellamy RF (eds): Anesthesia and Perioperative Care of the Combat Casualty. Department of the Army, Washington, DC 1995
8. Zajtchuk R (ed): Conventional Warfare: Ballistic, Blast and Burn Injuries. Department of the Army, Washington, DC 1991
9. Smith BD: Tactical Medics. JEMS 1999; 24(5): 49-64
Additional References
Heiskell, LE, Tang, DH: AIDS and HEPATITIS: What are the risks to Police Officers?
Police Magazine, Vol. 22 No. 1, pp.34-36, January 1998.
Carmona, R, Rasumoff DH: Guidelines for the Development of TEMS Programs.The
Tactical Edge, Vol. 16, No. 1, pp. 75-77, Winter 1998.
Rasumoff, DH, Carmona R: Advanced Life Support in TEMS: The Effect of New
Trauma Studies. The Tactical Edge, Vol. 15 No. 4, pp.78-80, Fall 1997.
Heiskell, LE, Tang, DH, Carlo,PA: Tactical EMS Training For The 21st Century. The
Tactical Edge, Vol.15, No.3, pp 76-79, Summer 1997.
Carmona R, Rasumoff, DH: Evolving Roles of the TEMS Provider. The Tactical Edge,
Vol.15, No. 3, pp. 57-59, Summer 1997.
Rasumoff D, Carmona R: Standardized Prehospital Care: The Next Major Issue In
TEMS. The Tactical Edge, Vol.15, No, 2 pp 59-64, Spring 1997.
Heiskell LE : Medical Management: K-9 Emergencies. Police Magazine, Vol. 21, No. 2,
pp 52-57, February 1997.
Heiskell LE, Carrison DM, H&K’s New Tactical Emergency Medicine Course is
Challenging, Demanding and on the Leading Edge. SWAT Magazine, pp 26-29, October1996.
Jones J, Reese K, Kenepp G, Krohmer J, Into the Fray: Integration of Emergency MedicalServices and Special Weapons and Tactics (SWAT) Teams. Prehospital and DisasterMedicine. Vol. No.3 pp 202-206, July-September 1996.
Rasumoff D, Carmona RH: TEMS Tips for the Medical Officer. The Tactical Edge, Vol.
14, No. 4, Fall 1996.
Carey G: TEMS Support for Small Law Enforcement Agencies. The Tactical Edge, Vol.
14, No. 4, pp 36-39, Summer 1996.
Heiskell LE, Carlo P: Scoop and Run vs Stay and Treat: Some Tactical Considerations.
TheTactical Edge, Vol. 14 No. 3, pp 61-63 Summer 1996.
Carmona RH, Rasumoff D: Trends in Tactical Emergency Medical Support. The TacticalEdge, Vol. 14, No. 2, p 52, Spring 1996.
Heiskell LE: Wellness for Police Officers: Developing a Healthy Lifestyle. Police
Magazine, November 1996.
Heiskell LE: Clandestine Drug Labs are Chemical Time Bombs. Police Magazine,
September 1996.
Heiskell LE, Tang DH: Medical Management of K-9 Emergencies Part 2. The Tactical
Edge, Vol 14. No.1, pp 44-52, Winter 1996.
Heiskell LE: Management of Tactical Medical Teams: Police SWAT Medical Personnel
Are Agency Assets. Law & Order Magazine, April, 1996.
Heiskell LE, Tang DH: Tactical Emergency Medial Support for Law Enforcement
Special Operations Teams. SWAT Magazine, pp 69-73, February 1996.
Leibovich M, Speer CW: Physician Involvement in Police Tactical Teams. The Tactical
Edge, Vol.13, No. 4, pp 48-50, Fall 1995.
Rasumoff D, Carmona RH: An Evaluation Period for TEMS Personnel: Do We Need
One? The Tactical Edge, Vol. 13, No. 4, pp 83-86, Fall 1995.
Miller C: Blast Injuries. The Tactical Edge, Vol. 13, No. 4, pp 45-47. Fall 1995.
Heiskell LE, Tang DH: Medical Management of K-9 Emergencies: Part 1. The Tactical
Edge, Vol. 13, No. 4, pp 51-56, Fall 1995.
Carmona RH, Rasumoff D: Use of TEMS on SWAT Operations. The Tactical Edge, Vol.13, No. 3, p 69, Summer 1995.
Arthur KE: Bag-Valve Alternative. The Tactical Edge. Vol. 13, No. 3, pp 19-20, Summer
1995.
Carmona RH, Rasumoff D: The Integration of Tactics and Emergency Medical Support.
The Tactical Edge, Vol. 13, No. 1, pp 69-70, Winter 1995.
Heiskell LE, Tang DH: HIV and Hepatitis B: Tactical Silent Enemies. The Tactical Edge,
Vol. 13, No. 1, pp 55-58, Winter 1995.
Rasumoff D, Carmona RH: The Africanized Honey Bee. The Tactical Edge. The TacticalEdge. Vol. 12, No. 4, pp 84-87, Fall 1994.
Carmona RH, Rasumoff D: Diet and Performance in the Tactical Environment. The
Tactical Edge, Vol. 12, No. 3, pp 82-83, Summer 1994.
Carmona RH: Cost Effectiveness Alternatives for thee Provision of Live-Fire Training,
The Portable Live-Fire Training House. The Tactical Edge, Vol. 12, No. 3, pp 21-23,
Summer 1994.
Heiskell LE, Tang DH: Medical Aspects of Clandestine Drug Labs. The Tactical Edge,
Vol. 12, No. 3, pp 51-54, Summer 1994.
Vayer J, Hagmann J, Llewellyn C: Refining Prehospital Physical Assessment Skills: A
New Teaching Technique. Annals of Emergency Medicine, Vol. 23, No. 4, pp 786-790,
April 1994.
Heiskell LE, Carmona RH: Tactical Emergency Medical Services: An Emerging
Subspecialty of Emergency Medicine. Annals of Emergency Medicine Vol. 23, No. 4, pp
778-785, April 1994.
Rasumoff D, Carmona RH: Position Paper: Use of Physicians in the Tactical
Environment. The Tactical Edge, Vol. 12, No. 2, pp 77-86, Spring 1994.
Carmona RH, Rasumoff D: Selection and Retention of Special Operations Team
Members. The Tactical Edge, Vol. 12, No. 1, pp 72-75, Winter 1994.
Heiskell LE, Tang DH: Case Study: The Moreno Valley Hostage Incident. The Tactical
Edge Vol. 12. No. 3, pp 36-38, Winter 1994.
Carmona RH, Rasumoff D: Inclusion of Physicians in Civilian Tactical Law Enforcement
Operations. The Tactical Edge, Vol. 11, No. 4, pp 70-71, Fall 1993.
Carmona RH, Rasumoff D: Echeloned Field Medical Care: Definition and Justification.
The Tactical Edge, Vol. 11, No. 4, pp 72-76, Fall 1993.
Carmona R, Rasumoff RH: Medical Aspects of the Force Continuum. The Tactical Edge,Vol.11, No. 1, pp 69-71, Summer 1993.
Heiskell LE: Triage and Transport: The Golden Hour Begins. The Tactical Edge Vol. 11,No. 1, pp 50-52, Summer 1993.
Rasumoff D, Carmona RH: How Are We Doing with TEMS? The Tactical Edge, Vol.11,
No. 2, pp 71-74, Spring 1993.
Heiskell LE: Profiling and Predicting the Suicidal Suspect. The Tactical Edge, Vol. 11, No.2, pp 43-45, Spring 1993.
Carmona RH, Rasumoff D: Understanding the Risks and Benefits in Selection of
Mission-Specific Personnel Protective Equipment. The Tactical Edge, Vol.11, No. 1, pp
68-70, Winter 1993.
Heiskell LE: Basics of Field Wound Management. The Tactical Edge Vol. 11, No. 1, pp
60-62, Winter 1993.
Sanders N: Should Physical Fitness Qualifications Be Required for SWAT? The TacticalEdge, Vol. 10, No. 4, p 30, Fall 1992.
Rasumoff D, Carmona RH: A Basic Strategy for Neurological Assessment. The Tactical
Edge, Vol.10, No.4, pp 62-67, Fall 1992.
Heiskell LE: Profiling and Predicting The Violent Suspect. The Tactical Edge, Vol. 10, No.4, pp 39-40, Fall 1992.
Carmona RH, Rasumoff D: Forensic Aspects of Tactical Emergency Medical Support.
The Tactical Edge, Vol. 10, No. 3, pp 54-55, Summer 1992.
Heiskell LE: Hyperthermia and Heat Illness: Considerations in Hot Weather Special
Operations. The Tactical Edge, Vol. 10, No. 3, pp 20-22, Summer 1992.
McArdle DQ: Integration of Emergency Medical Services and Special Weapons and
Tactics (SWAT) Teams: The Emergence of the Tactically Trained Medic. Prehospital
and Disaster Medicine, July-September 1992.
Rasumoff D, Carmona RH: Caring for Children in the Tactical Environment: It’s No
Small Thing. The Tactical Edge, Vol. 10, No. 2, pp 48-53. Spring 1992.
Heiskell LE: Aeromedical Evacuation in the Tactical Environment. The Tactical Edge,
Vol. 10, No. 2, pp 41-43, Spring 1992.
Carmona RH, Rasumoff D: Preliminary Review of Tactical EMS Survey. The Tactical
Edge, Vol. 9, No. 1, p 62, Winter 1991.
Heiskell LE: Hypothermia and Frostbite: Considerations in Cold Weather Special
Operations. The Tactical Edge, Vol. 10, No. 1, pp 26-29, Winter 1992.
Burg M: Tactical EMS. Emergency Medical Services, Vol. 21, pp 76-77, 1992.
Maunder M: Paramedics and Tactical Operations: The Integration of Medical
Personnel in Law Enforcement. The Tactical Edge, Vol. 10, No. 1, pp 33-34, Winter 1992.
Sanders N: Priorities for Forward Casualty Care: Lessons From the Battalion Medical
Officer. The Tactical Edge, Vol. 10, No.1, pp 28-29, Fall 1991.
Heiskell LE: Fundamentals of Wound Ballistics. The Tactical Edge, Vol. 9, No. 4, pp
22-24, Fall 1991.
Carmona RH, Rasumoff D: Evaluation of Risk Factors Causing Performance Decrement
During Special Operations. The Tactical Edge, Vol. 9, No. 4, pp 53-55, Fall 1991.
Carmona RH, Rasumoff D: Tactical Emergency Medical Support (TEMS) An Emerging
Specialized Area of Prehospital Care. Prehospital and Disaster Medicine, p 394, 1991.
Rasumoff D, Carmona RH: Combined EMT Class For SWAT Personnel. The Tactical
Edge, Vol. 9, No. 3, pp 58-62, Summer 1991.
Rasumoff D, Carmona RH: Burns in the Tactical Environment. The Tactical Edge, Vol. 8,No. 9, p 54, Spring 1991.
Carmona RH, Rasumoff D: Tactical Emergency Medical Support. The Tactical Edge, Vol.8, No. 1, pp 54-56, Winter 1990.
Carmona RH, Rasumoff D: Regionalization of SWAT Operations: Administrative and
Tactical Considerations. The Tactical Edge, Vol. 8, No. 4, pp 35-36, Fall 1990.
Carmona RH, Rasumoff D: Early Recognition of Impending Airway Difficulty in the
Tactical Environment. The Tactical Edge, Vol. 8, No. 4, pp 54-58, Fall 1990.
Carmona RH, Rasumoff D: Essentials of Tactical Emergency Medical Support. The
Tactical Edge, Vol. 8 No. 3, pp 54-56, Summer 1990.
Carmona RH, Brennan K: Review of the National Conference on Tactical Emergency
Medical Support. The Tactical Edge, Vol. 8, No. 3, pp 7-11, Summer 1990.
Carmona RH: Officer Safety In Special Operations: Assessing the Risk / Benefit Ratio.
The Tactical Edge, Vol. 8, No. 2, Spring 1990.
Rasumoff D, Carmona RH: Aggressiveness, Positive Attitude, and the Fight or Flight
Reactions. The Tactical Edge, Vol. 8 No. 2, pp 44-47, Spring 1990.
Murphy M: FBI SWAT Paramedics. The Tactical Edge, Vol 7, pp 22-24, 1989.
Quinn M: Into the Fray: The Search and Rescue Role with Special Weapons Teams.
Response, Vol. 6 pp 18-20, 1987.
Tactical
Emergency Care
An Introduction
for Physicians
Robert A. De Lorenzo. MD, FACEP
Major Medical Corps, U.S. Army
Objectives
Examine the impact of tactical environment on patient care
Explore the role of the physician in tactical care
Discuss the approaches and techniques unique to tactical care
Terms
Tactical emergency care
Tactical emergency medical support
Operational EMS
Tactical environment
Tactical medic
Tactical physician
Resources
Courses
CONTOMS (Casualty Care Research Center)
Heckler & Koch
Textbooks & Journals
Tactical Emergency Care. Brady/Prentice Hall 1999
Smith BD: Tactical Medics. JEMS 1999; 24(5): 49-64
Jones JS, et al: Into the Fray: Integration of EMS & SWAT. PDM 1996; 11(3):202-206
Tactical Edge
Current Status
TEMS widely recognized by SWAT teams
Various degrees of sophistication
Variable medical participation
TEMS practiced routinely by military
Parts of TEMS applicable to general EMS
Hostage/Barricade responses
Terrorist acts
Domestic WMD threats
Preventive medicine approach
Operational incident rehabilitation
TEMS
Tactical emergency care
3 stages of care
Remote medical assessment
Medicine across the barricade
Preventive Care
Medical threat assessment
PM, field sanitation
Basic Ambulatory Care
Team care
Clearance for incarceration
Tactical Care
Reflects the conditions
Austere, priority-directed
Focuses on expected threats
Prioritizes life-threats
Adjusts for mission requirements
Medical care in context of a larger mission is the sine qua non of operational EMS
Tactical Environment
Fast, furious, frightening
Hostile threats
Extremes of environment
Hot/cold/wet
All for prolonged periods
Darkness/light restrictions
Limited equipment
What you can carry
Fast and Furious
Extreme Environments
Medical Direction
Essential element in all EMS medical care
Physician should be involved and interested
Must have understanding of tactical environment
Must be qualified as an EMS physician
Must be available to support the TEMS mission and the tactical team
Role of Physician
Team Member in the field
Can be as far forward as appropriate
Some physicians go in as part of the "stack"
Most stay in rear where their skills and oversight can be best utilized
Medical Direction
Classic EMS medical direction with tactical overlay
Team Physician
Preventive Care and routine physical exams
Flight surgeon model
Responsibilities
To the Medic
The medical director should:
Provide training and credentialing
Assess clinical skills proficiency
Be available for medical backup and support
Explore innovations and changes to TEMS
Three Stages of Care
Care under fire
Tactical field care
Casualty evacuation
Care Under Fire
Stage 1
Patient under imminent threat - hot zone
Care is rapid, abbreviated, and austere
Primary Goal is get patient out
1st choice: Auto-extraction
2d choice: Rapid extraction
Priorities
Stage 1
Defend self and patient
Return fire
Cover and concealment
Remove patient rapidly
Auto or rapid extraction
Sometimes patient waits
Stop life-threatening hemorrhage
Tourniquet
Approach
Stage 1
Maintain small profile
Stay low
Low/high crawl
Approach from front
Use cover and concealment
Wear protective gear
Keep casualty between you and threat
Extraction
Stage 1
Getting the casualty out
Move to relative safety
Auto extraction preferred
Yell/whisper for casualty to crawl
Rapid extraction
Stay low
Drag along long axis
Rapid Extraction
Tourniquet
Stage 1
Only for life-threatening bleeding
Actively spurting or rapidly flowing
Oozing, trickling, clotted blood doesn’t count
Fast and easy application
Allows rescuer to concentrate on extraction
Tactical Field
Care
Stage 2
Threat present but not imminent
"Warm zone"
Care usually associated with tactical medic
Airway interventions
Bleeding control
Judicious fluid resuscitation
Limited medications
Initial Assessment
Stage 2
Airway
Manual methods
Naso-oro airways
ET intubation
Cricothyrostomy
Breathing
BVM
Needle decompression
Circulation
Control bleeding with direct pressure
Tourniquet prn
Large bore IV
Fluid resuscitation
?PASG
Focused and
Detailed Assessment
Disability
Rapid head-to-toe assessment
Splint and dress as needed
Drugs
Analgesia
Antibiotics
Evacuation
Airway Management
Stage 2
Unconscious/AMS
Manual methods
Naso-oro airway
ET intubation
Cric for obstruction
Light - Restricted
Environment
Laryngoscope has bright light
Can be lethal in tactical situation
Blankets/shrouds unsatisfactory
Visual techniques difficult in TEC
Options:
Digital intubation
Modified Laryngoscopes
Defer airway management
Confirming Intubation
Clinical methods
Difficult to use in dark, noisy environments
CO2 detectors the gold standard
Subtle color changes impossible to discern in low light
Esophageal detector device
Lightweight, simple, and tactile
Other Tactical
Considerations
C - spine immobilization
CPR
Fluids for resuscitation
Drugs (analgesics and antibiotics)
C - Spine Immobilization
C - Spine Protocol
Indications
High speed (50 km/h) MVC
Fall from height
Blast injury
Not Indicated
Penetrating neck trauma
Falls from standing or 1-2 m height
Exception: Pain, neuro findings
CPR in the
Tactical Environment
Situation CPR?
Penetrating trauma No
Blunt trauma No
Near drowning Yes
Hypothermia Yes
Electrical injury Yes
Chem/Bio Agent Maybe
CPR
Must be tactically feasible
Risk of fire
Evacuation time
Manpower and equipment
Must be medically appropriate
Have a predetermined protocol
Dead is dead
You can’t succeed when you don’t try
Fluid Resuscitation
Some controversy exists
Amount of fluids
Type of fluids
For practical reasons, these arguments miss the point
Issue is not WHAT TYPE of fluid, but WHEN to give fluids
Fluid Resuscitation
Analgesia
Morphine in 2 mg increments
Endpoints
Relief of suffering
hypotension
depressed respirations
Antibiotics
Cefazolin or mefoxitin 1 gm
Goal: infection prophylaxis in penetrating injury
Avoid in patients with known PCN allergy
Casualty Evacuation
Stage 3
Movement to medical care
Manual carries and drags
Ground vehicles
Air vehicles
Goal: bring patient to
Most appropriate
Closest facility
Principles of Movement
Use Long Axis of Body
Splint if time permits
Head or feet first ok
Keep protective gear on
Disarm
Remove protective gear once safe
M996/997 Humvee Ambulance
2 1/2 Ton Truck
M113 Armored Ambulance
Armored Medical Treatment Vehicle
UH-1 Iroquois "Huey"
UH-60 Blackhawk
Tactical Innovations
Remote Medical Assessment
Judging the condition of a patient by remote (eg binoculars) means
Can prevent unnecessary exposure to would-be rescuers
Medicine across the barricade
Remote care of hostages, usually by phone
Skill and protocols similar to "telephone CPR" used by EMDs
Preventive Medicine
Major environmental threats faced by tactical teams
Heat
Cold
Diarheal Disease
Vector-borne disease
Field Sanitation
Safe food and water
Sanitary waste disposal
Key points
Hot foods hot and cold foods cold
Don’t trust the water
Enforce sanitary bathroom practices
Rest Enforcement
Adequate sleep is key to ensuring alertness in any prolonged operation
After 18-24 hours of continuous wake, alertness suffers
?Role for caffeine/prescription stimulants
After 48 hrs alertness deteriorates to dangerous levels
2-3 hrs sleep can partially offset effects
?role for short-acting benzodiazepines
5 hrs sleep allows for prolonged operations
Basic Ambulatory Care
Routine Team Care
Care during prolonged operations
Physician can prevent operational deficits or complete mission failure merely by treating certain complaints
Protocols for medics needed
Physician not always present
Summary
Tactical medicine is a specific sub-specialty with its own unique body of knowledge
Key role for physician in TEMS
What Are Your Questions?
 |
|
|
 |
 |
|
 |
|
|
 |
|
|
 |
|
|
 |
|
|
 |
|
|
 |
|
|
 |
|
|
 |
|
|
 |
|