New Hampshire first responders recently experienced disastrous failures with two counterfeit tourniquets at the scene of a motorcycle accident. The windlass snapped in half, making it impossible to tighten the tourniquet, a failure that could be the difference between life and death. Counterfeits look remarkably similar to the real thing, so tourniquets should only be purchased from the manufacturer or authorized dealers. The CBS News article below goes in to more detail about the dangers of counterfeit tourniquets.
The recently released ‘First Responder Guide for Improving Survivability in Improvised Explosive Device and/or Active Shooter Incidents’ by the Department of Homeland Security was developed at the request of first responders to provide guidance in responding to these types of events. Recommendations fall in to three major categories, the first being Hemorrhage Control. The guide states that first responders should incorporate tourniquets as part of treatment as they have proven to be quick and effective at preventing severe blood loss from extremity wounds. The guide can be viewed here.
A good article on the gains in medical knowledge harvested from this current conflicts:
December 18th, 2013
Editor’s note: This morning, in Bethesda MD, the Executive Director of the American College of Surgeons, Dr. David Hoyt, presented the leadership of Walter Reed National Military Medical Center with a plaque recognizing its designation as an ACS-certified Level II Trauma Center. Walter Reed Bethesda is part of extraordinary chain of military health system facilities, providers, organizations, and techniques that have dramatically improved an injured service member’s odds of survival and recovery. As the authors of this post note, lessons learned during more than a decade of war are now being adopted into civilian care, to the benefit of children and adults in every corner of the United States and beyond. For more on emergency care, read the December Health Affairs issue, “The Future of Emergency Medicine: Challenges And Opportunities.“
Out of the ashes of 9-11 and the two wars that followed, a new paradigm has emerged that has benefited more than 50,000 injured warfighters and is transforming civilian trauma care. During the past decade of war, strategic investments in research and clinical care, coupled with contributions from world-class clinician-scientists, have produced the lowest case-fatality rate among combat casualties in the history of armed conflict.
At the beginning of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF), the combat injury case-fatality rate was approximately 18 percent. Over the subsequent decade, it steadily decreased to 5 percent despite an overall increase in injury severity. This remarkable achievement is grounded in advances in all aspects of trauma care, from the point of injury to optimum treatment in military rehabilitation centers.
As with all previous conflicts throughout history, clinical knowledge generated in the civilian setting was rapidly adapted in innovative ways to address challenges encountered on the battlefield. Now, it is coming full circle to improve the care and decrease the mortality of both injured warriors and civilian trauma victims. This reciprocal relationship between military and civilian medicine, recently highlighted in domestic terrorism attacks such as the Boston Marathon bombing and the mass shootings at Aurora and Tucson, is visible in daily practice in trauma centers throughout the country.
These improvements didn’t happen by accident; the military invested in relevant translational research and developed a flexible, evidence-based trauma system that rapidly developed, assessed, deployed, and refined new advances in trauma care and rehabilitation. In this post we highlight a number of these advances and the science behind them, and we offer a roadmap to ensure that these advances are not only preserved for use in future conflicts, but evolve to benefit all patients — military and civilian alike.
What Has Been Accomplished
Tactical combat casualty care. One of the first important advances was recognition, based on experience gained in the First Gulf War, that combatants themselves are the true “first responders” on the battlefield. Combatants are trained to recognize and promptly respond to life-threatening injuries, and medics and corpsmen are now trained in a realistic, scenario-based, and standardized fashion, based on the principles of tactical combat casualty care (TCCC). TCCC provides the training for the effective use of topical hemostatic agents (bandages with the ability to accelerate blood clotting) and, when necessary, tourniquets to control severe bleeding, along with other skills such as rapid assessment of injuries, airway control, treatment of traumatic pneumothorax (collapsed lung), and immediate pain control.
TCCC is divided into three phases that are relevant in both the combat and civilian mass casualty settings: care under fire, tactical field care, and tactical evacuation care. “Tactical” refers to individual and small unit activities, such as direct care rendered by a first responder at the point of injury, in contrast to “operational” and “strategic” activities, which involve larger units and broader geographic space. This coordinated approach achieved exceptional success; when adopted by elite units of the US military, it resulted in the near elimination of preventable deaths on the battlefield. Today, civilian emergency medical systems (EMS) are adopting the TCCC approach using a course offered by national organizations representing the EMS community.
Bleeding control. Early hemorrhage (bleeding) control, using tourniquets and topical hemostatic agents, are a prime example of how new or improved techniques on the battlefield can produce profound benefits at home. Previously tourniquets were not advocated for routine use for fear of limb loss. However, the need for tourniquets was quickly recognized as essential in modern warfare where severe extremity injuries are common and evacuation is often both timely and fast. Widespread adoption of tourniquets saved many lives in combat without secondary limb loss.4 As an adjunct, the use of topical hemostatics, was more than 90 percent effective. Over the course of the conflicts, these agents were modified several times. This allowed military doctors to optimize their effectiveness while minimizing side effects.
Both of these approaches to hemorrhage have quickly made their way to civilian settings, moving “from the sandbox to the street.” This was most clearly seen following the Boston Marathon bombings, where “without a doubt, tourniquets were a difference-maker and saved lives.”
Massive transfusion protocols. Advances in care did not end on the battlefield; they accelerated upon arrival at hospital settings. This began with new approaches to replacing blood loss from trauma. Prior to our experience in Iraq and Afghanistan, the most severely injured casualties were resuscitated in a step-wise fashion, first with saline solutions, followed by a gradual escalation to the use of blood products. Faced with less than ideal outcomes, military surgeons challenged this approach and looked for better ways to replace blood loss. Based upon solid lab research, these surgeons introduced the concept of “balanced resuscitation”, by immediately countering blood loss with key components of blood when the injured soldier or marine’s injury profile suggested the need for massive transfusion (unstable patients or those with severe injury patterns). This approach not only improved survival, it reduced the rate of complications in combat-wounded patients.
Adoption of “massive transfusion protocols” has become one of the most swiftly adopted changes in care coming from the battlefield. Today, a majority of Level I trauma centers in the US have shifted to this practice. This approach is also being adopted in surgical education, where trainees are taught to activate “massive transfusion protocols” to counter severe injuries.
“Damage control” surgery. The next major advance took place in the operating room where prompt surgical control of bleeding, closure of perforated bowel injuries, and early debridement of damaged tissue are key steps. Focusing on these priorities up front, leaving the abdomen “open” with temporary dressings, and deferring more complex definitive surgery for subsequent procedures has avoided the secondary insult of prolonged periods in the operating room. This led to a practice called “damage control surgery.” This concept was first introduced in the civilian trauma world (utilizing a term adopted from the military, where “damage control” refers to maneuvers to save a ship so it can continue to be effective). The technique caught on with military surgeons, many of whom who had trained in civilian trauma centers, and was swiftly refined under wartime conditions. As with the other advances discussed, the widespread application of damage control surgery has benefited military and civilian populations alike.
Neurocritical care. Patients with specific injuries, most notably penetrating head and extremity injuries, have also benefited from military medicine. In previous conflicts, many of these patients were assumed to have non-survivable injuries and were treated as “expectant” (i.e., only comfort care). Now, they are aggressively managed using techniques similar to those applied in damage control surgery.
For example, in cases of massive head trauma, a portion of the skull is temporarily removed to allow the brain to swell without creating a lethal rise in pressure that would stop blood flow to the brain. This is particularly important for patients faced with long medical evacuation times. Another technique involves preventing the spasm of major blood vessels that are necessary to support brain survival and function. Although this practice has not yet been widely adapted in civilian trauma, it may come to be widely used in future mass casualty events and conflicts.
Treatment of badly damaged limbs. Another advance that has seen widespread use is an integrated approach to early limb salvage versus amputation in patients suffering from massive extremity injuries with significant tissue loss and neurovascular damage. Military and civilian researchers have found that, for certain patients, early amputation results in better long-term functional outcome. For patients who remain good candidates for limb salvage, the innovations in soft tissue reconstruction have produced survivors who not only recovered, but in many instances returned to full duty and extremely active lifestyles.
Two key adjuncts to the successful treatment of severe extremity wounds are adequate pain control and aggressive, early rehabilitation. The adoption of regional pain control and integrated pain management teams has allowed rehabilitation to start while the patient is still in the hospital. All of these efforts come together in the treatment of the multi-limb amputees who face substantial challenges. Without these approaches, the amazing functional results that have been seen would not be achievable. Many of these techniques are now working their way into civilian practice, such as treatment of victims of the Boston Marathon bombings.
Rapid evacuation to tertiary care centers. Transporting injured personnel to centers capable of providing advanced levels of care required comparable innovations in tactical and strategic casualty evacuation. In conflict zones, tactical evacuation is largely accomplished by medical evacuation helicopters, while inter-theatre strategic evacuation over thousands of miles is achieved with large Air Force fixed wing aircraft outfitted with ICU pallets and staffed by specially trained Critical Care Air Transport Teams (CCATTs). This integrated approach has resulted in a reduced medical footprint in the conflict area as compared to previous conflicts. Equally important, improvements in hand-offs of care were devised to assure seamless transitions between the military, the U.S. Public Health Service, the Veterans Health Administration, and, ultimately, civilian trauma and rehabilitation facilities. The collective impacts of these advances in care are unprecedented in military history.
How It Was Done
Almost as remarkable as this progress is the manner in which it was done. Normally, progress in patient care is achieved through painstaking, incremental research, often tested and refined through large-scale randomized trials involving thousands of patients. It’s been written that the average time frame for research to reach the bedside and be widely adopted into care is measured in decades. The military health system didn’t have that sort of time. Lives depended on swift and sure decisions, backed by the best available evidence.
Much of the progress was made possible through creation of the Joint Trauma System (JTS), whose mission is to improve trauma care delivery across the continuum of care through careful data collection and analysis, to improve clinical outcomes in near real-time. This effort represents the largest combat registry ever created. In addition to monitoring the quality and outcomes of care, the JTS develops and implements clinical practice guidelines system-wide, and identifies the training and research needs for trauma care in the military.
The ability of the JTS to rapidly identify emerging injury patterns, develop best practices and research-based CPG’s, and subsequently disseminate and track such guidelines represents a paradigm shift away from costly, multi-year clinical studies to “focused empiricism” and continuous process improvement. Driven to address challenges identified by the JTS, the DoD continues to invest in mission-relevant research focused on biomarker-based care, regenerative medicine, and advanced approaches to hemorrhage control. While many civilian centers have adopted similar models with a degree of success, the widespread implementation of this approach could serve as a model for other large health care systems.
Early in what has proven to be the longest armed conflict fought by the U.S. to date, military medicine recognized that it needed to fundamentally change how it approached the care of wounded warriors. It did this by implementing data-driven decisions at every step in the continuum of care, from battlefields in two nations across 8000 miles and three continents to world-class hospitals and rehabilitation centers in Germany and the United States. Importantly, this work was done while the individuals involved were doing their utmost to provide the best possible care to every injured combatant and civilian they touched. As was true following the conflicts in Korea and Vietnam, lessons learned in the crucible of war are beginning to transform care in civilian hospitals in the U.S. and around the world.
The progress that has been made over the past decade is tenuous at best. Some of those who led these efforts have retired from the military, and others are struggling to contend with budget cuts, furloughs and funding constraints. It won’t be easy to maintain surgical skills honed over a decade of conflict. But this is essential to assure that military healthcare in any future conflict will be as good, and ideally better, than in the most recent ones. There is little doubt that thousands of service members and veterans are alive today thanks to the work of dedicated military and civilian health care professionals. Many of the insights they developed are beginning to transform care in the civilian world and millions will benefit.
The knowledge gained over a decade of war cannot be taken for granted. Continued work is needed to identify and manage challenges that are only faintly understood today. The progress that is made will not only help our warfighters in future conflicts, it will help save the lives of civilians as well.
An interesting and informational article:
Humanitarian aid has strategic benefits, too, military leaders sayBy Howard Altman | Tribune Staff
Published: December 15, 2013
TAMPA — From large-scale aid missions like the response to Typhoon Haiyan to an isolated team of Green Berets helping others, providing disaster relief and medical assistance has benefits for the U.S. as well as those being helped.
So much so that military involvement in such endeavors has become part of Pentagon planning, members of a panel at the Special Operations Medical Association Scientific Assembly in Tampa said Sunday.
It’s all part of what the past two Secretaries of State and a former Secretary of Defense have called “Smart Power” – combining the might of weapons with efforts like Global Health Engagement to achieve U.S. interests around the globe.
Major efforts, like the Marines who provided disaster relief in the Philippines, not only earn the nation goodwill but help the U.S. gain access and information and are useful for friendly nations, said Warner Anderson, director of International Health for the Office of the Assistant Secretary of Defense for Health Affairs.
On a smaller scale, there are other benefits, said Anderson, who is also a combat veteran. For example, a medic from a Green Beret team is not allowed to gather intelligence but can get information from a village chief about an area that might not be safe to go to, he said.
Such side benefits of providing assistance, he said, are not lost on the Chinese, who have launched their own hospital ship, called the “Peace Ark.” The ship not only provides medical care but also gives the Chinese access to waters in which its warships might be challenged. Two years ago, the Peace Ark visited Cuba.
“If you are packing up a hospital ship and moving 6,000 or 8,000 miles, you are mobilizing an expeditionary capability of a field hospital without going to war,” Anderson said during a session break. “That’s a great training exercise.”
Anderson recently returned from Saudi Arabia, where he attended an International Committee on Military Medicine conference. An increased Chinese presence there, along with the Peace Ark trip to Cuba, “looks to me like worldwide engagement,” he said.
For the military, the intersection of security and stability, of which health care plays a major role, has a long history, said Craig Llewellyn, a retired Special Forces colonel who became founding director of the Center for Disaster and Humanitarian Assistance Medicine. Green Berets, he said, helped villagers in Vietnam and Laos with their health and medical issues.
Navy Capt. David A. Tarantino Jr. said the health and relief efforts are “true” Pentagon missions. They are “a real and current mission – governed by a number of existing and forthcoming policies,” Tarantino said. He said miltary leaders incorporate medical stability operations into many levels of planning.
Anderson noted there is an inherent tension in such endeavors for medical professionals.
While they are supposed to remain neutral and humanitarian as medical professionals, military requirements often conflict.
Military medical professionals “have to be very, very careful about these things,” Anderson said. “We can’t do intentional harm and now we are finding that we have to guard against doing unintentional harm. Health care is a way to get people’s attention, to present ourselves in a positive light. We have to do positive things and be careful of unintended consequences.”
In Mass Attacks, New Advice Lets Medics Rush In
WASHINGTON — Seven minutes after the authorities in Sparks, Nev., received a call one day in October that a gunman was on the loose at a local middle school, a paramedic wearing a bulletproof vest and a helmet arrived at the scene.
Instead of following long-established protocols that call for medical personnel to take cover in ambulances until a threat is over, the paramedic took a far riskier approach: He ran inside to join law enforcement officers scouring the school for the gunman and his victims.
“He met the officers right near the front door, and they said: ‘Let’s go. There are victims outside near the basketball court,’ ” said Todd Kerfoot, the emergency medical supervisor at the shooting. “He found two patients who had been shot and got them right out to ambulances.”
Federal officials and medical experts who have studied the Boston Marathon bombing and mass shootings like the one in Newtown, Conn., have concluded that this kind of aggressive medical response could be critical in saving lives. In response to their findings, the Obama administration has formally recommended that medical personnel be sent into “warm zones” before they are secured, when gunmen are still on the loose or bombs have not yet been disarmed.
“As we say: Risk a little to save a little, risk a lot to save a lot,” said Ernest Mitchell Jr., the Federal Emergency Management Agency’s fire administrator, who released the new guidelines on mass casualty events for first responders in September.
The guidelines say that such events, which have led to more than 250 deaths in the past decade, are “a reality in modern American life” and that “these complex and demanding incidents may be well beyond the traditional training of the majority of firefighters and emergency medical technicians.” They recommended that any of those first responders sent into “warm zones” focus on stopping victims’ bleeding.
The guidelines also say that first responders should be equipped with body armor and be escorted by armed police, a policy that officials in Sparks and a handful of other cities had already adopted.
The new focus on moving faster to treat victims follows an earlier shift in thinking about how quickly the police should respond.
In the 1999 shootings at Columbine High School in Colorado, where two disaffected students killed 13 people, no officers entered the school until a half-hour after the shooting began and SWAT teams arrived to respond to a highly planned attack that involved a fire bomb and other explosive devices.
After Columbine, law enforcement officials made it clear that they wanted the first officers on a scene to act immediately instead of waiting for specially trained officers with body armor and high-powered weapons.
“These events like the shootings are usually over in 10 to 15 minutes, but it often takes over an hour for everyone to get there,” said Dr. Lenworth Jacobs, a trauma surgeon who created the Hartford Consensus, which brought together experts in emergency medicine and officials from the military and law enforcement after the Newtown shooting to determine better ways to respond to mass casualties.
“We’re seeing these events in increasing frequency, and unfortunately we have to change how we approach them to keep death tolls down,” Dr. Jacobs said.
While the United States military saved thousands of lives in Iraq and Afghanistan by practicing combat medicine developed over years of responding quickly to battlefield injuries, the medical response to the bombings last April at the Boston Marathon provided a dramatic example on American soil of how lives could be saved by acting quickly.
The bombs went off near the marathon’s finish line, where many nurses and doctors were stationed to care for injured or ill runners and major hospitals were not far away. The bombing victims received medical assistance almost immediately, and while three people were killed, more than 200 others who were injured survived, including a dozen or so who had limbs amputated.
Those medical professionals were taking a risk: They did not know how many bombs there were or whether they were putting themselves in the middle of a larger attack.
The new FEMA guidelines have been embraced by state and local officials. But they have heightened concerns about the risks to first responders and about whether response times for victims would grow even longer if medics were wounded in a danger zone.
They have also raised the specter that terrorists may target the first responders as they have in Iraq. In recent years, the Qaeda affiliate there has in many instances detonated a car bomb and then, as medical personnel arrived, set off others.
But Harold Schaitberger, who leads the International Association of Fire Fighters in Washington, said his organization played a role in creating the new guidelines and strongly supported them if employed correctly. The association represents 300,000 firefighters, paramedics and others.
Trying to save victims in “warm zones,” Mr. Schaitberger said, “is a different risk for firefighters, but not more of a risk than firefighters already take in responding into a burning structure.”
Mr. Mitchell, the fire administrator, said the gunmen and terrorists who mounted attacks in the United States over the past decade rarely made targets of first responders. But, he said: “We know that this possibility does exist, and part of the training of the fire and E.M.S. is to be observant and aware and to be on the look for suspicious activity and so forth.”
Other efforts have focused on educating civilians on the need to react quickly to danger.
This year, many police departments began education efforts that urged anyone caught in a mass shooting to “run, hide or fight” instead of waiting for help.
After all, the people at the scene can often stand in for first responders before they arrive.
“In Boston, you saw that the public didn’t run,” Dr. Jacobs said. “You need for the public to have the most education about how they can help to improve the survival results.”
From our Facebook page: Check out this awesome video on the Louisville Metro Police Department equipping more than 1200 officers with TacMed tourniquets and medical trauma kits. Officers have already saved four lives in the last month with the new equipment.
Tactical Combat Casualty Care (TCCC) has become the standard for medical care within DOD. It is slowly being adopted by law enforcement throughout the USA as more departments are embracing the fact that the first line of medical care after a felonious assault rests with the officer. The transition in the mindset over the last 10 years is remarkable. Initially, most LEOs thought of medicine as the domain of EMS, whereas departments are currently attempting to integrate military TCCC into their protocols. For instance, use of tourniquets as a first option for extremity wounds has been accepted as a priority in civilian medicine. However, all of the lessons learned during GWOT regarding TCCC do not neatly transition to the the civilian sector. Although extremity bleeding is the most common cause of preventable death on the battlefield, chest injuries are the leading cause of preventable death for LEOs. So why do so many officers only focus on hemorrhage control when deciding what to carry in Individual First-Aid Kits (IFAKS)? It is due to the dearth of research in the field of LEO medicine and a full adoption of the research from the battlefield.
One of the first studies to address this issue was published in Prehospital and Disaster Medicine in 2009 titled “Tactical Medical Skills Requirements for Law Enforcement Officers: A 10-Year Analysis of Line-of-Duty Deaths” by Matthew D. Sztajnkrycer, MD. He concluded that “…current emphasis of TCCC on control of exsanguinating extremity hemorrhage may not meet the needs of law enforcement personnel in an environment with expedited access to -well developed trauma systems. Further study is needed to better examine the causes of preventable deaths in law enforcement officers, as well as the most appropriate tactical medical set and treatment priorities.”
It is clear that more work needs to be done, but we will explore the issue more in the following posts.
Multiple casualties in the tactical environment or a disaster area that exceed both human and materiel resources require rescuers to triage rapidly, so the limited resources may be used for the most critical casualties. In the tactical environment, one may have to do so under fire, thereby increasing the chance of sustaining injury. In disaster zone, precious time may be wasted by attempting to access and treat vocal casualties, while delaying treatment for higher priority patients. Nonetheless, current methods for triage require rescuers to assess casualties one-on-one, delaying further the time to locate, triage and treat the most critical. A recent article in The Army Department Medical Journal succinctly captured the crux of problem noting:
Physiologic status assessment in casualties can be problematic in the military setting, where physical access to the injured individual may be complicated by terrain, weather and hostile action. Likewise, some civil sector settings may challenge first responders, particularly when victims are located remotely. The lack of a remote triage capability may therefore result in the medic attending to either a) a Soldier who is uninjured but caught in the vicinity of combat; or b) a Soldier under severe fire who has an injury that is deemed unsalvageable. Indeed, a combat medic may place himself in harm’s way to assist a Soldier who may not even be injured or may be unsalvageable. Data collected during the Vietnam War indicate that the fatality rate of US Army medics was double that seen in infantrymen.1
There is an initiative to remedy this situation within the Departments of Defense and Homeland Security. DHS, in cooperation with Boeing and Washington’s School of Medicine in St. Louise, developed a “Standoff Patient Triage Tool” in 2009 that allows a rescuer to assess pulse, body temperature and respiration. As the article from Science Daily notes, “The magic behind SPTT is a technology known as Laser Doppler Vibrometry, which has been used in aircraft and automotive components, acoustic speakers, radar technology, and landmine detection. When connected to a camera, the vibrometer can measure the velocity and displacement of vibrating objects. An algorithm then converts those data points into measurements emergency medical responders can use in their rapid assessment of a patient’s critical medical conditions.”2 Although the technology is not yet available, it is an interesting approach.
In addition to the above-mentioned, the US Army is currently seeking technologies that will allow them to have stand-off monitoring capabilities. Researchers seek to assemble a system that is functional from a human factors perspective (i.e., Soldiers will wear it and it will not hindered the mission) and useful with regard to discerning physiological signs of hemorrhage from normal combat stress. For instance, mental status and blood pressure, while useful, are unreliable indicators of hemo-dynamic stability.1 Moreover, they take time to gather. Researchers have therefor sought other “markers” that one can use to discern hemorrhage from stress. To this end, they investigated ECG readings, which can be attained remotely. Unfortunately, the readings are not sensitive enough. Another alternative is using “energy monitors” and algorithms that can detect physiological changes. The challenges are many, however. Location of monitors, for example, require Soldiers to have an uninjured limb. In the age of IEDs, this may be difficult, though researches found that in all but 6% of reported casualties an arm was viable for monitoring.
While technological challenges remain, the ability to quickly triage casualties in a tactical or civil disaster scenario is becoming more likely. Although these futuristic Star Trek device or Soldier-worn monitors lack feasibility currently, researchers are getting closer.
1. Ryan K, Rickards C, et al. Advanced Technology Development for Remote Triage Applications in Bleeding Combat Casualties. The Army Medical Department Journal. 2011;4/5/6:61-71.
2. Department of Homeland Security. “Triage Technology With A Star Trek Twist: Tricorder-like Device.” ScienceDaily, 1 Jun. 2009. Web. 8 Nov. 2012.
The SOF Tactical Tourniquet has always been TCCC approved, but until recently, it has been overlooked when it comes to official TCCC instructions and guides. Here is the link to the most recent Care Under Fire PowerPoint produced by the TCCC board that outline the instructions. Furthermore, the second link below has many other training aides for all phases of tactical medicine.
A principal learning objective taught in many tactical medical training programs is self-application of tourniquets. Although reports from current battlefields estimate the frequency of one-handed application at less 1/10 of 1% (o.oo1), it is still a valuable drill for those working alone (i.e., law enforcement officers). Unfortunately, the technique taught is often incorrect, as most disregard the fact that if one is applying a tourniquet to one’s limb, the limb is probably injured. Therefore, as the video demonstrates, one ought to train for real-world application.