Tactical Rescue: Considerations When Planning

In the last few years the topic of tactical rescue/high threat extraction has become increasingly popular. New techniques and products enter the field almost weekly. While some of the techniques have merit, some do not. Some of these are presented as a panacea, but have extremely limited application in the tactical or combat arena.
When performing a tactical rescue the most important component is the employment of proper tactics. Failing to have a well rehearsed tactically sound plan for varying terrain, building structures and locations (e.g., hallways, stairwells, rooms etc. ) within that structure will seriously hamper your efforts. We will not cover how to conduct a rescue due to the open nature of this blog, but we will cover several things to consider when developing your plan and selecting techniques.

Fitness levels/size
Keep in mind you will be moving a significant amount of weight when using a drag-device. For example, have your smallest operator move your largest operator and see how effective they are.

Terrain/surface
A technique that works well on a buffed tile-floor may not work well on a concrete walkway leading to the front of a house, or in the middle of a road in Baghdad. Increased levels of friction will seriously hamper your movement out of the danger area. If the surface is slick enough to facilitate casualty movement it also increases the risk of a rescuer losing their footing due to pooling blood or other bodily fluids.

Size of the rescue team
Find the balance between efficiency and clutter. A larger team brings more guns, but it is also a big target. A four-man rescue team can rapidly turn into a four-man team in need of rescue. Minimize the amount of human assets you place in harm’s way whenever possible, especially if they can more effectively engage from another position.

Who will provide security?
Will the rescuer provide their own security? How effective are they with their weapon when pulling the heaviest member of your team? Generally, they are not effective at all. If the rescuer is the only person available to provide security, it may make more sense to delay the rescue. All other options should be considered before this is chosen. It makes more sense for a security element to establish an over-watch position from a position of cover to provide security than to expose itself to an adversary that has the advantage of cover and deciding whether to engage or not. In a military setting this is less of a concern if suppressive fire can be placed on the enemy position during the rescue attempt.
Do I have a ballistic shield? How can I employ it into my rescue plan?

Determined enemy vs. just a bad guy
All bad guys are not created equal. A truly determined enemy will take risks and make sacrifices far beyond what you would see in a “regular” bad guy. This also holds true for the mentally ill or chemically impaired. Suppressive fire from a crew-served weapon may not deter some enemy combatants; do you think a lone soldier or officer firing his M-4 one-handed from the hip will? Most likely not. If your enemy is determined to kill you he will not be scared of a few rounds. You need to be in a position to make those rounds count, not just wildly spray a doorway or wall.

Abort criteria
At what point does this not make sense anymore? Set your limits and stick to them if possible. These limits should be set before emotions get involved. Don’t wait until it’s time to do it for real.

There is an old saying, “speed is security,” and this is a scenario where it holds true. The primary focus of the rescue team should be rapid movement out of the danger area. You cannot perform every task of a tactical rescue by yourself, while performing those tasks to standard. You cannot move casualties and effectively engage hostile personnel at the same time. It briefs well, but it does not go much farther than that. Instead of practicing 50 ways to use tubular nylon, pick 5, and then spend the rest of the day working as a team to save a friend’s life.

VA Tech Shootings After-Action

Below you will find copies of the two reports addressing the Virginia Tech Shootings, and the Police and EMS response to them. The first report gives an overview of the event, followed by “Key Findings” and “Recommendations”. The second report covers the EMS response more in-depth.

Unfortunately, active-shooter scenarios are events for which one must prepare. In doing so, one should study past occurrences to garner lessons-learned, so as to implement them in your response scenarios. Doing so allows one to examine one’s protocols against real-world occurrences, which may expose flaws.

How might you have done things differently?

Post answers to the comments section.

VA Tech EMS Report

VA Tech After-Action 1

Considerations When Planning/Conducting a 9-line Evac

The 9-line format for casualty evacuations is a standard format.  Due to the uniqueness of situations and different medics’ needs, I will only discuss generic considerations regarding its implementation.  During pre-mission planning, you should be aware of the following:

  1.  Enemy Situation(e.g, barricade, Meth-lab, etc.)

  2. Severity of wounds/injuries (e.g., understand MOI, and injuries you may encounter)

  3. Number of casualties (e.g., number of assaulters on the objective, suspects, etc.)

  4. Response time (i.e., are you close to a Trauma Center, what is the response time of air)

  5. Platforms available (e.g., horse cart, truck, and helicopter)

  6. Level of care on Platforms available (i.e., is there a PA onboard, EMT, medic)

  7. Travel time to next level of care

Obviously the above-mentioned will be in constant flux.  Also, you will not know all of these beforehand (e.g., severity of wounds).  However, you can assess the types of injuries you may encounter due to the type of mission, then plan accordingly with the type of gear you carry and your prepositioned equipment on a dedicated evacuation platform.  For example, if conducting an assault and inserting via fast-rope, then you may encounter long-bone fractures.  You would not carry a splint in your assault bag.  Instead, leave it on the evac-platform in your level 3 kit.  Another example would be a suspected meth-lab.  You may encounter inhalation injuries.  Therefore, you would have the requisite equipment for treatment on the evac-platform.  

Once you have initiated an evacuation, you should consider the following when prepping a casualty for hand-over:

  1. Remove Load bearing equipment

  2. Mission Essential Eqt stays in the field (e.g., ammunition, radios, weapons, etc.)

  3. Bag and tag all other effects (laundry bags or 4-mil heavy-duty trash bags work well)

  4. Lay out in priority – most critical will probably be loaded last

  5. Ensure casualties are marked appropriately with casualty card and glow-sticks (if at night)

  6. Protect your casualty: hypothermia prevention (blanket), Eye Pro, Ear Pro, strap them to the litter, secure IV lines

Hypothermia is of concern in hot climates as well.   Studies from Iraq indicate that in temperatures over 120 F, casualties are arriving at surgical units hypothermic.   You do not need to use external heat sources (e.g., heatpacks) if you PREVENT heat loss at the point of injury.  You must prevent so you do not have to rewarm.

Care Under Fire:Providing Treatment Behind Cover

Providing care under fire is a mentally daunting task. Few other phases have so little to do with medicine and so much to do with your surroundings. Even with a sizable piece of cover, it is easy to make mistakes and expose yourself during treatment when focused on patient care.

In the video you can see the medic doing a decent job of maintaining a low profile during treatment, then, while shifting from the casualty’s leg to his head, he elevates his body during movement. This action briefly exposes his head to enemy fire. An analogy we like to use to explain the atmosphere you are operating in when providing true “care under fire” is that it can be equated to working in confined space. The difference is that instead of bumping your head or elbow on a concrete slab, the concrete slab is replaced by incoming fire. It is generally best for everyone if the medic avoids bumping parts of his body into bullets.

The effort to maintain your position of cover is exponentially more difficult in urban areas or areas with varying points of elevation. You should regularly reassess the effectiveness of you position as the fight progresses. If the enemy force has moved to an elevated position, or possibly to the second or third story of a surrounding structure, you just lost about 50% of your position. Now you must either be more cautious when moving to provide treatment or you need to shift to maximize the use of the position you are in. If in a structure with external windows and “plunging fire” from surrounding buildings, the safest position is on an external wall, in the corners, away from windows. However, remember to consider the type of materials used to construct the building before selecting this position. This position is not recommended if in a vinyl-sided home or a 3rd world type structure.

Failure to practice working in tight quarters behind cover can lead to potentially fatal mistakes in combat. Incorporate these situations into your training and use them to increase the effectiveness of your equipment (e.g., how and where you store or pack it) and how to asses your positions.

Here are some tips for operating in this phase of tactical medicine:
-Keep items required for Care Under Fire or buddy-aid easily accessible.
-Reposition casualties to minimize their level of exposure and yours.
-Don’t lose touch with your surroundings, regularly reassess the enemy’s position.
-Don’t be afraid to move to a new position if the tactical situation allows.
-If in a structure, be mindful of interior and exterior threats.
-Keep your treatments as simple as possible then get back on your gun!

Phases of Tactical Medicine

The Care Under Fire Phase (Part 2)–Considerations

The Care Under Fire (CUF) phase of treatment requires a basic management plan. The plan is comprised of basic steps. Remember, it is the basics that save lives. They are as follows:

1) Regain your situational awareness.

  1. What type of threat have you encountered? An IED?
  2. What direction is the threat coming from? Will a secondary explosion/engagement occur? Is it occurring now?

  3. Are there any casualties? Am I a casualty?
  4. What do I do now? Treat the casualty? Return Fire?

2) Return Fire and/or take cover.

  1. Because this is the CUF Phase, which means you are still under fire, you are not a medic until fire superiority has been established. As the old saying goes, “fire superiority is the best medicine.”

3) Direct casualty, if applicable, to remain engaged in the fight.

  1. This may prevent the casualty from sustaining further injuries. This must be practiced in training. As Bruce Siddle has noted in Sharpening the Warrior’s Edge, practicing to play the casualty by quitting when shot during training will hinder one’s ability to do otherwise in real-world situations (i.e., do not get in the mindset that an injury precludes you from continuing to fight.

4) If patient is unable to continue to fight, direct him/her to move to cover and/or apply self-aid.

  1. This must be done in training. Get your operators out of the mindset that “doc will do medicine.” You must train them to provided self-aid, then buddy-aid, then, when applicable, expect medic-aid. The casualty is a casualty for a reason: The point of injury is dangerous, underfire, etc. Direct him to treat himself via yelling, radio, etc. Remember, however, that ears will be ringing post-explosion.

5) Prevent patient from sustaining additional wounds (SEE 3 and 4).

  1. In addition to 3 and 4, rescue ought to be considered. Practice tactical rescues in training. Train assaulters to quickly assess casualties during the tactical rescue. For example, if the casualty is talking, then airway is good. If responsive, ask where they are hit. Look for hemorrhage. Are they complaining about difficulty breathing? These are just a few examples.

6) Stop Catastrophic-Hemorrhage. (self-aid, buddy-aid, medic-aid)

  1. Use tourniquets where applicable.
  2. Hemostatic agents with pressure dressing if tactically feasible.

7) Airway management ought to be deferred until the Tactical Field Care phase.

  1. Not always possible. Be prepared to provide a surgical airway. If an airway compromise is sever enough to need attention during the CUF phase, then 99% of the time it will require a Cric. Do you have a Cric-Kit accessible? If it is in your bag, then it is not going to do the casualty much good. You need to have one in a mag-pouch, leg-bag, etc.

The above is a loose guide. Do not limit yourself to algorithmic medicine.

Primary Weapon Placement in Close-Quarters Battle

Selecting a technique for storage of a medic’s primary weapon during treatment is a difficult task.  While there are many excellent slings on the market, none are designed to functionally keep a weapon out of a medic’s way while he or she  is treating a casualty.  Some slings such as the V-tac sling provide an easily accessible point of rapid adjustment that allows a medic to push the weapon aside.  Although such slings are the best currently available, when wearing an aid-bag it can be difficult to prevent your weapon from striking the casualty, possibly causing further injury.

How might we mitigate such a problem? One method is to place the weapon behind your knees.  This technique, as with everything, has advantages and disadvantages.  The primary disadvantage is that the weapon is no longer attached to your body by a relatively strong piece of nylon.  If there is a large explosion or an incoming mortar round there is a chance you could be separated from your primary weapon.  If your environment doesn’t force you to deal with pesky insurgents lobbing mortar rounds, this may be of absolutely no concern.  Some of the advantages of this technique are well worth the possible disadvantages.  Keeping the weapon behind your knees ensures you always know where it is.  NEVER set your weapon on the ground beside you to work on a casualty.  Many highly skilled and experienced medics have left their weapons to respond to another casualty or initiate the evacuation of wounded.  Keeping it stored behind your knees is an uncomfortable reminder of your primary focus on the battlefield, and it is highly unlikely that you will forget where it is.

Some people will argue that storing your primary weapon in this location is a bad idea because of the amount of time it takes to put the weapon into operation.  The fact is that maneuvering a slung weapon while wearing an aid bag and a Camel-bak™ is not a smooth operation.  If you are presented with a threat serious enough to warrant immediate engagement that requires a reaction time of a few seconds, you are better of answering that threat with your secondary weapon.  Drawing your pistol and accurately engaging targets is something that is practiced over and over again on the range.  Take advantage of training and use it in this situation.  If you are providing aid, you should either be in a “secure” area, cleared room, or behind a position of cover.  If you face a threat that requires immediate engagement in this environment, it will likely be at close range.  If you are proficient with your secondary weapon, it should be more than sufficient to deal with the threat.  Targets at greater distances generally allow enough reaction time to access your primary weapon.

In addition to the benefit of forcing you to maintain control of your weapon,  placing the weapon behind your knees forces you to put the weapon where it belongs when moving about the objective or from one casualty to another: in your hands.  It doesn’t take long for “combat complacency” to kick-in and this is a passive means of fending it off.  A weapon slung across your back is not the best position for engaging targets.  Getting that weapon into a position that you can accurately engage targets after you have spent so much time keeping it out of your way can be difficult.  You are better off removing the weapon when you stop to treat a casualty, then slinging the weapon in a configuration suited for engagement when it is time to move.

You will have to decide what works best for you in your environment.  The key is to religiously practice the techniques you implement.  Don’t let your first time be the time that counts!

We will post an instructional video next week in order to demonstrate the above-mentioned techniques.

Phases of Tactical Medicine

The Care Under Fire Phase 

The Care Under Fire (CUF) phase of treatment requires a basic management plan.  The plan is comprised of basic steps.  Remember, it is the basics that save lives.   They are as follows:

1) Regain your situational awareness.

2) Return Fire and/or take cover.

3) Direct casualty, if applicable, to remain engaged in the fight. 

4) If patient is unable to continue to fight, direct him/her to move to cover and/or apply self-aid. 

5) Prevent patient from sustaining additional wounds (SEE 3 and 4).

6) Stop Catastrophic-Hemorrhage. (self-aid, buddy-aid, medic-aid)
    A) Use tourniquets where applicable.
    B) Hemostatic agents with pressure dressing if tactically feasible.

7) Airway mangement ought to be deferred until the Tactical Field Care phase.
                                                                                         
The above is a loose guide. Do not limit yourself to algorithmic medicine.

Next time we will examine each step more in-depth.

If you have any comments, please send them to alan@tacmedsolutions.com