Update on Tactical Medicine Concepts and Controversies

We are pleased to announce an upcoming educational opportunity. On Thursday, October 14, 2010, the Texas Health Presbyterian Hospital will be hosting a conference titled, “Update on Tactical Medicine Concepts and Controversies.” This is a great opportunity and we will be attending.


Conference Description:
This conference will address those new and innovative interventions, products and techniques whose implementation at the point of wounding (POW) will allow for a more stable and viable patient upon arrival at the tertiary facility and, hence, improved longterm outcome. Though originally designed for the military theater, Tactical Combat
Casualty Care (TCCC) concepts are rapidly being adopted within the civilian medical and law enforcement communities as they are asked to respond to terror incidents at home. Columbine High School, Virginia Tech and terror incidents in Russia and India are only a few examples of the world in which we live. This conference is as relevant to
law enforcement (local and federal) and medical first responders as it is to the Soldiers and Marines on the battlefield. It is also relevant to physicians, nurses and other care providers, both civilian and military, who have a need for familiarity with current medical care techniques in the tactical environment.

Contest: 101 Ways to Use a Trianguler Bandage

In an age when hemostatic agents and pocket-sized BP cuffs monopolize most conversations regarding combat casualty care, a command of the basics is being lost. While the abundance of choices of pre-made kits addressing the majority of field-treatable injuries reduces the chance of needing to improvise, one ought to have a command of the basics using available materials.

A medic cannot have a more basic piece of kit than a triangular bandage. Therefore, we are having a contest to encourage submissions of different ways to use a triangular bandage to treat combat trauma. The details are as follows:

Prize: $200 in free Tac Med gear

Submission Format: Either submit a description to the comments section or email them to alan@tacmedsolutions.com. How-to videos are welcomed, but not required. We will be filming the most unique and helpful techniques for the blog.

Deadline: All submission must be in by 1 MAR 2010. We will announce the winner by 15 MAR 10. Due to concerns with operational anonymity, we will request your approval before sharing your name.

Equipment Considerations: Level 2

As mentioned in an earlier post regarding Level 1 kit, you must pack your medical gear to reflect the mission requirements and constraints. Here are some considerations when packing your Level 2 gear:

1) Pack supplements to Level 1. For instance, medics may need more bandages and tourniquets.

2) Pack for Tactical Filed Care phase of treatment. In this phase, you may need:

    A. Drugs (e.g., Toradol) and associated items (e.g., syringes, heplocks)
    B. Splinting material
    C. Evacuation Platforms (e.g., poleless litters or a Foxtrot Litter)
    D. Fluids
    E. Needle Thoracostomy items
    F. Hypothermia Prevention
    G. Casualty Equipment Bag
    H. Casualty Documentation

3) An aid-bag for the above items. Err on the side of too small, as carrying a “tick” on your back might be more of a burden than an asset, depending on the mission. That is your call.

The above serves as a framework. We will cover Level 3 in the next post.

Needle Decompression Hazards

Historically, tension pneumothax has been the 2nd leading cause of preventable death on the battlefield. Therefore, this is an important skill and is being taught to medics at the lowest level of care. However, as with all procedures, risks are involved. Feedback from the field has indicated that medics are performing this procedure too often and TOO medial, causing multiple complications.

The above video covers the hazards of a needle decompression. Below you will find a brief review of indications, contra-indications, etc. As always, please follow local protocols.

Needle decompression is indicated for the treatment of:
A. Tension pneumothorax and / or
B. Tension hemopneumothorax

A. Chest decompression is indicated in the field only in the face of a life-threatening
tension pneumothorax. In that situation, there are essentially no contraindications since
the only alternative is almost certain death.

A. Blunt force trauma to the chest that ruptures a portion of lung tissue
B. Fractured rib that punctures the lung tissue
C. Spontaneous pneumothorax for no apparent reason
D. Conversion of a simple pneumothorax to a tension pneumothorax by positive pressure
ventilation as with a bag-valve mask device etc.
E. Open pneumothorax that is covered and left unattended developing into a tension

A. Chest pain
B. Severe respiratory distress
C. Tachycardia
D. Hypotension
E. Decreased or absent breath sounds on affected side

A. Cyanosis
B. Distended neck veins
C. Tracheal deviation away from affected side

Pic 3
(Source: Canadian Tactical and Operational Medical Solutions)

A. Creation of pneumothorax where none existed previously
B. Laceration of lung tissue
C. Bleeding from laceration of intercostal blood vessels
D. Severe pain to conscious patient (since this is life-threatening, the procedure must be
continued )
E. Local hematoma
F. Laceration and/or puncture of the heart

MCI Injury Patterns and Treatment


Bombs aimed at civilian populations are the most common
weapon used by terrorists throughout the world. Over the last
decade, we have been involved in the management of more
than 20 mass casualty incidents, most of which were caused
by terrorist bombings. Commonly, in these events, there may
be many victims and many deaths. However, only a few of the
survivors will suffer from life-threatening injuries.
and timely treatment may impact their survival. Due to the
complex mechanism of injury seen in these scenarios, treatment
of victims injured by explosions is somewhat different
from that exercised in blunt and penetrating trauma from
other causes. The intention of this article was to outline the
initial medical treatment of the injured victim arriving at the
emergency department during a mass casualty incident
caused by a terrorist bombing. Treatment protocols for stable,
unstable, and in extremis patients are presented.

MCI Stable Victims

Surgical Airway/Cricothyroidotomy: How to

This video is a supplement to training and is neither comprehensive nor a replacement for proper instruction.

A surgical airway/cricothyroidotomy is the advanced airway of choice in combat, due to the types of injuries encountered. Severe maxofacial trauma secondary to blasts are common and may require more invasive treatment when neither the recovery position nor NPA nor King Oropharyngeal Airway (King-LTD) will suffice. It is important to note that only airway management is generally best left to the Tactical Field Care (TFC) phase of treatment. Furthermore, less than 1% of trauma casualties require an airway, so prudence is required when deciding to intervene. The indications and contraindication are as follows:


–Airway obstruction due to maxillofacial trauma that cannot be corrected by positioning or a nasopharyngeal airway
–Anaphylaxis that is or is about to compromise the airway
–Inhalation burns injury
–Where other means to secure the airway have failed


–Airway can be maintained by other means

Please note that we illustrate a vertical incision instead of the traditional horizontal, because we feel it is the preferred method in the tactical environment. First, a vertical incision minimizes the risk of involving (e.g., cutting) the vascular structure of the neck. Second, it creates a larger “window,” thereby simplifying landmark identification. Finally, a vertical incision allows one to select a different location above or below the initial site, if one should misplace the initial cut, due to lack of familiarity with the procedure.

Three-Step Cric?

Below you will find an article published in Military Medicine. It argues that traditional ways of providing a surgical airway in a tactical environment are flawed. Therefore, the authors continue, a new approach is needed. Three-step Cric

Objective: Surgical cricothyroidotomy is the airway of choice in combat. It is too dangerous for combat medics to perform orotracheal intubation, because of the time needed to complete the procedure and the light signature from the intubation equipment, which provides an easy target for the enemy. The purpose of this article was to provide a modified approach for obtaining a surgical airway in complete darkness, with night-vision goggles. Methods: At our desert surgical skills training location at Nellis Air Force Base (Las Vegas, Nevada), Air Force para-rescue personnel received training in this technique using human cadavers. This training was provided during the fall and winter months of 2003-2006. Results: Through trial and error, we developed a “quick and easy” method of obtaining a surgical airway in complete darkness, using three steps. The steps involve the traditional skin and cricothyroid membrane incisions but add the use of an elastic bougie as a guide for endotracheal tube placement. We have discovered that the bougie not only provides an excellent guide for tube placement but also eliminates the use of additional equipment, such as tracheal hooks or dilators. Furthermore, the bevel of the endotracheal tube displaces the cricothyroid membrane laterally, which allows placement of larger tubes and yields a better tracheal seal. Conclusion: Combat medics can perform the three-step surgical cricothyroidotomy quickly and efficiently in complete darkness. An elastic bougie is required to place a larger endotracheal tube. No additional surgical equipment is needed.

Post-engagement Hearing Loss and Factors Affecting the Use of Diagnostics

One of the challenges associated with tactical medicine is the lack of diagnostic equipment at the point of injury and throughout the evacuation process. The tactical situation can limit the ability to use exam lights (of any color) and post-engagement hearing loss or environmental noise can eliminate your ability to use a stethoscope or to hear at all.

It is important to practice different techniques for assessing your casualties’ status that do not require the use of diagnostic tools or one specific sense. Hearing is the most regularly affected sense in the combat environment and it is the sense medics rely on the most heavily. Large blasts or firing a weapon can cause a significant ringing or a muffle in your ears. Therefore, when listening for slight variations in breath sounds or a fading pulse, it can be next to impossible to hear. That is why you must learn alternate methods for assessing your casualties’ status.

One skill that is often affected is measuring blood pressure. If you don’t know how to take a palp. blood pressure or know how pulse presence roughly correlates to levels of BP, you need to learn and practice the techniques. They also come in handy when working in the back of a helicopter or loud vehicle such as a track-vehicle or Stryker that are on the move. Here are some examples of pulse pressures associated with the presence of a pulse in various locations.

Pulse Location/Correlating Pulse pressure

Dorsalis-pedis pulse/90
Tibialis-posterior pulse/90
Radial pulse/80
Femoral pulse/70
Carotid pulse/60

These are very rough estimates and should only be used when no other means of measuring pressure are available. Studies have shown that this method often causes medical personnel to overestimate their patients’ pressure. We suggest this method be used to note which pulses are palpable during the initial set of vitals. Mark the location of these pulses with a Sharpie® when they are found. If a pulse that was present becomes weaker or disappears as time elapses, your casualty may be deteriorating, and you need to do something to address the cause of that deterioration. As stated earlier, this method should not be used if an accurate pressure is required.

The inability to use the sense most suited for the evaluation of a casualty is not just limited to taking blood pressure. It affects your ability to assess a needle decompression in a helicopter, looking for unilateral rise and fall of the chest, feeling for injuries and many other portions of your assessment. Regular practice of alternate methods of assessment should be included in your training regimen, because it’s too late to practice after your ears are ringing from the IED blast.

Training Company or Product Peddler? You Make the Call

Who is providing your training? Is it a company that manufactures or distributes products? If so, beware. We receive emails and calls weekly regarding training. We do not offer training, because it is difficult—perhaps impossible—to offer students quality training without conscious or unconscious biases impeding. Therefore, we recommend finding companies that do not have a vested interest in selling products. Finding quality training is difficult. Budget, geographical, and time constraints may limit your ability to receive quality TEMS/TCCC training. Unfortunately, factors beyond your control may force you to attend a class provided by a company that peddles their products behind a guise of training.

Below you will find a list of topics that ought to be covered by a training program, as well as telltales of product peddling.

1)Care Under Fire Phase techniques and considerations
2)Tactical Field Care Phase techniques and considerations
3)Patient evacuation methods, movement, equipment
–Litters (e.g., rigid, semi-rigid, pole-less)
–Rescue Tactics, which is the most important part, and equipment
–Hypothermia prevention/treatment
4)Hemorrhage control and treatments
–Tourniquets, Bandages, Gauze, Hemostatics how to use each
5)Airway/Breathing treatment techniques and considerations
–NPAs, Crics, occlusives, and needle decompression
6)Fracture ID/management/Splinting techniques and considerations
7)IV/IO techniques and considerations
8)Multiple Casualty/triage methods and documentation
9)Casualty model scenarios (live and simulated, the former being preferable)

Signs of product peddling: Instructors might display multiple products in one category (e.g., tourniquets) that you might see in your theater of operation. Next, they discuss the pros and the cons of each product. However, watch for the “cons” identified when discussing the product they sell. Instructors will highlight all the negatives of other products, often citing anecdotal cases or out-of-context research, while offering “vanilla” cons, if any at all, for their product.

That said, test products after learning their proper implementation in a course. Instructors do not hold a monopoly when it comes to knowledge. They may be basing their “facts” on assumptions, one poor experience or hearsay. Test items yourself. Call the company that provides products and ask the benefit of its product. Gauze, for example, is gauze. Therefore, if a company tries to tell you it has the best, question its judgment.

In the end, you ought to seek the best training and the best equipment, because yours is a business that saves lives. Do not become enamored with a company’s products because they provided training. Furthermore, because a national organization approves a course, product, or methodology do not assume it is best.

Here are a few US companies, with which we have no affiliation, that offer training and do not push products:

JTM Training Group

Mobile Asset Security and Training Group

Teir 1 Group

Importance of Marking PTs in Mass-casualty

In the study below, results indicate that marking casualties during the initial phase of mass-casualty management with both color tags and glow-sticks of corresponding color increases evacuation times remarkably. Furthermore, doing so reduces error rates when rescuers reenter the scene to evacuate previously sorted patients. In a non-tactical environment, using glow-sticks in conjunction with tags is permissible. At a minimum, you should carry a kit containing a set of glow-sticks, zone-marker tape, and a tracking system in order to facilitate the movement of patients on and off the scene.  Having the above items will allow you to set-up three sectors and a control point that rescuers can see from a distance in low-visibility situations.

Casualty Collection


Introduction: Mass-casualty incidents (MCIs) are on the rise. The ability to locate, identify, and triage patients quickly and efficiently results in better patient outcomes. Poor lighting due to time of day, inclement weather, and power outages can make locating patients difficult. Efficient methods of locating patients allow for quicker transport to definitive care.

Objective: The objective of this study was to evaluate the methods currently used in mass-casualty collection, and to determine whether the use of the Simple Triage and Rapid Treatment (START) triage tag system can be improved by using easily discernable tags (glow sticks) in conjunction with the standard triage tags.

Methods: Numerous drills were performed utilizing the START triage method. In Trial A, patients were identified with the triage tags only. In Trial B, patients were identified using triage tags and glow sticks. Four rounds of triage drills were performed in low ambient light for each Trial, and the differences in casualty collection times were compared.

Results: Casualty relocation and collection times were considerably shorter in the trials that utilized both the glow sticks and triage tags.An average of 2.58 minutes (31.75%) were saved during the casualty collections. In addition, fewer patient errors occurred during the trials in which the glow sticks were used. Between the four rounds, an average of four patient errors occurred during the trials that utilized the triage tags. However, there was an average of only one patient error for the drills when participants utilized both the triage tags and the glow sticks.

Conclusions: The use of the highly visible glow sticks, in conjunction with the START triage tags, allowed for more rapid and accurate casualty collection in suboptimal lighting.The use of the glow sticks made it easier to relocate previously triaged patients and arrange for expeditious transport to definitive care. In addition, the glow sticks reduced the number of patient errors. Most importantly, there was a significant reduction in the number of patients that initially were triaged via the START method, but were overlooked during casualty collection and transport.