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.

Performing A Wound Sweep

During the initial phases of treatment, one should perform a wound sweep to ensure there are no injuries that have been overlooked. There are different techniques, and ones tactical situation will dictate the best approach. The video above offers a broad framework and tips, which one can adjust as needed.

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

Antibiotic Impregnated Bandages for Penetrating Trauma

Early use of anti-biotics in combat trauma is now commonplace amongst most military medical circles. The liberal use of antibiotics in a tactical or combat environment has spawned numerous products to ease the process. Some of the items are very useful while others have little suitability to the injuries associated with trauma created by high-velocity fragments or penetrating trauma.

Antibiotics currently recommended for administration in the tactical environment generally are in pill or injectable form and they function on a systemic level instead of a local level. When considering the depth of the injuries associated with combat, placing a bandage impregnated with an antibiotic on the surface of an injury is almost senseless. It will serve to minimize or eliminate microbial activity at the surface of the wound, but it does nothing for the majority of the injury.

The real danger is when this type of dressing is used as a substitute for administering antibiotics in the field. Topical antibiotic treatment of penetrating trauma is similar to attempting to drink water without opening your mouth. You will wet your lips, which might make you feel better, but does little to help hydrate the body. These dressings do serve a purpose, however. For lacerations, abrasions and burns they are a sensible solution, but you wouldn’t treat a gunshot wound with Bacitracin. Therefore, don’t rely on the same concept in a different form. Administration of systemic antibiotics is the current accepted standard for combat trauma. Don’t accept anything less if you have the choice.

Treatment of Open-Chest Injury

Treating an open-chest injury is straightforward. There are, however, techniques that a medic ought to consider. As the video illustrates, identifying the wound is the most important step. Body-composition, position and wound type can complicate doing so. After locating the wound, the basics apply: perform a treatment, assess the treatment, and reassess the treatment after movement and at regular intervals.

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.

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

 Abstract:

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.

How Important is Personal Protective Equipment?

As the below presentation of  findings in a study conducted by the US Army’s Institute of Surgical Research indicates, PPE is crucial in preventing irreparable damage to operators’ hands.  As a medic it is your responsibility to ensure your men are practicing preventative medicine by utilizing PPE.  In the end, it will make your job easier, and, more importantly, increase the survivability and quality of life of you casualty.

ISR Hand Burns

Recent Research for TEMS

A number of abstracts and manuscripts relevant to Tactical Medicine have been published in recent months. These represent the cutting edge in medical knowledge. The [file containing the] … abstracts is below.

Recent TEMS

Recent TEMS