zacbol
09-01-2014, 11:15 PM
This past weekend I attended Insights Advanced Tactical Casualty Care taught by Mike Shertz, former SF Medic, emergency physician, and member of Committee for the Committee on Tactical Emergency Casualty Care (http://c-tecc.org/). John Holschen was also present, primarily assisting with scenarios (he didn't lecture) as well as a local paramedic, who I'm embarrassed I can't recall the name of (I'm terrible with names).
The first two days were largely lecture based with some hands-on practice sessions interspersed and some less involved scenarios at the end of day two. The third day of class was a full day of scenario-based training.
Day one Mike provided background on the class and how the course contents differ from many traditional medical classes. Tactical casualty care, he explained, addresses a high threat situation in which there is both a medical problem as well as a tactical problem. Good medicine may sometimes be bad tactics cause the mission to fail.
This was the first time the class had been offered to civilians, though there was a relatively high percentage of students in either executive protection, medical, or LEO. He explained that he had considered ways in which he should adjust the material, but ultimately felt there were no significant ways in which it needed to be changed for civilians.
Crucial to remember is that most civilian EMS know relatively little about hemorrhage control for life-threatening situations and many police officers do not have tactically relevant medical training. EMS mostly sees blunt trauma or non-fatal hemorrhage, because in cases of life threatening hemorrhage the person is generally dead before EMS arrives. Mike then explained the best data we have is from Vietnam as OIF/OEF data is skewed to blast injuries by IED usage. Until the US has these types of incidents, Vietnam has more data about the type of penetrating extremity trauma we see here.
Mike explained that rather than the traditional ABCDE used in most first aid classes, its’ more appropriate to use the acronym of MARCH:
M – Massive hemorrhage
A – Airway
R – Respiration (tension Ptx)
C - Circulation
H – Hypothermia prevention
Mike then spent an hour and a half with a basic overview of wound ballistics, including the different wounding patterns of various calibers (and how they are frequently misrepresented/misunderstood), the differences between physiological and psychological incapacitation, and the generally low mortality rate of gun shots victims.
Mike then segued into a discussion of hemorrhage control, including substantial discussion around the clinical evidence for various options. The CAT tourniquet is the preferred commercial tourniquet as other options are either not appropriate to field use due to fragility or, in the case of the SOF-T and even the theoretically better SOFTT-W, have only demonstrated a 50% success rate in full occlusion of blood flow in trials. Tourniquets should be placed 2- 4 inches above the injury and 2-4 inches below the joint. In most tactical situations, the tourniquet should be placed as high on the limb as possible. Tissue damage is rare if the tourniquet is applied for less than two hours and is properly applied. A single CAT tourniquet has been proven effective in 82% of cases. Two tourniquets side-by-side are effective in 92% of cases.
After discussing tourniquets Mike moved on to junctional hemorrhage, cases in which is hemorrhage at the transition between the torso and the extremities/neck (e.g. groin, armpits, neck) It is the largest cause of preventable death in Afghanistan. The proper procedure is to insert a finger into the wound and probe to feel something akin to a squirt gun, as this is the source of bleeding. Once the source of bleeding has been found, wrap gauze around the finger and insert to that point, then pack as *tightly* as possible into the wound, filling the cavity entirely and tightly. Once the wound is completely filled, you make a small mound of additional gauze on top and retaining pressure, apply a pressure bandage such as an Israeli trauma bandage. Secure this then wrap again with a cravat to provide adequate pressure.
Mike also reviewed the currently available hemostatic gauzes/agents. The only one he feels may be worthwhile is Combat Gauze, but even there the evidence is weak and when he reviewed the contents of his IFAK he mentioned if he didn’t have room (or the money) it’d be the first thing he ditched—substituting Kerlix gauze. If a limited amount of CombatGauze is available, it should be used first and placed nearest the point of bleeding.
Practicing Wound Packing at end of Day one:
http://i42.photobucket.com/albums/e335/zacbol/WP_20140822_002_zpse19671d9.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140822_002_zpse19671d9.jpg.html)
http://i42.photobucket.com/albums/e335/zacbol/WP_20140822_008_zps1a94802f.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140822_008_zps1a94802f.jpg.html)
On day two, we began with some practical exercises of applying tourniquets to ourselves and others. Next Mike discussed chest wounds (aka thorcic injury) and needle decompression. In cases of open pneumothorax (aka ‘sucking chest wound’) air can both enter and exit the pleural space. The military wants all open chest wounds be sealed and this has led to a proliferation of different chest seals, but there is no evidence this actually helps or is necessary. There are no OEF/OIF deaths reported from open pneumothorax. And it’s possible that in sealing an open pneumothorax, it can be turned into tension pneumothorax which *is* deadly. In tension pneumothorax, air can enter the pleural space but not escape leading to increased pressure. One should suspect tension pneumothorax if the patient has chest trauma and:
Low blood pressure (weak pulse)
Low oxygen level (anxiety, agitation, apprehension, confusion)
Tracheal deviation
Neck vein distension
Short of breath – not subtle
To treat tension pneumothorax use a large bore (10 or 14 gauge) needle and:
dfs
Locate clavicle on affected side and find third rib
Insert needle *over* third rib and penetrate until air escapes or is aspirated
Remove needle, leaving catheter
Secure catheter in place with tape or Asherman valve
Practicing needle decompression:
http://i42.photobucket.com/albums/e335/zacbol/WP_20140823_003_zps48e0f619.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140823_003_zps48e0f619.jpg.html)
http://i42.photobucket.com/albums/e335/zacbol/WP_20140823_005_zpsed7cd8c8.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140823_005_zpsed7cd8c8.jpg.html)
As needle decompression is considered a paramedic-level skill and tension pneumothorax typically starts showing up after 20 minutes or so, there is little reason to perform it in a civilian setting unless the situation dictates it. You may face legal liabilities if you do. Mike explained he was teaching the technique so to bookend the other information about recognizing symptoms.
The lecture also covered casualty movement techniques, and positioning casualties in the recovery position to aid access to the victim and open the airway, blast injuries, field triage an establishing a casualty collection point, and prevention of hypothermia, which is an issue with any significant blood loss even in hot climates such as Iraq. At the end of day two, we did some scenarios. They involved casualty transport, evaluation, and tourniquet application but were no where near the complexity of day three.
The third day of class was entirely scenario based. This part was in an abandoned building that is part of a school for the developmentally disabled in Buckley, Wa. We rotated with three different instructors doing different scenarios, with each student having two individual scenarios. Normally this is all they have time for, but we also had additional group scenarios at the end. Both live role players, with simulated wounds, as well as mannequins were used a victims. Mike explained the scenarios and would profiles were based on real-life events. Typically, you’d be given a little context and then would need to problem solve.
Preferred two person carry:
http://i42.photobucket.com/albums/e335/zacbol/WP_20140824_007_zpsb2fa82d0.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140824_007_zpsb2fa82d0.jpg.html)
Pack strap carry (with one hand free for doors)
http://i42.photobucket.com/albums/e335/zacbol/WP_20140824_010_zpsf9761ef4.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140824_010_zpsf9761ef4.jpg.html)
After my scenario (My wife sent me to Whole Foods on the way home and I got some interesting looks):
http://i42.photobucket.com/albums/e335/zacbol/WP_20140824_011_zps25cfec08.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140824_011_zps25cfec08.jpg.html)
Scenario:
http://i42.photobucket.com/albums/e335/zacbol/WP_20140824_017_zpsa33e0981.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140824_017_zpsa33e0981.jpg.html)
Scenario
http://i42.photobucket.com/albums/e335/zacbol/WP_20140824_021_zpsfb3d318a.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140824_021_zpsfb3d318a.jpg.html)
Scenario:
http://i42.photobucket.com/albums/e335/zacbol/WP_20140824_027_zps961d3b55.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140824_027_zps961d3b55.jpg.html)
This was an outstanding class from start to finish. Mike provided not just techniques but also the background information and clinical evidence for his recommendations. The final day of scenarios was run expertly and added immense training value in applying the techniques in life-like scenarios.
The first two days were largely lecture based with some hands-on practice sessions interspersed and some less involved scenarios at the end of day two. The third day of class was a full day of scenario-based training.
Day one Mike provided background on the class and how the course contents differ from many traditional medical classes. Tactical casualty care, he explained, addresses a high threat situation in which there is both a medical problem as well as a tactical problem. Good medicine may sometimes be bad tactics cause the mission to fail.
This was the first time the class had been offered to civilians, though there was a relatively high percentage of students in either executive protection, medical, or LEO. He explained that he had considered ways in which he should adjust the material, but ultimately felt there were no significant ways in which it needed to be changed for civilians.
Crucial to remember is that most civilian EMS know relatively little about hemorrhage control for life-threatening situations and many police officers do not have tactically relevant medical training. EMS mostly sees blunt trauma or non-fatal hemorrhage, because in cases of life threatening hemorrhage the person is generally dead before EMS arrives. Mike then explained the best data we have is from Vietnam as OIF/OEF data is skewed to blast injuries by IED usage. Until the US has these types of incidents, Vietnam has more data about the type of penetrating extremity trauma we see here.
Mike explained that rather than the traditional ABCDE used in most first aid classes, its’ more appropriate to use the acronym of MARCH:
M – Massive hemorrhage
A – Airway
R – Respiration (tension Ptx)
C - Circulation
H – Hypothermia prevention
Mike then spent an hour and a half with a basic overview of wound ballistics, including the different wounding patterns of various calibers (and how they are frequently misrepresented/misunderstood), the differences between physiological and psychological incapacitation, and the generally low mortality rate of gun shots victims.
Mike then segued into a discussion of hemorrhage control, including substantial discussion around the clinical evidence for various options. The CAT tourniquet is the preferred commercial tourniquet as other options are either not appropriate to field use due to fragility or, in the case of the SOF-T and even the theoretically better SOFTT-W, have only demonstrated a 50% success rate in full occlusion of blood flow in trials. Tourniquets should be placed 2- 4 inches above the injury and 2-4 inches below the joint. In most tactical situations, the tourniquet should be placed as high on the limb as possible. Tissue damage is rare if the tourniquet is applied for less than two hours and is properly applied. A single CAT tourniquet has been proven effective in 82% of cases. Two tourniquets side-by-side are effective in 92% of cases.
After discussing tourniquets Mike moved on to junctional hemorrhage, cases in which is hemorrhage at the transition between the torso and the extremities/neck (e.g. groin, armpits, neck) It is the largest cause of preventable death in Afghanistan. The proper procedure is to insert a finger into the wound and probe to feel something akin to a squirt gun, as this is the source of bleeding. Once the source of bleeding has been found, wrap gauze around the finger and insert to that point, then pack as *tightly* as possible into the wound, filling the cavity entirely and tightly. Once the wound is completely filled, you make a small mound of additional gauze on top and retaining pressure, apply a pressure bandage such as an Israeli trauma bandage. Secure this then wrap again with a cravat to provide adequate pressure.
Mike also reviewed the currently available hemostatic gauzes/agents. The only one he feels may be worthwhile is Combat Gauze, but even there the evidence is weak and when he reviewed the contents of his IFAK he mentioned if he didn’t have room (or the money) it’d be the first thing he ditched—substituting Kerlix gauze. If a limited amount of CombatGauze is available, it should be used first and placed nearest the point of bleeding.
Practicing Wound Packing at end of Day one:
http://i42.photobucket.com/albums/e335/zacbol/WP_20140822_002_zpse19671d9.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140822_002_zpse19671d9.jpg.html)
http://i42.photobucket.com/albums/e335/zacbol/WP_20140822_008_zps1a94802f.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140822_008_zps1a94802f.jpg.html)
On day two, we began with some practical exercises of applying tourniquets to ourselves and others. Next Mike discussed chest wounds (aka thorcic injury) and needle decompression. In cases of open pneumothorax (aka ‘sucking chest wound’) air can both enter and exit the pleural space. The military wants all open chest wounds be sealed and this has led to a proliferation of different chest seals, but there is no evidence this actually helps or is necessary. There are no OEF/OIF deaths reported from open pneumothorax. And it’s possible that in sealing an open pneumothorax, it can be turned into tension pneumothorax which *is* deadly. In tension pneumothorax, air can enter the pleural space but not escape leading to increased pressure. One should suspect tension pneumothorax if the patient has chest trauma and:
Low blood pressure (weak pulse)
Low oxygen level (anxiety, agitation, apprehension, confusion)
Tracheal deviation
Neck vein distension
Short of breath – not subtle
To treat tension pneumothorax use a large bore (10 or 14 gauge) needle and:
dfs
Locate clavicle on affected side and find third rib
Insert needle *over* third rib and penetrate until air escapes or is aspirated
Remove needle, leaving catheter
Secure catheter in place with tape or Asherman valve
Practicing needle decompression:
http://i42.photobucket.com/albums/e335/zacbol/WP_20140823_003_zps48e0f619.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140823_003_zps48e0f619.jpg.html)
http://i42.photobucket.com/albums/e335/zacbol/WP_20140823_005_zpsed7cd8c8.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140823_005_zpsed7cd8c8.jpg.html)
As needle decompression is considered a paramedic-level skill and tension pneumothorax typically starts showing up after 20 minutes or so, there is little reason to perform it in a civilian setting unless the situation dictates it. You may face legal liabilities if you do. Mike explained he was teaching the technique so to bookend the other information about recognizing symptoms.
The lecture also covered casualty movement techniques, and positioning casualties in the recovery position to aid access to the victim and open the airway, blast injuries, field triage an establishing a casualty collection point, and prevention of hypothermia, which is an issue with any significant blood loss even in hot climates such as Iraq. At the end of day two, we did some scenarios. They involved casualty transport, evaluation, and tourniquet application but were no where near the complexity of day three.
The third day of class was entirely scenario based. This part was in an abandoned building that is part of a school for the developmentally disabled in Buckley, Wa. We rotated with three different instructors doing different scenarios, with each student having two individual scenarios. Normally this is all they have time for, but we also had additional group scenarios at the end. Both live role players, with simulated wounds, as well as mannequins were used a victims. Mike explained the scenarios and would profiles were based on real-life events. Typically, you’d be given a little context and then would need to problem solve.
Preferred two person carry:
http://i42.photobucket.com/albums/e335/zacbol/WP_20140824_007_zpsb2fa82d0.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140824_007_zpsb2fa82d0.jpg.html)
Pack strap carry (with one hand free for doors)
http://i42.photobucket.com/albums/e335/zacbol/WP_20140824_010_zpsf9761ef4.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140824_010_zpsf9761ef4.jpg.html)
After my scenario (My wife sent me to Whole Foods on the way home and I got some interesting looks):
http://i42.photobucket.com/albums/e335/zacbol/WP_20140824_011_zps25cfec08.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140824_011_zps25cfec08.jpg.html)
Scenario:
http://i42.photobucket.com/albums/e335/zacbol/WP_20140824_017_zpsa33e0981.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140824_017_zpsa33e0981.jpg.html)
Scenario
http://i42.photobucket.com/albums/e335/zacbol/WP_20140824_021_zpsfb3d318a.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140824_021_zpsfb3d318a.jpg.html)
Scenario:
http://i42.photobucket.com/albums/e335/zacbol/WP_20140824_027_zps961d3b55.jpg (http://s42.photobucket.com/user/zacbol/media/WP_20140824_027_zps961d3b55.jpg.html)
This was an outstanding class from start to finish. Mike provided not just techniques but also the background information and clinical evidence for his recommendations. The final day of scenarios was run expertly and added immense training value in applying the techniques in life-like scenarios.