ABC s of Tactical Emergency Medicine Support Part I of II

Transcription

1 ABC s of Tactical Emergency Medicine Support Part I of II Deputy Sheriff Michael Gorham, BS, AEMT T

2 Peer to Peer, Educational Program for Justice Professionals Established in July 2014 Become a Member Today Our Mission To identify leading practices in all areas of criminal justice and providing a venue to share that information with other justice practitioners across the globe.

3 Introductions Session is Recorded Listen Only Event Type in Questions using GoTo Webinar

4 THE ABC IN TACTICAL EMS (PART 1)

5 PRESENTED BY MICHAEL GORHAM Law Enforcement Firefighter (South Wayne Fire Department) EMS AEMT with TEMS Endorsement #11467 I am an Instructor in Firearms, Tactical Response, EMS, BLS Army ILNG/ROTC, Civil Air Patrol, US Coast Guard Auxiliary Instructor with Southwest Technical College, Fennimore WI Lafayette County Sheriff s Office WI Cuba City Area Rescue Squad US Coast Guard Auxiliary

6 RECOGNITION This presentation comes from the assistance of many sources: Midwest Tactical Officer s Association Chad Stiles. Chris Cook, Steve Rabinovich, Shane Heilmann, Matt Savage John Hallbrook, State of Iowa Emergency Management Milwaukee and Oak Creek Fire Departments WI Arlington County Fire Department VA. National Tactical Officers Association (Specialized Tactics Operational Rescue Medicine) Instructors: Mark Gibbons, Sean Mckay, Kevin Gerold, Phillip Carmona North American Rescue, Brent Bronson Tactical Medical Solutions

7 CAVEATS I am a student just like you sharing my thoughts, so it if you disagree with my information, that is your right based on your experiences and training. I do not like the word expert. I have preferences in products however, I am not here to sell you any product or endorse one over another. (Beware of Counterfeits) My experience is a culmination of 30 plus years working in the military, private security, police, fire and EMS. My largest foundation comes from working in rural Southwestern Wisconsin. My second base was working in the Dane County Metro Area of Wisconsin ( Madison ) Some pictures are graphic

8 RHETORICAL VERSUS PRACTICAL The root question to most of all of public safety s crisis? 1. Anticipate Crisis or Problems (Reactive) 2. Why do we Plan? - Response to Crisis 3. Why do we train? - Performance in our response 4. Why do we work to get better at what we do? - expectations; Public and Personal The perseveration of life is the fundamental priority of all public safety.

9 There are three stages of crisis response when the situation is not prepared for Denial Deliberation Decisive Action Courtesy of the ALERT Presentation

10 NO TRAINING OR PLANNING Emotion And Instinct Varied Outcomes Usually lots of complications Example: Police Transport Shooting Victims in Aurora CO to area Hospitals

11 WITH PLANNING AND PREPARATION Consider Colonel Boyd s OODA Loop Response process 1. Observe 2. Orient 3. Decide 4. Act Can be applied to most if not all public safety situations

12 REMEMBER TACTICAL EMS IS STILL EMS

13 The response paradigm changes

14 ACTIVE SHOOTER EVENT DEFINITION An active shooter event involves one or more persons engaged in killing or attempting to kill multiple people in an area occupied by multiple unrelated individuals.

15 UNDERSTANDING THE PROBLEM Active shooter incidents happen everywhere in this country, from the small town to the largest cities These goofs study each other and learn Looking to Share their pain and looking for attention. Can cross any social economic barrier Low cost attacks Weapons can be obtained easily or homemade

16 THE FIRST RECORDED ASMCI May 18, 1927 in Bath Township, MI School board member Andrew Kehoe upset over property tax increase Killed wife and burned his barn before driving to school Three explosions leaving 45 dead and 58 wounded Still the deadliest attack on a school in U.S. history

17 VIRGINIA TECH - APRIL 16, 2007 Cho murders 32 with two handguns 7:15 a.m. West Ambler Johnston Hall Hilscher and Clark killed Returns to his apartment and reloads Leaves to mail pictures and video manifesto to NBC 9:45 a.m. Norris Hall murders Executions in five classrooms Kills 30, then himself

18 CHURCH INCIDENTS March 8, 2009 in Illinois Suspect Terry Sedlacek, 27 Fatally shot pastor before stabbing himself Two parishioners were stabbed trying to restrain suspect Suspect developed a mental illness after contracting Lyme disease

19 WISCONSIN INCIDENTS, OAK CREEK AND BROOKFIELD

20 Number Shot Courtesy of the ALERT Presentation

21 THE SHOOTER No Profile Revenge Mindset Some broadcast intentions

22 LOCATION OF ATTACKS Commerce Education Outdoors Other 0% 10% 20% 30% 40% 50%

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24 Number of Deaths Target availability How quickly the police arrive

25 3 MINUTES IS THE RESPONSE TIME ON AVERAGE How long does it take to get to victims? Assess, Treat Evacuate, and Transport

26 THE CHALLENGE FACING EMS National Registry standards for all levels of Medics in their training and testing, which are critical tasking BSI Body Substance PPE Pass/Fail Is the scene safe (safer) Pass/Fail

27 BULLETS VERSUS BOMBS IED s are somewhat harder to acquire Expense and skill to make IEDs Larger chance of being detected It does not mean IEDs are not going to be used Bath MI to Columbine to Boston Marathon Bombings Paradigms are rapidly changing

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30 UNDERSTANDING BALLISTIC TRAUMA

31 RIFLED AMMUNITION Lethality increases over 2200 feet per second

32 CONSIDER FUTURE ISSUES TRAUMA FROM IMPROVISED EXPLOSIVE DEVICES

33 WHAT CAN WE LEARN FROM

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35 THE BIBLE OF TACTICAL COMBAT CASUALTY CARE Following the SEAL casualties sustained during the invasion of Panama, the Navy Special Operations community conducted an extensive review of combat death and trauma care. The concept of TCCC was developed in 1996 after an extensive analysis of the Vietnam Casualty Database. Lessons from Grenada, Panama, Somalia were also applied,

36 WHERE IT BEGAN TCCC Tactical Casualty Combat Care or (T)Triple C is the military s response to trauma on the battlefield. (Note their patients are usually YOA males in excellent health. Combat Lifesaver is Combat First Aid on steroids

37 HOW PEOPLE DIED IN GROUND COMBAT BELLAMY, RF. CAUSES OF DEATH IN CONVENTIONAL LAND WARFARE, MILITARY MEDICINE. 1984

38 15% of Ground Combat Deaths are Preventable

39 TCCC (3) Phases of Care CARE UNDER FIRE TACTICAL FIELD CARE CASUALTY EVACUATION

40 TCCC TRAINING Assessment (Contact and Remote) Use of Tourniquet Use of Chest Seals Use of Nasal Airway Wound packing (Hemostatic agents) IV administration Medications (some) Casualty Evacuation

41 GENESIS OF MEDICAL SUPPORT IN SWAT Within a Decade after the formation of Specialized Tactical Units, the late (1980s) ubiquitously known as SWAT. Teams started adding in a integrated medical support. For 25 years often larger agencies have integrated prehospital care providers into law enforcement operations. The SWAT Medic was designed to care for the team members much like their military cousins. Many agencies have used integrated medical support in Search and Rescue operations

42 TEMS Post 9/11 TEMS or Tactical Emergency Medical Support is usually an integrated prehospital care provider sometimes referred to as Tactical Medical Providers(TMPs). TMPs are assigned to a SWAT team. (Models vary from First Responder to Paramedics)

43 COMMITTEE ON TECC ADOPTS TCCC FOR PUBLIC SAFETY The TECC website Sean Mckay, pictured on the left Committee Member (Yoda)

44 TECC TACTICAL EMERGENCY CASUALTY CARE

45 TECC (3) PHASES OF CARE 1. Direct Threat Care (Hot Zone) 2. Indirect Threat care (Warm Zone) 3. Casualty Evacuation (Cold Zone)

46 LEVELS OF CARE IN TACTICAL OPERATIONS 1. Self Aid/Buddy Aid taught to Police Officer 2. Internal Medical Support integrated into SWAT Tactical Medic. Deployed into the Hot Zone 3. External Medical Support and the Continuum Of Care Edge of Warm/Cold Zone transport to definitive care. 4. Rescue Task Force Support, a new concept. In the event of MCIs where the event involves violence, coordinated teams of Police, Fire, EMS enter the warm zone and evacuate the treatable victims out of the zone.

47 TECC TRAINING (VARIES) Assessment Contact and Remote Tourniquet Application Chest Seals Airway Management Wound Packing (Hemostatic agents) Generally ( No Needle Decompression) Casualty Evacuation ( Needs to comply with National Registry Scope of Practice) Addresses the issue of NREMT testing ( Is the scene safe)

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49 TOOLS OF TECC Tourniquet (Bleeding for exterimities) Chest Seals (Sucking Chest Wound) Nasal Airway (Airway Management) Hemostatic Gauze (Wound Packing) Emergency Trauma Bandage All First responders in the nation should be taught TECC- Gorham

50 A NEW HOPE RTF is the Rescue Task Force is the integration of police, fire, and EMS working in concert to treat casualties in an active killer mass casualty incident or AKMCI. However, the principles of a RTF can be scaled down to small incidents involving 1 4 victims

51 2013 MTOA TEMS FT McCoy

52 MY CONTACT INFO Facebook Michael Francis G Lafayette County Sheriff s Office

53 PART II THE ABCS OF TEMS For Justice Clearinghouse

54 PRESENTED BY MICHAEL GORHAM Law Enforcement Firefighter (South Wayne Fire Department) EMS AEMT with TEMS Endorsement #11467 I am an Instructor in Firearms, Tactical Response, EMS, BLS Army ROTC, Civil Air Patrol, US Coast Guard Auxiliary Lafayette County Sheriff s Office WI Cuba City Area Rescue Squad US Coast Guard Auxiliary

55 RECOGNITION This presentation comes from the assistance of many sources: Midwest Tactical Officer s Association Chad Stiles. Chris Cook, Steve Rabinovich, Shane Heilmann Matt Savage John Hallbrook, State of Iowa Emergency Management Milwaukee and Oak Creek Fire Departments WI Arlington County Fire Department VA. National Tactical Officers Association (Specialized Tactics Operational Rescue Medicine) Instructors: Mark Gibbons, Sean Mckay, Kevin Gerold, Phillip Carmona North American Rescue, Brent Bronson Tactical Medical Solutions

56 CAVEATS I am a student just like you sharing my thoughts, so it if you disagree with my information, that is your right based on your experiences and training. I do not like the word expert. I have preferences in products however, I am not here to sell you any product or endorse one over another. (Beware of Counterfeits) My experience is a culmination of 30 plus years working in the military, private security, police, fire and EMS. My largest foundation comes from working in rural Southwestern Wisconsin. My second base was working in the Dane County Metro Area of Wisconsin ( Madison )

57 Why are we here? REVIEW OF PART 1 Active Shooter Events What is the Significant MOI (Mechanism of Injury) Bullets and IED other penetrating trauma

58 REVIEW OF PART 1 TCCC Military Origin Victims Males Good health No restrictions as far as OHSA, NREMT, Etc TECC Civilian Adaptation Wider Population Scope of Practice NREMT, OHSA, other Medical oversight

59 COMMON QUESTIONS Training? What do I need to know TECC can be taught to LEOs and Fire There is no national standards or curriculum However, training should follow the Committee on TECC guidelines

60 COURSES National Tactical Officers Association; STORM Specialized Tactics for Operational Medicine Contoms National Association of EMTs has TCCC course selections Wisconsin has a variety of courses Be careful what you are buying into ask questions to the vendors Medical Background; Instructors; conforms to TECC

61 CAUTION WHEN PURCHASING MEDICAL KITS Tactical Emergency First Aid Kits are a hot topic now With that comes a desire to address the need We are a capitalist based economy

62 CAUTION WHEN PURCHASING MEDICAL KITS Think about these issues For example If you buy 14 gauge needles for needle decompression; are your people trained to do that. Does it fit within their practice How sustainable is it for your agency medical equipment has a shelf life (Hemostatic agents) Is the supplier reputable and are the products vetted either by the military or the

63 RECOOMENDED TOURNIQUETS SOFT-T Tactical Medical Solutions CAT North American Rescue

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65 PLATINUM 5 MINUTES AND THE GOLDEN HOUR What happens in this time frame often dictates the patients outcome

66 TREATMENT PARADIGM Stabilize injured using ACAB-E assessment and treatment Assessment sometimes referred to as Situation Circulation Airway Breathing Evacuation

67 MODALITIES ACRONYMS Threat Suppression Hemorrhage Control Rapid Evacuation Assessment Transport M assive bleeding A irway R espirations C irculation H ypothermia and Head out

68 TIME COMPETIVE Death from Hemorrhage 1-3 minutes Death from Airway compromise 4-5 minutes Death via Tension Pneumothorax 10+ minutes Golden Hour 60 minutes It is pointless to treat a casualty for a developing tension pneumothorax while he is dying by strangulation from a compromised airway or by uncontrolled bleeding.

69 9% KIA BLEEDING TO DEATH FROM EXTREMITY WOUNDS Normal Blood Volume Death probable

70 9% KIA BLEEDING TO DEATH FROM EXTREMITY WOUNDS

71 5% KIA TENSION PNEUMOTHORAX

72 1% KIA AIRWAY OBSTRUCTION

73 Train for contingencies What if your people don t have the equipment for what ever reason? Follow P.A.C.E. methodology in medical interventions Primary Alternate Contingency Emergency

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75 First responsibility stop the threat GOOD MEDICINE MAY BE BAD TACTICS

76 PUBLIC SAFETY RESPONSE Police agencies have made significant changes in their response since Columbine. Police are taught to engage the threat immediately rather than wait. Fire/EMS agencies still stand outside until the police have secured the scene. This may lead to the injured not receiving treatment and dying from wounds they received

77 TEMS is Tactical Emergency Medical Support for the SWAT Team The Rescue Task Force is the combined resources of the public safety team to mitigate a MCI which is a law enforcement driven incident. Both use Tactical Emergency Casualty Care, interventions

78 FIRE AND EMS RESPONSE GOALS 1. Provide rapid treatment to the wounded 2. Prevent those who have survivable injuries from dying 3. Use resources more efficiently and effectively 4. Evacuate the wounded to definitive care sooner 5. Provide the proper gear and security for the operators

79 THE REALITY Fire/EMS needs to take a more progressive response and assume more risk to save lives. Risk is nothing new the the fire service, we are willing to enter a burning building, confined spaces, hazmat releases, etc. to save lives. The risk is mitigated by the use of SCBA, turnout gear, training, equipment, and SOP s

80 THE REALITY In the active shooter incident the risk is mitigated with the use of ballistic gear, security, equipment, SOP s and training. The environment in an active shooter incident is more controllable then that of a building on fire.

81 RTF EQUIPMENT PPI level IIIA Hornet Tactical Vest PPI level IV Rifle Plates (Chest and Back) PPI level IIIA Special Ops. Helmet

82 RTF EQUIPMENT MEDICAL - VEST MOUNTED Tourniquet x 2 H-Bandage pressure dressing x 2 Hemostatic Gauze x 2 Chest seal x 2 NP airways x 2 14ga. 3.5 needles x 2 Tegaderms x10

83 THE QUESTION OF ARMING MEDICS 1. Varied Responses 2. Based on your Jurisdictional needs and resources 3. Minimally Medics should have weapons familiarization 4. Why? Disarming Downed Operators with Altered Mental Status

84 IF OFFICERS ARE BROUGHT OUT OF THE FIGHT; CHECK AMS DANGEROUS IF ARMED

85 RTF OPERATIONS

86 RTF OPERATIONS As the contact team moves through the building searching for the threat, location of wounded is relayed back to command After the contact team either neutralizes the threat or contains it the RTF is deployed RTF proceeds to the location of the wounded and begins treatment

87 RTF OPERATIONS

88 RTF OPERATIONS A PARADIGM SHIFT The RTF consists of 2 police officers and 2 medics Officers provide front and rear security and control movement Medics provide treatment and evac. of the wounded RTF operates in the warm zone Arlington Fire Department VA Initiative

89 RTF OPERATIONS

90 RTF OPERATIONS The objective of the first RTF is to triage then treat the wounded behind cover not in the line of fire. Then they switch objectives and begin evac of the wounded. The second and subsequent RTF s begin evac of those treated until the team ahead of them runs out of equipment and then they leap frog forward to finish treatment.

91 RTF OPERATIONS

92 RTF OPERATIONS

93 OTHER SKILL SETS THAT ARE NEEDED BREACHING PATIENT EXTRACATION AND EVACUATION

94 OTHER SKILL SETS THAT ARE NEEDED

95 Vehicle Platforms Pros and Cons

96 COMMAND AND CONTROL These types of incidents are very dynamic and the number of threats, victims, etc can change at any time. The first Fire/EMS supervisor and the first arriving PD command officer need to form a Unified Command. The number of RTF s formed is based on the availability of resources both FD/ EMS and PD. In Rural areas consider using VFD personnel to be litter bearers The location of the CCP is based on the building type, number of victims, threat location, resources, and environmental conditions. Movement is controlled by the police element of the unified command

97 THIS IS A LAW ENFORCEMENT EVENT Medicine does not drive Law enforcement tactics It is a crime scene and you will need good documentation

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99 BE A SCHOLAR AND A WARRIOR 1. What barriers are there going to be? 2. Urban versus Rural? 3. Paid versus Volunteers? 4. Time and Resources Competitive Goals? 5. Relationships and Networking?

100 LEADERSHIP: PLANNING Have a plan focus on strategies not specifics Work your plan, training isolation exercises to scenarios Need all stakeholders on board Study what works Take what works in your jurisdiction; discard what doesn t Public safety is an Applied Science

101 Be decisive, improvise, adapt, overcome.gunny Highway

102 MENTAL PREPARATION FOR THIS EVENT Most Fire/ EMS are not prepared for entering into the arena of violence. Sometimes Providers hesitate when treating victims of traumatic violence. ( Train through this; it is an adverse reaction) Lt. Col David Grossman (ret) has done extensive research on interpersonal violence. There are resources available to develop body armor for the mind. (ON COMBAT) (THE GIFT OF FEAR, Gavin De Becker) If you find your self excited by the events and overwhelmed remember to breath. Breathing slow and deep is good for you to function properly.

103 RESOURCE MATERIALS DAVID GROSSMAN RETIRED LTC GAVIN DE BECKER

104 RESOURCES 1) COMMITTEE ON TACTICAL EMERGENCY CASUALTY CARE 2) MIDWEST TACTICAL OFFICERS ASSOCITION 3) NATIONAL TACTICAL OFFICERS ASSOCIATION 4) NATIONAL ASSOCIATION OF EMTS 5) NATIONAL REGISRTRY OF EMTS 6) NORTH AMERICAN RESCUE 7) TACTICAL MEDICAL SOLUTIONS 8) QUICK CLOT 9) STATE EMS ASSOCITION (WEMSA)

105 MY REFERENCE MATERIALS

106 THANK YOU FOR DOING WHAT IT IS YOU DO THE MEASURE OF A PERSON IS DEFINED BY THE WAY HE MAKES THE WORLD A BETTER PLACE

107 MY CONTACT INFO Facebook Michael Francis G Lafayette County Sheriff s Office