24 JEMS JANUARY 2018 www.jems.com
How a rural EMS agency implemented a tactical EMS program By Will Smith, MD, NRP, FAWM & Kevin Grange, NRP www.jems.com JANUARY 2018 JEMS 25 PHOTO DAVID BOWERS
MISSION SUCCESS Patients are assessed and treated following an explosion at Cokeville Elementary School on May 16, 1986, after a heavily armed couple identified as David and Doris Young set off a gasoline bomb inside the southwestern Wyoming school injuring more than 65 people. AP Photos/Rick Egan The police officer was waiting for the EMS crew when they exited the ambulance. We have an active shooter at the middle school with multiple patients, he said, holding an AR-15 replica training rifle. The immediate area has been cleared but is not secured. Copy that, said Brian Carr, a captain with Jackson Hole Fire/EMS ( JHFEMS), before turning to his partner who was already to donning his tactical gear. Let s go! As Captain Carr and his partner, paramedic Chris Stiehl, followed the officer through the front doors, another officer joined their team. Carr felt his stress level rise, but continued to lead the rescue task force (RTF) team they d just created. Although he knew in his mind that this was a training scenario, there was just something about hearing the words active shooter and school that hit him in the gut and made his pulse race. The lobby of the school was eerily empty and quiet. A grey haze hung in the air with the smell of training ammunition smoke. As one officer led the crew through the school, snaking around corners and moving swiftly through open areas like SEAL Team 6, the second officer covered their tail. They could hear rounds popping off in the next building over and police officers shouting commands. Captain Carr and Paramedic Stiehl found their first patient, a middle-aged man, lying in a long hallway lined with classrooms. He had a gunshot wound moulaged to his chest and was struggling to breathe. Let s get him out of this hallway in case the shooter returns, Carr said quickly. With the police officers standing guard, Captain Carr and Paramedic Stiehl dragged the patient into a classroom a few steps away and immediately began administering care. Stiehl placed an occlusive seal over the patient s open chest wound; Captain Carr noticed the telltale signs of a tension pneumothorax and simulated a needle decompression on the left side of the patient s chest. Stiehl quickly unrolled a black tarp to transport the patient. Seconds later, the crew was dragging the patient to the casualty collection point (CCP) outside the school, and dropping him off to other EMS providers arriving on scene. Carr and Stiehl followed the police officers back into the school where they found a second patient, shot in the arm, with an uncontrolled arterial bleed. The team quickly applied a tourniquet, carried her to the CCP and then hurried back in to find the next patient. On and on the training scenario went, until Brian Coe, battalion chief of training at JHFEMS, announced over the radio that the simulation was over. Moments later, everyone met in the parking lot to debrief. Captain Carr and Paramedic Stiehl emerged from the school, looking exhausted and wet with sweat. It was late December, the school kids were out on holiday break and, as Chief Coe spoke, his breath billowed in the air. Great job, everyone, he began, addressing the different RTF teams from A, B, and C shift. I know no one wants to think about situations like this ever happening. But if it does we ll be prepared. ESTABLISHING OBJECTIVES Until 2014, Jackson, Wyoming, a small town with 10,000 year-round residents bordering Grand Teton National Park, had no tactical EMS (TEMS) program. But as active shooter incidents continued to occur in places like Columbine, Aurora, Virginia Tech and Sandy Hook, it became clear that mass violence could happen regardless of population size, community structure or geographic area. After all, an older generation of Wyoming residents knew this all too well. On Friday, May 16, 1986, David Young a former town marshal and his wife took 136 children and 18 adults hostage at the 26 JEMS JANUARY 2018 www.jems.com
elementary school in Cokeville, Wyo., just two hours south of Jackson. Young had an improvised bomb which went off prematurely. He subsequently shot and killed his wife and himself. Fortunately, all of the hostages survived, but 79 were hospitalized for injuries and burns. The shootings in Aurora, Colo., were a big wake-up call, says Coe. We realized that we were more vulnerable because a lot of us were putting our heads in the sand and thinking that it wouldn t happen here because we re so remote. But we now know that whatever happens in an urban setting, can happen here. Being a rural fire/ems agency with 23 full-time personnel and 80 volunteers in remote Wyoming, also meant the mass casualty stakes were higher if an incident did ever occur. Although there s an award-winning hospital in Jackson, with great ED physicians and surgeons, the closest Level 2 trauma center was two hours away by ambulance in Idaho Falls, Idaho. The closest Level 1 trauma center entailed a five-hour drive to Salt Lake City, and the moody weather in the mountains meant there was no guarantee that medevac helicopters and fixed-wing airplanes could transport patients if needed. Since getting patients to definitive care within the golden hour, wasn t always feasible, it placed an extra importance on those first critical minutes following a traumatic injury. We know with heart attacks and strokes, time is muscle and time is brain, explains Captain Carr. But with mass shootings and MCIs, time is life. The duty for EMS agencies to act fast in these situations is upon us in this time and age. With this recognition, it was clear that a special TEMS program with adapted training, protocols with defined phases of care, and specialized equipment was needed for JHFEMS. Will Smith, MD, the physician medical director of JHFEMS, who helped to develop the TEMS program for the National Park Service, was also eager to implement a similar TEMS program for JHFEMS. 1 Also serving as a lieutenant colonel in the U.S. Army Reserve with combat experience, Smith brought a unique perspective to the program. Inspired in part by what he read about TEMS by resources provided by the Firefighter Support Foundation and International Association of Fire Chiefs, 2,3 Chief Coe reached out to Rich Ochs, the director of emergency management in Teton County and organized a workshop with representatives from JHFEMS, Grand Teton National Park, the police department, sheriff s office, St. John s Medical Center and the school district. We needed everyone onboard with this idea before we adapted our standard of care, Coe says, By creating a symbiotic relationship between mutual agencies, it would ensure we would be doing the greatest good for the greatest number of people. This synchronization would be critical when an injury occurred in a joint tactical operation, either planned such as a drug interdiction, or unplanned such as an active shooter event, so that patient care between multiple agencies can be uniform and efficient. At the meeting, the core concepts of creating a TEMS program were introduced, namely that JHFEMS would be following the competent, camouflaged lead of the military. The conflicts in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom) have shown some of the lowest fatality rates of any modern conflict due to its Tactical Combat Casualty Care (TCCC), a collection of best practice guidelines for battlefield trauma care. 4 JHFEMS TEMS program would be based on Tactical Emergency Casualty Care (TECC), which began as an adaptation from TCCC in 2011 that applied similar TCCC concepts across multiple risk areas (e.g., tactical, hazmat, etc.) in the civilian setting and to a Rescue task force providers carry individual first aid kits (IFAKs) stocked with supplies needed for the types of reversible life threats that might be encountered during warm zone care. Photo David Bowers www.jems.com JANUARY 2018 JEMS 27
MISSION SUCCESS Armed police officers provide protection for tactical EMS providers as part of a rescue task force. Photo David Bowers slightly expanded patient population. 5 Patients treated with TCCC in combat settings were typically young and healthy. When a civilian tactical event occurs, the demographics are much more diverse. Potential patients also include children and elderly, patients with multiple medications which could be blood thinners as well as other issues such as federal/civilian legal constraints. The goal of JHFEMS was to provide TECC care into a formalized rescue task force (RTF) program. The RTF concept applies the TECC protocols in an integrated overall operational group during a larger event. In this model, after initial law enforcement efforts have isolated the threat to a hot zone, a combined EMS and law enforcement team could enter the warm zone (i.e., an area of indirect threat requiring protection of caregivers) and begin patient care. Escorted warm zone care, a key component of the RTF concept, is based on the idea that care provided near the point of injury could rapidly treat the similar type of reversible life threats identified during wartime. 6 The complex decision-making in each of these settings can be applied to not only mass violence events, but can also be used in other high-risk situations such as hostage barricade situations, emergency ordinance disposals, hazardous materials incidents, bus rollovers or other MCIs that may occur in the area. Along with operating in the warm zone to provide indirect threat care, the RTF program also emphasized creating a casualty collection point (CCP), a location used for assembly, triage, medical stabilization and subsequent evacuation of casualties. After Chief Coe outlined the program, the reception from all the different representatives in the room that afternoon was appreciation and awe. Law enforcement was particularly grateful, realizing that JHFEMS was now offering them additional support during active shooter incidents, serving high-risk warrants and officer rescue scenarios. For those willing to put on the hat of tactical EMS, we share a special bond, cut from the same cloth, says Teton County Sheriff s Sgt. Lloyd Funk, They have training and skills that make them an EMT, but they have something more [internally] that allows them to venture into harm s way to use those skills to help others. I think the perfect phrase would be angel on my shoulder. To know EMS is closer than ever is very reassuring. Now that JHFEMS had all the community stakeholders on board, Coe was able to move forward with the next step: TEMS training. COMMAND & CONTROL After interest had been gathered from JHFEMS staff, the first step was to send two firefighters Captain Carr and Paramedic John Tobey to the U.S. Park Police and Department of Health and Human Service s Counter Narcotics and Terrorism Operational Medical Support (CONTOMS) class, a 1-week, 56-hour course that presents a nationally standardized curriculum, certification process, and quality improvement procedure to meet the needs of those EMTs, paramedics, and physicians who operate as part of a law enforcement team. Although the CONTOMS course is specifically designed for tactical EMTs and paramedics operating in the hot zone and attached to SWAT teams, it also presented a lot of great information on working with law enforcement, reading a room, moving through a room, clearing a weapon of bullets, victim carries and officer rescue scenarios that could benefit any RTF team providing indirect threat care in the warm zone. The plan was for Captain Carr and Paramedic Tobey to bring the lessons learned from the CONTOMS course and then lead training back in Jackson Hole. Chief Coe, Captain Carr and Dr. Smith also knew it was time to supplement the training on paper. They spent countless hours drafting protocols. The components identified for a sustainable TEMS program began with strong medical oversight, protocols that outlined phases of care, specialized equipment and organized implementation with TEMS instructors. The best practices of TCCC and TECC, as well as other established TEMS programs, were reviewed and adapted to emphasize bleeding control with the acronym: XABC (i.e., exsanguination, airway, breathing and circulation). Other components of the RTF and escorted warm zone care were also introduced, such as the creation and implementation of CCPs. When the training and protocols were firmly in place, it was time to select the right equipment to get the job done in a safe, effective manner. The big debate was about what level of ballistic gear the department wanted. The department explored various equipment options and ultimately, decided upon Level 3A, which is capable of withstanding multiple hits and is designed to protect against pistol caliber threats up to.44 magnum at 1,430 feet per second or lower, including all lesser pistol calibers. In addition, the Level 3A ballistics gear 28 JEMS JANUARY 2018 www.jems.com
is also lightweight and flexible, so it wouldn t inhibit the ability of providers to move and provide patient care within the warm zone. The department also outfitted RTF providers with individual first aid kits (IFAKs) stocked with supplies needed for the types of reversible life threats that might be encountered during warm zone care: tourniquets, bandages, decompression needles, occlusive dressings and hemostatic agents. These kits were standard issue for all deploying soldiers in Iraq and Afghanistan, and law enforcement agencies now also issue IFAKs in many areas of the country. Emergency Management officials in Pima County, Ariz., credited several lives saved to TCCC training and universal deployment of IFAKs used during the Gabby Gifford shooting in 2011. 8,9 As these kits have been developed and deployed, training and medical tactics have also changed. Tourniquets are now recognized as the first step to controlling severe bleeding. Nasal pharyngeal airways (NPAs) are issued to help treat airway compromise. Medical treatments for tension pneumothorax with needle decompression and chest seals for open chest wounds also benefit patient care, and are generally standard issue in most IFAKs. Supplementing the ballistics gear and IFAKs, the department also created two MCI support units, along with CCP kits stocked with enough first aid supplies to treat 50 patients. The TEMS Program at JHFEMS was moving forward but the two biggest challenges awaited: funding the program and introducing the program to its members, some of whom were initially reluctant to accept this paradigm shift, additional risk and adjusted standard of care. ADAPTING TO OVERCOME Implementing a TEMS program proved to be expensive. The upfront costs for CON- TOMS training and equipment was pricey and many of the equipment items, such as the plates in the ballistic vests, expire after five years, regardless of whether they ve been used or not. Department officials also realized that they d hadn t budgeted for a TEMS program, so there was an initial lack of funding. However, by placing the TEMS program under the umbrella of its Regional Emergency Response Team (RERT), Chief Coe and his team realized they could apply for a State Homeland Security Program (SHSP) Grant through the U.S. Department of Homeland Security. JHFEMS was awarded the grant, leaving one last hurdle to implementing the TEMS program: getting all the providers on board. Initially, some of the leadership and a few of the providers felt like this wasn t part of the job description they signed up for, Chief Coe explains. There was also the matter of being a department made up of both paid staff and volunteers. Should volunteers be asked to incur this risk and enter the warm zone? To address the Why this? and Why now? questions of some of the members, Chief Coe, Captain Carr and Paramedic Tobey reiterated the specifics and safety precautions of the program the ballistic gear, the warm zone and indirect threat care, an armed police officer as force protection, the use of CCPs and reminded them that the tactical ballistic protection gear wasn t because leadership expected A Fire Chief s Perspective on Tactical EMS Before becoming fire chief of Jackson Hole Fire/EMS, Brady Hansen worked as assistant fire chief in Logan, Utah. Along with firefighting and EMS, Hansen has extensive experience with hazardous materials response, SWAT, arson investigation, bomb mitigation and technical rescue. In this conversation, he gives a fire chief s perspective on why he believes a tactical EMS (TEMS) program is essential for every community. Why do you think a TEMS program is necessary in this day and age? It s clearly evident that no community is immune from the risk of a mass shooting (or some other form of mass violence). We all have a need to face the facts and prepare our organizations for this risk. Without preparation, our organizations will be terribly limited in how we can respond to provide for our own safety. We also have a duty to provide care for law enforcement officers and citizens. If we equip our personnel and train them alongside law enforcement, the outcome for that fateful event will be immeasurably better for our EMS personnel, law enforcement, and the citizens. Why do you think it s important for EMS providers to incur a bit more risk to enter the warm zone and treat patients? We must make every decision with our personnel safety in mind. However, an active shooter event could put our EMS personnel in place where some risk must be taken in order to gain access to patients who are truly needing immediate lifesaving care. A review of the outcomes from active shooter events show that much faster access to patients may greatly improve patient survivability. Not addressing this active shooter scenario, or taking a position that EMS will stay in the cold zone until the threat is mitigated, actually increases the risk for the victims and for law enforcement. Partnering with law enforcement to develop a protocol, then training on TEMS, and providing appropriate levels of PPE will improve outcomes for everyone. How does having a TEMS program fit into our model as an all-hazards agency? We invest a lot of time, money and energy training on events that we hope will never happen to our community. However, we would all be naïve to think that our community is not at risk. We owe it to our personnel to help them be prepared. As an all-hazards fire and EMS agency we cannot underestimate the chance that our personnel will be paged to an active shooter call. Before it happens we must prepare them. Any last thoughts? I remember as a young captain in the mid- 1990s watching the news and commenting on all the violence, chaos and mass killings that were taking place in other countries. A wise fire officer told me then that one day that similar violence would come to the states. I can t say that I entirely believed him. Now, with hindsight, it seems he is correct. The preparation we do now to develop protocols and to train and equip our departments is preparing for a fast-growing trend of person-on-person mass violence. This violence is not going away. There s every indication it is going to get worse. So, we must prepare. www.jems.com JANUARY 2018 JEMS 29
MISSION SUCCESS providers to receive fire, but due to the nature of the incident. We reminded them that our priorities were safety first, action second and everyone goes home, adds Captain Carr. When the paid staff got more comfortable with TEMS theory and the equipment, everyone signed on. They didn t mind the additional risk if it meant better serving the community and saving lives. As for the volunteers, the leadership at JHFEMS decided they wouldn t initially ask them to be part of an RTF that made entry. However, they would train volunteers to play a key role during these incidents by setting up and running a CCP along with triaging patients, providing care and transport. Within months, the first tactical EMS team in the state of Wyoming was fully operational and JHFEMS personnel was back at the middle school for an all-department MCI training. There were both paid firefighters and volunteers in attendance, along with personnel from Grand Teton National Park, the sheriff s office, police department, as well as dozens of children and adults who had volunteered to act as moulaged, mock patients. When Chief Coe announced over the radio for the training to begin, dozens of emergency vehicles pulled into the school parking lot with their lights flashing. Although the agency names and badges were different, on that afternoon, they became a rescue task force (RTF), with one team and one mission: to save lives. FORWARD MOVEMENT In the ensuing years, the TEMS program at JHFEMS has continued to grow. Ongoing updates to the program have kept pace with the recommendations from the Committee for TECC. Many of the changes have mirrored the evolving TCCC recommendations, including administration of ketamine for sub-dissociative pain dosing and chemical restraint for excited delirium/behavioral emergencies. The department added prehospital administration of tranexamic acid (TXA) for a patient suffering from a serious hemorrhage. Conversion guidelines for extended tourniquet use have also been developed for prolonged field care situations and the TEMS instructors are also encouraged to integrate more complex scenarios after the initial training to better approximate real-world situations. The department has also worked hard to keep everyone at the same heightened level of preparedness for one of these high-risk, low-frequency events by having large scenarios in July and December (when school children are on break) and training frequently throughout the year in: 1) bleeding control (tourniquet use, wound packing, pressure dressings); 2) penetrating chest trauma, (needle decompression, chest seals); 3) IFAK check; and 4) protocol review. Having mastered the setting up and implementation of a CCP, many volunteers are now interested in serving their community to the fullest extent by getting RTF training to operate in the warm zone. Our folks have been incredibly willing to look at it from a practical point of view; there are so many lives we could potentially be saving, Chief Coe says. We re going to take the appropriate amount of risk to save as many lives as we can. JEMS Will Smith, MD, NRP, FAWM, is the physician medical director for Jackson Hole (Wyo.) Fire/EMS. He s a clinical assistant professor for the University of Washington School of Medicine s WWAMI regional medical educational program, is the medical director for the U.S. National Park Service and runs Wilderness & Emergency Medicine Consulting LLC. Visit him at www.wildernessdoc.com. Kevin Grange, EMT-P, is a firefighter paramedic with Jackson Hole Fire/EMS and author of Lights and Sirens: The Education of a Paramedic. Visit him at www.kevingrange.com. Learn more from Will Smith and Kevin Grange at the EMS Today Conference, Feb. 21 23 in Charlotte, N.C. EMSToday.com REFERENCES 1. Smith WR. Integration of tactical EMS in the National Park Service. Wilderness Environ Med. 2017;28(2S):S146 S153. 2. Prepared for anything: EMS response to tactical and active shooter threats (abstract). (April 2016.) International Association of Fire Chiefs. Retrieved Nov. 27, 2017, from www.iafc.org/topics-andtools/resources/resource/prepare-for-anything-ems-responseto-tactical-active-shooter-threats (abstract). 3. Firefighters Support Foundation Inc. (n.d.) Fire Engineering. Retrieved Nov. 27, 2017, from www.fireengineering.com/ training/ffsupport.html. 4. Holcomb JB, Stansbury LG, Champion HR, et al. Understanding combat casualty care statistics. J Trauma. 2006;60(2):397 401. 5. Overview. (n.d.) Committee for Tactical Emergency Casualty Care. Retrieved Nov. 27, 2016, from www.c-tecc.org/about/overview. 6. Smith ER, Shapiro GL, Callaway DW: Integrated response to terrorist attacks. In Cittone GR, editor, Cittone s Disaster Medicine, 2nd edition. Elsevier: Philadelphia, pp. 407 415, 2016. 7. Counter narcotics and terrorism operational medical support (CONTOMS). (n.d.) National Park Service. Retrieved Nov. 27, 2017, from www.nps.gov/subjects/uspp/contoms.htm. 8. Kleinman D, Kastre T. Beyond the tape: Law enforcement officers make major impact as initial care providers. JEMS. 2012;37(5):38 40. 9. Somashekhar S, Horwitz S. (Jan. 21, 2011.) First-aid kits credited with saving lives in Tucson shooting. The Washington Post. Retrieved Nov. 27, 2017, from www.washingtonpost.com/ wp-dyn/content/article/2011/01/21/ar2011012105860.html. Rescue task force EMS providers don ballistic protection gear not because they re expected to receive fire, but due to the potential danger of treating patients in the warm zone and extricating them to casualty collection points to receive definitive care. Photo David Bowers 30 JEMS JANUARY 2018 www.jems.com