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Home>Topics>>Mass-Casualty Emergency Care

Mass-Casualty Emergency Care

Tue, 4 Sep 2012|

This free training video from the Firefighters Support Foundation presents the basics of Tactical Casualty Combat Care (TCCC), an approach developed in combat zones over the last decade that has saved thousands of lives.



When do you. Civilian and I put a question more -- there because. At least I don't consider. EMS personnel. And firemen to actually be civilians. Become involved in law enforcement operations. More specifically. Won't -- in special operations. High -- situations. That could put them in the line of fire. My answer to this question though is frequently. Many paramedics -- state that -- policy and procedure that precludes them. From these activities. But its interest thing that in every single video that I've seen and news -- what I've seen of the events of 9/11. It -- firemen. And paramedics like yourself that were running towards the Twin Towers and not away from. Today we're going to address a concept. Called T triple -- tactical casualty combat -- Which addresses in a tactical manner the most common causes of violence related trauma bleeding to death. Now please don't be confused. This is not a law enforcement program. This is for traditional EMS and fire fighters. Nobody he'll be shooting any guns but you may find yourself in a situation. We're weapons have been fired and people have been hurt by those weapons. These techniques were developed. Based on our military's experience -- over the last decade in Iraq and Afghanistan. The concept was actually first thought about after Mogadishu's. They are just -- applicable. To domestic mass casualty events. As they or two armed military combat. These events include mass shootings and active shooter events. Anybody who watches the news knows this is happening more and more frequently. And natural disasters as well tornadoes hurricanes earthquakes. All of these techniques can be important. Let's first talk about the most common causes of preventable. Combat that and I -- combat death. Any death brought on by some type of violent act is what I'm talking about. Extremity hemorrhage. Bleeding to death. That's the most frequent calls 60% of the deaths -- calls by extremity hemorrhage. If you look at traditional. If you -- -- apply CP York to a person that had been shot you'd only be pumping blood out of them through there gunshot wound. Next is tension Nemo -- Which takes the lives of 33%. Of casualties. And then airway obstruction. 6%. The fate of the wounded. -- with those who apply the first wrestling. I tell this to everyone how much water operators. Because they may be applying the first dressing either to themselves or each other. And use EMS. And paramedic trained firemen. May be the ones that are applying the first dressings to the wounded not a doctor not a surgeon that you. Teach purposely tactical combat casualty care is not traditional. EM TE. -- care. It was developed by the Department of Defense. It's recognized by both the American college of surgeons. And the national association of -- This is very significant. Because these two groups hardly ever agree on any site. It focuses on penetrating trauma. The emphasis is on completion. Of the mission. Stopping ongoing violence. And protecting other innocents in the area. Completion of the mission for EMS. In a mass casualty scenario. Is to care for the wounded. Immediately with basic lifesaving skills own life. And then conduct safe movement of the wounded. To a secure area for follow warm traditional care. Or active shooter still an issue after column mind absolutely. March 2012. Oakland California. Seven dead and a high school. Jared -- longer. Has been identified as the man suspected of shooting congresswoman Gabrielle Giffords. -- was described by eyewitnesses at the Arizona shooting as a young white man who looked like a fringe character. His middleweight warnings clean shaven with short hair and wearing door clothing. It's usually after the shooting that they looks suspicious or different. There is no profile -- a book for a shooter. Longer was quickly arrested after he allegedly shot Giffords in some twelve other well. Others at a public event at a Safeway grocery store in Tucson Arizona. He reportedly shot the congresswoman. Point blank. In the head and they have come from inside the store. He attempted to flee after running out of ammunition. What was tackled by one of Giffords staffers. Another eight dead in Carthage north Carolina at a nursing home shooting in march of 2009. They lone gunman burst into a North Carolina nursing home Sunday morning and started shooting every thing. -- into rooms of terrified patients. Spurring some from -- Rampage without explanation while killing seven residents and a nurse that was caring for them. Two incidents. In -- -- North Carolina. One a thirteen year old was killed in the confrontation. With the -- -- county deputy. January 19 2010. Next a hornet county sheriff's deputy was shot in the leg during an incident with a suspect. Outside of the super more convenient -- If you look at slide thirteen you can read the details of December 10 2009. -- Virginia student was -- in the school shooting. But the frustrating -- was that no one really knew what they were supposed to do. Said the show would call 43 years old who was sitting in a sociology -- room on the third floor of the building when the shooting began on the floor above. She said she didn't hear the shots but was soon -- by another student who entered the classroom. And let her know what was going wrong. She thought do we wait here do we stay do we run out of the building this would -- said we had no idea. We had no idea. She also had no ideal. Of what to do with the injured. That were laying right in -- for. In yet another extremely. High profile. Active shooting. April 16 2007. The Virginia Polytechnic Institute and State University Blacksburg Virginia. At least 33 people were shot to death at Virginia Tech including a gunman who took his own life. That gunman. Is blamed. For at least thirty deaths and fifteen injuries in side and engineering building. Any -- read -- sixteen you'll see yet another mass casualty -- so -- July 22. 2011. In Norway. Both -- shooting and a bomb attack. If you'll notice from all of these slots. There is no pattern of pinpointed geographical locations of any of these incidents. No predictable pattern. Of -- -- -- it. Understand and know that it can happen in your jurisdiction. Now what are the goals. Of tactical combat casualty care. First treat the casualties. Treat your teammates. Treat yourself. Whoever needs treated you -- Prevent additional casualties. And then complete the mission give care to the victims. In contrast to traditional. EMS care. In -- triple C you're working very quickly from one victim to another providing only immediate life saving care. Then moved to the next victim. Any follow along care ore grade or monitoring. Comes -- another phase of care. To be successful. There are some very basic equipment differences. Between traditional -- here. And that needed for tactical combat casualty care. An example would be a traditional -- found on an ambulance. Vs a tactical fox trot -- As you can see here. Or. Drag straps. To -- -- quickly utilized. To move victims. From a point of fire to -- a safety. Or EMTs paramedic. -- traditional medical first responders. Going to be -- ballistic protection. Likely now however there or best made. For EMS and paramedics. And a variety of other first responders. We're -- Can all be placed up front on the responder. So that -- quickly accessible. Take for instance my personal tourniquet. And my ballistic -- -- hit the difference between the swat -- on word. And the best that the paramedic. -- EMS first responder will be wearing. Would be that there wouldn't be the thirty round magazines. For my -- four. But there would be six to seven -- -- -- placed across the front of my body. Plus two blowout -- on either side -- -- my back so I can immediately go to work from victim to victim as we discussed earlier. The ballistic -- that I mentioned. Earlier that would be on either side of the paramedics. Best may look something like this. These are excellent blowout -- for -- gunshot wound you've got dressings. -- Shares. He -- static agents. Nasal Airways and reclusive dressings. All in one -- it's easily accessible to the operator. Remember that as a paramedic. Or medical first responder. All of your ballistic care kits will be up -- So that they can be reached with either hand in any given position that you have to give care for -- The ballistic response -- Contains essential. First response medical gear for dealing with gunshot wounds. It's designed for ease of use. Ease of movement. And fast administration. Of that medical equipment necessary to deal with a gunshot wound. It's -- to -- the three leading preventable cause. Of combat trauma or violent death. That is in -- it's not carried ports not maintained. But please don't let me -- -- because I just talked about all of your gear and equipment being up -- And that we work for the first three to four gunshot wound victims you encounter. Next you can have this backpack on that contains all of the same year that you've got -- up -- Justin greater quantities. -- -- He was static agents chest decompression needles chest seals tourniquet -- And nasal -- Just in greater -- carried on the back. To be clear. This medical backpack is actually worn on the back. Of the paramedic going into the mass casualties -- Is there to supplement the equipment. That that operator house on -- fraud as we discussed earlier. What we want more time cover of the most common cause of preventable combat death. Before we talk about their treatment some solutions. Extremity hemorrhage. Tension numeral thorax. And airway obstruction. What we will talk about for the remainder of this program. Or the specific pieces of equipment. -- -- the individual paramedic. Who -- to address. These types of injuries. It is not my intention. To teach you how or when to do these procedures but only to address the equipment needed. First responders need to take a certifying. T triple -- course prior to performing these perceived. Extremity hemorrhage it's just a flesh -- remember the black Knight -- -- python's. Holy Grail. Gunshot wounds caused extremity hemorrhage as well was edged weapon damage and explosives. Extremity hemorrhage will likely be the most common wins you will see and deal -- When responding to a mass casualty incident brought on Bob violence suspect. Or terrorist attack. The extremity hemorrhage assessment. Where is the one. Mortar vessels are closer to the torso and bleed more. Vessels decrease in size as they approach the hands and they. Everything in the neck is close to major vessels. Forehead and scalp or full of superficial vessels. Lots of blood but -- bleeding to stop. Once you've located the wound. Keep in mind -- a screaming fountain of blood is about. It indicates or material -- and must be stopped. It will be bright red in color. A steady stream is likely be escalating it will be slower and it will be dark red. The reason I mention these basic medical facts to you highly trained professionals. Is because. It pertains to the kind of fast. Non traditional tactical care. You the first responder will be administering. -- slow deliberate traditional EMS field care. An example is the immediate use of a tourniquet. General treatment for an extremity hemorrhage. Seek cover. Remain tactical. And be defensive. Not something you hear very often is it. Locate the woman. Exposed to win. Or there -- or multiple wounds -- or an entry or exit -- and assess your trauma kit for what you're gonna need. Now I go back to seek cover. Remain tactical. And the -- You may be giving this care. While laying in a defense of position. Verses. Being able to take your time standing. Moving the victim so that it's easier for you to deal worked for instance on a Gurney and then the Gurney up in the year. You may be laying on the ground with the victim to help ensure your safety and his or her. Extremity hemorrhage direct treatments. This is the -- -- -- bandage package. And -- 27 shows the modular bandage open. Now let's talk about the modular bandage features. It's a self contained. Elastic bandage. Would -- Goals inside of it. They pressure cut to apply pressure to the wounded as you after you apply this bandage. And inclusive dressed like. It's sterile so don't open until you're ready to use it it has no human static agent. Like -- clock because for example. And it is used for mild abrasions. To -- probably. One of the features that I like best about this particular bandage. Is the fact that the band -- material. His belt road so that when you go to apply it it's not rolling -- away from him. If you look at -- -- The same modular bandage. That we just look that is being applied. In a very real world situation. As you all as medical professionals well -- Once this bandage has been applied correctly the role of direct pressure remains the famous it has for -- It may be applied with any material to slow bleeding. A sterile product is best but not always available. In a given violent situation. It will control bleeding in most cases. This modular bandage when applied properly provides direct pressure. And elevation is also helpful. Keep in mind equipment has changed and evolved over the centuries. The human body house -- the advantage. To this modular bandage. Is that it is all in one pack. Eliminating the need for dragging. Or packing and then unpacking unnecessary equipment. Into -- fast moving scene war environment. Again the modular bandage can be used to treat abrasions. Burns. And shallow lacerations. For an extremity hemorrhage that could not be controlled with direct pressure or modular bandage. We have the tourniquet. In a mass violence situation. These tactical turn markets give you greater flexibility. And are quicker to use than traditional EMS -- -- Advantages include. The tourniquet not slipping off. While the patient may be being transported roughly from one point of cover to another before getting to a triage area. The tourniquet should be placed in specific areas. Of the form and legs. Which -- -- be taught when you go to a -- triple C certifying course. -- to the point that the bleeding stops. If the bleeding hasn't stopped. Had a second tourniquet above the first but do you -- Release the pressure or remove the first tourniquet. These are used routinely in orthopedic extremity surgery. Today. Traditional. EMS. Still shots away from the use of a tourniquet. But let me talk about officer. Kimberly. Normally. You may know or name she is the officer who shot the Fort Hood shooter. But what many people don't realize. Is that officer Motley was also shot through the upper away. Powerful moral order rate was completely sever. A young soldier who had just been -- -- pre deployment training -- Iraq. Had a tourniquet in his pocket at the time of the shooting. He came up and placed that. All an officer -- in the proper manner. He then -- officer -- laid up against the wall. Officer -- received no further medical attention. Not -- -- not even and -- you okay. For 47 minutes. Officer my late today. Who runs those crosses. And continues to serve her community. Again. As medical professionals. You may already know this but just as a review. A tourniquet would be used when bleeding is uncontrollable. -- direct pressure and elevation. If there's an amputation. Or arterial bleeding from major vessels. Such as the four more for moral -- rate. In the five where the break you'll ordering. In the and of course it's these type of worms. That we are all much more likely the C. In an incidence of mass violence. Tourniquet -- or inch screen -- effective. When needed. And the benefits for outweigh the risks. User shortly to record the tourniquet time on the patient or at least write it down somewhere. Let's talk about the second most common calls. A preventable. Combat or violence related death the -- name of the war collapsed long. You -- thorax is their trapped between the outside -- -- belong in the chest wall. Tension they look for action occurs when this -- creates enough pressure to calls -- long to collapse. This can also squeezed for contributing. To death. Again your medical professionals. You know the calls of attention -- for acts. Now think about this one won't trauma can be forceful enough to create a gap between the long and the chest wall. How could this occur. In a mass violence situation. Blast structure or the over pressure created. By an explosion. There may have been a -- explosion. At your mass casualty incident. And you -- -- of victim. Laying down on the ground with no visible cuts scratches. Amputations. Yet there -- down there. Blast trauma can calls a collapse long. As well as penetrating trauma us improperly treated chest wounds. And -- your chest compression. Tension -- for acts again. With no penetrating chest one. Nick could have been calls by the over pressure from an explosive. During the situation you've arrived to. Who calls from shortness of breath. After or blow or they -- blow from the over pressure to the chest and back. And as the slide shows. With any penetrating chest wound war chest trauma. You can expect attention -- -- Chest -- treatments you want to properly -- the wound to lessen the chances. Of attention name -- thorax. Frequently checked the patients for signs of attention Nemo for -- -- they have actual missile -- Is the trachea. Moving away from the wounded -- this is called -- -- deviation. Properly -- a trip just one could include an inclusive dressing. Remember what came and our modular bandage. This works is an inclusive dressing. Or you can use an actual chest -- Designed to treat these types of injuries. Again you want to be airtight from outside to inside. You can use the plastic sheet from the modular bandage you can use petroleum -- and you need just a little bit of -- When the wounded stressed it is -- -- can watch the patient bring it. If you use the exclusive dressing found in the modular bandage. You want to tape up for -- odds -- but -- allowed just a little bit of -- to escape. If attention -- the thorax develops. Needle decompression. Is the additional treatment. An eighteen to fourteen gauge needle. On the affected side placed between the first and second ribs at the -- club back -- -- alarm over collarbone. First let's take a look at slide number 45. To look at what we call the needle decompression play in morgues so that you better understand. Where the needle was -- For the attention they look for action needle decompression procedure first you'll expose the chest. If you can clean it with alcohol. Find the landmarks. That you can see. Onslaught forty -- Insert the -- sliding over the top of the -- Listened for -- to evacuate the chest. Remove the needle and leave the catheter. The procedures and guidelines for dealing with -- attention needed name -- -- oral or no different than those you already know. It's that in a mass casualty incident. You can expect to see numerous. Tension Nemo borax war chest penetrating injuries. You may run into this frequently as Europe the -- Now let's talk about the third most common calls of combat or violence related death airway obstruction. Simply -- for auctions include bleeding. Soft tissue injury. The tongue. But all of this can be handled. With a -- fair and he'll airway. The -- -- GO -- the number one thing is to use lots of lubrication. Placed the double to the center. Usually using the right now scroll but away from the trauma. Insertion direction is straight towards the back of the head. You may need to switch -- -- stroll if there's a lot of resistance given. And again I remind you to use lots of lubrication. And most of these devices -- with some type of lubricate eating jelly -- them. For the application. The reason you want to carry multiple. There's -- -- dealer ways is that during a mass casualty. Incident or situation. They're much smaller and lighter. And many more of them can be carried and applied and other ways of opening an airway. Now remember we're talking about. Tactical medical kits which you may not use every day. So always keep yourself familiar. And trained with the contents. Of your tactical or mass casualty medical kit. Practice applying tourniquet it's not a skill that EMS use those all that often. Check your medical kit regularly. Replace lost used or expired items again this is stuff you -- to do. But if you don't use this -- on a regular basis you have to have some type of schedule set up to ensure that this is done. So that when the day comes and you needed. It's there for you. And again place your gear. Where you can reach it in -- tactical situation. Think about the difference in the -- you may be applying your medical skills. From a call to. A residence were no violence was occurred. To a call in the schools were a lot of violence was occur. I know I'm telling you to get new gear. But it's not that expensive. Everything that I've shown you in combination. Is probably right -- under 1000 dollar. Always remember. That your best medical kit is your tactical medical training. -- readiness. And your physical and mental conditioning. When the day comes that you have to respond to an incidence of mass violence. Eventually you will have to use this equipment don't be afraid to use it. You'll save yourself or another. -- worse injury or death. You're going to work with law enforcement. In many mass casualty situations you'll have to coordinate treatment movement and rescue efforts -- law enforcement. You might be moving. As -- -- integrated in with -- -- law enforcement team to get to the victims that you need to treat. A brief overuse of these tactics will fall. Keep in mind at a mass casualties saying when I state that you'll be moving with or officers. This will happen even after the -- spending. Clear. Secured. Safe. Whatever the case maybe -- the word used may be. Or law enforcement will still be out about pulling. 360. Degree security to ensure your safety while you're doing your job. The types of situations that you might find yourself involved with former law enforcement officers include. An active shooter to school and active shooter at a business. A hostage rescue operation by law enforcement. Injured downed officer of -- civilian. And others to include bank robberies home invasions methamphetamine. Laps. Any dangerous situation that law enforcement response to we all know that you respond to as well. Let's talk about the police response priorities the first one is to locate isolate and stop the shooter. But once this is done that's when you the first responder medical professional gets -- ball to treat and evacuate the injured. You or port of priority number two. We will establish containment. We will -- safety sweeps. We will help complete evacuations. Any eventually the crunching will be processed -- -- -- forward. The police response elements that you'll be working with and around. Include contact teams whose job it is to go in and isolate stop or neutralize the threat. Rescue teams. That -- -- medical professionals will be a port of perimeter teams that -- coming into the -- -- deal with and interact with. And an evacuation teams that would bring casualties -- -- you if you're running the triage center. The movement goals of law enforcement or to immediately locate the threat a movement to contact. Isolate that threat and then confront. Neutralize. Or apprehend the suspect. Multiple officer movement teams consist of two to four officers -- -- being the best case scenario. In a diamond formation. Which provides 360 degree security. No room entry will be made in -- the suspect is located. And they will use the proper movement speaks. Look at -- number 57. The diamond formation. With a point man to wings and a rear door. Next we're gonna talk about a rescue -- and what your role in this diamond formation is. Now let's look at the rescue -- this is the team that -- be a -- You. As a first responder. Paramedics or medical professional. Will be surrounded by four armed officers. You'll have a front door. Two wings. And a rear court. With -- yourself -- safely at the center of the formation. To move up to the wounded and provide immediate medical care. The goals of this rescue team -- as follows locate the injured. Provide immediate and quick treatment to the injured and then to follow on injured. -- -- And then evacuation. If necessary. And I think from looking at the diagram. It becomes very apparent why. The -- you Kerry needs to be small and compact. You can't really put. Up 200 -- Gurney in the middle of this formation and quickly move up a staircase. That's why the equipment were showing you goes on a backpack. For a fourth -- Medical type assault best. You're one -- -- movement. To the injured. Is to just maintain the same -- that the team -- maintaining. In order to get to the injured -- -- at the injured. These armed officers will provide the security that you need to comfortably do your job. Keep in mind that -- be -- -- and dealing with multiple injuries within a law enforcement perimeter. Keep in mind that in a mass casualty situation created by violence. You'll likely. Be working alone were -- typically. Are used to working with a Porter. And you're going to have to have a different mindset about what you're doing we call it a tactical mind -- And the restraining available. To both paramedics and law enforcement about tactical -- I would highly recommend taking more I would also recommend. Before you go to one of these real incidence and your staring face to face -- law enforcement wondered what to do. Don't -- your local law enforcement officers go out for one day and watch the swat team trying. Offered to support and then their training by just being there with an ambulance and getting to know them. That will make the day the incident much better for everybody involved. And keep in mind that while you're out in the tree -- -- evacuation area. The perimeter team is doing a very necessary job keeping you say. But they're also trying to reach their law enforcement goals with a perimeter which is one to shrink the perimeter. To provide a safe area for the evacuation of the injured. Three cut off any suspect escape routes. And for a while for the safe evacuation. For all -- and -- -- portion. Of whatever building as the ball. In your mass casualty incidents of violence. From the time of call out to an -- little mass violence keep -- tactical -- You're going into a hot -- have your -- swivel and always pay attention to detail. You might see more observe something law enforcement and missed -- has not seen yet. Based on their positioning vs your positioning at the same. Don't hang around exposed to possible gunfire. Seek cover and concealment until it's time to move. As -- -- -- law enforcement rescue team or into a secure triage area. Law enforcement cannot possibly deal with these saints without you we are all one thing.

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