BY AUGUST VERNON AND CHASE SARGENT
THE NOVEMBER 2008 COMPLEX ATTACKS IN MUMBAI, India; ongoing conflicts in Iraq and Afghanistan; and the deteriorating narcoterrorism/criminal insurgency situation on the United StatesMexico border these are events U. S. first responders should note, study, and use as the basis for developing effective public safety guidelines. These incidents have demonstrated the need for local, regional, state, and federal resources to plan for and respond to these events. The guidelines and procedures discussed in the article should not replace common sense and experience. Although it is not possible to plan for every situation that may occur, we can develop appropriate best practices and training based on lessons learned and make training available on an ongoing basis. Update these plans regularly. One way to prepare for these events is to look at the lessons learned from the operations in the highthreat locations of Iraq and Afghanistan.
The first question you might ask is, what lessons can municipal, regional, state, and federal public safety systems learn from operations in Iraq? Our intention is to present these lessons learned and the events, training, processes, and planning applied in a combat/ highthreat environment in a manner that will make them relevant to what you do and enable you to see how these lessons can be applied should a similar event occur in your jurisdiction.
This article presents a few issues we believe the fire, EMS, and law enforcement communities can use to challenge the status quo in a civilian or paramilitary environment. These issues are presented from the highthreat environment in which we have operated and with suggestions as to where they might apply in the U.S. public safety system.
Improvised explosive devices (IEDs) represent one of the largest hazards coalition forces face in Afghanistan and Iraq. Enemy forces are using IEDs as the preferred method of attack on U.S. forces; this approach provides the attacker with a standoff capability to initiate an attack and then an opportunity to quickly escape the area. At the time this article was written, 40 to 60 percent of all attacks began with an IED, and 50 to 70 percent of all U.S. casualties were caused by IEDs.
|(1) A reminder to plan every time you leave a safe area. (Photos by Chase Sargent.)|
Most IEDs are unique because the builders must improvise with the materials at hand. IEDs are also designed to defeat a specific target or type of target, so as they become more sophisticated, they generally are difficult to detect and protect against. The devices can be anything from old Soviet antiarmor mines to improvised artillery shells to homemade explosives to sophisticated explosively formed projectiles.
|(2) A simple final reminder for everyone before you go into the red area. What a wonderful idea! What bene!t do you think !re, EMS, and law enforcement could gain from something like this prior to deployment?|
U.S. forces and security contractor teams in Afghanistan and Iraq use several methods to deal with this hazard when on the road and conducting operations. All personnel in a vehicle remain constantly alert (360°) and look for these devices or places where they may be hidden. They also use the “5 and 25 method” whenever dismounting, checking the immediate five meters for any threat and then patrolling out 25 meters to ensure the inner zone is clear prior to establishing a command post, forward operations, or patrol. All vehicles stay in constant communication. Every vehicle has its “lane of fire.” The troops vary routes and times, switch lanes at random, go the wrong way on roads, and use many other means (not listed here because of security concerns) to reduce the risk from these devices and attacks.
The tactics described above are necessary in Afghanistan and Iraq because of the extreme environments. But, when responding to an IED event or a suspected IED in the United States (pipe bomb, bomb threats, suspicious packages, and so on), first responders need to become somewhat more “tactical” in their thinking. When responding, get all the predispatch information you can. Look at the routes into the incident as you are responding. Survey the scene for a moment (360°) during your “windshield survey.” Look for objects and people that seem out of place for the location or time of the call if it looks suspicious, it probably is.
If possible, maintain an escape route that will enable you to get out of the scene quickly. Look at the areas where you park, stage vehicles, and establish a command post. Be aware of secondary devices and attacks.
Note: First responders should not attempt to approach, move, handle, or disarm a confirmed or suspected IED; this is a job for specially trained personnel.
The methods of attack listed above are described in the Al Qaeda Manual and on several extremist Web sites and are easily available to anyone with an interest. Any of the means described above could be used in the United States during a terrorist or criminal attack. The design and implementation of these devices are limited only by the imagination of the bomber. An IED can look like anything!
Law enforcement agencies are constantly training for mass shooting/active shooter incidents, whereas fire and EMS agencies are not. For planning and training purposes, talk to military and highthreat security medics, and review the “battlefield medicine” discussed in the “Prehospital/Tactical Casualty Care” sidebar in this article.
Because your “bus crash” multiple casualty incident (MCI) is different from the bombing or mass shooting MCI, you, as first responders, must train in rapid rescueremoval techniques and equipment how to rapidly move multiple victims to safe areas; casualty collection points; and triage from structures, down hallways, and through windows.
PLANNING OR “NO PLAN SURVIVES INITIAL CONTACT WITH THE ENEMY”
It has been said, “The nice thing about not planning is that it is never preceded by long periods of worrying, and failure always comes as a complete surprise.” Even more important is what Will Rogers said, “It isn’t what you know that will get you into trouble, it’s what you know that isn’t true.”
The most critical portion of any plan is the “commander’s intent” put simply, it is what the commander expects as the ultimate goal of a mission. When going out on operations in Iraq or Afghanistan, there are at least five plans in case you are hit. You have methods to drive, push, tow, bail out, cross load/ evac, and “Alamo Up” with your teams for any given event. Of course, we have our preferences and then a list of choices in descending order, but we expect that some portions of our initial plan will fail in a contact with the enemy. The plan and the standard operating procedure have to be dynamic and flexible to address the changing situation and the expected, but unknown, consequences of an attack.
Additionally, everyone on the team and we mean everyone, including the most junior operator knows, understands, and hears the plan repeated time and time again during premission briefs and training. We realize that anyone on the team is just a “bullet or an IED away” from a leadership position in a very critical moment. Not only do we expect to have to adapt quickly and fill voids, we have seen it happen.
The main point here is, does everyone on your team understand the plan and how to execute it? Do they know what plans B, C, D, and E are when plan A fails in the first five minutes? At any given point during an operation, does everyone understand what the “Main Effort” is, and are they able to identify it and commit resources and effort to accomplishing it? Do they have the knowledge and training to step up into a leadership position and direct if necessary? What will your fire and rescue service do if your command officer has an accident on the way to a major event and never makes it or drops dead of a heart attack at a critical moment in the middle of a major event? What will your special weapons and tactics team do when it is making its approach to the door and someone steps out of the door or garage when you are halfway across the yard with an automatic weapon and shoots five operators in the stack in about five seconds? If you are a SWAT team, do you even have three or four different methods to approach a structure or building other than simply running a stack?
Planning and intelligence are critical to mission success. Intelligence comes in all forms. Fire, rescue, and law enforcement need to understand that it’s not just some clandestine information. It can be used for preplanning data bases, structural awareness, and updating information on your computer or in your computeraided dispatch system. The bottom line is, you had better plan every day, even when you do it every day.
Two sayings we hate to hear come from leaders’ mouths (when they say them, they are not acting as leaders) are, “Because we have always done it that way” and “That won’t happen here.” We have run a variety of routes when we travel in Iraq, and we vary our timing and movement as much as possible. When you run for months and months and don’t get hit, the device is 300 meters off, or the shots missed you by a mile, you may get complacent.
To help combat complacency, Chase Sargent put together a leadership lecture called “Signs of Iraq, Lessons from the Sandbox.” Every time you leave a green (safe) area for the red (danger) area, there is a large sign posted to remind you of what you should have already done: communications checks, weapons on red, combat lock doors, body armor, don personal protective equipment, and so on. You would think that after all this time soldiers, sailors, marines, and airmen would know this inside and out and that contractors and protective details would know this as well, but you know what? We get complacent. This is a reminder of where we are, what we are doing, and what to expect every time we move out to the red area. Wouldn’t it be nice if every precinct and fire and EMS station had a similar sign that your personnel look at every time they leave the station?
More soldiers, contractors, and responders have been killed because they have done it a “million times.” They met the millionth and one event that they should have been planning, training, and preparing for throughout their career, but they truly believed it would be the same as it had always been.
Nothing we do is routine. Nothing! The minute you start thinking that it is, alarm bells should go off in your head, and you should hear the warning: “Wait a minute; I need to be prepared for the unusual and unexpected in the middle of the mundane and common.” Every critical event is just hiding in plain sight, waiting to jump up and bite you or, worse, cripple or kill you. Facades that collapse two hours after the !re, teams that separate and get lost, law enforcement of!cers who get killed on the 2,000th traf!c stop of their career, EMS providers who walk into the “I’m sick” call only to have a gun stuck in their face, and the list goes on and on and on. Nothing is routine, and complacency will put you in a position to make you what we call a “soft target.”
The information presented here is just a small sampling of all the tactical, leadership, medical, planning, and other lessons we can draw on in !re, rescue, and law enforcement. We could write volumes and spend days discussing them to the benefit of U.S. homeland security, crisis management, and public safety services. However, our goal is just to get you asking questions of yourself and your operational system and, of course, about what you can do to apply this information when it is appropriate. This article is not a complete training tool in and of itself; many good organizations and instructors are available to help with such training and exercises.
Always follow your local guidelines and procedures, but if they are old or outdated and have not been revised to address current reality, they are more dangerous than helpful. Has anyone changed their approach since the Soviet experience with the Chechen/Al Qaeda operatives, the Virginia Tech shooting, or the Charleston (SC) furniture store collapse, just to name a few? It’s better to learn from what is operationally occurring around you, the current reality, than wait until reality hits you in the face and kills or cripples your team. The more our public safety agencies prepare, the better they will be able to respond to and effectively manage any type of critical incident that might arise.
AUGUST VERNON is the operations officer for the Forsyth County (NC) Office of Emergency Management. He returned to emergency management after serving a year in Iraq as a security contractor conducting longrange convoy operations. He has been employed in emergency management for 10 years and also served as a member of the fire service and as a fire service instructor. He was a CBRN (chemical, biological, radiological, and nuclear) operations specialist in the U.S. Army. He instructs in mass violence, incident management, emergency management, hazmat operations, and terrorism/weapons of mass destruction planning response and provides specialized emergency services planning and training on critical incidents at the local, state, and federal levels. He has served as technical reviewer for training films, is the author of the First Responders Critical Incident Field Guide (Red Hat Publishing), and has been published in national fire servicerelated publications.
CHASE SARGENT retired as a division chief/paramedic with the Virginia Beach (VA) Fire Department in 2005 after 27 years of service. He has an extensive background in CBRN and technical rescue that includes serving 15 years as the chief tactical medic for the Norfolk FBI Field office. Chase served as a task force leader with VATF2 FEMA US&R and as a member of the FEMA White IST. He is now working for the U.S. Department of State, International Narcotics and Law Enforcement Program as a PSD medic and personal protective specialist on a highthreat protective detail in Baghdad, Iraq, where he is entering his second year of service. Sargent has had numerous articles published in professional journals, was an expert witness in cases involving health issues associated with the World Trade Center attacks, and is the author of Buddy to Boss: Effective Fire Service Leadership (Fire Engineering, 2008) and Confined Space Entry (Fire Engineering, 2000).
Prehospital/Tactical Casualty Care
BY CHASE SARGENT
As a personal security specialist and special operations medic, I can tell you that some of the things I do in Iraq would get me fired in a civilian EMS service and maybe not in a tactical law enforcement setting. The reason is not that the practices are poor patient care quite the opposite; they are aggressive, proven techniques/protocols that save lives, but the fire, rescue, and law enforcement communities are slow to respond to care issues that might seem “radical.” I think this is so because some of the medical directors are very conservative; they do not see or accept how this standard of care fits into the “civilian world.” Most law enforcement tactical teams are a little more aggressive in accepting these concepts. The bottom line from a medical position is, “An arterial bleed is an arterial bleed, a gunshot is a gunshot, and a blast injury is a blast injury,” so learning from other operational theaters and applying them to the United States is entirely valid. To those who would say that there has not been an approved study or control group or valid testing, I would say you have not read the literature and research from the past eight years from Bethesda, the Medical Corps, Diplomatic Security, or other operational components actively involved in these conflicts.
There is the bottom line from a research perspective. There are more than seven years of medical, surgical, and trauma research and data from Operation Enduring Freedom and Operation Iraqi Freedom that clearly demonstrate the effectiveness, appropriateness, and application of certain prehospital care procedures, especially in trauma and surgical settings. So, the question is, how do the things we are going to outline apply?
I think any medical doctor, surgeon, or medic who orders Surgical Lessons from Iraq and Afghanistan from the government bookstore will be favorably impressed. The same goes for the Ranger Medic Handbook and the Special Operations Medical Guide. For the U.S. first responder community, the information in these books is applicable to any large explosion and terrorist, criminal, or accidental mass shootings. They all apply to the special weapons and tactics scenario or one in which a single officer is shot or stabbed during routine patrol. Let’s look at some of these protocols. These guides should also be applied to disaster medicine if the medical community would expedite changing the way it sees things in the civilian world. Just look at the changes in trauma care and surgery/rehabilitation coming out of these two conflicts. If the civilian world is as slow to adapt these proven changes to patient care as it was to adapt the changes from Vietnam, it has learned nothing.
- Tourniquets as a firstline treatment to stop arterial bleeding work and save lives. In incidents such as mass shootings and incidents involving explosive devices where there are multiple casualties, a medical care provider will not be able to hold pressure or complete the other measures necessary to control the numberone killer, exsanguination.
- Clotting agents, like combat gauze and wound stat, work in major bleeds where tourniquets cannot be applied or as a support mechanism for tourniquets. The bottom line is they work, and they work great when used properly.
- Items like the supraglottic airway larygophalyngeal tube (SALT) can provide and ensure almost 100 percent blind intubation and control of the airway no matter what the position in which you may find yourself.
- Fluids by mouth to hydrate or fluid loading a conscious trauma patient who can maintain the airway is appropriate. Fluids are fluids, whether intravenous (IV) or taken by mouth. If the patients need them, they need them.
- Field application of antibiotics IV, intramuscular, or by mouth for trauma patients, even with short transport times, are appropriate. In extendedcare scenarios, they are even more important. During Hurricane Katrina, for example, 50 people were stuck on a bridge, and only a few medics were available to care for them.
- Sternal IOs (IV needles that go directly into the sternum) need to be a standard piece of trauma gear for fluid resuscitations. They are fast, easy, and quick.
- Fentynal lozenges (an oral painkiller used like a lollipop) is an appropriate and excellent painmanagement technique for trauma patients.
Are these all the lessons? Not by a long shot, but these few can be applied with great success by a system that is interested in improving its care across the board.
There is a tremendous need in the U.S. Law Enforcement Tactical, Disaster Medicine, and EMS systems for independent duty paramedics with an expanded scope of practice beyond that of a standard paramedic. This section would take up an entire book, but the bottom line is, when you have 100 patients stranded on a bridge in New Orleans, a tactical team operating remotely, or a largescale disaster such as Hurricane Katrina and large wildfires, standard paramedicine is not good enough. All of these concepts are currently applied in the military operational combat theater and in the highrisk protection theater. These concepts have been proven to work and have been applied, studied, revised, and improved over the past seven years actually many, many years before that time. These operational combat areas have given us a tremendous amount of data and number of patients to examine for good scientific trends. These, no doubt, are applicable to the scenarios we have outlined in this article and many, many more.