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This year I attended the SOMA Conference for the first time as an actual SOMA member. While I’ve been going to SOMA for the past three years, its always been limited to the Expo. There’s a lot of value in attending the Expo, but now I know the break out sessions are the true blood of the conference.
I would HIGHLY encourage anyone involved in “tactical medicine” to join SOMA. An added perk is that SOMA has joined forces with the Journal of Special Operations Medicine (JSOM) and all SOMA members will now receive the journal as part of your SOMA membership.
I’d like to point out I’m writing this article from my personal notes as I wanted to attend as a “first responder” and not in a direct media capacity. I wanted to be able to focus on the things I found important and not have the pressure of trying to “report” on what I saw there, so this article is a culmination of those shorthand notes. I take full responsibility for any errors that may come up as a result and encourage anyone who attended to address any corrections in the comments below.
TCCC / C-TECC updates
Since we want to get you the latest TCCC / C-TECC updates first, this article will cover changes to TCCC / C-TECC. The follow-up article will cover things I thought were interesting during the TEMS breakout sessions. There were a few SOF breakouts which would have been great to sit in on, but I wanted to stay in my lane and get the most out of the TEMS sessions.
TCCC December 2013 Updates
There are four main updates to the TCCC guidelines. While some of this may have been in the works and you may have seen them already, these updates were confirmed by LTC Mabry himself. Also new is that JSOM will now push all new TCCC information and updates.
*A quick edit that I wanted to add as of 12-21-13. The reason the TCCC guidelines have not been updated formally is that the person in charge of completing the updates has been “laid off” due to the sequestration. Until the funding comes back the December updates will not show up. I wanted to put that out there in case anyone is waiting around for something formal to present to your COC or other reasons.
- Vented chest seals are now recommended over non-vented. Knowing there may be times when a non-vented chest seal will be the only option, it’s recommended that the casualty be closely monitored for the development of a tension-pneumothorax.
- The restrictions on Tranexamic acid (TXA) have been removed and are now approved for everyone, not just SOF personnel.
- TCCC casualty cards will now be under a DOD number for access by all services: DD 1380. Link to the proposed card HERE.
- There is now a Triple-Option Analgesia plan. Since this didn’t relate to me and was pretty complex I didn’t take notes directly from the lecture. Here is a link to the changes which should be published shortly and the updates are as follows:
- The Meloxicam and Tylenol in the TCCC Combat Pill Pack are for casualties with relatively minor pain who are still able to function as effective combatants;
- Oral Transmucosal Fentanyl Citrate (OTFC) is for casualties who have moderate to severe pain, but who are not in hemorrhagic shock or respiratory distress and are not at significant risk for developing either condition; or
- Ketamine for casualties who have moderate to severe pain, but who are in hemorrhagic shock, respiratory distress or are at significant risk for developing either condition. Ketamine may also be used to increase analgesic effect for casualties who have previously been given opioids (Morphine or Fentanyl.)
C-TECC 2013 Updates
Dr. Dave Callaway discussed updates to what’s happening on the TEMS side of the house. Most of these were administrative in nature, but it’s important to know that there’s a big shift coming to get EMS and Fire personnel into the “hot zone” and setting up Rescue Task Force tactics, I’ll touch on that more later.
- There are now Homeland Security grants for TEMS related training and equipment. While some these may have been around for some time, the recent active shooter and bombings have brought this to the forefront. The trick (as always) with getting these funds is doing your research and figuring out how to access them.
- FEMA has a new Active Shooter document which talks about incorporating tactical medicine into active shooter events. This goes right along with other lectures during SOMA which talked about ways to get EMS and FD into the “hot zone.”
- The National Fire Protection Association (NFPA) Chiefs now support the Rescue Task Force (RTF) concept. From what Dr. Callaway was saying, this is a big deal as it talks about equipping FD personnel with body armor and sending them into the “warm and hot zones”, which has been almost unheard of up until now. Read the NFPA document Here. There’s a department in California that is actively looking to issue body armor and helmets to their firefighters/paramedics but the only holdback currently is funding.
- The International Association of Fire Fighters (IAFF) also recognizes the need for RTF concepts and has a written statement on it. Read the IAFF document Here.
- As some of you know the National Tactical Officers Association (NTOA) has a TEMS position statement. A keynote from this paper states “The revised position statement recognizes the need for all police officers to have basic TEMS medical training.” See the NTOA statement Here.
- Something that wasn’t in Dr. Callaway’s presentation was the International Association of Chiefs (IACP) of Police 2013 resolutions. The first thing on the list is getting all Police TEMS training. See the IACP resolutions Here.
- The Hartford Consensus 2. There are two links I’m going to provide on this and I highly encourage everyone to read each. This will be a huge help in getting tourniquets out to patrol level officers with the proper training. It will also help get EMS and FD personnel into the “hot zone” and not stage as they normally do.
Dr. Callaway also went over specific updates to the Adult TECC guidelines as follows:
- Hextend has been removed from recommendations.
- Additional emphasis placed on extraction and CPP management.
- Phases of care language streamlined.
- Tourniquet placement: Support most proximal placement (go high or die.)
For pediatric guidelines (JSOM Winter 2013):
- First of its kind.
- Based on TECC and existing trauma literature, but largely expert opinion.
- Defines existing best practice and outlines knowledge gaps.
TECC goals listed by Dr. Callaway:
- Expand pediatric TECC guidelines.
- Assist Federal efforts surrounding common operating language and guidelines Active Shooter and IED preparedness.
- Expand TECC training for LEO, schools and other first responders.
- Formalize relationships with:
- ACEP TEMS Section
- ACS COT
Stay tuned for the follow-up article with my thoughts on the TEMS break out sessions. Here’s a quick rundown of things I’ll be covering:
- Boston Bombing
- After Aurora
- Advanced Law Enforcement Rapid Response Training (ALERRT)
- Information on Rescue Task Force programs
- Sikh Temple shooting lessons learned
- National TEMS initiative
- Dignitary Medicine
- Watertown Manhunt
- London Bombing
Note: Please share all questions in the comments below, as I won’t be answering questions posted on social media.
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After the Boston Marathon and other domestic incidents, I believe that TCCC training would be a real benefit to have. I also travel in third world countries where it's not that the medicine is not modern, but transport and first responder care is entirely absent. Is there a civilian track to TCCC certification?
We have allocated money from our budget for 2014 for Ballistic vests and helmets for our FireMedics. There are multiple departments in our area that are purchasing and in most cases requiring the personnel to wear this equipment on certain incidents. We are planning to put them in the first due apparatus and in the station.
@SweMedic Alltså, bilden på sid 41... Inte mycket kvar av den ambulansen :/
It is interesting to see the continued debate on vented chest seals vs. unvented. I just got back from Ft. Sam Houston less than a month ago for 68W school (I had my MA, IL, and NREMT EMT certifications from before) and our instructors were saying that the research they've seen showed vented CSs didn't prove to be any better than unvented, so I'd be curious to see what research they are using. In civilian EMS we were taught to tape down three sides of an occlusive dressing, so again I have to wonder what research is being used and is this from the civilian or military side of medicine? We were taught exactly what was outlined here about analgesics, and as medics this was something we had to become very familiar with.
We're teaching the "warm zone EMS" option here at Rancho Cucamonga Fire, in So Cal too.
We've been doing it for almost ten years with level IIA vests and PASGT helmets then added 3A vest over the 2A's about 5 years ago. We've been collaborating with Arlington, VA Fire who does a very similar program.
Funny, we are just now getting calls from all the surrounding departments to help them train on this. Looks like we'll be doing a number of classes for the various San Bernardino county agencies in 2014. It's become a huge priority.
Like what was mentioned a few times, not really intended for fire fighting operations. However, our dept became "armored" for the LA riots and those bro's did wear their vests under their structure gear. I believe they had little intention of interior firefighting though, mainly planned on (defensive) exterior attack.
@ITStactical EMS use to wear them back in the day.
@ITStactical provided for every medic in Austin for at least 10 years.
@ITStactical parts on NC already have EMS wear vests
So soon American firies will be issued with a bulletproof vest, under or over the jacket, harness, SCBA, ect. Has whoever thought this up actually TRIED crawling around in body armour and fire fighting gear? It don't sound that easy, really. And finally, how are you meant to put a bulletproof vest under, or over, a fire helmet?
Or am I missing something?
@paragraf_13 It takes a village to raise a child or . . Writing an SOP
@harunalrashid From what I understood from the talks at SOMA, was that a vented helped in the Care Under Fire phase as you did not necessarily have to monitor the patient for a tension pneumothorax and move on to other care. If you use a non-vented then you have to monitor the patient closely. Just my take away which may not be correct at all.
@NinjaMedic @ITStactical But does your EMS/Fire still stage during "shootings" or do they link up with LEOs and go into the warm and hot zones?
@ReedMattocks @ITStactical Are they staging or using Rescue Task Force tactics?
@Snoopy12 This is for use during active shooter and bombing events. Rescue Task Force puts the first arriving LEO and EMS/FD into teams which goes into the "warm or hot zone". Lots of talk at SOMA about how to make this work on both the LEO and Fire side.
Likely it is not for use under bunker gear. Many fire departments and EMS agencies already have armor on the trucks for when the crews wish to wear it, or when policies require it. Usually it gets put on while the crew is staging, and comes off once they leave the scene.
@SweMedic Mhmm, över lag en bra PDF med viktiga poänger även om organisationerna inom t.ex. Polis inte ser ut riktigt på samma sätt i .se
@CENTCOM_Survivor@harunalrashid Hmmmm...I can understand the logic but also (at least as medics) we don't do any treatments in CuF beyond tourniquets on the extremities because of the tactical situation (chest seals would expose the casualty as you would have to remove his body armor and you would be a sitting duck as well). Tactical Field Care is when we would go through the actual assessment algorithm and apply chest seals and NCD when signs and symptoms of tension pneumothorax are present for such. Tension Pneumothorax will take a few minutes to manifest itself anyways so regardless you will have to be monitoring for respiratory distress.
I suppose also the other side of the logic (to play devil's advocate), also as I understand it, is that a vented chest seal really isn't a direct escape path for trapped air inside the thorax and that the cavity created by a projectile may potentially "re-seal" itself with fluids and tissue; however an NCD is because it is a physically inserted catheter that you know has went right into the chest cavity at the appropriate depth and physically keeps an opening open for air to escape. As I said, from what I have heard and been taught it doesn't make a difference what you use, so long as you use it properly.
My theory is that they don't really know which truly works better, but since there is nothing to disprove the theory behind the vent and it hasn't killed anyone yet they are going with vented as the preferred. I think the logic makes sense behind the move, but like I said and from what I have heard, there hasn't been a statistically significant difference in what works better.
@CENTCOM_Survivor@Snoopy12 So we aren't talking about wearing them during actual firefighting, but simply when crews are helping in rescue/medic operations. I'm still finding it difficult to see how it would work if an actual fire was present. i.e. fire-bombings or whatever. I think you would definitely have to get specialist equipment, like a bulletproof fire helmet, or a Kevlar vest maybe. I can fully see that it is possible to make equipment work for both purposes, but my (admittedly very inexperienced) mind is thinking that wearing metal plates over your torso in a fire could be a bad idea. Not to mention ditching the fire-helmet for some bulletproof one. Probably not good to take equipment designed for military and police use, and throw into a fire situation off the shelf. (My $0.02
@paragraf_13 vist är det så, men mentaliteten är not rätt lika ändå.
Yep my mistake on citing treatment during care under fire, should have been TFC. Here is a article talking about the changes, although as you stated they don't point out any direct deaths from using a non-vented seal.
Management of Open Pneumothorax in the
TCCC Guidelines Change 13-02
There was no "selling" needed, our department bought in 100%. I believe there is the ability at the individual level (should an event occur) to elect to not go directly into the warm/hot zone. Several FF's have voiced concern over entering an "unsecure" area. We basically left it up to each person, as to how far they wanted to go. Most guys are in agreement that they would enter a potential hot zone with an LE escort to treat/exfil the wounded. Risk a little to save a little, risk a lot to save a lot.
This year (we have been trying for almost a decade) we finally got buy in to staff TM-6 (TacMed 6) with several paramedics/EMTs off each shift to practice TEMS with Metro SWAT. Currently they respond with SWAT and suit up....but have to stand by at the command post. Baby steps.....they want to eventually make entry and go to an academy.
Im gonna try to PM you...I have several guys who would love to chat with you about your situation and could shed light on our active shooter program as well.
Hi Jess, though not directly asked this may help (here's the simplified version).
We've found that their are Four essential elements to get a Tactical Response Program off the ground but first:
SELL THE PROBLEM, NOT THE SOLUTION. All involved personnel need to admit and understand that there is a major possibility of the active shooter scenario. Research all the incidents that have happened in the last 20+ years and present data for a case to have a solution.
"The Four Pillars"
1. Organizational buy in (obviously). The three following groups need to feel they have a say in the process or there will be blow-back.
a. The Association - Talk to the union reps, especially Ops. Mine said that they would require the propper PPE's & training and then they would support it.
Some unions may balk because it does affect working conditions, a bullshit reason in my book but attitudes may vary. I'm on the E-board, by the way
b. Management - These guys, if motivated by the mission should be supportive but they have to be on board.
c. The Body- talk to the the big players on the floor that have credibility. Get them to help sell the solution in the stations. Former military guys that have a tactical experience can very good for this, unless of course they lack credibility.
2. Equipment. We where able to use Homeland security grants for approx 75% of the ballistic equipment. Look into grants.
For example, but I'd say at a minimum:
a. Ballistic vests -safety gear budget
b. Ballistic helmets - safety gear budget
c. TECC trauma gear - medical gear budget
d. Litters - medical gear budget
e. chem-lights, tactical flashlights, triage tape - various budgets
3. Training - Get TECC training as well as small unit tactical training. Guys need to know how and when to move, cover vs concealment, etc.
4. Fire/LE Relationships & training. Critical!!!!
a. The program won't fly without joint cooperation and TRUST.
b. Train Fire/EMS personnel to move inside a diamond formation, in a stick formation, etc.
c. Live drills with the LE agency that you will be responding with!
Remember, it's all theory until proven by experience but drilling is a step closer than talking about it in a classroom.
You guys probably know most of this but may not have found a way to frame it to "sell the product". This worked for us and I hope it helps you guys.
@Gilk10180 @CENTCOM_Survivor Is this Malak Gilkey? It's Jess Fulkerson from Mason County. Are you guys (Central Pierce) doing TEMS? Or is that through the Sheriff's Office? Also...if you had to "sell" the concept of warm zone entrance of FD....any tricks/tips you recommend in our efforts to sell it to our Chief(s)?
@Gilk10180 Sounds like you guys are doing it right. What departement?
@Snoopy12 @CENTCOM_Survivor This link is in the article, but take at look at this PDF as it does a great job of describing the RTF concept and how the FD/EMS would be equipped. http://www.vdh.virginia.gov/OEMS/Files_Page/symposium/2012Presentations/OPE-4006.pdf