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Rethinking Casualty Care in Tactical Situations, Part 2

In Part 1 I provided some background on the Army’s former procedures for casualty care in tactical settings and discussed the changes made based on lessons learned in the Battle of Mogadishu and particularly from sustained combat operations in Iraq and Afghanistan. Here I’ll consider the conditions produced by the prevalent first aid training in most law enforcement agencies, how to train for the CUF model, and recommended equipment.

A study of tactical medical care provided by law enforcement officers was published in 2007 in the journal Prehospital and Disaster Medicine. Officers responding to the study’s questionnaire could score a maximum of 38 points; the actual average was 15.5, and the maximum actual score was 25. Clearly, current medical care training in most law enforcement curricula isn’t adequate to the task of teaching tactical casualty care. The Rochester, Minnesota Police Department has developed a training program based on military standards, and we’ll look at some of that program’s principles here.

For simplicity this program (called Basic Tactical Combat Care or BTCC) uses two designations: sick and not sick. A “sick” victim is defined as one likely to die within 20 minutes without medical care. In addition to evaluation, BTCC teaches proper assessment process and lifesaving medical procedures: tourniquets, chest trauma treatment, needle decompression of a tension pneumothorax, and nasopharyngeal airway insertion.

Casualty assessment is a procedure that the Army calls a head-to-toe (HTT) assessment. The responder starts at the head and runs his or her hands over the victim (including reaching under to check the back). The goal is to identify the presence of clear cerebrospinal fluid (indicative of a serious head injury), blood, broken bones, burns, and wounds. In BTCC the emphasis is on finding blood, since CUF concentrates on stopping life-threatening bleeding above all else.

Experience with this training has demonstrated that officers tend to treat the assessment more like a pat-down. While finding hidden weapons on a suspect is indeed one goal of the sweep, the most critical function is to locate bleeding. With gloved hands this normally has to be done visually since blood (especially in small quantities) is unlikely to be felt. The assessment must be performed while maintaining maximum situational awareness, which means head up and looking around, but the officer must glance down at his or her hands periodically to see whether blood is present. Finding blood on your hands at the end is not particularly helpful if you have to go back and locate the wound. (Checking beneath body armor is a necessity, too.)

The second important lesson learned was that in a multi-victim scenario involving officers, suspects, and bystanders, responders understandably tended to go to the officers first. Much like trying to reach a casualty under fire, this improperly emphasizes medical care over security. Unless it is possible to maintain eyes on any (presumably) injured suspects at all times, they should be searched and cuffed prior to rendering care to anyone else. Obviously, the number of officers responding to a situation will drive the exact execution of some of these procedures, but it is important to adhere to the basic philosophy that failing to secure any threats present can easily lead to more injured or dead officers.

Finally, in scenarios that included a suspect with arm injuries (including some that required a tourniquet), officers often seemed hesitant to cuff the individual because they thought they might aggravate the injury. Again, security is the priority. While reasonable steps to prevent further injury are understandable, a suspect must be restrained even if he or she is apparently dead.

The ability to provide adequate casualty care also requires the right equipment. The Army Improved First Aid Kit (IFAK) now issued to every soldier has the following contents:

The items in the kit are specifically designed for combat casualty care. They can address the most critical injuries, and both the tourniquet and the combat dressing can be applied one-handed by the victim if necessary. (Remember that as mentioned in Part 1, CUF specifies self-care by the injured person if possible.) One handy addition is a small foil pouch of surgical lubricant, as the nasopharyngeal airway is much easier to insert when lubricated, important since a conscious but disoriented victim may not be all that cooperative when you shove a rubber tube up their nose.

Compared to most of the gear on a standard duty rig, the Army-issue IFAK is a bit bulky, but you can either purchase or assemble a kit that will fit into a smaller pouch. This is important because successful TCC requires immediate availability of treatment supplies. Running back to retrieve the kit from your trunk or passenger seat may not be an option in some situations and at best will delay medical care.

Various types of training material are available. Some agencies have been developing training courses as the Rochester P.D. did, and at a minimum the Army’s TCCC procedures are publicly available, including here. The most important points are that you understand the priority of security over immediate medical aid and how to assess a casualty for critical injuries that must be treated first. Hopefully you will never spend much time in the aftermath of a tactical situation without backup from EMS, but as the saying goes, hope is not a strategy. Besides, for the most serious injuries even minutes can count. Knowing how to properly provide care in these settings may very well save a life.


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