We live in a time of insecurity. In our civilian life we experience extreme situations such as kidnappers, robbery, active shooters, and hostage takers. The police have specialists that are supposed to carry out the missions to protect the citizen and the law. In these types of missions it is estimated injuries in over 30% of the tactical operations and tactical related training. An interesting aspect here is the training to respond tactical, but not in tactical medicine. To treat wounded persons during violent encounters is a special skill that needs to be trained. This training is often missing.

The last years a new medical system called “Tactical emergency medical support” (TEMS) have been developed to provide a medical skill for this type of events. It is not sufficient to be a paramedic; you need to be a paramedic trained for a tactical environment. To have a paramedic that is tactically trained might turn the game totally in field operations.

A protocol for a normal paramedic will not fit for a Tactical paramedic. Standard prehospital protocols don’t fill the need in a tactical environment; when war is happening you cannot follow a peace protocol. In the field as a tactical paramedic you will have pressure, limited resources, and lack of transport, hard injuries, a ticking clock and a lot of pressure. Perhaps the enemy is just around the corner; searching for you. It exist guidelines for care in combat tactical environment, but care in CTE – Civilian Tactical Environment (shooter episodes and terrorist attacks) is without direction. CTE in medical care is something between combat medicine and standard prehospital care; in between there are no guidelines or protocols. The discussion has been taken in the big organs, but still it has not resulted in anything greater. It exist a semi-official recommendation about using a TEMS program based on TCCC; the military system of Tactical Combat Casualty Care.

Then what is TCCC? This is a system of trauma care in a combat tactical setting focusing on keeping the tactical operator (soldier) capable of continuing to fight. Tactically trained paramedics were found to be the solution. TEMS are thought to fill the gap between combat medicine and civilian pre-hospital EMS.

It is three phases of tactical care in the TCCC system: Care Under Fire (CUF), Tactical Field Care (TFC) and Tactical Evacuation Care (TACEVAC). The CUF phase is the presence of an immediate direct threat; the most dangerous time to deliver care. Here the Tactical paramedic might need to engage with the enemy. Main goal in this phase is to prevent further injury to the wounded; normally, this phase in limited to treating life-threatening haemorrhage. Note that airway management are normally moved to TFC (tactical field care phase). The TFC phase start at once you are protected from the immediate threat. Here you might do limited advanced life support (ALS), Airway management, seal chest wounds, and relax tension pneumothorax. It is also normal to use bandage on wounds, fractures splinted and prevention of hypothermia. Then the TACEVAC phase starts. The main focus is on transport to definitive care. Remember that the faster a patient gets to final care the bigger chance for survival. In this phase ALS are used to its fullest extent. The tactical paramedic use chest tubes, advanced airway management, wounds are rechecked, tourniquets might be reconsidered, if needed analgesics and antibiotics.

These three phases are important to remember since they give us an important image of the conditions a tactical paramedic have to work under, and how the lack of safety inflict on the services that he might provide. A normal paramedic wait until the scene is secure, but the tactical paramedic enters; 12% of all EMS occurs in potential unsafe situations. He will give a reduced EMS, but the person will get a bigger chance for survival. A situation occur any place, and the nature of a tactical scene is the lack of mobility. A tactical paramedic needs a protocol that permits more flexibility than other paramedics to conduct more advanced care. At the same time we also need to remember that the tactical paramedic has less equipment and work under additional types of pressure.

Suggestions to protocols might be that the equipment a tactical paramedic carry with himself are adjusted for the work he might conduct. In CUF we find that the normal treatment conducted are focused on haemorrhage control. Haemorrhage might be controlled by a tourniquet; late use of tourniquet might cause death. Early use of tourniquet saves life on the battlefield; conventional EMS tourniquet is used way later than in tactical EMS. Giving easy accessible tourniquets, bandages and blood stoppers like (QuickClot, HemCon Strip First Aid (Formerly KytoStat) and WoundSeal (formerly QR Powder)) a central place in the equipment of a tactical paramedic. Blood stoppers (haemostatic agents) are to be used where tourniquets cannot be used as on the axilla, groin, torso, neck, face and scalp. The key here is simplicity and only the needed; nothing more. Airway dysfunction is rather rare in tactical settings. CPR is also not recommendable of tactical reasons.

Extremity wounds often causes haemorrhage, and can easily be controlled with a tourniquet. To stop a bleeding quickly are life or death in the field. This leads us to another important topic, the use of tourniquets. Tourniquets are proven effective, but limb elevation with pressure lack evidence. The use of tourniquets also frees the hands of the tactical paramedic. It is basic procedure to use tourniquets on heavy bleedings in the CUF phase. When the wounded is extracted, we find the tactical paramedic review the bleeding and perhaps removing the tourniquet. Note here that some say that you should not move a tourniquet if you have put it. You cannot use tourniquets on other places than the extremities and direct pressure doesn’t always work; making a haemorrhage on other places more difficult to stop. Then we use haemostatic agents that some unique dressings that possess properties to form clots formation. In practise you find the bleeding wound with this agent and put pressure bandage on top.

Reaching TFC we find place for more medical treatments. The focus on airways increases and thereby we have the need to tools to seal chest wounds and catheters to decompress tension pneumothorax. It is also a need to have more bandages and easy accessible ways to splint fractures and a system to give heat. Perhaps the tactical paramedic is not giving the best EMS treatment possible, but given the working conditions it is the best. Waiting to give treatment will harm more than to treat simpler under fire. The tactical paramedic need to enter where a normal paramedic don’t.

We need to consider the management of Shock in the TFC stage. Haemorrhage might cause a hypovolemic shock, and need to be controlled to avoid the patient to go from a compensated shock to an uncompensated shock. Paramount here is intravenous liquid in TFC we need a hypotensive resuscitation approach. This is a restrictive administration of IV fluids and blood. The goals of keeping mean arterial pressures (MAP) high enough for essential organ perfusion but lower than normal in order to limit bleeding. It is less blood loss at lower blood pressures; less acute blood loss and less coagulopathy. Remember to not give a high volume resuscitations and stick to a more restrictive approach; damage control resuscitation (DCR). Tactical paramedics aim to avoid and treat the acidosis, hypothermia, and coagulopathy triad. DCR are divided into three: 1. Permissive hypotension with a goal of 70-90mmhg in systolic blood pressure. 2. Use fresh frozen plasma (FFP) early with packed red blood cells (PRBC’s); 1:1 ratio, as the main fluid. 3. Limit the use of crystalloid IV fluids to about 150cc. Remember, an elevation of MAP during acute haemorrhage increases blood loss; less blood loss at lower MAPs, and we get an increased survival time in uncontrolled haemorrhage. The tactical paramedic will balance between low blood pressure leading to organ dysfunction and lower survival, and higher blood pressure leading to increased blood loss and organ dysfunction. This is a difficult balance and even worse under pressure; a comfort is that controlled hypotension may be beneficial. An optimal blood pressure is still unclear. It is indicated that a systolic pressure down to 70 mmhg or and a MAP of around 50 mmhg are completely okay in patients without problem with hypotensive management, but not when head injury!

Haemorrhage should be followed with fluid administration to prevent hypovolemic shock. Normally the main indicator of the need of fluid is related to absence of a palpable radial pulse, an altered consciousness and change of blood pressure. When the radial pulse goes from not palpable to palpable the fluid administration should finish. As we have mentioned before the amount of fluid might be discussed on one side damage control resuscitation (DCR) recommends 150ml and other recommendations is 20 ml/kg of normal saline (0.9% NaCl). If the bleeding continues it is recommended with a limited fluid administration to maintain a peripheral perfusion.

Then we move to the TACEVAC phase. Here the goal is to get out and to final treatment facility as FAST as possible. Research has shown a 90% increased survival rate if the wounded is transported fast from the battlefield to the final treatment facility; meaning the essence is speed and efficiency.  The tactical paramedic will focus on spinal motion restriction (SMR), but the importance is reduced compared to normal paramedics. On a battlefield most injuries are penetrating bullet wounds or related to cuts, bleedings and broken bones. It is less cervical damage, and that is good news for the Technical paramedic that cannot focus on SMR in the tactical environment.  Tactical paramedic’s empathies on moving faster where others slow down to reach final treatment facility. Rememner the Golden Hour: 60 minutes: 3600 secounds.

A tactical protocol need to focus on elements that other EMS protocols don’t focus. Here we need to have triage as a main problem, or who go first? The triage need to be well defined and drilled. It is no place for discussions and emotions when handling this topic in the field and in hot situations. Another topic is resuscitation decision-making what is the criteria and who have the final word. Don’t forget that many needs help of the tactical paramedic and using his time on a “lost” or time consuming patient might kill others, the concept of remote assessment (observing a potential patient on distance to decide his viability) indicate the need of decisions and competence. Oxygen is very important, but a tank of oxygen might explode if hit by a bullet so it better not to bring it into the hot zone. As we have mentioned before SMR is of less importance in tactical medicine; tactical paramedics have less to do with car crashes, this is bullet, bombs and knifes. SMR requires equipment that is not easy to transport and multiple providers to efficiently provide SMR help. In a battlefield we find a low incidence of cervical spine (c-spine) injuries, penetrating trauma is the main cause of combat injury; making SMR to be tuned down by tactical paramedics in the hot zone.

The same goes cardiopulmonary resuscitation (CPR). CPR is not easy to do when you are in the hot zone. We also need to remember that this will occupy the tactical paramedic for a long time, and he cannot attend others. It is also needed to consider the possibility to reach final care with the CPR needed patient. A rule that is often used is victims with explosive trauma or other significant penetrating trauma with no signs of life should not be resuscitated; rules are to be broken!

An important problem in tactical operations is the number of seriously injured people that suddenly might occur; mass casualty incidents (MCIs). The tactical paramedic need to be ready to sort casualties and quickly analyse injuries; triage. Triage might be one of the most difficult aspects in a tactical environment. To decide who lives and who are left to die. The drive is to help as many as possible. For example you have five injured persons. One cannot breath and need CPR, one have a massive haemorrhage, one has a broken arm, have lost a leg but doesn’t bleed yet and the last got a penetrating chest wound after a bullet. In the triage the tactical paramedic literary runs around to get an overview and do minor super quick first aid maximum 1 minute per person. It is no time for CPR, and if nobody else can do it that person will have to be left. The broken arm can wait for later. The haemorrhage need to be stopped with a tourniquet or pressure bandage. The leg might also be treated with a tourniquet. The chest wound need to be closed with a proper sticker and to be evaluated for a pneumothorax. If the tactical paramedic stops with CPR patient, he will not save the bleeders. When he is finish with his lap, he might go back to the CPR needed and start to help him. Another problem is transport of wounded out of the hot zone. Helicopters might help, but most likely they need to carry the wounded for hours.

As you easily understand tactical paramedics cannot follow standard traditional EMS protocol. It is many aspects that need to be considered and decisions to be taken under extreme stress and under tremendous personal danger. Tactical paramedical techniques might be used in a civilian prehospital setting, but normal paramedical skills are dangerous in a civilian tactical environment. Civilian tactical medics must have TEMS-specific protocols to justify their actions. It is advisable to connect these protocols to TCCC guidelines. All protocols need to be adjusted to local law and environmental considerations.

SUGGESTION TO PROTOCOL FOR TACTICAL PARAMEDICS:

Tactical supportive care:

When to resuscitate follow this limitations:

• Care Under Fire(CUF):
  • No CPR; only if resources and no additional danger
  • No oxygen
  • No spinal motion restriction (SMR)
  • Depending on triage decisions
• Tactical Field Care(TFC):
  • CPR only if resources
  • Oxygen if applicable
  • Spinal motion restriction (SMR) only if possible
  • Depending on triage decision
• Tactical Evacuation Care (TACEVAC):
  • Do everything possible.

When to do remote assessment:

• If resources for RA, investigate all wounded.

How to do triage:

• Do triage when more than one wounded.
• Give as many as possible the chance for survival
  • If two can be saved for the cost of one; save two.
• The consideration needs to include two calculations:
  • The chance for survival for the patient
  • Combat readiness for the soldier
• Skip triage if dangerous and unpractical to move between wounded.
• The main key to triage is available resources.

Other focus areas:

• Tension pneumothorax is high on the list over preventable combat death.
  • Seal open chest wounds with plastic.
  • Penetrating trauma to the chest = pneumothorax
    • If progressive respiratory distress.
  • Conduct needle decompression in the presence of torso trauma
    • If respiratory distress, regardless of progression.
  • Closed airways
    • Consider endotracheal intubation only when:
      • Respiratory compromise directly associated with trauma-induced airway obstruction
    • Blind insertion airway devices might be an option
    • When significant maxillofacial trauma might complicate intubation.
    • Artificial light is often needed when working with closed airways; careful.
    • Surgical cricothyrotomy if permanent air supply is needed
    • Blind insertion airway devices: multilumen oesophageal airway device (Combitube) or a laryngeal tube airway(King LT)
    • IO – IntraOseo (FAST1 device)