The violence of 2014

The year 2014 is shaping up to be one of the most violent years for law enforcement in recent times. Thirty-three officers have been shot and killed between January 2014 and September 9, 2014. By comparison, there is a 72% increase in gun related deaths in 2014 over the same period in 2013. Seventy three law enforcement officers in total have lost their lives on duty so far in 2014. (www.odmp.org)

 

Being shot and killed remains the number one cause of death for law enforcement officers and the numbers are growing. It is almost double that of car accidents. In addition to human deaths, seven law enforcement service dogs have been killed in 2014. Five being shot to death and two stabbed. Despite what appears to be a growing public perception that law enforcement officers can make "superman" like decisions in split seconds, and have adequate training to prepare them for all types of situations, the numbers are asserting otherwise. There is no acceptable rate of injury or death for those who protect and serve us making continuous learning necessary to keep up with today’s violence.

 

An important part of officer safety is training both the law enforcement officer and the first responders in civilian tactical medicine. The medical community is actively working on evidenced based pre hospital care that is designed and proven to be effective for civilian first responders. Currently, the military's Tactical Combat Casualty Care doctrine (“TCCC”) is the only proven type of training that has been shown with great success to be effective on the battlefield. Unfortunately, the mechanism of battlefield injury does not parallel the injuries seen predominately in civilian life. The tactical situations of the battlefield, though occasionally compared, have few similarities with majority of the situations encountered by law enforcement. Evacuation and transportation to tertiary care centers is typically fairly constant throughout the metropolitan areas of the United States, thus unlike the military, does not play a significant role in injury survival.

 

Catastrophic bleeding, similar to military findings, is the number one cause of civilian trauma death with survivable injuries. It is recognized that an arterial injury can lead to death in as little as three minutes with loss of consciousness occurring as fast as 90 seconds. The importance of bleeding control has trickled into first responder training in various regions of the country. There are, now, numerous case reports in the civilian literature regarding immediate blood loss control by first responders, including law enforcement officers, where the victim survived due to the care they received at the site of injury.

 

The introduction of the modern battle tourniquet has been the most significant contributor to civilian tactical medicine training and pre hospital bleeding control since the US Civil War. In 2006 after uniform distribution of tourniquets to all US combat forces, the US Army Institute of Research reported an 85% reduction in extremity bleeding deaths in Afghanistan and Iraq. On the civilian side, the aftermath of the Boston Marathon Bombing saw the largest use of tourniquets for bleeding control than in any other previous critical incident in the United States. The quick action of the numerous Massachusetts National Guardsmen who were present, all previously trained in TCCC, saved the lives of many of the victims by using their issued battle tourniquets. Their actions were mimicked by multiple Good Samaritans who used anything they could find to create a tourniquets and saving even more lives.

 

As specifics of civilian trauma death are further defined, more research is being performed to develop a TCCC like tactical medicine doctrine for civilian first responders. Definitions regarding the immediate tactical situation are being adapted from TCCC to give first responders guidelines on when medical care is appropriate and expected versus the volatile situation where rendering medical aid is too tactically risky.

 

It is recognized that poor tactics or omitting high risk zones are not acceptable protocol  in first responder doctrine or training. The creation of tactical zone language has helped define the priorities in high risk critical incidents where tactics and injury management are combined. The high risk zone or "Hot Zone” is defined as an area where an immediate threat is imminent and the top priority is threat management. Active shooters, structurally unstable buildings, bombings and natural disasters may all be considered hot zone situations where medical aid stands behind tactical considerations in regards to priority decisions. The "Warm Zone" is defined as the area close to an imminent threat that has some form of security and protection. In this location, tactical considerations remain top priority, but with adequate security, medical aid can be initiated following the medical BABC's (Bleeding, Airway, Breathing and Circulation). The warm zone may at any time convert back to a hot zone where the top priority converts back to threat management with the emphasis on tactics. The warm zone is mostly where the services of law enforcement, Fire and EMS will merge and work in union, each bringing their unique expertise. The "Cold Zone" is defined as where advanced medical aid is performed and transportation and evacuation are planned and executed. This area is either a significant distance from the ongoing imminent danger or the threat has been neutralized whereas the location has been declared safe.

 

The definitions of the tactical zones are an example of how civilian tactical medical response can be performed in an effective and safe manner. Additionally, continued civilian based research driving improvement to pre hospital care training, will provide first responders the knowledge, mindset and skillset to operate and survive in the increasingly violent environment that today’s millennial society is becoming. The seventy-three law enforcement officers who have died while on duty in 2014 are only a fraction of the first responders on duty deaths this year. Firefighters and EMS personal also face high risk situations. September 11, 2001 is a somber reminder of this fact. Uniform process, updated training procedures and continued research are paramount in keeping our law enforcement and first responders safe.

 

As an aside, though very graphic, the video of the 2011 Sindh Ranger shooting in Karachi, Pakistan displays how quickly human mental status changes with severe blood loss followed by death and stresses the need for civilian tactical medical training for first responders.

Is Tactical Combat Casualty Care (TCCC) worth the investment?

Are the practices of Tactical Combat Casualty Care (“TCCC”) training a good investment for civilian emergency medical services (“EMS”)? The year 2014 brings a continuation in declining training budgets for first responders. Currently, civilian EMS systems lack the comprehensive death and injury data base that have been developed by the military and little to no national research has been done on the results of Tactical Emergency Medicine Support (“TEMS”) teams in the United States.  In a budget conscious environment, is it a lack of conclusive data to support the cost or lack of unified standards to make TCCC an integral part of Emergency Medical Services training?

 

The 20th anniversary of the introduction of TCCC will occur in 2016 marking its first adoption by the US Navy SEALS and US Army 75th Rangers. By 2014, all US forces and the US Coast Guard have incorporated TCCC into their standard combat training. Multiple combat allies have also accepted the validity of TCCC and integrated it into its own training standards. Despite this, the question arises if TCCC is meaningful training in the civilian EMS environment. 

 

The US Army and Canadian military forces have recently published its death and injury data from 2001-2011 combining both Iraq and Afghanistan theaters. Unsurprisingly, traumatic hemorrhage remains the leading cause of preventable death on the battlefield. The predominate mechanism of injury for both military forces was explosive. Tension pneumothorax and loss of airway continue to follow hemorrhage as the leading causes of preventable death but only a distant second and third respectively. 

 

The US military command and its allies have committed millions of dollars to train their troops in TCCC. Evidence based review demonstrates this was money well directed. The armed forces trauma information system is used to track injury, patho-physiology of death, battlefield circumstances, pre-hospital treatment and hospital management. The military tracking system also includes detailed autopsy reports. Currently, the US civilian emergency medical system has yet to achieve a comprehensive data base capturing the continuum data from point of injury to hospital based care. Despite the lack of a broad based civilian trauma tracking system, the increasing incidents of public mass shootings and bombings, similar to the Boston Marathon, have brought awareness to some important deficits in civilian EMS capabilities. Education and training for mass traumatic hemorrhage is paramount and its recognition has unequivocally saved thousands of lives in terrorist type situations worldwide.

 

Yet still it is said that combat casualties and civilian injuries are not mirror images of one another. The development of Tactical Emergency Casualty Care (“TECC”) has been an attempt to create a "civilian" version of TCCC that better addresses the civilian needs given the uptick in traumatic attacks on the public. Critics of TECC argue that it too closely resembles TCCC training and does not address the top causes of death in the civilian world. This argument exists because the top causes of traumatic civilian death have not been well demonstrated. TECC, like TCCC, is centered on teaching the “MARCHE” algorithm. Massive bleeding, Airway, Respirations, Circulation, Hypothermia and Evacuation make up the MARCHE methodology. The core skills taught are tourniquet placement, chest needle decompression and recovery airway position in both TCCC and TECC.

 

Detractors of TECC suggest that management of mass bleeding is the only addition needed to the traditional "ABC"s of standard U.S. EMS training. However,  tension pneumothorax leading to death in the civilian population is extremely rare making the chest decompression skill a nice addition, but far from necessary. The Canadian military data from Afghanistan support this argument against teaching chest decompression. The Canadian findings indicate the majority of soldiers who attempted a needle decompression on the battlefield performed it incorrectly. Teaching the recovery airway position may also be a poor utilization of resources. Following "ABC" training, U.S. EMS's goal is a definitive airway. The recovery airway position taught in TCCC and TECC is not an acceptable management of an unconscious person in the U.S. system. It is not difficult to appreciate the argument against acceptance of an entirely new training system when the current nationwide U.S. EMS protocols can be modified to meet the evolving needs.

 

The need for tactical training is strongly supported across the United States by local, state and federal law enforcement, fire and EMS. Multiple national organizations and government agencies representing these entities have publicly supported and are actively developing programs to prepare EMS and firefighters to work in more austere or violent environments. Unfortunately, unlike the military, there is no nationally unified tactical emergency medical training. Laws, policies, and organizational development vary extensively from state to state. California is one of a few states that has a centralized governing body for all law enforcement standards and education which includes tactical training. This allows for the development of a statewide tactical training program that fit the needs of the state’s centralized EMS system. The other 49 states may have institutional differences and their tactical programs vary by each state’s or region’s standards of training. This creates the need for a national standardized training program, but the implementation, is understandably, difficult due the wide ranging variation in institutional structure, training and working environment.

 

A recent national study on the strategic planning and training for American law enforcement indicates that 2-year plans are being created to be more flexible with the dynamics of the external traumatic environment. Currently data regarding crime rates is available in the U.S.  Partnering with the National Board of Critical Care Transport Paramedic Certification and further analysis of crime data may pinpoint training in regions with and above a certain crime rate index  to begin nationalizing mandates and require a TEMS program with locally tailored TECC training or newly modified “ABC-H” training

Training supervisors are expected to carefully scrutinize training expenditures. Hemorrhage control and tactics training for a violent environment are two components of TCCC that have repeatedly proven valuable training in the more recent civilian terrorist events. To accomplish the incorporation of this new training into the current standards and protocols, it may require an unprecedented partnership between federal, regional, state and municipal law enforcement, fire, and EMS to make meaningful progress. Basic unified standards that are adaptable for localized training programs and additional funding will  prepare present emergency medical services in times of crises derived from our increasingly global and violent society.