Incidents such as an active shooter or mass casualty call necessitate that law enforcement personnel be prepared to provide immediate life-saving first aid to injured civilians; fellow officers; and, perhaps, even themselves.
Tactical Emergency Casualty Care (TECC) for EMS and law enforcement is an adaptation of military Tactical Combat Casualty Care (TCCC), whose guidelines differ from the Advanced Trauma Life Support (ATLS) guidelines on which civilian trauma care has been based.
TECC teaches EMS practitioners and other prehospital providers how to respond to, and care for, patients in a civilian tactical environment. It is designed to decrease preventable deaths in a tactical situation.
There are three phases of tactical care in TECC:
- Direct threat care which is rendered while under attack or in adverse conditions;
- Indirect threat care which is rendered while the threat has been suppressed, but may resurface at any point; and
- Evacuation care which is rendered while the casualty is being evacuated from the incident site.
In an active shooter incident, it may take longer for EMS personnel to reach victims than it takes to bleed out. A “blow out” kit (trauma kit) containing at least a tourniquet and a hemostatic agent needs to be part of your everyday carry. Training is also essential.
The Paris attacks in November 2015 provide an extreme example of a general principle of active shooter attacks: Emergency personnel cannot reach shooting victims until the threat has been neutralized. It was over 160 minutes from the time the terrorists fired the first shots in the Bataclan Theater until the first responders were able to reach those inside the venue.
Individual First Aid Kit
When purchasing or putting together an IFAK (Individual First Aid Kit)/trauma kit, stick to the basics. Just remember, “Stop the bleeding, start the breathing.” There’s obviously a lot more to emergency first aid, but those are the most immediate concerns. They are what a trauma kit is intended to address. Your goal is to stabilize the patient until EMS arrives.
It’s a well-known axiom in combat medicine that the complexity of an individual trauma kit is inversely proportional to a manufacturer’s or operator’s actual combat medical experience. Keep your med kit simple.
Top Causes of Preventable Death in Trauma
Hemorrhage is the leading cause of preventable trauma deaths. Roughly 80% of combat deaths and 50% of civilian trauma deaths can be attributed to hemorrhage. It’s the most preventable cause of death in compressible injuries – approximately 50% of injuries. An average adult body with a weight of 150 to 180 pounds contains 4.7 to 5.5 liters of blood. A child under 80 pounds contains approximately half that amount.
Acute fluid or blood loss is a life-threatening emergency. It makes the heart unable to pump essential blood to the body and results in multiple organ failure. This hypovolemic shock has four stages, each based on the amount of blood loss. Stage I is under 15% by volume; Stage II between 15 and 30%; Stage III between 30 and 40%; and Stage IV more than 40%.
Based on a US Army Institute of Surgical Research (USAISR) study, stopping blood loss while the patient is in Stage I shock (i.e., keeping the blood volume loss below 15%) keeps the survivability rate high – about 94%. If blood loss continues and the patient goes into Stage II shock or greater, survivability rate goes down to just 14%.
Approximately 20% of people who have died from traumatic injuries could have survived with quick bleeding control. The only thing more tragic than a death from bleeding is a death which could have been prevented.
Exsanguination (bleeding out) can occur in less than five minutes from a femoral artery bleed. The national average response time for a Basic Life Support (BLS) ambulance is ten minutes; paramedics are 12 to 15 minutes. And, in an active shooter or terrorist event, EMS may not render aid until the scene has been secured.
Tourniquets have emerged as the standard of care in the tactical environment due to their ease of use, rapid application and complete stoppage of blood loss. Current protocol considers the tourniquet an initial lifesaving intervention to control massive hemorrhage from an extremity.
The old dogma of “save a life, lose a limb” has been proven to be false. A tourniquet can remain in place for two to four hours. Thousands of combat veterans are walking around today with all their limbs because their lives were saved by tourniquet use.
Popular commercial tourniquets include the C-A-T®, SOF®TT-W, SWAT-T™ and RATS® tourniquets. Each has its pluses and minuses. The C-A-T and the SOFTT-W are the only two tactical tourniquets the US Military Committee of Tactical Combat Casualty Care (CoTCCC) recommends.
In scientific studies, the C-A-T, SOFTT-W and SWAT-T have proven 100% effective in occluding blood flow in upper and lower extremities. As of this writing, there are no scientific studies on the RATS that I am aware of, although, it remains a popular option and has been successfully employed in combat.
My everyday carry (EDC) are a C-A-T and a SWAT-T. They’re compact, lightweight and complement each other.
The C-A-T (Combat Application Tourniquet®) is a CoTCCC recommended tourniquet which has been used by the US military since 2005. It’s the most fielded tourniquet in combat.
Now in its seventh generation, the C-A-T features a patented windlass system which is robust and easy to use (one-handed) for self-application. The Gen 7 C-A-T has a single routing buckle system which facilitates both a fast application and effective slack removal. The C-A-T is distributed in the US by North American Rescue (www.narescue.com). Although the C-A-T is simple to use and instructions are included, an untrained individual is unlikely to quickly figure it out under stress.
The SWAT-T (Stretch, Wrap And Tuck Tourniquet), from H&H Medical (www.swat-t.com/ or https://buyhandh.com), features a unique stretch retention design which is intuitive to use, making it more likely to be used by a bystander. Instructions are printed on it.
The SWAT-T is a medical multitool which may be employed as a tourniquet, pressure dressing, occlusive device, elastic bandage, sling and swathe, and more. It can be successfully employed for higher axillary and groin applications. Plus, it can be employed for pediatric and K9 applications, whereas windlass tourniquets cannot. The SWAT-T is being fielded in combat theaters and is standard issue in a growing number of law enforcement agencies. Rapid one-handed self-application with the SWAT-T does take a little practice. It’s not as easy as the C-A-T in this regard.
A fine-point Sharpie® permanent marker should be kept in the kit for writing the time of application on the tourniquet(s) and a “T” on the cheek (now preferred placement) or forehead of the patient.
Not all wounds lend themselves to tourniquet use. For bleeding which can be stopped or slowed only by compression, or with the need for a tourniquet removal due to an evacuation time longer than two hours, a hemostatic (clotting) agent should be used.
TCCC guidelines specify the application of a clotting agent in conjunction with the application of at least three minutes of direct pressure.
Hemostatic agents (compounds which promote clotting) have become increasingly popular in TEMS. They are designed to stop or slow bleeding more quickly than traditional direct pressure. This does not mean they are without controversy. While the general consensus is that these agents are a valuable addition in the effort to stop blood loss, some see less value in their use.
The overall answer may be that, when it comes to these products, they must be thought of as an addition to the means to an end. No hemostatic agent alone can stop significant bleeding. All must be coupled with direct pressure and the principles of blood pressure, blood flow and blood clotting.
When applied in conjunction with pressure, hemostatic agents can accelerate clotting and slow or stop bleeding. Such agents work very well as the material used to pack deep wounds. When combined with surface pressure or a compression bandage, the results are almost always favorable.
Controlling blood loss can be a major problem for some individuals, particularly those who take blood thinners and those who suffer from inherited or acquired bleeding or clotting disorders. The blood in these individuals does not clot quickly. Even the smallest cut can be a real problem. Again, hemostatic agents may be a valuable addition to controlling bleeding in these patients.
Hemostatic agents are employed for compressible (external) hemorrhage not amenable to limb tourniquet use or as an adjunct to tourniquet removal when evacuation time is anticipated to be longer than two hours. They’re primarily employed to control life-threatening bleeds. They’re not for use in penetrating thoracic or head trauma. They can be used for deep lacerations as long as pleural or peritoneal space hasn’t been breached.
Several brands are available commercially. All of them perform well on heavy bleeds. The latest generation of hemostatic products perform significantly better than earlier generations. The shelf life of these products is related to sterility, not efficacy.
Z-Medica® QuikClot Combat Gauze® (https://quikclot.com), CELOX® Gauze (www.celoxmedical.com) and ChitoGauze® (https://tricolbiomedical.com) are CoTCCC approved hemostatic dressings. They work by different modalities. All have proven safe and effective. They are irrigated out of the wound at the hospital during treatment of the wound.
Current QuikClot products are Kaolin-based which do not create heat. Kaolin is a clay mineral which works by activating the body’s own clotting cascade.
CELOX and ChitoGauze are chitosan-based. Chitosan is derived from the hard outer skeleton of shellfish, including crab, lobster and shrimp. It forms a gel-like clot when it comes into contact with blood.
Your kit should include a pressure bandage. It is utilized to direct and maintain pressure on a wound with the goal of creating enough pressure to stop the bleeding. It reinforces wound packing. When utilizing any pressure bandage, beware of tourniquet effect which can occur if the bandage is applied too tightly. Always assess distal pulse after application.
Many types of pressure bandages are available commercially. I went with the North American Rescue Flat Emergency Trauma Dressing (ETD®) (www.narescue.com) for my EDC kit. This dressing features a flat folded vacuum configuration which reduces its footprint. It has a multifunctional all-in-one design and simple application. There are no pressure bars or hooks to deal with. The bandage features both hook and loop, as well as C-Clip, securing devices. The 42 inch (unstretched) elastic bandage has a 4″ x 6″ nonadherent sterile ABD pad.
Occlusive Dressings/Chest Seals
Laypersons can treat penetrating chest injuries (sucking chest wounds) by the application of an occlusive dressing. These chest seals may slow the development of tension pneumothorax and allow for better breathing. Both entrance and exit wounds need to be treated.
Occlusive dressings are designed to form a barrier and prevent outside air from entering the pleural cavity from an open pneumothorax (sucking chest wound). Many types of occlusive dressings are available, including the HALO® Chest Seal, HyFin® Chest Seal, Asherman Chest Seal™ (ACS), FOX Chest Seal, Bolin Chest Seal, and Vaseline® Gauze.
CoTCCC guidelines specify a vented or three-sided dressing as the first choice and nonvented as second choice. I stay clear of the ACS, as it doesn’t stick as well as the newer designs and the valve is prone to clogging. Carry two chest seals to treat both entrance and exit wounds.
I went with the HyFin Vent Compact Chest Seal Twin Pack from North American Rescue (www.narescue.com) for my kit. The HyFin Vent features three channel pressure relief vents, as well as an advanced gel adhesive which sticks well to blood, sweat and hair. It has a large red tab for quick peel and stick application and “burping” the seal if needed. If the patient gets worse, the seal should be burped to ensure clogging hasn’t occurred.
Chest Decompression Needle
Tension pneumothorax is another leading cause of preventable deaths. It’s the progressive buildup of air within the pleural space between the lung and the chest wall. Although tension pneumothorax normally develops over one to two hours, it can develop rapidly. It is 100% fatal, if not treated. The only treatment when it occurs is a needle thoracostomy (needle decompression) performed by skilled medical personnel.
Most trauma kits do not come standard with a chest decompression needle for several reasons. Needle decompression is an advanced skill. Most kits are designed so that it can be safely and effectively employed by anyone with a small amount of medical training.
If you have the authorization, training and the need, a “chest dart” can be added to the kit. One of the best is the ARS® Chest Decompression Needle, 14-gauge, 3.25″ from North American Rescue (www.narescue.com).
The ARS Chest Decompression Needle features a rugged needle/catheter protective tube and an easy open container for quick access. It also features an easy ID textured twist top with a clip and a capless flash chamber for immediate confirmation of needle placement. It’s not much bigger than a standard pen.
Personal Protective Equipment (PPE) is essential. Gloves are the first thing on and the last thing off. Eye and face protection is also important.
Nitrile (latex-free) gloves are a must in any kit. A significant percentage of the population has a latex allergy which is a sensitivity to proteins found in latex. Latex allergy symptoms can range from mild to severe and can be life-threatening.
A barrier device (pocket mask, microshield or faceshield) for mouth-to-mask rescue breathing, such as those from Laerdal® (www.laerdal.com) or MDI® Microtek™ Medical which is owned by Ecolab® (www.ecolab.com), is also good to have in the kit.
Trauma shears or a safety cutter should also be included. I keep a Benchmade® 7 Hook safety cutter (www.benchmade.com) in my EDC kit for cutting away clothing, including footwear, and for cutting seat belts in a rescue situation. It’s compact, made of 440C (58-61 HRC) stainless steel and has a large coated handle which works well with gloves. It safely cuts through clothing like a hot knife through butter. It has been proven superior to trauma shears in military studies.
Having the necessary tools is only part of the equation. Equipment is only as good as the training. Basic emergency medical training should cover the entire spectrum of lifesaving skills. And, like shooting, they are perishable skills.
Even the best med kit is of limited use unless you have been trained how to use it. Emergency medical training should be part of the basic skill set of every firearm owner. In fact, it should be part of the basic skill set of everyone. The time to learn how to use a trauma kit is not when someone is bleeding out.
The National Association of Emergency Medical Technicians (NAEMT) (www.naemt.org) is a good source to find TECC-accredited training in your area. The 16 hour NAEMT-accredited TECC classroom course covers the following topics: hemorrhage control; surgical airway control and needle decompression; strategies for treating wounded responders in threatening environments; caring for pediatric patients; and techniques for dragging and carrying victims to safety.
BleedingControl.Org (www.bleedingcontrol.org), an initiative of the American College of Surgeons (ACS) and the Hartford Consensus, is another excellent resource which can direct you to courses in your area.
Dark Angel Medical (http://darkangelmedical.com) offers an outstanding two day Direct Action Response Training (D.A.R.T.) tactical aid course at various locations around the country. There are no prerequisites for the class. It is a very thorough class with extensive hands-on training. Surgical airway control and needle decompression is not covered in the D.A.R.T. course since Dark Angel Medical feels that this should be left to skilled medical personnel (EMT/paramedic) in a civilian setting, a position taken by most law enforcement agencies. I attended and covered the course for another publication.
Although the Dark Angel Medical D.A.R.T. course doesn’t offer TECC certification, the classes are nationally accredited and count towards 16 hours of refresher training for nationally registered EMTs and paramedics through CECBEMS and every student receives a certification in basic Bleeding Control (BCON).
Dark Angel Medical also offers a FREE online introductory course designed to teach the basics of bleeding control. The company also has an extensive line of well-thought-out med kits, as well as separate kit components.
Eugene Nielsen is a private consultant and a former police officer.
See also The Rescue Essentials TCCC IFAK