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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5198_Библиотеки_им_академика_М_И_Перельмана.pdf
Tactical Emergency Medicine,
Procedures andPoint-of-Care
Evaluation inAustere Environments
MichaelBlaivas, AshotE.Sargsyan,
andDimitriosKarakitsos
52
Introduction
Most physicians never experience the practice of medicine
outside the hospital, emergency department (ED), or the
ofce clinic setting. Some physicians will spend time on
ground or rotary wing ambulances where capability is signicantly limited over the broad scope of the ED and trauma
bay. However, most modern ambulances and especially air
ambulances have electrical power, EKG (electrocardiogram),
and ventilator capability as well as debrillation, suction,
and many other pieces of equipment that allow the welltrained emergency providers to complete an array of critical,
lifesaving procedures. eFAST (Extended Focused
Assessment with Sonography in Trauma) available via a new
generation of highly portable ultrasound machines is a cornerstone of trauma imaging evaluation by methods other
than plain X-ray, computed tomography (CT), angiography,
or magnetic resonance imaging (MRI).
Hospital-based clinicians are typically surprised by the
varied procedures performed with equipment carried in a
physician’s backpack with a Special Weapons And Tactics
(SWAT) team aided by the use of a portable ultrasound
machine. Not only are many of the same procedures performed in the ED or trauma bay possible in the eld, but
accurate diagnosis of potentially life-threatening or lifethreatening injuries such as pneumothorax, hemothorax,
main stem bronchial intubation, head injury, and others are
M. Blaivas (*)
University of South Carolina, School of Medicine,
Columbia, SC, USA
University of South Carolina School of Medicine, Department
of Emergency Medicine, St Francis Hospital, Columbus, Georgia
e-mail: mike@blaivas.org
A. E. Sargsyan
Wyle Science, Technology & Engineering Group/NASA
Bioastronautics, Houston, TX, USA
D. Karakitsos
University of South Carolina, School of Medicine,
Columbia, SC, USA
possible in the most remote locations. Although there is evidence to support a scoop-and-run approach for trauma
patients in typical settings, these studies are not applied well
to a situation where evacuation is unsafe such as a combat
zone, or impossible due to remoteness or inaccessibility of
the setting [1–5]. In such cases, intubation and ventilation,
placement of thoracostomy tubes, and other procedures are
hours to days off and may have to be performed on-site.
Austere andTactical Environment
Emergency Medicine
The austere and tactical emergency medicine environments
are typically similar but not synonymous. One tends to
assume that in most tactical situations organized help is readily at hand and standing by. However, in some similarity to
an austere setting, the tactical emergency physician may be
deployed with a SWAT team seeking an active shooter in a
modern ofce building of a large city, and have no access for
hours to equipment or gear other than what they carry on
their back. While most SWAT team members carry gear in
addition to their body armor and helmets, such as gas masks,
they are not weighed down as much as a tactical physician
who carries a large amount of medical equipment on his/her
back (Fig.52.1). Despite the encumbrance a large heavy bag
provides, it is necessary for the tactical emergency physician
to perform their job. In many cases, tactical physicians are
armed only with side arms and do not carry long guns. They
are tasked with protecting their patients who may be victims,
SWAT team members, or even suspects but are typically not
the rst to enter a building.
Physicians performing emergency care in a non-tactical,
austere setting still benet from a well-stocked equipment
bag. Not wearing body armor, helmet, or other tactical gear
saves weight and may allow the physician to carry additional
medical supplies. As opposed to a tactical deployment, a
physician providing care in the austere environment may be
much further away from potential evacuation and medical
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_52
453
454
Fig. 52.1 A tactical
emergency physician
equipped with a medical pack,
portable ultrasound machine,
body armor, and weaponry
M. Blaivas et al.
help and be required to care for their patients not just for
hours but days. Prolonged care without evacuation is most
likely to happen in a remote expedition setting, and patients
may have to be cared for through recovery and continuation
of the expedition.
Equipment fortheTactical andAustere
Environment
Although it is still unrealistic to carry a laboratory analyzer
in the physician’s bag, some point-of-care testing consisting of small analyzers using cartridges could be transported. Such tests typically evaluate cardiac-related
processes such as troponin and beta natriuretic peptide, but
other additional testing such as electrolytes may also be
available. For a physician traveling to an austere environment such equipment may be desirable, especially if members of the group are older and/or have existing illnesses.
Such portable blood analyzers are less likely to benet the
tactical physician on a deployment or rendition. Equipment
recharging capability may be available by employing one
of a host of over-the- counter solar recharging kits often
capable of slowly charging batteries in portable devices.
One piece of equipment that provides broad diagnostic
imaging capability is found more and more frequently in
tactical and austere settings [6–10]. As Fig.52.1 shows, the
portable ultrasound machine has its place in tactical medicine as well as in austere environments.
The remainder of the gear focuses on critical procedures
and traumatic injury care. Since blunt trauma is always a
risk, the equipment bag should include a cervical collar and
splinting material, the latter of which could be of the inatable variety. Almost like an athletic trainer, tape and bandages are important to have. In reality, one would bring much
of the trauma bay if room allowed. Equipment trays take up
too much space, but essential sterile pieces can be brought.
Chest tubes, typically two, suture equipment, and a stapler
are essential. Clotting material such as a lava rock product is
imperative along with tactical tourniquets for hemorrhage
control. Compression devices to occlude the abdominal aorta
or ipsilateral common iliac artery may be lifesaving in cases
of inguinal wounds where hemorrhage cannot be adequately
controlled with local compression [11, 12].
Intubation equipment is likely to be limited to one handle
and one or two blades as well as several endotracheal tubes.
A cricothyrotomy kit is essential, as well as a bag valve mask
valve apparatus. Suction is typically limited to a large syringe
and rubber tube to suction the mouth and airway if absolutely needed.
Medications are essential, including intravenous uids,
but providers are unlikely to have more than one or two doses
of any medicine, and carrying more than one or at most two
liters of uid may signicantly weigh down the medical bag.
Antibiotics are more critical for longer expeditions and a
large portion of the pack may have to be devoted to a variety
of antibiotics, anti-parasitics, and anti-fungals, depending on
the destination. Antibiotics carried would include broad-
52 Tactical Emergency Medicine, Procedures andPoint-of-Care Evaluation inAustere Environments
455
spectrum drugs in states not requiring refrigeration. Coverage
would typically include skin, bowel pathogens, urinary tract,
and pulmonary tract pathogens. Realistically, a handful of
antibiotics such as a third-generation cephalosporin, a broadspectrum uoroquinolone, and a lincosamide can be used to
cover a broad swatch of bacterial illnesses encountered.
Tactical physicians will have few antibiotics, mostly in the
case of open fractures and deep penetrating wounds providing coverage for skin and bowel pathogens. These would be
given when immediate evacuation is impossible such as in a
relatively remote area or when the area may remain unsecured for a prolonged period of time, limiting Emergency
Medical Services (EMS) or aircraft access. Essential medications include paralytics and sedatives along with standard
Advanced Cardiac Life Support (ACLS) medications such as
epinephrine, atropine, and others. Pain medications are likely
to be required with penetrating wounds and blast injuries as
well as blunt trauma.
Procedures
Procedures such as intubation, thoracostomy tube placement, and peripheral and central line placement are performed in much the same way one would in a trauma bay or
ICU setting. Intraosseus (IO) access can be a rapid, albeit a
very temporizing measure to obtain access. The inherent vulnerability of an IO line to unknown dislodgement is exaggerated in the eld where the patient may be moved rapidly and
roughly due to terrain, weather, or even gunre. However, no
backup is likely to be available, and other than portable ultrasound, no follow-up imaging to conrm either chest or endotracheal tube placement. Pain control may be required in
either tactical settings or austere environments; in either
case, capabilities to provide long-term pain management are
likely to be limited. In some cases nerve blocks may be ideal
in dealing with signicant extremity injury, especially in settings when evacuation is likely to be delayed.
Procedures are likely to be performed in less than satisfactory conditions and improvisation may be required. An example is a resuscitation during a SWAT team deployment in
Columbia County, Georgia, in 2006. A SWAT team containing two tactical physicians entered a house of an armed barricaded suspect. Upon entry the suspect produced a handgun
and shot himself in the left anterior chest. The suspect was in
impending respiratory arrest but continued to struggle and
resist assessment and treatment within the connes of his
small bedroom. A peripheral IV was established and the
patient was given etomidate and succinylcholine. However,
during the struggle the IV inltrated and he did not receive
the medications. Additional saline for dilution of the succinylcholine was unavailable and the physicians mixed the last
dose of etomidate with the powdered succinylcholine. The
medication was injected directly into the suspected femoral
vein due to the failure of another IV line. The patient was
bagged and rapidly intubated. Auscultation, however, revealed
no breath sounds in the left chest even after endotracheal tube
withdrawal. The patient’s chest was needled and physicians
proceeded to place a thoracostomy tube. The equipment bag
had been overturned and bedsheets mixed with the equipment. Additionally, electrical power was cut during the raid,
and procedures were performed under illumination of the
SWAT team weapon’s lights. Clamps for blunt dissection to
the ribs and penetration into the thoracic cavity could not be
located. After scalpel incision the physician placing the chest
tube was forced to bluntly dissect with his thumb through the
soft tissue and was able to penetrate through the chest wall,
releasing a large amount of air. The chest tube was inserted
but no needle drivers could be located to suture the chest tube
in place. A utility tool borrowed from a SWAT team member
was used to complete suturing. A latex glove with a nger cut
distally was taped at the end of the tube to act as a Heimlich
valve. A large quantity of chlorhexidine was available and
airlifted and survived to discharge. He required no surgical
intervention during his stay in the hospital.
This example serves to highlight the need for improvisation in tactical and remote conditions. Such improvisation
especially critical in combat zones where patients may have
to be treated rapidly and moved to a more secure location.
Assessment andTesting
Performing point-of-care laboratory testing during prolonged expeditions may be possible in some cases. For most,
the physical examination is the major assessment tool. Even
more than in the hospital environment, the tactical physician
is likely to have a rst-hand understanding of the limitations
of the physical examination, the accuracy of which is being
questioned more than ever [13]. Patients may be severely
injured and unconscious or be in loud environments or unsecured locations. It may be necessary to maintain a covert
position and the use of lighting at night might be too risky.
The portable ultrasound machine is an ideal all-purpose
diagnostic tool and an extension of the physical exam. The
tactical physician will typically use eFAST applications to
search for free uid, cardiac injury, pneumothorax, and signs
of head or vascular injury. In the austere environment of an
expedition, the physician may encounter general medical
complaints and be required to image the gallbladder, bowel,
and pelvis among others. The tactical physician is not
immune to such requirements either. During a large-scale
drug raid in 2005, a tactical physician performed not only
several trauma-related examinations but a lung examination
diagnosing pulmonary edema in one bystander, as well as an
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M. Blaivas et al.
abdominal ultrasound examination revealing a large left
adnexal mass that later turned out to be an ectopic pregnancy
in another bystander. These assessments were necessitated
due to the remote rural location of the raid and the large
curtained- off area that took time to secure.
Conclusions
Tactical and austere medicine both provide a wide variety of
potentially critical ill patient scenarios. The critical difference is the need for a physician to be prepared for combat in
the former. Many of the same procedures performed in a
modern trauma bay or ED may be performed at the patient’s
side in combat or remote areas. With limited backup and
evacuation options such procedures may be life-saving.
Improvisation is critical, and the use of the only imaging
technology available from a pocket or backpack, the portable
ultrasound unit, greatly enhances the providers’ capabilities
and accuracy. With proper training and preparedness, the tactical and austere medicine provider will serve a critical role
in patient care and in turn be rewarded with a unique work
experience few participate in.
Key Notes
• Most procedures available in the trauma bay may be
required in the eld.
• Prepare with intubation and resuscitation medications and uid.
• Few diagnostic tests are available.
• Portable ultrasound greatly enhances the providers’
diagnostic and therapeutic capabilities.
• Improvisation and use of available tools can help
overcome limitations in the eld.
References
1. Solomon SD, Saldana F. Point-of-care ultrasound in medical education–stop listening and look. N Engl J Med.
2014;370(12):1083–5.
2. Rainer TH, Houlihan KP, Robertson CE, Beard D, Henry JM,
Gordon MW.An evaluation of paramedic activities in prehospital
trauma care. Injury. 1997;28(9–10):623–7.
3. Di Bartolomeo S, Sanson G, Nardi G, Michelutto V, Scian F.HEMS
vs. Ground-BLS care in traumatic cardiac arrest. Prehosp Emerg
Care. 2005;9:79–84.
4. Davis DP, Peay J, Serrano JA, Buono C, Vilke GM, Sise MJ,
Kennedy F, Eastman AB, Velky T, Hoyt DB.The impact of aeromedical response to patients with moderate to severe traumatic
brain injury. Ann Emerg Med. 2005;46:115–22.
5. Ryynänen OP, Iirola T, Reitala J, Pälve H, Malmivaara A. Is
advanced life support better than basic life support in prehospital
care? A systematic review. Injury. 2013;44(5):634–8.
6. Blaivas M, Kuhn W, Reynolds B, Brannam L. Change in differential diagnosis and patient management with the use of portable ultrasound in a remote setting. Wilderness Environ Med.
2005;16(1):38–41.
7. Shorter M, Macias DJ. Portable handheld ultrasound in austere
environments: use in the Haiti disaster. Prehosp Disaster Med.
2012;27(2):172–7.
8. Whelan L, Justice W, Goodloe JM, Dixon JD, Thomas SH.Trauma
ultrasound in civilian tactical medicine. Emerg Med Int.
2012;2012:781570.
9. Gay DA, Ritchie JV, Perry JN, Horne S. Ultrasound of penetrating ocular injury in a combat environment. Clin Radiol.
2013;68(1):82–4.
10. Nations JA, Browning RF.Battleeld applications for handheld
ultrasound. Ultrasound Q. 2011;27(3):171–6.
11. Blaivas M, Shiver S, Lyon M, Adhikari S. Control of
hemorrhage in critical femoral or inguinal penetrating
wounds–an ultrasound evaluation. Prehosp Disaster Med.
2006;21(6):379–82.
12. Lyon M, Shiver SA, Greeneld EM, Reynolds BZ, Lerner EB,
Wedmore IS, Schwartz RB.Use of a novel abdominal aortic tourniquet to reduce or eliminate ow in the common femoral artery
in human subjects. J Trauma Acute Care Surg. 2012;73(2 Suppl
1):S103–5.
13. Wipf JE, Lipsky BA, Hirschmann JV, etal. Diagnosing pneumonia by physical examination: relevant or relic? Arch Intern Med.
1999;159:1082–7.
An Introduction toTactical Medicine
Concepts
Military and Law Enforcement Medical
Considerations
WilliamGuse, ShaunCowan, AndrewBeckett,
andKenjiInaba
53
Introduction
Tactical medicine can be dened as medicine practiced in
direct support of military or law enforcement operations.
This typically applies only during tactical operations, however includes aspects such as supporting the team in training,
training the team in self-aid, medical mission planning, and
acting as a medical intelligence source operations.
Tactical medicine grew from research and the recognition that past clinical practice guidelines were not preventing combat deaths. In 1984, Col. Bellamy released his
pivotal paper: “The Causes of Death in Conventional
Land Warfare: Implications for Combat Casualty Care
Research.” His longitudinal retrospective research into
combat casualties and causes of death in WW2, Korea,
and Vietnam demonstrated a trend of preventable deaths;
9% of casualties exsanguinated from wounds to the
extremities, 5% died from tension pneumothorax, and 1%
suffocated from airway obstruction [1]. While law
enforcement and military medical operations have signicant differences in injury patterns, variable operational
assets, and mission priorities, the last decade has demon-
W. Guse
Royal Canadian Medical Service, Canadian Armed Forces,
Ottawa, ON, Canada
S. Cowan (*)
Departments of Surgery and Critical Care, University of Alberta,
Edmonton, AB, Canada
e-mail: cowan@ualberta.ca
A. Beckett
Royal Canadian Medical Service, Canadian Armed Forces,
Ottawa, ON, Canada
Department of Surgery, University of Toronto,
Toronto, ON, Canada
e-mail: andrew.beckett@forces.gc.ca
K. Inaba
University of Southern California, Los Angeles, CA, USA
e-mail: Kenji.Inaba@med.usc.edu
strated lessons and experience of both law enforcement
and military medical care that can be adapted and applied
between the two broad areas of tactical medical operations. These lessons and experience create valuable synergy; however, it remains important to be critical of dogma
and implement medical intervention and care based on
environment-specic evidence when available and with
carefully applied expert consensus when evidence is
scarce.
Military Tactical Medicine: ARecent History
In 1996, Butler etal. released the rst Tactical Combat
Casualty Care (TCCC) guidance. These recommendations
were based upon 2 years of research sponsored by the
United States Special Operations Command (USSOCOM).
These guidelines recommended a scenario-based approach
to casualty care, divided into specic phases, within a
special operations environment. Each phase had specic
skills and interventions recommended, established on the
unique and dynamic realities of combat. This approach to
tactical medicine was calculated to treat preventable
deaths effectively, while maintaining the safety of the care
provider and, further, not jeopardizing mission success.
Interventions and recommendations were conceived with
the understanding of the austere environment, adverse
lighting, environmental factors, limited supplies and
assistance, multiple casualty events, and specic evacuation platforms that make up this particular operational
environment [2].
In 2001, the Committee on Tactical Combat Casualty
Care was established to examine new equipment, procedures, and interventions to integrate within TCCC
Guidelines. As a pan-service mission, the committee’s
members include: medics, pararescue, special operations,
and physicians to ensure a realistic and relevant approach
to tactical medicine. The committee meets regularly to
© Springer Nature Switzerland AG 2025
L. Marshall Gillman, S. Widder (eds.), Trauma Team Dynamics, https://doi.org/10.1007/978-3-031-86312-7_53
457
458
W. Guse et al.
update guidelines on current research and practice [3]. The
TCCC Guidelines are reviewed quarterly and updated as
required, in association with the Joint Trauma System
(JTS), which ensures evidence- based practice guidelines
[4]. The TCCC guidelines have also been part of the
Prehospital Trauma Life Support (PHTLS) manual and
program since their Fourth Edition publication. PHTLS
now publishes a specic military edition of their manual
centering on the more in-depth nuances of TCCC [5]. “The
trauma care recommendations found in the Prehospital
Trauma Life Support Manual carry the endorsement of the
American College of Surgeons’ Committee on Trauma and
the National Association of EMTs, making TCCC the rst
set of battleeld trauma care guidelines to have earned this
dual endorsement” [6]. Tactical Combat Casualty Care has
been adopted by the ABCA (America, Britain, Canada,
Australia, and New Zealand militaries) and the majority of
NATO [6].
The success of Tactical Combat Casualty Care has
been undeniable. Both the 75th Ranger Regiment and
the Canadian Armed Forces have reported an incidence
of 100% application of life-saving interventions in
combat (Fig. 53.1). These units have experienced
greater casualty survival rates than others in recent
conflicts [7, 8].
Fig. 53.1 A Canadian Forces Medic on patrol, equipped for dismounted medical care. (File photo, W.Guse)
Law Enforcement Medicine: ARecent History
While military forces around the world have long recognized the need for medical support on the battleeld dating
back to Napoleon and earlier, where early triage and evacuation concepts originated, the close support of law enforcement operations by medical support personnel is new by
comparison [9]. The civil environment of the United States
in the 1960s saw the development of SWAT or tactical
teams to counter increasing civilian violence; however,
most traditional models used civilian ambulances staged in
a cold (green) zone and were not initially integrated into
forward operations [10].
Early integration of medical provider integration within
police tactical operations occurred in Los Angeles County in
the early 1970s, thanks to the recognition and advocacy by
Cpt. Kolman and Cdr Rasmunoff with the Los Angeles
Sheriff’s Department, where EMTs were integrated within
the tactical teams within the county. Concurrently, a similar
model evolved in Tucson, Arizona, with the Pima County
Sheriff’s Department under the direction of Dr. Carmona
[11]. With the early experiences of these teams to guide discussions, in 1989, conference proceedings discussed standardization of tactical emergency medical support (TEMS)
in the USA.Law enforcement community and annual representation of TEMS within the tactical law enforcement community evolved [12, 13]. This culminated in a position paper
by the National Tactical Operators Association, formally
establishing TEMS as a component of police tactical operations in the USA in 1993 [14]. In 2001, the National
Association of EMS Physicians endorsed the TEMS concept
through their own position paper recognizing the need for
specialized tactical medical providers in law enforcement
operations [15].
The above is a brief overview of several key historical
points in the development of TEMS.Many others have contributed to the development and growth of tactical medical
support systems over the past three decades since the original NTOA position paper and formalization of TEMS standards and utilization. The concurrent domestic experiences
of these units, coupled with the lessons learned from military
special forces medical support have resulted in synergistic
growth in TEMS utilization, as well as the recognition of
specialized training and experience needed for these medical
providers in law enforcement operations. Bridging these
synergistic relationships between military and law enforcement medical elements and promoting research in these
areas, the Special Operations Medical Association (SOMA)
brings a formal collective body of shared experience and
research [16]. Training and experience are needed in a multitude of spheres to develop a competent and reliable tactical
medical operator. Team tactics, weapons and less lethal
munition knowledge, tactical communications, hazardous
53 An Introduction toTactical Medicine Concepts
459
materials safety, and many other aspects comprise the tactical training required; however, this is only but a single pillar
in developing an individual tactical medical operator.
Training and experience in the unique aspects of medical
care in hostile and austere environments, remote assessment
and medicine across the barricade, medical intelligence,
sports medicine, and leadership are also critical elements
beyond civilian EMS or medicine training required for a
well-trained tactical medical operator.
An Approach toTactical Medicine
Much like the doctrine of Advanced Trauma Life Support
(ATLS) programs gives an approach for civilian trauma care,
the phases of care in tactical medicine, including an algorithmic
approach within each phase, guide appropriate care as dictated
by the environment and tactical situation. Similar to planning
for a thoracotomy in the radiology department is not optimal,
obtaining vascular access or placing a patient in spinal motion
restriction in the middle of a tactical situation or kinetic operation are equally, if not more egregious, errors in medical decision-making. An often repeated dictum of tactical medicine
outlines that good medicine often equates to bad tactics, and
good tactics may not allow the best medicine to be practiced at
the time. The understanding of this intricate balance is a key
skill, which any medical provider in a tactical environment must
master in order to allow sound critical thinking and safe decision-making in a dynamic tactical environment.
Tactical operations fall into two categories primarily,
upon meeting engagement or planned operations. An example of met engagement is the police ofcer who comes under
re during a trafc stop or a unit of soldiers who trigger an
Improvised Explosive Device (IED) while on routine patrol.
Resources available during this type of incident are limited
to individual or small unit organic skills and supplies.
Planned operations, by comparison, include the following
examples: a Law Enforcement tactical team raiding a known
criminal location with prior reconnaissance or surveillance, a
Special Operations team boarding a target ship underway, or
an Army combat team conducting an organized counterinsurgency sweep. Since these operations are planned,
rehearsed, and executed with a command and control structure, greater assets are available to the operators on the
ground as well as pre-stage assets, including medical and
evacuation planning and assets.
Phases ofCare
In most common doctrine, tactical medicine is divided into
three phases of care. The rst phase occurs when an active
threat is still ongoing. This is commonly referred to, within
military circles, as Care Under Fire. It is abbreviated as CuF.
Law Enforcement teams may use different terms, such as
Direct Threat Care (DTC). DTC can also be dened by operational zones. These zones include cold (green), warm (yellow), and hot (red) zones, with CuF being comparable to the
hot (red) zone. An example of this includes an active gun
ght or a planned assault on an objective. In the CuF phase
of care, the best medicine is prevention of additional casualties and rapid control of exsanguinating hemorrhages, primarily, tourniquet application. The doctrine of this phase of
care centers around winning the ght and eliminating the
threat to prevent additional casualties. Self-extraction of conscious, capable wounded casualties, self-application of tourniquets, and then in specic circumstances, application of
tourniquets to casualty are the only medical treatments
included in this phase of care.
Tactical eld care (TFC) is the second phase of care, referenced in Law Enforcement, as Indirect Threat Care (ITC),
the yellow zone, or the warm zone. This phase is when the
majority of eld medicine occurs. Conceptually, a threat still
exists, although it’s either controlled, not active, or sufcient
hard cover exists, while medical treatments are being rendered. In order to provide security, control, and efcient use
of resources, casualties are collocated in a Casualty
Collection Point or CCP.Casualties will likely be moved to
this location using drags, carries, and improvised means. In a
military setting, the majority of care done before the casualty
is moved to the CCP is completed by soldiers or troops specially trained in Tactical Combat Casualty Care. Once moved
to the CCP, this may be the rst time that they are treated by
a medic. Depending on the law enforcement agency and
operational structure, arrival at a CCP may be the rst time
that casualties will be seen by a medical professional as well.
A paramedic, doctor, or both could be in place depending on
the team structure and source of medical support members.
Regardless of team structure, in military or law enforcement
settings, Tactical Field Care is the care provided in active
areas of operation when the threat is controlled, often to variable degrees, resulting in dynamic and nuanced shifts
between care under re and TFC approaches. The response
to the Boston Marathon Bombing is an excellent example of
Indirect Threat Care within a civilian setting, where the
attacks and injuries had occurred, but the threat of additional
bombs or attacks was not contained while medical care was
being provided.
Tactical Evacuation Care (TEC) is the third phase of care
and includes the medical therapies and treatment modalities
rendered during the evacuation of a casualty from the point
of injury to some level of medical treatment facility.
Remember, in an austere military setting, this phase allows
more medical assets, both advanced equipment and advanced
providers, access to the patient depending on the evacuation
platform. Helicopters and armored ambulances are reliable
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W. Guse et al.
platforms in most military scenarios. In a Law Enforcement
operation, this is simply referred to as Evacuation Care.
According to the triage done onsite, Advanced Life Support
Paramedics in traditional wheeled ambulances or helicopter
transport can be brought into play at this time with evacuation to an appropriate trauma center.
immature operational settings, a fourth phase of care comes
into play. Prolonged Field Care is now being considered a
fourth phase of care, where the evaluation phase is delayed
for tactical, geographical, or limited resource reasons. The
general concepts in prolonged eld care mirror many of the
principles associated with wilderness medicine, critical care
medical, and nursing care.
The MARCHE Algorithm Approach
Combat injuries historically attribute 9% of casualties exsanguinated from wounds to the extremities, 5% died from tension pneumothorax, and 1% expired second to airway
obstruction discussed above [1]. The MARCHE algorithm
(Table53.1) was initially set up to address Col. Bellamy’s
report on preventable deaths rapidly with follow on stabilization and precautionary interventions implemented later in
the protocol [2]. As the tactics, techniques, and technology
of tactical medicine evolved, the MARCHE algorithm continues to be updated by governing bodies based on best practices and novel medical devices [3, 17]. Programs such as the
American College of Surgeons “Stop the Bleed” program
have simplied protocols for the trauma layman but maintain
the principles of MARCHE [17, 18].
During CuF or DTC, the only indicated interventions
include tourniquets and, when feasible, recovery position,
dependent upon the tactical situation. Extremity hemorrhage
and simple airway interventions are the only acts safe enough
to be performed rapidly in active combat [17].
There are tactical considerations and actions a tactical
medic must undertake outside the MARCHE algorithm that
must be performed prior to any medical intervention. The rst
consideration is securing a safe location to collect and treat
casualties. This was discussed previously as the establishment
of a Casualty Collection Point. Casualties with an altered
mental status must be disarmed for the safety of providers.
Additionally, communications, lighting, and explosive equipment on these casualties must be either removed or turned off
to further secure casualty, provider, and team safety and security. Triaging casualties as they enter the CCP should be completed rapidly to identify those that most urgently need and to
organize the CCP for efcient follow on care.
Table 53.1 MARCHE approach to tactical eld care (TFC) and common interventions
Tactical medicine: MARCHE approach to casualty management
Interventions
M—Massive hemorrhage Tourniquets
Wound packing
Hemostatic gauze packing
Junctional tourniquets
A—Airway Positioning
Basic airway adjuncts
Supraglottic airway
Surgical Airway
R—Respirations Chest seals
Needle, nger, and tube thoracostomy
Positive pressure ventilation
C—Circulation Non-massive bleeding control
Vascular access
Blood and uid resuscitation
Tranexamic acid
Pelvic binder
H—Hypothermia and head injury Cooling prevention
Active warming
Hypoxia and hypotension prevention
Hypertonic saline
E—Eyes & everything else Monitoring and documentation
Pain management
Antibiotics
Secondary survey
Management of other wounds
Nursing care
53 An Introduction toTactical Medicine Concepts
461
Massive Hemorrhage Management (“M”)
Tourniquets
Traditional methods of direct and indirect pressure are
used as a temporizing measure in MARCHE. The preferred method of gaining hemorrhage control for extremity injuries is tourniquets, with windlass and ratchet styles
of tourniquet preferred. Elastic-based tourniquets are not
recommended [19, 20]. It is recommended that commercially available tourniquets be used rather than improvised tourniquets (Fig.53.2). Studies have demonstrated
that non-windlass improvised tourniquets fail to control
extremity hemorrhage in 99% of tests consistently. While
windlass improvised tourniquets are more effective in
controlling extremity hemorrhage, there is still a 32%
failure rate [21, 22].
Wound Packing
For ballistic or blast injuries with deep wound tracts or junctional injuries (i.e., groin or axillary injuries), wound packing is recommended to gain direct pressure along the wound
tract. The packed wound should then be covered with a pres-
sure bandage or closed with a hemostatic clamp [20].
Effective wound packing is a key hemorrhage control skill
for tactical medical providers and is critical to effective use
of most hemostatic dressings.
Hemostatic Dressings
With uncontrollable hemorrhage in wounds not amenable to
a tourniquet, there are a few options available. Hemostatic
packing materials, such as QuikClot Combat Gauze, Celox
Rapid, or HemCon ChitoGauze, can be used to gain control.
While they have different mechanisms of action, they are
generally applied using wound packing with gauze [23].
While lab data is favorable for the use of these agents for
massive hemorrhage control, there is a lack of human data
supporting use of hemostatic agents over regular gauze
appropriately packed for bleeding control. Direct clinical
translation of this data has not been studied, and given the
dynamic and diverse environments, users and injury patterns,
may never be well studied. The use of hemostatic dressings
in tactical environments is nonetheless widespread but
should be considered for use with consideration to cost,
expiry, and frequency of use [24].
Fig. 53.2 Tourniquet training with coalition forces. (File photo,
W.Guse)
Junctional Tourniquets
Junctional Tourniquets, such as Abdominal Aortic and
Junctional Tourniquet, Junctional Emergency Treatment
Tool, and SAM Junctional Tourniquet, can be used to gain
hemorrhage control. Junctional tourniquets have been demonstrated to be simple and effective with the ability to be
applied rapidly in multiple studies [25, 26]. They are, however, cost-prohibitive and require additional training and
ongoing skill practice for effective and rapid use.
Airway Management (“A”)
Once massive hemorrhage is controlled, at least temporarily,
focus shifts to the airway. In conscious casualties that can
follow directions, simple positioning can be used to manage
the airway. Positioning can also be used as a temporizing
measure for casualties prior to the use of airway adjuncts.
The lateral recumbent position commonly referred to as
recovery position for unconscious casualties or sitting or tripod position for chest trauma or maxillofacial injuries has
been used effectively and is often a position of comfort for
these patients. A high index of suspicion is required for any
casualties with blast exposure or enclosed space res as the
airway can rapidly deteriorate due to edema from superheated gas exposure.
462
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Limiting airway intervention to basic adjuncts is preferred
in the tactical environment. Simple manual airway techniques including a chin lift or jaw thrust maneuvers to allow
inspection, manual sweeps of oral pharynx and suctioning,
when tactically feasible, are the initial standard of care. The
routine use of orotracheal intubation is not feasible in an
operational environment when considering adverse lighting,
equipment required, monitoring, and provider skill fade. For
unconscious casualties with no impending airway collapse,
the nasopharyngeal airway (NPA) is recommended as it is
well tolerated and requires little monitoring [3]. With casualties with impending airway collapse, supraglottic airways
are the next step, when tactically feasible, for their ability to
be inserted blindly and simplicity of insertion facilitate rapid
airway management. Any supraglottic airway that uses an
air-lled cuff needs to be constantly monitored to avoid overpressurization and ensure continued placement, especially in
the context of pressure changes in aircraft evacuation or
changes in altitude. The CoTCCC specically names the
I-gel™ as the preferred supraglottic airway. The gel-lled
cuff is simple to use, decreases the requirement for monitoring, and avoids the dangers of cuff over-ination [27].
In the event of failure of the aforementioned interventions, the surgical airway is the next recommended intervention when appropriately trained providers are available. An
open surgical technique, with or without bougie, is preferred
in the austere environment. This procedure relies upon tactile
guidance and landmarks, allowing use in low or no light conditions. There are multiple prefabricated kits available on the
market or a trimmed 6.0 ET tube can serve as an improvised
cricothyrotomy tube. Early use of the awake surgical airway
is recommended in patients with severe maxillofacial trauma
and casualties with signs of inhalation injuries. This can be
facilitated via local and transtracheal administration of local
anesthetic [28].
All casualties with airway adjuncts or surgical airways
should be monitored using pulse oximetry to ensure adequate
oxygenation and end-tidal carbon dioxide monitoring via
colorimetric, or ideally, capnographic devices. The use of
supplemental oxygen is best deferred to the evacuation phase
for a number of reasons. Operators involved in tactical operations, as a rule, are very healthy individuals and, therefore,
have a large physiological reserve. Delivery of oxygen (DO2)
is a function of cardiac output (CO), hemoglobin (Hb), and
its saturation (SaO2) and, to a much lesser extent, dissolved
in plasma (PaO2).
CO Hb Sa
By maintaining hemostasis, cardiac output is stabilized
which has a direct effect on arterial oxygen concentrations.
Aggressive hemorrhage control and IV blood products are
most effective in maintaining adequate perfusion in these
patients. Additionally, oxygen tanks are explosive if pene-
13
003
aO
2
trated by projectiles, a real risk in combat environments. It
would be akin to carrying a bomb on one’s back. The current
technology for miniaturized oxygen concentrator is not
robust enough for an operational environment.
In both law enforcement and military settings, supplemental oxygen should be available on evacuation platforms.
Supplemental oxygen is recommended during the evacuation
phase, especially when at high altitude or aerial platforms
are used [29].
Respiration (“R”)
Any penetrating injury to the thorax should be covered by a
vented chest seal. A non-vented chest seal can be used as an
alternative but carries an increased risk of developing into
tension pneumothorax [30, 31]. In some cases, maintaining
an open thorax may be prudent to avoid tensioning the thorax; monitor and “burp” the chest as required. Due to the
unpredictable wound tracts of ballistic injuries, it is generally accepted that any wound from the umbilicus and superior should be managed as though there is thoracic
involvement. For multiple penetrating chest injuries, the
vented chest seal should be applied to the largest defect,
and occlusive dressings are appropriate for the remaining
wounds [27].
In ballistic or blast injuries, maintain a high index of suspicion for tension pneumothorax. Severe/gradual respiratory
distress or tachypnea, unilateral decreased or absent breath
sounds, decreased O2 saturation of less than 90%, shock or
cardiac arrest without obviously fatal wounds are the wellknown symptoms. However, it can be as insidious as progressively worsening mental status in a seemingly uninjured
casualty after a blast exposure [27].
Casualties with suspected tension pneumothorax should
be decompressed using a 10–14 gauge 3.25″ catheter unit at
either the fth intercostal space on the anterior axillary line
or the traditional second intercostal space in the midclavicular line by a trained provider [32, 33]. Additionally, for
advanced trained providers, a simple nger thoracostomy
can be used on the fth intercostal space on the anterior axillary line [34–37]. A traditional tube thoracostomy can be
completed in TFC/ITC as well, with a simple duckbill oneway valve (Heimlich valve) inserted on the distal end of the
chest tube to prevent air reentry and promote one-way ow
out of the thorax. During the evacuation phase, an appropriate drainage management system should be attached. For
casualties with severe torso trauma or blast injury and vital
signs absent (VSA), a protocol for triage of potentially salvageable patients should be established, considering signs of
life such as pupil response and downtime. A protocoled set
of actions including bilateral thoracic decompression is recommended before discontinuing treatment [27].