Yesterday I attended the 17th Annual Rao R. Ivatury Trauma Symposium hosted by VCU Health. I took away multiple “nuggets” to incorporate into both my prehospital and ED practice. The conference is geared towards anyone taking care of trauma patients – not just doctors but nurses, social workers, nutritionists, therapists and EMS providers, too. I highly recommend checking it out next year. Save the date: Wednesday, March 29, 2017.
Always a leader in EMS advancement, members of the Richmond Ambulance Authority (RAA) presented a poster on delivering “Good Medicine in Bad Places.” To the credit of RAA, they have developed a council with their partners in Police and Fire, to address regional response needs to unique and dangerous situations (i.e. active shooters, bombers, terrorist attacks). The data they presented is accurate – the number of incidents is rising, and the fatalities climbing.
Tactical Combat Casualty Care (TCCC) is specialized training that originated in the military. TCCC is currently being tested and studied in the civilian public safety setting. The TCCC conversation is an important one. Specialized training for these situations is an unfortunate necessity in the United States. A little background info on how these things are currently handled – most cities have specialized SWAT Medic teams comprised of talented, elite individuals adept at not only the delivery of prehospital medicine, but also in things like shooting, hand to hand combat and law enforcement. These providers are a special breed – in most cases considered the best of the best in their public safety organizations. I’ve been hearing the rumble and chatter over the last year, and it was again echoed by RAA yesterday. There is current shift in conversation towards training 100% of EMS providers to enter the warm and hot zones, to render care to patients while under fire.
It’s well known and proven that the current model of Fire/EMS waiting to enter scenes causes treatment delays that increase patient morbidity and mortality. In the December 2015 issue of the Journal of Emergency Medicine, Peter Pons of the Hartford Consensus commented that “fire/rescue and EMS personnel must work with law enforcement agencies to enter these scenes earlier than has been traditionally performed, intervene promptly to stop ongoing external hemorrhage, and incorporate basic concepts of tactical combat casualty care/tactical emergency casualty care into their education, training, and practice.” I don’t disagree with that, but I’m not sure it makes sense for us to immediately assume ALL Fire and EMS personnel should be entering scenes with active shooters – as if it’s simply one more bullet point we can just tack onto the job description.
If you think about our existing public safety system, some firefighters enjoy both patient care and fighting fire, while others if given the choice, would only ever fight fire. Similarly, some Fire and EMS providers might be part cop/soldier at heart – both capable and interested in taking on TCCC. I can assure you that not everyone on an ambulance has that police/soldier side that wants to run into an active shooter scene. Yes, EMS is a dangerous job; I’ve been punched and had a knife drawn on me in the back of the ambulance (no one tell my Mom please). Of course you can never predict what may happen and need to be ready for anything. That’s not what I am talking about in this instance. What I’m saying is that if a call goes out for an active shooter, it might not be wise to require 100% of the Fire and EMS personnel to be able to enter that active scene. Here are just a few reasons I think that could be a bad idea.
Negative Effects on Recruitment
As I mentioned, not all EMS providers want to take on the police/military type role of being armed with a weapon, entering dangerous scenes and providing care under fire. I don’t know how big of a chunk of people that is, as it hasn’t been surveyed yet to my knowledge. I can say personally, having been in a building with an active shooter, I have zero interest in doing so again, even with the most state of the art training. How many of the 840,000 certified EMS in the US might we lose if that bullet point gets added to the job description? Additionally, 22% of those 840,000 certified EMS personnel are volunteers. Some volunteers might want to play a part in TCCC, but if you have a family and derive no paycheck or medical benefits from your volunteer EMS gig, can you really afford to enter that scene? And what will become of all the career providers who want to do patient care, but don’t want to risk their lives. Perhaps we will we see them shift into the hospital in ED Tech, CNA and RN roles.
Distraction Away from the Medicine
Even right now, EMS education has two large components: 1) the medicine, taking vital signs, deciding what drugs to give and when and 2) operational aspects, entering a scene safely, driving an emergency vehicle, operating a portable radio, etc. As an ED Physician, I admit my bias towards the importance of #1. We’ve all had the trainee who wants to drive lights and sirens before he’s mastered taking a blood pressure. With only ~160 hours of instruction in the current NREMT course, I worry that adding the required training for TCCC will shift focus away from the medicine and negatively impact patient care, potentially leading to more morbidity and mortality across all patients, improving outcomes for those victims requiring TCCC, but leading to a net decline in overall care. Perhaps the solution will be increasing the course length. I’m not saying it can’t be done; I just hope someone studies and considers that before implementing blanket curriculum changes.
Are EMS Providers Physically Fit Enough?
Sadly, three quarters of active emergency responders in the US are overweight or obese, and 75% have been diagnosed as hypertensive or prehypertensive. All in all, we are not a healthy bunch when compared to our counterparts in Police, Fire and the military. How many EMS providers will meet the physical demands required for TCCC? Even if people want to take part in TCCC, will they meet the physical requirements to do it safely, or perhaps be pushed out of a job they love, despite providing excellent medical care.
Would it actually improve care?
To justify the risk associated with TCCC, you must be able to prove that more lives would be saved than lost, and not just during active TCCC situations, but across prehospital care as a whole. It just hasn’t been studied yet. Perhaps once studied, it will prove to be net beneficial, but right now we just don’t know.
So those are my thoughts; I’m curious to hear yours.
~Steph
TeamLouka 
love to chat about this with you sometime
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Ditto. But how can I reach you?
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Perhaps you need more understanding of TCCC and The Rescue Task Force Concept and get the feeling of Ems
outside of Virginia. The undertone of your article seems to be bashing the TCCC concept without full understanding .
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I understand TCCC. It’s one specific training course in tactical medicine. What’s concerning to me is that the chatter is to alter/expand/modify it to require 100% of EMS providers to be ready, able and willing to enter warm and even the hot zone depending who you talk to. TCCC is important and effective for those that want/can execute it effectively. I’m not bashing the TCCC at all. There’s plenty of evidence it works.
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So – maybe we should start by using the right vocabulary. (Full disclosure: in addition to being a cross trained police/paramedic assigned to SWAT, I went to law school and strongly believe that words matter.)
The military uses TCCC, stateside we use TECC. And no, it’s not just a rebadging of the same stuff. Similar enough to be siblings, but not identical twins.
– TCCC supposes that all the GoodGuys are trained. TECC recognizes this is a response to a mostly untrained lay community.
– TCCC is designed for 18-35 year old people who got a 90 or better on their last physical fitness test. TECC thinks about patients who are unfamiliar with the word “treadmill” and take 3 different anticoagulants to keep their blood in a liquid state.
– TCCC providers are all armed at every step of the way. TECC recognizes that some people are armed with low medical training and those with more medical training are less likely to be armed.
– TCCC says “if it’s good biology, have at it” and trains 19 year old Lance Corporals to decompress cheats. TECC understands that scope of practice and tort law can influence what care happens where and by whom.
It’s not “just semantics” – TCCC and TECC are not the same thing.
Thanks.
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You have some very interesting points but I so think you may be misinformed about care at the point of wounding. Rescue Task Force should NEVER be in the hot zone and they don’t operate alone in the warm zone either. Spot on about fitness though. I also disagree that the training shouldn’t be required. TCCC/TECC is useful on everyday calls. I constatnly get follow ups stating, “I was able to integrate TCCC into my last trauma and it made a huge difference!” Being an RTF medic should be voluntary. There are plenty of jobs to be done outside the warm zone.
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Thanks for your comment Chris. I may not have been clear in my writing. But I think TCCC is extremely valuable, and everyone should have some level of familiarity and training in tactical medicine. What I’m concerned about is requiring it of all EMS providers when many might be incapable or unwilling to execute it.
And regarding warm vs hot zone, there is chatter here locally that includes EMS entry into the hot zone. I’m unaware of anyone who has implemented it yet, but even the mention of it raised quite a few questions in my mind (hence me writing the post). Thanks for taking the time to read it.
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I would be scared too since VA is kinda of the model for RTF. Talk to Arlington County FD, they pretty much wrote the book. RTF has no business in the Hot Zone. I would direct whoever you heard spouting that to http://www.c-tecc.org to talk with the many subject matter experts. Probably just needs some education.
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Anyone else find it funny the SWAT medic/Lawyer guy who says “words matter”, Yet, talks about “Lance corporals decompressing “cheats”.
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Haha. You got me..but your quote within a quote is missing a close quote.
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Mongo thumbs small phone keyboard. I’m lucky autocorrect didn’t totally jack that up either.
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Steph, Thanks for your article! I am the program director for a tactical medicine program of a municipal police department in Southern California. Together with our medical director and SWAT team physician, we provide tactical medicine training for police officers (not solely SWAT cops) in our region. The program is based upon the concepts and principles of TCCC and is focused upon the treatment of the leading causes of preventable death in austere environments.
As of late, we’ve been doing a substantial amount of active shooter training in our region. Together with our first responder partners in the fire/EMS service, we’ve been working diligently on the coordination of warm zone operations between law and fire resources. Our response model involves law enforcement resources providing force protection for EMS resources, forming Rescue Task Force (RTF) elements, and together going downrange in the warm zone to treat and triage casualties. In our region, Hot Zone operations where the threat is direct and immediate are still off limits for fire/EMS resources as they are generally unarmed and have no way to effectively protect themselves. It’s on us (law enforcement) to be self-sufficient and provide effective pre-hospital trauma care in environments where traditional EMS cannot or will not provide medical support. Hence, the reason for the development of our tactical medicine program.
I can’t help but wonder if the push for EMS participation in hot zone operations is a regional issue that you’re experiencing. I know from my travels in this area that it certainly is not being pushed as a national model and is contrary to industry standards and best practices. Here’s a link to the UFF Position Statement posted by the National Fire Protection Agency (NFPA) on the issue:
file:///home/chronos/u-bd5124435954bdde764fd086f30c5958b5e31a8f/Downloads/UFFActiveShooterPositionStatement.pdf
and the US DHS FEMA Fire/Emergency Medical Services Department Operational Considerations and Guide for Active Shooter and Mass Casualty Incidents:
Click to access active_shooter_guide.pdf
You will not find either document that advocates Hot Zone operations for fire/EMS personnel on a national basis.
Best,
Tony
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Tony, thanks for the great info. Will definitely read further. I agree with everything you said. My alarm bells just went off when more than one person is now talking about EMS in the hot zone. Perhaps it is just regional. It’s good to know there are already some direct policy statements out there.
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So…as someone who has spent the better part of the past 6 years teaching the concepts of TECC and Rescue Task Force to first line EMS providers, maybe I can help clear up a couple of things.
1: We don’t encourage any unarmed/unarmored personnel to enter any hot zone, but we also know that the world is a dynamic and complex space, and things that the “heat” of a call can suddenly jump from cold to roasting hot. Best to be prepared and schooled up on what to do/how to do it when the time comes.
2: Part of the Rescue Task Force idea is that – like other parts of EMS – it’s a system. A big piece is teaching the police what is really a life threatening problem and what can bunker down and wait while they go about solving the tactical problem. That understanding between agencies allows collective decisions on risks & rewards.
3: Take that nonsense that EMS providers only operate in cold/safe zones and throw it in the garbage. It just isn’t true.
3a: Patient A: 45 year old male, 200 pounds, on the third floor, dislocated knee. We are moving that guy slow and easy down the stairs, using our training and equipment to hedge the bet against the dangers of moving someone. Same patient, but he is asthmatic, respirations 50 and barely audible, and his 3 children under 10 are in the room – everyone reading this is taking a little extra risk to get that guy down those stairs. Why? Because we make judgment calls and balance risk and reward every day. Knee Guy isn’t going to die so I’m not risking much for him, but Asthma Guy is definitely going down the drain, so I will.
3b: Overturned car, same 45 year old guy with a broken wrist and some legit neck pain. I’m letting Fire or Rescue crib that car until it looks like Home Depot threw up on it. Put a 7 year old with an unstable airway in the back seat and I’m going to let them crib that car a little so it won’t roll on us and I’m getting my butt in there. Again, so is everyone reading this. Why? Because we balance risk and reward, and sometimes we have to use the assistance of another agency or service and their training and equipment to make an area safe enough to work. Mr. Neck Pain will be fine while we wait, Airway Kid will die. EMS should – and does – powwow with Fire/Rescue to make good judgments calls to save lives.
Violent scenes are the same: No one is suggesting we send EMS personnel charging into gun battles, but when the police have fought it out and made that BadGuy dead, fled or possibles and they have the ability to meaningfully categorized victims as patients who have life threatening injuries or not, the two agencies can and should work together to hedge bets and stop the dying.
I’ll give an example: recently in my capacity as a police patrol sergeant, I responded to a residence where a complex domestic dispute had occured. Mom, Dad, 20-ish kids were all squabbling, and in the process Grandpa had some chest pain. Police officers on the scene separated the various parties and we called the medics to stage about a block off. In a matter of moments, Gramps went from pink to pale to grey and began a loud cardiac wheeze. Posting one cop at the front door with line of sight to the next cop who had line of sight to a cop in the doorway to Grandpa’s room, we basically set up a “warm corridor” to get the medics into this very sick – and getting sicker – man. Did the police “own” the whole house? Nope. We hadn’t thoroughly searched every kitchen cabinet or even fully frisked every subject in the house, but we were confident we had a pretty good handle on it and it was “cool enough” to bring in some medics who are professional heads-up, squared away, dialed-in, switched-on or whatever euphemism you like.
In my home county I’m confident in our medics because I know we train them on seeking cover, staying off walls to avoid frag, not to tarry in fatal funnels, pulling wide-view angles and a bunch of other basic movement tactics. And several times a month we send cops and medics to drill together on integrated movements, so that everyone gets it once a year.
And 4: When these “never” events happen, EMS is going to deploy. We can choose to think about how we want to do it and do our best to come up with some ways to do things safely now, or we can just wing it and come up with a plan on the fly when it happens. I think we all know how well each of those two options works out.
*These views are my own, and they do not represent the official positions of my employers. Thanks.
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I think this comes back to the age old argument of whether EMS is a public safety entity that enters the clinical realm of medicine (interface of medicine and public safety operations), or a healthcare delivery and transportation service.
The strong reality of our current world, and that of the foreseeable future dictates that we must be able to face the challenges these outside forces to our industry, impose. Basically, we need to evolve our practice. If you think we are a public safety entity primarily, which full integrates clinical care into a unique operating environment (including that of a day to day field provider, which we already do) then you see the necessity for being ” all hazards” trained, not specialists per se but adaptable prehospital clinicians. In regard to active shooter or terrorist incidents, in most jurisdictions the early and major response will be from units deployed on the street, not tactical or task force units which need to assemble.
If you see EMS as strictly the practice of clinical medicine outside of the hospital environment, you will wait in a “safe” casualty collection point awaiting casualties to provide care. Much like an ED staff that has activated its external disaster plan.
I think the question to be asked is how does our hybrid purpose fit in and are we to the point where we have plateaued in clinical development and need to shift to a much forgotten operational purpose?
Maybe we need to change our standards to meet these goals both in fitness ( no idea how fitness, even in the current state, is thrown by the wayside) and hiring standards and education.
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Hi, do you have an email address, we have addressed this problem somewhat and it would be good to hear your views.
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Here in the UK we have set up regional HART (Hazardous Area Response Teams) in Scotland SORT (Special Operations Response Teams) these are teams of Paramedics sat waiting in each geographical area of the U.K for a major incident. They perform a range of duties:water rescue, rescue from heights, chemical incidents, decontamination, and shooting major incident type events. They wear body armour helmets flame resistant suits and carry bullet proof shields. The aim is to move behind SF/ police and perform the minimum life saving interventions for the maximum people. So NPA, tourniquet, blast bandages etc and of course triage the patient. These paramedics have volunteered to become part of these teams and are sat ready 24/7 at various locations throughout the UK.
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I read your commentary with great interest. It is critical that all understand the full intent and import of my comments in the article that I wrote. At no time did I suggest that EMS and fire personnel enter an active shooter scene while active shooting was still occurring. What I said, which you quoted accurately, is “fire/rescue and EMS personnel must work with law enforcement agencies to enter these scenes earlier than has been traditionally performed, intervene promptly to stop ongoing external hemorrhage, and incorporate basic concepts of tactical combat casualty care/tactical emergency casualty care into their education, training, and practice.” The traditional response to a situation such as this has been that first responders and EMS personnel stage at a safe location until such time as the scene has been declared “safe” for them to enter. In most cases involving active shooters, this has meant a prolonged delay, in the delivery of medical care until law enforcement has completely cleared whatever location was involved, even though the actual incident shooting have long been over.
What we have accepted is a completely “no risk” entry into the scene for EMS. In my opinion, what we need to consider is more of a “managed risk” entry into the scene for EMS. The concepts of TCCC/TECC clearly identify phases of care based on the existing threat. We have traditionally only had EMS involved in the “evacuation care” phase. I believe that we instead should be looking to have EMS involved in the “tactical field care” or “indirect threat care” phase when the threat has been contained or initially neutralized. And, no, I am not advocating for EMS to enter a “hot zone” or be part of the “care under fire” or “direct threat care” phase.
I also am not advocating for arming EMS. Instead I think we need to have much more of a cooperative team approach and not the sequential approach that has been the typical response paradigm. The rescue task force concept of teams (contact team of law enforcement to engage and stop the killing, casualty search and rescue team that combines law enforcement with EMS and enters subsequently to address critical life-threats in the wounded) makes tremendous sense to me and is what I believe we should now be working towards.
The only thing more tragic than a death…is a death that could have been prevented.
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Dr. Pons, thx for your comment. I agree completely. My concern which I may not have articulated well is that people are taking the TCCC concept and discussing pushing the model further and sending EMS into the hot zone. I also agree that in some cases we’ve swing so far the other direction to overstaging. “Patient complaining of dyspnea but with psych hX” so we stage an extra 5-10 minutes awaiting police clearance.
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The Rescue Task Force concept that is deeply routed in TCCC is for warm zone ops. HOWEVER, we train in TCCC and Rescue Task Force about Hot Zone ops in the event that a team transitions to a contact team (and shelters EMS) or when any scene suddenly becomes violent. The idea is not to enter a hot zone, but prepared if your scene suddenly becomes one. It is important to train a mentality of “any scene can become a hot zone”.
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Here in the uk we are trying to move away from the risk averse culture and manage risk. Using any intelligence to target the right areas for EMS moving fast but safely….however this is a problem itself as speed reduces safety but too much safety reduces speed. Our teams utilise drills to move through areas with shields triage casualties and minimum life saving interventions move on, any lull is used to evacuate and restock. This is physically demanding work, very physical and very labour intensive. Walking wounded should be directed to safe zones via safe routes …there are many questions to be answered, do we clear rooms? Do we mark rooms with casualties or drag casualties to the door …do we treat EMS / SF / Police differently or do they get treated in same priority as civilians? How much kit do we carry and what kit, …do we need more advanced kit in case we get marooned with a patient and need more longer advanced care or is this a waste when just trying to do the minimum for the most? How do we evacuate …..how do we move forward behind SF / police how far behind? A safe tactical bound or longer? What about kit dumps? Emergency RV points if the area becomes dangerous. ..man down procedure? What about reinforcements, use of vehicles and resupply? How long can EMS work effectively in this environment without becoming so tired safety is compromised? DO paramedics become task orientated and lose situational awareness..? Do we routinely search casualties for suicide vests or weapons? Do we have the power to do this? O we search for casualties or look for battle signs and if non move on to the next room..We have our own answers to these questions but probably not good putting all the answers out on this forum. But points to consider..! If anyone would like to chat about this please contact me, I teach this ..
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Your article is spot on.
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The model in Richmond is different to other localities. There is no intention to create EMS based medics as hot zone working, cammo wearing, sworn, black tinted window suburban driving SWAT Medics. The RAA/RPD system, is to train Police Officers who are a. Sworn trained LEOs and SWAT operators and b. EMTs or Paramedics. They work the scene and then hand back to EMS awaiting handover in a staged and safe place.
The SWAT medics are infact contracted non paid employees of the RAA in order to allow them to work under the licence of the RAA OMD ( as a result of a MOU signed by Chiefs of RAA, RPD and the OMD). This model is seen as progressive and the right way to go.
The TCCC faculty has generated Both TCCC and TECC trained staff. A cadre of instructors has been developed to continue the training which is, by the way superbly done. Having viewed the training many times now it is emphasized again and again that a SWAT medic in the hot zone this course does not make.
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