Local police and fire departments often respond and work together in a variety of incidents. This joint response is becoming all too common with the current increase in the number and magnitude of “active shooter” events.

Recent events such as the Aurora movie theater shooting, the Sandy Hook Elementary School tragedy and Santa Monica campus shooting underscore the increasing concern in the fire service over active shooter attacks by terrorists armed with weapons in public areas, such as schools, shopping malls, churches and other places where large numbers of people congregate. These events typically involve one or more suspects who participate in ongoing, random or systematic shooting sprees or other violence with an intent to harm others and result in mass casualties.

On April 2, 2013 the Department of Homeland Security and the Federal Bureau of Investigation, in cooperation with the International Association of Fire Chiefs (IAFC) and the International Chiefs of Police, convened a meeting to address, “Responding to Mass Casualty Shootings – Strengthening Fire/Law Enforcement/EMS Partnerships.” The International Association of Fire Fighters (IAFF) and the Fraternal Order of Police also participated in the meeting.

Based on the proceedings of this meeting, there is a real and present threat and an obvious need for all organizations involved to work together when confronted with an armed individual who has either already killed and injured people or is threatening to do so.

In light of recent events and the nationwide initiative, the IAFF Executive Board felt it prudent to release position statements in regard to the expected changes in response paradigms and standard operating procedures (SOPs) for fire departments responding to active shooter events.

The position statements are relevant to IAFF locals in fire departments that are changing response protocols or SOPs in an effort to embrace a more assertive approach to rendering life-saving care and rescuing viable victims in areas considered to be “warm zones” (not fully secured) during such an event.

The Active Shooter Event Position Statement and the Rescue Task Force Training Position Statement are intended to assure that IAFF locals have a guidance template for use when discussing appropriate actions and safety considerations during fire department SOP development.

Based on the passage of the Active Shooter Position Statements, it was necessary for the IAFF to clarify its position on Tactical EMS. The IAFF considers Tactical EMS very different from the active shooter protocols previously discussed. Therefore, the IAFF Executive Board also developed a position statement on Tactical EMS for IAFF locals to use as a reference during departmental discussions of IAFF members being trained and participating as part of a tactical SWAT Team.

More on the subject of responding to active shooter events will be addressed at the upcoming John P. Redmond Symposium/Dominick F. Barbera EMS Conference scheduled for August 21-24, 2013, at the Hyatt Regency in Denver, Colorado.

For more information about the IAFF position statements, contact Dr. Lori Moore-Merrell at lmoore@iaff.org.

Article provided by International Association of Fire Fighters

It was an otherwise quiet morning in Pima County, Ariz., when, at 10:11 a.m. on Jan. 8, 2011, the Pima County Sheriff’s Department received a 9-1-1 call advising of a shooting in progress at a local shopping center. During the next 20 minutes, details of a horrific and historic scene unfolded, despite the lone shooter being taken into custody within five minutes of the original 9-1-1 call.

Before it was all over, that isolated shooter had fired 30 rounds into a crowd gathered for the Congress on Your Corner event with Congresswoman Gabrielle Giffords (D-Ariz.) outside a busy Safeway grocery store on the outskirts of Tucson. Facing the arriving deputies were 19 injured and/or dying people all in close proximity. Luckily, they had trained for such situations. Is your department prepared to receive a 9-1-1 call like this?

The Northwest Fire Rescue District (NWFRD) serves the suburban area of Tucson where the mass shooting occurred. A NWFRD paramedic rescue ambulance and three ground ambulances from Southwest Ambulance were dispatched based on the initial information received by dispatch from the initial 9-1-1 call. Three ALS engines, a ladder company and EMS Captain and Battalion Chief (BC) Lane Spalla also responded on the first-alarm MCI response. Three medical helicopters were also placed on standby based on the scope of the incident.

Although the first EMS/fire units arrived on scene in just five minutes, they were held off in a safe staging area by law enforcement until 10:23 a.m., when the scene was declared safe for entry.

This scene was also different from many other active-shooter mass casualty incidents (MCIs) because the arriving deputies were all trained in MCI and advanced care procedures that enabled them to play a major role in the treatment and survival of the multiple critically wounded patients who were inside the incident hot zone prior to the secured arrival of fire and EMS responders.

In the critical minutes of an incident involving gunfire and the need to secure the scene, where patients had the potential to exsanguinate, the deputies arriving on scene were armed with special emergency care packs that were strategically positioned behind the headrest of each patrol vehicle for easy access and deployment.

During the 47 minutes that deputies were with the injured at the scene, they treated 10 of the 19 injured patients. They controlled bleeding, provided rescue breathing and chest compressions, deployed hemostatic agents, bandaged numerous wounds, and assisted citizens and congressional staffers in the care of the injured.

The first seven patients were triaged, treated and transported from the scene by 10:35 a.m. All were transported by 11:01 a.m.

The early combat and control of hemorrhage before the onset of shock has been proven by the military in the Iraq and Afghanistan war zones to be the key factor in preventing death from severe hemorrhage.

Emergency department (ED) physicians and trauma surgeons from Tucson’s level one trauma center University Medical Center acknowledge that the quick actions of the Pima County Sheriff Department deputies and their specialized training and EMS equipment resulted in decreased hemorrhage, improved vital signs and less need for shock resuscitation for multiple victims.

Initial First Responders

It’s essential that treatment begin immediately and patients be transported expeditiously in accordance to the severity of their injuries. And even in an urban environment, the time it takes for EMS to arrive on scene can mean the difference between life and death for the wounded. Too often the first responder is a law enforcement officer faced with a tactical situation of providing a law enforcement function that must quickly transition into providing first care to civilians or a fellow officer.

The Safeway shooting happened in a geographic location in Pima County that’s readily served by multiple paramedic units from three large fire departments. But it’s conceivable that this same scenario could occur with one or more of the following situational complications:

>> Extended EMS unit response to a rural or remote setting;

>> EMS resources committed on other high-priority calls and delayed in response or arrival;

>> Traffic congestion that delays or prohibits EMS access to a scene;

>> An unsafe scene that doesn’t allow fire and EMS providers to approach immediately.

Any of these complications can significantly affect the well-being of the wounded, because the EMS provider would be markedly delayed in arrival and their ability to provide essential emergency care.

Early Involvement

In a 2007 study published in Prehospital and Disaster Medicine, the authors noted, “No widely accepted, specialized medical training exists for police officers confronted with medical emergencies while under conditions of active threat.”1

Given the knowledge’ acquired from historical and modern battle, culminating in the trauma combat casualty care (TCCC) guidelines, we know the following are causes of preventable death on

the battlefield:

>> Hemorrhage from extremity wounds;

>> Tension pneumothorax; and

>> Airway compromise.

Each of these conditions can be managed early and effectively using relatively simple techniques and minimal equipment. Unfortunately these techniques and equipment are rarely taught to law enforcement officers.

Even in an urban environment, the time it takes for EMS to arrive on scene can mean the difference between life and death for the wounded. Law enforcement personnel routinely are the first arriving responders to arrive at tactical situations. They are also often the first to arrive at such mass casualty situations as major traffic collisions involving multiple patients.

At tactical incidents, officers are often faced with the challenge of initiating law enforcement functions and almost simultaneously ensuring that needed care is started on critically injured fellow officers and civilians.

Special weapons and tactics (SWAT) teams have long understood how important it is to have paramedics imbedded in their teams, immediately available for any medical need and tactically trained and aware of how to react and respond in a hostile or active shooter environment. Tactical EMS (TEMS) providers can readily address airway, breathing and circulation problems that create an urgency that transcends the response times of most staged civilian medical assistance units.

Although it’s not always practical for law enforcement agencies to employ paramedics to work in the field with officers, much can be done to train police officers to care for themselves, their colleagues and other patients.

Tactical Paramedic Training

In the spring of 2009, the leadership of the Pima County Sheriff’s Department recognizing the need for global training for all staff with “feet on the street.” They took elements of TCCC and results from the research done by Valor Project and created the First Five Minutes, a tactical emergency medical training program that was rolled out to all deputies during annual advanced officer training. This specialized EMS and law enforcement training program was developed with assistance from Richard Carmona, MD, MPH, the 17th U.S. surgeon general and former Pima County Sheriff’s Department SWAT team leader and medical director.

Although the First Five Minutes program isn’t the first medical training course taught to Pima County sheriff’s deputies, it’s different from their normal medical training because the primary goal is to give police officers the training necessary to sustain themselves or others in situations with life-threatening medical emergencies.

Along with the training, a special emergency response equipment kit was developed and issued to all deputies after they completed the training. The law enforcement individual first aid kit (IFAK) was assembled to include essential supplies and devices necessary to combat the three most common causes of preventable traumatic death, namely 1) hemorrhage in accessible and controllable regions; 2) hemorrhage in inaccessible or uncontrollable areas and 3) airway/respiratory management.

Officer safety and tactical considerations are incorporated into every aspect of the First Five Minutes lesson plan. Officers are reminded that they’re police officers first and medical providers second. The program introduction relates the importance of providing immediate medical care to the downed officer. The Fort Hood (Texas) Police Department shooting and the murder of Phoenix Police Department Officer Travis Murphy illustrate this issue.

At numerous points during the class, instructors emphasize that this program isn’t designed to be a first aid class, but rather a survival class for police officers. A law enforcement IFAK is issued to each student at the beginning of the class so become familiar with its contents to ensure rapid retrieval of essential items when necessary.

Although the IFAK is designed primarily for law enforcement professionals to treat fellow officers, deputies are told to use their discretion at emergency scenes. They’re encouraged to use their IFAKs, once the scene is secure, to stabilize civilians when they feel it can be life-saving in advance of EMS arrival. Such was the case at the Safeway/Giffords MCI scene.

Because the assisting officer is often the first person to contact the injured person, the training stresses the idea that the officer’s observations and findings are the most significant issues in long-term care and recovery of the wounded person. Officers are told to report the following to EMS providers:

>> The nature of the injury;

>> Patient’s mental status, including any changes in mental status;

>> Airway control necessary, rates of breathing and circulation;

>> Injuries they saw, who they treated, and how they treated those injuries; and

>> Any unusual findings or concerns.

At the conclusion of the training, the officers’ skills are evaluated through participation in multiple scenarios. Two evaluators are used for each scenario: one evaluates officer safety, use of cover and concealment, tactical movement and other skills related to police work; the second (an EMT or paramedic) evaluates the medical triage and care provided to the patient.

Other Programs

Similar emergency medical training programs address this need. This includes the specialized tactics for operational rescue and medicine program (STORM), developed by the Georgia Health Sciences University in conjunction with the National Tactical Officers Association.

The STORM course provides clearly defined medical strategies, procedures and rescue techniques to enhance the safety of law enforcement personnel and the populations they serve. STORM is tailored to five unique tactical audiences: self aid-buddy care, operator, paramedic, medical director and commander. Each course consists of didactics, hands-on skills stations and tactical scenario-based training.

The Nashville Police Department recently implemented a modern-day “first aid” program, which was taught once a week for five months to their entire roster of 1,400 active-duty officers. The training featured lecture and practical skill sessions training kits, which were issued to each officer as they completed the training program (see “Partners in Crime,” p. 52–55).

Conclusion

Not all law enforcement agencies consider emergency care to be part of a police officer’s job. With the ever-increasing call load and requirements placed on officers, it’s easy to see how agencies can lessen liability and workload by eliminating a job that’s already served by fire departments and EMS agencies.

However, a wounded officer, or an officer responding to a mass casualty incident well in advance of EMS, presents an opportunity for lives to be saved by law enforcement personnel.

Every officer should have the necessary training and equipment to provide on-scene emergency medical self care. They also should be able to assist other officers and civilians injured during a law enforcement operation.

Key aspects of implementing a successful law enforcement emergency care program are simplicity and ease of use in an emergency. Without those two factors, officers are limited in what they can effectively do at a scene.

The training and equipment used by law enforcement personnel prior to EMS gaining access to the scene of the Safeway shooting incident proving it to be worthwhile in a time of crisis, resulting in saved lives. The First Five Minutes program is easy to teach, simple to understand and effective in treating the injured before EMS arrival. JEMS

David Kleinman, NREMT-P, is a detective with the Arizona Department of Public Safety and a tactical paramedic with Pima Regional SWAT. com. He can be reached at 3450drk@comcast.net.

Tammy Kastre, MD, is the medical director for the Pima County Sheriff’s Department SWAT team and a board-certified ED physician.

References

1. Sztajnkrycer MD, Callaway DW, Benz AA. Police officer response to the injured officer: A survey-based analysis of medical care decisions. Prehosp Disaster Med. 2007;22(4):335–341.

First Five Minutes Training

The concept of training law enforcement officers in initial care and providing them with special medical kits isn’t new. This is a concept that has been used by the U.S. Secret Service for decades, with special kits immediately available to each agent and all agents familiar with the items in the kit. However, the First Five Minutes program is one of the first in which the care provided by officers before EMS arrival has been lauded as having saved several patients. The four-hour First Five Minutes training includes the following elements:

>> Scene safety and orientation components, including familiarity with area fire and EMS agencies and services.

>> The capabilities of local hospitals and the availability of helicopter rescue.

>> Body substance isolation (BSI) and real-world applications.

>> Assessment of circulation, airway and breathing. This includes methods to establish and maintain an open airway, as well as how to provide rescue breathing and continuous compression resuscitation (CCR).

>> How to contact an injured officer.

>> When and how to remove body armor.

They also learn a 90-second assessment of the situation and patient medical conditions with primary focus on hemorrhage control maneuvers and identification of shock. At the end of each assessment, deputies are encouraged to make transport decisions: Do they stay at the scene and wait for EMS, or do they transport the wounded rapidly via police or private vehicles? For hands-on training, the deputies participated in a skills lab that includes the use of the emergency compression bandages, hemostatic combat gauze, chest seals and tourniquets.

The IFAK

The contents of the IFAK are chosen specifically for law enforcement officers who would need to provide care to trauma patients before EMS arrives on scene. The IFAK includes the following items:

>> A zippered bag with interior elastic straps for holding contents in place. The exterior of the bag has multiple attachments points—allowing it to be mounted in the vehicle, on a backpack or even on a duty belt.

>> A pair of trauma shears.

>> Two emergency compression bandages.

>> One package of hemostatic combat gauze.

>> One chest seal.

>> One tourniquet.

The individual first aid kit includes supplies and devices necessary to combat the most common causes of preventable traumatic death.

This article originally appeared in June 2012 JEMS as “Beyond the Tape: Law enforcement officers as initial responders.”

Part I: Introduction

Active shooter attacks are dynamic incidents that vary greatly from one attack to another.

The Department of Homeland Security (DHS) defines an active shooter as “an individual

actively engaged in killing or attempting to kill people in a confined and populated area.”

In its definition, DHS notes that, “in most cases, active shooters use firearm(s) and there

is no pattern or method to their selection of victims.” The New York City Police

Department (NYPD) has limited this definition to include only those cases that spill

beyond an intended victim to others.1

The type of police response to an active shooter attack depends on the unique

circumstances of the incident. In the event of such an attack, private security personnel

should follow the instructions of the first-responders from the NYPD.

Because active shooter attacks are dynamic events, the NYPD cannot put forward a

single set of best-practices for private security response to such incidents. However, the

NYPD has compiled a list of recommendations for building security personnel to mitigate

the risks from active shooter attacks. The recommendations draw on previous studies of

active shooter attacks and are presented in Part II.2

The NYPD developed these recommendations based on a close analysis of active shooter

incidents from 1966 to 2012. This Compendium of cases, presented in the Appendix,

includes 324 active shooter incidents. It is organized chronologically by type of facility

targeted, including office buildings, open commercial areas, factories and warehouses,

schools, and other settings.

The NYPD performed a statistical analysis on a subset of these cases to identify common

characteristics among active shooter attacks. This analysis is presented in Part III and the

underlying methodology is presented in Part IV. The analysis found a large degree of

variation among attacks across some broad categories, including: sex of the attacker, age

of the attacker, number of attackers, planning tactics, targets, number of casualties,

location of the attack, weapons used, and attack resolution. The analysis also provides

insight into the frequency of active shooter attacks.

READ FULL REPORT HERE

By MICHAEL GRACZYK — The Associated Press

HOUSTON — One Houston firefighter remained hospitalized in critical condition Saturday, a day after a massive motel and restaurant fire killed four of his fellow firefighters.

A total of 14 were hospitalized Friday afternoon. Houston Fire Department spokesman Jay Evans said Saturday that other injured firefighters had been released over night, but he did not have a precise count.

Among the four killed were veterans of the department and a newcomer just a month out of the academy.

The fire broke out at a restaurant connected to the Southwest Inn along a busy freeway, and was the deadliest in the 118-year history of the department. Three firefighters died at the scene, while the fourth died at a hospital, according to the mayor’s office and a medical examiner.

One of the dead is 29-year-old Robert Garner. His father, Jerry Veuleman, told the Houston Chronicle ( http://bit.ly/1aMsrEe) that Garner was proud of his work and had set his sights on becoming a firefighter after leaving the military. He joined the department in 2010.

“‘Use your training. Don’t be a hero. God will look after you,’ ” Veuleman recalled telling him. “God chose it was time to take Robert and the other firefighters. We are sorry, but we are also blessed.”

The others who died were: 35-year-old Capt. Matthew Renaud, an 11-year veteran of the department; 41-year-old Robert Bebee, who joined almost 12 years ago; and 24-year-old rookie firefighter Anne Sullivan. She had graduated from the training academy in April.

Fire officials said they took a high risk in aggressively fighting the fire because they believed people were inside the motel. When a portion of the building collapsed, the firefighters were trapped.

In 1953 and 2000, two Houston firefighters were killed in a single fire. Three firefighters died in 1929 when a train slammed broadside into their engine.

Information from: Houston Chronicle, http://www.houstonchronicle.comBy MICHAEL GRACZYK — The Associated Press

HOUSTON — One Houston firefighter remained hospitalized in critical condition Saturday, a day after a massive motel and restaurant fire killed four of his fellow firefighters.

A total of 14 were hospitalized Friday afternoon. Houston Fire Department spokesman Jay Evans said Saturday that other injured firefighters had been released over night, but he did not have a precise count.

Among the four killed were veterans of the department and a newcomer just a month out of the academy.

The fire broke out at a restaurant connected to the Southwest Inn along a busy freeway, and was the deadliest in the 118-year history of the department. Three firefighters died at the scene, while the fourth died at a hospital, according to the mayor’s office and a medical examiner.

One of the dead is 29-year-old Robert Garner. His father, Jerry Veuleman, told the Houston Chronicle ( http://bit.ly/1aMsrEe) that Garner was proud of his work and had set his sights on becoming a firefighter after leaving the military. He joined the department in 2010.

“‘Use your training. Don’t be a hero. God will look after you,’ ” Veuleman recalled telling him. “God chose it was time to take Robert and the other firefighters. We are sorry, but we are also blessed.”

The others who died were: 35-year-old Capt. Matthew Renaud, an 11-year veteran of the department; 41-year-old Robert Bebee, who joined almost 12 years ago; and 24-year-old rookie firefighter Anne Sullivan. She had graduated from the training academy in April.

Fire officials said they took a high risk in aggressively fighting the fire because they believed people were inside the motel. When a portion of the building collapsed, the firefighters were trapped.

In 1953 and 2000, two Houston firefighters were killed in a single fire. Three firefighters died in 1929 when a train slammed broadside into their engine.

Information from: Houston Chronicle, http://www.houstonchronicle.com

The Department of Defense Joint Trauma System Committee on Tactical Combat Casualty Care recently made recommendations regarding changes to the Tactical Combat Casualty Care (TCCC) Card. In our effort to stay on the leading edge of combat medicine, Chinook has responded to these changes and we are the first to offer this revised product. BUY THE REVISED CARD HERE

The Tactical Combat Casualty Care
Casualty Card
TCCC Guidelines – Proposed Change 1301
30 April 2013

COL Russ S. Kotwal, USA
CAPT Frank K. Butler, USN (Ret.)
MSG Harold R. Montgomery, USA
CDR Tyson J. Brunstetter, USN
Capt George Y. Diaz, USAF
COL James W. Kirkpatrick, USA (Ret.)
Ms. Nancy L. Summers
Col Stacy A. Shackelford, USAF
COL John B. Holcomb, USA (Ret.)
Col Jeffrey A. Bailey, USAF

DISCLAIMER:
The recommendation contained herein is the official position of the Department of Defense Joint Trauma System Committee on Tactical Combat Casualty Care. This recommendation is intended to be a guideline
only and is not a substitute for clinical judgment. This document was reviewed by the Director of the Joint Trauma System, the Public Affairs Office, and the Operational Security Office at the U.S. Army Institute of Surgical Research and approved for unlimited public release as of 30 April 2013.

Abstract
Optimizing trauma care delivery is paramount to saving lives on the battlefield. During the past decade of conflict, trauma care performance improvement at combat support hospitals and forward surgical teams in Afghanistan and Iraq has increased through Joint Trauma System and DoD Trauma Registry data collection, analysis, and rapid evidence-based adjustments to clinical practice guidelines. Although casualties have benefitted greatly from a trauma system and registry that improves hospital care, still lacking is a comprehensive and integrated system for data collection and analysis to improve performance at the prehospital level of care. Tactical Combat Casualty Care (TCCC) based casualty cards, TCCC after action reports, and unit-based prehospital trauma registries need to be implemented globally and linked to the DoD Trauma Registry in a seamless manner that will optimize prehospital trauma care delivery.

Background
In 2007, a Committee on Tactical Combat Casualty Care (CoTCCC) working
group was convened to address the lack of prehospital care documentation in the conflicts in Iraq and Afghanistan. At that point in time, there were over 30,000 casualties from these conflicts, but less than 10% of these casualties’ records had any documentation of the care that was provided before the casualty reached a medical treatment facility. Unit-level reporting formats were used in almost all cases of successful documentation. It was noted at the conference that, in many instances, the first responders providing care were not medical personnel. Documentation of care provided by non-medical first responders requires a format that they understand and can use effectively. (Butler 2010) The DD Form 1380 Field Medical Card that was in use by the DoD at the time was not believed by conference attendees to be optimally configured for documenting first responder care on the battlefield.

Three possible choices for battlefield trauma care documentation were reviewed at the conference. One was the DoD paper form 1380. The second was the Battlefield Medical Information System—Tactical (BMIS-T)—a PDA device. Neither format was felt to sufficiently meet the needs of the prehospital providers in the tactical environment.

The third option was the casualty card that had been developed by the 75th Ranger Regiment. This card was identified by the working group as an immediate, cost-effective, and easily-fielded interim solution. This card was developed largely by Ranger medics, has proven easy to use, and has been very well-accepted by the Rangers and by other Special Operations groups. Using this format, the Ranger Regiment had effectively documented the care provided to almost all of the approximately 450 battle injury and non-battle injury casualties they had sustained in Iraq and Afghanistan at the time of the conference. This card was recommended by conference attendees and endorsed by the CoTCCC as the preferred method for documenting TCCC on the battlefield. The 2007 version of the TCCC Casualty Card is shown in Figure 1. (Butler 2010)

The TCCC casualty card was endorsed by the Defense Health Board (Wilensky 2009) and adopted as the standard format for documenting prehospital care by the Department of the Army. (ALARACT 2009) The applicable Army Regulation
(AR 40-66 Medical Record Administration and Healthcare Documentation) was amended to permit the TCCC casualty card (DA Form 7656) to become a part of the Health Record without a medical officer’s signature. The DD 1380 Field Medical Card requires a medical officer’s signature in order to become a part of the Health Record. The TCCC casualty card was used successfully by the
Ranger Regiment to create the Ranger Prehospital Trauma Registry, which is the single best unit-based trauma registry to emerge from the conflicts in Afghanistan and Iraq and which enabled the most comprehensive study on prehospital care rendered in a combat unit to emerge from these conflicts. (Kotwal 2011) Only 14% of casualties have pre-hospital care documented upon arrival at a Role
II/III facility. The lack of consistent prehospital documentation of care continues to be a requirement gap across the Services. (Caravalho 2011)

Discussion Points
There have been a number of updates to TCCC since the current version of the casualty care card was adopted in 2007. These new interventions include TXA, the CRoC, ketamine, and others. Although the previous TCCC casualty card was designated as an approved Army form, the other services did not follow the lead of the Army on this issue. There is a need to have a form that is acceptable to and used by all services in the DoD. The Defense Medical Materiel Program Office has noted this need and initiated
the effort to have a single “DD” form approved for use throughout the DoD. The revised card maintains the simple format of the previous card, but incorporates a number of modifications that will allow better documentation of prehospital care. Upgrades included in the revised TCCC card include:

- The casualty Battle Roster Number (to link to the DoD Trauma Registry)
- Better definition of the mechanism of injury
- Improved documentation of tourniquet use
- Adds a section to record the use of junctional tourniquets
- Incorporates the use of prehospital plasma and blood
- Provides for documentation of hemoglobin oxygen saturation
- Adds a section for documentation on pain level 4
- Incorporates a section for supraglottic airway use
- Provides a space for the type of supraglottic airway
- Provides a space for type of chest seal
- Adds ketamine in the analgesic section
- Incorporates the use of tranexamic acid
- Provides a space for documentation of an eye shield
- Provides a space for documentation of combat pill pack usage
- Provides a space for documentation of hypothermia prevention equipment

The draft of the updated card was developed as a joint effort of the CoTCCC, the
DMMPO, and the JTS. It was subsequently circulated to all members of the JTS
and the CoTCCC and their suggestions for improvements were incorporated into
the working draft.

A teleconference meeting of the CoTCCC with DMMPO and service participation was held on 28 March 2013 and the revised card was discussed. Following the meeting, several proposed modifications to the new TCCC Casualty Card were incorporated into the new card. Some teleconference participants also requested that a format for the card be considered that had all of the information that would be filled out by a non-medical combatant on one side of the card and the sections that would typically be filled out by a medic, corpsman, or PJ on the reverse side of the card. Such a format was subsequently developed. On 4 April 2013, CoTCCC members were sent four versions of the casualty card:

- Card 1: DD Form 1380 – the current DoD casualty card
- Card 2: DA Form 7656 – the previous CoTCCC-endorsed casualty card
- Card 3: DD Form xxxx – the new proposed card from DCDD using the non-combatant/combat medic information on different sides format, as described above
- Card 4: DD Form xxxx – the new proposed card from DMMPO, JTS, and USSOCOM

A clear majority of the CoTCCC voting members selected Card 4 as the preferred version. This card was then forwarded to CoTCCC voting members for a “yes” or “no” vote, with the results as noted below.

Conclusions
The lack of adequate documentation of prehospital care rendered to U.S. casualties is a clear obstacle to ongoing TCCC and JTS efforts to improve that care. “You can’t improve what you can’t measure, and you can’t measure without data.” (Eastridge 2011) Since 87% of combat fatalities occur in the prehospital phase in the continuum of care, (Eastridge 2012) documenting and analyzing what occurs in this phase of care is crucial.

The difficulty of documenting prehospital care on the battlefield is well recognized. Successful accomplishment of this task, however, can be accomplished through command attention and the use of tools such as the TCCC Casualty Card and unit-based prehospital trauma registries such as that developed by the 75th Ranger regiment. Process  improvement in TCCC in the future will depend heavily on the DOD’s ability to ensure that prehospital trauma care is adequately documented. The tools are there; we need to have our combat leadership ensure that they are used. (Kotwal 2013, Butler 2012)

The TCCC casualty card (DA Form 7656) needs to be updated and designated as a Department of Defense document. The CoTCCC endorses the use of the newly developed proposed DD Form as shown in Figure 2 for this purpose.

Proposed Change

Current Wording in the TCCC Guidelines

Tactical Field Care
19. Documentation of Care

Document clinical assessments, treatments rendered, and changes
in the casualty’s status on a TCCC Casualty Card. Forward this information with
the casualty to the next level of care.

Tactical Evacuation Care

19. Documentation of Care

Document clinical assessments, treatments rendered, and changes in
casualty’s status on a TCCC Casualty Card. Forward this information with the
casualty to the next level of care.

Proposed Wording in the TCCC Guidelines

Tactical Field Care

19. Documentation of Care

Document clinical assessments, treatments rendered, and changes in the
casualty’s status on a TCCC Casualty Card (DD Form XXXX). Forward this
information with the casualty to the next level of care.

Tactical Evacuation Care

19. Documentation of Care
Document clinical assessments, treatments rendered, and changes in
casualty’s status on a TCCC Casualty Card (DD Form XXXX). Forward this
information with the casualty to the next level of care.

Level of evidence: N/A

Vote: The proposed change noted above passed by the required 2/3 or greater majority of the CoTCCC voting members.

Considerations for Further Research

Tracking prehospital care documentation is a top priority for the Joint Trauma System. The Deployed JTTS Director should ensure that TCCC Casualty Cards are captured into both the DoDTR and the Electronic Medical Record. Feedback to Regional Command Senior Medical Leaders regarding the percentage of casualties from their RC who arrive at the MTF with a TCCC Casualty Card
should be provided monthly and should be tracked as a PI indicator. Future efforts to leverage technology and develop electronic methods of capturing prehospital medical care should be encouraged and funded.

Unit-based prehospital trauma registries were identified by the Defense Health Board as the #1 priority for battlefield trauma care RDT&E. At present, the documentation of in-theater trauma care is inconsistent, incomplete and often not transferred to either unit-based prehospital trauma registries (such as that
pioneered by the 75th Ranger Regiment) or a trauma system registry, such as the DOD Trauma Registry. Improved methods to document prehospital care are essential. Further, command attention is vital to this aspect of combat trauma care and would help to ensure that our troops continue to receive the best possible battlefield trauma care. (Dickey 2012)

References

ALARACT 355/2009: TACTICAL COMBAT CASUALTY CARE (TCCC) CARD
FOR POINT-OF-INJURY DOCUMENTATION; Office of the Surgeon General of
the Army All Army Activities Message Date Time Group 242018Z DEC 09.

Army Regulation 40-66 Medical Record Administration and Healthcare
Documentation, Rapid Action Revision (RAR) Issue Date: 4 January 2010.

Butler FK, Blackbourne LH: Battlefield Trauma Care Then and Now: A Decade of
Tactical Combat Casualty Care. J Trauma Acute Care Surg 2012;73:S395-S402.

Butler FK, Giebner SD, McSwain N, Salomone J, Pons P, eds. Prehospital
Trauma Life Support Manual. Seventh Edition – Military Version. November
2010.

Caravalho J. OTSG Dismounted Complex Blast Injury Task Force; Final Report.
18 June 2011:44–47.

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A beautiful tribute to those that risk their lives for freedom.

We thank you this Memorial Day.

Two members of the FBI’s ultra-elite Hostage Rescue Team were killed Friday during a training accident involving a helicopter off the coast of Virginia Beach.

A spokeswoman for the FBI’s Norfolk office, Vanessa Torres, confirmed Sunday the accident occurred Friday afternoon off the Virginia Beach coast, but did not provide additional details. The FBI said in a statement that the two men killed were Special Agent Christopher Lorek, 41, and Special Agent Stephen Shaw, 40.

“We mourn the loss of two brave and courageous men,” FBI Director Robert S. Mueller said. “Like all who serve on the Hostage Rescue Team, they accept the highest risk each and every day, when training and on operational missions, to keep our nation safe. Our hearts are with their wives, children, and other loved ones who feel their loss most deeply. And they will always be part of the FBI Family.”

Lorek joined the FBI in 1996 and is survived by his wife and two daughters, ages 11 and 8, while Shaw joined in 2005 and is survived by his wife, 3-year-old daughter and 1-year-old son.

The Norfolk Medical Examiner’s office told WAVY-TV in Portsmouth, Va., that no information regarding the cause of death would be released from that office until Monday morning, at the earliest.

The HRT, as it’s known, earlier this year celebrated its 30^th anniversary. The team, which reportedly handles the toughest assignments within the U.S., was formed ahead of the 1984 Los Angeles Olympics. “By law, the military cannot operate within the U.S. without presidential or legislative approval, so officials needed other tactical alternatives,” according to the FBI’s website.

“When Los Angeles won the nomination . . . the question was, ‘Who would handle an event such as Munich?’ And there weren’t a lot of good answers,” said FBI Deputy Director Sean Joyce.

At the Munich Olympic Games in 1972, terrorists shocked the world by taking 11 Israeli athletes hostage and later murdering them.

“That’s how the idea of a Hostage Rescue Team evolved. As an elite counterterrorism tactical team for law enforcement, the HRT is one of the best, if not the best, in the United States. They are elite because of their training,” Joyce said.

The Associated Press contributed to this story.

Scientists have crafted an injectable foam containing oxygen-carrying microparticles that could potentially be used to resuscitate patients undergoing severe oxygen deprivation. The team of researchers, most of whom work at Children’s Hospital Boston, demonstrated that the microparticle solution could rapidly oxygenate the blood of rabbits struggling to breath in low oxygen conditions. They report their findings in the latest issue of Science Translational Medicine.

“This is a potential breakthrough,” Peter Laussen, cardiac intensive care doctor at Children’s Hospital Boston who was not involved in the work, told ScienceNOW. “You can apply this across healthcare, from the battlefield to the emergency room, intensive care unit, or operating room.”

A body deprived of oxygen is a body in trouble. When major organs like the brain and heart don’t receive an adequate supply of oxygen they falter and fail, sometimes in minutes. Traditionally, physicians used therapies such as CPR and tracheal intubation, where a breathing tube ventilates the lungs after being inserted into a patient’s windpipe, to deliver fresh oxygen to the bloodstream of a person in the midst of a medical emergency.

The microparticles, which consist of spherical shells of lipids surrounding a small bubble of oxygen gas, deliver oxygen almost immediately to red blood cells in a way that is safer and more rapid than currently used methods. The research team, led by Children’s Hospital Boston cardiologist John Kheir, found that the solution could completely saturate red blood cells in oxygen-deprived rabbits within seconds of injection, and they kept rabbits with totally blocked airways alive for 15 minutes using the oxygen-infused microparticles. “Essentially as soon as we started injecting it, clinically we started to see an effect,” Kheir told ScienceNOW.

Researchers are now testing the microparticle solution on large animals, and if those and later human clinical trials are successful, the therapy could make its way into the clinic or other emergency situations. “This is still in its infancy,” Laussen added, “but this idea of a new and novel way to effectively deliver oxygen is, I think, very exciting.”

By Bob Grant | June 29, 2012