It_s one in the morning. You_re the medical provider for the Special Weapons and Tactics (SWAT) team responsible for serving a high-risk warrant on a felon suspected of dealing crack cocaine and firearms. After the door is breached with a battering ram, the first team member is shot on his way through the door. The other officers on the team instinctively return fire and drag the downed officer to your position only a few feet from the door.
You quickly secure the officer_s weapon, assess the ABCs and do a quick secondary survey. Gunfire continues in the house. In the dark shadows, the muzzle flashes of automatic gunfire are your only light. Because any light could make you a target, your exam relies mostly on palpation. The officer is unresponsive, and his breathing is rapid. When you check for a femoral pulse, you feel blood spurting from a wound in his leg. You make the appropriate interventions and plan for evacuation to a safer area. Fortunately, this SWAT officer is a computerized human patient simulator, and this is a simulated tactical medical training exercise.
The Basics of Tactical Medicine
Tactical medicine involves medical care and rescue operations within the tactical scene and transporting casualties to appropriate hospitals. The field of non-military tactical medicine has been evolving into a subspecialty of emergency medicine during the past 15 years.
Initially, most tactical medical support was simply an ambulance stationed several blocks from the scene. Now, medical personnel often function as an integral part of the tactical law enforcement team. This shift has placed medical support in more hazardous situations and requires special training beyond that of traditional EMS training and care.
Thus, several tactical medicine courses have been developed to cover the unique aspects of EMS in the challenging tactical environment. The first civilian training effort was the Counter Narcotics Tactical Operations Medical Support program (CONTOMS), which was developed jointly by the Uniformed Services University of the Health Sciences and the United States Park Police, Special Forces Branch. The CONTOMS program includes a week-long course that trains medical personnel in the multiple facets of tactical EMS (TEMS).
TEMS is a subspecialty of EMS and is part of the continuum of patient care that extends from the tactical environment. It encompasses preventative medicine, medical preplanning, coordination and communication with local EMS agencies and hospitals, as well as evaluation and care of police, bystanders and perpetrators.
Deprived & Overloaded
Several reports in the medical literature have described various TEMS programs and the multiple aspects of such units. The literature discusses how TEMS personnel must be able to provide medical care under extreme conditions, such as total darkness or active gunfire. These adverse conditions force the TEMS provider to rely heavily on palpatory skills.
In order to perfect these skills, students at CONTOMS and other training programs engage in exercises that force them to use touch as their only means of assessment. Two techniques have been developed to refine patient assessment skills ƒ Sensory-Deprived Patient Assessment (SDPA) and Sensory-Overload Patient Assessment (SOPA).
In SDPA, the student is blindfolded and has to perform a complete primary and secondary exam using palpation only. To prevent missed injuries, students are taught how to perform a complete systematic exam, relying solely on their sense of touch.A TEMS provider performs sensory-deprived patient assessment on the portable Laerdal SimMan.
In contrast, the SOPA technique is designed to simulate the distractions of a tactical situation by overloading the visual and auditory senses using smoke, strobe lights, loud music and gunfire.Tactical medics assess a SimMan during sensory-overload conditions under close supervision of a tactical physician.
Until recently, SDPA and SOPA training involved the use of static mannequins ƒ often made to look as though they have injuries ƒ and people acting as casualties or hostile/friendly combatants. We were unable to find any literature describing the use of full-scale human patient simulators (HPSs) in the training of tactical medicine teams outside of the military setting.
However, civilian full-scale HPSs are being used more frequently for training health-care personnel. A 2001 study showed that prehospital and hospital-based providers felt that the clinical scenarios were more realistic when using HPSs.
The Allentown (Pa.) Emergency Response Team incorporated human patient simulation into ongoing tactical medicine training for local civilian TEMS personnel. We used two different HPSs in our training ƒ the portable Laerdal SimMan and the stationary METI HCS simulator.
Both HPSs are controlled by computer and have variable physiologic functions, including pulse, blood pressure, chest rise and fall with exhaled carbon dioxide, and breath sounds. Such procedures as intubation, needle thoracentesis, cricothyrotomy, IVs, CPR and defibrillation can be performed on both simulators. The ECG rhythm can also be manipulated to produce a variety of rhythms (e.g., A-fib, V-fib, SVT).
In addition, the airway conditions can be changed to simulate a difficult airway, forcing alternatives to intubation. Special add-ons can be used to simulate arterial bleeding, salivation and lacrimation. They can also be adapted to mimic injury.
The main difference between the two HPSs is whether the response to medication and intervention is controlled by a computer or by a live operator. The METI HPS can automatically respond to medicine and interventions through physiologic modeling. For example, administration of a fluid bolus in a hypotensive patient should automatically result in blood pressure increase in real time. By contrast, the Laerdal SimMan_s reaction to interventions is controlled by an operator using a laptop with drop-down menus. For example, the operator manually enters a new blood pressure in response to a fluid bolus.
The implementation of HPSs in our training programs sought to improve the patient assessment skills of TEMS providers in SDPA and SOPA exercises. For the sensory-deprived scenarios, the TEMS providers were blindfolded, which forced them to use palpation as the only means of assessing the patient.
For sensory overload, the HPS lab was transformed to create a sensory environment similar to a real tactical situation. Loud noises, including gunshots and explosions, were created using an audio system. Smoke from dry ice was used to limited visibility, simulating a room filled with tear gas. Strobe lights, emergency response lights and bullhorns were also used for effective sensory overload. Participants were expected to appropriately use two-way radio communications throughout the training session.
The HPS itself was placed on the floor with appropriate moulage. The TEMS trainees crawled into the room and took up a position next to the injured person, preferably keeping the patient between themselves and the hostile individuals. While approaching, they were not to give away their position with light or sound. They informed the patient of their role quietly and efficiently by whispering ˙rescueÓ near the patient_s ear.
After checking for a verbal response, they began a head-to-toe physical examination. On first pass, weapons were found and removed. Trainees then performed a primary survey ƒ feeling for breath at the mouth, palpating the chest for rise and fall, and pulse check.
After the quick primary survey, trainees performed a systematic head-to-toe secondary survey with palpation to identify specific injuries. This secondary survey covers the entire body with the palms of both hands. Moulage for the HPS simulated such injuries as gunshot wounds, degloving extremity injuries, impaled foreign bodies and eviscerations. These prefabricated injuries replaced normal appearing areas of the HPS body.
After assessing the patient, our TEMS providers left the HPS lab and reported their findings. In other scenarios, they might be asked to remain in position while continuing to monitor the patient until other tactical issues were resolved.
The Marks of Success
On a fairly consistent basis, the TEMS providers were able to determine the respiratory and pulse status of the HPS. Some were able to note when the patient lost pulses and expired in their presence. In some cases, the HPS was set to have carotid pulse but not peripheral pulses, indicating profound hemorrhagic shock with SBP of 60.
Weapons were missed in the initial training exercises, but the TEMS providers became better and better at identifying and removing possible threats. Feeling for breath on the face was also difficult, but TEMS providers who palpated the chest rising and falling were able to determine the correct respiratory status of their patients. Frequently missed areas during the complete head-to-toe exam included the anterior neck, genitalia and buttocks.
The addition of an HPS significantly enhanced the realistic assessment of an injured patient in an artificial tactical environment. Obviously, a real-world grenade detonation and a recording of the event are drastically different, but the overall concept of enhanced simulation was achieved. Additionally, the sensory-deprived and sensory-overloaded environments were created with relatively inexpensive means.
The absence of the total-body palpation skill set was clear at the beginning of the training. However, TEMS providers were able to rapidly develop their patient assessment skills with limited realistic sensory cues. By the end of the training period, our trainees were able to consistently identify concealed weapons, simulated injuries and simulated wounds.
Further, the HPS eliminates concerns that may arise in palpation training. In many tactical medicine courses, students are paired off with same sex partners and asked to practice palpation. Even in that setting, students may be reluctant to perform the complete physical examination. Commonly missed areas are genitalia, buttocks and the female chest. Students from all levels of medical training seem more likely to perform the complete physical assessment on an HPS, which isn_t embarrassed by anything the examiner must do.
Also, the HPS allowed the trainees to experience a dynamic physical examination. How else could we train on a patient with only central pulses other than in a simulated environment? Some actors may be able to greatly vary their respiratory rate, but physiology dictates that they probably can_t breathe at a very high or low rate for a long time.
Beyond initial assessment, dynamic HPS can be incorporated into scenarios involving the entire tactical team to add realism to training. Scenarios involving an officer down, injured hostages and non-traumatic medical emergencies can be created to take full advantage of the HPS. The next step is to incorporate an HPS into the routine training and education of local tactical teams. The portable Laerdal SimMan that we used, as well as many of the newer portable HPSs, are ideal for training TEMS providers because they can be set up almost anywhere there is electricity.
With the modern focus on terrorism, the role of the tactical medic is rapidly expanding. The need for education and training for possible responses to biological and chemical weapons is increasingly more important. Because patient assessment in these situations is made more difficult by hazmat and specialized PPE worn by tactical personnel, practicing patient assessment under these conditions is crucial for success.
By using dynamic HPSs, patient physiology can be simulated to include respiratory arrest from botulinum toxin or tachycardia from an anticholinergic chemical poisoning. Properly assessing these physiologic changes and relaying them to an on-scene medical commander is critical so that the general class of toxin might be clarified, thus facilitating appropriate decontamination and containment procedures.
As HPSs that mimic human anatomy and physiology become more affordable and portable, the routine training of tactical medical providers will inevitably include the simultaneous use of multiple simulated patients. The full-scale physiologic modeled human patient simulators (such as our METI HPS) can be more than $200,000; however, the latest portable dynamic HPS (the Laerdal SimMan) costs approximately $24,000 to $40,000.
Although these costs may place such resources within the reach of academic medical centers and government agencies, they may still be too expensive for local EMS training agencies. Clearly, regional sharing of resources will be needed to continue using HPS for civilian tactical medical training. HPSs are an incredibly valuable training aid for TEMS, EMS, emergency medicine and all medical specialties. They add realism that static mannequins or actors cannot.
About the Authors
Andy Nicholes, DO, was a third-year Emergency Medicine resident at Lehigh Valley Hospital in Allentown, Pa., at the time this article was written. He is now a practicing Emergency Medicine Physician in Grants Pass, Ore. Nicholes is a graduate of several tactical medical courses, including CONTOMS and HK. He is also a reserve deputy sheriff, an active SWAT team member and helps trains tactical medics from several agencies. Contact him atANicholes@asante.org.
Rob Rupert, NREMT-P, is a full-time instructor at George E. Moerkirk Emergency Medicine Institute. He has 20 years of experience as a paramedic with Allentown EMS and 10 years of experience as a tactical medic. Rupert is involved in training tactical medics from several agencies, using computerized human patient simulators. Contact him atRobert.Rupert@lvh.com.
William Bond, MD, FACEP, is a practicing emergency physician at Lehigh Valley Hospital, Muhlenberg Campus in Bethlehem, Pa. He_s a clinical assistant professor of emergency medicine at Pennsylvania State University College of Medicine. He_s also a cofounder and current chair of the Society of Academic Emergency Medicine Simulation Interest Group. Contact him atWilliam.Bond@lvh.com.
John F. McCarthy, DO, FACEP, is chief of Prehospital Emergency Medicine for Lehigh Valley Hospital in Allentown, Pa. He_s also medical director for Allentown EMS and University MedEvac. Contact him atJohn_F.Mccarthy@lvh.com.
The authors would like to thank the Allentown Emergency Response Team Tactical Medics for their participation and Scott Dornblaser for his excellent photography.
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