Key Goals in SWAT Medicine
- Treat the casualty.
- Prevent further casualties.
- Complete the mission.
- Go home.
Most tactical emergency medical services (TEMS) and special weapons and tactics (SWAT) activations are planned warrant, drug, or gun raids. However, hostage situations and barricaded-suspect events are probable and occur in many cities and municipalities across the United States. The latter of the two events is referred to as a Signal 100 in Akron.
TEMS is more than just medics wearing helmets and vests. TEMS medics are versed in many topics and must be prepared to think outside the box to assist command in problem solving and mitigation. Even though a TEMS medical director oversees the team, their ability to give orders on scene is stymied by many factors. As a result, the medical director gives medics standing orders. TEMS interventions are unique and require some leeway for tactics and treatments to change given the complexities of the encounter at hand.
Training
Akron’s SWAT and TEMS teams function in a unique manner based on best practices. Even though our education and knowledge base are derived from a vast number of sources, we do not depend on one specific standard. Our training is a culmination of research-based case studies and hands-on, psychomotor repetition acquired in-house and from nationally recognized training conferences such as the Ohio Tactical Officers’ Association (OTOA) Conference, which is held every year in Sandusky, OH.
Other trainings include the Ohio Fire Academy in Columbus, OH, and Counter Narcotics and Terrorism Medical Support, better known as CONTOMs, courses found throughout the country. The Akron Fire and Akron Police way of training is very effective; however, it is not necessarily a paradigm for all departments. And it may not fully fit the environmental and geographic demands faced in other parts of the country. The needs of the community are paramount; SWAT and TEMS best practices must address and fit these needs.
As most prehospital professionals know, not all situations fit neatly into an algorithm or protocol. TEMS medics work in the “grey areas“ and must be able to utilize their mental file folders to mitigate a bad scene. These mental schema or file folders are built through years of experience, education, skill development, unconventional training, problem solving, heuristics, and common sense. TEMS medics are trained in operator tactics, firearms, less-lethal weapons, tactical combat casualty care (TCCC), tactical emergency casualty care (TECC), explosives, explosive breaching, blast injuries, and many more specialties.
Development of SWAT and TEMS
SWAT teams were developed in the late 1960s in Los Angeles due to increasing violence aimed at the civilian population and police officers after the Watts Riots. In 1971, Los Angeles SWAT became a full-time position due to rising violence and narcotics in the city. At that time, tactical medicine and tactical medics were not developed in the civilian world. Tactical medicine grew from necessities in the military. Battlefield deaths were rampant because there were no triage or treatment protocols. For example, about 89% of casualties on the battlefield in the Vietnam War died of exsanguination.
Prior to TCCC, casualty fatality rates (CFRs) on the battlefield in WWII were 19.1%. In the Vietnam War, CFRs were 15.8% and, in the Iraq/Afghanistan conflicts, the CFRs were 9.4%. Tourniquet use was nonexistent and then minimal, at best. It was not until the early 2000s when a cravat and stick was utilized as a tourniquet. No hemostatic agents were used, and no junctional treatments were made available. Moreover, IV fluid, which has no oxygen-carrying capacity, was used at tremendous amounts to raise blood pressure numbers. This over-irrigation of the vascular system was busting up clots, dropping oxygen levels, expediting full exsanguination, dropping body temperature, and making the body more acidic.
There was a need for profound change if lives were to be saved. Subsequently, military studies were conducted and TCCC guidelines were incorporated. This included triage changes and new treatment modalities at the point of injury. SWAT teams had recognized the need for medical interventions during training and real-time deployments, since SWAT trained and worked in austere environments similar to the military. A committee for tactical medicine was formed comprised of doctors, attorneys, police, medics, and academics. This committee is referred to as the committee for tactical emergency casualty care (CoTECC). TECC standards and guidelines were created in May 2011 to provide a paradigm for SWAT and other incidents in the civilian world.
TCCC had its limitations in the civilian world due to scope of practice and language. An example illustrating this point is the use of chest tube placement by medics in the military. If severe thoracic trauma is assessed and definitive care is hours away, then it makes sense for medics in the military to perform more invasive treatments. However, in the civilian world, trauma centers are usually close enough to limit a medic’s scope of practice.
Chest seals and chest decompression techniques are adequate when treating operators, victims, and suspects on SWAT calls, which are less invasive than a chest tube insertion. Military medics do have the luxury of treating 17-to-45-year-old service members who, for the most part, are in great shape and have a low number of medical issues, if any at all.
Military medics, however, do have to handle many traumatic injuries especially if they are deployed into war zones. In the civilian realm, TEMS medics must treat many types of patients. We must treat the obese, disabled, pediatric, elderly, and patients with medical issues such as diabetes and prior heart attacks during SWAT runs.
SWAT and TEMS Complexities
We must also work as a team with our firefighters to handle and mitigate complex events. Just recently, in Akron, we had a complex SWAT call where a suspect shot his girlfriend in the head outside on the driveway. He then entered his house after he set the front porch on fire. Fire crews were dispatched at 6:56 p.m. Tower #5 was first in pumper at 7:02 p.m., making an interior attack. The body was found in the driveway at 7:03 p.m. and the crew went defensive at 7:04 p.m. due to safety concerns. Fire crews were extinguishing interior fire and the porch fire when they found the girlfriend deceased, shot in the head multiple times. The fire crews transitioned and went defensive after they backed out of the house. The fire lieutenant on scene, who was also a SWAT medic a few years ago, suspected that there was someone else in the house, which was likely the suspect.
Akron Police Department (APD) also had calls for shots fired at that location and in the area. SWAT crews and TEMS medics were activated as were the police hostage negotiators. The transitional fire attack had knocked down enough fire on the porch; however, there was more fire on the first floor and the basement. The body was moved from the driveway by TEMS medics. APD’s BearCat (armored vehicle) was used to push a vehicle out of the driveway, as the rally point, and as cover to fight fire transitionally.
Super-sock rounds (40 mm) were used to bust windows out to spray water. SWAT team command and fire command would not let the firefighters enter for close to three hours due to safety concerns. A small fire in the basement smoldered for hours until it grew, producing heavy smoke.
The suspect’s phone pinged in another location, but he was not there once officers checked. There was too much smoke in the house to be tenable for the suspect if he were inside. Therefore, the command staff made the decision for the fire crews to enter and extinguish the fire while wearing ballistic vests under their bunker gear at 9:51 p.m. Once entry was made, the suspect was found dead, with a self-inflicted gunshot wound to the head, at 10:00 p.m.
To add to the call’s complexity, as the SWAT/TEMS teams and the fire crews cleaned up and debriefed, there was a call for the TEMS medics to respond to where the suspect’s phone had pinged. The suspect’s father was at this location, interviewing with officers when he collapsed. The TEMS medics on scene determined that the suspect’s father had a massive stroke, and he was transported to the hospital. These complex SWAT calls are rare in Akron; therefore, these events are considered low-frequency but high-risk, posing much danger to our firefighters, medics, and police officers.
Even though tactical medics are in place during SWAT events to practice good medicine in bad places, I would be remiss if I did not mention that there is a caveat: timing. Good medicine in the tactical setting, but at the wrong time, equals bad tactics. Bad tactics equals operator or medic death. Death equals mission failure and a grieving partner or family.
Return of fire is the best medicine, depending on the stage of the incident. The medical threat assessment (MTA) is the most important factor for mission success from a medical standpoint. This is what I will be discussing in the next section. Always plan for the “What if?” scenario. Failure to plan will produce a “What now?” mentality. Furthermore, failure to plan is nothing more than saying you plan to fail.
Medical Threat Assessment (MTA)
The MTA is a multifaceted, fast-paced, changing assessment of the mission. It is planned days before (raids), hours prior (raids), or on the way to a Signal 100. Part of the MTA is designating a rally point, which is a more secure location, usually two to three houses away from the target house. At this point in my SWAT/TEMS career, our team was able to procure an armored vehicle referred to as a BearCat. We refer to it as a MEDCAT.
This armored vehicle protects us from ballistics and has medical supplies and oxygen on board. We use this as the rally point now for most of our SWAT runs. This provides much better cover than a house or a tree. Cover can stop projectiles such as bullets, fragmentation, and shrapnel. Concealment only obscures the person and may not stop projectiles.
The rally point should be in the direction of the evacuation route if things go bad. This is the meeting place to retreat to if needed, extricate operators and victims, and to treat the injured prior to evacuation.
Considerations in the MTA should include but are not limited to the following:
- air-med proximity
- amount of resources and supplies
- animals
- atmospherics
- closest backup medical units
- closest engine/ladder
- equipment adequacy and maneuverability
- geographics
- ground evacuation plans
- hospital(s’) capabilities/distance
- injuries
- medical capabilities on scene
- neighborhood culture (friendlies/unfriendlies)
- number of casualties
- number of operators/medics
- number of suspects
- operator & medic blood types
- operator health/exposures
- remote location
- scene size-up
- suspect(s) background
- time on scene
- weather
- wind direction
Other considerations are dependent on the situation at hand.
Signal 100 SWAT runs can be fast, dynamic, and complex. MTAs must have a template, which can be altered if needed. These kinds of missions can also stretch out over many hours. For example, I have been on a SWAT call that lasted over four hours in 14° weather. We had snipers deployed on buildings at this time.
Hypothermia was a big concern and our snipers had to be rotated into a warm environment. Calls like these require a united effort to mitigate the dangers of environmental factors not just suspect violence on scene. Once SWAT and TEMS respond to the scene, the SWAT commander, TEMS lead medic/doctor, and negotiators collaborate to devise a plan.
Hostage situations require quick, upper-level thinking and patience. Many dangers are considered such as firepower of the suspect, explosives knowledge and implementation by the suspect, and drugs on scene. Medics must be prepared to be able to utilize every facet of their training and must know how their equipment functions. SWAT officers have been exposed to high-potency drugs during signal 100s and raids.
Medics must be ready to decontaminate anyone exposed to drugs. For this very reason, our TEMS medical unit carries large amounts of naloxone and a hydrant bag. If needed, we can hook up to a hydrant to irrigate exposed skin, eyes, and wounds.
Common Injuries Treated in SWAT
If injuries do occur, our goal is to prevent death. The top three preventable deaths in the tactical setting have been researched to include exsanguination, tension pneumothorax, and airway compromise. To be more specific, extremity trauma exsanguination comprises 60% of preventable deaths. Tension pneumothoraces are 33% and airway compromise has been found to be approximately 6% of preventable deaths. The “other” category, into which remaining injuries fall, is the designation for 1% of preventable deaths. Junctional and abdominal wounds sustained in the tactical setting would be two examples that fall into this category.
You can control extremity exsanguination by simply applying a tourniquet high and tight. This approach serves two main purposes.
- Stopping hemorrhaging. If there is more than one wound to the extremities located in various areas, then placing the tourniquet high and tight will stop the hemorrhaging. Placing the tourniquet a few inches above the wound may be adequate for that wound; however, if you cannot visualize the entire extremity there may be wounds located higher on that extremity.
- Making compression easier. Even though the medical terms and bone sizes are different, the bones in the upper extremities mirror the bones in the lower extremities. The upper arms have one bone (humerus), while the lower arms are comprised of two bones (radius and ulna). And the upper legs are the femurs (one bone), while the lower-leg bones are referred to as the tibia and fibula (two bones).
The arteries, veins, and nerves traverse along the medial aspect of the upper arms, for example. It is much easier to compress the vasculature against one bone. This is more effective than compressing below the elbow joint because the arteries, veins, and nerves run in between the radius and ulna. Hemorrhage is very difficult to stop when compressing vessels in this area. Anatomically speaking, this is the same for the lower extremities.
Zones of Care
When assessing a casualty in the tactical setting, an initial assessment based on a general impression is a good place to start. A rapid trauma assessment will suffice if the patient assessment is broken down into four main sections:
- Extremities.
- Junctional.
- Cranial.
- Truncal.
Stop any hemorrhaging you find. Place a tourniquet high and tight on extremities. Junctional wounds at the neck, armpit, and groin should be packed with a hemostatic agent with pressure held for 30 seconds to 3 minutes, depending on what hemostatic agent is being used. Truncal wounds need to be covered with a gloved hand if chest seals are not readily available. Once chest seals are put in play, place the seal’s valve directly over the wound. Be sure to check for exit wounds, which may be located anywhere on the torso—check from the neck to the naval, 360°. If a medic runs out of chest seals, they should turn to defibrillation pads, which have been shown to provide an adequate seal. However, the pad will need to be burped.
If a tension pneumothorax is developing, perform a chest decompression. Find the clavicle; the first rib is located directly under this bone. The second rib is located approximately one finger width below this bone. The third rib is found measuring the distance the same way. Insert the 14 g/3.5-inch needle over the third rib into the intercostal space. This insertion site should be mid-clavicular on the injured side.
If the trauma is located on the left side of the patient’s thorax, then be careful not to insert the needle into the heart. Angle the needle slightly laterally, which will direct it outside of the cardiac box. If the mid-clavicular insertion site cannot be accessed (which is common in the tactical setting), then insert the needle over the fifth rib on the anterior axillary line. This is also to be performed on the injured side of the thorax. Due to SWAT operators’ vests and gear, the mid-clavicular insertion site is usually difficult to access.
Stages of care in the tactical setting are categorized by levels of danger. Care under fire/direct threat, or the hot zone; indirect threat care/tactical field care, or the warm zone; and tactical evacuation care (TAC-EVAC), or the cold zone; overlap at times depending on the severity of the operation. The hot zone is the area where the operator, victim, hostage, or medic is taking direct fire, for example.
The goal is to get the operator off the “X.” In other words, we need to extricate or direct the operator out of the danger zone. The best medicine is to return fire and find cover. If the operator can self-extricate, then get off the “X” as quickly as possible. If the operator is pinned down, then staying in place may be the best course of action until other plans are enacted. An injured operator needs to either return fire and find cover to self- treat or, if pinned down, stay behind cover and self-treat immediately.
Care Under Fire/Direct Threat Care
At times, medics may need to provide medicine across the barricade. In some situations, the injured cannot self-extricate and cannot be extricated by team members or medics due to heavy fire. The medic essentially directs the injured on how to self-treat via the portable radio.
Depending on the severity of the injury and the level of blood loss, the medic must be able to articulate treatment procedures clearly and in a succinct manner. Heavy blood loss will confuse the injured individual, especially if stages of shock are present.
Speak slowly and calmly to keep the injured semi-relaxed and focused on self-treatment. Every step of the self-treatment process must be explained at an elementary level to avoid confusion if blood loss has led to shock. Prior medical training with operators is essential. Explaining medical procedures to operators who have the knowledge and skill set will have a higher performance/success rate—one that reduces mortality and morbidity.
If an operator is injured and he cannot return fire, order him to enact the R.E.S.C.U.E. mnemonic:
- Remote assessment and treatment (place tourniquet).
- Evaluation of threat(s) location.
- Situational awareness (This is “observe, orient, decide, and act,” also known as the OODA loop).
- Cover fire (ask for).
- Utilization of assets and distraction (smoke, CS).
- Evacuation/extraction method and egress options. (“Help us help you.”)
John Boyd, an Air Force officer and pilot, coined the OODA Loop. It gives the injured operator the ability to think logically, looking for cues and patterns in the decision-making process. If something is missed or misunderstood, the injured can always go back to the observation part of the loop and reassess from there.
Indirect Threat Care or Tactical Field Care
Warm zone medical treatment involves focusing on the airway and breathing after hemorrhaging has been stopped. However, be sure to recheck the tourniquet placement for accuracy and effectiveness. This is especially true after a casualty is moved from the hot zone to the warm zone for prolonged treatment. Moving patients can render prior interventions inadequate and useless. Tourniquets and dressings shift or get caught on carpet and other areas or objects. Tourniquets have unraveled and have been fully displaced due to snagging on objects during patient movement. Moreover, muscles contract, which can lead to tourniquets loosening. It’s important to reassess these prior interventions. And subsequent intervention, such as retightening a tourniquet or placing a new tourniquet above or below the previously applied tourniquet, may be required.
Airway patency and work of breathing are very important while treating in this zone of care. This zone is usually located at the rally point. Medics are still in danger if the situation escalates or encroaches into the warm zone. Operators and other law enforcement personnel are still needed to provide security. Medics should perform the M.A.R.C.H.H. assessment to check for injuries. This includes:
- Massive hemorrhage.
- Airway.
- Respirations.
- Circulation.
- Hypothermia/head injury.
B.A.T.H. is a new rapid trauma assessment researched by DHS/FEMA and instructed by active and retired first responders through Louisiana State University. It stands for the following:
- Bleeding.
- Airway.
- Tension pneumothorax.
- Hypothermia.
The legs are assessed first (front and back), using a “raking/blood sweeping” method. The head is checked then the arms (front and back). The thoracic and abdominal areas are next. Finally, the back is checked for blood and exit or entrance wounds.
If any extremity wounds are found and direct pressure does not work, then a tourniquet is placed high and tight. If a junctional wound is found in a spot such as the armpit, groin, neck, or buttock, then the pack the wound with a hemostatic gauze or a regular gauze. Apply pressure for 30 seconds to 3 minutes with a hemostatic gauze (depending on the type of hemostatic used) and for 5 minutes with regular gauze. In the case of multiple casualties, triage patients. The Akron Fire Department’s EMS protocol to sort patients based on severity of injuries uses S.A.L.T. This one stands for the following:
- Sort.
- Assess.
- Lifesaving interventions.
- Treatment/Transport.
This approach has been pretty successful in our EMS system, in terms of accuracy and speed of patient care. Check for trauma to the airway due to blunt-force trauma, projectiles, thermal sources, and exposure to drugs. Start with the head-tilt chin lift to access the airway if no trauma is involved. A jaw-thrust maneuver is warranted by trauma though. Place a nasal or oral airway adjunct and bag the patient if breathing is inadequate or non-existent. More advanced airway devices may need utilized such as a supraglottic airway device or endotracheal intubation. A last resort is to perform a cricothyrotomy by inserting an airway device through the cricothyroid membrane for definitive airway security.
Akron Fire Department’s protocol allows us to use a scalpel to cut vertically over the cricothyroid membrane. We then find the landmarks for the cricoid cartilage ring and the cricothyroid membrane. We make a horizontal cut into this membrane. We follow this with a bougie; an endotracheal tube is slid over the bougie and into the opening. We inflate the cuff and secure the tube with tape or a commercial tube holder before we deliver breaths with a bag-valve mask. Follow your local protocols regarding procedures, however.
Breathing adequacy is a necessity. Place both hands on the chest walls to feel for equal chest rise and fall. Gathering a full set of vitals in this zone may not be viable. A quick assessment of lung sounds using a stethoscope would allow the medic to locate the development of a tension pneumothorax. If the patient is awake and alert, they may be able to tell you they cannot breathe adequately. Abnormal respiration rates, audible wheezing and/or rhonchi, and jugular vein distension are more telltale signs of a tension pneumothorax. Tracheal deviation is a late sign and may not be seen at all. More than likely, the medic will have difficulty bagging the patient with a bag valve mask. An absence of lung sounds on one side or the other is another good indicator of this injury.
Chest decompression on the injured side is one treatment to use. A chest seal is another treatment you can use in this zone if a sucking chest wound is found. If an explosion occurs, especially inside of a structure, the victim may sustain blast lung. Depending on the severity of the injury, enclosed space, venting, type of explosive, and the amount of the explosive, the signs and symptoms of blast lung will vary. Loss of consciousness, shock, apnea, tachycardia, dyspnea, cough, hemoptysis, chest pain, and hypoxia are common. This may lead to various levels of shock. Your goal is to stop the patient from going from compensated shock into decompensated shock and eventually into irreversible shock. A late sign of shock will be a considerable drop in blood pressure.
Tactical Evacuation Care
Vital signs and IV/IO access should be referred to the cold zone (TAC-EVAC). The cold zone is where casualties, operators and medics are considered secure from further danger regarding the suspects’ attempts to perpetuate harm. This is not to say that dangers may not arise while in transport such as vehicle collisions. Cold zone treatment requires an “all hands on deck” approach. You must recheck all prior interventions. More advanced treatments such as IV/IO initiation and fluid replacements fall into this zone. Drug administration may be warranted if the patient goes into full arrest. Drugs, which protect from clotting compromise, should also be considered such as tranexamic acid.
It’s also important to prioritize protection from hypothermia since blood will not clot once the core body temperature falls below 90°F. Exposing the patient is necessary; however, covering the patient with blankets and increasing the temperature in the transporting unit is critical. Placing hot packs on the neck, armpits, and groin will also help keep the core body temperature elevated to promote clotting.
If time allows, you can assess the C (circulation) and H (hypothermia/head injury) of M.A.R.C.H. in the warm zone. If not, then assess and treat them in the cold zone. Assessing the circulation section should focus on the levels of shock. Is the casualty compensating? Decompensating shock is avoidable if bleeding is stopped, and thoracic injuries are treated appropriately. When vital signs are accessible, be sure to check for a low blood pressure and a rising pulse, which is usually a late sign of shock (irreversible shock). Package the patient up for evacuation and follow your department’s protocols for trauma transport.
Lethal Triad of Traumatic Death
Keep in mind that interventions are important but must be performed with accuracy and care. For example, initiating an IO and running the fluid wide open to raise blood pressure has been shown through research to be counterproductive and deadly. Prolonged and excessive hypothermia will also lead to higher levels of mortality if gone unchecked. An acidic system and a drop in core body temperature, respectively, will break down current clots and will not allow the body’s natural clotting cascade to function properly. This will lead to the injured bleeding out. Just remember that acidosis + hypothermia + coagulopathy = exsanguination. Coagulopathy is simply a big term used to refer to the inability of the post-trauma body’s blood to clot due to the heavy loss of red blood cells, plasma, platelets, and enzymes. The body cannot produce more of these blood components as fast as the body is losing each component. Since the oxygen levels drop significantly, due to the blood loss being so severe, the body’s cells shift from aerobic metabolism to anaerobic metabolism. Anaerobic metabolism’s byproduct is lactic acid. Lactic acid breaks down previously formed clots. Severe vasoconstriction adds to this lack of oxygen as well. When the core body temperature reaches 90°F, the blood’s clotting enzymes will not form. This is referred to as the lethal triad of traumatic death. A more in-depth explanation of this phenomenon follows.
When there is a breech in the integumentary system, the vascular system will also be compromised if the trauma is deep enough. Once the vascular system is breeched, the body’s clotting factors are activated to stop the blood loss. When someone loses enough blood due to a critical injury, the core body temperature will drop. The vascular system constricts to raise the blood pressure. However, the amount of circulating blood is not adequate for perfusion of the cells.
Oxygen, nutrients, and water are lacking at the cellular level now. When the cell does not have an adequate oxygen supply, the cell’s metabolism changes from aerobic to anaerobic. The byproduct of anaerobic metabolism is lactic acid and other substances. Lactic acid causes the pH to drop from the normal range of 7.35 to 7.45.
Unfortunately, in the past, medical personnel have loaded the patient with high levels of normal saline or lactated ringer’s solutions. These fluids have no oxygen-carrying capacity. Moreover, the average temperature of an IV bag of fluid is approximately 70°F-72°F, give or take a few degrees. In addition, the chloride in normal saline is measured to be a 5.5 on a pH scale. This is a high level of acidity being introduced into an already acidotic vascular system.
Post trauma, keep the patient warm by increasing transportation unit temperatures, placing blankets on the patient, and removing the blood-soaked clothing if possible. Remember to place hot packs on the neck, armpits, and groin area. Avoid introducing too much IV/IO fluid into the patient’s system. Simply maintain peripheral pulses at 90-100 systolic. Too much fluid will bust up previously formed clots. The chloride effect will also break down previously formed clots, too. This adds to subsequent hemorrhaging. The temperature of the IV/IO fluid will also exacerbate a deteriorating core body temperature. IV/IO fluid warming devices, which heat up intravascular fluids, are a great practice during transport. Ideally, administration of packed red blood cells and fresh plasma is a good solution in trauma. Moreover, an even better solution is giving whole blood. Slowing acidosis and hypothermia can be done but this is usually an uphill battle depending on the severity of the injury, time of injury, response times/distances, supplies/equipment, and competency of the crews responding.
Extended Training in TEMS
Working in austere and dangerous environments is not new for prehospital professionals. Dangers are around every corner and a good level of situational awareness is a necessity. Tactical medics face difficult situations and are required to perform at their highest level every time they are dispatched for a raid or a Signal 100. Preparation is the key and training is paramount. When training is inadequate or lacking, every mission should be considered compromised. Keep your medical and tactical knowledge up to date. Train daily to keep your skills intact and fluid. Knowledge is required; however, it must be transferred from the mental file folders to the hands for psychomotor skill enhancement.
Knowledge not utilized is only knowledge if the medic cannot perform accurately and competently in the field when it counts. Use your knowledge to develop skills through constant training. Operators, victims, and fellow EMTs/medics deserve only the best, so train hard and always bring your A-game. To quote the ancient Greek poet Archilochus: “We don’t rise to the level of our expectations; we fall to the level of our training.”
References
Active Threat Integrated Response Course (ATIRC), First Edition, Louisiana State University: National Center for Biochemical Research & Training (NCBRT), April 2020.
“Conference training courses for TEMS paramedics,” Springer, MD, Wright State University: Dayton, OH. Ohio Tactical Officers’ Association (OTOA), 2017.
Cotton, B.A., et al, “The Cellular, Metabolic, and Systemic Consequences of Aggressive Fluid Resuscitation Strategies,” Lippincott, Volume 26, Issue 2, pp. 115 121, 2006. journals.lww.com.
Gerecht, Ryan, “Trauma’s Lethal Triad of Hypothermia, Acidosis & Coagulopathy Create a Deadly Cycle for Trauma Patients.” Journal of Emergency Medical Services (JEMS), April 2014. jems.com/2014/04/02/trauma-s-lethal-triad-hypothermia-acidosis/.
Springer, Brian, and Verbillion, Meagan, “Tactical Emergency Medicine,” Trauma Reports, Relias Media, March 1, 2017. reliasmedia.com/articles/140073-tactical-emergency-medicine.
Tactical Combat Casualty Care: Lessons and Best Practices. Center for Army Lessons Learned, CALL Publications, 2014.
TECC: Tactical Emergency Casualty Care, Second Edition, Course Manual, National Association of Emergency Medical Technicians (NAEMT), Jones & Bartlett Learning, 2019.
Train-the-Trainer Course Manual: Version 3.1, Cooperative Agreement (EMW-2019-CA-00022) administered by the Department of Homeland Security (DHS) and the Federal Emergency Management Agency’s National Training and Education Division (NTED).
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