It’s Time to Train and Equip EMS Personnel to Respond to Active Threats

Over the past decade we’ve focused a great deal on attention to educating and equipping our law enforcement officers with individual first aid kits (IFAKs). We’ve not only equipped our officers with at least one commercially produced tourniquet and hemostatic dressings, but also trained them to manage severe extremity and junctional bleeding. Although much of the focus has been on law enforcement embracing the self-aid buddy aid (SABA) philosophy, many agencies have overlooked providing the same equipment and training to our EMS and fire department first responders.

One reason behind this oversight may be a flawed thought process, that EMS providers and fire department personnel are medical professionals and, therefore, are already trained to manage these types of emergencies. Although our EMS system personnel are medical professionals, the vast majority of our frontline personnel aren’t tactical medical providers.

Undeniable Need

While in my early years of EMS, there was no real need to think about training all frontline personnel in what is now Tactical Emergency Casualty Care (TECC), the threat matrix has changed. Following large-scale shootings across the country, the Boston bombings and most recently our Austin serial bombings, it’s undeniable that the matrix has now changed enough to now justify TECC training for all first responders.

The question may remain for some as to why this training is necessary for people who are already professional medical first responders. The answer is relatively simple: Medicine on the “X” is dramatically different from how we approach our standard patient utilizing the 9-1-1 system. The “X” is the location of the point of injuring such as a shooting, stabbing or explosion. The concept is that the “X” is the location chosen by the actor to inflict harm and that “X” remains a dangerous place to stay.

During normal EMS operations, we tend to encourage managing the trauma patient where they’re found, stabilizing them and then carefully moving them in a coordinated fashion in order to prevent further injury. Care on the “X” is strictly tailored to manage acute immediately life-threatening bleeding–and that’s it!

Anything other than a hastily applied tourniquet should be done from a position of cover. Rather than applying a C-collar, loading them on to a scoop stretcher or backboard and then onto the stretcher. The casualty on the “X” should be moved by the most expeditious method possible. This may be a compact patient movement device such as a MegaMover, a carry or even a drag. These options are less preferable to simply calling to the casualty to determine if they can move themselves off of the “X” to a position of cover or possibly instructing them to apply a tourniquet to themself.

Although these concepts seem intuitive, even for the untrained individual, they are not. In fact, it’s quite difficult to overcome the usual pattern of prehospital care unless you’re not only trained, but also regularly practice these TECC concepts.

Another barrier to providing bleeding control adjuncts on individual EMS and fire first responders is the notion that the equipment in located on the ambulance or fire apparatus somewhere, therefore personnel carrying on their person would be unnecessarily redundant and expensive. The concept of TECC, particularly as it relates to care on the “X” requires that tourniquets be with the responder at the first point of contact with the casualty.

Video of the Texas Department of Safety Trooper shooting as well as the Pennsylvania State Police video demonstrate the fact that tourniquets were immediately available made the difference between life and death. Although law enforcement officers are more likely to be the victims of penetrating injuries, EMS and fire personnel aren’t immune from threat while in the workplace.

In Austin-Travis County, we’ve learned through our tourniquet deployment with the Texas Department of Public Safety that law enforcement officers aren’t only utilizing tourniquets and other IFAK items to save themselves and their colleagues, but they’re also using them on members of the public, and even the perpetrators of the violence one they’re in custody. The same arguments that were made to get these lifesaving adjuncts as a ubiquitous part of today’s law enforcement uniform should also be used as the rationale for our EMS and fire first responders to carry IFAK-style kits on themselves at all times.

“˜Two is One and One is None’

The next item to address is what and how many adjuncts to carry in the EMS and fire IFAK. Many will refer to the military expression, “Two is One and One is None,” which, in fact, holds true. I would much rather have one tourniquet than none, however, we’ve found through many years of clinical experience in the civilian setting of tourniquet application that although a single tourniquet may be effective in an upper extremity injury, the success rates for a lower extremity wound are much less. Therefore, first responders should carry at least two tourniquets.

Tourniquets carried on the first responder are designed to manage one casualty, either for the first responder themselves or a single victim. In general, EMS systems that carry tourniquets may have one or two in a standard duty or trauma bag.

Once again, we’ve learned through multiple mass casualty incidents (MCIs), such as the Reno Air Races disaster in 2011, that this is simply not enough. The result of the Reno crash was 15 immediate amputations that had to be managed with only a few commercially available tourniquets available. Some systems have deployed larger caches of tourniquets and hemostatic dressings with command vehicles or EMS supervisors. This may be a cost effective, but its operational efficacy is highly dependent on the distribution of these units in the coverage area.

As a guide, consider that a two-person ambulance crew may be able to effectively triage and initially manage 5-10 patients depending on severity of injuries in an MCI. Therefore, a five ambulance response with an EMS supervisor may be able to initially manage 50-100 casualties. Although transport and definitive management will require substantially more resources, it’s essential that each unit have enough equipment for initial management of an appropriate volume of casualties. Each ambulance would need 10-20 tourniquets, and each EMS supervisor or command vehicle would need 20-40. It’s important to note that while IFAKs require tourniquets that can be applied with a single hand, tourniquets for MCIs don’t depend on this feature, which often means they’re less expensive.

Be Prepared & Ready

MCIs have become a new normal for us in the United States, and no jurisdiction is immune from this possibility. We’re no longer in an age where we can excuse lack of foresight and preparation for these types of emergencies. Learn from what so many other communities have faced and ensure your service is ready to answer the call.

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Mark E.A. Escott, MD, MPH, FACEP, NRP, is the medical director for Austin-Travis County EMS System. He's also a medical director and founder of Rice University EMS in Houston and an assistant professor in the Department of Emergency Medicine at Baylor College of Medicine. He's the chair of the American College of Emergency Physicians Section of EMS and Prehospital Medicine and board-certified in emergency medicine and subspecialty board-certified in EMS.

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