Quality Corner: Tactical Medicine Isn’t Just for SWAT Anymore

Prior to 1999 the typical plan of action throughout the United States for responding to school invasions was to cordon off the area and call SWAT. The Columbine High School shootings in April 1999 changed that mind-set forever. At Columbine armed police and EMS did exactly what they were trained to do: Cordon off the school and wait for SWAT. SWAT entered Columbine 45 minutes after the first shot was fired. A ramp-up time of 45 minutes for a tactical team not centrally located and whose members’ primary responsibility was everything but SWAT—which is the case throughout most of the country—is about as quick as can be expected. But giving shooters 45 minutes to continue shooting children was quickly recognized as unacceptable.

In reviewing Columbine and other recent mass shootings, the National Tactical Officers Association (NTOA) identified a paradigm shift in the motives of armed attackers entering schools and other large-occupancy buildings. In the past most such cases resulted in hostage situations, but in recent years the intent of many of these armed invaders has become to kill as many people as possible before committing suicide. Many have no intention of negotiating or surviving themselves. NTOA also recognized that in almost every mass shooting, as soon as the shooters were engaged by police, realizing their killing spree was over, they quickly committed suicide, ending the massacre. As a result the NTOA developed the concept of Immediate Action Rapid Deployment (IARD), whereby the first-arriving police officers team up, rapidly pursue and engage the shooter as quickly as possible.

As a sidebar, the NTOA committee that investigated Columbine and came up with a more effective response strategy is the perfect example of an objective retrospective quality review process. This is important, especially for critical events. Countless lives have been and will be saved because of the NTOA’s after-action report on Columbine.

The most good that can be done when a mass shooting or other kind of attack occurs will come from the law enforcement and EMS providers who are on duty and in closest proximity. While SWAT medics spend lots of time training for terrorist attacks, as they should, sometimes there’s not enough attention paid to preparing the EMS providers who, in the vast majority of cases, will have the greatest capacity for limiting loss of life and limb.

One EMS agency in southeastern Pennsylvania has recognized the need for an aggressive tactical medicine training program. As an extension of its PHTLS trauma training, Second Alarmer’s Rescue Squad, located in Willow Grove, has implemented the NAEMT’s Tactical Combat Casualty Care (TCCC) course and encouraged all of its employees to take it. The squad has also taken this course on the road to other EMS agencies as far away as Kentucky.

The TCCC course coordinator at Second Alarmer’s, Craig Hall, is a paramedic and experienced military medicine instructor. He professes that, contrary to popular belief, “Under pressure, you do not rise to the occasion, you fall back on your training.”

Tactical medicine is a completely different ballgame than conventional EMS. The biggest difference is the chaotic mass-casualty environment with large numbers of patients, including many time-sensitive life-threatening wounds that must be quickly recognized and mitigated. No matter how good and experienced an EMS provider is, if they attempt to manage the tactical situation as they would a typical mass-casualty incident, they will almost surely fail in their goal of saving the most salvageable lives. They will face smoke, noise, slippery blood-soaked floors, patients screaming for help while other patients lie close by, some dead, others alive but appearing dead, multiple amputations and massive bleeding—total and complete chaos.

No training can totally prepare someone for the horror and chaos of a mass shooting or bombing, but this same NAEMT TCCC course provided to the military today has resulted in many critically wounded casualties surviving in Iraq and Afghanistan where others died in previous wars.

For more see https://www.naemt.org/education/TCCC/tccc.aspx.

Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He is the quality improvement coordinator for both of these midsize third-service agencies. He has 30 years’ experience in EMS. Contact him at jhayes763@yahoo.com.