Tactical Emergency Casualty Care Courses Focus on the Basics in High-Threat Environments

Active shooters aren’t uncommon, and civil unrest these days is just a viral video away. We all know we may be called upon to function in high-threat environments; that explains the growing popularity of tactical casualty care-type courses for EMS.

But consider that concept of a “high-threat environment” a little further. Bombs and guns aren’t the only sources of risk to you and your patients.

“I would argue,” says E. Reed Smith, MD, FACEP, cochair and cofounder of the Committee for Tactical Emergency Casualty Care (C-TECC), “that the daily operations of a fire-rescue department are a dangerous thing too.”

Take something as common as answering an MVC on a busy highway. Even with multiple responders and apparatus and traffic control, you’re at risk of an inattentive driver plowing you all down. If you’re first on scene, that risk is even greater. You might also face fire, fuel spills and other hazards.

“That,” says Smith, also medical director for the Arlington County Fire Department in Virginia, “is a high-threat scene. A threat doesn’t have to mean a blast or a bullet—a threat can be cars, collapse, fire or any unknown situation. Things like technical rescue are incredibly dangerous.”

That’s where tactical emergency casualty care comes in. Designed for ongoing high-threat situations, it gives providers a framework for balancing risk vs. benefit and limiting medical care—separating the nice-to-dos from the have-to-dos—until a scene is safe or a patient is someplace safer.

Think military or disaster medicine on a smaller scale: In extenuating circumstances, normal protocols may be trimmed back to the fast, simple essentials geared only to sustaining life through those initial moments.

“A lot of what we do is nice to be done,” says Smith. “Starting an IV is nice to be done in about 99% of situations. But why would I start an IV in a dangerous landslide area, trying to save somebody trapped in the mud? That’s too dangerous. And yet standard medicine doesn’t take that approach. Standard medicine assumes everything is safe. So when we have to work in situations that aren’t safe, like we do every day, there’s a need to scale the medicine back. If it doesn’t save lives, it should wait till later.”

Building Blocks

A number of recent events have helped drive that message home, and there are multiple TECC-type courses out there. Optimally departments might develop their own, based on their own unique threats, populations and circumstances. If that’s not practical, courses are available from industry groups and private organizations. These are generally based on C-TECC guidelines, but they’re not C-TECC products or officially endorsed.

The actual skills used to care for casualties in high-threat scenes are pretty standard: hemorrhage control, opening the airway, sealing an occasional pneumothorax. Imparting basic trauma skills isn’t really what TECC courses are about. C-TECC sees it as providing building blocks; it’s up to departments to embrace and operationalize them as they deem appropriate.

“I don’t need to show you how to use a tourniquet—you should know that just by being an EMT-Basic,” says Smith. “The operationalization of the TECC guidelines is about when you do things. You do this based on this risk, you do that based on that risk.”

The when is generally based around three phases of care identified in the military experience:

• Direct threat care—Care delivered while under attack or in adverse conditions;
• Indirect threat care—Care delivered while the threat has been suppressed but may resurface at any point;
• Evacuation—Care delivered while the casualty is being evacuated from the incident site.

These roughly coincide with our concepts of hot, warm and cold zones. In the hot zone you’re at high risk of injury or death, so actual care is minimal—you keep the patient alive and get them out. In the warm zone there’s still indirect or potential threat—a secondary bomb, a stabilized structure or trench failing—but you can, with some risk, carry out additional interventions. In the cold zone, the threat is minimal and you can deliver full care.

“What we’re doing is empowering the provider to change the protocol based on risk,” says Smith. “If my perception of risk is that it’s at the highest level, I’m going to use this set of rules. If my perception is that risk isn’t as high, then I can use this second set of rules. If my perception of risk is low, then I can use this third set of rules.

“As a whole, TECC is very simple. It’s just about when you do the intervention based on what’s going on around you, and how you marry the operational situation with the priority of medicine. It’s how you determine which takes priority in which situation.”

For more: https://c-tecc.org.