"To every man, there comes in his lifetime that special moment when he is tapped on the shoulder and offered the chance to do a very special thing, unique and fitted to his talents. What a tragedy if that moment finds him unprepared and unqualified for the work that would be his finest hour."-Sir Winston Churchill
Rescue of downed law enforcement officers is a critical function of tactical teams. Specific algorithms have been developed on the subject.2 As many as 90% of combat fatalities succumb to their wounds before ever reaching a site of definitive medical care.3,4 Twenty percent of early combat deaths (occurring less than one hour after injury) occur from readily treatable causes, particularly exsanguination and untreated tension pneumothorax.3-6 Early identification of and interventions for these injuries by trained medical personnel is therefore critical to patient outcome.
Last year, the fifth annual Medic Up competition, sponsored by the International Tactical EMS (ITEMS) Association, was held at Strategic Operations, a state-of-the-art training facility in San Diego, CA. Ten two-person tactical medical teams competed in four events: dynamic entry, victim rescue, extraordinary deployment and the "gauntlet." This article describes elements of the victim-rescue scenario and lessons learned from it.
The Victim-Rescue Scenario
The scenario: A radio patrol car responded to a report of shots fired in a residential neighborhood. Upon stepping out of the vehicle, the officer either stepped upon an improvised explosive device (IED) or an IED was detonated in close proximity. The officer sustained grievous blast injuries, including amputation of the right lower leg at mid-calf, resulting in significant blood loss.
A first-response tactical element, consisting of three tactical operators and two tactical medics, was tasked with officer rescue. After performing a remote assessment and noting the severity of his injuries, they deemed self-extrication impractical, and the medics advanced under cover provided by the tactical operators. No ballistic shield was available for deployment, nor was a rescue vehicle available for extraction.
During the medics' return to cover, an armed suspect emerged from a nearby building, firing two rounds at the tactical element. The closest officer was struck by a single round through the right upper arm, causing him to drop his weapon. The remaining tactical element engaged the suspect and neutralized the threat. Once in a location of cover and concealment, the tactical medics suddenly found themselves with two patients requiring emergent medical management.
Lessons Learned: Patient One
The first victim sustained multiple traumatic injuries as a consequence of the IED blast, including traumatic amputation of the right lower leg and profuse arterial bleeding. Without prompt intervention, he would die. Although the presence of an IED would be more expected in a combat zone than in a civilian setting, secondary devices have been deployed in the United States. For example, data from the U.S. Drug Enforcement Administration's El Paso Intelligence Center (EPIC) reveals that between 0.4-0.8% of all clandestine drug labs contain IEDs or other booby traps.7
The U.S. Special Operations Command Committee on Tactical Combat Casualty Care (COTCCC) has identified three distinct echelons of care in combat casualty management: care under fire, tactical field care and combat casualty evacuation care (CASEVAC).8 Analysis of early combat deaths demonstrates that 22%-38% of exsanguinating hemorrhage deaths occur in anatomic locations amenable to at least temporary lifesaving hemorrhage control by simple first aid measures.3,4,6 Recent experience in Iraq demonstrates that 77% of casualties surviving to presentation at a Forward Resuscitative Surgical System (FRSS) sustained extremity injuries.9 As a result of these findings, COTCCC has recommended that the medical management of casualties while under effective fire be limited to control of life-threatening external hemorrhage.6,9,10 In these circumstances, the tourniquet (TQ) is recommended for definitive control of exsanguinating extremity trauma.6,8,10,11 To this end, every U.S. Army and Marine Corps soldier is now being equipped with a TQ as a component of their Improved First Aid Kit.