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Officer Down in Tactical Environments

Written by Ron Wenzel

Is your tactical team prepared to treat injuries sustained under effective hostile fire during tactical missions? What is your contingency plan for such an emergency?” The answers I hear from Team Leaders are typically, “Load and Go” with the downed officer, i.e., place the officer into a patrol car and race to the nearest mission, that being to enter a building and locate a wanted suspect. During this scenario the SRT will methodically search the building using the best of tactics. The same tactics your team trains with at least once, if not more times a month.

As your team searches, a barrage of gunfire erupts from within the building. The suspect is shooting at you with some pretty heavy firepower and one of your team members is hit in the right leg. Your downed team member is screaming and a massive amount of blood is pumping from a completely severed femoral artery.

With the suspect still producing effective hostile fire, how are you going to implement your plan? How are you going to get your injured officer into a patrol car, and how much time do you have before he bleeds to death?

If your plan is to simply end the mission and pull out, don’t forget your suspect is still shooting at you. It might not be possible to get to your officer until you neutralize the suspect or “gain real estate” within the building. Is your team prepared to do this within two to four minutes? They better be this good because your downed officer, with the completely severed femoral artery, will die within those four minutes.

No simple answers exist for the above scenario, but there are changes that can be made, such as those being made by the United States Coast Guard’s Tactical Operations (TACOPS) Section at Sector, New York. This tactical unit was created following the September 11, 2001 attack in answer to the Coast Guard’s understanding that the United States Maritime Infrastructure needed to be protected from possible terrorist attacks.

Originally called “Sea Marshals,” the unit sends teams offshore to board and take positive control of high-risk/high-consequence vessels that are entering the Port of New York & New Jersey. The concept is to have armed Coast Guard law enforcement officers ready to defend the vessel, and to prevent an adversary from taking control of the vessel and using it as a weapon (as was done with aircraft on 9/11/01).

The newly created unit had to address emergency medical issues early on. Lieutenant Commander Gary L. Jones, TACOPS immediate past officer-in-charge and one of its three assigned Tactical Medics, “Here we are sending specialized teams into harm’s way looking for bad people who want to do bad things without any inherent medical support.”

“Our TACOPS teams are highly trained for the environment that they operate in; they need to be equipped with and deserve more than basic first aid. As a medic and operator myself, I feel that it’s critical to have a tactical medic program. Including tactical medics gives the teams the confidence that if they went down we could continue the mission while providing them care under fire and appropriate evacuation.”

Lieutenant James Cullen, Tactical Operations Reserve Section Chief, explained that the level of medical training its members received was limited to the basic first aid instruction given in to all Coast Guardsmen in boot camp. TACOPS found some of its members receiving potentially life-threatening injuries during normal, non-hostile operations. Some of these injuries were out on the open water, with emergency medical services (EMS) not readily available.

As a result the USCG operator needed to rely on his boot camp basic first aid course. Could you or any of your police colleagues depend on your level of first aid training to sustain you during active tactical situations? Are you mandated to re-certify or further your EMS knowledge?

With no corpsman assigned to the USCG TACOPS unit, it was determined that a Department of Transportation approved First Responder Course would be run for the unit’s members. While the First Responder training was beneficial, there were still some unsolved issues.

The major issue was that the First Responder emphasized treating victims in ideal conditions, with ideal equipment and with ideal transportation readily available. The course did not teach the members how to treat a person while being shot at, in austere conditions and with limited medical equipment. And this was the very training that was needed!

Additionally, the entire TACOPS team does not have the luxury of stopping their advance on an adversary to pause and treat a wounded team member. If an adversary has taken control of a vessel to use as a ramming/explosive weapon (say, a gasoline tanker with 7 million gallons of high-octane fuel aboard) stopping to treat a teammate will almost certainly result in casualty for all. The threat must be immediately neutralized and control of the vessel regained to ensure the survival of the team.

Most of the first aid courses police officers are given are not designed for the combat setting that includes incoming fire, darkness, environmental factors, casualty transportation problems and command decisions.

Fort Sam Houston, TX is the training center for all of the Army’s medics. The Coast Guard’s questions were posed to Donald Parson, curriculum developer and senior instructor for the Army’s Combat Medic Training Program who explained that the military has “Tactical Combat Casualty Care (TCCC) Guidelines” that addressed USCG TACOPS’ exact concerns.

TCCC was created in answer to the unfortunate events that occurred on October 3 and 4, 1993 in Mogadishu, Somalia. Some very valuable lessons were learned from that peacekeeping mission that went terribly wrong, as made obvious in the movie Blackhawk Down.

As explained by retired Army SFC Robert Miller, a TCCC Committee member, SOF medic from the Ranger Regiment and Director of Research & Development for North American Rescue Products who traveled to the USCG’s Sector New York headquarters to run a TCCC Train-The-Trainer program, TCCC separates treatment into three separate and distinct phases of care: 1) Care Under Fire, 2) Tactical Field Care and 3) Casualty Evacuation.

TCCC Guidelines can be employed to both military operations and civilian SRT. Both civilian law enforcement and military tactical operators wear a uniform and protective body armor, carry weapons, operate in dangerous conditions, and would want to live to see the next day.

Both have similar missions: Civilian SRT teams often conduct missions in buildings and structures, in alleyways, and on the street while modern battlefields are more often on urban streets rather than in a jungle. A simple change of uniform color morphs military tactical operations to law enforcement missions.

Care Under Fire

The Care Under Fire phase is rendered by the medic or teammate while he and the casualty are still under effective hostile fire. Medical equipment is limited to what is carried in the casualty’s or medics’ assault bag. At a minimum, every member of the team should have a small kit located in a standardized location (such as the left BDU pants pocket). The kit, commonly referred to as a Bleeding Control Kit or BCK, should contain a trauma dressing, tourniquet, 28F naso-airway, vacuumed gauze, and an occlusive dressing.

Medical treatment will be extremely limited with attention given only to life-threatening bleeding, defined as bright or dark red arterial and venous spurting blood. Treating this bleeding will serious defy what you may have learned in a basic first aid, first responder or EMT class.

Treatment of an extremity wound that has serious venous or arterial bleeding will be the placement of a tourniquet two to four inches above the wound site. Under TCCC guidelines a tourniquet is the first line of defense for massive hemorrhage control while under fire. Research has shown that bleeding to death from an extremity wound is the number one cause of preventable death on the modern day battlefield. Both research and common sense indicate it is better to sacrifice a limb than to bleed to death.

Key points for the Care Under Fire Phase are to return fire as directed or required (the best medicine on the battlefield will be fire superiority!), allow the injured member to stay in the fight unless mentally or physically unable, keep additional members of the team from getting injured, keep the injured member from receiving additional injuries, and stop any life-threatening hemorrhaging by using a tourniquet or hemostatic dressing (i.e., Quickclot or HemCon).

In the civilian world of medicine, hemostatic dressings are still controversial mainly because of myth. Many hemostatic agents are made from natural materials such as Zeolite (a granular mineral substance), shrimp shells and potato starch. While the Food & Drug Administration has recently approved many of these agents, they are a form of medical treatment and you’d be well advised to check with your local medical oversight facility for approval to use.

In the event the injured officer has a compromised airway, it is best to defer treatment until the Tactical Field Care Phase. You must also remember that although you may have a medical component (also known as Tactical Emergency Medical Support, TEMS) embedded into your SRT operations, the SRT leader has the ultimate authority with decision making.

Tactical Field Care

The Tactical Field Care phase refers to that period when the injured member and medic personnel are no longer under effective hostile fire. The medical treatment is still limited to the equipment carried in the casualty’s or medic’s assault bag. During this phase personnel are guarded by a sense of cover or concealment from the threat, thus allowing a higher level of effective care to be provided to the injured officer. First, reassess the mental status of your injured officer. If the officer’s mental status is compromised, then he must be disarmed immediately.

Airway concerns can then be addressed. Airway care is not tended to during the Care Under Fire Phase because the injured officer is going to be moved, and during movement it will be very likely that attempts to maintain the airway will be lost. Under the Tactical Field Care Phase, TEMS personnel can assess for airway problems. Conscious injured officers who have no signs of airway obstruction will have a nasopharyngeal airway inserted. The injured officer will then be placed into the recovery position.

Unconscious injured officers with an obstructed airway will also have a nasopharyngeal airway inserted and placed into the recovery position, but will need more advanced treatment performed by someone who is certified in Advanced Life Support (ALS). TEMS personnel must assess whether or not penetrating chest trauma or blast injuries are causing airway problems.

Chest trauma can cause a pneumothorax, of which there are four types: simple pneumothorax, hemopneumothorax, open pneumothorax, and tension pneumothorax. For our purposes we will only look at a hemopneumothorax and a tension pneumothorax. A hemopneumothorax is associated with gunshot wounds to the chest and may be lethal if too much blood from the wound is lost. Treatment is to place an occlusive dressing over the chest wound to seal the wound yet allow air to escape. Preferable occlusive dressings include Vaseline impregnated gauze or the Rusch Asherman Chest Seal.

A tension pneumothorax is a condition that results from a progressive deterioration and worsening of an open pneumothorax. This condition may cause oxygenation and perfusion deficits from pressurized gas between the lung and the chest wall. As time passes the air in the chest cavity begins to fill the pleural space and begins to place tension on the heart, lungs and trachea. This will result in pressure on the lungs, the trachea deviating from its midline, and decreased cardiac output.

Tension pneumothorax is the second leading cause of preventable death on the modern day battlefield. This condition will cause extreme respiratory distress for an injured officer and must be treated and monitored. Treatment for this condition is achieved through a procedure called “Needle Decompression.”

A needle decompression catheter, typically 10 gauge in size, is inserted into a prescribed location in the chest wall, allowing the air to escape, thus relieving the tension in the chest cavity. While many jurisdictions require needle decompression to be performed only by ALS personnel, needle decompression is a simple procedure in which the Army is currently training all its First Responders.

A decrease in gunshot wounds to the chest and resulting tension pneumothorax can be attributed to the increased use of body armor in both the military and civilian agencies. A common issue with gunshot wounds to the chest is the fact that rescue personnel often focus too much on the entrance wound and sometimes forget to check for an exit wound. Exit wounds must be cared for!

Bleeding will be reassessed during this phase. If a tourniquet was used the TEMS member will need to decide whether the tourniquet will remain in place or can it be replaced by a hemostatic dressing or a pressure bandage such as an Emergency Trauma Dressing (ETD).

After bleeding has been checked, fractures can be splinted and the distal pulse checked. Splinting can be done very creatively with a Sam Splint, a revolutionary thin piece of aluminum, covered with a type of foam, that when molded correctly will provide a very suitable splint. The splint can then be secured with tape or Coban wrap. Sam Splints are extremely lightweight and will fit in a gear bag nicely.

By far, the most important part of this phase of treatment is to keep in constant communication with your injured officer. Reassure him of what is going on and what you are doing. This will not only afford a sense of comfort, but it also will help ensure a proper airway and good air exchange.

If your team is fortunate enough to have ALS TEMS embedded, then pain medications and fluid resuscitation can be determined and administered accordingly. After your downed officer is stabilized you must now determine a means for evacuation.

Casualty Evacuation

Casualty Evacuation allows for the utmost care of your injured officer, that is if you are working under ideal conditions. If your operations are at times in “challenged conditions” such as being waterborne or in the mountains, you must factor time into your contingency plan. If your operations require use of medevac, you must then factor in landing zones, aircraft availability and weather conditions.

TCCC factors in the possibility that evacuation during military operations can take up to several hours and special operations can take even days. This is not the case for civilian teams who should tailor TCCC to their specific needs.

This does not mean the Casualty Evacuation Phase will not apply to civilian teams. Rather, you should consider setting up a “casualty collection point” somewhere in the area, most likely near the command post. A casualty collection point is a designated area where the injured (police, by-standers or suspects) are taken to be prepared for transport to a medical facility.

The casualty collection point will have a designated transport ambulance, ALS unit and support people available, some who must be trained specifically in gunshot and improvised explosive device (IED) injuries. Ideally, these medics should be trained in the TCCC Guidelines and train with the SRT team frequently.

This TCCC cross training is important as the medic or embedded TEMS personnel may be among the casualties. Also, all personnel must be on the same sheet of music when it comes to treatment. As an example, the application of a tourniquet during the Care Under Fire Phase should not be second-guessed by personnel unfamiliar with TCCC guidelines. ALL members and support personnel should be trained in the TCCC Guidelines, especially by focusing in on “buddy and self aid.”

Those teams fortunate enough to have embedded TEMS personnel have to address liability. Are your TEMS members sworn officers or civilians? Training some of your sworn officers as Emergency Medical Technicians will alleviate any liability issues of having non-armed, civilian personnel with you during operations. However, the use of non-sworn personnel is not to be completely avoided. Just the opposite, non-sworn medical personnel are essential for the casualty collection point. Their professional, daily involvement in providing emergency medical care is critical to the survival of the injured.

The availability of trained personnel and appropriate equipment at the casualty collection point could be limitless, provided you can get the injured there alive. Once the injured officer is at the casualty collection point, he will be reassessed using the same steps as were used in the Tactical Field Care Phase. In addition oxygen therapy can now begin. (Oxygen is of limited or no value during the first two phases; in fact, it can pose a serious hazard when under fire. A projectile piercing an aluminum or steel oxygen bottle, filled with 2000 PSI of pure oxygen will turn it into a wayward missile).

While we can’t prepare for every situation, we can improve the survival of our teammates by evaluating our contingency plans for officer down situations. Team Leaders need to decide if their downed officer contingency plans are acceptable or if they can be improved. TCCC Guidelines provide a structured element for not only the care of the downed officer, but also care of the remainder of the team and the mission.

Officer down scenarios need to be practiced during every training session. A lecture on tactical medicine once every six months is not acceptable. To be the most proficient, your team will need to apply the TCCC guidelines at least monthly during stressful scenario-based training. Good tactical medicine has to be a combination of good medicine and good tactics.” In Tactical Combat Casualty Care, there are three objectives: treat the casualty, prevent additional casualties, and accomplish the mission.

Petty Officer Ron Wenzel is a Boarding Team Member/Tactical Medic, United States Coast Guard Sector New York, Enforcement Branch, Tactical Operations Section and may be reached at ronwenzel@optonline.net.

Published in Tactical Response, Mar/Apr 2006

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