Tactical medical solutions for the tip of the spear.
CSAT’s Tactical Medical Integration Course
By Daniel Huie
Combat Shooting and Tactics (CSAT) recently presented a one-week Tactical Medical Integration course. The goal was to teach a system to officers in the individual and team skills required to solve tactical problems that involve casualties. CSAT’s course focused on the Care Under Fire (CUF) phase of Tactical Combat Casualty Care (TCCC) or the Direct Threat (DT) phase of Tactical Emergency Casualty Care (TECC) and the transition of the casualty to civilian Emergency Medical Services (EMS).
Located on Nacogdoches, Texas, CSAT is owned by USAR MSG (ret) Paul Howe. Howe served in the US Army for 20 years, 10 years of that in Special Operations. While assigned to SpecOps, he saw combat in multiple operational areas. Howe’s philosophy is to combine sound tactics with good medicine. This class was about the tactics of processing a casualty and the “when and where” of medical care.
TCCC and TECC are military and civilian tactical-operation medical care guidelines. Treatment for casualties is divided into three phases, which are driven by the mission and tactics, not by medicine. The phases are a fluid continuum that can rapidly shift from one to the other. The phases of care are about the most appropriate medical care at the earliest opportunity. Participants at each level should have the corresponding tactical and medical skills to match. Medical care progresses from self aid, to buddy aid, to medic care.
First, Care Under Fire (CUF) or Direct Threat (DT) is when officers are under immediate or imminent fire. Second, Tactical Field Care (TFC) or Indirect Threat (IT) is when the potential for direct engagement remains elevated but is not immediate or imminent. Third, Casualty Evacuation (CASEVAC) or Tactical Evacuation (TACEVAC) is where the threat is low.
The first principle of TCCC and TECC is to gain tactical superiority. Before rendering definitive medical care, a secure area should be created to treat the wounded. CSAT provided a system for an individual officer or team to solve a tactical problem, secure an area to treat wounded, and then transition to a higher level of medical care.
The first day began by dividing the 21 law enforcement, military and medical students into four teams with an experienced law enforcement team leader each. For the skill level of our class, we were live firing all of our training modules. Live fire training requires students to be fully ‘switched on.’ It is an experience that can’t be duplicated with dry weapons or simulation rounds.
Howe reviewed CSAT’s recommendations on the ‘when and where’ of medical care. He explained the inverse relationship between tactical capability and medical care for participants during tactical operations. Since tactical dominance is the priority in the hot zone, the need for tactical skills is high there while the need for medical capability is low. As the scene transitions from hot to cold, the need for medical capability increases while the need for tactical capability decreases.
Howe recommended the deployment of operators trained in basic medical skills in the hot zone. If available, a medic trained as an operator can provide advanced medical care to casualties once the tactical advantage and a secure site are gained. A medic with basic tactical skills can also be inserted into a secure area to render intermediate medical care to a casualty if necessary.
Finally, once a transition zone where officers can hand off casualties to EMS is established or a scene is secured, traditional civilian EMS assets can be used. With this structure, even in the absence of tactical medics, officers with sound tactics and basic medical skills can still effectively process casualties.
We were instructed to use the MARCH acronym as the order of priority to treat casualties in the tactical environment. MARCH stands for 1) Massive bleeding, 2) Airway, 3) Respiratory, 4) Circulation and 5) Hypothermia and Head trauma.
We reviewed tourniquets and wound dressings as the medical skills to be used during the week. Teams were issued tourniquets, wound bandages, soft litters, and strobes. CSAT used third generation SOF-T tourniquets for our class. Along with the Combat Application Tourniquet (CAT), the SOF-T is one of the tourniquets approved for use by the Committee on Tactical Combat Casualty Care.
Howe divides casualty movement into short, medium and long distances. For short distances, we reviewed drags and carries. For medium distance movements, he issued soft litters. Soft litters have the positive attributes of portability, compactness, light weight and the ability to navigate narrow interior hallways when loaded with a casualty. For longer distances, he discussed rigid litters. CSAT recommends electronic strobes to mark locations and for link-ups. The strobes can be bought at sports stores and are the size of a small key chain.
The rest of day one was spent on weapons skills assessment on the square range. Howe used the time to ensure that our firearms skills were at the appropriate level, before our live fire training modules. We shot both pistol and rifle. We practiced linear marksmanship, along with weapons safety and manipulation while moving around fellow team members. CSAT uses a proprietary 5 percent hostage target that requires a shooter to balance his speed and marksmanship to successfully engage the threat target without hitting a hostage.
The second day started with one-man, two-man and team Close Quarters Battle (CQB) tactics. CSAT’s training method is modular and graduated. Its modules build on one another from the individual to team level. The modules are designed to share common tactical elements from real life problems.
Howe recommended processing room casualties in this order of priority: 1) neutralize the threat; 2) secure the suspect and weapon, 3) identify the casualty; 4) move the casualty to a defensible location; 5) treat the casualty; and then 6) package the casualty for evacuation to EMS.
Each CQB module included a simulated casualty with a bleeding extremity wound. Howe instructed the students on how each module should be run. We then practiced each exercise with unloaded weapons until we were ready to perform it live fire. We processed each casualty in the recommended order of priority. As operators were added to the training, more hands became available to solve the problem.
The third day began with a review of our CQB live fire runs. Howe then lectured on team hallway movement and casualty recovery. Afterward, we moved to the CSAT shoot house to practice hallway movement with casualties. At the shoot house, Howe instructed us on hallway movement and applied day one’s CQB techniques to secure adjoining rooms near the hallway casualties. He recommends moving hallway casualties into rooms for treatment. We maintained the same priority of gaining tactical superiority before securing a safe area for medical treatment.
Our order of work was to neutralize any threats, secure any threats and weapons, identify casualties, move casualties to defensible positions, treat casualties while maintaining security, and package casualties for movement to EMS.
After successfully practicing dry runs, we moved on to live fire training. In this evolution, Howe placed multiple simulated casualties in various locations down a long hallway. Our four teams serially secured the long hallway and rooms. As our teams processed the hallway, we recovered the casualties to secured rooms. Once recovered, we treated the casualties and then packaged them for movement to EMS.
The fourth day began with a review of our hallway runs. Howe then lectured on exterior movement and officer rescues. This module applied to open field casualties, including an officer down at the front of a home or car while answering a call to a tactical team suffering an injury on the way to the breach. We then moved back to the CSAT shoot house.
At the shoot house, we first practiced bounding techniques before adding an “officer down” en-route to the breach. Our order of work was to neutralize the threat, secure the area, identify the casualty (in this case an officer down), move the casualty to a defensible position, treat the casualty, and then move the casualty to EMS. We maintained security throughout.
The final day consisted of multiple individual live fire drills. The drills tested the student’s ability to engage threats while maintaining situational awareness, fire superiority, and combat mindset while applying self aid to a wound.
Officers in critical incidents are in an immediate position to render life saving care. Any officer can make a huge difference with solid tactical skills combined with basic medical knowledge and a practiced planned transition to traditional EMS. CSAT’s Tactical Medical Integration Course teaches the individual officer or tactical team the skills to do just that.
Tactical Medical Integration is an excellent course. Howe’s instructional system is modular and graduated, which ensures that his Tactical Medical Integration, Basic/Advanced SWAT, Shoot House Instructor, Advanced Hostage Rescue and Weapon Courses all complement each other. The Tactical Medical Integration class is restricted to law enforcement and military students.
Daniel A. Huie, MD, JD, is a Family Medicine physician. He is a reserve police officer with the Hillsborough, Calif. Police and the medical director of the regional tactical medic program. He is a graduate of California POST tactical medicine, basic SWAT, firearms instructor, and patrol rifle instructor courses. He may be reached at email@example.com.