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Cops play prominent role in surgeon's world


Doctor spends a great deal of time as SWAT team member


Dennis Andrews, trauma and burn surgeon at John H. Stroger Hospital, displays the x-ray of a shooting victim. (Antonio Perez, Chicago Tribune / November 12, 2009)





His team was already dressing for battle, and Andrew Dennis was trying to catch up.


With the trunk of his car open, he secured his rifle. Helmet. Headset. Pistol. Taser. He was then quickly briefed about the night's target: a small home on a dark Harveystreet with someone inside rumored to carry a gun on his hip.


Cook County sheriff's police believed there also were drugs inside, and the hostage barricade and terrorist team was going in to find them.


About 30 minutes earlier, Dennis had raced out of Stroger Hospital from his other job, where he treated one last patient who came in from a car crash on State Street.


The emergency was left in the care of a co-worker. Now, Dennis would help provide cover to a fellow team member who would toss the flash-bangs that sound exactly like their name. If things went wrong and someone got hurt, a message on the headset would signal Dennis and other medics to come inside.


Standing at the back of his car, Dennis quickly took in the information from a colleague and nodded. He was ready -- he'd switched from scrubs to fatigues, and had a new purpose.


Dr. Andrew Dennis, 39, a trauma surgeon with a special skill for reconstructing abdominal walls, was ready to help kick in a door.


For about eight years, Dennis has straddled two worlds brimming with violence, working as a surgeon in one of the busiest trauma units in the U.S. and as a sworn police officer and unpaid member of two area SWAT teams: Cook County's and its north suburban counterpart.


"Anything can go wrong," Dennis said, when asked about similarities of the work. "Police officers learn how to face-read and mind-read and are typically more hyper-aware of situations, especially SWAT cops. Trauma surgeons are not that much different. You learn how to read patients."


Dennis' primary focus as a member of the SWAT teams is to provide immediate care to anyone who gets hurt during a raid or a hostage-barricade situation. He did fellowships in trauma, burn and surgical critical care at Cook County Hospital. But he's also described by colleagues as a good shot and quick on his feet.


The mission with Cook County took less than a minute. When it was over, Dennis waited in the front yard with his team as the house was cleared. Nearly four pounds of marijuana and a gun were seized. A 21-year-old man was charged with weapons and drug violations.


Dennis made a point to remind a reporter that he is not normally the one poised at the top of a gangway with an assault rifle ready to fire. He usually goes in as a "protected entity," which puts him, pistol in hand, in the back of the stack of officers who line up and forcibly enter a building. He has never had to fire his gun in the line of duty.


Adding medics or doctors to SWAT teams is an idea that has grown. At a national SWAT conference in September, the sessions on tactical emergency services filled up before any other section -- for the first time ever. Many SWAT teams train members as medics or embed other medical professionals. It is rare to have a trauma surgeon assigned to a SWAT team who is also a sworn officer.


He fell into the work in 2001 after police officers he met during his residency at St. James Hospital suggested he join a team. After a series of calls, he found himself in Glencoe meeting with Mike Volling, who was then commander of a cooperative SWAT team that is part of the Northern Illinois Police Alarm System, a mutual support system of departments.


"My first thought was, something is wrong with this guy," Volling said. "Why does this physician want to come out and play with the police?"


Soon Volling recognized that Dennis was not merely interested in kicking in doors. Volling could tell he wanted to bring expertise to the team.


"He explained to me that on a busy night at Cook County he treats 10 to 15 victims," Volling recalled. "I said this is the guy we've got to get."


The Des Plaines police took Dennis on as an unpaid part-timer, which provided him a place where he could train and get certified as a police officer.


The worst-case scenario Dennis or other medics face is someone suffering a critical injury, most likely a gunshot, as happened in Dallas in 2007, when doctors assigned to that SWAT team saved an officer shot in the neck at a raid.


The more likely scenario is a twisted ankle or a heart attack.


"Should something like that happen -- God forbid -- if we can save one life or save someone from prolonged injury, we did a good thing," said Bill Evans, the commander of Cook County's hostage barricade and terrorist team.


Dennis regularly deals with other issues as a member of the teams, from training injuries to panicked calls about getting the HINI shot. He has taught them how to recognize heat exhaustion or what a sucking chest wound sounds like.


"The majority of issues we deal with on SWAT are not traumatic in nature," Dennis said. "It's is someone gonna have the big grabber today? ... Officer survival is paramount -- to empower and equip these individuals, who are putting their lives on the line for you and me, to be able to go home to their families."


Back at Stroger Hospital -- where Dennis sports pink scrubs -- he is one of seven surgeons in the Cook County Trauma Unit. A typical day starts with rounds at 8 a.m., wearing his signature wooden clogs. He is on call to tend to any trauma injury that comes through the large swinging doors and also to shepherd patients through the recovery process with surgeries.


Dennis has brought his police colleagues to the hospital to learn the clinical side of gun violence and shootings. He also has asked them to give lectures to his residents on gang signs and trends because of the victims treated at Stroger.


Usually, the two worlds -- hospital and law enforcement -- are a natural fit, Dennis said. But at times they collide.


Last year, it was Dennis who pronounced Chicago police officer Nathaniel Taylor dead after he was shot in the head during a shootout. Minutes later, another patient came through the doors: Lamar Cooper, the man accused of killing Taylor, also wounded in the shootout.


In the following hours and days, Dennis was among the surgeons who saved Cooper's life.






Copyright © 2009, Chicago Tribune

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When I was a student in NY there was a PA who worked part-time in a local ED; his full-time job was with NYPD's ESU (Emergency Services Unit). Our MD/PA field response team has done occasional medical coverage for local ESU teams on things like high-risk warrants, but always in the cold zone.

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I do not believe that I have ever met a PA who enters the hot zone, or follows the swat team in while they are clearing and securing the scene


I disagree with the whole premise. UNTIL the scene is reasonably secure, there is nothing that a medic, PA or Doc can truely offer the team that is more advantageous to him on standby in the perimeter.


Otherwise, I think it is simply a PA/Doc wanting to play cowboy.


Join the military if that's what you wanna to do, they will get you plenty of trauma exposure, and, if you are lucky enough to go out on patrol, ()and get shot at), you might change your mind about the "glory" and the "jaz" of being there.


Adamently against the whole idea.



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Otherwise, I think it is simply a PA/Doc wanting to play cowboy


Agreed, but I understand the desire. The best place for that trauma surgeon is out at the truck pulling (at most) perimeter security and getting ready to receive casualties. What happens if he gets shot moving through the door? I'm sure he's not first or second in the stack, but still- he's taking an unecessary risk.





I'd be lying if I said I wasn't jealous as hell tho!!! :D

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Just a quick question...


For teams that have multiple medical officers that are commisioned and trained to perform duties on an entry team, what is the feeling about puting one of them with the people that have the highest chance of injury? I realize the chance is remote but, would it not be to the team's advantage to have medical with an injured individual in an unsecured scene where medical personel are on perimeter cannot directly deal with the issue at hand?

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There is NOTHING that a medic/physician (probably, especially a physician), can offer to an assault team during a firefight in an unsecured scene.


Creavat bandage, pressure dressings...all members of the team can do that.


But, during a firefight, you tend to be somewhat busy. And, as the team is usually the assaulting team, you also tend to have personnel that can haul the insured back behind the LOF to the secondary zone.


The idea here is to achieve the objective, secure the scene, THEN attend to the wounded.


NO ONE will be putting trach, tube, IV, etc in during the firefight... in fact, mosta the time, the medic would be being told to keep his darn head down.


Again, in civilian life, we are not needed in a hot zone.


IF you are a phsycian or medic who also is an assault trained officer, then, IMHO, your on that scene acting as an officer, not medic. But do not confuse those lines of responsibilities.





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Thank you for that response and input. Also thank you for the advice on not confusing my role as LEO vs. medical. To this point I have never had that issue, and being recently retired from my team, won't.

I do however respecfully submit the idea that if medical is already in a secured location, and the team has he ability to insert a LEO/medic into an entry team, why would it not place the resource where it has the best access to the potentially injured?

I do understand that my hypothetical situation is rare at best, not being able to extract an injured Pt. to a secure location. But, if it were me that was injured, I would want a trained medical person as close as possible.

I'm not trying to be argumentative or even suggest I'm right, just offering information based on may own experience.:o

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I thought this article was interesting. It is in this month of JEMS.



Toward the Sound of Shooting

Arlington County, Va., rescue task force represents a new medical response model to active shooter incidents

E. Reed Smith, MD, Blake Iselin, FF/EMT-III, Assistant Chief W. Scott McKay

December 2009 JEMS Vol. 34 No. 12

2009 Dec 1

In November 2008, a group of 10 well-trained terrorists with good communications systems and a well-coordinated plan essentially held Mumbai, the largest city in India, paralyzed for more than 24 hours. Although the coordination and scale of the Mumbai attack went beyond what we’ve seen in the U.S., active shooter scenarios aren’t foreign to us.

An "active shooter incident" is commonly defined as an incident in which one or more people use deadly force on other people and continue to do so while having unrestricted access to additional victims. Almost every year, several of these incidents happen throughout the country, injuring and killing innocent civilians. They range in size, scale and publicity, with the most infamous being the killings at Columbine High School (12 killed, 23 wounded) and Virginia Tech University (32 killed, 17 wounded). On Nov. 5, an Army major went on a shooting rampage at Ft. Hood, Texas, killing 13 and wounding 30 others.

In the past decade, the EMS community has spent a lot of time and effort training to increase awareness, detection and response capability for weapons of mass destruction. But we’ve failed to address what could possibly be the greatest threat for mass casualty—the well-armed, well-supplied lone gunman who is willing to or intends to die in the act of killing and injuring others, including fire and EMS responders.

Other first responder groups have addressed this issue. After the Columbine High School shooting in 1999, police agencies across the country addressed what appeared to be failures in their tactical response to active shooter scenarios. They developed proactive response plans, which established a standard that’s now commonplace. Prior to Columbine, the police model was to cordon off the area and wait for the arrival of a SWAT team to engage the threat. In most circumstances, this process allowed the shooter to continue to be active inside the perimeter and led to a significant delay in getting victims to medical care.

In a paradigm shift following Columbine, police departments moved to an aggressive response in which police immediately pursue, establish contact with and neutralize the shooter; the idea is that the sooner the shooter can be contained, captured or neutralized, the fewer the casualties.

To meet this objective, first responding patrol officers organize and deploy in three- or four-person teams as soon as they arrive on scene; they move quickly through unsecured areas, bypassing the dead, wounded and panicked citizens with the goal of engaging and eliminating the active threat. They’re now trained to "move toward the sound of shooting."

In contrast, fire/EMS hasn’t followed suit. The current standard fire/EMS response to the active shooter is to stage in a secure location until police mitigate the threat and secure the area to create a scene safe for fire/EMS operations. But there’s a basic problem with this response: While waiting for a secure scene, those injured inside the building aren’t receiving care and are dying from their injuries.

In our agency in Arlington County, Va., we recognized this weakness in our EMS response during after-action briefings for a large active shooter drill in which EMS assets were staged for more than an hour before police declared the scene safe for medical operations. Subsequently, in conjunction with the Arlington County Police Department, members of the Arlington County Fire Department developed a new EMS response to active shooter incidents—the Rescue Task Force (RTF)—that takes the current military medicine model of Tactical Combat Casualty Care (TCCC) and applies it to civilian EMS.

The goal of this response is to get medical resources to the patient’s side within minutes of being wounded while continuing to mitigate provider risk. Although our tactical medics were already familiar with TCCC, we felt this small group was limited by their primary role of working directly with our SWAT team and would likely be delayed in their deployment to the scene. The Rescue Task Force, similar to the police response to active shooters, must be implemented almost immediately. So, in order to fully implement the concept, we trained all of our paramedics in TCCC and the operational aspects of the RTF.

The Basics of TCCC

Tactical Combat Casualty Care represents significant advancement in prehospital battlefield care. After the Battle of Mogadishu in 1993 (represented in the movie and book Black Hawk Down ), U.S. Navy Capt. Frank Butler, USN MC; Lt. Col. John Hagman, USA MC; and Ensign George Butler, USN MC, wrote a landmark paper that defined the concept of TCCC and changed the paradigm of how medical care was applied on the modern battlefield. Taking into consideration the limitations due to the austere conditions inherent in combat, TCCC essentially defines a set of principles and medical practices aimed at decreasing preventable deaths at the point of wounding. It defines what needs to be done immediately and in what order.

TCCC is evidence based and well supported by combat data. The Wound Data and Munitions Effectiveness Team study (1967–1969) examined combat wounds from the Vietnam War and found that approximately 20% of all soldiers killed in action died from extremity hemorrhage, tension pneumothorax or airway obstruction, all of which are readily treatable in the field without extensive equipment or medical support. Similar findings were reported in a 1984 study: 9% killed in action from exsanguination from extremity wounds, 5% killed in action from tension pneumothorax and 1% from airway obstruction. Although these wounds are all readily treatable, they’re very time sensitive. Any delay in treatment will increase the risk of mortality; thus, the best chance for survival after ballistic wounding is with a response configuration that puts medical care at the patient’s side within seconds or minutes. "Far-forward" placement of medical assets is therefore essential. The success of such aggressive application of medical care has been proven in the U.S.’ current conflicts, with survival rates of 90% in Operation Iraqi Freedom and Operation Enduring Freedom.

The overriding principal in TCCC is to perform the correct intervention at the correct time in order to stabilize and prevent death from the readily treatable injuries. For the civilian provider, this approach requires a shift in thinking. Airway control is not the first priority. Not only are exsanguinating extremity wounds far more common than airway injury, but a person can bleed to death from a large arterial wound in two to three minutes, while it may take four to five minutes to die from a compromised airway. Therefore, in TCCC, life-threatening bleeding is addressed first, followed closely by airway control. Open chest wounds and tension pneumothorax are of concern as well, but they generally don’t cause mortality for 10–15 minutes, so they’re addressed third. In TCCC, the traditional ABC mnemonic (for airway, breathing, circulation) is replaced by CAB (for circulation, airway, breathing).

Because supplies and resources are limited in combat and austere environments, medical treatment and stabilization must be done expediently with minimal supplies. Tourniquets are emphasized and prioritized as a quick and effective method to control extremity hemorrhage. This practice is based on retrospective medical data that refutes the prevalent civilian EMS doctrine regarding their use and complications. Multiple studies and case reports from Iraq, Afghanistan and Israel have shown the safety of tourniquet use, especially when they can be discontinued within one to two hours. Although patient evacuation may be delayed hours or even days in a military combat zone, in civilian active shooter scenarios, patient evacuation is usually performed within 60–120 minutes and definitive medical care is often easily accessible after evacuation. Thus, for any exsanguinating hemorrhage, tourniquets can be applied immediately and quickly de-escalated once the patient is evacuated to a higher level of care.

For non-exsanguinating hemorrhage, mechanical pressure dressings with wound packing are used. Some wounds, including those in the femoral triangle or in the neck, are not amenable to tourniquets. These wounds are controlled using hemostatic agents, such as Celox, QuikClot ACS and HemCon, in conjunction with direct pressure. These agents enhance the coagulation cascade and increase clotting through local mechanisms in the wound itself. Although the initial versions of the hemostatic granules had morbidity from the exothermic reaction with blood in the wound, the newer versions of these chemicals have addressed and resolved this complication.

For airway control, nasopharyngeal airways are emphasized over oropharyngeal or endotracheal intubation; nasal airways are fast, stable and effective in all unconscious or altered mental status patients, regardless of the presence of a gag reflex. Intubation is de-emphasized because it requires extra equipment and loss of situational awareness. If more definitive airway control is needed, blind insertion devices and cricothyrotomy are the procedures of choice. For breathing, re-establishing chest wall integrity with an adhesive occlusive chest seal and early management of tension pneumothorax is emphasized. Because tension pneumothorax can be difficult to recognize in the uncontrolled setting, aggressive and proactive use of needle chest decompression is used in patients with thoracic injury and respiratory distress.

Translation to Civilian Care

After examining the weapons used by active shooters, the patterns of morbidity/mortality, and the medically austere conditions in which active shootings have taken place, it became clear to our department that civilian active shooter scenarios presented similar conditions and injuries as in combat.

The approach to redefining our medical response to these scenarios is based on the same concept used by firefighters involved in an interior attack on a structure fire: The risk is mitigated by proper equipment, training and tactics. Understanding that time to care is the key to saving lives, EMS personnel must get into the scene of an active shooter as quickly as possible to provide rapid stabilization. It’s no longer acceptable to stage and wait for the affected area to be cleared by the police; doing so defeats all principals of TCCC and can result in a number of preventable deaths.

The RTF is essentially a simple response model made up of multiple four-person teams that move forward into the unsecured scene along secured corridors to provide stabilizing care and evacuation of the injured. Each team consists of two police patrol officers to provide front and rear security, and two medics to stabilize patients using TCCC principles and equipment. In addition to the security of the escorting officers, these medics are outfitted in ballistic vests and helmets to further mitigate the risk of operating in this environment. Based on daily staffing in Arlington County, a total of seven RTFs can be formed at any time, each equipped to carry enough supplies to treat up to 14 victims, depending on their injuries.

Using input from military and medical subject matter experts and considering the operational limitations of the RTF mission, reliable, well-constructed and user-friendly medical and personal protective equipment was chosen and purchased with grant funds secured from the Metropolitan Medical Response System. The following is a list of what was chosen for the RTF:

Personal Protective Equipment

>> Level IIIA Hornet Tactical Vest from Protective Products International with Level IIIA biceps protectors

> Lightweight with a large amount of overall chest and back coverage

> MOLLE webbing across chest for easy attachment of equipment carriers

> Adjustable in size to fit all medics in the department

> Identification with large Arlington County Fire Department patch on front and biceps protectors,

as well as ‘RESCUE TASK FORCE’ on back (see p. 50)

>> Level IIIA Special Operations Helmet

> Lightweight with high-cut back for greater range of motion

> Four-point harness to prevent helmet from sliding over eyes during patient care

Medical Equipment

>> TQS Medical Emergency Tourniquet (MET)

> Open loop system with solid construction

> One-handed operation

>> H Bandage from H&H Associates

> Firmly secured pressure device and solid construction allows for greater amounts of

pressure and easier application

>> Bolin chest seal occlusive dressing

> Strong gel-based adhesive allows for easy fixation and stability during transport

>> QuikClot ACS hemostatic agent

> New formulation of the Zeolite with decreased exothermic properties

> Small gauze pouch design eliminates powder issues and can be used as

wound packing

>> 14 gauge 3" needles for chest decompression

> Current recommendation of Committee for TCCC for use of longer needle

Response Team in Action

If an active shooter incident occurs in Arlington County, the first four or five responding police officers quickly form an initial contact team and enter the building; this is the standard police response. This contact team moves quickly to the sound of the shooter, bypassing wounded victims and other threats in an attempt to eliminate the most immediate threat. In doing so, they essentially clear a corridor into the building and relay important reconnaissance information back to command. Although these officers don’t provide direct assistance to the wounded, they identify the need and call for the RTF.

Once this need is identified and communicated to police command, the RTF is formed with two police officers providing security for two medics as they move into the building down the corridor secured by the initial contact teams. Although directly under police command, the RTF is essentially a unified command asset. Once inside the building, the RTF police officers are directed through the incident commander to move the medics to the injured victims identified by the initial contact teams.

RTF communication functions on two different radio zones: 1) the RTF police officers communicate with police command, giving such information as location of the team within the building and receiving updates on location of the injured, the contact teams and possible threats; 2) the RTF medics communicate with fire command to report the number of victims and injuries. This dual communication allows for accountability and effective use of the teams as well as for planning and management of both the external casualty collection point and additional EMS resources.

The first one or two RTF teams that enter the building move deep inside to stabilize as many victims as possible before any one victim is evacuated. As victims are reached, the RTF police officers provide security in place while the medics treat the victims. Using the concepts of TCCC, they stabilize only the immediately life-threatening wounds on each patient they encounter, but leave these patients where they are found and move on.

The number of victims that can be stabilized by these initial RTF teams is limited only by the amount of supplies carried in. Once out of supplies, teams start moving back out of the building, evacuating patients they’ve treated. At the same time, additional RTF teams are formed as personnel become available; these teams are brought in with the primary mission of evacuating the remaining stabilized victims. They can also be tasked to move further into the building in a "stabilizing but not evacuating" mode to take over for the initial RTF teams that have run out of supplies and begun evacuation.

A supply depot is set up near the entry point to the area of operations to allow for quick re-supply and turnaround for RTF teams. If needed, an internal casualty collection point will be set up near a secure entry point, where casualties can be grouped to allow for faster and more efficient evacuation by non-RTF EMS personnel. All patients are eventually evacuated to an external casualty collection point well outside the building in a secure location where traditional EMS care is initiated.

Skills & Drills

Since RTF inception, we’ve conducted monthly training on the application of care according to TCCC principles, the new personal protective and medical equipment, and RTF operational considerations. Every paramedic in the county, regardless of assignment to engine company or medic unit, is capable of functioning on the Rescue Task Force. For police, the RTF represented a paradigm shift as well; thus, training sessions to teach the concept, the role of security and movement for the medics, and operational details of command and control were held for all patrol and command officers.

Several successful drills have since been conducted to reinforce the concept, training and command/control. The largest of these drills was a full-scale, multi-jurisdictional simulation of a multi-victim high school shooting similar to the Columbine incident. Using a local high school, multiple victims with moulaged ballistic and blast injuries were spread over a large area, simulating a scenario in which shooters moved indiscriminately throughout the school. Additional fixed threats, such as improvised explosive devices (IEDs) that required integration of bomb mitigation squads and limitation of ingress/egress, were also added.

In this drill, the RTF proved feasible and effective. The initial police contact teams requested the RTF within 10 minutes of entering the building; four RTF teams were deployed into the building, and within 30 minutes, all 44 victims had been stabilized and evacuated to the external casualty collection point. This drill reinforced the fact that, using the RTF concept, a large number of severely wounded patients scattered through a large building could be effectively and efficiently treated and evacuated before law enforcement cleared the entire building. In comparison, using the traditional EMS response in a similar drill that year, the first patient contact wasn’t until more than 90 minutes into the drill, and overall, it took more than 2.5 hours to clear the building of patients. Without question, after 2.5 hours, many would have succumbed to their injuries.

Virginia Tech Lessons

The response to the shootings at Virginia Tech University on April 16, 2007, demonstrated the effectiveness of rapid medical intervention via forward placement of medical personnel. Because of prior shootings on that campus, both of the local SWAT teams near Virginia Tech were active, and each had a tactical medic assigned and present with the team. Thus, when the call went out, both teams were formed up, nearby and ready to respond. The teams were inside the building within 12 minutes of the first 9-1-1 calls.

These medics quickly set up an internal casualty collection point and began triaging and stabilizing the injured as they were moved there by officers. Those treated and stabilized with probable life-saving interventions included a young man with a femoral artery injury that was controlled with a tourniquet and a young woman who had a tension pneumothorax relieved by needle chest decompression.

The entire building was declared clear by the tactical teams after 29 minutes, and only then did the rest of the local medical response enter in full force. In this case, although small and limited, the forward medical component was able to apply stabilizing and life-saving interventions near the point of wounded.

Overall, this was an improvement over other incident responses, but two points should be clarified. First, the availability of SWAT teams that day was by chance, only due to the prior activation of the team. On any other day, neither team would have been formed up and available to respond with a tactical medic within 12 minutes. Second, patrol and tactical officers were still required to evacuate the injured to an internal collection point and then out of the building. Essentially, this process left fewer officers available to perform a secondary search for additional shooters, explosives or other threats.


The Rescue Task Force, using the proven military medical concepts of tactical combat casualty care, is a proactive response to a real threat that every fire/EMS department in this country faces. As recent events have shown, the threat of coordinated small arms attacks in public places is not only real but likely in the current global economic and political environment. Prehospital medical response must change the current model of waiting for a secure scene, even though this may involve assuming a higher level of risk. Risk is nothing new for us; every day, we risk our lives to save people from dangerous situations, doing it with a safety net of protocols, training and equipment. The Rescue Task Force concept does the same, using a safety net to move fire/EMS to a new standard. JEMS

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  • 3 weeks later...

That is crazy, why does a trauma surgeon need to be in harms way. I think police officers that are trained as swat medics can stabilize a pt just as well as some field doctor. Then transport the pt to a trauma center, where the surgeon who is out of harms way can fix the pt. I think this is reckless for trauma surgeons to put themselves in harms way. Surgeons are not easily replaced , and can be more useful to the community in a hospital setting(that is why we have paramedics). Just my .02

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I LIKE the TCCC concept.


It really makes sense.


But I agree w/ last 2 posters: the TCCC medical teams do NOT need PA/MD (even RN ) intervention.


At most, EMT/paramedic. Tournequet and chest decompression skills are easily taught and can be accomplished in the field by the assaulting team, not needing the skills of emt/paramedics or higher.


Presumably these scenarios (and evacuating the injured out of the hot jone) is not gonna take much more than 20-30 minutes (if you got there, the scene is reasonably secure).


As an aside: Now that I think about it (and remember my combat casualties), the control of hemorrhage before airways as a policy makes a lot of sense.. in point of fact,. that's what we all do: most guy're screaming or crying and the airway's patency is apparent, but approaching pts from an ABC to a BAC triage makes sense.


Thanks for the article





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The leading causes of preventable death in this environment are hypovolemic shock due to exsanguination (bleeding out), airway problems and tension pneumothorax.


Thus TCCC places a lot of emphasis on using the tourniquet early, how to use the Nasopharyngeal Airway, and how to properly diagnose Tension Pnuemo and do a needle decompression to relieve it.


Doesn't take the level of training a PA has to perform a MARCH...


The acronym stands for:


M- Massive bleeding- prevent exsanguination

A- Airway- secure a patent airway with a Nasopharyngeal Airway

R- Respiration- properly diagnose Tension Pnuemo and do a needle decompression to relieve it

C- Circulation- appropriate use of fluids to maintain cerebral functioning/LOC, but not too much/too fast/too soon..!!!

H- Head/hypothermia- head injuries/warmth


This was the order for treating a casualty when I was in Iraq (60 days), Afghanistan (90 days), Sudan (335 days) with DynCorp in 2005 & 2006.


Like TCCC, the first priority is Fire Superiority!



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I can definitely understand that the PA/MD does not need to make entry with the fire team, however I still believe it would be beneficial to have a PA/MD on scene. As others have said, he or she should be at the periphery performing duties appropriate for perimeter areas. Additionally, any PA/MD on a scene like that ought to be trained and equipped to defend himself and others should things get out of control. What is the likelihood that things will get out of control? Honestly, I don't know. It makes sense that the likelihood would be extremely low. That said, the PA/MD can still provide valuable medical care on scene and en-route to the hospital.


My $.02. And, I should state, I am not a LEO. I am an EMT and I plan to work with our PD in some capacity when I finish PA school.



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  • 1 year later...

I used to teach TC3 for the State Department. I completely agree that emergency medicine should take a back seat to LE activity. One of the biggest issues I had with my students was that once we trained them to provide medical care, they would get themselves in big trouble in the field exercise. They would do way too much too soon, and completely forget about encouraging the down agent to perform self care. The absolute best solution is fire superiority. If the officer/agent is well trained and well practiced, they can and should be able to apply their own TQ. I've seen soldiers do it. Treating the second leading cause of death, tension pneumo, is a bit more difficult. Extraction/Evacuation to at least partial cover, and the assistance of another person is pretty much required. But again, fire superiority and scene control come first. I'm of the opinion that all LEO's/military should be trained in Care Under Fire at minimum. I'm hoping to get back into tactical medicine after PA school, but using my NREMT-P certification, not in the PA capacity.

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Some data points from my neck of the woods:

1) University of Cincinnati's emergency medicine residency program places residents with area SWAT teams. They are trained as part of the entry teams. I don't know

how they are actually used on scenes.

2) Several area SWAT teams use medics as part of their entry teams. They are usually 3 or 4 persons back and responsible for cuffing people unless providing

medical care. They train with all the firearms. However, I'm only aware of 1 which lets the medics carry a weapon without being a commissioned police officer.

3) The former head of Ohio ACEP, who had maintained his police commission from his early days, was a SWAT team member, including serving as a sniper.


So, it is not an uncommon practice.

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GREAT article - very helpful for those of us who don't have anything like this set up. I'm a PA student about 6 weeks out from graduation. I'm also an EMT on my local volunteer department. We had a situation several years back in which we lost an officer because there was no way to get to him after he'd been injured. Now, TCCC wouldn't have helped a lot in that the shooter had full view of the field and had pinned down all officers and medical personnel in the area. That being said, our policy was to stage everyone at the station and wait for the "all clear" before rolling a wheel - in this situation it was prudent because the shooter definitely had the high ground and there's no way to be certain what he was able to hit from his stand. At any rate - this is our policy and I am of the opinion that if we have any future shooting incidents we need to approach them differently.


Now, since our department is volunteer we have only 3 medics total thus making sure we have 1 available at any given moment is difficult. Thus my hope is to operate at the paramedic level (with whatever additional training the state sees necessary) on my local department. Given that the TCCC concept makes sense, I would be a proponent of it for us (at least having the equipment and training with the officers every few months). In our situation, we need to train whoever we can get to commit to this role - it's sort of an "all hands on deck" situation. I'm not a proponent of PAs doing this job - we are trained to do something entirely different. But if a PA is going to operate in pre-hospital medicine, heading up the training, preparation, and implementation of this concept makes sense.


Can you provide a link to that article by chance? I'd like to pass it along.



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Coming from a Paramedic background, I found most doctors, nurses, or whoever in the way. They had nothing to bring to the table that a trained Paramedic can't do and the Paramedic does it most every shift he works. Any scene needs some form of command structure for medical care from injury scene to ER. A doc trying to step in out of his element is just in the way.


With a doc like the OP used as an example, I suppose he has melted into the care system but would question the necessity.


How the good Samaritan law would apply, and how legal would look at him in relation to what is standard and acceptable practice compared to his surgeon peers would be a matter of concern as well.

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