By Michael Rallo

Not a day goes by without a tragedy. Mass shootings, major accidents, terrorist attacks, and natural disasters are constant threats to our society. As the government, military, and other major institutions plan for these incidents, the medical field must also prepare its professionals.

Known as tactical or disaster medicine, this field encompasses a wide-range of operations related to the treatment of sick and injured individuals in unstable situations. Doctors in this field epitomize the belief that early interventions are critical to saving lives that would otherwise be lost. To understand the role of a modern battlefield doctor, one must look to the evolution of this soldier-physician throughout history.

Hippocrates, a Greek physician practicing around 400 B.C., postulated the role of medicine on the battlefield with his claim that “he who desires to practice surgery must go to war.”1 This assertion is still supported today, as wartime surgeons repair injuries not often seen in general practice, thus enhancing their surgical knowledge and skills.

Since many of our advances in emergency care — like ambulances, tourniquets, and wound dressings — have combat origins, learning and innovation on the battlefield remain a constant theme in trauma medicine. These examples demonstrate that improving tactical care will continue to benefit medicine as a whole.

Advancements in trauma care have boosted the survival rate in modern combat to an unprecedented 90% as compared to 80% in previous conflicts. However, of those who do die in combat, most (around 77%) succumb to their injuries before they can reach a hospital.2 Therefore, it is critical that pre-hospital care is initiated immediately following an injury and that the most advanced techniques and equipment are utilized.

Although many may never serve as healthcare providers in war, there is an underlying need to understand the warzones from which emergency management is evolving. This knowledge can be applied to a variety of mass-casualty incidents whether they are the strategic, battlefield-like emergencies seen at active shooting sites or major multi-vehicle accidents on highways. For example, emergency physician Dr. Michael Neeki employed the skills that he learned during the Iran-Iraq war in the 1980s to aid the victims of the mass shooting last year in San Bernardino, CA. Dr. Neeki, a member of the Inland Valley SWAT team, was able to use his combat experience to serve and protect his community during the tragic situation.3

Combat care is constantly changing; however, it has been increasingly recognized that this care is effective not just in warzones, but in civilian medicine as well. Tactical Combat Casualty Care (TCCC) is a system for the evaluation and health management of military personnel. While based on principles of general emergency care, TCCC includes special considerations for battlefield-specific injuries such as gunshot wounds and blast trauma. TCCC was first developed and used in the mid-1990s by Special Forces units within the U.S. Military. Its subsequent success has led to its widespread civilian adoption.4

The primary focus of TCCC is to treat three preventable causes of death on the battlefield: life-threatening bleeding, tension pneumothorax (collapsed lung), and airway obstruction, and do so while employing effective combat tactics. In the TCCC protocol, care is provided under three distinct phases: (1) care under fire, (2) tactical field care, and (3) combat casualty evacuation care. While providing care under hostile fire, providers must focus on defending the unit, controlling any major hemorrhage, and moving the casualty to safety.

Tactical field care varies by situational constraints (ie. time, hazards) but typically gives the heath care provider the opportunity to secure the airway, re-inflate a collapsed lung, and continue to control any bleeding. Additionally, combat casualty evacuation care is typically more extensive because additional supplies and personnel can be brought in with the evacuation team.5

More recently, these guidelines have been updated and modified for civilian use under the name Tactical Emergency Casualty Care (TECC). While the focus for care in TECC remains the same as its predecessor, variations were implemented to account for a diverse civilian population. For example, TECC includes pediatric-specific guidelines that do not apply to military personnel, who are generally young to middle-aged adults.6

A group of physicians have formed the Joint Committee to Create a National Policy to Enhance Survivability from Active Shooter and Intentional Mass Casualty Events. This forward-thinking team works to evaluate responses to prior incidents and implement new evidence-based care for the future.7 Those who have taken first aid classes may recall that, until recently, tourniquets (devices for blocking blood flow to an injured extremity) were either completely removed from protocol or considered to be a last resort. It was thought that applying a tourniquet would always require the amputation of the extremity to which it was applied. However, data from the battlefield and subsequent work by the Joint Committee has reinstated the use of tourniquets in civilian emergency medical care – such as the care provided by first responders in our communities.8

The increased interest in tactical medicine has made it an active avenue of research with implications for disaster response and general trauma care. A major focus of this research is how to translate techniques from the battlefield to civilian healthcare systems. For example, clinicians in local hospitals are in dire need of new methods for handling major blood loss. One such battlefield-derived method is massive blood transfusion, in which a severely hemorrhagic patient receives greater than ten units of blood products within twenty-four hours.9

Physicians and scientists are now working to modify techniques for use in general trauma care. The results of these trials are published regularly in several journals, such as Special Operations Medicine and Prehospital and Disaster Medicine.

Training in tactical and disaster medicine has taken a multi-faceted approach, with healthcare providers seeking education along all levels of the medical spectrum. Emergency medical services (EMS) agencies have been a driving force in the advancement of tactical medicine in the civilian world. Both corporations and individual providers are preparing for incidents of intentional violence by developing response protocols and training Tactical EMS (TEMS) units. The state of New York has taken a major step towards readiness through programs at the State Preparedness Training Center (SPTC) located in Orisknay, NY. The SPTC offers an intensive three-day course for EMS providers and law enforcement officers, in which students are trained in advanced tactics and combat medical care.10

For undergraduate students interested in learning more about the field, involvement in EMS is a great way to gain hands-on experience. Additionally, medical students can engage in more formal training through electives in areas such as EMS and Disaster Medicine. Faculty at Rutgers-New Jersey Medical School have been evaluating methods to integrate terror medicine into the medical school curriculum at multiple phases such as orientation, foundations classes, organ systems classes, and electives.11

Opportunities for training in tactical medicine are vast for current physicians, especially those specializing in emergency medicine. In a 2008 survey of emergency medicine residency programs in the United States, 18% offered their residents some form of exposure to tactical operations  during either a dedicated tactical rotation or within EMS rotations.12

While we typically think of only emergency medical technicians (EMTs) and paramedics in the context of pre-hospital care, physicians also play an integral role in providing direction and supervision to the EMS system. The protocols under which EMS providers operate are typically developed and approved by emergency medicine doctors.

These physicians also often provide online medical assistance to field medicine providers via phone, radio, or in person. By maintaining contact with providers, physicians can suggest treatments that otherwise would not be administered in the pre-hospital setting.

Intentional violence, such as terrorist attacks and mass shootings, and natural disasters, including forest fires, tornadoes, and floods, may not be a pervasive part of every community. However, every municipality must work to develop a plan for how they will respond to such incidents. This can start with local police departments and ambulance services training together to improve operational interactions during true emergencies. Additionally, hospitals can consider their ability to handle a sudden influx of severely injured individuals.

Eventually, conversations should occur between public safety officials and the general public regarding expectations during major incidents.  Physicians almost always face the possibility of being the only ones standing between a patient and death during these critical situations. By being prepared with a response plan and having a passion for driving the field of tactical medicine forward, they have the potential to make a difference in the outcome of mass tragedies.

References:

1. Davis, Henry Smith. History of Medicine. Chicago: Cleveland, 1907. Print.

2. United States. Defense Health Board. Office of the Assistant Secretary of Defense Health Affairs. Combat Trauma Lessons Learned from Military Operations of 2001-2013. N.p.: n.p., n.d. Web.

3. Gupta, Sanjay. “San Bernardino Doctor Was First Responder.” CNN. Cable News Network, 5 Dec. 2015. Web.

4. Butler, Frank K., and Lorne H. Blackbourne. “Battlefield Trauma Care Then and Now.” Journal of Trauma and Acute Care Surgery S5 73.6 (2012): S395-402. Web.

5. Butler, Frank K., and John Hagmann. “Tactical Combat Casualty Care in Special Operations.” Military Medicine S1 16.1 (1996): n. pag. Web.

6. Callaway, David W., E. Reed Smith, Jeffrey S. Cain, Geoff Shapiro, W. Thomas Burnett, Sean D. McKay, and Robert L. Mabry. “Tactical Emergency Casualty Care (TECC): Guidelines for the Provision of Prehospital Trauma Care in High Threat Environments.” Journal of Special Operations Medicine 11.3 (2011): 104-22. Web.

7. Jacobs, Lenworth M., David S. Wade, Norman E. Mcswain, Frank K. Butler, William P. Fabbri, Alexander L. Eastman, Michael Rotondo, John Sinclair, and Karyl J. Burns. “The Hartford Consensus: THREAT, A Medical Disaster Preparedness Concept.” Journal of the American College of Surgeons 217.5 (2013): 947-53. Web.

8. Kalish, Jeffrey, Peter Burke, Jim Feldman, Suresh Agarwal, Andrew Glantz, Peter Moyer, Richard Serino, and Erwin Hirsch. “The Return of Tourniquets: Original Research Evaluates the Effectiveness of Prehospital Tourniquets for Civilian Penetrating Extremity Injuries.”JEMS: Journal of Emergency Medical Services 33.8 (2008): 44-46. Web.

9. Murphy, Colin H., and John R. Hess. “Massive Transfusion.” Current Opinion in Hematology 22.6 (2015): 533-39. Web.

10. “SPTC CityScape Debuts with Advanced Active Shooters Scenario (A2S2) Course.” SPTC News. State Preparedness Training Center, 21 Oct. 2014. Web.

11. Cole, Leonard A., Katherine Wagner, Sandra Scott, Nancy D. Connell, Arthur Cooper, Cheryl Ann Kennedy, Brenda Natal, and Sangeeta Lamba. “Terror Medicine as Part of the Medical School Curriculum.” Frontiers in Public Health 2 (2014): 1-4. Web.

12. Bozeman, William P., S. Brock Blankenship, and James E. Winslow. “Resident Involvement in Tactical Medicine.” The Journal of Emergency Medicine 34.3 (2008): 338-39. Web.

13. “Tactical Medicine Fellowship.” Johns Hopkins Medicine. Johns Hopkins University. Web.

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