Tactical Emergency Medical Services

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Tactical EMS (TEMS) Trainin g Module

WORKFORCE RELEVANCY STEWARDSHIP EDUCATION

E M E R G

E N C Y M E D I C A L S E R V I C E S

E M E R G


N

ATIONAL

P

ARK

S

ERVICE

T

ACTICAL

EMS (TEMS)

T

RAINING

M

ODULE

Version – May 2012





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C

OURSE

R

EQUIREMENTS

Required for completion

1. Registration of TEMS course with WASO

2. This presentation by NPS TEMS Instructor

3. Stations (with completed skill sheets)

a. Bleeding Control (Wound Packing/PressureDressing/Tourniquet)

b. Chest Trauma (Needle Decompression/Chest Seal)

c. IFAK and NPS TEMS Protocols

4. Online Test (InsideNPS) – Pass 80%





E M E R G

E N C Y M E D I C

A L S E R V I C E S

E M E R G

E N C Y M E D I C

A L S E R V I C E S

Provider Levels – Basic Life Support (BLS)*

EMR (Emergency Medical Responder)EMT (Emergency Medical Technician)

Provider Levels – Advanced Life Support (ALS)*

Parkmedic

AEMT (Advanced EMT)

Paramedic

RN/NP/PA/MD

*All TEMS programs/providers require Local EMS Medical Advisor(LEMA) Approval

NPS TEMS P

ROVIDER

L

EVELS





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E N C Y M E D I C

A L S E R V I C E S

E M E R G

E N C Y M E D I C

A L S E R V I C E S

A

FTER

C

OMPLETION OF

NPS TEMS T

RAINING

M

ODULE

, A

LL

PROVIDERS WILL:

1. Recognize stages of patient care and treatment priorities

a. Care Under Fire / Direct Threat Careb. Tactical Field Care / Indirect Threat Care

c. Tactical Evacuation / TEMS Transport

Tactical Combat Casualty Care (TCCC) vs. TEMS Terminology





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E N C Y M E D I C

A L S E R V I C E S

E M E R G

E N C Y M E D I C

A L S E R V I C E S

A

FTER

C

OMPLETION OF

NPS TEMS T

RAINING

M

ODULE

, A

LL

PROVIDERS WILL: (CONT)

2. Recognize and treat preventable causes of death in a tactical

setting#1 - extremity hemorrhage (60%)

#2 - tension pneumothorax (33%)

#3 - airway obstruction (6%)

3. Be competent to implement TEMS in your park withappropriate approval (LEMA, EMS-Coordinator)





E M E R G

E N C Y M E D I C

A L S E R V I C E S

E M E R G

E N C Y M E D I C

A L S E R V I C E S

3 C

ATEGORIES OF

C

ASUALTIES IN THE

T

ACTICAL

E

NVIRONMENT

1. Patients who will live regardless

2. Patients who will die regardless

3. Patients who will die from preventable deaths unless

proper life-saving steps are taken immediately

GOAL OF NPS TEMS

To Minimize Preventable Casualties





E M E R G

E N C Y M E D I C

A L S E R V I C E S

E M E R G

E N C Y M E D I C

A L S E R V I C E S

T

ACTICAL

C

OMBAT

C

ASUALTY

C

ARE

TCCC developed by military, and adapted for TEMS

Two important principles

1. To perform the correct intervention at the correct time inthe continuum of Tactical Care

2. A medically correct intervention performed at the wrong

time in combat may lead to further casualties





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E N C Y M E D I C

A L S E R V I C E S

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E N C Y M E D I C

A L S E R V I C E S

T

ACTICAL

C

OMBAT

C

ASUALTY

C

ARE

Conventional civilian medicine was not appropriate for

optimizing casualty care within the tactical environment.

• Butler, et. al., Military Medicine 1996

• After 1993 Battle of Mogadishu‘Black Hawk Down’

CoTCCC – Committee on TCCC

Updates guidelines on a regular basis





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E N C Y M E D I C

A L S E R V I C E S

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E N C Y M E D I C

A L S E R V I C E S

D

RIVING

F

ACTORS OF

TEMS

1. Mission

2. Overall Team Health

a. Self-care

b. Buddy Care

c. Team Care

3. Protection of:

a. Victims/Hostages

b. Bystanders

c. Team Members

d. Perpetrator





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E N C Y M E D I C

A L S E R V I C E S

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E N C Y M E D I C

A L S E R V I C E S

COMPARISON OF SURVIVAL AFTER TCCC (AND OTHER FACTORS)

World War II Vietnam War Iraq &

Afghanistan

KIA 23.7 21.3 12.5

DOW 3.4 3.5 4.1

CFR 19.1 15.8 9.4

KIA = Killed in Action; DOW=Died of Wounds; CFR=Case Fatality Rate

Holcom b JH et al. J Trauma 2006





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E N C Y M E D I C

A L S E R V I C E S

E M E R G

E N C Y M E D I C

A L S E R V I C E S OIF – Operation Iraqi Freedom; OEF – Operation Enduring Freedom (Afghanistan)

CNS – Central Nervous System

MSOF – Multi-System Organ Failure

FST – Forward Surgical Team

CSH – Combat Support HospitalMost Preventable





E M E R G

E N C Y M E D I C

A L S E R V I C E S

E M E R G

E N C Y M E D I C

A L S E R V I C E S

TCCC/TEMS R

ECOGNIZED

B

Y

:

• DOD – all branches of the U.S. Military

• DHS, other federal agencies• National Tactical Officers Association (NTOA)

• National Association of EMTs (found in Prehospital

Trauma Life Support [PHTLS] Manual – MilitaryEdition

• American College of Surgeons





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E N C Y M E D I C

A L S E R V I C E S

E M E R G

E N C Y M E D I C

A L S E R V I C E S

PHTLS

AND

TCCC G

UIDELINES

7th Ed. - 2011 May 2010





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E N C Y M E D I C

A L S E R V I C E S

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E N C Y M E D I C

A L S E R V I C E S

L

EVELS OF

C

OMBAT

C

ARE

(TCCC) / TEMS

Self Aid

Buddy Aid

IFAK – Individual First Aid Kit(Similar available to NPS TEMS Providers)





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E N C Y M E D I C

A L S E R V I C E S

E M E R G

E N C Y M E D I C

A L S E R V I C E S

L

EVELS OF

C

OMBAT

C

ARE

P

ROVIDERS

(TCCC)

Combat Life Saver (CLS) - Military

NPS BLS TEMS Provider - NPS





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E N C Y M E D I C

A L S E R V I C E S

E M E R G

E N C Y M E D I C

A L S E R V I C E S

TCCC S

KILLS

• Rapid casualty assessment (Triage)

• Control hemorrhage

• Treat penetrating chest trauma

• Maintain BLS airway

• Initiate saline lock and IVF (NPS ALS TEMS Provider)

• Package casualty for transport





E M E R G

E N C Y M E D I C

A L S E R V I C E S

E M E R G

E N C Y M E D I C

A L S E R V I C E S

ALS L

EVELS OF

C

OMBAT

C

ARE

(TCCC)

Military

• Combat Medic

• Special Forces Medic

NPS

• NPS ALS TEMS Provider





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E N C Y M E D I C

A L S E R V I C E S

E M E R G

E N C Y M E D I C

A L S E R V I C E S

3 P

HASES OF

TCC/TEMS C

ARE

• Care Under Fire / Direct Threat Care

• Tactical Field Care / Indirect ThreatCare

• Tactical Evacuation

Recognize treatment priorities of each





E M E R G

E N C Y M E D I C

A L S E R V I C E S

E M E R G

E N C Y M E D I C

A L S E R V I C E S

XABC

X – eXsanguinating hemorrhage

care/eXtractionA – Airway management

B – Breathing

C – Circulation





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E N C Y M E D I C

A L S E R V I C E S

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E N C Y M E D I C

A L S E R V I C E S

C

ARE

U

NDER

F

IRE

/ D

IRECT

T

HREAT

C

ARE

• Return fire and take cover

• Expect casualty to remain engaged as acombatant (if appropriate)

• Provide basic care (self aid)

– Stop eXsanguination; bleeding (Tourniquet)• Direct or move patient to a Casualty Collection

Point (CCP) if safe

• Try to keep the patient from sustainingadditional wounds

• Airway management is deferred until TacticalField Care/Indirect Threat Care Phase





E M E R G

E N C Y M E D I C

A L S E R V I C E S

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E N C Y M E D I C

A L S E R V I C E S

C

ARE

U

NDER

F

IRE

/ D

IRECT

T

HREAT

C

ARE

Bleeding Control

• ‘Tourniquet First’ for life threatening extremitybleeding

• C-A-T Tourniquet (NPS recommended)

• Tighten to Stop Bleeding AND Loss of Distal Pulse• Expose Tourniquet and

mark application time





E M E R G

E N C Y M E D I C

A L S E R V I C E S

E M E R G

E N C Y M E D I C

A L S E R V I C E S

C

ARE

U

NDER

F

IRE

/ D

IRECT

T

HREAT

C

ARE

Tourniquet Key Principles

• Width >1 inch

• Mechanical arm (cam)

• Easy application (<60 sec)

• Self-applied

• Adjustable• Non-slip





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A L S E R V I C E S

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E N C Y M E D I C

A L S E R V I C E S

C

ARE

U

NDER

F

IRE

/T

ACTICAL

F

IELD

C

ARE

(DIRECT/INDIRECT THREAT CARE)

Bleeding Control (NPS TEMS Skills Station 1)

Options:

• Direct Pressure

• Wound Packing• Pressure Bandage

• Tourniquet (C-A-T)





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E N C Y M E D I C

A L S E R V I C E S

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E N C Y M E D I C

A L S E R V I C E S

T

ACTICAL

F

IELD

C

ARE

/ I

NDIRECT

T

HREAT

C

ARE

• No longer under direct fire

• Mental Status – AVPU• Airway, Breathing

– Chin lift or jaw thrust

– NPA – Recovery position (on side)

– Rescue breaths if needed

• If a victim of a blast or penetrating injury is foundwithout a pulse, respirations, or other signs of life

DO NOT attempt CPR





E M E R G E N C Y M E D I C A L S E R V I C E S


W

OUND

P

ACKING

(

VIDEO

)

For a demonstration, Click

Here to view the WoundPacking Video

http://www.fresno.ucsf.edu/em/parkmedic/downloads/woundpackingvideo.flv










H

ARMFUL

E

FFECTS OF

G

RANULAR

C

LOTTING

A

GENTS

• Kheirabadi, J Trauma 2009

• Exothermic local effect to soft tissues (injury tonerves and surrounding vessels)

• Embolic events (Pulmonary Embolism / Stroke)

Remove all granular clotting agents from TEMS Kits

Other Granular Agent Concerns:

• Wind/Rotor wash – Blow granular agents into eyes

– Disable team member temporarily/permanently

• Cost without benefit







CT A

NGIOGRAPHY

Kheirabadi, J Trauma 2009







W

HY TO

R

EMOVE

G

RANULAR

A

GENTS

(

VIDEO

)


Here to view the Quick ClotBurning Demo Video

http://www.fresno.ucsf.edu/em/parkmedic/downloads/QuickClotburning.flv










T

ACTICAL

F

IELD

C

ARE

/ I

NDIRECT

T

HREAT

C

ARE

Penetrating Chest Trauma (Skill Station 2)

• Needle decompression (NDC)

• Cover open chest wounds – 4 sides







C

HEST

A

NATOMY

• Needle Decompression (NDC)

– 2nd InterCostal Space (ICS) - over 3rd rib – Mid-clavicular line (MCL)

See protocol 1120-T







P

NEUMOTHORAX

Simple Pneumothorax

• Immediate field treatment notneeded (close monitoring)

Tension Pneumothorax

• Severe Respiratory Distress• Life Threatening Emergency

• Requires Needle Decompression(NDC)







W

OUND

P

ACKING

(

VIDEO

)


Here to view the Open ChestWound Video 1

http://www.fresno.ucsf.edu/em/parkmedic/downloads/OpenChestWound1.flv










O

PEN

C

HEST

W

OUND

Chest Seal (cover the open ‘sucking’ wound)

• Goal: optimize spontaneous respiration• Maintain negative intra-thoracic pressure =

lung expansion







O

PEN

C

HEST

W

OUND

(

VIDEO

)


Here to view the Open ChestWound Video 2











W

HEN TO

P

ERFORM

N

EEDLE

D

E

C

OMPRESSION

(NDC)

Penetrating Chest Trauma

• Bullet• Knife

• Other penetrating Object

‘If there is a Hole’

-AND-

Worsening or Severe Respiratory Distress







W

HEN

NOT

TO

P

ERFORM

NDC

Blunt Chest Trauma

• Per BLS TEMS Protocols

Penetrating/Blunt Abdominal Trauma

Other causes of respiratory distress

• Asthma

• Anaphylaxis• Anxiety







C

ASE

1

GSW to the left abdomen, no radial pulse, altered

mental status, and respiratory distress

Do you perform a needle decompression?

Answer: (next slide)









C

ASE

2

GSW to the left upper back with difficulty breathing,

gasping for air







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G E N C Y M E D I

C A L S E R V I C E S

E M E R

G E N C Y M E D I


C

ASE

2

GSW to the left upper back with difficulty breathing,

gasping for air


Answer: YES





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G E N C Y M E D I


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G E N C Y M E D I


C

ASE

3

Patient with GSW to the leg and then gets stung by a

bee and begins having an allergic reaction withdifficulty breathing, hives, wheezing anddiaphoresis







E M E R

G E N C Y M E D I


E M E R

G E N C Y M E D I


C

ASE

3

Patient with GSW to the leg and then gets stung by a

bee and begins having an allergic reaction withdifficulty breathing, hives, wheezing anddiaphoresis


Answer: NO





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G E N C Y M E D I


E M E R

G E N C Y M E D I


T

ACTICAL

F

IELD

C

ARE

/ I

NDIRECT

T

HREAT

C

ARE

Splint Obvious Fractures





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G E N C Y M E D I C A L S E R V I C E S

E M E R


T

ACTICAL

E

VACUATION

(TACEVAC)

Have medical ‘pre-plan’

• Nearest hospital• Evacuation resources

• Etc.

Additional care rendered while the patient is beingevacuated, generally more advanced ALS (airway,medications, procedures, etc.)





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E M E R


H

YPOTHERMIA

P

REVENTION

Triad of Death - Hypothermia Kills

• Hypothermia• Coagulopathy

• Acidosis

Even in Iraq, 18% of pts arrived T<36C (96.8F)

Temps in critical trauma pts < 34C (93F) = near 100%mortality

Arthurs 2006 Am J Surg





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H

YPOTHERMIA

P

REVENTION

& M

ANAGEMENT

K

IT

(HPMK)

Keep your patients warm with HPMK kit or other

tools!





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E M E R


NPS TEMS BLS P

ROVIDER

Rapid casualty assessment (Triage) – TCCC/TEMS

Control hemorrhage

• Direct Pressure, Wound Packing, Pressure Bandage, Tourniquet

Treat penetrating chest trauma• Needle Decompression, Chest Seal

Maintain BLS airway

• OPA/NPA

Package casualty for transport

S ( S)





E M E R


E M E R


NPS TEMS IFAK

Individual First Aid Kit (specific for each member)

See NPS TEMS Protocols

Self/Buddy Aid for XABC

T ti l EMS (TEMS) T i i M d l





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E M E R


NPS TEMS ALS P

ROVIDER

Rapid casualty assessment (Triage) - TCCC

Control hemorrhage

• Direct Pressure, Wound Packing, Pressure Bandage, Tourniquet

Treat penetrating chest trauma• Needle Decompression, Chest Seal

Maintain BLS airway/Consider ALS airway

• OPA/NPA• Consider King Tube/Intubation/TTJI

T ti l EMS (TEMS) T i i M d l





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NPS TEMS ALS P

ROVIDER

Consider IV/IO vascular access

• Permissive hypotension

– Titrate fluids to mental status and radial pulse (BPapproximately 80-90 mmHg)

• Standard trauma protocols of 2 L NS/LR may increasedbleeding and cause dilution of coagulation factors leading to

increased mortality.*

Package casualty for transport

Plus ALS Skills (all standing orders in tactical setting)

*Haut et al – Ann Surg 2011






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E M E R


NPS TEMS M

EDIC

K

IT

• Basic kit for team medic

• Adjust contents based on mission

• See NPS TEMS Protocols






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E M E R


D

OCUMENTATION

Documentation of Care

• Clinical Assessments• Treatments rendered

• Changes in status

Forward information onto the next level of care

Initial notes and/or triage/TCCC card informationneeds to be later transcribed onto formal ePCR(emsCharts)






E M E R


E M E R


S

KILLS

S

TATIONS

Station 1: Bleeding Control (skill sheet)

• Wound Packing

• Pressure Dressing

• Tourniquet (C-A-T)

Station 2: Penetrating Chest Trauma (skill sheet)• Needle Decompression (NDC)

• Chest Seal

Station 3: IFAK and NPS TEMS Protocols (skill sheet)






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E M E R


O

NLINE

T

EST

InsideNPS

• BLS NPS TEMS Test –15 Questions• ALS NPS TEMS Test – 25 Questions

• NPS TEMS Instructor – 30 Questions

Passing is greater than 80%






E M E R


E M E R


R

EFRESHER

6 month refresher on skills/test (1-2 hr.)

– Ensure IFAK complete and familiar with contents – Perform skills to maintain proficiency and

indications

Every 2 years complete NPS TEMS module




( ) g


E M E R


E M E R


Q

UESTIONS

?

Developed by – Jay Shields, Will Smith, Mark Jacoby, Geoff Stroh,

Clay Anderson, Dean Ross, and NPS EMS Advisory Council




( ) g


E M E R


E M E R


P

ILL

P

ACK

– REMOVED J

ANUARY

2012 –

NOW

OPTIONAL

• Acetaminophen (Tylenol) – Pain

– 500 mg x 2 tabs = 1 gram

• Ibuprofen (Motrin, Advil) – Pain

– 800 mg x 1

• Levofloxacin (Levaquin) – fluoroquinolone antibiotic todecrease infections

– Decreased morbidity/mortality from infection/sepsis

If allergic to any of these, modify pill pack in IFAK per LEMA

• For Levaquin (Fluoroquinolone) allergy suggest: – Flagyl 1 gram plus Zithromax 500 mg




( ) g


E M E R


E M E R


P

ILL

P

ACK

– REMOVED J

ANUARY

2012 – N

OW

OPTIONAL

See individual NPS TEMS protocols

In general take pill pack for any open combat wound

Ensure no allergies and monitor kit for drugoutdates/expiration (every 6 months)

Per Local EMS Medical Advisor (LEMA)

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Tactical Emergency Medical Services

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