Riot Medicine: Civil Disturbance Applications of the National Tactical Emergency Medical Support Competency Domains.

The Portland, Oregon, Bureau of Fire & Rescue (PF&R) established a tactical emergency medical support team embedded within the Police Bureau's Rapid Response Team (RRT). The authors describe the team's training and their recent work.

An Interview With SOMA President Steven Viola, SOCM, ATP, NREMT-P.

Interviewed by COL (Ret) Andre Pennardt, MD.

Integration of Tactical Emergency Casualty Care Into the National Tactical Emergency Medical Support Competency Domains.

Tactical emergency medical support (TEMS) is a critical component of the out-of-hospital response to domestic high-threat incidents such as hostage scenarios, warrant service, active shooter or violent incidents, terrorist attacks, and other intentional mass casualty-producing acts. From its grass-roots inception in the form of medical support of select law enforcement special weapons and tactics (SWAT) units in the 1980s, the TEMS subspecialty of prehospital care has rapidly grown and evolved over the past 40 years. The National TEMS Initiative and Council (NTIC) competencies and training objectives are the only published recommendations of their kind and offer the opportunity for national standardization of TEMS training programs and a future accreditation process. Building on the previous work of the NTIC and the creation of acknowledged competency domains for TEMS and the acknowledged civilian translation of TCCC by the Committee for Tactical Emergency Casualty Care (C-TECC), the Joint Review Committee (JRC) has created an opportunity to bring forward the work in a form that could be operationally useful in an all-hazards and whole of community format.

Development of a National Consensus for Tactical Emergency Medical Support (TEMS) Training Programs--Operators and Medical Providers.

INTRODUCTION: Tactical teams are at high risk of sustaining injuries. Caring for these casualties in the field involves unique requirements beyond what is provided by traditional civilian emergency medical services (EMS) systems. Despite this need, the training objectives and competencies are not uniformly agreed to or taught. METHODS: An expert panel was convened that included members from the Departments of Defense, Homeland Security, Justice, and Health and Human Services, as well as federal, state, and local law-enforcement officers who were recruited through requests to stakeholder agencies and open invitations to individuals involved in Tactical Emergency Medical Services (TEMS) or its oversight. Two face-to-face meetings took place. Using a modified Delphi technique, previously published TEMS competencies were reviewed and updated. RESULTS: The original 17 competency domains were modified and the most significant changes were the addition of Tactical Emergency Casualty Care (TECC), Tactical Familiarization, Legal Aspects of TEMS, and Mass Casualty Triage to the competency domains. Additionally, enabling and terminal learning objectives were developed for each competency domain. CONCLUSION: This project has developed a minimum set of medical competencies and learning objectives for both tactical medical providers and operators. This work should serve as a platform for ensuring minimum knowledge among providers, which will serve enhance team interoperability and improve the health and safety of tactical teams and the public.

High-altitude pulmonary edema: diagnosis, prevention, and treatment.

High-altitude pulmonary edema (HAPE) is a lethal, noncardiogenic form of pulmonary edema that afflicts susceptible individuals after rapid ascent to high altitude above 2,500 m. Prevention of HAPE is achieved most effectively by gradual ascent allowing time for proper acclimatization. Certain prophylactic medications may further reduce the risk of ascending to high altitude in individuals with a prior history of HAPE. The most effective and reliable treatment of HAPE is immediate descent and administration of supplemental oxygen.

Safety and efficacy of oral transmucosal fentanyl citrate for prehospital pain control on the battlefield.

BACKGROUND: Acute pain, resulting from trauma and other causes, is a common condition that imposes a need for prehospital analgesia on and off the battlefield. The narcotic most frequently used for prehospital analgesia on the battlefield during the past century has been morphine. Intramuscular morphine has a delayed onset of pain relief that is suboptimal and difficult to titrate. Although intravenously administered morphine can readily provide rapid and effective prehospital analgesia, oral transmucosal fentanyl citrate (OTFC) is a safe alternative that does not require intravenous access. This study evaluates the safety and efficacy of OTFC in the prehospital battlefield environment. METHODS: Data collected during combat deployments (Afghanistan and Iraq) from March 15, 2003, to March 31, 2010, were analyzed. Patients were US Army Special Operations Command casualties. Patients receiving OTFC for acute pain were evaluated. Pretreatment and posttreatment pain intensities were quantified by the verbal numeric rating scale (NRS) from 0 to 10. OTFC adverse effects and injuries treated were also evaluated. RESULTS: A total of 286 patients were administered OTFC, of whom 197 had NRS pain evaluations conducted before and approximately 15 minutes to 30 minutes following treatment. The difference between NRS pain scores at 0 minutes (NRS, 8.0 [1.4]) and 15 minutes to 30 minutes (NRS, 3.2 [2.1]) was significant (p < 0.001). Only 18.3% (36 of 197) of patients were also administered other types of analgesics. Nausea was the most common adverse effect as reported by 12.7% (25 of 197) of patients. The only major adverse effect occurred in the patient who received the largest opioid dose, 3,200-µg OTFC and 20-mg morphine. This patient exhibited hypoventilation and saturation of less than 90% requiring low-dose naloxone. CONCLUSION: OTFC is a rapid and noninvasive pain management strategy that provides safe and effective analgesia in the prehospital battlefield setting. OTFC has considerable implications for use in civilian prehospital and austere environments. LEVEL OF EVIDENCE: Therapeutic study, level IV.

The use of fresh whole blood transfusions by the SOF medic for hemostatic resuscitation in the austere environment.

The leading cause of death on the battlefield is uncontrolled hemorrhage. Non-compressible (truncal) hemorrhage is the cause over two thirds of these deaths. This makes truncal hemorrhage the leading cause of potentially survivable death on the battlefield. Over one third of the casualties who arrive at the emergency department (ED) or combat surgical hospital (CSH) in need of a blood transfusion are already suffering from acute traumatic coagulopathy which is associated with an 80% mortality. Early aggressive treatment and prevention of this coagulopathy through hemostatic resuscitation has been shown to increase survival. Hemostatic resuscitation involves the very early use of blood and blood products as primary resuscitation fluids to both treat intrinsic acute traumatic coagulopathy and prevent the development of dilutional coagulopathy. Few, if any, of the products used in hemostatic resuscitation are currently available to the Special Operations Forces (SOF) medic. Warm fresh whole blood transfusions could be a powerful tool for the SOF medic to use in order to begin hemostatic resuscitation in the field.