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April 1, 2015

How civilian and combat triage differ

The triage process implemented by civilian EMS professionals has a few similarities to the process used in the combat environment by tactical medics. Considering America's ongoing involvement in military operations overseas and events such as the Boston Marathon bombing, increased attention has been made toward bridging the gap between the approaches of military and civilian trauma care.

Trauma injuries and scene safety challenges seen in domestic attacks and in combat are similar. A safe and responsible civilian EMS approach is reflected in a growing trend to prepare civilian EMS professionals for the domestic combat or tactical environment. This transition begins with a different approach to the triage process. Let's discuss a few of the differences to consider.

The goal of civilian triage
According to the Centers for Disease Control and Prevention, the leading cause of civilian death from age 1 to 44 in the United States is unintentional injury.[1] In the world of combat, the leading cause of death is hemorrhage.[2]

Field triage remains a vital initial component of prehospital care with the general goal of "getting the right patient to the right place at the right time".[1] The daily field triage decisions made by prehospital professionals are supported by research and require effective critical thinking.

Upon arrival at the scene of an injury, EMS professionals identify the severity and type of injury. Considering the evidence-based guidelines, prehospital professionals then determine which hospital or specialty care center would be most appropriate to improve patient outcome. CDC research supports the sound triage decisions of EMS professionals. Research demonstrates that the overall risk of death is 25 percent lower when care is provided at a Level I trauma center than when it is provided by a non-trauma center.[1] However, proper field triage ensures that patients are transported to the most appropriate health care facility that best matches their individual level of need.

In 2011 the CDC published guidance on the field triage process in "Guidelines for Field Triage of Injured Patients, Recommendations of the National Expert Panel on Field Triage".[3] . You can download the guideline, and even update yourself and receive CEUs by taking a free course through the University of Michigan, linked on the site. The profound importance of the triage process must be recognized and remain part of every EMS professional's ongoing plan of continuing education.

The goal of combat triage 
The National Association of Emergency Medical Technician's Tactical Combat Casualty Care (TCCC) course trains civilian EMS professionals to consider and implement the special challenges with triaging and caring for trauma patients who have received combat injuries.

The course is traditionally designed to train combat EMS/military personnel deploying to support military operations, however, it can be adapted for civilian law enforcement special operations and EMS professionals. NAEMT offers a special version for tactical emergency casualty care. Learn more

The TCCC guidelines discuss the specifics of casualty care (care in the combat setting). Casualty care in the tactical setting will depend on three main factors:

1. The tactical situation
2. The injuries sustained
3. The medical equipment available coupled with the knowledge and skills of the first responder[4,5]

In contrast to the civilian setting where the patient is the mission, in combat situations, the patient is only part of the mission. The triage priorities of TCCC accomplish three main goals:

1. Treat the casualty
2. Prevent further casualties
3. Complete the mission[4,5]

Training for personnel in civilian incidents is adapted from the military version of the TCCC guidelines. Three zones/phases of care are based on "potential cover, concealment, terrain, distance to threat, sniper coverage, and effective firepower."[4,5] Each zone/phase provides recommendations for which interventions may be appropriate based on the potential threat.

The three phases include:

1. Care Under Fire
This is the most dangerous time to deliver care. In this phase, the tactical operator will remain engaged with the perpetrators. If possible, the tactical medic will prevent additional injuries to patients and treat life-threatening hemorrhage.

2. Tactical Field Care
Once protected from immediate threat, the injured receive advanced life support (ALS) measures. This may include basic airway management and if needed, surgical airway interventions. Other injuries such as sucking chest wounds, tension pneumothorax, fractures, venous bleeds, and hypothermia can be managed.

3. TACEVAC
Transporting to definitive care centers is included in this phase. Additional ALS care, reassessment, and administration of analgesics and antibiotics can be implemented.

On the battlefield, the most critical phase of care is the period from the time of injury until the time that the patient arrives at a surgically capable medical treatment facility (MTF). While developing the TCCC triage guidelines, the researchers swallowed a bitter pill: It is estimated that almost 90 percent of military service men and women die from combat wounds before they arrive at an MTF. Therefore, the importance of battlefield trauma care cannot be overstated.

To meet the special needs of combat injuries, battlefield trauma care technology was developed and remains an ongoing focus of breakthrough research. Some of the trauma care technology devices include commercial tourniquets, hemostatic agents, junctional tourniquets, chest seals, and prehospital fluid resuscitation devices to list a few. There are many different types of these devices on the commercial civilian EMS market.

Civilian paramedics must consider the growing risk of domestic acts of terrorism and other tactical incidents. The combat and civilian paramedic can both face delays in transporting patients to definitive care. As in the combat situation, civilian paramedics must make appropriate risk vs. benefit decisions regarding safety and medical care provided. Prehospital professionals must remain knowledgeable of triage guidelines and well trained in the complex decisions that accompany these unique triage incidents. EMS professionals play a vital role as active voices and participants in the development of protocols that involve potentially tactical incidents.

References

1. CDC. Ten Leading Causes of Death and Injury. (2014, November 14). Retrieved March 6, 2015, from http://www.cdc.gov/injury/wisqars/leadingcauses.html

2. Eastridge, B. J., Hardin, M., Cantrell, J., Oetjen-Gerdes, L., Zubko, T., Mallak, C., Blackbourne, L. H. (2011). Died of Wounds on the Battlefield: Causation and Implications for Improving Combat Casualty Care. The Journal of Trauma: Injury, Infection, and Critical Care, 71(Supplement), S4-S8. doi:10.1097/TA.0b013e318221147b

3. CDC. Guidelines for Field Triage of Injured Patients, Recommendations of the National Expert Panel on Field Triage. (2015, March 04). Retrieved March 6, 2015, from http://www.cdc.gov/mmwr/pdf/rr/rr6101.pdf

4. Tactical Combat Casualty Care. (2014, November 1). Retrieved March 6, 2015, from http://www.naemt.org/education/TCCC/tccc.aspx

5. Campbell, J. E. (2012). Tactical medicine essentials. Sudbury, MA: Jones & Bartlett Learning.

About the Author

Dean Meenach, RN, BSN, CEN, CCRN, CPEN, EMT-P has taught and worked in EMS for more than 20 years and currently serves as Director of EMS Education/Paramedic Instructor and co-teacher in the Paramedic to RN Bridge Program at Mineral Area College. He has served as a subject matter expert, author, national speaker, and collaborative author in micro-simulation programs. Dean continues to serve patients part time as a member of a stroke team and in a pediatric and adult trauma center. He can be reached at dmeenach@mineralarea.edu.
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