"POLICE OFFICER USES A TOURNIQUET TO SAVE A LIFE!" -THE COOPERATIVE EFFORTS BETWEEN SURGEONS AND POLICE FORCES TO IMPLEMENT STRATEGIES TO PREVENT NEEDLESS DEATHS FROM EXSANGUINATION- INTERVIEWS WITH LENWORTH JACOBS, ALEXANDER EASTMAN, FRANK BUTLER, DANIEL LINSKEY.

"POLICE OFFICER USES A TOURNIQUET TO SAVE A LIFE!" -THE COOPERATIVE EFFORTS BETWEEN SURGEONS AND POLICE FORCES TO IMPLEMENT STRATEGIES TO PREVENT NEEDLESS DEATHS FROM EXSANGUINATION- INTERVIEWS WITH LENWORTH JACOBS, ALEXANDER EASTMAN, FRANK BUTLER, DANIEL LINSKEY.

           On October 13 2016 Boston CBC reported "Tourniquet Credited With Saving Life Of Officer Wounded In Shootout". The night prior to that report, a Boston Police Officer was shot during an attempted arrest. In the midst of a gun battle, a tactical officer pulled him from harm’s way and applied a tourniquet, saving his life. Boston Police Commissioner William Evans reported that the officer who applied it had just had tourniquet training less than a week before. Commissioner Evans noted that, while tourniquets were credited with the survival of several victims of the Boston Bombing in 2013, the crude devices used during that situation were created and applied by citizens. Since that time Boston police have had ongoing training on the use of combat tourniquets. Earlier in the year a Boston officer saved his own life by applying a tourniquet after a potentially fatal gunshot wound.

          I found it interesting that I was reading this on October 17^th, just immediately prior to our American College of Surgeons Committee on Trauma Business Meeting whereby Lenworth Jacobs, Jr MD MPH FACS presented the most recent information regarding the Hartford Consensus and American College of Surgeons ongoing efforts with the “STOP THE BLEED!” campaign {and presented the following day during the Excelsior Surgical Society/Edward D. Churchill Lecture "Strategies to Increase Survival in Active Shooter and Intentional Mass Casualty Events"}. My attention was captured as Dr. Jacobs clearly pointed out some disturbing news:

1. Major Shooting events are becoming alarmingly common.

2. Educational areas remain the second most common location for these events to occur- and these types of events are definitely increasing.

3. No environment seems immune!

4. While it is fortunate that most of these events are over within minutes, large volumes of ammunition have been expended during that short time frame injuring countless people.

5. First responders may not have access to victims for easily 30-45 minutes

6. Most life-threatening hemorrhage is terminal within 5 minutes without STOPPING THE BLEEDING!.

7. More than likely, the person next to you (your friends or strangers) will be the one who has the greatest opportunity to save your life.

8. After these events a Police officer is likely to be the person closest to the victim and capable of successfully applying a tourniquet, thereby saving a life.

                    

         With this in mind I began to wonder

a. when did the military first implement the use of tourniquets in their Individual First Aid Kits (IFAK's),

b. Was Boston the first Police force to utilize these tourniquets.

c. are any other police forces carrying these.

d. What is the response of the folks in the field regarding their being requested to be trained in, carry and utilize these in the midst of potential dangerous situations, whereby theoretically it is diverting their focus

e. Are any communities posting these STOP THE BLEED KITS and using them yet?

Fortunately, I know some of the members of the Hartford Consensus Conference, so I contacted them for some answers.

 

         Frank Butler, MD (Credentials below) relayed to me that while select military units (SEALS, RANGERS, PJs..…) may have carried tourniquets and hemostatic dressings prior to 2005, widespread use in U.S. Military IFAK’s (Individual First Aid Kits) did not begin until 2006. CAPT Butler, the US Special Operations Command Surgeon at that time and COL John Holcomb, Commander of the US Army Institute of Surgical Research, spearheaded the Tactical Combat Casualty Care Transition Initiative (initiated in 2005) which was designed to ensure that all deploying Special Operations forces had the recommended TCCC equipment and were trained to use it. To quote from the 2015 Hartford Consensus Compendium:

       “The TCCC Transition Initiative was funded by the USSOCOM and conducted by the USAISR. This effort, led by Sergeant First Class Dom Greydanus, was basi­cally the medical equivalent of a rapid fielding initiative. It provided TCCC training and equipping to deploying special-operations units and incorporated methodology for determining the success or failure of the newly intro­duced TCCC measures. The TCCC Transition Initiative (and the U.S. Army) chose the C-A-T as the tourniquet to field.

        The TCCC Transition Initiative was a resounding suc­cess and documented 67 uses of tourniquets in special-operations units with good effect and with no loss of limbs to tourniquet ischemia. The first four-star en­dorsement of the TCCC and tourniquets occurred when General Doug Brown, Commander of the USSOCOM in 2005, mandated TCCC training and equipment for all deploying special-operations units. The U.S. Central Command, largely through the efforts of former Colo­nel Doug Robb, also mandated in 2005 that all indi­viduals deploying to that combat theater be equipped with tourniquets and hemostatic dressings.

       As awareness of the success of the TCCC Transition Ini­tiative and the U.S. Central Command directive spread throughout the military, conventional units began to adopt the TCCC, including tourniquets. In 2005 and 2006, tourniquet use expanded rapidly throughout the U.S. military. The beneficial impact of the battlefield use of commercially manufactured tourniquets was very well documented by an army orthopaedic surgeon, Col­onel John Kragh, during his time at a combat support hospital in Baghdad in 2006.”

          Dr. Butler explained that the first Hartford Consensus Conference in Jan 2013 concluded that “Life-threatening bleeding from extremity wounds is best controlled initially through use of tourniquets, while internal bleeding resulting from penetrating wounds to the chest and trunk is best addressed through expeditious transport to a hospital setting. Optimal response to the active shooter includes identifying and teaching skill sets appropriate to each level of responder without regard to law enforcement or fire/rescue/EMS affiliation.” By the time of the Jan 2016 Hartford Consensus IV, Dr. Eastman reported that 8 major cities had initiated Trauma Kit Preparedness protocols (NYPD, Washington, Edmonton, San Francisco, Honolulu, Vancouver, Phoenix and Raleigh). By 2015 over 400 readiness courses teaching close to 7000 LAW ENFORCEMENT students have been carried out. In Denver the Tactical Casualty Care for law enforcement first responders (TCC-LEFR) has been taught at over 125 courses and 2500 LEO’s and EMTs. Known data has revealed that five officers and r civilians have been saved thus far due to this training. Admittedly up to this point clear data has been difficult at best to collect and report, but a data base for LEO TECC use nationally is in progress. During the Hartford conference, John Holcolmb reported on data from Houston whereby 105 trauma patients were treated with a PREHOSPITAL tourniquet resulting in a 3.2% mortality rate compared to 17% treated with an ED applied tourniquet.

 

          In an effort to learn more regarding the use of these kits in the police and civilian arena, I contacted Alex Eastman, MD and Lenworth Jacobs, MD (Credentials below). Dr. Jacobs and Dr. Eastman relayed that efforts to initiate use in the field of personal equipment including a tourniquet began some time back in police service. Alex Eastman stated that he has been a member of the Dallas Police Department since 2004 and has served as the Medical Advisor for the Major Police Chiefs Association since 2011.  Dr. Eastman said they have had a version of the combat kits in their specialized units since 2006. In the Dallas Police service, 3700 sworn officers and 400 civilian employees have been trained.  By now Parkland Hospital has taught 1000 civilians and is currently working with businesses to move this out even further into the private sector. Dr. Jacobs relayed that in other police units implementation was likely via police staff with prior military experience (Special Forces, Medics, etc).  Use of tourniquets was likely met with some hesitancy to accept officially because the Police clearly have more pressing priorities during a Police action.  By now, there is no hesitancy to support this with policy and training.

 

The Dallas Police Department Kits contain the following Equipment: Quick clot ($35roll), SOFTT-W tourniquet (25 each), Wide gauze and gloves. Their Carrying cases are typically donated. Courtesy Alex Eastman

 

         I was curious how much resistance the group met when this was proposed several years ago. Dr. Jacobs explained that initially there were some challenges in asking police staff to take on the training but through a series of collaborating events the vision became reality (NOT IN DALLAS THOUGH as Dr. Eastman relayed). “You need to keep in mind that Police have the primary responsibility of ending the violence and providing a safe scene for other first responders. Having said that, the police realize that they are there on the scene and able to first respond when the paramedics are likely to be delayed.”

         Daniel Linskey, (Boston Chief of Police during the Boston Marathon Bombing) explained the tourniquet implementation process in Boston to me: “We did urban shield exercises which used amputees moulaged up as if they had just lost a limb. We identified tourniquets as a gap. Dr. Rickey Kurt took over as our assistant medical director at Boston EMS. He began to train our teams on tactical EMS getting into our stack. He taught hemorrhage control to our special ops guys and many started carry tourniquets. After the marathon we got tourniquet training and quick clot for all our officers before the July 4th event 2013.  I have been explaining the need for tourniquets around the country with law enforcement. I was at a third presentation in North Carolina when an officer approached and said he saw my earlier presentation tapped his tourniquet that he got for himself and the officers he worked with. He then went on to tell me of an officer who crashed his car and they then used a tourniquet to save his life. I've spoken to dozens of groups and hundreds of departments. Just spoke to 150 officers from 30 plus agencies today in St LOUIS every one said their guys carry tourniquets on their patrol officers’ duty belts some kept extra in their glove box. “

             So if that was a challenge, I could only imagine the challenge in obtaining citizen group buy in. Dr. Jacobs explained that, “the Boy and Girl scouts already are trained on first aid so it is a natural pathway to teach.” To save live citizens simply have to be trained. Communities must have policies in place to assure citizens and first responders are trained to give permission to those who are the first responders. We need to empower the responder to help. Expectedly, the initial reaction to attempts at implementation of policy were very hesitant but the events that occurred over the years, especially in Washington, prompt a positive response. The credibility of these programs continues to grow as people realize that these “rare events that will not happen in our community” are happening at an alarming rate. Add to that the non-rarity of police and citizen events in everyday trauma where there may be one person with one chance to save a life.  People are slowly realizing that the further away from care that you reside, the more reinforcement of this training is necessary.  It has been proven that waiting to get the patient to the ED to stop the bleeding is not good practice.  “When our soldiers know better how to treat exsanguination than our doctors, we have a bad situation on hand but we need to train the medical students and residents!”  People are taking this seriously now. We need surgeons to take the leadership in their community and empower them to train the citizens.

        So what does any of this have to do with working in a small, especially rural hospital? That turns out to be similar to the questions others ask: “we never have to deal with exsanguinating hemorrhage from penetrating trauma! We are a small town, small hospital. We don’t have penetrating trauma.” At first that seems like a worthy question and conclusion. However when one listens to Dr. Jacobs and others explain the realm of this problem, it becomes clear that in some situations you may be the first with an opportunity to provide this life saving care. It is certainly not inconceivable that an injury on or adjacent to the property could result in profuse hemorrhage that could be controlled by trained personnel. It takes minutes to train, little money to support and saves lives.

 

Kenneth A. Lipshy, MD, FACS

www.crisismanagementleadership.com

 

Sources:

CAPT Frank K. Butler, Jr., MD Member of Hartford Consensus Conference. USN Retired US Navy, diving medical Officer, Director of Biomedical Research for the Naval Special Warfare Command. Platoon commander Navy Underwater Demolition and SEAL (Sea/Air/Land commando) teams. Diving Medical Research Officer, Navy Experimental Diving Unit. Chief of Ophthalmology - Naval Hospital Pensacola. Naval Special Warfare Command. Ophthalmic consultant to the Divers Alert Network.  Chairman, Committee on Tactical Combat Casualty Care, Department of Defense, Joint Trauma Systems (Feb 2015).

 

Alexander L. Eastman, MD, MPH, FACS, DABEMS Member of Hartford Consensus Conference Lieutenant and Deputy Medical Director Dallas Police Department (SWAT), Interim Medical Director, The Trauma Center at Parkland (UT Southwestern Medical Center). Medical advisor to the Major Cities Chiefs Association.

 

Lenworth M. Jacobs, Jr., MD, FACS, Trauma Surgeon Hartford Con., American College of Surgeons (ACS) Regent and Chairman of the Hartford Consensus.

 

Chief Daniel Linskey, Boston Chief of Police during the Boston Marathon Bombing.

 

Joint Committee to Create a National Policy to Enhance Survivability From Mass Casualty Shooting Events

Lenworth M. Jacobs, MD, MPH, FACS Hartford Hospital, American College of Surgeons (ACS) Board of Regents

Norman McSwain, MD, FACS Medical Director, Prehospital Trauma Life Support

Michael Rotondo, MD, FACS Chair, ACS Committee on Trauma

David S. Wade, MD, FACS Chief Medical Officer, Federal Bureau of Investigation (FBI)

William P. Fabbri, MD, FACEP Medical Director, Emergency Medical Support Program, FBI

Alexander Eastman, MD, MPH, FACS Major Cities Chiefs Association (Lt. Dallas Police Department)

Frank K. Butler, MD Chairman, Committee on Tactical Combat Casualty Care

John Sinclair International Director and Immediate Past-Chair, International Association of Fire Chiefs-EMS Section (Fire Chief, Kittitas Valley Fire and Rescue)

 

• Improving Survival from Active Shooter Events: The Hartford Consensus  June 1, 2013
• Active Shooter and Intentional Mass-Casualty Events: The Hartford Consensus II
  September 1, 2013
• The Hartford Consensus III: Implementation of Bleeding Control July 1, 2015
• The Hartford Consensus IV: A Call for Increased National Resilience March 1, 2016
• Butler FK, Holcomb JB. The Tactical Combat Casualty Care (TCCC) Transition Initiative. Army Medical Department Journal PB 8-05-4/5/6:33-37
• Butler FK, Hagmann J, Butler EG. Tactical Combat Casualty Care in Special Operations. Mil Med. 1996;161(supp):1-16.
• Butler FK. Current State of Preparedness and Resilience. Hartford Consensus IV 8 Jan 2016
• Butler FK, Blackbourne LH. Battlefield trauma care then and now: A decade of Tactical Combat Casualty Care. J Trauma Acute Care Surg. 2012;73(6S5):S395-402
• Butler FK. Military History of Increasing Survival-The U.S. Military Experience with Tourniquets and Hemostatic Dressings in the Afghanistan and Iraq Conflicts Journal of Special Operations Medicine 2015; 15(4):149-152.