By Jarred R. Alden
You are assigned to a busy engine/medic combo company in the Akron (OH) Fire Department today. Your crew is comprised of four firefighter/medics. After your morning checks and routine housework, dispatch sends a tone for a residential house fire. You arrive on scene to a fully involved house fire. You and your crew make an interior attack and extinguish the fire. No victims were found, and salvage and overhaul reveal no fire extension.
Once the benchmarks are complete, the incident commander (IC) sends you and your crew back to the station to clean up and get back in service. The fire lasted two hours because of salvage and overhaul efforts. Your crew is exhausted but happy that no civilians were injured or killed.
The cook is ready to start lunch when a tone is sent to your station for a medic response. The crew loads up and you radio to dispatch, “Medic 14 is responding to 1234 1st Ave.” Dispatch informs you that this is a multiple shooting reported by neighbors in the area. Dispatch does not know the number of victims or if the police are on scene.
Responding to a Multiple-Victim Shooting
You read the notes as you respond and notice that the police are now on scene. As your ambulance pulls up to the staging zone, you notice numerous police cruisers positioned blocking the street from access. One crew member grabs the trauma bag, which contains trauma dressings, bandaging supplies, a plethora of tourniquets, and other trauma-related necessities.
You radio to dispatch, asking if the scene is secure and safe. Dispatch states that the police have the scene secure and need medical ASAP. The police are waving you toward them. The officers inform you that the scene is safe. The officers have four patients who have been carried two houses to the south of where the shooting occurred. The suspect has barricaded himself in the target house with three hostages. This warm zone area where the officers have extricated the patients will have to be a temporary triage, treatment, and evacuation zone.
Prior to your arrival, officers who are Special Weapons and Tactics (SWAT) trained had applied tourniquets to extremity wounds. After your arrival, your crew triages the patients based on severity and survivability. There are three RED Tags and one YELLOW Tag. A 55-year-old female patient has a gunshot wound (GSW) to the neck with no airway compromise. The wound is packed, and pressure is being held; however, her blood pressure is dropping, and her pulse is rising fast. Her extremities are cold and clammy. There is a pool of blood underneath her back and head.
The next patient is a 20-year-old male who has bilateral femoral GSWs. Both upper thighs have tourniquets in place. Both tourniquets were placed appropriately by the officers—high and tight. The patient has also lost a lot of blood. Even though the bleeding has stopped, you maintain that this patient is still a RED Tag, since humans can lose 1,500cc of blood inside of one thigh. Since there are bilateral GSWs to the thighs, this accounts for possibly 3,000cc or approximately half the volume of blood for most adults. This does not account for any blood loss outside of the body. Therefore, the patient more than likely has lost even more blood sustaining this high level of trauma.
The third patient, a 25-year-old female, was shot in the abdominal region, right chest wall, and right groin area. You pack the junctional wound at the groin with a hemostatic gauze and have an officer hold pressure. You direct a crew member to place a chest seal on the chest wound. The abdominal wound is covered with a dressing and bandaging; pressure is being held by another crew member.
Stop the Bleeding: Basic Hemorrhage Control
The last patient, a 30-year-old male, has a GSW to his right hand and upper arm. A tourniquet was placed by the police; however, there is a large amount of blood still streaming down his arm. Since you performed an ongoing assessment of all interventions, you noticed this issue. You leave the tourniquet in place but tighten it up more. The bleeding stops and now this patient is deemed a YELLOW Tag.
You inform dispatch that you want to make this a limited-victim incident. This notification activates the local trauma hospitals, medical directors, EMS Bureau captain, EMS Bureau district chief, and other essential entities. You request four medical units as you assume the role of medical IC. During your command of the scene, you had designated one crew member as the EMS control officer. The other crew member was deemed the triage officer. The fourth crew member was assigned to treatment officer duties.
During the above scenario, these roles, responsibilities, and interventions were executed in a few minutes with positive results. Even though you were not attached to the Tactical Emergency Medical Services (TEMS) unit this day, you implemented and executed the needed interventions. TEMS medics are required to have this level of expertise and confidence when performing their duties regardless of their rank.
You also informed dispatch to have the incoming medical units enter onto 1st Ave. off Larry Boulevard to pick up patients, then exit down Frost Parkway (which is a cross street). Frost Parkway leads back to Larry Boulevard and to the trauma centers. This tactic is safe since the target house is four houses past Frost Parkway to the north. This allows the incoming medical units to exit the scene safely by preventing them from having to pass in front of the target house. All patients are transported safely to the nearest trauma centers.
The SWAT team and negotiators have also been activated to mitigate the situation. When SWAT is activated, the TEMS team is notified to respond also. The SWAT team and the TEMS medics arrive on scene and are briefed by SWAT command and you, the medical IC. Medical incident command is now assumed by the medical officer from the TEMS team. You are told to return to service after clearing the scene.
The scenario above is similar to how a call may develop in Akron. However, the methods and procedures articulated here may or may not reflect how a situation may be approached in other cities or municipalities. Moreover, TEMS policies, procedures, methods, and tactics are not universal.
SWAT and TEMS Activation and Best Practices
This type of scenario is referred to as a “Signal 100” in Akron. The majority of TEMS and SWAT activations are planned warrant/drug/gun raids. However, this type of scenario is probable and occurs in many cities and municipalities across the United States. TEMS is more than just a medic in a helmet and vest. TEMS medics are versed in many topics and must be prepared to think outside the box to assist command in problem solving and mitigation. Even though there is a TEMS medical director who oversees the team, his ability to give orders on scene is stymied by many factors. Therefore, medics are given standing orders by the medical director. TEMS interventions are unique and require some leeway for tactics and treatments to change given the complexities of the encounter at hand.
The Akron SWAT and TEMS teams function in a unique manner based on best practices. Even though our education and knowledge base are derived from a vast amount of sources, we do not depend on one specific standard. Our training is a culmination of research-based case studies and hands-on, psychomotor repetition acquired in-house and from nationally recognized training conferences such as the Ohio Tactical Officers’ Association (OTOA) conference, held every year in Sandusky, Ohio. Other trainings used are the Ohio Fire Academy in Columbus, Ohio, and CONTOMs courses found throughout the country. The Akron Fire and Akron Police way of training is very effective; however, it is not necessarily a paradigm for all departments and may not fully fit the environmental and geographic demands of other parts of the country. The needs of the community are paramount; SWAT and TEMS best practices must address and fit these needs.
As most prehospital professionals know, there are situations that do not fit neatly into an algorithm or a protocol. TEMS medics work in the gray zone and must be able to use their mental file folders to mitigate a bad scene. These mental schema or file folders are built through years of experience, education, skill development, unconventional training, problem solving, heuristics, and common sense. TEMS medics are trained in operator tactics, firearms, less-lethal weapons, tactical combat casualty care (TCCC), tactical emergency casualty care (TECC), explosives and blast injuries, and many more specialties.
SWAT and TEMS Inception and Development
SWAT teams were developed in the late 1960s in Los Angeles because of increasing violence aimed at the civilian population and police officers after the Watts Riots. In 1971, Los Angeles SWAT became a full-time position because of rising violence and drugs in the city. At that time, tactical medics were not developed. Tactical medicine grew from necessity in the military. Battlefield deaths were rampant because there were no triage or treatment protocols. For example, roughly 89% of casualties on the battlefield in the Vietnam War died of exsanguination.
Tactical Emergency Casualty Care for High-Threat Environments
Prior to TCCC, casualty fatality rates (CFRs) on the battlefield in World War II were 19.1%. In the Vietnam War, CFRs were 15.8%, and in the Iraq/Afghanistan conflicts the CFRs were 9.4%. Tourniquet use was nonexistent and then minimal at best. It was not until the early 2000s that a cravat and stick were used as a tourniquet. No hemostatic agents were used, and no junctional treatments were made available. Moreover, IV fluid, which has no oxygen-carrying capacity, was used in copious amounts to raise blood pressure numbers. This overirrigation of the vascular system was busting up clots, dropping oxygen levels, expediting full exsanguination, dropping body temperature, and making the body more acidic because of chloride in normal saline.
There was a need for profound change if lives were to be saved. Subsequently, military studies were conducted and TCCC guidelines were incorporated. This included triage changes and new treatment modalities. SWAT teams had recognized the need for medical interventions during training and real-time deployments since SWAT trained and worked in austere environments like the military.
A committee for tactical medicine was formed comprised of doctors, attorneys, police, medics, and academics. This committee is referred to as the Committee for Tactical Emergency Casualty Care. TECC standards and guidelines were born in May 2011 to provide a paradigm for SWAT and other incidents in the civilian world. TCCC had its limitations in the civilian world because of scope of practice and language. An example is the use of chest tube placement by medics in the military. If severe thoracic trauma is assessed and definitive care is hours away, then it makes sense for medics in the military to perform more invasive treatments. However, in the civilian world, trauma centers are usually close enough to limit a medic’s scope of practice. Chest seals and chest decompression techniques are adequate when treating operators, victims, and suspects.
Medical Threat Assessment
Even though tactical medics are in place during SWAT events to practice good medicine in bad places, I would be remiss if I did not mention that there is a caveat: timing. Good medicine in the tactical setting (at the wrong time) equals bad tactics. Bad tactics equals operator or medic death. Death equals mission failure and a grieving spouse. Return of fire is the best medicine depending on the stage of the incident. The medical threat assessment (MTA) is the number-one most important factor for mission success from a medical standpoint. Always plan for the “What if?” Failure to plan will produce a “What now?” mentality.
The MTA is a multifaceted, fast-paced, changing assessment of the mission. It is planned days before (raids), hours prior (raids), or on the way to a Signal 100. Part of the MTA is designating a rally point—a more secure location usually two to three houses away from the target house. The rally point should be in the direction of the evacuation route if things go bad. It is the meeting place to retreat to if needed, extricate operators/victims, and treat the injured prior to evacuation. Considerations in the MTA should include number of suspects and their background, number of operators/medics, weather, animals, wind direction, neighborhood culture (friendlies/unfriendlies), geographics, atmospherics, hospitals’ capabilities/distance, remote location, air-med proximity, ground evacuation plans, injuries, number of casualties, medical capabilities on scene, equipment adequacy and maneuverability, amount of resources and supplies, scene size-up, time on scene, operator health/exposures, closest backup medical units, and closest engine/ladder. Other considerations depend on the situation.
The Need for Joint Hazards Assessment Teams
Signal 100 SWAT runs can be fast, dynamic, and complex. These kinds of missions can also stretch out over many hours. They require a united effort to mitigate the dangers on scene. Once SWAT and TEMS respond to the scene, the SWAT commander, TEMS lead medic/doctor, and negotiators collaborate to devise a plan. Hostage situations require quick, upper-level thinking and patience. Many dangers are considered such as the following: suspect’s fire power, suspect’s explosives knowledge and capabilities, suspect’s implementation of these capabilities, and the possibility of drugs on scene. Medics have to be prepared to use every facet of their training and must know how their equipment functions. SWAT officers have been exposed to high-potency drugs during Signal 100s and raids. Medics must be ready to decontaminate anyone with exposures to drugs. For this reason, our TEMS Medical Unit carries large amounts of Naloxone and a hydrant bag. If needed, we can hook up to a hydrant to irrigate exposed skin, eyes, and wounds.
Preventable Deaths in the Tactical Setting
If injuries do occur, our goal is to prevent death. The top three preventable deaths in the tactical setting include exsanguination, tension pneumothorax, and airway compromise. To be more specific, extremity trauma exsanguination comprises 60% of preventable deaths. Tension pneumothoraces are 33%, and airway compromise has been found to be approximately 6% of preventable deaths. “Other” is the category into which remaining injuries fall and are considered 1% of preventable deaths. Junctional and truncal wounds sustained in the tactical setting would be two examples that fall into this category.
(1) In this multifaceted and high-speed exercise, tactical medics observed and coached the SWAT operators as they dragged a 185-pound dummy and applied a tourniquet to a live operator with a simulated femoral artery injury. These activities are performed as the operators are now energy depleted after shooting exercises and physical exertion. Fine motor skills are usually the first to become compromised when the stress is high and energy levels drop. Tunnel vision may also set in as the operators’ focus is on the injured operator and a successful completion of the task. The operators’ right hands are taped as they hold a tennis ball to simulate an injured and inoperable hand secondary to a GSW. Tactical medics have the responsibility to train SWAT operators in medical treatments because they may never make it to the hot zone to render care, as the down operator is taking heavy fire. (Photos courtesy of Captain Chris Karakis, Akron Fire Department EMS Bureau.)
Extremity exsanguination can be controlled by simply applying a tourniquet high and tight, which serves two main purposes. If there is more than one wound to the extremities located in various areas, then placing the tourniquet high and tight will stop the hemorrhaging. Placing the tourniquet a few inches above the wound may be adequate for that wound; however, if you cannot visualize the entire extremity, there may be wounds located higher on that extremity. Another reason to place tourniquets high and tight is basic anatomy. Even though the medical terms and bone sizes are different, the bones in the upper extremities mirror the bones in the lower extremities.
The upper arms have one bone (humerus); the lower arms are comprised of two bones (radius and ulna); the upper legs are the femurs (one bone); and the lower leg bones are referred to as the tibia and fibula (two bones). The arteries, veins, and nerves traverse along the medial aspect of the upper arms, for example. It is much easier to compress the vasculature against one bone. This is more effective than compressing below the elbow joint because the arteries, veins, and nerves run in between the radius and ulna. Hemorrhage is very difficult to stop when compressing vessels in this area. Anatomically speaking, this is the same for the lower extremities.
Zones of Patient Assessment and Treatment
When assessing a casualty in the tactical setting, an initial assessment based on a general impression is a good place to start. A rapid trauma assessment will suffice if the patient assessment is broken down into three main sections: extremities, junctional, and truncal. If hemorrhaging is found, stop it. Place a tourniquet high and tight on extremities. Pack junctional wounds at the neck, armpit, and groin with a hemostatic agent, holding the pressure for 30 seconds to 3 minutes, depending on what hemostatic agent is used. Cover truncal wounds with a gloved hand if chest seals are not readily available. Once chest seals are put in play, place the seal’s valve directly over the wound. Be sure to check for exit wounds, which may be located anywhere on the torso; check from the neck to the navel, 360°.
If you notice a tension pneumothorax developing, perform a chest decompression. Find the clavicle because the first rib is located directly under this bone. The second rib is located approximately one finger width below this bone. The third rib is found measuring the distance the same way. Insert the 14g needle over the third rib in the intercostal space. This insertion site should be midclavicular on the injured side. If the trauma is located on the left side of the patient’s thorax, then be careful not to insert the needle into the heart. Angle the needle slightly lateral, which will direct it outside of the cardiac box. If you cannot access the midclavicular insertion site (which is common in the tactical setting), then insert the needle over the fifth rib on the anterior axillary line. Also, perform this on the injured side of the thorax. The midclavicular insertion site is usually difficult to access because of the SWAT operator vests and gear.
Stages of care in the tactical setting are categorized by levels of danger. Care Under Fire (hot zone), Tactical Field Care (warm zone), and Tactical Evacuation Care (TAC-EVAC) (cold zone) overlap at times, depending on the severity of the operation. The hot zone is the area where the operator, victim, hostage, or medic is taking direct fire, for example. The goal here is to extricate or direct the person out of the danger zone. The best medicine here is to return fire and find cover. If the person can self-extricate, then he should do so as quickly as possible. If this person is pinned down, then staying in place may be the best course of action until other plans are enacted. If the operator is injured, then he needs to either return fire and find cover to self-treat or stay behind cover and self-treat immediately if pinned down.
Hot Zone Treatment
At times, medics may need to provide medicine across the barricade. This is when the injured cannot self-extricate and cannot be extricated by team members or medics because of heavy fire. The medic essentially directs the injured how to self-treat on the portable radio. Depending on the severity of the injury and the amount of blood loss, the medic must be able to articulate treatment procedures clearly and succinctly. Heavy blood loss will cause the injured to become confused, especially if stages of shock are present. Speaking slowly and calmly will potentially keep the injured calm and focused on self-treatment. Every step of the self-treatment process must be explained at an elementary level to avoid confusion if blood loss has led to shock.
(2) This photo illustrates the need for tactical EMS in today’s world. Active shootings are on the rise, as is the use of explosives. This training was a collaboration of the Akron Fire Department’s Tactical EMS crews and the Akron Police Department’s SWAT team during a two-day, scenario-based training in conjunction with Cleveland Clinic Akron General & Summa Health Systems in Akron, Ohio. The injured patients in this scenario were shot in multiple areas of the body; operators and medics were required to take command of the scene, communicate, provide security in the warm zone, perform triage, treat patients appropriately, and get the injured to definite care quickly. Controlling blood loss and preventing hypothermia are crucial. Blood will not clot appropriately as the core body temperature drops.
If an operator is injured and cannot return fire, order him to enact the R.E.S.C.U.E. mnemonic: Remote assessment and treatment (place tourniquet), Evaluation of threat location, Situational awareness (OODA Loop), Cover fire (ask for), Utilization of assets and distraction (smoke, CS), and Evacuation/Extraction method and egress options (help us help you). The OODA Loop was coined by John Boyd, a U.S. Air Force officer/pilot. Observe, Orient, Decide, Act (OODA) gives the injured operator the ability to think logically, looking for cues and patterns in the decision-making process. If something is missed or misunderstood, he can always go back to the observation part of the loop and reassess from there.
Warm Zone Treatment
Warm zone medical treatment involves focusing on the airway and breathing after hemorrhaging has been stopped. However, be sure to recheck the tourniquet placement for accuracy and effectiveness. This is especially true after a casualty is moved from the hot zone to the warm zone for prolonged treatment. Moving patients can render prior interventions inadequate and useless. Tourniquets and dressings shift and loosen. These items also get caught on carpet and other areas or objects. Tourniquets have unraveled and have been fully displaced after snagging on objects during patient movement. Moreover, muscles contract, which can lead to tourniquets loosening. These prior interventions must be reassessed, and subsequent intervention may be required, such as retightening a tourniquet or placing a new tourniquet above or below the previously applied tourniquet.
Airway patency and work of breathing are very important while treating in this zone of care. This zone is usually located at the rally point. Medics are still in danger if the situation escalates or encroaches into the warm zone. Operators and other law enforcement personnel are still needed to provide security. Medics should perform the M.A.R.C.H. assessment to check for injuries: Massive hemorrhage, Airway, Respirations, Circulation, Hypothermia/Head injury. Triage patients if multiple casualties are found. S.A.L.T. is used in Akron’s EMS protocol to sort patients based on severity of injuries: Sort, Assess, Lifesaving interventions, and Treatment/Transport has been used with success in our EMS system regarding accuracy and speed of patient care.
Check for trauma to the airway from projectiles, thermal sources, and exposure to drugs. Start with the head-tilt chin lift to access the airway if no trauma is involved. A jaw-thrust maneuver is warranted by trauma though. Place a nasal or oral airway adjunct and bag the patient if breathing is inadequate or nonexistent. You may need more advanced airway devices such as a supraglottic airway device or endotracheal intubation. A last resort is to perform a cricothyrotomy by inserting an airway device through the cricothyroid membrane for definitive airway security. Follow local protocols regarding procedures.
EMS Response to the Active Shooter
Breathing adequacy is a necessity. Place both hands on the chest walls to feel for equal chest rise and fall. Gathering a full set of vitals in this zone may not be viable. A quick assessment of lung sounds using a stethoscope would allow the medic to locate the development of a tension pneumothorax. If the patient is awake and alert, he may be able to tell you that he cannot breathe adequately. Abnormal respiration rates and audible wheezing and rhonchi are more tell-tale signs of a tension pneumothorax. The medic will, more than likely, have difficulty bagging the patient with the bag valve mask. An absence of lung sounds on one side or the other is another good indicator of this injury. Chest decompression on the injured side is one treatment to use. A chest seal is another treatment used in this zone if a sucking chest wound is found.
Cold Zone Treatment
Vital signs and IV/IO access should be referred to the cold zone. This is where casualties, operators, and medics are considered secure from further danger regarding the suspects’ attempts to perpetuate harm. This is not to say that dangers may not arise while in transport such as vehicle collisions. Cold zone treatment requires an “all hands on deck” approach. All prior interventions must be rechecked. More advanced treatments such as IV/IO initiation and fluid replacements fall into this zone. Drug administration may be warranted if the patient goes into full arrest. Consider drugs that protect from clotting compromise. Protection from hypothermia should also be of high importance since blood will not clot once the core body temperature falls below 90°F. Exposing the patient is necessary; however, covering the patient with blankets and increasing the temperature in the transporting unit are critical.
The Circulation and Hypothermia/Head Injury in M.A.R.C.H. can be assessed in the warm zone if there is time. If not, assess and treat them in the cold zone. Assessing the Circulation section should focus on the levels of shock. Is the casualty compensating? Decompensating shock is avoidable if bleeding is stopped and thoracic injuries are treated appropriately. When vital signs are accessible, be sure to check for a low blood pressure and a rising pulse, which is usually a late sign of shock. Package the patient for evacuation and follow department protocols for trauma transport.
Lethal Triad of Trauma
Keep in mind that interventions are important but must be performed with accuracy and care. For example, initiating an IO and running the fluid wide open to raise blood pressure have been shown through research to be counterproductive and deadly. Prolonged and excessive hypothermia will also lead to higher levels of mortality if gone unchecked. An acidic system and a drop in core body temperature will not allow the body’s natural clotting cascade to function properly. This will lead to the injured bleeding out. Just remember that acidosis + hypothermia = coagulopathy. Coagulopathy refers to the inability of the body’s blood to clot posttrauma. This is referred to as the lethal triad of trauma.
When there is a compromise in the integumentary system, the vascular system will also be compromised if the trauma is deep enough. Once the vascular system is breached, the body’s clotting factors are activated to stop the blood loss. When enough blood is lost from a critical injury, the core body temperature will drop. The vascular system constricts to raise the blood pressure. However, the amount of circulating blood is not adequate for perfusion of the cells. Oxygen, nutrients, and water are lacking at the cellular level now. When the cell does not have an adequate oxygen supply, the cell’s metabolism changes from aerobic to anaerobic.
The byproduct of anaerobic metabolism is lactic acid and other substances. Lactic acid causes the pH to drop from the normal range of 7.35-7.45. Unfortunately, in the past, medical personnel have loaded the patient with high levels of normal saline or lactated ringers solutions. These fluids have no oxygen-carrying capacity. Moreover, the average temperature of an IV bag of fluid is approximately 70°F to 72°F, give or take a few degrees. In addition, the chloride in normal saline is measured to be a 5.5 on a pH scale. This is a high level of acidity being introduced into an already acidotic vascular system.
Posttrauma, it is important to keep the patient warm by increasing transportation unit temperatures, placing blankets on the patient, and removing the blood-soaked clothing if possible. Avoid introducing too much IV/IO fluid into the patient’s system. Simply maintain peripheral pulses at 90 systolic. Too much fluid will bust up clots formed previously. The chloride effect will also break down clots formed, too. This adds to more subsequent hemorrhaging. The temperature of the IV/IO fluid will also exacerbate an already dropping core body temperature. IV/IO fluid warming devices that heat up intravascular fluids are a great practice during transport. Ideally, administration of packed red blood cells and fresh plasma is the best solution in trauma. Slowing acidosis and hypothermia can be done, but this is usually an uphill battle depending on the severity of the injury, time of injury, response times/distances, supplies/equipment, and competency of the crews responding.
Ongoing Training
Working in austere and dangerous environments is not new for prehospital professionals. Dangers are around every corner, and a good level of situational awareness is necessary. Tactical medics face difficult situations and are required to bring their “A” game every time they are dispatched for a raid or a Signal 100. Preparation is key and training paramount. When training is inadequate or lacking, every mission should be considered compromised.
Keep your medical and tactical knowledge up to date. Train daily to keep your skills intact and fluid. Knowledge is required; however, it must be transferred from the mental file folders to the hands for psychomotor skill enhancement. Knowledge not used is only knowledge if the medic cannot perform accurately and competently in the field when it counts. Use your knowledge to develop skills through constant training. Operators, victims, and fellow EMTs/medics deserve only the best. To quote Ancient Greek Poet Archilochus: “We don’t rise to the level of our expectations; we fall to the level of our training.”
Endnotes
1. Springer and Verbillion (2006). “Tactical Emergency Medicine:” AHC Media-Continuing Medical Education. https://reliasmedia.com/articles/140073-tactical-emergency-medicine.
2. Gerecht, R. (2014). “Trauma’s Lethal Triad of Hypothermia, Acidosis & Coagulopathy Create a Deadly Cycle for Trauma Patients.” Journal of Emergency Medical Services (JEMS) April 2014. https://www.jems.com/2014/04/02/trauma-s-lethal-triad-hypothermia-acidosis/.
3. Springer, MD (2017). Wright State University: Dayton, OH. Ohio Tactical Officers’ Association (OTOA). Conference training courses for TEMS paramedics.
4. Cotton, B.A., et al (2006). The Cellular, Metabolic, and Systemic Consequences of Aggressive Fluid Resuscitation Strategies: journals.lww.com (Shock: August 2006-Volume 26-Issue 2- p. 115-121).
5. Mott, J.; Hill, B.; and Parson, D. (2014). Tactical Combat Casualty Care: Lessons and Best Practices. Center for Army Lessons Learned (CALL Publications).
6. Eastman, A.; Flory, D. (2019). TECC: Tactical Emergency Casualty Care, 2nd Edition. Course Manual; National Association of Emergency Medical Technicians (NAEMT), Jones & Bartlett Learning publisher.
Jarred R. Alden is a lieutenant, paramedic, and operations officer for the Akron (OH) Fire Department (AFD). He has 17 years of experience as a firefighter and 15 years as a paramedic. He also has 12 years as a tactical medic with the AFD/Akron Police Department. He has functioned as an arson investigator and investigated postblast scenes where explosive devices were used. Alden has a master of arts degree in applied behavioral sciences from Wright State University in Dayton, Ohio, and a baccalaureate degree in sociology/criminology from Urbana University in Urbana, Ohio. He served as an instructor in sociology at the University of Akron for six years.
