During a strategic threat-and-risk assessment carried out by Durham and Cleveland police forces in 2008, the need was identified to provide immediate trauma care for authorised firearms officers (AFOs) and casualties in a ‘non-permissive’ environment; this is where support from healthcare providers cannot be provided for tactical reasons).
Cleveland and Durham Police Tactical Training Centre began providing specialised, trauma-based first aid training for AFOs. There was no agreed national standard for such a programme, which was termed the tactical team medic (TTM) course. This training followed established military doctrine by prioritising the assessment and treatment of catastrophic haemorrhage using military paradigms taken from recent conflicts and was more extensive than the Health & Safety Executive (HSE) emergency first aid at work training used in the police.
In parallel, the National Police Improvement Agency, in consultation with the Royal College of Surgeons (RCS) in Edinburgh's faculty of prehospital care, began to develop a first aid curriculum related to the firearms role and driven by trauma management, which would meet the needs of all firearms roles and operations. All AFOs in Cleveland and Durham constabulary attend the course to gain the TTM qualification.
In 2014, the TTM course was observed by the RCS faculty and has since been accredited and approved by its faculty of prehospital care. An agreed set of skills is incorporated into the National Police Firearms Training Curriculum in module D13 and there is a core reference manual produced (College of Police Training, 2013).
Training for this curriculum is provided by military and civilian doctors and paramedics, along with the forces' own training team. Importantly, while the main aim of the course is to provide emergency treatment for firearms-related trauma, it was also recognised that AFOs would often be first on scene at a variety of emergencies and the syllabus was widened to include a range of scenarios and responses to medical emergencies. As the course has developed and the scope of practice of the TTMs has matured, the question of analgesia as a clinical intervention has often arisen.
This article covers the steps taken and the considerations given to introducing a firstline form of analgesia for TTMs to administer. It examines drug types considered and their profiles, and lists the advantages and disadvantages of each. It finishes by cataloguing the training pathway that was undertaken once a suitable agent had been agreed upon.
Considerations
Any change to TTM policy or procedures has to follow a strict process; this involves the convening of the course clinical governance body, the Tactical Medical Advisory Group (TMAG). This faculty comprises a clinical lead (currently a UK military anaesthetist), emergency medicine doctors, both military and civilian paramedics, and TTM trainers.
TMAG members discussed general points of view regarding analgesia, then considered potential analgesic agents. Beneficial aspects of analgesia were discussed, as well as how alleviating or relieving pain is a fundamental humanitarian aim, and how firearms operations may prevent access by skilled clinical practitioners from other healthcare providers.
Analgesia may reduce heart rate and blood pressure and, therefore, blood loss (Trivedi et al, 2007). Masking clinical signs is not a reason to withhold analgesia and non-pharmacological methods of pain relief have a place in prehospital care in the same way as the immobilisation of a limb to relieve pain in fractures.
The TMAG also suggested that during multidisciplinary working with specialist paramedics in the hazardous area response teams (HARTs) and prehospital doctors, these paramedics may be able to administer analgesia.
It was hypothesised that no ‘perfect’ agent existed that would allow all firearms officers to administer analgesia at the point of wounding and it was highlighted that there are no data to support a requirement for firearms officers to be issued with potent and potentially dangerous drugs. The faculty agreed that the potential agent should be made available to all TTMs at all times (so would have to be highly portable); have a minimal regulatory and training burden; have a rapid effect with minimal side effects; and, finally, its use should not conflict with current practice in prehospital medicine (e.g. UK Ambulance Services guidelines (Association of Ambulance Chief Executives (AACE) and Joint Royal Colleges Ambulance Liaison Committee (JRCALC), 2016).
During the TMAG faculty meeting, it was agreed that a paramedic member of the faculty would conduct a retrospective review of patient report forms to ascertain how many patients seen by TTMs may have benefited from pain relief. This assumption would be made by a qualified paramedic and consider pain scoring, mechanism of injury and the practitioner's professional experience. A total of 66 patient report forms were reviewed by the TMAG military paramedic; mechanism of injury ranged from road traffic collision to deliberate self-harm, assault and falls. It was assessed that 46% of the patients seen would have benefited from analgesia (Carr et al, 2017).
It was agreed that, once the review had taken place, a report would be submitted and another TMAG faculty meeting would be convened to discuss the findings and subsequent decisions regarding an analgesic option for TTMs.
Analgesic types
The lawful purchase, handling, storage and administration issues around controlled drugs are far more complex than those for prescription-only medicines. Morphine is listed in section 1 of schedule 2 of the Misuse of Drugs Act 1971 as a class A drug and is commonly misused (Department of Health and Social Care (DHSC), 2013). Law and regulation prevent it from being lawfully possessed unless this is subject to certain conditions such as being held in a pharmacy or having been prescribed. The law provides for police officers to have lawful possession of controlled drugs but only in the prevention or detection of crime.
Fentanyl lozenges (Actiq®) were one of the first analgesic agents to be considered by the TMAG as they are already used by UK and US military and UK mountain rescue teams (Aldington and Jagdish, 2014). Advantages of this strategy included a simple administration technique that could be taught to all TTMs along with a safe risk/benefit profile. The lozenge is stable and easily portable so would be readily available. Because of its continued use in the military setting, experiences could be compared to develop and change practice.
Disadvantages of fentanyl included the fact that it is a controlled drug so there were legal implications to consider. In addition, the drug has potential side effects, including respiratory depression, nausea, vomiting, lethargy, confusion and anxiety. The drug could be contraindicated in people with head or chest injuries, which would make training lengthy and complex. A final consideration was the potential conflict with UK Ambulance Services guidelines (AACE and JRCALC), 2016); paramedics transporting people treated with fentanyl may not be able to continue providing patients with the drug, and managing these patients could affect their scope of practice.
Morphine was the next analgesic to be considered and was agreed as being the gold standard against which other analgesics are judged. It can be administered intramuscularly, intravenously or orally. Morphine is the standard analgesia used by paramedics, mountain rescue teams and prehospital doctors. The UK military uses 10 mg ‘auto jets’ of morphine, issuing two to all soldier, sailor and air personnel (Anonymous, 2003). The dose required to achieve optimum analgesia varies, especially when the intramuscular (IM) and oral routes are used. Morphine is a controlled drug and records need to be kept of its storage and use. Intravenous (IV) morphine takes 5–15 minutes to have an effect and peak effect time may be considerably longer (Aubrun et al, 2012). Effectiveness via the IM route can take at least 45 minutes. The most significant side effects of morphine were agreed to be respiratory depression, nausea and vomiting. These effects can be counteracted with naloxone.
For completeness, ketamine was considered as it is recognised as the prehospital gold standard drug of choice for experienced, specialist prehospital emergency care teams. It was felt that ketamine was not appropriate for someone whose primary role was not medical. The potential risk:benefit ratio was considered too high for TTMs (Burkey and Carns, 2005). Following the discussion regarding analgesia types, potential routes of delivery were considered.
Analgesia delivery
IV is the preferred route of delivery for trauma patients as absorption is predictable, regardless of the casualty's physiological status (Tveita et al, 2008). Obtaining IV access is a difficult skill requiring training (initial and ongoing) and can be especially difficult in a patient who is in shock. Moreover, this task can be challenging when wearing cumbersome personal protective equipment (PPE) and gloves and carrying two weapons, all in a semi-permissive environment.
Generally, it is accepted that IM injections are of limited value in trauma. This is because absorption in a patient in shock is unpredictable. However, IM injections require very little training and, because absorption is slower, are safer than IV injections of potent opioids. After a review of these and other options, the UK military decided to continue with IM analgesia (morphine) for firstline battlefield analgesia.
Intranasal (IN) opiates or ketamine have been used in prehospital settings with reported positive effects. Absorption is good and predictable (Sin et al, 2018). Problems with this route include drug selection and delivery to obtain consistent results (e.g. a higher-than-normal concentration of the drug is required and dilutions may give rise to error), plus drugs outside Ambulance Services guidelines (AACE and JRCALC), 2016) are most commonly used (e.g. fentanyl or ketamine).
Oral administration, including ‘lollipops’ containing potent opioids (fentanyl), is used by the US military routinely while on operations. Although this route theoretically produces predictable absorption, it cannot be titrated as accurately as IV injection.
One opiate is available in a sublingual preparation (buprenorphine). This is not a potent analgesic and is not used by ambulance services; for this reason, both the drug and the route can be discounted.
Methoxyflurane (Penthrox®) (Galen Limited, Craigavon), an inhaled analgesic, has been widely used in Australasia for around 33 years, and in combination with the Penthrox drug delivery system for the past 17 years. The Penthrox inhaler permits a small dose to achieve adequate analgesia (3–6 ml, with a maximum dose of 15 ml a week). In Australia, it is used by ambulance services, the military, first aid officers, in ski fields and mines, and in the emergency departments of several major hospitals. It is also used during short surgical procedures such as dressing changes, biopsies and colonoscopies.
Despite a large volume of published literature supporting the efficacy and safety of methoxyflurane at analgesic concentrations in both adults and children, a limited number of controlled studies on its use in good clinical practice have been conducted. Grindlay and Babl (2009) conducted a review of the literature on the use of methoxyflurane in emergency departments and prehospital settings. Their conclusions were that methoxyflurane is likely to be an efficacious analgesic and no significant adverse events have been associated with it at analgesic doses. It produces rapid analgesia, with each ampoule lasting about 25 minutes. There have been historic reports of ambulance drivers feeling the effects of methoxyflurane expired by casualties and potential nephrotoxicity (Dayan, 2015) but this has been addressed by re-engineering the device and adding an activated carbon chamber. It was agreed unanimously that the redesigned methoxyflurane would be the best fit for the Durham and Cleveland Police TTMs.
Implementation
After the decision had been made, three members of the TMAG attended a ‘train the trainer’ methoxyflurane administration course delivered by the ATACC team for Galen Pharmaceuticals. A 6-hour course with summative assessments was designed and delivered by the TMAG faculty to all TTMs over a 4-week period.
The chair of the TMAG agreed to be the signatory for the prescription-only medicine document and a standard operating procedure was produced. Sufficient stocks of methoxyflurane were then purchased and distributed to both police forces' armed response units, together with updated patient report forms, administration documents and user feedback forms, which are completed by TTMs after incidents and used for audit.
To date, methoxyflurane has been administered by TTMs who attended the course on six occasions. Four were for traumatic injuries relating to road traffic collisions, one occasion was for knife assault injuries, and one time was for an injury to an elderly male who had sustained a neck of femur fracture resulting from a fall.
The first administration of methoxyflurane was recorded within 7 days of the new process going live. The casualty was a male motorcyclist who had collided with a stationary vehicle. He had an obvious broken femur and was in severe pain. The TTM conducted a primary survey and, following the agreed protocols, started to administer methoxyflurane. A paramedic then arrived and allowed the officer to continue with administration to facilitate fracture reduction. Pain relief was rapid and reduction was achieved quickly.
The assault incident involved a man who had been stabbed with a knife, resulting in a 3” deep laceration to the thigh and defensive wounds to the hands. The male was administered methoxyflurane before an iTClamp® haemorrhage control device was applied.
Other uses of methoxyflurane related to road traffic collisions included the treatment of trapped vehicle occupants and a range of injuries such as rib, sternal, vertebral, wrist and skull fractures.
In all cases, the TTMs who administered methoxyflurane stated they were surprised at how effective and immediate pain relief was and how easy the equipment was to set up and use. The end-user feedback forms will be collated over a 12-month period from the go-live date and a follow-up article written detailing the findings.
Summary
This article describes the process involved in making a potent, prescription-only analgesic available to TTMs. Methoxyflurane was decided to be the best analgesia available for TTM use and came closest to fulfilling the criteria of the perfect analgesia.
The use of methoxyflurane gained rapid acceptance and appears to have been used successfully in the first few cases, suggesting there is a minimal learning curve and skill fade after a 6-hour structured teaching session.
The journey that was undertaken and the governance considerations given to increase the scope of practice of TTMs and the ultimate patient benefit can be described as a success. The authors feel these early findings may be of benefit to firearms medics in other organisations. Forces using the same device may be interested in comparing feedback, and those who do not have a form of analgesia in their clinical capability may be interested in following a similar pathway.
Finally, ambulance trusts may be interested in learning more about the device as their staff could be receiving patients in a multi-agency scenario who have self-administered methoxyflurane under police firearm medic guidance.