Cleveland and Durham Police Tactical Training Centre began providing specialised trauma based first aid training for Authorised Firearms Officers (AFO's) in 2008 as part of both forces Strategic Threat and Risk assessment (STRA). This STRA identified the need to provide immediate trauma care for AFOs and casualties in a ‘Non-Permissive’ environment (where support from healthcare providers cannot be provided for tactical reasons). There is no agreed national standard for this programme which was termed the ‘Tactical Team Medic’ (TTM) programme. Training followed established military doctrine by prioritising the assessment and treatment of catastrophic haemorrhage and exceeded the police standards of Health and Safety Executive (HSE) emergency first aid at work. In parallel the National Police Improvement Agency (NPIA), in consultation with the Royal College of Surgeons in Edinburgh's Faculty of Pre-hospital Care (RCS Ed. FPHC), began to develop a firearms role related, trauma driven first aid curriculum, which would meet the needs of all firearms roles and operations. The resulting D13 curriculum specified many of the same aims and learning outcomes contained within the Durham & Cleveland's Tactical Team Medic Course.
In 2014 the TTM course was observed by the RCS Ed, FPHC and has since been accredited and approved. An agreed set of skills was eventually incorporated into the National Police Firearms Training Curriculum in Module D13, with a core reference manual (www.app.college.police.uk, 2013)
Course content
Training in this curriculum is provided by military and civilian doctors and paramedics along with the forces own training team. Importantly, whilst the main aim of the course was to provide emergency treatment for firearms related trauma, it was also recognised that AFO's would often be first on scene at a variety of emergencies and the syllabus was widened to include a range of scenarios and appropriate responses to medical emergencies.
Training
The course runs over a two-week period and is followed up by four subject specific annual refresher training days. Between 2008 and 2017 approximately 90 TTM's were trained. Five AFOs are on mobile patrol in each county at any time and at least one of these will be a trained TTM with enhanced medical capability. AFOs are frequently the first responders at serious incidents and are more often deployed in a non-firearms role rather than as a response to a specific firearms operation.
This article explores the Patient Report Forms (PRFs) generated by AFOs and reviews the interventions used and patterns of injury seen. Whilst all police forces have been mandated to train firearms officers to Module D13, this data has not been reported before and provides a unique review of where training resources and equipment could possibly be focussed.
Methods
A retrospective PRF review was undertaken involving anonymised manual data collection of PRFs from TTM officers dating 2013-2016. Data including demographics, times, mechanism of injury (MOI), medical interventions and treatment given were recorded.
PRF analysis
In total 66 PRFs were available for interrogation. There was a 225 % annual increase in PRF completion noted for the time period (Table 1).
| Year | PRFs completed (n) |
|---|---|
| 2013 | 8 |
| 2014 | 11 |
| 2015 | 21 |
| 2016 | 26 |
34 (51.5%) patients were male, 21 (31.8%) were female and the gender not reported in was 11 (16.6%). Of those where gender was reported 51.5% were male, which is in-keeping with an increased incidence of trauma amongst males. Wohltmann for instance found in his multi-centred study that males were 27% more likely to die in trauma than females. (Wohltmann et al, 2001)
Injury following assault was the most common reason for officers to attend and provide medical treatment (Figure 1). Medical cases accounted for 18% of treatment provided. The medical cases included collapse query causes, cerebro-vascular accident, shortness of breath and respiratory and cardiac arrests. The causes of cardiac arrests ranged from patients found arrested at road traffic collisions (RTC), attempted suicides and other medical causes. Falls, including suicide attempts from height accounted for 15 % of cases. Where the mechanism didn't fit specific criteria it was labelled miscellaneous. This included a digger bucket falling onto foot and a firework exploding in hand and accounted for 3% of total cases with overdoses with no other injuries accounted for 3%.
Injury location
Isolated injuries most commonly affected the head, neck and chest and are consistent with assault mechanism. Multiple injuries affected all body regions with the majority being causes to limbs.
Lessons learned
This data is unique in reflecting first aid care; delivered at the scene, by UK police officers. The only other published series from the United States shows (as expected) marked differences. Data from The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) Tactical Medical Programme reported a larger dataset (254 PRFs) and, strikingly, almost half (44.9%) of patient encounters were with their own officers (which was 1 case (1.5%) of our reported series (Tang et al, 2014). Whilst the reason for this is unclear it could be possibly due to different Policing methods and tactics, volume of workload and cultural and socio-economic demographics. The most common interventions performed in this series were wound care (61; 26.9% vs. 20% in the UK TTM data) and control of bleeding with direct pressure (43; 18.9% vs. 21%).
The completion rates for PRFs increased dramatically during the first four years of training TTMs. Recent PRFs are reviewed at the refresher training and so this provided direct feedback for officers and reinforced the value of these reports. It is felt that a response rate of 26 reports for 2016 is still a significant under-reporting but unfortunately there is no other data collection method to substantiate this.
The clinical content of the TTM course reflects the injury distribution figures at Fig 2. Particular emphasis during the course is placed upon the traumatic preventable causes of death rather than medical treatments.
Combat Application Tourniquets (CAT)® application is taught and practised at length during the course. Whilst only four CATs were applied during the period this intervention is a life-saving intervention and as such a great deal of emphasis is placed upon the correct and expeditious application of the device. The four tourniquets that were applied during the period were a result of TTMs being first on scene at incidents without assistance from trained healthcare professionals. TTMs are in these cases providing the life-saving interventions prior to hand-over (a clinical summary of the casualties condition usually using an ATMIST format. ATMIST is an acronym for Age, Time of Injury, Mechanism, Injuries sustained, Signs and symptoms and Treatment given and was widely used by the UK military during Operation Herrick. It was a used for its accuracy, brevity and clarity and subsequently adopted by the TTM course). Additionally, TTM's are trained to place tourniquets as distal as possible on the limb which contradicts the FPHC teaching recommendation. This approach to provide a flexible and appropriate training package is underpinned by robust clinical governance.
It was noted that more than twice as many OPAs than NPAs were inserted. OPAs were most frequently used during cardiac arrests and reflects that fact that officers are more comfortable using OPAs as first line airway adjuncts in unresponsive casualties. This has been addressed recently adding training for more advanced airway interventions with Supraglottic airways (iGel LMAs) which have been shown to be easy to learn and provide a better airway in a cardiac arrest (Häske et al, 2013). iGels are proven to have a 90-100% first time insertion success rate. This highlights the fact that, with robust clinical governance training can be adapted to a reported need.
Chest injuries are also covered in detail with theoretical lectures and practical application of skills. Sessions include recognition of life threatening chest injuries, treatment of open pneumothoracies and thorough breathing assessments. In total six patients had Chest seals applied (8.9%) and these patients were an equal mix of isolated and multiple trauma penetrating chest wounds.
28% of patients received oxygen via a non-rebreather mask. This is slightly high compared with the current guidelines (Brit-thoracic.org.uk, 2017) however TTMs are frequent first on the scene and are taught to administer oxygen to any seriously injured casualty until initial primary assessment is completed. Once more clinical information is established TTMs are taught only to administer oxygen to reach a suggested target saturation range of 94-98% with a reading from a pulse oximeter. In practice, this is usually at handover to an ambulance paramedic team and therefore not captured on our PRFs.
The most commonly performed intervention to manage circulatory issues was a combination of direct pressure and dressings (29; 41%) to address active bleeding. This is reflected in the number of limb injuries treated (Fig 2). This stresses the need for a range of approaches to haemorrhage and limb injury (such as haemostatic gauze, packing and splinting) rather than the use of a CAT which may well be the initial action in a tactical scenario.
Head and neck injuries combined account for (19; 27%) of all injuries seen. TTM students are taught how to treat neck wounds including novel devices such as the IT clamp® and to identify head injuries, recognising the signs and symptoms such as obvious head wounds, during the D or disability phase of the system approach including reduced Glasgow Coma Score (GCS), pupil size and reactions and pass this information across to other healthcare providers.
Physical and tactical environmental factors are considered in every case and addressed with re-covering patients with clothing, removing from source and applying blankets.
The data collected on the PRFs is valuable for focussing further training needs, for example review of these PRFs suggest that 46% of patients may have benefited from some form of analgesic agent.
Finally of note was the “on-scene” time with patients that TTMs encountered. This ranged from 5 minutes to >60 mins. 0-20 minutes (22), 20-40 minutes (15), 40-60 minutes (10) and >60 minutes (1). This is a considerable amount of time to spend with a significantly injured patient. The reason for these protracted on-scene times aren't made clear but it can be postulated that this could be due to a combination of the tactical situation, lack of available resources and communication difficulties. From a TTM training perspective it means that emphasis should be continued to be placed upon the Disability and Exposure and Environment aspect of the CABCDE system approach.
International comparison
One significant difference between the ATF and UK TTM data was their increased scope of practice. The ATF medics able to prescribe and administer medicines which TTMs are currently unable to do at this stage.
The most common ATF medications administered were ibuprofen (28; 25.2%), topical antibiotic (12; 10.8%), and acetaminophen (Paracetamol) (12; 10.8%). This is significant if the TTMs develop a broader scope of practice in the future.
The Mechanism of Injury for TTM incidents was compared with that of the North-East Ambulance Service (NEAS) during a 12-month period until Mar 14. The figures gave some interesting comparisons and significant similarities to TTM statistics. Of note NEAS and TTMs respond to the same top four MOIs. These are RTC, Falls, DSH and Assaults. Where the stats differ is the “Medical” MOI element of TTM data as this is not a factor at all in NEAS Major Trauma candidacy. Also of note was the significant amount of burns casualties encountered by NEAS compared to no burns patients encountered by TTMs.
Limitations
This review has certain inherent limitations, due to the nature of a retrospective PRF review. The analysis of TTM data can be difficult when the data is collected in the often confused and complex tactical situations. The number of patients included in this study was small, and it is therefore difficult to draw any novel clinical conclusions.
Conclusions
The TTM model training model clearly works in the authors opinion. The MOI at incidents attended by TTMs absolutely compliments the course objectives. The significant increase in PRF reporting year on year is to be commended and encouraged to continue. It is clear that the TTM has utility in the pre-hospital arena and are likely to be the first medical footprint at complex incidents. The training is clearly fit for purpose and will continue to evolve in line with clinical best practice.
Potential future improvements
A potential trial and feasibility study into the introduction of a non-invasive analgesic agent could be investigated. This could allow the TTMs the ability to administer pain relief to patients under a Patient Group Directive (PGD). 46% of this patient set could have benefitted from some sort of analgesia. Finally, an audit into the unreported reasons for protracted scene times could also be investigated.