Using hemostatic agents in the tactical environment

Some people enter this career for very basic reasons, like to make a difference in the life of just one person, or save at least one life.  On a chilly December day, Deputy Patrick Esser of the Waukesha County Sheriff’s Department got his chance.  Arriving as the second squad to a one vehicle crash, Esser heard Deputy Moonen describe the driver’s injuries over the radio: “severe neck laceration.” 

Esser came prepared.  He used ChitoGauze hemostatic dressing. 

“The laceration on the victim’s neck was roughly from the front trachea area, around his right side towards the rear of his neck.  It was open by about one-and-a-half to two inches,” recalled Esser. 

He then packed the gauze into the injury site, using the entire roll, held pressure, and controlled the bleeding until the EMS arrived.  In fact, considering the circumstances, Esser’s efforts may have been more effective than those of the initial-arriving medical units.  The driver was transported to the Level One Trauma Center, where his severed carotid artery was discovered.  It was in the ER that the “amazed” doctors credited the saved life of the driver, to the quick thinking and response by Deputy Esser.  This incident and it’s uniquely positive outcome did not become front page news, but is more than worth our time to take notice, especially because the original intent of the skills, was to save cops’ lives!

Use of hemostatic agents
The tactics used by Deputy Esser are not new.  For the last ,three to five years tactical operators, patrol-level first responders, and medical personnel have been getting information and training derived directly from our Military engagements.  The perception of these skills being “new” is largely due to the overall reluctance of their mainstream acceptance, and limited scope of career-wide practice  The tactics have been collectively referred to as Tactical Combat Casualty Care (TCCC), and until recently were the primary resource for hot zone medical care in non-military austere environments.  We followed their recommendations based on effective working protocols and empirical data, but also in large part with the assumptions of varying degrees of applicability from the military to civilian theaters. 

Tactical Emergency Casualty Care (TECC) was comprised in 2011 to fill that gap.  Based on a similar essential core curriculum, the Committee on TECC takes into account many variants of law enforcement work on our streets, and applies them to the known, battle-proven TCCC skills.  There is now direct input to these medical tactics from cops, firefighters, and doctors who work our cities and Emergency Departments.  So, if in the past we were met with resistance to accept this training, because it was “combat based”, rest assured that its direct applications to us have only been reaffirmed. 

For example, Care Under Fire has been revamped as Direct Threat, to encompass potential situations from active shooters to natural disasters.  These applications are not only regularly revisited, but also reflect directly on the curriculum and standards of training.  Standards have been embraced and endorsed by National Tactical Officers Association, Midwest Tactical Officers Association, state organizations, National Association of Emergency Medical Technicians and the American College of Surgeons. 

The use and application of hemostatic agents within these standards has been refined over the last few years.  Today, the Quik Clot Combat Gauze along with its cousin the HemCon ChitoGauze, are the only products recommended.   These were selected as preferred adjuncts for several critical reasons, among which are: effectiveness, ease of application, side and tactical considerations.  Neither product currently produced has any heat associated with its use.  Gone are most former issues, but check individual disclaimers and details from each manufacturer.  Additionally, the gauze form allows for optimal packing at the point of wounding.  There are some differences to note, if the options in the field allow for discerning use.  If the bleeding is visible, Combat Gauze is the recommended product.  Combat Gauze appears to be more effective with injuries where the source of bleeding cannot be localized, such as a large wound bowl, or a more complex exit wound.  But before you run out and buy these products as the save-all field intervention, consider the following.  The application of any gauze, but specifically hemostatic gauze, requires packing the injury bowl as much as possible.  The hemostatic application further dictates two to three minutes of direct pressure to assure that the clotting factors engage, and then application of a suitable bandage.  Considering this, “hot zone” tactical environment is probably not the best time to commit to these interventions. 

The use of tourniquets remains the primary means of Care Under Fire, and now – Direct Threat stage, for severe extremity bleeding.  Additionally, most injuries are well suited for a direct application of a tourniquet, combat bandage, or pressure.  Where hemostatic gauze products are uniquely suited, are the areas where other adjuncts are difficult or impossible to apply.  The neck injury treated by Deputy Esser is a perfect example.  As are the armpit and groin areas, which are frequently neglected by most body armor.  Use of these agents in tactical environments should be reserved for times when additional resources are available. 

A Note to Trainers and Administrators
Deputy Esser took his training seriously.  I have a feeling that as one of the Field Training Officers for his agency, those he trains from this point forward will also become cognizant of the life saving value these tactics bring to our daily job tasks.  Unfortunately, it’s not always the case.  We become complacent and ignorant until something happens, and then scramble to catch up.  We can not progress with such a mentality, especially considering the trends of last three years.  Even if you are fortunate enough to get this training and have the equipment at your disposal with minimum “out-of-pocket” effort, ask yourself if it’s a true sense of knowing or just a false sense of security. 

If you are a trainer, you are also the link between the “new” skills which save your students and partners.  You are the advocate to the bosses and administrators who have questions, concerns and simply don’t know the improvements you can bring.  The life-saving drills and medical tactics should be incorporated with current curriculums, after an initial introduction period.  If you don’t translate these skills for the rest, who will?   If you are higher up in the command chain, I am sure at times someone may have associated the word “liability”, with any given training task or every single job task asked of your officers or deputies.  It’s easy to get caught up under the liability umbrella, and deny the higher level of training to those who need it most.  We have seen it done under the guise of conflicting responsibilities, budget issues, and liability. 

However, after a brief country-wide survey conducted in 2011 prior to the round table discussion held at the International Law Enforcement Trainers and Educators Association, a clear majority of responding cops indicated that their first aid training is limited to little more than CPR.  Other said that they have been exposed to Self Aid and Tactical Care, but woefully need more.  So when your officers respond to a crash scene of a car versus tree, and look at the blood-covered driver, and stop there to wait for an ambulance, who is liable?  Moreover, who is liable when it’s one of your own, and no ambulance will ever get to them?  The simple truth is, that by improving tactical medical skills, you not only improve community service and the mission of what every law enforcement agency strives to do — you do it through giving your people the skills to save a life.  Their own! 

Patrick Esser knew that the moment he got out of his squad. 

There is somewhat of a misnomer out there, that tactical medicine and it’s applied and associated disciplines are the forte of SWAT operators.  The accuracy of this assumption fails when one looks at the assault, injury and line of duty death statistics.  The practical nature of it is that street cops who work the beat day in and day out are the true First Responders.  They are the ones who need the tools to help themselves and others.  So, if you are that operator who has the kit and the training, is comfortable applying the tourniquet or an occlusive dressing in the dark, in the rain, with gloves on, in ten seconds – I challenge you.  I challenge you to make sure that at least 5 patrol officers or detectives on your shift know the same.  That you make sure your buddy who stacks next to you at that SWAT training tells 5 more, and that those cops become comfortable in knowing that they can help themselves.  And, that you are comfortable knowing if it’s you life – they can help you too, or at the very least do everything they could trying. 

Don’t Do It Alone
As with anything, my colleagues and I encounter hurdles and resistance to be expected, and I think you can tell this is kind of personal.  I am fortunate to be surrounded by passionate people who care to give all they can to this cause. You have that, and more at your disposal.  Remember that we don’t work in our own little world.  At some point, Emergency Physicians, Paramedics, Aero Medical resources and other agencies all come into play.  Through the effort of my friends and colleagues, we were able to familiarize some docs at the Level 1 Trauma Center with what a hemostatic gauze is. 

Deputy Esser wisely turned over an empty package from his ChitoGauze to the transporting ambulance crew.  He advocated for the driver by telling the medics what interventions were taken, and asked them not to remove the gauze.  We have seen this save lives before, and it has again.  Consider your technical college system as an option for grant funding, hosted training, and regional asset allocation.  After seeing several such venues attempt to bring this training on board, the Waukesha County Technical College has taken the lead by proactively recognizing the needs and wants of their public safety audience.  The school offers a variety of ongoing courses, with realistic training and a unique instructor base.  From a four-hour Tactical Casualty Care in-service block of orientation to experienced cops, to a 40-hour class for Tactical Emergency Management Services (TEMS), offered to team operators, medics, and all levels of medical providers.  As an added benefit, Law Enforcement and Emergency Medical personnel are able to interact and network professionally, which results in a more coherent and well-rounded skill set for all involved.  The courses are further tailored to the needs of a specific group or host agency, with the practical feedback immediately applied to improve the end-user outcome. 

As of this writing, I was informed a recent life saved by officers of the Elm Grove Police Department, utilizing Quick Clot Combat Gauze, and another one in Florida. The basics and priorities remain constant. Address and control the threat.   Decide on rescue alternatives.  Apply the TECC skills.  As so often stressed, these are mere tactics to add to the ever-changing tool box available to us.  As a career culture, we must wholeheartedly embrace the fact that changing dynamics and paradigms of our work, also require flexible attitudes and a proactive shifts in thinking. 


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