The scenario below did not play out in the combat zone in Iraq; it happened at the scene of a terrorist attack in Europe. However, there is a strong link between the two: the attack had been carried out by ISIS, it was a mass terror attack resulting in gunshot wounds and trauma, and in both scenes a casualty is lying on the floor in agony, aware of the ensuing discussion around him. "Where is stretcher? Why is it not here yet?" and, "Hold both feet and get him up.” Somebody takes over and picks him up, puts the casualty on his back; both collapse onto the floor. Long seconds pass. If indeed they do manage to evacuate the casualty in time to receive the required treatment, someone will deserve a medal.
1. Casualty medical evacuation - The new perception that never came:
Effective point-of-wounding extraction techniques are critical links in the chain of survival for casualties injured in high-threat environments. In real world events, the need for unconventional extraction continues throughout all care phases, including casualty hand-off to higher echelons of care. When creating rescue guidelines, it is important to fully understand the relevance and shortcomings of mission-based rescue capabilities, and to ensure that existing evacuation equipment is relevant to each mission’s environmental variables.
High-threat military and civilian arenas are evolving and becoming more complex both for fighting and for casualty extraction (high density buildings, urban and topographically complex areas). This has dramatically changed the perception of what equipment should be used in the field, yet when it comes to casualty emergency extraction the traditional stretcher is still the most common means in use.
2. Casualty medical evacuation - Methodology:
Casualty extraction is a critical principle in TCCC/TECC guidelines, from the point of wounding throughout various care phases. The Medical Evacuation care phase is the phase when casualties are moved from the hostile and austere tactical environment in which they were injured, to a more secure location capable of providing advanced medical care.
When examining evidence based treatment modalities, it is crucial to remember these should not be performed until the casualty and rescuer are behind cover. Studies show that faster medical evacuation was lifesaver for U.S. troops to Afghanistan. Moreover, the combination of reduced pre-hospital transport time and increased treatment capability are likely contributors to casualty survival. The consensus of all active protocols is that rapid extraction to safety is critical to casualty survival. The strict guideline is: “DO NOT DELAY casualty extraction/evacuation for non-lifesaving interventions.” How is it then that despite understanding the importance of rapid evacuation, no change has been made to the traditional stretcher model in use?
3. Casualty medical evacuation - Characteristics of medical evacuation events
We have already mentioned the evolution of High-threat Military and Civilian arenas. Combat arenas in urban areas, high density buildings and topographically complex areas all have similar unique characteristics:
1. Low maneuverability, large numbers of obstacles and limited ability to move.
2. Narrow passages, narrow corridors with limited access, removal of casualties from multi-storey structures.
3. Breaching for casualty egress through restricted areas (padlock systems, drywall, concrete block walls, etc.)
4. Evacuation under fire and under high risk conditions.
5. Small combat units deployed over relatively large areas.
6. Mass casualty events.
7. Short to medium range extraction from the field to the evacuation vessels or to casualty collection points.
4. Casualty medical evacuation - Is the traditional approach appropriate for the evolving arenas?
Traditional stretchers are still widely used today as emergency evacuation measures, semi-rigid stretchers built of textile surface stretched between rigid aluminum rods, such as the 8 and 4 models that can be found in the field today. These models weigh about 6 kg and even folded on a dedicated carrier they occupy the back of one of the rescuers. Carrying the stretcher reduces the fighting capabilities of the carrier. Mostly because of weight and size limitations not more than one stretcher can be taken on a mission, so in the case of an event with more than one casualty, evacuation takes place by other members of the force lifting the casualty in the unsafe 1 on 1 form, or by dragging the casualty on the ground, or by lifting the casualty by holding him by the legs and upper body. All of these options can harm the casualty and lower the ability of the rescuer to react to events around him. In complex scenarios the opening of the stretcher and its use become impossible; for example inside buildings, narrow hallways, stairs and rooms you cannot go through with a stretcher so that it becomes useless, as well as in topographically complex terrain.
So, is there a preferable alternative medical evacuation system to the traditional stretcher?
5. Casualty medical evacuation - The psychology:
It has traditionally been thought and taught that additional movement of the spine in a patient with a spinal injury would actually worsen the condition or result in a secondary injury. In fact, there are really no data to support this. There's no evidence that simple movements of the C-spine cause additional damage. Even if that's assumed to be true, to stop the C-spine from moving would require the neck to be completely immobilized in all axes of movement. It's taken over 20 years to develop the necessary body of scientific evidence to change our practices of spinal immobilization. What has driven this process over far too long a period are fears of exacerbating a spinal injury, fears of missing a spinal injury and last but not least, fears of litigation.
In consequence we've made our patients uncomfortable, sometimes hurt them, and made their healthcare more complicated and more expensive. Abandoning these outmoded practices is one of the best steps that EMS can take.
Rarely does a day go by when we don't learn of an EMS system that has abandoned backboards and the older archaic practices of pre-hospital spinal immobilization. The impetus for these changes has come from various scientific studies which show that spinal immobilization, as previously practiced, was ineffective. Studies have indeed demonstrated that spinal immobilization practices have possibly been causing harm. Spinal immobilization is in fact rarely useful. The tactical situation should dictate rescuer actions, and the risk of immediate death to the rescuer should be weighed against the risk of further spinal cord injury from the non-stabilized extraction of casualties.
6. Casualty medical evacuation - the new approach
As we have seen above, the traditional stretcher does not fit present high-threat military and civilian arenas and impairs the effectiveness of medical evacuation. The new evacuation concept emphasizes the importance of matching the evacuation means to those events that have evacuation characteristics as discussed in Section 3 above, in order to maximize the rescuer’s ability to completely and rapidly evacuate the area:
1. Soft and flexible design.
2. Small size, designed to fit any rescuer carrying the equipment, fits inside any pouch.
3. Low weight, up to several hundred grams only
4. No need for “free back” for it to be carried. Neither does it restrict movement.
5. Rapid opening, like opening a personal bandage.
6. Suitable for deployment and placing the casualty in any area, dense and complex as it may be.
7. Carrying capacity for two rescuers in tight spaces and up to 4 rescuers (like traditional litter).
8. Easy carrying, enabling rapid extraction to short and medium range, shortening extraction time.
9. Allowing for low silhouette and enabling the rescuer to react to threats around him.
10. Owing to the small size and low weight, combat forces can considerably increase the number of stretchers dispersed throughout the force, thus enabling them to simultaneously evacuate a large number of casualties.
7. Casualty medical evacuation - Evacuating the traditional approach to a lifesaving treatment:
As EMS systems are abandoning older archaic practices, more and more products with characteristics suited to take advantage of the new evacuation approach are available, including NAR Flexible stretchers, Treetac TRN system and more.
Few of the recent advancements in EMS have been this significant. Understandably, these changes have caused some angst among both military and civilian pre-hospital providers and first responders. However, it's been said that the first step toward change is awareness. The second step is acceptance. As Winston Churchill once said, "To improve is to change; to be perfect is to change often." Change can be good, in our case it can be lifesaving.