Access to the Patient

The very nature of barricade medicine implies that there is severely limited access to the person or persons requiring medical help, and in most cases, there is no direct or visible contact. In the search and rescue realm, the situation may have different threats and limitations, but the techniques and technology may overlap with a hostage crisis. For the sake of this chapter, the focus will be on situations in which the provider and the injured are completely separated with only voice communication. Access can be accomplished by a variety of means including voice communication, radio, telephone, or Internet communication. US&R personnel sometimes secure access to a patient by creating a small caliber borehole into void spaces where the patient is trapped. The holes can be used for passing food, water, and medical supplies. The teams are trained to deploy hardline phones (also known as “throw phones”), cell phones, radios, and microphones. They can even lower fiber optic cameras through such openings to obtain visual data. These methods are also used by law enforcement agencies during crises as needed, with traditional landlines and cell phones being the primary means used when infrastructure is not disrupted by the disaster or other causes. Additionally, LE agencies may use fiber optic cameras to see inside barricaded structures or use robot-mounted cameras of various types.

Several factors should be considered regarding the use of cell phones during a crisis. For instance, if law enforcement is concerned that an explosive device may be present, cell phone towers may be taken out of service to prevent remote detonation by the perpetrator. Additionally, if the event is ongoing and high profile, the cellular networks may be overwhelmed with local civilian traffic, effectively jamming communication across the barricade. While a cellphone could be very useful if a hostage can use it to provide photos, video, or video conferencing of wounded persons to expedite remote care, their utility may not outweigh the risks of battery depletion, inopportune signal loss, and illegal signal interception. For scene and personal security reasons, it is important to consider the potential danger of outside monitoring of the radio and cellular signals. ^, This may seem innocuous, but civilians or media may gain information and subsequently reveal details of an ongoing event or investigation without proper corroboration or clearance.

Many SWAT teams use robots to assist in high-threat environments. Some are simple and consist of little more than a camera attached to a radiocontrolled, wheeled vehicle. Others are significantly more complex, with features such as video and infrared optics, two-way communications, and even weaponry. They may also have special functions, such as using robotic arms to open doors and deliver hardline telephones or radios to gain access and communication without putting an officer in harm’s way. These could be used to deliver medicines and medical supplies in a similar way.

Communications

All communications in and out of a crisis should be directly monitored by the Incident Commander (IC) or hostage negotiator. If needed, they will reach out to medical support to provide assistance. It is most likely that in an ongoing, tense hostage situation, a specialized negotiator will be the primary person in contact with any suspects or hostages, by either phone or radio, and any medical involvement will be in the form of advice from tactical EMS to the IC. In the extremely rare event that a TEMS provider would be required to have direct communication with perpetrators or hostages, the provider chosen should have some prior TEMS training and, ideally, familiarity with barricade medicine and remote assessment and treatment.

As part of their EMT-tactical training program, CONTOMS teaches a specific section called Medicine across the Barricade.

Several key points are taught to the provider. First, it is critical, using the EMD model of orderly assessment, that the provider focuses immediate lifesaving interventions. The acronym “XABC” is used among tactical medicine providers to remember the order of care given. It is modified from the typical first aid approach to include control of “eXsanguinating hemorrhage,” then airway, breathing, and circulation. The IC should ensure that a medical provider chosen for this stressful task be well versed in emergency care and communication under stress.

Second, it is fundamental to prevent role confusion by the provider. There is ongoing debate outside the TEMS world regarding the ethics and utility of a physician acting as a police officer who is placed in a situation where lethal force may be required of that provider. In that same vein, it is critical that in a barricade medicine situation the physician knows his or her role is to provide medical assistance only, and not to attempt any tactical maneuvers, such as making promises, negotiating, or performing overt reconnaissance. Again, all communications should be monitored and controlled by the IC.

Medical Assessment

It can be assumed that the vast majority of crises with medical needs will be because of trauma to hostages or suspects, but it cannot be forgotten that hostages also may have chronic medical conditions and medication needs that must be addressed. The amount of time the crisis lasts may dictate the attention needed for different types of preexisting medical conditions. Insulin and food for diabetics becomes a problem early on. Some hostages may have needs that require several days to manifest, such as ongoing dialysis therapy or alcohol dependence with withdrawal symptoms. These things should be considered at the outset of a crisis, and every attempt should be made to contact relatives of known hostages to get medical information as early as possible.

Once verbal communication is established with the medical provider, that provider must use the information he has been given and that he can obtain over the phone to direct care. The role of the person with whom the physician is communicating will dictate the flow of the situation. The easiest encounter would involve direct verbal interaction with the injured person. A complete history and descriptive exam is clearly best obtained if the patient is conscious and talking on the phone. In a situation like this, the patient can provide care to him- or herself and can easily verbalize information regarding his past medical history and medication needs. However, if the person in need is not responsive or otherwise incapacitated, another person must act as an intermediary to relay historical information and to provide the care directly. The provider must be able to ask questions and give instructions in concise, simple, layperson vernacular, taking special care to avoid complexity. Three competencies are critical. These include the ability to remain calm, to avoid the use of medical jargon, and to complete a head-to-toe assessment using another’s eyes, ears, and hands. ^, Should the provider have to speak directly with a perpetrator, the situation may be much more complex and volatile, depending on perpetrator’s state of mind. This added layer of complexity requires direct supervision of the entire conversation by a trained IC or negotiator, to avoid misspeaking or agitation of the suspect. In such a high-stress situation, even the coolest heads may not perform at their peak. One protocol recommends a team approach to medical assessment and treatment; that is, always work with a partner. The role of the partner is to act as a “coach” to help the speaking provider stay calm and to provide reminders and notes to ensure no details are missed.

They can listen in by speakerphone or headset and can provide silent, written notes to the speaker as needed. If the proxy being spoken to is the perpetrator, the partner can step in and take over the provider role if the relationship between the perpetrator and the first provider turns sour.

There are different approaches to a remote, systematic evaluation of a patient. For the purpose of this chapter, we will assume the patient is unable to provide any information, and the proxy is a hostage. The medic must first introduce him- or herself, his partner, and provide calm reassurance. The medic asks the proxy his or her name or how he or she to be addressed, and if he or she has any prior medical or first aid training.

Next, the medical provider should ask for a quick overview of the state and position of the patient keeping in mind the XABC protocol as above. Some key considerations include whether the patient is injured or ill, presence of significant bleeding, state of breathing, presence of pulse, and level of consciousness. The rescuers must first treat any life-threatening injuries with emergency interventions, such as applying tourniquets, opening the airway, and/or occluding open chest wounds as needed. The ability to improvise materials may save a life. Therefore the provider must get information from the proxy regarding the presence of medical supplies, first aid kits, and other accessible nonmedical equipment that can be used for tourniquets and splints.

After the XABC survey, the proxy must be coached through a rapid head-to-toe assessment, noting as many physical findings as possible. These include, but are not limited to, reactivity of pupils, general appearance of head, eyes, ears, nose, and throat (HEENT), trachea, presence of bulging neck veins, motion of chest during breathing, visual appearance of abdomen, whether the abdomen is soft to the touch, pelvic stability, bony deformities, and the presence of central and distal pulses. Appearance of the skin, including color, temperature, and moisture, may help the provider determine the presence of shock. Armed with a summary of injuries and findings, the provider can now work to give instructions to render aid, knowing that all interventions must be accomplished as dictated by necessity and availability of equipment.

There may be no other situation during which communication is the most vitally important consideration for the outcome of the patient and the overall mission. There should be regular updates to the IC to keep him or her apprised on the patient’s condition. Be prepared to supply information in a clear, concise form, remembering that the IC may not have a medical background. The TEMS provider has no role in discussing the case with anyone, including the media, unless specifically put in that position by the IC, and remembering that Health Insurance Portability and Accountability (HIPPA) patient confidentiality rules still apply.

Equipment and Training

Similar to most TEMS missions with SWAT teams, the primary choice for a piece of medical equipment and supplies may be extremely limited or altogether unavailable. Therefore the rescuers must either deliver diagnostic and therapeutic equipment to the involved parties or be able to describe how to improvise equipment from items available in the victim’s environment. Being able to find creative solutions to complex problems using rudimentary or improvised materials (such as a tourniquet from a cravat and stick, or a cervical collar made of a structural aluminum malleable splint) could be the difference between life and death. ^, Even when equipment is available, resupply may be hindered or impossible.

Training is essential to master the medical and communication skills necessary to be successful in these situations. ^, Drills for these skills should be constructed and performed at least annually by TEMS providers, as most likely, they will be selected by the IC or police to serve as the primary physician or medic on scene. These training scenarios only require low-tech equipment and imagination, and can be as simple as a story and two rooms connected by a telephone. Alternatively, they can be incorporated into a larger, multiagency disaster drill. Important training concepts should include having nonmedical personnel acting as the hostage and perpetrator on the phone and ensuring that there is no visual contact between the TEMS provider and the patient. Also recommended, train with both standard and improvised equipment. In line with this, it is proposed that certain fixed and malleable traits, such as personality, coping style, decision-making style, emotion regulation, and emotional intelligence, may play a role in the ability of individuals to successfully perform and cope with their role.

Documentation

Documentation, even if unable to be written in real-time, should be recorded as soon as possible. This may be helpful for use by emergency physicians after transport from the area and could be used as criminal evidence. Conversations on phones can and should be recorded. The after-action report (AAR) should be as complete and detailed as possible, as these records can also be valuable as training tools. The paperwork should include key points of the history and physical examination by proxy, notes between provider teammates, interventions recommended, and tourniquet times if applicable.