Company Tree Street Medical Group
Whipple Free Library
67 Mont Vernon Rd
New Boston, NH 03070
Method of Instruction
Blended Training: PowerPoint, Lecture, Demonstration, and Practical Exercises
Class started on time at 0800. Instructors greeted students and gave a brief bio. Both instructors are active law enforcement and had previously served as combat medics in elite military units. A brief history on Tree Street Medical Group was given. Greg Miller named the company ‘Tree Street’ because much of the treatment he has provided whether in Nashua, NH or overseas, happened on roads and streets named after trees.
Mindset was addressed early on in the lecture. Instructors stressed the importance of not only training, but also carrying the right gear, and in the right location. Medical supplies not on your person will likely be left behind when responding to an incident. (Note: Several police videos were played to demonstrate the good and bad actions during traumatic events. Videos were not analyzed on a tactical level, but were instead analyzed for quality of treatment).
Boyd’s Loop (OODA)
An explanation of Boyd’s Loop was provided. John Boyd was a fighter pilot that developed an explanation of reaction time as: Observe, Orient, Decide, Act. Key take away is: the person that cycles through the loop first and identifies and reaches the act phase is usually the victor in an engagement.
Note: Boyd’s Loop is usually a part of most tactical training only in this class the most important element was hammered home and that is reaching the act phase quickly.
Preventable Causes of Death | Military
• Bleeding Extremity 60%
• Tension Pneumothorax 33%
• Airway Obstruction 6%
An important distinction between military/civilian mortality was addressed, with military having more death to bleeding extremities than civilians. This is likely due to service members wearing body armor protecting their vital organs.
For wounds with arterial bleeding tourniquets are recommended in most scenarios. Past indication for tourniquet use was based on the appearance of bright red (oxygenated) blood. A better indicator may be the presence of massive bleeding from an extremity regardless of color. Also, in the past it was recommended that the tourniquet be tightened until the presence of bright red bleeding stops, where currently it is recommended to tighten until all bleeding stops.
Two tourniquets were introduced to the group: SOF Tourniquet (SOF-T), and the Combat Application Tourniquet (CAT). Both tourniquets of course have pros and cons. The CAT Tourniquet is superior for one handed self-aid, but is a one-time use and should not be practiced with, because it’s made of inferior material: nylon, with a plastic windlass.
The SOF-T on the other hand is made of high strength webbing with a metal windlass and clip and can be used for practice and still carried after. The one draw-back of the SOF-T is; it is somewhat more difficult to apply when it comes to one-handed self-aid.
Many old myths were put to bed about the modern use of tourniquets. The old mindset was that a person would lose a limb once a tourniquet was applied, and therefore tourniquets were used as a last resort. With the knowledge that a person can bleed to death from an arterial wound in around two minutes and the wide use of tourniquets during the Global War on Terrorism (GWOT) we have learned that tourniquets need to be applied rapidly and can typically remain in place for a period up to about two hours without loss of the limb.
Note: There have been recorded scenarios where patients have had a tourniquet on for up to six hours without losing a limb.
Placement – No longer are tourniquets placed two to four inches above the wound. They are now placed high and tight on an appendage. Attention must be exercised to ensure that the tourniquet doesn’t go so high up on a joint that the tourniquet has a slanted bikini affect. The tourniquet must remain perpendicular.
Junctions (neck, groin, armpits)
To treat non-compressible areas where a tourniquet will not work ‘wound packing’ should be used. Multiple forms of packing gauze were introduced to include: Z-Medica’s Combat Gauze, and Celox Brand. Both types contain hemostatic agents to accelerate clotting.
When packing a wound, one should find the source of the bleed inside the wound using a gloved hand. Once identified the rescuer should make a small “superball” with the gauze and place it directly over the damaged vessel. Once that is accomplished the rest of the wound cavity should be packed with gauze and the remainder of the gauze should be bunched up like a “tennis ball” and placed on top of the wound to act as a pressure dressing. Once complete a a field type dressing should be applied.
Two field type bandages were recommended the ‘Olaes Bandage’ and the ‘Israeli Dressing.’ Both bandages are essentially a large gauze pad, placed in the center of an ace wrap.
- The Israeli has a specially made plastic bracket that works well to increase direct pressure on the wound.
- The Olaes bandage has a pocket filled with gauze that can be left in place to absorb blood or taken out to pack wounds. One positive advantage of the Olaes bandage is that it has a piece of plastic inside the pocket that can be used as an occlusive dressing for a sucking chest wound.
Occlusive Dressings/Sucking chest wounds and penetrating injuries to trunk.
Tension Pneumothorax – When a projectile penetrates the chest cavity the likelihood of a pneumothorax is very high. A pneumothorax happens when air from outside the chest gets pulled in through a wound and fills the plural cavity around the lung, causing the lung to collapse.
The recommended treatment for this condition is the occlusive dressing. An occlusive dressing basically provides an airtight seal that occludes air entering the cavity at the wound. Two products demonstrated to treat this condition were the Asherman Chest Seal, and the HyFin Vent Chest Seal. Both products are clear, adhesive, occlusive dressings. The HyFin is considered to be the superior product as the valve used is more advanced.
Note: While tourniquets have become ubiquitous as carry gear in law enforcement, police officers might be better served with hemostatic gauze and wound packing training. Tourniquets are an excellent addition, however, the statistics when it comes to law enforcement shootings doesn’t necessarily support that choice and officers would be well served to carry both tourniquets, and hemostatic packing gauze.
Getting to an emergency room rapidly is key to survival. There is a 95% chance of survival if wounded are brought immediately to a hospital. A study was used as a reference where gang members either brought shooting victims immediately to the ER and then left the person vs EMS responding and transporting the person to the hospital. More shooting victims in the former scenario survived due to rapid delivery to ER.
The ballistics lecture covered the difference between rifle and pistol rounds and differentiated the characteristics of both. An explanation of temporary wound cavitation vs permanent wound cavity was explained.
Responding to active shooter events/triage
While covering casualty collection points and triage the concept of dirty wall/clean wall was introduced. This technique can be used to prioritize care. When encountering several casualties, the officer announces, “anyone that can hear my voice move over to this wall.” With this technique, you can separate all of the walking wounded patients from people that need urgent care.
Note: Dirty wall/clean wall is also used when searching a group of people. People that have been searched are place against the clean wall, while unknowns remain on the dirty wall.
Two different, two-man carries were explained and demonstrated. Both were good but one offered the advantage of having the front rescuer beside the patient and holding the patient’s crossed leg by the pant leg. This allows the front officer to still utilize a weapon while moving patients.
Attendees were briefed on the importance of sharing their traumatic stories. Also, discussed was the stigma associated with officers getting help. Stress after an incident is a person’s normal response to very abnormal experiences.
The instructors used a multi-modal approach to the training. The use of Lecture, video, and PowerPoint, accompanied by group discussion added greatly to the training. Prior to practical exercises, instructors used an: Explain, Demonstrate, Imitate, Perform, (EDIP Method) to take the students from lecture to actually performing the task.
The Instructors were experienced in both law enforcement and trauma medicine, and that combination is hard to find. The instructors based the program on the Tactical Combat Casualty Care standards and referenced statistics from that and also from law enforcement shooting statistics showing that the procedures are backed by not only their experience, and statistics, but from established, accepted guidelines.
The instructors taught the class in a professional, respectful, peer to peer manner that worked well with the group.
I highly recommend this company for any agency, department that needs trauma training for their officers, or agents.
Career Federal Law Enforcement Officer/Instructor and former Army Medic.