TECC Familiarization
Course Welcome
Welcome to Microlearning TECC. This course has seven modules
and are as follows:
The goal of this training course is to provide evidence-based Tactical
Emergency Casualty Care skills during an active shooter or other mass casualty
event.
This course should take approximately 40 minutes to complete.
Select this link to access a printable version of the entire course.
Module 1: Introduction
Welcome to the course on Tactical Emergency Casualty Care, also known as TECC. The purpose of this course is to support your learning of evidence-based Tactical Emergency Casualty Care skills. These skills could mean the difference between life if you find yourself in a high threat situation such as an active-shooter incident. This course is not intended to take the place of a hands-on TECC or a Stop the Bleed Course. We recommend that this training be taken as an introduction to or as a refresher to an in-person course.
We recommend taking the following two courses first: FEMA s IS-905 Responding to an Active Shooter: You Can Make a Difference prior to taking this course and , to learn about preventing active shooter incidents, take FEMA s IS-904 Active Shooter Prevention: You Can Make a Difference course.
Module 2: Active Bystander
Mass casualty events, whether because of an active shooter incident, natural disaster, or accident, are rare, but they do happen. First responders will always come when called, but their response takes time, time that some injured do not always have. When first responders initially arrive at the scene, there may not be enough of them to provide immediate care to all those who are wounded. When these mass casualty events occur, uninjured or minimally injured citizens may choose to be Active Bystanders and provide lifesaving care to those in need. Although this course focuses on reviewing techniques to treat the wounded in a disaster, it is tailored to address injuries that are likely from an active shooter incident. This course also addresses the fact that while you are tending to the injured, some danger may still be present.
Next, you will learn the mindset of an active bystander and will learn steps to treat the casualties around you.
Prepare to become an Active Bystander
To best prepare yourself to be an Active Bystander, you will need to:
1.
Recognize the threat and be prepared to take action,
2.
Respond according to your situation and any
emergency plans in place,
3.
Rescue the injured and initiate casualty care,
and
4.
Report to 911 or first responders on the scene
what you know and where you are
Recognize The Threat and Prepare to Take
Action
In an uncontrolled situation such
as an active shooter, you MUST quickly recognize exactly what is occurring to
begin determining your next actions. While deciding what to do and implementing
your action plan, you must become aware of your immediate surroundings such as
where you are, where nearby exits are, and what you can use or do to make
yourself safer. You must also maintain awareness of the overall situation to
understand the nature of the threat. Pay attention to distant sounds, sights,
and smells that can help you identify hazards. For example, do you smell smoke
or hear explosions? By paying attention to your immediate surroundings as well
as the overall situation, you will know what hazards to look for and can
quickly determine how to effectively respond and react.
In the midst of recognizing you are in a dangerous situation, you may experience a number of physical and psychological reactions all of which are normal responses to intense stressors. Being able to recognize these physical and psychological reactions is a key step to preparing yourself to become an Active Bystander. You MUST overcome your natural inclination to deny the situation or deliberate about what to do.
Physical Effects of Stress
When under immense amounts of stress, our bodies respond by releasing a number of chemicals such as adrenaline. This dump of adrenaline may affect your system in a number of ways. It may produce tremors, increase strength and focus, decreased pain response, and initiate general responses such as flight, fight, and freeze. These reactions may be shocking or confusing in the moment. When activated through the fight-or-flight response, your autonomic nervous system makes it hard for your higher brain to think clearly and use logic to function. By regaining control of your automatic nervous system, you will have greater ability to make decisions and initiate actions. One way to gain control of your autonomic nervous system is by controlling your breathing through a technique called Box Breathing , or simply breathing rhythmically to help calm your mind and body. Here is how it is done: Take a deep breath over 3 or 4 seconds, hold it for 3-4 seconds, then slowly exhale for 3-4 seconds. Repeat this several times. Doing this, taking control of your breathing, can send a signal to your brain to decrease the activity of your autonomic fight or flight response.
Psychological Effects of Stress
As explained in the book The Unthinkable by
Amanda Ripley,
Denial is often the body s way of coping with an unexpected and
uncertain event. In some circumstances, denial may be helpful because it buys
us time to think, but in the case of an active shooter, this lack of or latent
reaction could actually increase our chances of dying
or prevent us from helping others.
Once we get through denial, we often deliberate, meaning we take time
to carefully consider and discuss the circumstances, trying to determine what,
if anything, to do. When faced with an advancing threat, deliberation takes up
valuable time.
Finally, we move into decisive action. With a little preparation, your
decisive action can be a set of swift and well-informed response actions.
However, you may choose to take no action and that can be disastrous. When in
doubt, take immediate action.
As described in the course IS-905 Responding to an Active Shooter: You can Make a Difference, this three-phase process of Denial, Deliberation, and Decisive Action is called the Arc of Survival. For a more comprehensive explanation of the Arc of Survival, Watch Amanda Ripley s PrepTalk The Unthinkable, Lessons from Survivors.
Respond according to your situation and any emergency plans
in place
If you have not already, be sure to take IS-905 Responding
to an Active Shooter: You can Make a Difference to learn more about how to get
to safety quickly by following the principles of run, hide fight, and the
importance of having a personal emergency action plan and following your
organization s plan, if one exists.
Rescue the injured and initiate casualty care
Once you have successfully
navigated the steps of recognizing the threat, preparing to take
action, and responding based on your individual and organization s
emergency action plans, it s time to move on to the third step of being an
active bystander: Rescue the injured and initiate casualty care .
Introduction to TECC
The medical care described in this program is based on the guidelines published by the Committee for Tactical Emergency Casualty Care. TECC comprises medical guidelines that describe the care that should be provided for a patient who is injured in an active threat or high threat incident such as an active shooter. TECC establishes treatment guidelines based on the order in which somebody will die from their wounds or injuries and how close you are to the threat. TECC is closely modeled on military medical guidelines, but it accounts for civilian population differences, resource differences, and scope of practice differences. TECC is appropriate for use at all levels of civilian providers.
The techniques used in TECC have been adapted from the military battlefield medical guidance of Tactical Combat Casualty Care or TCCC. TCCC is the starting point for the TECC guidelines. While TECC and TCCC may address some similar injuries, the individuals being trained, and the context surrounding the situations where techniques may be used, are drastically different. While medical skills obtained during combat-oriented training are transferrable, TECC is designed for civilian use. The differences include:
1.
Reducing access to potential targets in active
shooter situations. This means, as a civilian, you will not fight to gain
access to wounded individuals.
2. As civilians not engaged in recurring emergency medical training, you should only engage in actions that are within your ability.
3. Unlike the military, TECC does not endorse specific medical products as that may limit the options for civilian agencies based on local availability. We encourage you to schedule local training within your organization to review the contents and use of the tools in your medical kits.
Rapid care improves survival
When dealing with mass casualty event such as an active shooter, there may be multiple injured people with multiple wounds. When someone is injured, it is important to understand which injuries are life-threatening and how they might be treated. Some injuries may also be beyond the ability for a bystander to treat. Rapid care for treatable injuries saves lives. There are three main types of injury that active bystanders may be able to treat successfully:
Wounds to extremities or anatomic junctions which is where the extremities meet the body
Penetrating wounds to the torso that disrupts breathing
Direct wounds to the airway
In addition to these injuries, hypothermia can be a significant problem for those with serious injury so you should understand how to recognize and treat it.
The goal of treating these injuries is to stop the clock on all causes of preventable death that is, taking action to stop the injury from being immediately fatal, and giving the injured the chance to be treated in a hospital. To accomplish this, the rest of this course will cover:
Effective and efficient casualty movement,
Direct pressure, tourniquets and bleeding control,
Basic airway management and positioning,
Basic strategies for penetrating chest injury,
Hypothermia prevention, and
Psychological support for the wounded
SCAB-E
When an incident occurs and you decide to act, it is important to provide victim care in a systematic fashion. This means you must prioritize your care. The best way for a bystander to do this is to follow the SCAB-E priority list. SCAB-E stands for:
Situational awareness
Circulation
Airway
Breathing
Evaluate or everything else.
This priority list is based on the medical research that balances how common the injury is with how long it would take a person to die if the injury were uncontrolled. Although first aid has traditionally been directed towards airway first interventions, in intentional mass casualty incidents, massive bleeding from an extremity or wound in an anatomic junction is common and can lead to a rapid death. It takes longer to die from a blocked airway (about 4-5 minutes) than it does to bleed to death from a large arterial bleed (3-4 minutes), so the bleeding should be addressed first. A torso injury involving the lungs is the most common injury in these events but can take 10 or more minutes to cause significant effect, so it s in the priority list behind bleeding and airway.
Next you will learn how to go through the SCAB-E priority list.
Warning: Understanding the guidelines and techniques of TECC are important; however, some of the topics and images in this training course may be disturbing to some participants.
Module 3: Situational awareness
When responding to victims of an emergency situation such as an active shooter, it is most important to always maintain situational awareness. You first must decide if your location is safe. If your location is not safe, take steps to increase your safety by, for example, closing and locking doors or using a heavy object to barricade yourself and others in a room or office space. If you cannot make the location safe and victims are present, you will need to think about moving them. Moving a victim improperly can cause you to exert a high level of energy that may cause rapid fatigue. Next we will demonstrate two different options for moving a casualty who cannot walk.
The first option for moving a casualty is called the elevated one-person carry. This carry is ideal if you must move someone by yourself. You first need to ensure that the person s head is oriented in the direction that you want to move. If they are not oriented in the direction of travel, the best way to move them is to grab their arm and spin them around until their head is pointed in the direction of intended travel. Once that is complete, you are ready to move. To begin the lift, grab the clothing covering the shoulders, pull the person to a sitting position, and slide your body toward them until they are in a seated position leaning forward slightly. Once they are in a seated position, reach under their armpits, grab their wrists, and bring their arms toward their own torso. Then, place your chest on the person s back and move into a squatting position. You are now ready to lift and move. Next, stand and lift their body so you are supporting the weight of their upper body while their feet are still touching the ground. Finally, begin to walk backwards with the individual, allowing their feet to drag as you move them to safety.
If more than one person is available to carry the injured person, you can use the two-person carry method, also called the fore-aft carry. This carry begins the same way as the elevated one-person drag with one rescuer at the patient s head. The rescuer at this position will lead and coordinate the process. This person should grab the clothing covering the injured person s shoulders and pull them up until they are seated slightly forward. The rescuer should then reach underneath their arms and bring their wrists to their torso keeping his or her chest close to their back. The second rescuer should position him or herself in between the patient s knees facing the patient s feet, and then reach down and grab underneath the knees or on top of the pants if necessary. Now both rescuers can get into a squatting position and prepare to lift. The rescuer at the patient s head can give the command to lift on the count of three: 1-2-3 lift. Both rescuers can stand. The rescuer at the victim s feet will need to position the body so they have a firm grip of the patient under the knees. Then the rescuer at the victim s head can issue the command to move by saying ready, move. Both rescuers move in the same direction and get the patient to safety.
Module 4: Circulation
If you are in a safe place and have moved any casualties, you can continue with SCAB-E by tending to any injuries involving circulation. Circulation awareness means looking for and addressing life-threatening bleeding. If you see major bleeding, you MUST immediately apply direct pressure to the wound. Applying direct pressure means using your hands to push directly on a wound to begin the process of bleeding control. Wounds that are just oozing blood require only direct pressure, while wounds producing more blood will need greater attention. Once you have applied direct pressure, you can decide if further treatment is necessary. If there is a wound to an extremity, and direct pressure does not stop the bleeding, you have several options. The fastest option is to use a tourniquet. If you do not have a tourniquet, or if the wound is on an area of the body where are tourniquet cannot be used, such as an anatomical junction, you can perform wound-packing or pressure-dressing. These methods will be covered next.
Tourniquet
Using a tourniquet is the fastest way to stop major bleeding to an extremity. Tourniquets should be used only on the arms and legs below the anatomical junctions not on the arm pits and groin area. It can stop bleeding in approximately 30 seconds and should be applied as soon as possible for best results. If a casualty has multiple wounds and you have a limited number of tourniquets, apply one to the extremity with the most bleeding. If a limb has been amputated, the tourniquet must be applied to that injury first.
Many kinds of commercially manufactured tourniquets are available, but the most common tourniquets used in TECC or Stop-the-Bleed kits are the Special Operations Tactical, or SOF-T tourniquet, and the Combat Application Tourniquet, or CAT. If available, it is always best to use a commercially manufactured tourniquet, but you can construct one from improvised materials as well.
As an active bystander, if you need to apply a tourniquet for life-threatening bleeding, quickly place the tourniquet as high up on the injured leg or arm as possible. Never put a tourniquet over a joint, such as a knee or elbow, or directly over an open fracture with a bone sticking out or exposed. To apply a commercially manufactured tourniquet, first open the package and unbuckle the strap. Place the end of the strap under the knee or the arm and work it up to the top of where the limb meets the body. Apply the tourniquet over the clothes. If using the CAT tourniquet, place the strap through the buckle and tighten it to take out as much slack as possible. Once the slack has been taken out, Velcro the strap to itself to secure it. If using the SOF-T tourniquet, secure the buckle before tightening. Then tighten the windlass which is a small stick attached to tourniquet to twist it and make it very tight. Tighten the windlass until you see the bleeding stop, then secure it in place so it does not come undone. Note the time the tourniquet was placed. This will help medical professionals when they begin treating the wound. Once the bleeding is stopped, do NOT remove or loosen the tourniquet. This may cause the patient to begin bleeding again. If the tourniquet begins to fail or break, apply a second tourniquet just below the first if available without removing the failed tourniquet.
There are a few things you should remember when using a tourniquet. Place the tourniquet over the clothing and tighten as much as you can. Placing a tourniquet over the clothing may be different than you have been taught before, but remember: you may be in an active violence situation and under significant stress, so don t waste time removing the clothing. You may have to move very quickly and might need to care for more than one person. TECC simplifies care in these difficult situations. Remember, if you need to use a tourniquet:
Place it as high on the limb as possible and over the clothing
Tighten the windlass as much as you can. Doing so might be painful, but it is life-saving.
Once you tighten the tourniquet, do NOT remove it!
Once applied, secure the windlass/mechanism so it does not loosen, and note the time the tourniquet was placed.
Continue to assess the injury and check for bleeding. Tourniquet failure is more common in the legs where muscles are larger, making it difficult to compress the blood vessels. If the tourniquet begins to fail and the wound starts to bleed again, apply another tourniquet just below the first one.
As previously mentioned, using a commercial tourniquet is always preferred. However, if you don t have one, you can improvise a tourniquet using a cloth folded into a 2-3 inch wide strip, or a cloth such as a necktie, along with a stick or ruler as a windlass. Make sure to use cloth only! Leather belts do not work as they are too stiff and may worsen bleeding, and shoelaces are too narrow and will cut into the skin, causing damage while not stopping bleeding.
To apply an improvised tourniquet, wrap the material fully around the limb once, then tie an overhand knot onto the material. Place the windlass on the knot and tie another overhand knot to keep the windlass in place. Then lift and turn the windlass, tightening as much as possible. Tightening the tourniquet may be painful, but it is life-saving. Once the tourniquet is as tight as you can get it, secure the windlass in place using a second tie around the limb.
Tourniquet application is an easy option for controlling bleeding. However, the number of tourniquets available may be limited, so you should prioritize their use. As previously mentioned, amputations can be treated only with a tourniquet. So, if there are multiple bleeding wounds and one is an amputation, use the tourniquet on the amputation.
Wound Packing/Pressure Dressing
Some wounds are not conducive to tourniquet application because of where they are located on the body. Wounds in anatomical junctions where the head and limbs meet the torso, such as the neck, groin, or armpit, CANNOT be treated with a tourniquet. For these wounds, the best options to stop major bleeding are wound packing and applying dressings. Wound packing and dressing may also be used on arms and legs.
Never pack wounds in the head, chest, abdomen, or back! If the casualty has a deep wound to one of these areas of the body, the best thing to do is simply apply direct pressure to slow the bleeding until emergency medical personnel can help.
Packing a wound involves inserting gauze or a similar cotton material deep into a wound to stop bleeding that is below the surface. Dressing a wound involves placing a clean material over a wound that has been packed to keep the packing in place. The manner in which you dress a packed wound depends on its location on the body. Both wound packing and dressing are very effective. However, these methods take more time than applying a tourniquet, so you must work as quickly as possible to minimize blood loss. The next sections will describe these two tasks in more detail.
Wound Packing
Applying direct pressure is an effective way to stop bleeding, but when a wound is deep, the source of bleeding may be well below the skin. Applying direct pressure to this type of wound may not put pressure on the actual source of bleeding. Deep wounds should be packed with gauze or other cotton material so that the pressure applied at the surface of the skin will transfer to the packing, and apply pressure at the source of the bleeding. Packing a wound should be done with gauze if it is available. However, you can use anything cotton such a handkerchief or strips of a t-shirt. As a note: some gauze bandages are treated with hemostatic chemical that helps to clot blood faster, but hemostatic gauze is not necessary.
When packing wounds or doing any type of wound management, it's recommended that you wear gloves and other personal protective equipment, or PPE, if they are readily available.
The first step when packing a wound, just like when controlling any other bleeding, is to keep direct pressure over the wound, even as you prepare the materials. If somebody else is there to assist you, ask them to hold pressure on the wound. That will enable you to use both hands to open the packages quickly. If you are alone, however, you can use your knee on top of the wound to generate pressure.
Packaged gauze may come in a flat compressed square or a roll. You must unpack it, find the end, and wrap some of the gauze around your index finger. Using your gauze-wrapped finger, sweep the blood out of the wound and try to identify where the bleeding is coming from. Then take that finger with the gauze around it and push it into the wound where the bleeding is. That gauze should stay on the source of bleeding the entire time. Then take the rest of the gauze and extend it or even throw it over your shoulder to help facilitate the packing process. Without removing pressure, switch your fingers and push more gauze into the wound. Continue alternating fingers until the wound is filled with the gauze. Fill the entire wound space without ripping or making the wound bigger, if possible.
Once the wound is packed, take the remaining material and bunch it up directly on the wound and apply firm pressure. Maintain pressure for a minimum of 3-5 minutes before attempting to dress the wound.
Wound Dressing
Once you have held pressure for the appropriate amount of time (at least 3-5 minutes), you can prepare to dress the wound. Dressing will help to keep the packing material from coming out of the wound. The method of dressing a packed wound depends on its location. A general dressing holds packing material in the wound without applying pressure. This is appropriate if the wound is in an anatomical junction, such as the armpit or neck, where applying extra pressure is not feasible or safe. A pressure dressing holds packing material in the wound and applies extra pressure. This is appropriate if the wound is on a limb.
To apply a general dressing over a packed wound that is in an anatomic junction like the armpit or neck, use an elastic bandage, shirt, or other material to secure the packing material in place. You can do this by holding the packing material in place and wrapping a bandage around the wound and lightly tying it in place. As an example, you can loop a bandage around the packing in a neck wound and then under the opposite armpit. You can apply some pressure and keep the packing in place without affecting the airway. This will keep light pressure on the wound and secure the packing material inside it.
To create a pressure dressing over a packed wound that is on an extremity, start by asking someone else or even the patient to hold the gauze used for the wound packing then open the wrapping materials. Next, take the end of the bandage and start wrapping the material around the limb over the packing materials. It is important that the material lays flat against the limb. Don t allow it to spin or curl up. Once a wide base is established, you can put one twist in the bandage over the top of the wound and then repeat that again, so you make an X across the wound. can use the rest of the bandage to continue wrapping, and then tuck the end under itself, so it does not come undone. Continue to monitor the bandage for bleeding periodically and make sure that it remains tight if the victim is moved.
Once you have packed and dressed any wounds as appropriate, you can continue with the SCAB-E priority list.
Module 5: Airway and
Breathing (Are one Module)
The next steps in SCAB-E are Airway and Breathing. Airway and breathing are considered two separate components of the SCAB-E treatment model. Treating an airway has to do with ensuring there are no blockages in the mouth to the throat. Breathing refers to the anatomical functioning of the lungs. Both are essential to ensuring unimpeded respiration.
Airway
After tending to life-threatening bleeding, you can move to assessing the victim s airway. Simply assisting in keeping the airway open and clear allows the injured person to breathe. When an unconscious victim, or a victim with severe wounds of the mouth or jaw, lies on their back, face up, the tongue and tissues of the airway are pulled backwards by gravity, which can block the airway. This position could be deadly for victims who are unconscious. Managing the airway of a victim can be as simple as checking for a blockage and repositioning the patient in a position that allows air to freely move through the airway.
To begin clearing the airway, use your hands or fingers to gently clear the mouth of any blood, teeth, vomit, food, or other foreign body. Then evaluate the patient to see if he or she is having airway issues by looking for signs of breathing, looking for blockages in the airway, and listening for choking sounds. Once you are done with treatment, position the unconscious patient on his or her side with the mouth pointed slightly downward. This position is called the recovery position, and it allows gravity to keep the tongue forward and drain blood, vomit, and other fluid away from the airway out of the mouth, keeping the airway open. You should do this with any unconscious victim, especially one with severe wounds to the mouth or jaw. However, if a patient is awake and responsive, NEVER force the person into any position. Allow the awake, alert person to lay in whatever position he or she chooses. If the person goes unconscious, turn them on their side so they are in the recovery position.
Breathing
Next on the SCAB-E list is Breathing. Breathing is different from the airway in that breathing refers to the mechanical process of moving air in and out of the lungs. For this to occur, several conditions must be met. Effective breathing requires an intact chest wall and functioning diaphragm to generate the negative pressure that allows the lungs to draw air in. Essentially, breathing is a process of changing pressures being generated inside the chest. During inspiration, or the process of inhaling, the muscles of the chest wall expand and the diaphragm contracts, increasing the volume of the chest cavity to create a negative pressure that pulls air in through the trachea to fill the lungs. During expiration, or the process of exhaling, all the muscles relax and go back to their initial position, decreasing the size of the chest cavity. This increases the pressure inside the chest and pushes the air out of the lungs through the trachea and out of the body. The lungs and chest work like a bellows: expand to pull air in, compress to push air out. This whole system works because there is only one way for air to get in and out of the chest via the mouth, nose, and trachea in response to the pressure change.
However, when a puncture is introduced into the system from an object such as a bullet or knife, a second hole in the chest is created. Air then has a second way to get in and out of the chest in response to the pressure changes created during breathing. The second hole allows air into the chest but outside of the lungs. Air that fills up the chest cavity, outside of the lung, will prevent the lung from expanding and will cause the lung to collapse. This is called an open pneumothorax. The hole in the chest has to be at least two-thirds the size of the trachea (about the size of a nickel) to create an alternative pathway for air to enter the chest. The larger the hole, the more significant effect on a patient s breathing.
So, if a chest wound is creating a problem, the simple fix is to cover it up with something that will restore the integrity of the chest wall, allowing air to then move in and out of the mouth, the way the system is supposed to work. However, if the lung underneath the wound is punctured, air could spill out into the chest cavity, creating pressure. The pressure can build up over a period of 10 to 20 minutes and cause a condition called tension pneumothorax. This condition is lethal and needs prompt attention.
The best way to restore breathing and prevent a tension pneumothorax is to apply a commercial non-occlusive chest seal. The non-occlusive seal prevents air from being pulled into the chest cavity through the wound but allows air to escape the chest cavity which prevents tension pneumothorax, as it has a one-way valve. This keeps the flow of air one-way through the chest seal, from inside the chest cavity out of the body
To treat a wound like this, first check the area from the belly button to the shoulders in the front and back of the body, looking for
A hole in the chest cavity that is larger than
the size of a nickel,
A wound that is bubbling or making a sucking sound, and
A wound causing respiratory distress for the patient.
If you see this kind of wound, you will need to prepare to apply a commercial non-occlusive chest seal (also called a vented chest seal) directly over the wound. The seal comes in a plastic package. Open the package and use the gauze inside to wipe away blood from the wound. Then apply the seal. The seal has a hole to allow air to vent from the wound. Place the hole in the seal directly over the hole in the chest cavity and press the seal around the wound so that it sticks to the skin. If the seal does not stick well, use tape to reinforce the seal.
If you do not have a non-occlusive seal, you can improvise a seal with any plastic, such as from a grocery bag, to cover the wound and use tape on three and a half sides. Make sure to leave one corner unsealed. This will simulate the vent in the non-occlusive seal and allow air to escape but keep air from entering the chest cavity. This can be visualized through a brief demonstration. If you hold the back of your palm in front of your mouth and breathe out, the air will escape. If you inhale your hand will get suctioned to your mouth. In principle, this is how an improvised non-occlusive seal works. If you only have an occlusive or non-vented seal, or if the vent in the non-occlusive seal should fail, then you will need to burp the seal. Burping the seal will periodically allow air to exit the wound if air is building up in the chest cavity. This procedure is easily done by peeling the chest seal back to fully uncover the wound, and then gently massaging the wound to open the wound track and allow air to escape from inside the chest. Once the pressure is relieved, and the patient s breathing improves, place the seal back over the wound to prevent air from being sucked into the chest. You will know if you need to burp the wound if the patient has increased difficulty breathing or gasping for air, is breathing more rapidly, has increasing anxiety and restlessness, or is turning blue around the lips. If any of these occur, you should burp the wound.
Module 6: Evaluate or Everything Else
The last element on the SCAB-E list is to evaluate or care for everything else. Once a patient is treated and seems stabilized, you should
Check for additional wounds with brief head-to-toe assessment,
Monitor mental status
Assess for shock,
Prevent hypothermia,
Position the patient, either conscious or unconscious,
Provide psychological support, and
Evacuate to definitive care as soon as feasible.
Check for Additional
Wounds
In this stage you should evaluate if any other serious injuries are present and use the previous steps to treat them. Remember that you need to be checking for life-threatening wounds and not worry about minor cuts and bruises.
Evaluate Mental Status
AVPU
Next you will need to evaluate the mental status of the patient to check for and prevent shock. To evaluate the mental status you can use the AVPU acronym. This stands for Alert, Verbal, Painful, and Unresponsive.
Alert check if the patient is alert and responsive
Responsive to Verbal commands or questions someone may be confused, but if they respond to verbal commands or questions, they are considered responsive.
Responsive to Painful Stimuli someone may seem asleep or confused, but if they respond to painful stimuli, they are considered responsive
Unresponsive this means a person is unconscious and unresponsive to outside stimuli
Continue to evaluate the person s mental status. If their status is declining, you might try to evacuate them before others, or you can give this information to responders when they arrive.
Shock
Next you want to assess the person for signs of shock which may occur if the person has lost a significant amount of blood from a trauma. Essentially, you have been treating the victim to prevent him or her from experiencing severe shock by controlling bleeding, by supporting the airway and breathing, and by keeping the airway open and clear through proper positioning. If the person has a chest injury, monitor him or her for worsening respiratory distress, as well as for the other signs of tension pneumothorax.
Most people in shock will complain of thirst. If the person wants to drink, let them sip clear fluids. The mental relief from that simple act may help to keep spirits up and increase the will to live. Use common sense, however don t give the victim food, and don t let them drink a large amount of fluids.
Hypothermia
Another potential problem when someone is injured in a traumatic event is hypothermia. Hypothermia occurs when the patient s body temperature begins to drop. This can reduce the body s ability to clot blood. You can prevent hypothermia by taking a few easy steps:
Remove any wet clothing and keep the person dry.
Cover the injured with anything that will retain heat such as clothes, jackets, curtains, throw rugs, newspapers, plastic bags, etc.
Insulate the injured person from the ground. People can lose significant heat while lying directly on the cold ground. Place the injured person on something to insulate them from the ground. For example, place them on carpet instead of the bare floor.
Place the injured near a heat source such as in direct sunlight near an outward facing window. If possible, turn up the thermostat. Anything helps.
It is important to take these steps as quickly as possible since hypothermia is easier to prevent than to treat. Hypothermia has been linked to increased blood loss. Taking steps early saves lives.
Positioning
You will need to make sure the victim is positioned in a way that will support their immediate needs. Several positions may help different injuries, but any patient who is unconscious should be placed in the recovery position to keep the airway open.
For head injuries, elevate the head a little to decrease pressure build-up inside the head, if possible. If this is not possible, and the person is awake, keep the person flat. Avoid putting the head below the level of the body.
For chest trauma patients who are unconscious, place them in a recovery position with the injured side down. If conscious, allow the person to sit or lay however they are comfortable; often this will involve them lying on their back.
Patients with abdominal trauma are typically most comfortable lying on their back or side with their legs drawn up. This reduces the stretch on the abdominal muscles and may relieve some pain.
Patient s with facial or mouth injuries will naturally want to sit up and lean forward to allow the blood and saliva to drain out of their mouth and airway.
Always remember regardless of the injury, if a patient is awake, allow him or her to lie or sit in whatever position he or she chooses. Never force a person to lie down or lay in a position he or she does not want to be in. If they become unconscious at any time, place them in the recovery position. This means placing them on their side with their hips and legs rotated forward slightly with the face and airway pointed slightly downward, to allow any saliva, blood, or vomit to drain from the mouth.
Psychological Support
Finally, you need to provide psychological support to the wounded. Even if the patient has injuries that you are unable to treat, or has severe injuries and is dying, you can give them comfort. You can also give them the will to live. Tell the injured person that they will be okay, that they are not alone, and that you will take care of them. Keep the person talking and engaged. Tell them to concentrate on you. Explain that help is coming and that he or she will be rescued.
You may need to give the person a psychological hook to survive. Ask them about that one person or thing that they need to live for; it may be a child, spouse, friend, parent, or pet. Remind the injured person that they need to fight and stay alive for that loved one. Talk, encourage them, and keep them in the moment and fighting. Even if the person dies from the wounds, you will have given them a chance and some peace.
Evacuate to Definitive Care as Soon as Possible
As soon as the situation is safe, evacuate yourself and the victim to a location where they can receive treatment from emergency medical providers. While caring for the casualty is paramount, ensuring that first responders are informed before and after they arrive is essential. Here we will cover the types of information you should be ready to report to law enforcement and medical personnel.
As soon as possible after the mass casualty event, contact 911, if they have not been contacted already. Be prepared to report information to the 911 operator, and get ready to encounter law enforcement and medical first responders when they arrive.
When reporting information to 911, be prepared to
Describe the nature of the emergency,
Provide the what, when, and where of the incident,
Remember to speak clearly and control your breathing, and
Offer medical information about victims injuries and the care you have provided or are providing.
Once law enforcement arrives, be prepared to
Remain calm and follow instructions,
Put down any items in your hands such as bags or jackets, and
Keep hands visible by raising them and spreading your fingers.
When emergency medical services, arrive be prepared to
Identify yourself as a trained Active Bystander,
Report on the injuries sustained, treatments that you have performed, and patient mental status, and
Step back and let medical personnel take over care; by this point, as an active bystander, you will have done everything you could do.
Module 7: Conclusion
During this refresher course on Tactical Emergency Casualty Care. You have learned evidence-based Tactical Emergency Casualty Care skills, including:
The role of and how to prepare to become an
active bystander
Recognizing threats and taking informed actions
SCAB-E which includes
o Situational Awareness
o Circulation
o Airway
o Breathing
o Evaluation and Everything Else
These skills could mean the difference between life and death for you and any casualties of an active shooter or other mass casualty event. This course is not intended to take the place of a hands-on TECC or Stop the Bleed Course. We recommend that this training be taken as an introduction to or as a refresher to an in-person course.
Lastly, choosing to become an active bystander can be one of the most rewarding and difficult things you may ever take on. There is no right or wrong way to feel after having engaged in such a situation. Just being present for a mass casualty event is traumatic. Taking an active role may cause additional trauma. It is essential that you seek support for yourself from psychological professionals such as a counselor or therapist in the weeks, months, and possibly years following the mass casualty event.
If you have not taken it already, we recommend taking FEMA s IS-905 Responding to an Active Shooter: You Can Make a Difference. IS-905 will discusses how you may prepare yourself to effectively respond if you are ever faced with an active shooter incident. Also, to learn about preventing active shooter incidents, take FEMA s IS-904 Active Shooter Prevention: You Can Make a Difference course. IS-904 shares tools and perspectives you may use to reduce the likelihood of an active shooter incident.
Congratulations! You have completed the Tactical Emergency Casualty Care refresher course.