Page 139 - Journal of Special Operations Medicine - Fall 2016

mass shootings. This work, like the work of Holcomb, C-TECC has an executive board and a voting commit-
Eastridge, Kotwal, and others did for the military, has tee that are responsible for the organization’s messag-
the potential to drive evidence-based response to high- ing. Second, as most know, the open-source TECC,
threat incidents. In fact, the ACEP Task Force in which is based on the highly successful military TCCC
5–7
partnership with the ACS COT is using the Smith et al. recommendations, places a heavy emphasis on rapid
article as support to call for a comprehensive national hemorrhage control. TECC guidelines, like TCCC, are
preventable death analysis of high-threat civilian mass both evidence-based (when evidence is available) and
casualties (e.g., active shooter incidents, civilian public best practice/consensus. Both sets of guidelines support
mass shootings and targeted acts of terror). early and aggressive hemorrhage control as part of a
broader system to reduce potentially preventable mortal-
Unfortunately, I have also recently listened to a small ity. Comprehensive TECC-based response systems have
group of learned and influential individuals speak been implemented across the nation. And in places such
about the damaging nature of this article. In the same as Virginia, Indiana, and North Carolina, it has been
breath, they bring attention to the methodological used to justify tiered high-threat prehospital trauma-
flaws of the trial (which are clear and not insignificant) response initiatives such as law enforcement tourniquet
and concurrently argue that this one study will some- programs. 12–16 The TECC guidelines have gained such
how threaten everything that has been established in wide support that this May, representatives from ACEP,
civilian high-threat response. Anchoring on the word NAEMSP, NASEMO, SOMA, NTOA, and NAEMT
“myopic,” they argue that the article will be used to voted in support of TECC as the core medical domain
counter calls for prehospital tourniquets and unravel for the National TEMS Core Competency Domains.
11
all ongoing national hemorrhage control initiatives. Primary source information to inform honest discussion
These individuals state with certainty that medical di- and counter any influence operations can be found at
rectors across the nation will cite this article in sup- c-tecc.org or on pubmed.com. Alternatively, any inter-
port of removing tourniquets from EMS, Fire, and Law ested individual can attend the next C-TECC meeting
Enforcement. In essence, they are arguing that medical that will be held at the Governor of Virginia’s High-
directors will blindly change their practice based on a Threat Response meeting in December 2016.
flawed interpretation of a flawed study. This line of rea-
soning ignores and undermines the significant profes- In my opinion, the only component of the article that
sionalization that has occurred in the EMS subspecialty is inaccurate is the statement that “[the results] . . .
including the recent move to create an American Board bolster our concern that current, TCCC based recom-
of Emergency Medicine certification process. Further, mendations will not impact outcome in civilian active
it suggests that professional medical directors will use shooter events.” This sentence was likely meant to ad-
this faulty interpretation of a single study to counter dress TCCC-influenced, hemorrhage-control ONLY ini-
position statements from their own national profes- tiatives. I suspect it was targeted to groups who claim
sional organizations, including the American College of that they “do TCCC,” but, really, they only do CAT/
Emergency Physicians (ACEP), the American College of SOFTT-W and Combat Gauze, neglecting the other
Surgeons (ACS), the National Association of EMS Phy- critical components such as management of airway and
sicians (NAEMSP), the National Association of EMS chest trauma as well as damage control resuscitation.
State Officials (NASEMSO), the National Association Regardless, the statement in the article is misleading and
of EMTs (NAEMT), the National Tactical Officers As- should be addressed in a response from the authors.
sociation (NTOA), the International Association of Fire
Fighters (IAFF), as well as the Federal Fire Administra- There should exist no doubt that hemorrhage control
tion, Federal Emergency Management Agency, and the remains a critical component of civilian high-threat re-
Department of Homeland Security (DHS). Fortunately, sponse both during active shooter incidents and “rou-
there is no objective, or even anecdotal, evidence to tine” operations. Tourniquets are a great tool; put them
support this position. In fact, since the electronic pub- on high and tight and get the victim to the trauma center.
lication of this article, states such as North Carolina Hemorrhage control is easy to teach and well- designed
have expanded prehospital hemorrhage control pro- programs will have a major return on investment in
grams, now outfitting all Highway Patrol officers with terms of lives saved. But, prehospital systems must do
the lifesaving tourniquets. more than stop the bleeding. This is the conclusion of
the “Smith Paper,” of C-TECC, of CoTCCC, and even
Some have also used the authors’ disclosed affiliations of the Hartford Consensus. We must continue to ask
to argue against TECC, the current civilian standard for hard questions and look critically at the results. We must
high-threat response. 8–11 First, it is important to note that have passionate and informed debates. However, to at-
this article represents academic research from George tack a researcher for asking the question is intellectually
Washington University faculty; it is not a C-TECC article. dangerous and not in our community’s best interest.

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