Page 88 - JSOM Spring 2020

Box 1 Hot, Warm, and Cold Zones: Different Zones of Care
“Zones of care” is the term used in the prehospital setting to de- insufficient amount of equipment. The five tactical physicians were
lineate locations that require different levels of care and/or safety. the first and only responders in position to treat the victims in-
These zones help delineate the personnel and equipment that can side the Bataclan. The conventional rescue teams were situated in
and should be used depending on the type of incident. The defini- the cold zone and when these teams received clearance to enter
1
tion of different zones can be applied in both military and civilian the warm zone, all living casualties had already been extracted.
settings, for instance in a mass shooting or other mass casualty in- The final evacuation was performed 4.5 hours after the start of
cidents. The most dangerous zone of care within tactical medicine the attack. In civilian setting, Emergency medical Services, more
4,5
is care under fire, also known as a hot zone or red zone. This zone commonly known as EMS, can be based in a fire department, a
poses the highest risk to life, and therefore limited care should be hospital, an independent government agency (i.e., public health
provided. The only medical treatment in this zone should be essen- agency), a non-profit corporation (e.g., Rescue Squad) or be pro-
tial hemorrhage control, for example, pressure or tourniquet use. vided for by commercial for-profit companies. These are examples
6
The second zone of care is tactical field care (TFC) also known as of professional first responders. The hot zone is dynamic in nature
a yellow zone or warm zone. This is generally where Emergency and dependent on the location of the threat, the mobility of the
1
medical Services (EMS) and tactical support personnel will work. threat, and the mobility of the patient. The hot and the warm zone
2
When the TFC phase is entered, more medical interventions are can, at different times, be the same location. The warm zone is
possible. These include airway control and for instance the treat- where most of the care of the sick and injured is accomplished, in
ment of tension pneumothorax and application of a vented chest respect to tactical medicine. Care can be varied depending on the
seal to open entry and exit chest wounds. Bleeding control with equipment available, the location of local hospitals, and expertise
tourniquets, hemostatic gauzes or junctional tourniquets should of personnel. Introducing advanced bleeding control options into
be continued. Resuscitation with hypovolemic fluid resuscitation the warm zone could improve outcomes.
through intravenous (IV) access or intraosseous (IO) access is rec-
3
ommended for rapid fluid delivery and resuscitation. The third References
zone is the Tactical Evacuation zone (TACEVAC), also known 1. Goldstein S, Martin L. EMS, Zones of Care. https://www.ncbi.
as the green zone or cold zone where basic emergency manage- nlm.nih.gov/books/NBK436017. Accessed October 27, 2018.
ment services can be performed. Incident command posts, triage 2. Pearce J, Goldstein S. EMS, Tactical, Movement Techniques
areas and ambulance staging areas are located in this zone. This (Concealment, Fatal Funnel, Stack, Wedge, and Pie). https://
is the zone outside of immediate danger and transportation to de- www.ncbi.nlm.nih.gov/books/NBK499869/#article-31847.s5.
finitive care is usually available. In this zone, continued care and February 28, 2019.
reassessment are the keys to ensure patient safety. In the 2015 3. Tactical Combat Casualty Care Handbook, Version 5. https://
1
Paris Bataclan attack three tactical physicians were in the hot zone usacac.army.mil/sites/default/files/publications/17493.pdf
performing triage and applying tourniquets and hemostatic dress- 4. Lesaffre X, Tourtier JP, Violin Y, et al. Remote damage control
ings. They were on the scene 11 minutes after the attack started. A during the attacks on Paris: lessons learned by the Paris Fire
dressing zone was established in the warm zone to perform damage Brigade and evolutions in the rescue system. J Trauma Acute
control resuscitation (DCR). Two other tactical physicians joined Care Surg. 2017;82(6 suppl 1).
the team in the dressing zone. This involved the application of 5. Service Medical du RAID. Tactical emergency medicine: lessons
tourniquets, dressings and the use of tranexaminic acid and the from Paris marauding terrorist attack. Crit Care. 2016;20:37.
administration of fluids. Not all of the DCR recources were used 6. EMS.gov. https://www.ems.gov/whatisems.html
because of a mismatch between the number of casualties and the

and tactical training for complex situations. They can be de- or ultrasound experience could be trained to acquire the skills
ployed in mass casualty events or terrorist attacks. Medical to adequately place an endovascular sheath in a femoral ar-
support for the casualties is a secondary task in addition to tery flow model and subsequently place a REBOA catheter in
their primary task. At times, however, first responders are the aortic zone I, using our previously published microteaching
only professionals initially at the scene of the incident, and curriculum on a task training model. 5
improving their ability to control hemorrhage is a logical way
to improve outcomes when advanced medical providers are Methods
not immediately available. Before considering making these
advanced skills available to first responders, the ability to train This study was conducted under a protocol reviewed and ap-
them must first be assessed. proved by the Dutch Ministry of Defense (MoD) and both the
Institutional Review Board and medical Ethical Committee of
There are a few formal training curricula designed to train Alrijne Hospital, the Netherlands (NWMO 17-15, 17.409rt.
the skills necessary to perform REBOA: the Basic Endovas- tk). All participants completed an informed consent to partic-
™
cular Skills for Trauma (BEST) and the Endovascular Skills ipate in this effort, including permission for video recording.
for Trauma and Resuscitation (ESTARS) and Endovascular
™
Resuscitation and Trauma Management (EVTM) courses. Our Participants
Advanced Bleeding Control study group recently published Participants were members of a Quick Response Team of the
two papers on vascular access and REBOA training. These Haaglanden Fire Brigade, The Hague, the Netherlands. In this
studies showed that a comprehensive theoretical and practical study we included the six members of this QRT-FF team. These
training program can be used for effective introduction of the QRT-FF performed the identical procedure a second time as
skills necessary for percutaneous femoral access and REBOA a posttest after 2 hours of additional endovascular training
placement in personnel without prior ultrasound or endovas- during this EVTM workshop in Leiderdorp, the Netherlands.
cular experience. The aim of this current feasibility study Eleven Special Operations Forces (SOF) medics from a previ-
4,5
was to determine whether QRT-FF with no prior endovascular ous EVTM training functioned as control group for technical

82 | JSOM Volume 20, Edition 1 / Spring 2020