Medical and Operational Challenges of Tactical EMS (Non CME)

- [Rick] All right. So welcome to our, this is our 10th, I guess, Tactical Webinar. I'm very excited for this to continue. Welcome everybody. If you would, some housekeeping items. If you're not presenting, if you would put your mics on mute, that helps with the background noise. If you have a question during the presentation, several options, you can use the chat box to put your question and we'll pass it on to the presenter. You can use the raise your hand option, to raise your hand, or at the Q and A section, open your mic, and you can ask your question online. And with that, I guess, I will turn it over to the presenter first.

- [Florian] All right. Fantastic. Thanks for having me, and hi to all of those who do and do not know me yet. I'll give a quick introduction of who I am and how I came involved in law enforcement here. And then we'll basically talk a little bit about my unique setup, some lessons learned over the last few years, and then have a Q and A. Ideally, I'll have my sheriff join us in a little bit as well, to be able to provide some insight. The main idea is basically, have this be as interactive as possible. I'd love to learn from everybody in here and maybe impart some knowledge from like what I've learned so far. So please ask questions, feel free to interrupt as well, that's fine with me, and we'll have a good conversation, I hope. Talking a little bit about the support functions of law enforcement from a medical perspective, the key medical issues that are fairly unique, that, I mean, most of us are very familiar with. But to review my thoughts on medical and tactical gear, some tactical consideration that I've learned, brief case report about an officer involved shooting, and then a Q and A and discussion as well. My background is, I got started in medicine and tactical medicine as a medic in the Austrian army. I started off in basic infantry, had a grand old time, and then I decided to also train to be a medic. The level of medic is about the same as a civilian medic. Just a lot more combination of tactical medicine included with that, but it has the central advanced life support scope. That knowledge, I then took on later on to work in different conflict regions, then combined with my emergency medicine residency and the knowledge I gained in there. I'll show some photos of that in a second. Right now I'm one of the two medical directors for the paramedic division of the Tennessee County Sheriff's Department. And I'm the alternate ACEP representative for the advisory committee of TECC. So a little bit about my time in the military basically, it was quite a few years ago now, but a very formative time and kind of turned me towards the more tactical emergency medicine kind of track and the combination of, how do you support both military and law` enforcement operations? I've gained some knowledge there and used it in various conflict regions, which is my big passion outside of emergency medicine, in the states. And I've been pretty much all over the world with various NGOs, one of which I'm a board member of. This is a photo, for example, of the Karen people in Burma, Myanmar, during their civil war. And there, we actually trained up some of their backpack medics, which are a combination of civilian and military medics who work in support of the Karen people who are being persecuted, now, unfortunately again, by the central government. It's a very unique environment, in that, it's all jungle based fighting, and kind of tropical medicine meets tactical emergency medicine. We've been training them and building up a curriculum for them, which included a fair amount of prolonged field care, given the lack of definitive care for most of them. The setup there, for example, was, point of injury, buddy care, transport to their medic, if possible. Get patched up as much as possible, and then go to a casualty collection point, after which it would take days to weeks to be transferred to a hospital, really. The only hospitals available being in Thailand. So that included the border crossing and everything else. Big emphasis on both immediate care and prolonged field care. I've worked in various other regions, most recently in Ukraine, in support of... By invitation of the Ukrainian government and the WHO, in support of direct medical surgical missions, as well as critical care transport and education. Where we taught TECC/TCCC, to Ukrainian medics. Something that was, unfortunately, very necessary. You can see the part of the level of equipment. I obviously am showing this more interesting photos here, but they have a good mixture of very modern and somewhat dated medical equipment, combined with very much of an old school mindset to trauma medicine. So it was very interesting implementing TECC and TCCC there, as well as doing some forward medical and surgical operations there. The key thing talking about the law enforcement support here, I'll talk a little bit about the setting that I'm currently working in, and I'm hopeful there'll be some questions for the Q and A as well. Genesee County includes Flint, Michigan, which is infamous for, unfortunately, a number of things. Not the least it's high crime rate. And the unique setup, not quite unique. But the individual setup we have there, is that actually, the Sheriff's Department has a paramedic division. The setup is as follows. We have various transporting BLS and ALS agencies that serve all of Genesee County, which is rather large county, kind of centered around Flint, Michigan, in the middle. And you have these Tahoes by the Sheriff's Department that provide advanced life support for either if a BLS unit is responding, or if it's a particularly serious call. The advantage is also, you have sworn deputies who are actually on those vehicles. Meaning, they serve a kind of a dual purpose of policing and medical care, all under the big umbrella of community engagement as well. That's actually something I credit our good relations with the population with. When somebody shows up when you call 911, yeah, it may be a deputy showing up, but that deputy can not just throw you in jail, but also actually, provide medical care and quite expertly. So they are, by far, the most well respected part of the pre-hospital team in Genesee County, and really the gold standard, as far as pre-hospital care in the county, which is wonderful to work with them. We have two medical directors, myself and Dr. Ryan Reese, and we basically try to provide... They do a fantastic job at their own education and everything else, but we try to both be available for them, ride with them and provide on the job kind of training and also experience, but also have educational sessions for them on particular topics that they need or want more training for. I think the setup is probably not that easy to replicate, but it is an interesting intersection between like, "You have somebody who's both in a tactical role, but also in a medical role." And that provides... It brings me a little bit back to my military medical role, where you're like, "You're a soldier first, and then medic second." Same for these men and women who kind of respond to medical emergencies, but also, once in a while, have to do a warrant, engage in a car chase or high... high risk situations, and are not infrequently in the line of fire as well. The big advantage for them is obviously, their level of training. They can respond to necessary medical emergencies. They have the medical knowledge, the toolkit, and the experience, given the high crime in the area. But what is relatively rare and we're very blessed for that, is actual violence against police. And I credit this dual role, a fair amount for that. You have a very good community relations, and that's something that they take very, very seriously. I'll talk a little bit about roles of medical support in law enforcement and kind of how I see it, what my thoughts on this. And I would love to have a little bit of a discussion afterwards in the Q and A as well. These are my thoughts, and I know people have different thoughts. People here have breadth of experience, from what I've seen, and I would love to get a little bit of back and forth. And I'll start with what we've been doing for the officer training. There's been some amount of training for pre-hospital officers that are not involved with... That are not part of the paramedic division. And for those, the TECC guidelines are an ideal setup for them, in terms of being able to gain the necessary knowledge on how to work in hot zones, warm zones, cold zones, and so on, and how to structure the response. So this is what we've been using for some of the regular deputies, non pre-hospital providers. And we kind of start teaching them about hot zone, and direct threat care. In our trainings always, just emphasizing the key components of TECC, which is adapted from TCCC, and really made suitable for the prehospital setting in support of law enforcement. I think, as physicians and as the emergency physicians, specifically, for us, the key thing here is kind of emphasizing this hot zone care for our officers, and knowing that mitigating the threat is important, moving to a safer position. Staying engaged in the fight, is something that we've been very much emphasizing as well, and kind of stopping life threatening external hemorrhage, the usual hot zone levels. We do teach recovery position only. We teach nasopharyngeal airways, but we don't focus too much on any other significant airway or other procedures, in particular, not for the hot zones. We do actually use the MARCH algorithm, at least for basic knowledge for our pre-hospital personnel for warm zone treatment. A big emphasis is also on securing weapons, both on your own patients, if one of the offices was to get hit, but also for any patient. So taking prehospital medicine and putting it into the context of... Very much in the context of tactical medicine as well. Focusing, really, what I found is that, the key things they want to hear about is penetrating injuries, really. And we do a lot of teaching on kind of recognizing, I mean, the late person offices don't know what a pneumothorax is, they don't know that a chest seal exist. They definitely know about tourniquets, these days. But at least, being aware of these and knowing how to utilize your resources, when to bring in the medics, when to bring in if there's no deputy medic available. And then also, lots and lots of practice. I think all of the people on this call, probably have done trainings with their own agencies and their prehospital providers. And the practice patterns are interesting, to say the least. I'm sure everybody here has had their own issues, in terms of getting people trained up and doing it right. There's a lot of mistakes that can be made. And we found that, repeat trainings was necessary for the non-provider kind of officers in order to actually utilize them well. And then, the other thought is integrating. And this is always the individual part, right? Integrating the medical care in the tactical scenario. And this is where the TECC guidelines come in very handy. And being able to kind of both train and practice how to include tactical medicine in the overall scenario, and having the support, not only from medical personnel, but having a really joint trainings with everybody involved. We're cheating a little bit. Our deputies are medical personnel, for the most part here. So that makes it easier. But it's certainly something that's a bit of a challenge as well. As far as medical and tactical gear that we're talking about, there's obviously the thought of like, "How do we best supplement available equipment when you as the physician show up on scene?" And this really comes in the thoughts on your own personal protective equipment, but also like, "What can you offer as the physician?" We'll talk about that, and I'd love to discuss that a little bit more. We talk about evacuation care, all the way up until movement of the patient. And this is something that certainly needs to be practiced as well. And also there should be, at least, an understanding of evacuation for injured officers as well. And that should be something that should be discussed with your departments as well. Because there needs to be a clear standard and clear understanding, that everybody understands how to best evacuate your casualties, which is the go-to trauma center. And also an understanding, the usual go-to for most officers and deputies will be throwing them in their car and racing them to the hospital. Which is presumably, in many cases, a suitable scenario. However, there needs to be immediate care for what we've talked about, the hot zone care that needs to be stopping life threatening hemorrhage, ensuring that basic airway procedures are being performed. And then also, making sure that we're not just arriving at the hospital without any kind of pre-announcement. So these are all things that we've, unfortunately, had to implement somewhat recently, end of last year. I'll talk about that in a second. But also something that I encourage people who are supporting law enforcement personnel to kind of consider as well. So the other thing is paramedics and tactical medics. I assume a lot of people on this call are in the process of also training, not just with their law enforcement agencies, but also working with the medical pre-hospital providers, who actually will be in charge of the medical care. And in many counties, in many different cities, they are integrated as well in the overall response. There's obviously many different scenarios to talk about, like, "As simple as a combative patient, where the pre-hospital providers need to work together with law enforcement." There's a high risk considerations, such as high risk warrants, where you might want to have medical personnel on standby, spot operations. And then, as unfortunate recent events have shown, active shooter scenarios, where the medical response, certainly, is a key component as well. The other focus then is, "What do you need to focus on when you train your medical personnel?" There is the tactical operations, which includes things such as, where do you stage? What are the different timings? What are the different stages of an operation, from a law enforcement agency? For example, when they serve a warrant, where should the EMS be stationed? When are they clear to come in? How will the communication work? Those components. And then the other thing is, are you including any medical personnel, actually, as part of entry teams, as part of law enforcement, in this case? Or is all patient care being done immediately by body aid at the point of injury, and then you bring the patient back to a collection point? And then, having a plan for the evacuation phase as well. So these are the things that need to be implemented when you as the physician are kind of tasked with supporting law enforcement operations, and kind of the interface. You need to be the interface between all the different agencies, because you have the overview of the operation as well. And then obviously there's the medical component of that. And this is something that everybody on this call fully understands. But you may be tasked with supporting an operation that does not necessarily have a lot of penetrating injuries in their county or their city. I mean, lot of places may have high risk police activities that are happening in an area where EMS is just not used to. I mean, there's paramedics out there who've never had to apply tourniquets, and deal with the pneumothorax. And there's varying levels of actual intervention that our pre-hospital providers are comfortable with. So I work at multiple sites. And one of my sites, any penetrating trauma is a big deal, because that area does not see a lot of penetrating trauma. In Flint, there's a lot of penetrating trauma. This is everyday operation. So certainly not a unique scenario, and our pre-hospital personnel are very much used to that as well. So you need to kind of adapt your teaching for the setting as well. Here are the things that kind of I've been working with and we've been working with our pre-hospital personnel, both in Genesee County, and also to some extent, in Washington County. Tension pneumothorax, sucking chest wounds, basic simple stuff. Just the reminders of penetrating injuries and the secularial of those. Hemorrhage control, tourniquet use. To some extent also, hemostatic lesion, if they're in use. Though not necessary. Spinal cord injuries and patient movement, has been very important, and then, airway management and surgical airways. Me and Dr. Reese had a great training on surgical airways because that is unfortunately, something that becomes more and more necessary for our prehospital personnel, when dealing with penetrating wounds and wounds, due to the violence. There we found it to be an important kind of skill set to balance the need for immediate airway control and kind of also discuss different scenarios. We have a very high rate of surgical airways in our county, and trying to see which of these are truly necessary, which ones aren't. And when they're necessary, how to best provide this and how to best conduct it as well. Because we need to make sure that our providers have the right tools for the job, but also apply those tools in the right and suitable situations. So certainly something we've been a little bit struggling with, but also have been addressing in the past to work on that. So then there's the part of physician oversight and medical direction. And that's kind of what I said, "You are in charge of kind of the medical aspect, but really you should be bringing it all together." And for those of us in this kind of goal, there's the thought of, "How you're best useful in this scenario." I think there's two different things. There's the, "I myself am a resource that can be utilized on scene." So for example, you show up on scene, you can help, you can provide more advanced procedures, or perhaps be useful in a variety of patient cases, not necessarily only injuries, but also general medical emergencies. And then there's the other part, there's the oversight component and having the connections to combine the medical component with the tactical component, and having the medical background to kind of bring all the different parts together. And if you're combined with a supportive environment, which we're lucky enough to have, then that's a very useful scenario for you to actually be helpful to your community. If you find yourself in a position where you can actually be in the field, there's many thoughts on, "Well, what do I carry? What do I bring?" There's basic components of like, "You should be able to take care of yourself. You should have all your officers, all your pre-hospital personnel, have their own medical equipment for self aid." By this point, every officer will have tourniquets. But there's certain things you may consider as well for your officers, which is, just basic gauze, consideration of an NPA, chest seals, needle decompression. Depending on the level of training that you or your agency has provided as well. And then also, you can kind of think, "If I myself I'm there, what is my personal role? What can I provide that's outside the protocols for my pre-hospital personnel, for my medical personnel that may already be on scene?" So for example, in our county, we very infrequently have pediatric airways and our medics do not intubate most pediatric airways. Something that you can bring to the table. You should consider, "Is finger or tube thoracostomy a part of the local skill set?" Which it really is. Is that something that you should be able to perform for an officer that's been injured, for example? You bring a whole bunch of airway management expertise to the scene, if you're available. And certainly also, with surgical airways. And then something that, maybe a good consideration is also like, "You can bring some very simple stuff with high impact to the scene." Simple stuff, minor medical issues, being able to deal with them, being able to assess an ankle, being able to do simple suturing, is something that you certainly can consider at that point. You need to kind of consider the responding physician set up. There's numerous examples in the community out there. There's your non-sworn in, you're sworn in, there's advantages and disadvantages to both. We're sworn in various deputies and that helps in terms of having a certain level of protection. There's a question of, "Do you carry arms with you when you do this? Will you respond and go into the hot zone? If there's an active shooter, what is your plan like?" Having that in your mind and discussed with your team. Will you be the ones going in immediately, will you be taking up the rear? Kind of considerations of these scenarios. And then also training with your department, and then training your department. So those are the different components. They're both important, right? Training with your team allows you to be an effective part of your team. So both Dr. Reese and I, regularly work on the trucks, and are available for them for any needs they have. We know them all. We're known quantity, they know our skill sets, we know their skill sets. We know their equipment. It's a time investment, but it's one that's very worthwhile. And then there's the second part to that is, also training them and being able to tailor that to a level of need. So in our case, it is very much advanced life support and above. In your case it may be, very basic training for your officers and more advanced life support to your tactical medics. But it really has to be well suited to all the different roles involved. So the last thing I wanna formally talk about before we kind of go into our Q and A, is a case report of what happened to one of our deputies last year. This is something that just is important to note and be prepared for. Because I think the response and the situation went quite well. I think big credit of that goes towards very experienced deputies that were responding to this incident. And a very inexperienced, very new deputy, who actually was injured and still had a good amount of training and knew exactly what to do in that scenario. This is one of our deputies, Deputy Brandon Fachting, and multiple of his colleagues, were in pursuit of a man who was shooting randomly around himself, outside a residential home, and started targeting homes. They responded to scene and used good tactics to actually, get ahold of the perpetrator. And perpetrator started fleeing on foot, but did not drop his weapon. So they followed him, and ultimately, were able to subdue him. However, in soon struggle, our deputy jumped over fence, fence fell on the perpetrator. Perpetrator underneath the fence shot one deputy and one officer multiple times. Was in return killed by our deputy. But our deputy was gravely injured in this scenario. And they actually did a fantastic job in the minutes after this. So this is someone who, the shots actually went right above the vest, which was worn correctly, stopped one other shot. But there was one shot that went straight into the chest and caused significant hemopneumothorax for our deputy. And our deputy was essentially incapacitated due to this rapidly declining. The responding sheriff's paramedics were on scene within minutes and loaded him up in their Tahoe, and drove him to our level one trauma center. They actually were able to perform some interventions in the back of the wagon. And our deputy who was also a paramedic, did recognize the for a needle decompression, which they actually performed in a moving wagon, and they had in a moving police vehicle. And they were able to do that, which allowed him to actually improve quite a bit for their report. Our patient then arrived in the emergency department and had a operating room thoracotomy done, and just about to have been in the trauma bay, it was significant. So I was rushed to the operating room. I'm happy to say that he recovered quite well, but there's multiple lessons that the department and everybody involved has learned from this, in terms of initial response, how do you best deal with a tactical situation? Self-help, body help, and availability of equipment. It went quite well, luckily. They had appropriately sized needles for decompression, with the appropriate length of the needles. They knew the right indications, were able to utilize them. They did not delay transport. They were able to announce their arrival in the emergency department. And it was, as far as operations go, a relatively smooth operation. So we're quite happy with how this all went. Our deputy has significantly improved, and essentially back at full force. It's quite wonderful to see that. It is, however, a sobering reminder of, that our deputies or potentially ourselves, we can certainly be in the line of fire at times, when putting yourself in harm's way. And being able to train both our deputies, our prehospital paramedics, and everybody involved in emergency responses, is a big calling and something that we should all be striving for. I'm gonna see if my sheriff is available and I'm gonna open it up for discussion right now so we can chat a little bit more about this.

- [John] Great. Well, thank you very much, Florian. We appreciate that. Are you gonna make a text to your sheriff or what are you gonna quick phone call or what?

- [Florian] Yeah. I'm texting him right now. It looks like he will not be able to join us. So I apologize for that. There's an operational issue that came up for him that's urgent. Sorry about that, but I should be able to give some input as well, if people have questions. I see quite a few in the chat here.

- [John] Yeah, exactly. We got a couple of questions there. Dr. Keegan Bradley had a couple of questions. Keegan, why don't you go ahead and ask some of your questions there. There's good ones.

- [Keegan] Yeah. After a couple of, I don't know if... You mentioned you have some medical officers, some medical personnel, are they all paramedic level, the ones that aren't physicians? 'Cause the one... We're setting up one out here, and right now it's all paramedic level. But my thought was, sometimes, depending on how many people you have and the resources you have, an EMT base or in advance, would probably be able to bring a lot of the skill set needed for a lot of tactical situations, probably. And it's better than nothing. And then, my other question was about the Tahoe. I don't know if y'all have fitted that specifically for patient transport, or it's just kinda a Tahoe and you throw someone in it?

- [Florian] Great questions. Thanks. I appreciate that. Our setup, as far as the training is, everybody's trained as a paramedic. We almost never have deputies with no prior experience. So we try to hire people with significant pre-hospital experience. So some have flight experience, some have other civilian kind of experience. We have a bunch of former military medics as well. I think this is fairly unique to our setting, because we run kind of the ALS intercept for a lot of high acuity kind of patients. I do agree with you that, for a more tactical role, that's more exclusively tactical, I think EMT basic up to AEMT, is probably sufficient for a lot of these cases. Because the interventions are not all that involved, when you think about your basic... I mean, think about your six year risky kind of level of training. You don't necessarily need the whole breadth, but you can focus on the specific skills that is necessary for the pre-hospital tactical provider. I don't see any issue at all with training him up to be the AEMT level, for example. I don't know if people agree, disagree with that. But my second point, actually, our Tahoe, the back is actually more of a... The second row is really locked off for potential prisoner transport. So no, not really. It's not meant for patient transport. This is a last resort kind of set up. It has enough space. It's comfortable enough to actually have a couple of people in there providing transport, but this is a non-standard use of the vehicle by any means. It's something that's tacitly accepted for this specific scenario, but we don't... And we are also lucky, in terms of our transports from our more urban centers within Flint, where the majority of our penetrating injuries happens. Our transport times are fairly short. So we're lucky enough to have rapid transport. So it becomes less of an issue. The furthest we go out is like a 40 minute transport. But if somebody gets shot in our very rural areas, we will probably have an ambulance transport before anything else. If you are a few blocks from the trauma center... As in this case, this is a very brief transport that the Tahoe was more than sufficient for that.

- [Keegan] Thank you.

- [Florian] I appreciate that. Yeah. Are there any other questions or comments? I'm also very curious to see what people have been experiencing in their own kind of setups.

- [John] One of the questions from a younger physicians. For example, Dr. Song is a first year resident down that program, first medicine program in Orlando. He was talking about, how do you actually get started with the Sheriff's Department or a City Police Department as a physician? How did it start off for you, and hat do you do to make advances over the years?

- [Florian] So for me, it actually started kind of doing residency. I was working as well in Flint, Michigan. I basically noticed, "Hey, the patients that come in, who are these paramedics that actually know that stuff?" I approached Emoltima and realized that they were also a dual deputies. And really just reaching out to the communities, is what helped. I reached out to the EMS coordinator. It turns out, there's a lot of interest in physicians helping out in pre-hospital medicine, as most of you probably know. Literally, all it takes is an email. Both in the two counties I work in, your skills are very much sought after. Getting involved in that setup is relatively easy, right? Because you really want to be included as much as possible. The second component then is like, "How much you do actually wanna take part in a law enforcement kind of role?" For me, this came more natural, in terms of my military background, other places that are not on the sheriff's deputy kind of model, might have requirements for other training and everything else. So that's something that is highly individualized. I would certainly just start reaching out, both the law enforcement agencies. "Hey, can we work on some training up your offices on the basic training?" And then also reaching out to your prehospital providers, because there's a lot of tactical programs out there that are just dying for physician kind of help, and they're hungry for it, for sure. I see somebody has their hand raised, it looks like.

- [Robert] Yes. Thank you. Bob Margulies, sir. Are you sworn and commissioned or functioning in a physician role only?

- [Florian] I'm a sworn officer. Both of us as medical directors are sworn officers. It is a little bit sworn deputies, I should say. It is a little bit of a difficult mix, in terms of how to best utilize your roles. On medical calls, both the paramedics and us, we try to very much be on the paramedic and medical provider side. But being deputized one end, actually does allow for a certain amount of help, in terms of being able to also perform law enforcement duties. I don't think it is absolutely necessary, in terms of being able to support an agency. So it certainly can be done without that. And there may even be some advantages. But it's something that we found works for us, and our sheriff was generous enough to make that happen for us.

- [Robert] Thank you.

- [Florian] The question is regular deputy.

- [Robert] Thank you. If could address Dr. Song for just a second. I've done it both ways. I've been a fully commissioned sworn patrol officer, at the same time as teaching my officers. And now as a retired officer, I'm still teaching several departments, not just the department I was with. The Bend County Sheriff's Office here has actually asked for any, almost a TCCC. You're not going to give us enough time to do that. But there is an interest, and anything that you can bring to the table, if it's done gently, will generally be well accepted by law enforcement. Thank you, sir.

- [John] Those are great comments. Thank you. We definitely agree with you, Bob. I think Dr. James's gotta be, first of all, become a good doctor, get your residency, get that training squared away, become a good emergency physician, have that as a background. And then along the way, develop to whatever degree you feel like you have time, the relationship to local law enforcement. Find out, what do you really wanna do? What's your interests? What do you actually want to do? Do you wanna be fully inside the hot zone, inner perimeter type operations, or are you more comfortable not going in such a risky area, maybe staying at the command staff level? There's different options out there, and everybody does a little bit differently. First decide what you kind of wanna do. And then if they recognize you're a good hearted soul, which I'm sure you are, and you've got some skill set, and you're not out there to shoot the bad guy, that's your job, but you're there to provide medical support. They know that you being there is gonna increase their chances of getting home to their family. So that's always a good thing. And they wanna make sure that, if you are allowed to be armed, if you're to become deputies and you're armed, to protect yourself and your patients, they wanna make darn sure that you're not gonna be doing something stupid, like shooting them in the back, or shooting somebody inappropriately, causing embarrassment to the Sheriff's Department and Police Department. So whenever you do go to train with them at the range, already have a good skill set developed. You don't have to go there and have them teach you. I'd recommend, going to the shooting range with your other physician friends, as long as some of them know what they're doing, you can develop a good handgun and rifle safety marksmanship, and as far as safety, be able to handle and load an unload a weapon, make sure you got a good muzzle awareness. Be familiar with all those key things, before you go to the police range with the police. If you can get that basic skill set down, then they say, "Hey, this doctor already got pretty good skillset." He is not real cocky. He's not running around trying to show us how to shoot, but instead he's safe, he knows what he's doing, he knows how to handle a weapon, he's not gonna be flashing us with muzzle. And yeah, this guy probably is gonna be okay operationally." So those are kind of things you need to demonstrate to them, that's gonna increase their trust in you and allow you to function as a better teammate with them. Other comments from the group.

- [Florian] I fully agree with that. I think just big part of it is being present, being a known face, being a known quantity, and being available for... And being on their speed dial when things happen, is a big component of that. Because that's what they're looking for. Not necessarily just for, the being in the hot zone kind of fun stuff, let's call it that, but also just being available for questions, being available for trainings, and all of that has been good. It looks like Dr. Wong has another question here. You also have to line up where you'll get supply liability coverage. Yeah. Those are excellent points. That needs to be certainly... Yeah, very good. It certainly needs to be organized. For us we're lucky enough that, given that it's a medical agency as well as a police agency, both, all of those things come as a package neatly wrapped up. And so, they all have all the equipment already for us, both the protective equipment as well as the medical equipment. But certainly something, if you're in medical support of an agency. I guess what I would probably do is, try to also work with a civilian agency, as far as their tactical team of most of your transporting agency, and see if you can get your equipment through them. That may be the easiest way. I know what other people have experiences with that.

- [Dominique] I agree. And also the team concept is useful, because if you're working 15 shifts a month, whatever, 18 shifts a month, that limit your ability to go out on short notice call outs. So it's helpful if you're not just leaving 'em high and dry. Three times a month that they call you, it's helpful if, you can't do it, if your partners can do it, if you have a team of medics that are really well trained, that can help with that sort of thing. Because again, you do have a work life that probably pays your bills more than... For most of us, more than this would. Working with the team is useful. We didn't have great experience with EMTBs on our team. There were a lot more who wanted to do that, that were EMTBs than medics, that wanted to be part of the team. But in the end, from a law enforcement point of view, I don't think we had a lot of trust from the law enforcement with EMTBs. Frankly, where our protocols for EMTB is, basically you could train your law enforcement officers to do the exact same thing. And then you didn't have the extra EMT that maybe hadn't come the last three trainings, and now they don't know whether they trust them or not. When you can basically train up all of the officers to the same level as an EMTB. That was our experience.

- [Florian] I think that's a good point, right? 'Cause how much of an EMTB class is really trauma based care that needs to be at the point of injury, right? Absolutely minimal compared to... You don't need to train up your officers, how to recognize a stroke? You need to train him how to apply a tourniquet and do a point of injury care. So that makes a lot of sense.

- [John] Great. I had a question, Dr. Schmitzberger. When you've been overseas, what kind of interesting things have you learned from the local populations, whether it's been over Ukraine or Burma? What are some neat things that you've learned from them that you brought back to the United States and used in your day-to-day operation? Anything particular sticks out in your mind there or...

- [Florian] So much. Every time you work with a different kind of group of people, it's a give and take, as far as learning. I mean, other than specific medical tricks on how to work with very limited resources. I mean, for example, anesthesia in Ukraine, is done essentially pulse sucks, if you have it. But really, there's a handover to mouth to see if there's any breathing happening. There's some very, very low tech kind of little things that I've learned in that regard. There's certainly... I think the bigger picture has been just patterns of behavior resiliency and all that, is something I've really taken away. The two times I went to Ukraine recently, it's just been seeing how resilient and resourceful the local people were, in terms of joining up and fighting the oppressor, has just been eyeopening and really gives me and everybody I talk to, a lot of strength, in terms of overcoming challenges when the third patient of the day, really is just here for a Turkey sandwich. It really puts things in perspective, right? In terms of being able to deal with any kind of hardship, be it minor or major. So I think, as far as things that I've learned, probably those kind of interpersonal and personal level kind of skills. I don't know if people have some more questions or any comments, I would love to... Dr. Christianson, I think raised his hand.

- [John] Hey, click your unmute button there, Randolph. It'd be great. Thank you. There you go. Now we can hear you.

- [Randolph] In terms of EMT training, regardless of the level, EMT, A, B, intermediate and above, basic trauma life support program, which I've attended a couple of times, seems to cover most of the basic things I would expect to find in immediate trauma. In fact, perhaps that could be a good baseline training for EMTs that want to get involved, 'cause anybody had any experience with that program or what it might provide to EMTs.

- [Florian] I personally haven't, but I know other people have.

- [John] Yeah, I'd certainly agree with you, Randolph. The BTLS principles, you can get those down and be able to function with those principles. And the heat of the moment, that's where it's all at pretty much, probably 90, 95% of trauma can be handled with PTLS, stuff like that. I think the key thing is, how actually do you bring to your training environment, the realistic scenario based, bloody, fake blood type of high stress, make a decision quickly type of training, that basically just stress inoculates them. It gets used to making rapid decisions accurately in a very chaotic situation, especially when you're used to working with these tactical officers or the law enforcement officers are your friends, you've known 'em for years. All of a sudden they're laying there on the ground, they're coughing up blood, they're breathing fast, they look really pale, and you've gotta get things done. So how do you keep your act together? How do you train people in a realistic environment? What are the skill sets? What are the equipment? How can they improvise what they have to make it meet the ends? Especially with Florian who's been overseas, and you have hospitals that, "You're injured, shot in a belly." And we can get you to a hospital in about 30 hours. Well, what are you gonna do between now and that 30 hour mark? So what are your resources? What can you pre-plan? What's your transportation mechanisms? What's your options? What's your communication? All that stuff factors into there. Certainly the first aid is a key component of it. Get 'em stabilized, and then work on everything from there at that point on. Good point.

- [Rick] I'll just mention that the ITLS course, that is the ACEP supported course that's administered by the Illinois Chapter. I think it was developed in Alabama. Dr. John Campbell developed that in the eighties. And they have several, there's the ITLS basic course, and there's about four or five different courses in their family of courses. I think it's itrauma.org, maybe is their website.

- [John] Yeah, I think you're right. That's what it is. They have annual meetings and very good group of folks. They also have special military version of the textbook out. So you can actually look at that, for the more, the tactical type of things too. Definitely some good resources out there.

- [Dominique] Do you have any recommendations for people who are interested in going overseas for the first time?

- [Florian] Yeah, certainly. The key component for first time travelers is finding a reputable organization that has an existing kind of setup. I think the most important part is the local partners. So having been in... Especially in hot zones, warm zones, having spent a lot of time in the Middle East, you have to have reliable local partners. Same just now in Ukraine. It lives and dies, and you live and die by the people you work with. So I think finding someone, it doesn't need to be a large organization, but it certainly should be an organization that has an established kind of setup. So for example, in Ukraine, our team is all former military with some support by, well, current civilian physicians with travel experience. And if you don't have that experience, you get hooked into kind of a warm zone setup, where you can kind of learn those skills for the first time and then move on from there. There's actually thoughts on... There's a few courses out there, I won't mention 'em by name there, but they're easy to find, that are kind of a tiered by some of the standards and protocols that are being developed, in terms of, how do you improvise medicine in a less ideal environment? Obviously, a lot of it is wilderness medicine, as part of this tactical medicine is part of this. So as good preparation, those are useful. I think everybody in this call, probably is very much well versed in this. But the travel component, really, I think, reaching out to organizations that have capacity. If anyone here is interested in any of these opportunities, please just email me directly and I can very much make the right introductions. We're in dire need of qualified physicians who are willing to do training, medical care, and anything else. It's really always a battle to get the right people at the right place.

- [John] What's the relative threat level over in Ukraine area right now? I guess if you stay in Poland, you're relatively safe. Would you recommend a physician go to Ukraine or other places you've been to necessarily, or is that just kind of a role of the dice-

- [Florian] I think the threat level is very variable. If you try to get insurance right now for yourself, it's about $8,000 a day. But that does not account for the different threat levels within the country. Kiev had one missile attack in the last couple of days and had quiet since before then. If you are in Lviv, which is the one of the largest kind of cities where most NGO's based, there're operations out of these days, the threat level is absolutely minimal. I mean, yes, you'll have your daily alert alarms, you'll have a slight risk of a rocket attack, but really, the risk level is probably... The risk of staying in the city is probably lower than driving there, with the kind of driving that goes on there. There's a huge variation in risk. If you go east, if you go south to the hot zones, the risk can be quite high, obviously. But if you go with a reputable organization, they will not send you there unless you have... I mean, our team is all former soft people with our security officers and well research locations. Plan A, B, and C for exfiltration, all these things. So the risk is manageable, but if you stick to warm zones, it's fairly, or in cold zones, there's a lot of work that can be done, particularly on the training front. So we've trained hundreds of people in TCC/TECC, and that's been... We've gained reports of them actually, utilizing their skills on the front lines, and that's both sad and encouraging at the same time. Dr. Margulies, do you still have your hand up or is that from before? Sorry, I just-

- [Robert] I do. Yeah. I wanted to do two things. First of all, I want to emphasize something that you were saying, John. If you want to get into this field, the best thing that you can do is become a really competent emergency physician. After 53 years in this game, I can tell you that you will be better adapted to respond to unexpected unusual circumstances, if you get a really good base in EM. Besides that, you've got several other things. Any chance you get to take a outside the basic residency course, wilderness medicine, great idea. If you haven't seen the video, I think it was videoed. Dr. Springer gave an excellent summary about police handguns. One of the things that you could invest some time in is actually not just going to the range with friends, but getting some formal training, if there's an interest. If that's not the part you're interested in, ignore that. But if it is, start getting your formal training. There are short courses that you can travel to, two day courses, excellent schools. It's a great investment. You'll learn the basics much better than just standing on a range at seven yards and throwing lead down range. Besides that, take advantage of the other things that are available, rifle, shotgun, all become useful. But you're at a point where, the first thing you have to do is be a really good EP. Everything else is on top of that. Thank you.

- [Florian] I really appreciate that. That's very thoughtful.

- [John] So Keegan, you're still there. Keegan's got a Team Rubicon shirt on. Can you tell us about Team Rubicon, Keegan, since we're kind of talking about concept of overseas operational medicine type of thing?

- [Keegan] Yeah, yeah. I did Team Rubicon for quite a while, while I was a fellow. They're a great group to get with, if you want to deploy internationally. I know they had one or two docs go over to Ukraine already. I deployed with them to the Bahamas after hurricane. They're primarily veterans, but they'll take anyone who wants to go out there and work hard and help. They're a good group. They're based out of Arlington. But Dr. Callaway is their a medical director. He's a good one to reach out to, if you're interested in that, and they'll cover all your expenses. So it's a pretty good deal.

- [John] Where are they deploying to now, what countries and places?

- [Keegan] Last I saw, Ukraine was the big one for medical. They may be having a little deployments around the country as well, but Ukraine's kind of been their big one. The doc I know he went to Poland, and he kind of bounced back and forth, I think, along the border.

- [John] Very good. Thank you. All right. Does anybody else have any questions? We've got about, little bit over an hour in the presentations. Dr. Schmitzberger, I want to appreciate your excellent presentations and topics, everything. Is there anything else you'd like to say or summarize, anybody else have any questions?

- [Florian] No. I just really appreciate everybody being here and listening to me ramble, and giving feedback and input. I would love to stay in touch with anyone and look forward to more of these in the future. Thanks so much for your help also, Dr. Wipfler.

- [John] Yep. You betcha. And I think your contact information is on the the webinar invitation there. So anybody has any question, I'm sure Florin would be happy to communicate with you.

- [Florian] Put it in the chat as well. So reach out please. Thank you so much.

- [John] Great. Well, thank you very much. Well, we appreciate joining everybody and thank you for your time. Any comments? I hope everybody stay safe and stand ready. Thank you.