Taking Emergency Medicine in the Field to a SMART Level

Dr. Neeki and three medics pose for photos at the Colton inpound area. By Dr. Michael Neeki
Associate Clinical Professor of Emergency Medicine
Arrowhead Regional Medical Center 

I left Iran more than three decades ago to escape fanatical religious extremism. As one can imagine, I was greatly disheartened upon seeing such zealotry in my home of the United States that fateful day of December 2nd, when the San Bernardino terrorist attack occurred.

I am greatly honored to have been part of the Inland Valley SWAT team, supporting the brave members of the San Bernardino city police and fire department during that tragic event. However, this experience was profoundly sad and devastating due to the loss of life to 14 innocent people, all of whom simply went to work that morning. The work of the first responders to the terrorist attack prevented further loss of life that day.

While we may be the most culturally diverse and socially advanced country in the world, we have not had to experience the suffering and traumatic incidents that some of our allies have endured. This war of conflicting ideologies is not going to end, and we have been dealing with this here in the United States for the past 30 years.

Every few years or so, terrorism returns to harm our communities, and with complete honesty and a heavy heart, I believe that the next attack will occur much sooner than expected*. We are in great need of specially trained personnel to deal with these tragedies in order to increase the survivability of the victims.  It is the right thing to do for our communities, as this is a matter of public health and prevention that will continue to negatively affect us if action is not taken now.

In response to this need, I propose an innovative program entitled Special Medical Anti-terror Response Team (SMART). This program would make teams of trauma-trained doctors, nurses and paramedics available 24-7 to respond to mass casualty incidents. This will include not only terrorist attacks and active shooter scenarios, but also natural disasters.

Teams would consist of volunteer members from regional trauma centers who train and practice trauma medicine on a regular basis. Each team would be made up of two physicians, two registered nurses, and two medics from local agencies. This team would operate as an ancillary consultant to EMS personnel, as opposed to serving as tactical medics. It would be protected in the field by the local law enforcement agencies. Each local trauma center will have teams who report directly to the tactical and emergency medical services incident commanders. Teams would drive a dedicated vehicle carrying basic and advanced trauma resuscitation equipment along with direct communication technology from the field to the in-hospital trauma team. A mini-team consisting of three members could also be flown by a helicopter to any remote incident to initiate the trauma care in the field.

The teams would be specially trained to ensure a solid understanding of how tactical and EMS operations work. This means training hand in hand with local, state and federal agencies. Training would be a regular, collaborative effort with the local EMS and tactical teams to ensure that both groups can comfortably work together and understand one another’s needs. It is important to note that these teams would not be self-deployed, but instead only respond when called on by the incident command under regional EMS regulation and oversight.

Some have asked, “Why would we need a special trauma team when we already have paramedics on scene to treat victims and get them to a hospital?” In response, I first address that paramedics are vital members of the medical team because they can react quickly to injuries and quickly transport patients with more serious issues to the hospital. However, many life-saving invasive emergency techniques have been eliminated from the regular paramedic scope of practice and are not performed on a regular basis to be effective. Emergency medical services’ scope of practice is limited to airway management, needle placement in the chest (to treat tension pneumothorax) and tourniquet placement (to stop life-threatening bleeding). Consequently, personnel are unable to perform emergency airway management, chest tubes insertion, pericardial aspirations (to treat cardiac tamponade) and field amputations, to name the few.

With the proposed SMART program, trauma experts are on scene with a highly-reliable skill set both to diagnose the patients and perform more critical procedures. As the members of the trauma center, they would have direct contact and communication with their colleagues to inform them of ongoing situations while also performing the procedures on the way to the receiving trauma hospital.  Furthermore, this may help to pave the road for civilian paramedics to increase their advanced trauma capabilities and eventually lead to the expansion of their scope of practice in the field. SMART can act as a pilot project to evaluate this concept.

Ultimately, the goal is to increase the survivability of victims, thus ensuring all patients receive effective treatment within the “Golden Minutes” rather than the “Golden Hour” – which is generally the accepted time for transport of critical trauma victims to a hospital for definitive care. For example, if an explosion caused one hundred injuries, trauma centers would get 30 to 50 patients of varying severity of injuries, which can overwhelm hospitals’ resources, physicians and staff. Doctors, nurses, and medics trained in trauma care provide a means of not only treating serious injuries immediately or on the way to the trauma center, but also being able to determine which patients require immediate attention on scene and which patients can be transported. This would prevent the trauma centers from being overwhelmed to the point that the quality of patient care is compromised.

Unfortunately, this idea has faced much resistance over the past. Many are resistant to changing an established practice and will criticize the idea, claiming financial and other issues exist. However, such issues can be resolved with open discussion, time, and legislative support. The advance of pre-hospital trauma care in any way or shape would ultimately benefit our communities and humanity across the globe.

While I completed my Emergency Medicine residency post-graduate training in Toledo, Ohio, I was part of a trauma team that transported medical emergencies via helicopter. This is similar to the concept of the SMART program. Similar teams, like I am proposing, have operated in Europe for years with good patient outcomes.

As emergency medicine providers, we stand at the front line of medicine, and thus we must respond to the changing world and population to provide secure, safe and innovative practices to give optimal medical care to our patients. After the Dec. 2nd attack, I realize that there are many patriots around me, with a profound love for our country, willing to serve in positions such as that on the SMART team and use their medical knowledge and skills to save those in need. The resurgence of terror attacks and mass casualties is a public health emergency that demands all of our attention and efforts.

 

*Note from the Editor: This essay was authored and submitted prior to the terrorist attack in Orlando, Florida, on June 12, 2016.

 

Dr. Neeki is an associate clinical professor of Emergency Medicine at Arrowhead Regional Medical Center in Colton, CA. He volunteers his time to be part of the Inland Valley SWAT team, which is made up of officers from the California cities of Colton, Fontana and Rialto. He was born in Iran, imprisoned four times for refusing to subscribe to that country’s radical religious belief. He was subsequently drafted to the long and bloody Iran-Iraq war from 1983-1985. He fled Iran in 1986 and eventually joined his family in the U.S., where he became a citizen and received his medical training.

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