Improving Capability to Save Lives
Developing a chain of survival
Tactical Chain of Survival
Like other forms of resuscitation, a chain of survival exists and is a solid framework to establish a continuum of progressive resuscitative care in New Zealand. In order to successfully implement this chain in New Zealand, we need to:
Understand the Chain | Practice the Chain | Add the first link in the chain | Strengthen the chain
Understand the Chain: Building a Learning Response System
International data prioritises building a learning response system. Locally, we need to capture and analyse data, mix with information from overseas and openly share insights to ensure that our trauma system continues to adapt as those who wish to visit violence on our communities do. This recommendation is based on a current data gap due to a lack of good quality data to drive systems improvements, with analysis being limited to lessons learnt, case reports and after-action reviews. Internationally, there are limitations on access to autopsy records to fully understand what interventions will benefit casualties in these incidents, limiting the strength of recommendations around appropriate bystander and pre-hospital interventions.
The anticipated result of a learning response system is the development of a shared mental model that breeds interoperability, reducing the timeline of a therapeutic vacuum.
Practice the Chain
There is a need to break down organisational barriers and build interoperability. This includes reviewing the accepted lanes that each emergency response organisation operate in to identify areas of potential cross-over, building the capability to operate synergistically in a dynamic threat environment. Measures include cross-training police to provide immediate aid and training medical personnel to accompany armed police into an incident zone.
The 1999 Columbine High School shooting highlights an event where agencies operating in their silos resulted in a delay in medical care. Contrast this with After-Action Reviews from the Boston Bombing (2013), Orlando Pulse Nightclub attack (2016) and the Las Vegas Massacre (2017) which highlights the life saving role law enforcement played in initiating medical care to survivors. Feedback from those involved in the Christchurch Mosque attack’s also highlight the lifesaving role Police had in the initial minutes – applying tourniquets and chest seals to prevent further fatalities.
The success of the medical response to the Paris Attacks of 2015 was in part due to the employment of senior tactical clinicians embedded in the Police response. While not part of the medical response, and primarily focussed on supporting the tactical activity, the medical command and control enabled rapid evacuation, triage and medical intelligence to be passed to the scene commander in a timely and useful manner. Anecdotally, it has been suggested that the addition of this capability to the Norwegian Police response to the Utoya Island attack may have had a significant impact on the fatality rate.
It is anticipated that these steps would build a shared mental model of capabilities and understand the fluidity that can exist between organisations and roles of care as the situation in the incident evolves. This brings life saving interventions into the hot or warm zone early in the incident, potentially reducing preventable deaths.
Adding the first link: Immediate Responders
Within the current therapeutic vacuum, opportunities exist to mobilise immediate responders to provide life-saving interventions. As witnessed during the Boston Marathon bombing of 2013, after fleeing the immediate threat, by-standers returned to begin rendering aid to those injured in the bombing.
Coupled with the evidence based interventions from a learning response system, immediate bystanders remove the therapeutic vacuum in its entirety.
Strengthen the Chain
Strengthening the chain is all about continuous improvement. Once the chain is successfully established, strengthening the chain will be an ongoing process.
International evidence has found that accepted triage tools – including those in use in New Zealand – are inadequate for a complex coordinated terror attack. This evidence shows that life-threatening casualties are often under-triaged as they are often able to walk, resulting in a delay to life-saving treatment. Extrapolate this out to a large scene with dozens of casualties and this conceivably could result in an increase in the number of potentially preventable deaths. Inexperienced responders have been found to over triage, further complicating secondary triage and evacuation measures.