Second Aid: Preparing for Medical Emergencies
R. E. Rick Colliver,
As a former Emergency Medical Technician and Rescue Diver, I have seen first aid and trauma kits of varying sizes, shapes and colors that included enough equipment to operate a Mobile Army Surgical Hospital (MASH) unit at the site of a catastrophe for a month. On the other hand, the most experienced flight nurse/combat medic I’ve ever known once said that if he had a 2X2 bandage and a pair of rubber gloves, he was “good to go” for almost any occasion. This illustrates that it’s the “carpenter and not the tools” that usually gets the job done, and thus competent, recurrent training becomes an essential component in the protection specialist’s toolbox.
In a protective detail, every one of the members should be current in their first aid, Cardiopulmonary Resuscitation (CPR) and Automatic External Defibrillator (AED). However, at least one member of the detail should have advanced training and be able to operate under a physician’s direction/protocols if the need arises. Additionally, they should be familiar with the protectee’s medical profile so that they understand what types of treatment s/he might require on a day-to-day basis. The responsibility that comes with this includes a knowledge of and compliance with various confidentiality regulations including the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) http://www.hhs.gov/news/facts/privacy.html . In other words, if the protectee shares personal medical information with you as a part of your duty, you are now legally bound to keep it confidential.
Protection personnel who want additional training in the United States can contact their local fire departments, Emergency Medical Services (EMS), their family physician or local colleges that offer emergency medical training, for information and discussion about what programs would best support their career goals. Advanced training is also available online through organizations such as Federal Emergency Management Agency (FEMA) and the Fire Services Emergency Training Institute.
In the United States, there are three generally-accepted levels of pre-hospital care training that are nationally recognized (excerpted http://www.bls.gov/oco/ocos101.htm). These certifications require extensive classroom and clinical exposure:
EMT – Basic
Coursework consists of about 120 hours of classroom and ten hours of hospital internship, and emphasizes emergency skills, such as managing respiratory, trauma, and cardiac emergencies, and patient assessment. Formal courses are often combined with time in an emergency room or ambulance. The program provides instruction and practice in dealing with bleeding, fractures, airway obstruction, cardiac arrest, and emergency childbirth. Students learn how to use and maintain common emergency equipment, such as backboards, suction devices, splints, oxygen delivery systems, and stretchers. Graduates of approved EMT-Basic training programs must pass a written and practical examination administered by the State certifying agency and/or the National Registry of Emergency Medical Technicians (NREMT).
EMT – Intermediate
Training requirements vary by State; the nationally defined levels (EMT-Intermediate 1985 and EMT-Intermediate 1999) typically require 30 to 350 hours of training based on scope of practice. Students learn advanced skills such as the use of advanced airway devices, intravenous fluids, and some medications.
Paramedics receive training in anatomy and physiology as well as advanced medical skills. Most commonly, the training is conducted in community colleges and technical schools over 1 to 2 years and may result in an associate’s degree. Such education prepares the graduate to take the NREMT examination and become certified as a Paramedic. Extensive related coursework and clinical and field experience is required. Refresher courses and continuing education are available for EMTs and paramedics at all levels.
Other valuable training that is available above the level of basic first aid, and may be offered in your area include custom First Responder programs (30-40 hours), EMT-Wilderness and EMT-Tactical programs, which can run between 40 and 80 hours each. Depending on where you envision your career or your protectee taking you, you might investigate any of these options. An excellent course on Tactical Treatment of Gunshot Wounds is available through Defense Training International at: http://www.defense-training.com/courses/tacmed.html.
But remember, your primary contribution to the continued health of your protectee/ patient begins long before you recognize the need for treatment. Your very “first” aid is to establish a confidential relationship with the protectee that will enable you to identify pre-existing conditions that could lead to a medical emergency. Consider a “near miss” that we experienced in our nation’s capital a few years ago:
“Due to threatening correspondence received, and heightened adverse media exposure relating to a new drug our company was putting on the market, security had been increased for several executives who were traveling to major cities and participating in conventions and public conferences. In a by-the-book security advance, we had met with Washington DC police and local security personnel to ensure safety of our routes, vehicles and venues, and had agreed to meet the covered executive in the lobby in preparation for departure. Adorned in our tuxedos, we were fairly confident (as confident as you dare to get) that we had covered all of the bases and could perform our mission satisfactorily. When I emerged from the elevator, I was stunned to see our protectee sitting on a luggage cart in the middle of the lobby, sweating profusely and tugging at his collar. He was telling one of the other executives in attendance that he didn’t feel well and that he couldn’t catch his breath. The co-worker was telling him to ‘go to your room and have a drink…you’ll feel better later’.
I immediately called my partner, who at the time was an EMT-I and served as our team medic. As he began his assessment, he asked the protectee a number of questions including, ‘are you allergic to anything?’ The protectee responded that he was in fact seriously allergic to peanuts, and after a moment’s thought he surmised that he might have accidentally ingested some in a cookie off a buffet line moments earlier. My partner then asked if he had his prescribed epinephrine with him, and upon hearing that the ‘stick’ was left at home on his dresser, looked at me and said ‘This is a load-and-go”.
Rather than wait for the emergency squad, we immediately transported the principal to GWU hospital in the car we had waiting outside, along a route we had already advanced.”
“First Aid vs. Second Aid”
In the end, the executive was treated with drugs and was able to return to his hotel room that night. Had he taken the advice of his co-worker and gone to his room, we might have lost him, thus I credit my partner with a ‘save’ that night. The skills he offered were a quick identification of a medical emergency, and a competent application of response protocols for an incident of this nature. All of that was ‘second aid’. The first aid he provided was the training, education and experience that he had sought out over the preceding years, and the inclusion of a potential medical emergency in our security advance.
When attempting to build a medical profile for your protectee, keep in mind that a) they may consider this an invasion of their privacy and thus none of your business, b) they may not want protection at all, and the fact that you ask for this information may send them over the edge, and you back to the Board of Directors (or their publisher or their business agent) with an empty notebook. So, there may be a limit as to what information you can get and what you can’t. Suffice to say, that trust is the key. If you can carefully explain to your Principal the importance of considering pre-existing medical conditions as just as serious a threat as abduction or assault, the executive may cooperate. Always assure them that medical history information will remain tightly confidential. When conducting an interview of this nature, unless you’re a qualified healthcare provider, I would recommend that you use a prepared form that identifies critical information that may be of value to your protective mission; similar to this: http://www.harvardvanguard.org/info/AdultMedicalHistory.pdf.
Working with your client’s healthcare provider or company nurse, you should construct your own forms, so as to avoid any copyright issues, and to exclude ultra-personal questions that probably don’t apply to your mission. Access to this form then becomes on a strict need-to-know basis, and all personnel need to be admonished that any release of this information will seriously damage their client’s interests and compromise your entire protection program. Make sure that you have 24-hour contact information for the protectee’s physicians and specialists and that you have ample supplies of any prescription medications. This becomes increasingly important when traveling abroad, as some medications we use in this country are not available overseas. Or if offered abroad, they may not be offered at the proper strength, or could be diluted, adulterated or counterfeit. Check with your protectee’s physician as well as the WHO and CDC to see what kinds of medical issues you may face when you land.
Regardless of how elaborate your emergency medical kit is to be, there are probably some things that are bare essentials. As a matter of fact, we recommend the same kit for firearms instructors who may face trauma injuries on the line:
- Body substance isolation pack; basically latex or nitrile gloves, a disposable HEPA mask and eye protection.
- Disposable CPR barrier or collapsible mask.
- A nasal trumpet; standard nasopharyngeal airway to be used to establish an airway, especially in the event of a mouth or jaw injury.
- Israeli Battle Dressing.
- Angiocath helps to re-establish breathing after a pneumothorax injury and will require specialized training by medical professionals prior to you acquiring or using it.
- Medicines or treatments specific to the protectee.
- Equipment or supplies indicated by the environment or venue (eg, splints or cervical collars if spinal/skeletal injuries are possible, poison ivy blocker and ointment if traipsing through the woods etc).
Terms With Which to Be Familiar
In your state or country, your occupation as a protection specialist may place you in a category of being a “professional rescuer” and as such, you may need to be aware of certain legal requirements. Below are some frequently used terms that you should understand so that you recognize how they pertain to your employment situation. These terms are covered in detail in emergency medical training programs. However, if you are unfamiliar with them, you should discuss your occupational requirements with your family attorney to ensure that you jeopardize neither your client’s safety nor your wallet:
Before you touch or treat a conscious, adult patient, you must first obtain their permission. If they are under 18 (US) or mentally compromised, you must obtain consent from their parent or legal guardian. If the patient is unconscious, then consent is usually implied.
Duty to Act
If you are assigned to a protection detail, your mission elements include the “prevention of medical emergency” and you therefore have a “Duty to act”. Failure to provide a suitable standard of care could result in charges of negligence.
Standard of Care
Use the skills that you have acquired competently and don’t exceed the level of your training. Don’t perform invasive or experimental procedures unless you have the correct diploma on the wall.
If you begin treatment on a patient, you are legally obligated to continue treatment until you are relieved by a better-qualified provider, unless the patient tells you to stop, or you are physically unable to continue. If you abandon a patient, you can be charged with negligence.
The basis for many lawsuits, this term is not easily explained to the average person. In general terms, it can be defined as a failure to act properly.
Know Before You Go!
The consideration of medical emergencies should be a valid part of any protection specialist’s advance work. And, like any of our other specialized training, we need to be trained early and often by competent instructors. When you begin an advance, always make sure that your team’s first aid/CPR cards are current and that they have been briefed on any potential medical issues that the protectee may face. Also ensure that everyone in the party is properly immunized consistent with the needs of the mission and the recommendations of the CDC: http://wwwn.cdc.gov/travel/contentVaccinations.aspx.
Remember; an Assault on Principle (AOP) doesn’t have to be a big guy with a gun…it can be a germ with an attitude.
About the Author
Rick Colliver is the program developer and lead instructor in the Principal Protection program at the Ohio Peace Officer Training Academy and is an adjunct instructor in protective operations in several police, military and academic organizations. He is also the global security director for a multi-national corporation with operations in 24 time zones, and has managed protection details in Europe, Africa, Asia and the Americas.
Published by Dr. Robert O' Block in The Annals of Psychotherapy fall 2014.