Through the late 20th Century, Australia reformed what was previously non-regulated and varying First Aid instruction, largely conducted previously by voluntary and community organisations, to a Competency Based Training (CBT) framework enabling standardisation and portability of vocational qualifications. Since then, through the focus and growth of Workplace Health and Safety (WHS), industries have invested heavily in first aid compliance, emergency response plans and workplace mental health programs, yet the majority of organisations remain ill- prepared for the first few minutes of a traumatic, violent, or high-threat incident regardless of meeting supposed ‘regulatory compliances’.
Australia’s current challenge is determining whether minimum competency remains sufficient for modern risks. The emergence of Tactical Emergency Casualty Care (TECC) guidelines from globally renowned mass casualty incidents bridges that gap by giving responders, security teams, venue staff and high-risk workforces a practical trauma baseline before paramedics arrive.
Australia….. the ‘Lucky’ country
Aside from a small number of notable disasters or incidents of recent, Australia could largely resemble it’s coined ethnographical tag of the ‘Lucky Country’ within the context of mass casualty and first response situations. Numerous examples of lives saved by sheer coincidence of a clinician, service-person or other off-duty emergency responder during high profile incidents suggest mortality rates over the last few years would be worse. From the presence of a trauma anaesthetist at the Bondi Beach mass shooting who was finishing a surf, Afghanistan Special Forces veteran passing a haemorrhaging driver within a vehicle accident on the NSW Coast or assisting Paramedics at Bondi Beach, a Queensland Paramedic neighboured to a severely incompressible arm bleed from a window glass pane laceration or to one of SOTER’s own in a remote Queensland petrol station bathroom applying a makeshift tourniquet of ‘two triangular bandages and butter-knife’ to stop a haemorrhaging post-surgical popliteal artery suture failure; all of these incidents highlight a common re-occurrence, that ‘if not for luck’ Australia’s First Aid baseline exhibits gaps that if not addressed, would likely result in greater mortality particularly in haemorrhagic traumatic injuries.
In another ‘Lucky country’ moment, Australia has been largely exempted of the terrorism and religiously targeted extremism experienced elsewhere around the globe over the last two decades. But with the modern world advancing further, faster and with greater engineered potential risk into the very critical infrastructure we live in, let alone violence, remote worksites and annual natural disasters …… is our immediate medical preparedness still fit for purpose?
Where to then….
TECC was an outcome-based solution from the Hartford Consensus post the SandyHook massacre in the Connecticut USA, providing a civilian trauma framework to mass casualty scenarios. Adapted from the highly successful military trauma program developed from a retrospective study on potentially survivable battlefield deaths, Tactical Combat Casualty Care (TCCC). TECC drew from its successes from battlefield injuries throughout the Global War on Terror that have been largely adopted by the first world military community. Its focus was on:
• controlling catastrophic bleeding;
• acting under threat or uncertainty;
• prioritising survivability in the first minutes;
• simple, repeatable decision-making to the 5 common causes of death; and
• aligning all first responders, security, clinicians and command personnel.
It provides a clear clinical and procedural framework enabling a common operational readiness that is scalable to provider level, the knowledge and training to assess, treat, extricate and expediate immediate casualty care of the most life-threatening injuries in dynamic threat environments, regardless of the stimuli.
That’s not my job, wait for the Paramedics
A common joke amongst some jurisdictional ambulance services is the first on the scene to a major motor vehicle collision is the ‘Towie’ (Tow Truck Driver). Which given the scale to which our emergency services are often required to attend, highlights the premise that ‘First-on-the-Scene’ and those able to provide the most immediate significant in immediately life-threatening injury, are commonly not our emergency services. Brigadier-General Dr. Nicholas Senn (1844-1908), Surgeon-General of the Illinois and Wisconsin National Guard, popularised the phrase, “The fate of the wounded lies with the hands of the ones who apply the first dressing”, an adage which within civilian constructs in Australia seems to have been diminished with a potential over-reliance within society on the professionalisation of emergency services outside of CPR for sudden cardiac arrest (SCA). This highlights the fact that it is likely the by-stander, work colleague, security guard or passer-by and not the Paramedics, Police, Fire or volunteer Emergency Services (SES, CFA, VFR, VRA etc) that remain vitally important in benefitting from such basics to reduce the risks associated with the 5 most common causes of death from severe trauma, all taught under TECC.
If one thing has been made evident in Australia’s vast geographical expanse, is that time to hospital matters for severe trauma. Without the admirable services of various aviation medical services in this country, even moderate traumatic incidents could well be additional mortality statistics waiting for Ambulances to transfer patients let alone high-risk incidents requiring them to be staged outside the Hot and Warm zones. Just as both incidents at Bondi showed, the primacy of keeping blood in the body and urgency of immediate transport to definitive surgical care, any serious event of significant distance will fail to have the positive outcomes of the recent Bondi incidents under current first aid competencies. We do not rise to the level of our expectations; we fall to the level of our training.
Helplessness hurts too
When traumatic tragedy does occur, regardless of local or remote proximity to hospital, the effects are rarely spared on those responding. Ask any emergency services responder globally from their repetitive attendance at societies most challenging occurrences, the compounding burden on mental health to our front-line personnel isn’t probably a matter of if, but when. But consider that a significant casualty in trauma isn’t just the physically affected, but also those less prepared. Morale injury, Survivors Guilt, Secondary traumatic stress and Post Traumatic Stress are often by-products of the feeling of helplessness suffered by professional first responders who have the remit to attend these most challenging events daily. ‘Mental health conditions are also one of the costliest forms of workplace injury. They lead to significantly more time off work and higher compensation paid when compared to other injuries and diseases……‘The median time lost from mental health serious conditions claim (2022-23) was almost 5 times the median time lost across all serious claims’ whilst ranking 4 out of 5 in ‘Nature of Injury/Disease’ serious claims groups.
TECC skills our first responders not only in current global best practices immediate life support clinical interventions, but also in a recognised behavioural preparedness model. It gives people a structured mnemonic, language and intervention pathway, opportunity for rehearsal to reduce hesitation, uncertainty and passive observation or helplessness; and the knowledge, that they are doing everything possible to buy precious time at point of injury whilst advanced medical care arrives.
Preparedness is protective – not just physically, but psychologically.
Within military special forces organisations, ‘Operators’ is a term attached to qualified special forces members due to being highly cross-trained in an array of specialist skills to a very high level. Yet still, within extremely capable special operations units, we commonly required extra depth of sensitive and specialist capabilities commonly referred to as ‘Enablers’; Specialist skills or equipment that without that individual’s or asset’s attachment to the given force element, would render that team significantly less capable to achieve their given mission. Given that all of our Emergency Services cohort and/or any other professional first response service maintains their core varied skills, TECC should could be an enabler to their core function, yet in a trainable capability to managing trauma, benefitting both provider and patient that may reduce mental and physical suffering; through giving clear, actionable pathways and understandable outcomes when fostered and rehearsed as a foundational behaviour. Should personnel be unprepared, they are more exposed to helplessness, believing ‘more should have been done’ or psychological burden generally amplified. We cannot remove trauma exposure, but we can help reduce it through realistic exposure training and clear actionable pathways along with post incident assistance.
Organisation Risk and the Insurance-Workcover cost
Safe Work Australia reported that mental health conditions accounted for 9% of serious workers’ compensation claims in 2021–22, up 36.9% since 2017–18; median compensation for mental health claims was $67,400, compared with an aggregate of physical trauma of $50,911 for all injuries excluding CNS and spinal injuries, and median time lost was 34.2 weeks, compared with 8.0 weeks.
By 2023, mental health claims accounted for 10.5% of all serious claims, with median time lost more than five times longer than all injuries and diseases. Safe Work Australia also confirms psychological injury compensation can include PTSD, anxiety and depression where work is a significant contributing factor.
For emergency services and high-risk public-sector workforces, Comcare guidance cites public administration and safety — including government, police, fire and emergency services — as having 88% of disease claims for mental health conditions in 2019–20 data.
Emergency services evidence point
For Paramedics, the risk trend is particularly clear. A Monash-led NSW healthcare study found psychological injury claims by ambulance officers increased 138.5% between 2012–15 and 2018–21, while incidence rose from 10.5 to 44.5 claims per 1,000 workers between 2013–15 and 2019–21. Data that may suggest that Paramedics are unfortunately finding themselves in dynamic situations to which they are potentially morally challenged as caregivers yet becoming targets themselves.
What is so scary about ‘Tactical’?
Whilst commonly associated with its military application ‘Of or pertaining to (military or naval) tactics’, a brief history of the definitions of tactical, as per the Oxford English Dictionary, shows various foundations and more accurate and generalised applications in:
2a. ‘Of or relating to arrangement, esp. the arrangement of procedure with a view to ends’, and
3. ‘Of a person, his or her actions, etc.: Characterised by skilful tactics, skilful in devising means to ends’’ .
Explanations that exhibit how superficial assumptions can often shape perception, causing individuals to fear, avoid or misunderstand concepts before appreciating their true purpose or value.
TECC has grounds to be elementary to a broader first responder resilience system through physical readiness, psychological preparedness, governance and post incident support as part of a greater wellness ecosystem and approach to caring for our First Responders.
Join SOTER International at DEMC for “From First Aid to Threat Care” and explore why Australia’s trauma baseline must evolve — not only to save lives, but to better protect the people expected to respond.