At no time during an operation is the tactical medic more vulnerable than during the physical extraction of an injured patient. Carrying an injured patient from a hostile environment often leaves the rescuer without the benefit of self-protection and limits his mobility, reflexes, and visualization of his surroundings. It is for this reason that the medic must be familiar with multiple methods for transporting an injured patient. The medic must take into consideration the patient’s condition, available resources, available manpower, and the immediate safety of the environment in which he will be operating. The ultimate goal is to provide rapid patient removal in the most reasonable manner while providing the greatest safety for both the medic and the victim.

Many situations require that a patient be removed from an unsafe region before any further medical treatment may be provided. The medic must be able to assess the scene and quickly determine how to best remove the patient to a zone where more definitive care may be safely initiated. Often, the patient assessment must occur from a remote distance because the medic does not have immediate access to the patient. A conscious patient may be able to assist with his own extraction, or the medic may be able to assist the patient to an area of increased visual concealment or physical cover. An unconscious patient must be assessed to determine which method of removal is safest and most appropriate. For example, the unconscious patient with a gunshot wound to the head and an active shooter in sight surely poses a much greater risk to the medic than benefit to the victim, but the unconscious patient that fell from a height would require a completely different extraction technique that is more appropriate to his injuries.

Above all, it is important to remember that the tactical environment is a dynamic scenario that requires the medic to adapt to the surroundings to choose the best rescue method based on available resources, manpower, scene security, and mechanism of injury.

The initial assessment of a casualty will dictate the method used to physically extract him from an austere environment. The mechanism of injury is the most important factor in determining the approach, rescue, and retreat technique for the casualty, but the medic must also consider the most reasonable and timely approach given the immediate threat and the condition of the casualty.

Immobilization of the cervical spine should be reserved for high speed motor vehicle collisions, falls from heights, or significant blunt or blast injuries. There is no indication for cervical spine immobilization for penetrating head or neck trauma or for falls from <1 to 2 meters unless there are neurological deficits or localized pain of the cervical spine. The average time for adequate cervical spine immobilization by a trained paramedic is five and a half minutes. Unless specifically indicated, unnecessary spinal immobilization will create a significant time delay that may place the casualty and the rescuer at risk for additional injury without providing additional benefit to the patient.

Tourniquets are rapidly employed to control life-threatening extremity hemorrhage prior to transport from the hot zone until the patient can be moved to a more
secure environment and the wounds may be assessed further. The splinting of injured extremities should occur prior to the patient’s extraction only if time and security permits safe application by the medic. With all transports, it is essential to guarantee that the patient’s weapon is secured prior to any movement. Remember that an alert but partially immobile patient may still be able to provide additional firepower for a team during approach or retreat.

In situations where the patient is not physically accessible but is alert, the most appropriate initial rescue technique is to verbally direct the casualty to the nearest cover or concealment until the immediate threat is neutralized. Commercially available throw ropes can be deployed and clipped to the casualty’s vest to physically assist a patient’s movement a more secure location when direct approach is unsafe. It is important to note that the attachment points to the vest must be strong enough to drag the casualty. Attachment points on many vests are not strong enough for this task. The use of a web harness specific for this task may improve the ability to drag the casualty to safety. The nonalert casualty that cannot safely be approached requires the medic to observe the casualty from a distance (binoculars may be helpful) to perform remote assessment and determine the overall status of the patient. Important considerations include the survivability of the patient’s wounds, the degree of patient movement, the quality of the patient’s breathing, the estimated blood loss, the presence of obvious extremity injuries, and the overall color and appearance of the patient. Once these are noted, the medic will better understand how much assistance the patient can give to his own extraction and determine the resources and manpower required to provide the safest and most appropriate method of rescue.

When the decision is made to approach the patient, the medic must utilize all available resources. When faced with an active shooter and the casualty requires an open field approach where no cover or concealment is available, the goal is a rapid and safe retreat to a more secure environment. Diversionary tactics, such as the use of noise (flashbangs, sirens, bullhorns, and car alarms are all readily available), smoke, or cover fire, may distract or confuse an active shooter and provide additional security during such an approach. If they are available and time permits, shields and vehicles should always be utilized to provide additional cover during an open field approach with an active shooter.

The type of extrication technique utilized depends on the available resources and manpower, the level of consciousness of the casualty and the amount of assistance he can offer and the security of the immediate surroundings. The ABCs of extraction dictate Ambulation Before C

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