Issues identified and published position statements important to tactical emergency medical support (TEMS) can historically be identified in many well-known organizations. These include the National Tactical Officers Association (NTOA) (1), American College of Emergency Physicians (ACEP) (2), National Association of EMS Physicians (NAEMSP) (3) and other professional associations that have issued policy statements. Statements such as these helped to shape the early public policy of TEMS.

Public opinion and public policy are important considerations in TEMS future. The impression of the lay public and legislators needs to be accurate regarding TEMS. Highly visible to these key groups are media-based images of specialized law enforcement teams, both civilian and military, engaged against criminals and enemies of our nation. However, the supporting medical assets safely ensconced far from the threat of injury or concealed as one of the responding officers are practically invisible to the same key groups.

Public policy regarding the utilization of specially trained law enforcement personnel required locally for forced entry, warrant service, hostage negotiations, and other missions different than the routine has been well established. The public policy regarding TEMS as an integral team member in these specialized law enforcement operations is less well established. For example, funding provided for specialized operations may be wrongly assumed by the lay public and legislators to include provision for sufficient TEMS during these operations. The reality is that TEMS-specific funding is often not adequately provided and, in some situations, is actually being reduced. This is creating a public policy concern of supply and demand.

The supply of appropriately selected, trained, and maintained TEMS personnel may not be able to meet the demand of the specialized teams and operations they are designed to support. It is important that appropriate emphasis on the medical support of missions be recognized and maintained.

This and related complexities of TEMS must be appreciated by jurisdictional administrators (JA). The maturing of communications and detailed operational guidelines between law enforcement agencies are vital relationships being established to meet such important TEMS issues. Every TEMS provider can play an important role in establishing the proper public policy.

The role of the jurisdictional authorities may be described as to protect the law enforcement officers that protect the
citizens through TEMS (4). The law enforcement agency officer-in-charge, through careful review and interpretation of on-going intelligence, risk analysis, and after-action reports, is charged with determining the assets required to meet the daily challenges encountered. For some missions, the use of a special operations unit (e.g., a SWAT team) may be the most effective and the safest. This established need for a SWAT team may or may not include TEMS in the jurisdictional law enforcement.

Funding is an important determining factor in the inclusion of TEMS. For those jurisdictions unable to financially maintain or physically staff a SWAT team, law enforcement mutual aid agreements commonly permit regionalization of SWATs to assist local law enforcement with the complex missions beyond their capabilities.

Mutual aid agreements can identify a TEMS unit that will travel out of their jurisdiction to another in tandem with their SWAT team. This requires advanced deliberations that created the logistics and communications to incorporate a paramedic with a weapon or to perform advanced prehospital medical procedures in the local jurisdiction (5). The local law enforcement officer-in-charge and the incoming SWAT team’s officer-in-charge will have to arrange for local assets if the mutual aid SWAT-TEMS is unable to travel with the SWAT team due to staffing shortages or the unfortunate limitations inherent in mutual aid agreements between prehospital care agencies or crossjurisdiction practices of prehospital care.

The mutual aid model of providing such TEMS support has limitations. Some states and regions in somee states do not permit out-of-county or out-of-jurisdiction prehospital care personnel to, in essence, work within that county or jurisdiction without specific protocols, policies, and procedures, especially when a paramedic may be armed. Mutual aid agreements between law enforcement agencies may be separate and distinct from those between prehospital care agencies. This distinction should be flushed out and addressed through dialogue and research of the existing jurisdiction Scope of Practice statutes and the regulations of the TEMS prehospital care providers. Adjustments to these statutes or regulations may have to occur before the advancement of jurisdiction policies, procedures, and protocols to permit out-of-jurisdiction TEMS to be able to interface with indigenous prehospital care (6).

One example of a roadblock to appropriate incorporation of TEMS involved a lack of physician support of TEMS in Illinois due to malpractice fears. On September 29, 2004, the Illinois Law Enforcement Alarm System (ILEAS), composed of the majority of law enforcement agencies statewide, approved a resolution to support the TEMS inclusion into the E.M.S. Act. The ILEAS was facing the growing threat of methamphetamine labs and increased awareness and subsequent development of local law enforcement capabilities of terrorist threats. Their commanders astutely determined that medical care of tactical teams was being delayed inappropriately. Their conclusion was that this care can be provided only by TEMS medics, but EMS protocols forbade EMS system members to enter the inner perimeter of an incident until the scene was safe and the mission had ended. Appropriately, they recognized that TEMS, a subspecialty of emergency medicine, would provide maximum protection. However, in Illinois, physicians would not volunteer their services because of the fear of medical malpractice liability. The ILEAS and the Illinois Department of Health (IDPH) created a TEMS taskforce, establishing a TEMS/EMS region with standardization of TEMS through state sponsorship and certification, which allowed TEMS physicians to receive limited medical indemnification through the EMS Act (7). On January 20, 2006, Illinois State Senator Dan Cronin introduced SB 2968 to the Illinois General Assembly, amending the Good Samaritan Act for various health care providers who provide volunteer TEMS services. As of April 4, 2006, both Illinois Houses passed the revised bill that amends the Good Samaritan Act, providing immunity from civil damages for EMT and first responders, as those terms are defined in the Emergency Medical Services (EMS) Systems Act (in addition to law enforcement officers and firemen), who provide emergency care in good faith without fee or compensation (instead of only without fee) (8).

Legislative issues regarding the weapon-carrying allowance of TEMS are an important issue. If the JA and law enforcement agency’s officer-in-charge determine that for their SWAT to be successful TEMS is required, a key element to be decided is if the TEMS members will be armed (9). The legislative authority hurdles involved, including new statutes required to permit a paramedic to carry a weapon, may be significant.

Public policy and related legislative issues are also found in the types and amounts of education and training TEMS providers receive. The degree of law enforcement and SWAT specific training for each TEMS member resides with the SWAT officer-in-charge in coordination with the TEMS officer-in-charge. Standard paramedic and EMT training programs do not incorporate the rigorous physical, emotional, and intellectual decision-making components necessary for TEMS members. Again, this may require jurisdiction legislators to add statutes to accept prehospital care providers into programs with some level of security clearance for initial and subsequent maintenance education and training programs. A related example of this issue is found in Georgia.

On July 1, 2006, Chapter 5 of Title 35 of the Official Code of Georgia Annotated was amended to provide the Georgia Public Safety Training Center for emergency medical personnel beyond the previous limitation of only state and local law enforcement officers (10). Jurisdictions may choose to cross certify specially trained and certified emergency

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