Medical personnel supporting tactical operations must plan for the rescue and evacuation of casualties to sources of care beyond the scope or capabilities of those at the scene. Crisis situations may develop during any phase of operations. These can affect bystanders, adversaries, or operators. Critically ill or injured casualties will almost always require supportive care or definitive management at a hospital or trauma center. Concise and flexible contingency planning affirms the role of the tactical medical provider (TMP) as the operational commander’s medical advisor. TMPs plan, coordinate, and facilitate expeditious transportation of casualties from the scene to an appropriate emergency department (ED) or specialty referral center while maximizing the level of care during patient movement or transition of care. Preparation for foreseeable medical or nonmedical crises is essential for mission success.

Medical care during evacuation (MEDEVAC) can be conducted over the earth’s surface, through its atmosphere, or some combination of these. Organized ground-evacuation systems have been employed since the Napoleonic Wars of the 19th century. Tactical casualty evacuation (CASEVAC) by rotorcraft was introduced during the Korean War, but MEDEVAC by air was really expanded and refined by both military and civilian organizations since the Vietnam War (1).

The development of civilian out-of-hospital medical response shares a direct relationship with the military. The early 1970s witnessed an explosion of educational programs as a large pool of veteran Vietnam medics transitioned to civilian emergency medical services (EMS) providers. Following a seminal white paper just before this period (2), legislatures across the nation recognized the possibilities for reducing mortality, and moved quickly to implement these and other programs to initiate a new era of out-of-hospital medical care in the United States.

In any health care system, each separate component is interrelated and relies upon the others. The out-of-hospital portion is vitally important. Actions taken by all providers in the evacuation chain influence subsequent care and ultimate outcome of critical casualties (3). Medical skills brought to the tactical arena will vary widely—from civilian EMS providers of basic life support (BLS) to highly trained and experienced tactical physicianparamedic teams.

Although the medical literature regarding tactical emergency medical support (TEMS) continues to grow, there is still precious little evidence regarding the efficacy of recommended techniques and procedures. Nonetheless, practitioners of TEMS—whether law enforcement, military, or
other—prepare for and face a variety of difficult challenges. Many of these would tax even the most experienced out-of-hospital providers. On-scene management and tactical evacuation of seriously ill or injured casualties are on one extreme of this spectrum. The dedication, training, experience, planning, and on-the-spot judgment of a TMP may be the only hope for casualty survival, regardless of whether there is literature evidence to support any specific course of action (COA). Extrapolations from the military and nontactical literature may be made in some cases, but must be critically reviewed for applicability to any given system or situation.

From its very conception in the late 1980s, TEMS has focused on mitigating risk in a high-risk environment. This has been done by conducting preventive services for team members and augmenting personnel, planning for medical support of training and mission operations, providing medical advice to commanders and other decision-makers (i.e., being their “medical conscience”), and managing the sequelae of illnesses and injuries in a variety of settings. When faced with critical casualties, the expected stressors of out-of-hospital care are only compounded by direct threat of injury from adversaries, low-light or high-noise environments, restrictive personal protective equipment (PPE) (e.g., gloves, body armor, chemical-biologicalradiological (CBR) masks and suits), inability to directly or immediately access casualties in some scenarios, and casualties potentially being friends or co-workers.

Operational security (OPSEC) is a risk-management tool used to deny adversaries information about a tactical unit’s intentions and capabilities (4). Polices and procedures must exist to identify and protect critical information that could compromise mission accomplishment. In part, it was a breach of OPSEC during the raid on the Branch Davidian Compound near Waco, Texas on February, 28 1993 that contributed to 32 operator casualties (four fatal gunshot wounds, 20 nonfatal engagement wounds, eight nonfatal injuries) and seven adversary casualties (3 fatal and four nonfatal gunshot wounds). During the planning phase of Operation TROJAN HORSE, a dispatcher in the local EMS system informed a friend in the media that three ambulances had been placed on standby for Monday (1 March) by the Bureau of Alcohol, Tobacco, and Firearms. A paramedic also told a reporter at the scene of an unrelated accident that “something big” was going to happen on Monday (5).

During the planning, as well as execution and debriefing, of tactical operations, all personnel must ensure the commander’s OPSEC guidance is not violated. TMPs must have a systematic process to obtain critical information, identify and analyze potential threats, assess risks and vulnerabilities, and implement appropriate countermeasures for medical threats, while maintaining the necessary level of security. Should unintentional exposure of mission-critical information occur, unit and team commanders must be briefed without delay to determine any potential impact on the planned mission.

Establishing scene safety prior to rescue is common to both tactical and nontactical settings. Although some threats may be different, a higher level of risk may be acceptable during TEMS. Each tactical unit’s commander allocates medical assets based on resource availability and perceived risk. Military units have different missions, methods, and resources than typical law enforcement units, though overlap in many principles, concepts, and techniques should be leveraged where possible.

When planning for the possible evacuation of critical casualties, TMPs must have solid understandings of the capabilities and limitations of a wide variety of transportation platforms ranging from improvised litters to mobile intensive care units (MICUs). Manual carries are discussed in Chapter 19. Preplanned surface evacuation vehicles are usually ground ambulances, but they could be watercraft in some scenarios. Preplanned air evacuation from tactical settings is most often accomplished by helicopter, but airplanes may be required for longer distances. Vehicles of convenience can be employed when absolutely necessary, but this usually represents a failure of premission contingency planning.

Box 15.1 provides some key questions related to evacuation platforms. Some missions may require specialized rescue, evacuation, or medical assets. Underground and underwater operations are an example. Breeching or cutting tools are others. Occasionally, potential patients may be known to require medications not typically carried by TMPs or civilian EMS.