How to Set Up a Tactical Emergency Medical Service Program

Richard B. Schwartz

Navin K. Sharma

“TEMS is a dynamic discipline that will continue to positively impact public safety, but with a knowledge and organizational base that will always be evolving based on the threats and missions before us, advances in scienceand technology, and last but not least, our imagination and passion to pursue excellence.”

Richard H. Carmona

U.S. Surgeon General

Starting a tactical emergency medical service (TEMS) program can be a daunting task. However, with planning and proper acceptance from key partners, a successful program can be assured. There is no one best design for a TEMS program and each team must develop its program to meet its individual mission and resources. Historically civilian tactical teams have operated as a tactical unit without the unit’s own direct medical support. In this system medical support of these units has consisted of calling 911 if there is an injury during training or callouts. A step up from this system is the notification of existing EMS services that an operation is taking place in a general area and a unit may or may not be stationed on the scene. This level of support may be inadequate in many TEMS settings. Over the past several decades there has been a trend toward the increased recognition of the need of integrated TEMS. Many professional and law enforcement agencies have recognized this need to have emergency medical care
available at the scene of any incident involving police tactical operations (1). Despite this growing acceptance, there are still many tactical units without integrated medical support. A 1996 survey indicated that 78% of Special Weapons and Tactics (SWAT) teams did not have a medical director and that 23% did not have a medical preplan (2). These statistics have undoubtedly improved since 1996, however, when presented with the concept of TEMS there still may be resistance from both the law enforcement and the medical community during the early development of a TEMS team. This chapter helps provide a framework to assist in the initial development and sustainability of a TEMS program.

ESTABLISHING NEED

Identifying the need for TEMS and gaining acceptance from law enforcement command staff as well as the medical chain of command is a crucial first step in the process. Commanders should be made to recognize not only the critical nature of emergent medical care inside the perimeter but also the importance of medical threat assessment, preventive medicine, and the other aspects of TEMS in maximizing mission effectiveness. In fact, a greater amount of time is spent on these other activities than on actual combat/tactical casualty care (3). When properly briefed, commanders should understand the advantages of having an integrated TEMS program. Additionally, commanders should be aware of the potential economic consequences from liability incurred when falling below a standard of care (3). Assistance in this area can be obtained from a number of national, federal, and state organizations, including the International Tactical EMS Organization (www.items.org), the National Tactical Officers Association (www.ntoa.org), the Medical College of Georgia Center of Operational Medicine (www.mcgcom.com), and the Uniformed Services University’s Casualty Care Research Center (www.ushuhs.mil/ccr/ccr.html). In areas where local physicians or the EMS community is not familiar with the TEMS concept, a similar education process may be necessary. Discussion with agencies that have TEMS programs and TEMS physicians on their staff would be an excellent start. The above-named support organizations can also be extremely helpful in helping local medical program directors (MPDs) network with their physician peers across the country with experience with TEMS units.

MISSION, GOALS, AND OBJECTIVES OF THE TACTICAL EMERGENCY MEDICAL SERVICE UNIT

The mission statement is a broad statement that defines the overall purpose of the program and why it exists. How this mission is to be accomplished can be defined by goals and objectives for the unit. Broad goals of tactical medicine are listed in Box 25.1. These goals have expanded over the years. Initially TEMS providers focused only on the care and evacuation of the wounded; however, their role has expanded far beyond that and the majority of the effort of TEMS providers is now spent on health maintenance, preventive medicine, threat assessment, mission planning, and other aspects of TEMS (1,4).

Box 25.1. General Goals of Tactical Emergency Medical Services

▪ Enhance mission accomplishment
▪ Prepare medical threat assessment
▪ Monitor the medical effects of environmental conditions
▪ Reduce death, injury and illness, and related effects among team members, innocents, and perpetrators
▪ Reduce line-of-duty injury and disability
▪ Reduce lost work time
▪ Maintain good team morale
▪ Maintain team members’ health and provide preventative medicine
▪ Coordinate with surrounding agencies and hospitals
▪ Decrease liability
▪ Possess basic forensic knowledge and crime scene preservation

Adapted from Marx J, Hockberger R, Walls R, eds. Rosen’s Emergency Medicine Concepts and Clinical Practice. 6th ed. Philadelphia, PA: Mosby Elsevier; 2006.

Unit-specific goals can also be utilized. Objectives can be developed in the context of the unit’s medical capability and the overall mission of the team in mind. For instance, if one is able to develop only a basic life supportlevel TEMS unit, then the objectives and expectations of the unit should match that level of medical expertise. Changes to the objectives would need to be made as the unit evolves to advanced life support standards or if the team takes on additional missions such as maritime operations.

STRUCTURE OF A TACTICAL EMERGENCY MEDICAL SYSTEM PROGRAM

The details of team composition and basic capabilities and equipment are covered in Chapter 1, however, it is important that essential elements be highlighted here, as the functioning of the TEMS program will depend on its structure. As indicated earlier, there is no best single structure for a TEMS program. In broad terms there are two basic structures: internal and external. Internal support refers
to teams that have medical support that are both trained and certified medically and are sworn officers. External refers to teams that have medical support from other organizations, and they are generally not sworn officers (3). In reality there are advantages and disadvantages of both systems. Internal systems with experienced medical providers seem the most desirable, as the medical providers have unique training and certifications that give them credibility and the ability to work both medically and tactically. Officer safety issues, the use of force continuum, and general police tactics are second nature to this type of an internal support medical provider. However, this combination of an experienced medical provider who is also a full-time law enforcement officer is not as readily available to many jurisdictions as is the external structure counterpart. External teams are able to provide highly competent experienced medical providers but they do not have arrest powers and have limitations in the tactical environment. Despite the limitations of external teams, this is the model for the majority of tactical teams in the United States (3). There are teams of both organizational structures that function well, and a balance of medical and tactical skills is desirable.

How your team is established will depend on your available resources and local command structure. Team makeup is highly variable and, again, depends on your resources. Internal teams generally are made up of members with medical certifications at the EMT-B through EMT-P level. These programs will often have volunteer medical direction and oversight from a local physician familiar with TEMS. Several organizations have full-time physician support either as employees or under contract (5). This kind of arrangement is appealing and assures that the physician oversight is integrated with the tactical elements, as opposed to a volunteer arrangement, which may be less reliable. The MPD should meet the qualification standards for EMS medical directors established by the American College of Emergency Physicians and the National Association of EMS Physicians (6,7). Additionally, the MPD for a TEMS program should have TEMS-specific training and experience to most effectively provide medical oversight. Some tactical teams have been successful with physician/nurse TEMS programs. Some locations have even integrated TEMS support into graduate medical education programs (4).

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