Medical control in its infancy existed on the battlefield of Napoleon’s armies in the use of crude evacuation methods and treatment of wounded soldiers at or near the battle-field (1). Medical treatment, stabilization, evacuation, and control were further expanded during and after the Civil War (2), when in 1775 the Continental Congress authorized the creation of the first Army Hospital Department. With the development of ambulance units, evacuation routes, and basic front-line lifesaving care and the beginnings of the first fixed treatment centers staffed with doctors and nurses, the inception of what would be an early form of medical command control was initiated. A significant leap was made prior to the beginning of World War I, during which private intracity hospitals and hospital-based ambulances began to respond, transport, and care for patients under an ad hoc system that was largely separate from government control and oversight (3).

From a tactical standpoint, there were no formal centrally controlled forward medical units or organizations until World War I. In the 1950s and 1960s, following World Wars I and II, the United States initiated what could be considered an early National Response Plan (NRP) with air raid drills in preparation for the inevitable Russian ballistic missile strikes that never occurred. Since that time, incident and disaster medical care have been primarily a local joint collaborative effort by both governmental and private organizations. At times, these interagency efforts have been ineffective on-scene, making it difficult to have appropriate utilization of medical resources (3).

Following September 11, 2001, the National Incident Management System (NIMS), the National Readiness Plan (NRP), the Federal Emergency Management Agency (FEMA), local Emergency Operation Plans (EOPs), and the Incident Command System (ICS) were either created or improved to address more effective interagency resource allocation and use (4).

At the city and county level, tactical emergency medical service (TEMS) members have been active, in very small numbers, since the mid- to late 1980s (2). As a result of events like September 11, 2001, Columbine, and other high-visibility mass casualty events, as well as the increased use of TEMS by police forces and the need for a centralized control of medical assets, the Special Weapons and Tactics (SWAT) Medical Commander has become a very important member of the ICS general staff (2,5). The importance of improved tactical incident medical control and planning is eloquently stated in the 1897 quote by Nicholas Senn, M.D., 49th President, American Medical Association: “The fate of the wounded rests in the hands of the one that applies the first dressing.”

NIMS was issued, by the President, on February 28, 2003, and directs all federal agencies and municipalities, through the Secretary of Homeland Security, to adopt a common incident response and action plan. Per FEMA document 501-1, “NIMS provides a consistent nationwide template to enable Federal, State, local and tribal governments and private-sector and nongovernmental organizations to work together effectively and efficiently to prepare for, prevent, respond to, and recover from domestic incidents, regardless of cause, size, or complexity, including acts of catastrophic terrorism” (4). NIMS is not a template for local states, governments, or municipalities to create an action plan for an isolated small incident but, rather, a framework and standardization of training, qualifications, planning, resource utilization, and communications to improve intercity, state, and federal coordination when largescale national disasters occur (4,6, 7, 8, 9, 10 and 11).

Although NIMS is broader in scope and practice than most local incidents, a disaster of monumental proportions such as September 11, 2001, can happen at any time and anywhere. As such, the tactical medical commander needs to understand how to create a medical response plan that effectively coordinates with and integrates the utilization of national resources when needed. These include being proficient with and creating a medical response plan that fits within the NIMS and ICS framework and being adept at utilizing the Multi-Agency Coordination Systems when local medical needs are greater than local medical assets (12,13).

The ICS was developed in the 1970s to simplify the coordination of multiple agencies that may be involved in responding to a particular incident. It has been utilized in numerous scenarios, for example, the Columbine High School shootings. In a general sense, it creates a framework from which numerous agencies can understand how to appropriately interact and from whomdirections should be taken (14,15). As such, this tested system provides agencies that have not had the opportunity to train together with a structure from which they can integrate. The command and organizational structure of the ICS is very complex and a significant amount of overlap exists among several agencies. For example, the tactical medical commander, as part of the ICS general staff, would interact with the liaison officer at the Incident Command (IC) headquarters for local, state, and national agency coordination. He or she would coordinate with the finance chief for potential medical claims, the logistics chief for the medical units and assets and establishment of supply points or resupply operations, and the operations chiefs for establishment of triage sites, staging areas, and air evacuations and coordination of TEMS with the team commander and task force leaders. However, even with this level of complexity, the established hierarchy of the ICS improves these interactions and interagency coordination (14).

Despite the numerous obstacles that existed during the Columbine incident, the agencies involved had a sound grasp of the ICS matrix. As a result, predefined command structures became secondary to the ICS, allowing for improved incident response and appropriate interagency coordination among police, firefighters, SWAT, EMS, and local hospitals, even though the majority of these agencies had previously never drilled or worked together. In a position statement following the event, it was suggested that while interagency drilling is important, it is more important to have a sound understanding of the ICS among all agencies and personnel responding to ensure appropriate resource utilization and successful incident resolution.

The SWAT tactical medical commander is part of the general staff of the ICS, reports to and advises the IC, and is responsible for every aspect of medical command, control, and oversight that occurs in the training, medical planning and execution phases, during and after a small- or large-scale incident, disaster, or terrorist act (14). As such, the medical commander, in the perfect situation, would be involved in the selection, training, and certification of all emergency medical personnel, would have total control over the treatment and evacuation assets on- and offscene, and would have enough organic assets for casualty evacuation (CASEVAC) to local hospitals without having to use standard EMS. However, under the current system, there are no stand-alone SWAT TEMS systems that can handle more than an isolated small encounter before outside agency assistance is needed (2).