Medical Preplanning Considerations for Tactical Emergency Medicine Operations

Kermit D. Huebner

John G. McManus Jr.

OBJECTIVES

After reading this section, the reader will be able to:

1. Describe the importance of medical considerations in preplanning phase of the tactical mission.

2. Describe some of the most important medical aspects that can affect mission outcome.

3. List tactical considerations that effect treatment, evacuation and logistical medical support.

INTRODUCTION

Providing tactical emergency medicine care can be a dangerous endeavor. Unlike most traditional emergency medical service (EMS) systems, tactical emergency medical service (TEMS) units must be prepared to provide care under fire in austere environments. Planning for medical support to tactical operations is vital to ensure appropriate medical support is provided in the right place at the right time without interrupting or interfering with tactical procedures. Although preplanning is vital, there are two competing truths that must be reconciled. First, “proper prior planning prevents poor performance” and second, “best laid plans always fall apart when bullets start flying.” Although personnel must be able to adapt to the tactical situation, it is imperative that medical plans are incorporated seamlessly into the tactical plan and possible courses of actions on the objective should be reviewed and rehearsed prior to the event. This chapter will discuss planning considerations for tactical medical plans and effects of on-scene treatment and evacuation, logistics, and command and control.

PLANNING CONSIDERATIONS

Defining the Mission

In order to formulate an appropriate medical plan, planners must understand the proposed tactical plan. Medical planners must be intimately familiar with the tactical unit, its capabilities, as well as tactics, techniques, and procedures (TTP) that will influence courses of action on the objective. Knowledge of these components and an understanding of the tactical commander’s philosophy will allow the medical planner to anticipate the medical support needs and develop a medical threat assessment. The military uses a well-defined process for deliberate planning: the military decision-making process (MDMP). This process consists of eight steps: (i) receipt of mission, (ii) mission analysis, (iii) course of action development, (iv) course of action analysis, (v) course of action comparison, (vi) course of action approval, and (vii) orders production (1). Medical planning should occur parallel to tactical planning. Remember, “good medicine” can sometimes be “bad tactics” and “bad tactics” can lead to mission failure.

The initial step is to develop the medical mission from the tactical mission. Key questions that need to be addressed include:

What medical support is required?

Where is the medical support needed?

When is the medical support needed?

What are the types of casualties anticipated and what is the likely casualty flow?

These questions can be better addressed after evaluating the following mission variables.

Enemy Capabilities

Number of Personnel

How many suspects are expected to be on-site? How many bystanders are anticipated to be on-site or in the immediate area? These numbers have a direct impact on the casualty estimate.

Weapons

What types of weapons systems is the enemy likely to employ? Although the goal of treatment is to treat the wound, not the weapon, consideration of the weapons types may allow the medical planner to better estimate the types of wounds that may be seen. During tactical assaults, the anticipated wounds would be expected to result from bullets; however, consideration must be paid to ballistic, blast, and thermal effects that may result from explosives. Gunshot wounds are the most common injuries sustained by suspects, followed by contusions and abrasions (2). On the conventional battlefield, multiple small fragment wounds of the extremities are the most common injury patterns seen (3). Tactical teams must also be aware of the potential for secondary devices.

Likely Enemy Courses of Action

What tactical intelligence is known about the suspects? Information that may influence medical actions includes the anticipated level of aggression of the suspects and suspected courses of action once the assault begins. As the situation unfolds, the zones of care on the objective may change and medical assets may need to be repositioned to provide timely medical care and evacuation.

Potential for CBRNE Agents

Is it possible that the targets have access to chemical, biological, radiological, nuclear, or high explosive materials? Each of these poses a unique set of challenges in the tactical environment. Chemical agents may consist of traditional chemical warfare agents, such as the mustard agents, pulmonary agents, nerve agents, incapacitating agents, and riot-control agents, as well as toxic industrial chemicals and materials. Biological agents of concern include: bacteria (such as Bacillus anthracis spores, Francisella tularemia, and Yersinia pestis), viruses (such as orthopox viruses, equine encephalitis, and viral hemorrhagic fevers), and toxins (such as botulinum toxin, ricin, and staphylococcal enterotoxin B). Ionizing radiation threats include alpha radiation, beta radiation, neutron radiation, and gamma rays. Tactical situations that may result in exposure to chemical, biological, radiological, nuclear and explosive (CBRNE) agents need additional preplanning to include pre-exposure and postexposure prophylaxis, depending on the agent, as well as personal protective equipment (PPE) and decontamination requirements. Guidelines for medical management of chemical, biological, and radiological agents (4, 5 and 6

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