Tactical Emergency Medical Support

Tactical emergency medical support (TEMS) draws its roots from military medics in conflicts in the Napoleonic wars. Later conflicts, such as World Wars I and II, the Korean War, and Vietnam War, saw the role and capability of the combat medic expand. Medical care and evacuation became an essential part of the battle plan. The modern day infantry medic participates in combat alongside other infantrymen as a fully integrated member of the platoon.

The National Tactical Officers Association defines TEMS as “the provision of preventative, urgent, and emergent medical care during high-risk, extended-duration and mission-driven law enforcement special operations.” Although models vary from one team to another, the basic premise of TEMS includes medical personnel integrated with tactical units to provide on-site medical care and assist in the planning process. This may include police officers who are cross-trained in medical care, paramedics or physicians who are fully integrated into teams but lack police powers, or medical support that remains outside of the inner perimeter. Each model has advantages and disadvantages that will be discussed later. TEMS medics have tactical training that enables them to enter high threat environments with the team.

The importance of having medical support embedded with the team is most evident when one examines scene safety doctrine among conventional emergency medical services (EMS). EMS are often ill-trained to function in a high-threat setting, such as one where active hostile fire is present, and will therefore wait outside the “hot zone” until their safety can be guaranteed. Without tactical medical support, long delays in care may result as EMS wait for the tactical situation to be resolved before making patient contact. A short distance of 100 yards may still prove deadly to a victim who is actively hemorrhaging in an unsafe area. In the Columbine High School Massacre in 1999 a teacher was wounded inside the school and bled to death as he waited more than 3 hours for medical care to arrive at his side. His family later settled a lawsuit with the Jefferson County Sheriff’s Office for the delay in care, receiving a settlement of $1.5 million. In the 2013 Los Angeles International Airport shooting a Transportation Security Administration (TSA) agent was shot by a lone gunman; 30 minutes passed before medical care was rendered due to the concern for additional threats. In the North Hollywood shootout of 1996, one perpetrator bled to death for 30 minutes after being shot at close range by police. Because there were two mobile, heavily armed shooters firing indiscriminantly at police and civilians, it was felt that the situation was too volatile for EMS to enter. His family sued, which resulted in a hung jury, and later dropped the suit in exchange for an assurance to provide additional training for officers. Whether any of these victims could have been saved with earlier care is uncertain, but this highlights the difficulty in bringing care to the hostile environment.

Historical perspective

In the 1960s and 1970s high profile incidents, such as the 1966 Texas Bell Tower Incident, where a lone shooter climbed the clock tower at the University of Texas in Austin, killing 17 people and wounding 31 more with a high-powered rifle, created the impetus to form specialized, highly trained, and versatile police tactical teams to intervene on high-risk incidents. The Los Angeles Police Department and Los Angeles Sheriff’s Department organized two of the first tactical law enforcement teams in the United States in the latter part of 1966. ^,Hostage rescue, apprehension of violent, armed criminals, special reconnaissance, clandestine drug lab operations, and protection of special assets or high profile persons are among the missions that law enforcement tactical teams may be asked to accomplish. These special weapons and tactics (SWAT) teams are comprised of law enforcement and support personnel under a unified command structure for maximum versatility. With the high likelihood of injury and death posed by these missions, it was not long before embedded medical support was part of the SWAT team profile. Teams drew on the military medical model of line medics who are closely aligned with tactical team members to minimize the distance to competent medical care from the point of injury. To operate in this high threat environment, additional training must be provided so that the medic does not become a liability to the team. The top priority always remains: mission first. The mission is what will prevent more casualties and loss of life. The medic may therefore defer medical care or bypass casualties in order to continue the mission and eliminate the threat.

Current practice

Delivery Models

The basic premise of medical support on tactical teams remains constant: to reduce death, injury, and illness through care, training, and preventive measures. The composition and training of TEMS units remain diverse at the local level. Not all SWAT teams have organic medical support embedded in their organization. This is sometimes due to funding, lack of available trained personnel, or jurisdictional conflict between the police department and other organizations that may provide support. There are some team commanders who incorrectly believe that providing medical care is inconsistent with the organizational mission and that doing so would invite additional liability. The opposite appears to be true, however, and rapid medical treatment and stabilization will improve liability posture. Table 87-1 illustrates some common delivery models with advantages and disadvantages of each.

Table 87-1

TEMS Delivery Models

Advantages	Disadvantages
Sworn Police Officers Cross-Trained in Emergency Prehospital Medicine
Role flexibility: can perform enforcement duties and change to TEMS when needed. Can go where the team goes. Have statutory authority to arrest and carry weapons where they may otherwise be prohibited. Can provide for their own defense. Training standard for weapons is defined in state or federal law. Statutory liability protections may exist.	Potential role confusion if both duties are required. Cross-training dual roles could mean less expertise than their single-role counterparts. Training programs for police vary from 120 hours to over 700 hours. EMT requires 140 hours, and paramedics an additional 1000-2000 hours. These courses represent a substantial investment of time that may be prohibitive.
Nonsworn Medical Personnel (Physicians, Physician Assistants, Paramedics)
Can go where the team goes. Typically have continuous practice in their field. No role confusion or arrest powers.	Poor clarity on legal liabilities, and may have limitations on carrying firearms in all places (government buildings, schools). If unarmed, another operator must provide defense.
Conventional EMS Units Staged for Support
Little to no cost burden for the law enforcement agency. Law enforcement agency can refute liability for medical care. No role confusion.	Inadequate for tactical medical support. No tactical training, weapons, or rescue skills. Must remain far from the danger area and cannot enter the hot zone, which can delay care. No training in team health, operational sustainment, temporizing treatments to maintain mission profile. Limited understanding of unique SWAT personality types, and limited trust due to lack of regular training with the team can be detrimental to care. Lack of ability to train SWAT officers in tactical medicine for self-care. Ambiguity in chain of command, and leadership confusion when a medical emergency occurs.

Training, Preventive Medicine, and Mission Sustainment

A core function of TEMS includes advising the commander and team members of hazards that may compromise mission success and lead to undesirable outcomes. Gathering medical intelligence about the operational area is paramount. Weather, food and water sources, endemic illnesses, and likely patient population to be encountered will factor in to equipment selection and training. The TEMS provider has the responsibility to educate the commander and tactical operators on medical issues and procedures that will enhance mission effectiveness and prevent injury. All team members should be taught by their TEMS provider how to perform basic bleeding control, application of chest seals, use of basic airway tools, and drags and carries for moving injured casualties. Hydration, prevention of heat and cold injuries, poisonous fauna, and management of simple ailments are other items of interest to the tactical team.

The TEMS provider will have to consider hygiene, toileting, and food and water sources for extended operations. In a disaster setting these may provide significant challenges. Management of minor injuries and illnesses must be considered, particularly if evacuation is onerous or not tactically feasible.

Echelon Staging of Medical Gear

One way the medic can maintain maximum mobility is by determining where in each phase of care certain equipment will be needed. For example, direct threat care items, such as tourniquets, chest seals, and nasal airways, might be located on the medic’s primary load carriage or vest. Additional equipment for multiple casualties may be kept in a medical bag that can be dropped and then quickly retrieved at a point of entry into a building, whereas more advanced equipment for extended care may be kept in a kit in a vehicle.

Mission profile will greatly dictate what and how much equipment is carried. A high-risk arrest warrant executed in an urban house is likely to encompass few issues when it comes to casualty evacuation and handoff to civilian EMS. The same warrant on a rural methamphetamine lab may involve significant travel by vehicle and on foot to avoid detection. In some missions tactical teams and their medical support may need to shelter in place to remain hidden until it is time to make contact with the target. Body armor, helmet, water, weapons, ammunition, and other protective gear may weigh upwards of forty pounds. Equipment selection is therefore of utmost importance. TEMS medics will often repackage gear to reduce space and weight. Packing equipment that can be utilized for multiple purposes, sometimes in unusual ways, will help maintain the medic’s mobility. Some techniques are listed in Box 87-1 .

Box 87-1

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