Zones of care

The areas of operation for a tactical mission are usually based on the threat level. Traditionally, terms such as inner and outer perimeter have been used. While the concept of static inner and outer perimeters is useful in planning tactical operations, its application to tactical medical support is limited because as the incident evolves, areas of safe refuge or egress may rapidly change. Stratifying the medical areas of operations based on risk better reflects the dynamic process of treating the injured in the tactical arena.

The area with the greatest risk is the hot zone, where an immediate threat is present. This risk may be secondary to a known threat or to hazardous conditions. Medical priorities in the hot zone must be limited to patient extraction or applying a tourniquet for life-threatening hemorrhage. Even these procedures may be delayed because of the potential risk for further injury to both the patient and the rescuer.

The cold zone is the area with neither significant danger nor threat. Medical care in this area parallels that in the routine EMS world.

The warm zone is the area of potential or indirect threat. Medical care provided in this zone is dictated by weighing the risk/benefit ratio and the perceived level of threat. Thinking in terms of graduated zones provides a basis to critically analyzing medical treatment options in a highly dynamic environment [19].

The military, in its Tactical Combat Casualty Care paradigm, has developed a similar classification that also divides the area of care into three zones. “Care under fire” is analogous to the hot zone. Preventing further injury, tourniquet application, and retreating to safety are the only acceptable interventions. “Tactical field care” is similar to the warm zone and includes airway management, breathing and circulation intervention. Needle thoracostomy, vascular access, and other immediately life-saving procedures are part of this phase. “Tactical evacuation care,” or TACEVAC, includes more definitive management as the patient is evacuated away from the threat by any available means and is analogous to the cold zone [20].

Weapons safety and less lethal weapons

Tactical emergency medical support providers should be familiar with the specific weapons of the tactical team’s arsenal, along with their associated medical risks and appropriate treatment strategies for patients exposed to them. Basic training in weapon handling is a minimum requirement for the TEMS provider since casual or improper handling can have tragic consequences.

Handling of unfamiliar weapons poses an even greater threat, and a protocol for the safe transfer of such a weapon to a tactical team member is encouraged.

Weapons designed to incapacitate suspects while minimizing the risk of death or serious injury are known as less lethal weapons (LLWs). They include chemical irritants, kinetic impact projectiles, noise/flash diversionary devices (NFDDs), and conducted energy weapons (CEWs). The term “less lethal” indicates that lethal effects are less likely than with traditional firearms but that death is possible.

Hazardous materials

Clandestine labs pose a special problem for both law enforcement and TEMS providers. Many of the materials used to produce illicit drugs are flammable or explosive, increasing the possibility of burn and blast injuries from ignition due to weapons fire, CEW deployment, or even light switches.

Acute and chronic health effects from toxic exposure must be considered since illicit drug operations rarely use safe materials or practice safe handling procedures.

Additionally, booby traps are a known hazard of clandestine operations with the potential to cause routine and unusual wounding patterns.

Forensic evidence collection

Loss of evidence because it was unrecognized, disturbed, improperly stored, or not maintained in a chain of custody can damage an investigation. One study concluded that emergency care providers often overlooked, lost, or discarded forensic evidence [31]. The TEMS physician must have knowledge of the principles and procedures used to maintain evidence integrity.

The patient care report should also document forensic findings, including evidence that may be lost in transport or continuing care of a patient, such as firearm soot on clothing or skin.

Special patient populations and excited delirium

Tactical medical providers may be faced with pediatric, geriatric, and/or chronically ill individuals with special medical needs. In addition, it may be difficult to determine if acute medical conditions are contributing to the behavior of some patients. An example that has received a great deal of attention in the professional and lay press is excited delirium.