Tactical emergency medical support, or TEMS, was patterned after the successful military model of specially trained medics embedded within remotely deployed fighting units. While the military took full advantage of specialized medical support years ago, it was not until the late 1980s that civilian law enforcement began to embrace the concept of integrated medical care.1
Briefly describe the origins of tactical emergency medical support (TEMS).
Describe various models of the provision of TEMS along with advantages and disadvantages of each.
Explain basic concepts of tactical operations.
List ways in which the medical element in tactical operations enhances mission success.
List specific medical threats that must be managed during tactical operations.
List unique considerations specific to a TEMS program.
TACTICAL EMERGENCY MEDICAL SUPPORT
Most EMS providers are taught to stage away from a scene where their personal safety may be in jeopardy. Police action, by definition, is inherently unsafe, making civilian EMS providers unable to deliver expeditious care in areas of high threat. Several high-profile incidents, however, have reinforced the need for EMS providers trained to function “inside the perimeter” where a scene may not be totally secure. In February 1997, two heavily armed robbers entered the Bank of America in North Hollywood and engaged law enforcement officers in a long and bloody firefight. Ultimately, one of the robbers committed suicide while the other was shot by police as he tried to flee and later died at the scene. Surviving family members soon afterward brought suit against the Los Angeles Police Department alleging that his death was due, in part, to lack of timely medical care.2 One of the more vivid illustrations of the value of embedded tactical medical support came in October 2007 when a SWAT officer was shot in the neck during a high-risk warrant service. Two physicians with the Dallas Police Department were immediately at the injured officer’s side where it was determined he was without a patent airway. The tactical physicians achieved hemostasis and performed a surgical airway saving his life.3
Being a tactical medical provider, however, is more than simply taking an on-duty medical crew and donning them with ballistic helmets and vest. Highly specialized medical training should precede any provider’s deployment for real-world missions with a law enforcement team.4 Dozens of civilian and government-sponsored training programs in tactical medicine exist, but students seeking such training should carefully examine the curriculum choosing schools that focus on medicine in the tactical environment as opposed to schools that seem to center on weapon manipulation and tactical techniques. While important, these fundamentals of tactical movement should be learned and practiced with the student’s own team.
The configuration of tactical medical support varies greatly across the country. Some agencies still depend on EMS standby far away from the incident scene in the cold zone. While this model certainly reduces the burden of training needs on the part of the medical provider, it defeats the advantage of utilizing proximate and immediately available medical expertise in times of critical injury. In 1994, the National Tactical Officers Association released its official position statement on the provision of TEMS stating: “…the ultimate goal should be that TEMS providers are deployed within the operational perimeter in proximity to tactical operations. Doing so permits rapid access to casualties, the opportunity to provide medical countermeasures, and enables TEMS providers to make recommendations to team leaders.”5 Integrated TEMS providers should complete a recognized tactical medical course along with an agency-specific basic SWAT school. This will allow the medical staff to seamlessly fit into the tactical movement of the team, become familiar with a team’s capabilities and region-specific tactics, and cultivate the necessary trust among officers so that they may feel comfortable seeking medical advice or care from TEMS providers and so providers can recognize subtle changes in an officer’s behavior or mannerism that might be recognized as an early indicator of illness or injury.
Yet another variation on medical support exists in the form of cross-trained commissioned officers who are sent to EMT or paramedic training. This model provides for a fully functional SWAT officer with the added capability of medical training. While this model may seem attractive at first, one must consider that maintaining a dual skill set can be time consuming and cost prohibitive. Not only must the officer maintain law enforcement certifications and training, he must also attain regular civilian medical employment to retain assessment skills and technical acumen. The EMS physician must consider all options in consultation with the SWAT commander when designing a new tactical medical support program.
BASIC CONCEPTS OF TACTICAL OPERATIONS
Tactical law enforcement operations typically involve assignments that are beyond the scope of enforcement of standard patrol officers. Types of police actions that necessitate tactical operations include high-risk warrant service, barricaded subjects, hostage situations, and even executive/dignitary protection details.
SWAT response to any given assignment or threat involves a multilayer response utilizing surveillance techniques, patrol officers, detectives, tactical long riflemen, and a medical support element. Operations may be planned weeks in advance or be escalated into direct action quickly depending on the dynamics of the given circumstance. Such situations have a unique set of challenges making the operation even more demanding. For example, the protective equipment itself is necessary but can be cumbersome. Ballistic helmet, vest, gloves, and gas masks add to the weight the officer must bear while still trying to maintain maximum flexibility and efficiency of movement (Figure 66-1). These stressors contribute to emotional stressors already in place in a high-threat environment. It also taxes the physical stress which may be exacerbated when tactical operations must be conducted in extremes of heat or cold. Tactical medical staff must take these unique considerations in mind when anticipating medical threats and when preparing for a given response to a tactical incident.
The medic is not without his own stressors, however. When providing medical care in a high-threat environment, significant operational limitations exist that are not typical of the classical health care environment. For example, a patient assessment may need to be performed with limited lighting if not total darkness at times as a light signature could betray a team’s location or diminish night vision adaptation. The tactical medic must also function while maintaining noise discipline and in environments where auscultation may be impossible due to the need for hearing protection or due to background noise. Medical care must also be provided using principles of cover and concealment, which may necessitate care being delivered in alternate positions that are less than ideal. In fact, medical care may even need to be performed remote from the actual victim in the form of instructions over a phone or across any type of barricade.6
INTEGRATING THE MEDICAL ELEMENT IN TACTICAL OPERATIONS
Tactical teams spend a great deal of time training. As such, much like the military experience, a great source of morbidity for specialty teams is during training exercises, making it important for a tactical medical presence to be in attendance for all training sessions in addition to actual operations.7 Medical staff should be comfortable evaluating and managing common musculoskeletal complaints and should also have baseline medical records of the team members paying particular attention to status of immunizations, overall health, and level of fitness. Not only does this enhance the value of an integrated medical element, it also facilitates the development of trust between medical providers and law enforcement personnel.8
Upon obtaining this information, the tactical medic should also take advantage of the opportunity to educate the officers in basic buddy aid and self-aid. By serving as a single point of contact for the medical needs of the team, the medic may serve as the medical conscience for the commander.9 It is in this role that the medical element should be present for the planning stage of an operation. Issues for consideration are numerous (see Box 66-1).
Box 66-1 Threats to the Team
Resources required to mitigate threats
Adequate number of tactical medical staff
Size of area of operations
Complexity and dynamics of mission
Potential for multiple casualties
Anticipated duration of operation
Possible need for HazMat resources
Patient care areas
Operational safe area/zones of operation
Casualty collection points
Special needs of hostages or suspects
Underlying medical conditions
Implanted medical devices or hardware
Best ingress and egress plans
Availability of trauma centers
Specialty resources anticipated
Knowledge of hospital diversion plans
MEDICAL OPERATIONS IN A TACTICAL INCIDENT
In a departure from routine civilian medical care, medical care in the tactical environment has unique constraints and requirements which may alter the manner and location of provided treatments. Initial treatment of a casualty may be minimal at the site of injury and while under effective fire. During this “Care Under Fire” stage, removing the casualty from harm and ending the threat is of primary importance. Expanded care is performed after the provider and casualty are no longer under direct threat but only with equipment which can be carried by the medic. Care begins to resemble routine civilian medicine once evacuation has begun, and definitive care is undertaken well removed from the threat environment. Full description of the tactical role of the medical element is a large topic, and readers should seek instruction from a number of dedicated texts and courses on the subject for full operational methods.
Tactical operations can expose the medical provider to a wide range of possible illness and injury patterns. Criminal activity is not limited to a particular time, location, or environment, and, therefore, SWAT operations must be carried out across any possible spectrum of circumstances. This requires the medical support element to be prepared and experienced in the treatment of a very broad set of possible maladies in both officers and civilians. In addition to the expected traumatic injuries possible during any violent physical encounter, persons in a tactical environment are prone to heat and cold stress, a host of medical illnesses, chemical and biologic agents, as well as some unique injury patterns from specialized tools used by SWAT teams.
Regardless of the possible suspect danger encountered by the tactical team, the environment in which they operate is a significant and constant threat to both their operational readiness and health. While the key maneuvers in ending a potentially violent situation may last only several seconds, the overall time of deployment is hours to even days. During this time, officers will be exposed to the elements in full tactical equipment likely consisting of a Nomex or similar suit, heavy body armor, helmet, APR mask or respirator, ammunition loadout, and specialized breaching tools. This equipment can weigh in excess of 40 lb and does not allow effective evaporative cooling. In some situations, officers may be wearing occlusive chemical suits, which severely limit their homeothermic mechanisms. These factors make heat illness a very real threat to the team members. Dehydration, heat cramps, heat exhaustion, and even heat stroke can affect team members even in seemingly inactive duties. Medical staff should reinforce oral hydration guidelines and be vigilant for any suggestion of early heat illness. Oral hydration requirements can reach 0.5 to 1 L/h with moderate activity in hot and humid environments.10 Adequate rest-work cycles should also be ensured during prolonged deployments to help avoid both environmental and mental stresses. CBRNE environments mandate rotation of personnel to ensure a minimum amount of time is spent in chemical/biologic occlusive suits and respirators, and medics should provide pre and postentry medical exams to ensure operators are fit to return to duty. Full protocols are beyond the scope of this text; however, suggested standards can be found in OSHA hazardous material operations and NFPA regulations.11 While heat illness is often the more common malady faced by team members, cold injury is also a significant threat. Much of a deployment may be spent outside in a concealed position awaiting a moment of entry. Wet conditions greatly accelerate heat loss due to water’s significantly greater heat capacity and conductance compared to air. In addition, adaptive responses are less effective and hypothermia becomes more profound if the rate of cooling is slow. This is especially critical with marksmen/observers who may be in a fixed position for prolonged periods of time and must maintain a high degree of mental activity. Uniform selection must take into account these factors and hypothermia must be avoided. Decreased body temperature has significant detrimental effects on critical thinking, reaction time, muscle power, coordination, and morale.12–15 All these effects can seriously decrease the capability of the tactical element. Lastly, dehydration is still a threat in cold environments due to a combination of decreased perceived need for fluids as well as increased renal filtration from peripheral vasoconstriction.