This model is comprised of full-time law enforcement officers (LEOs) with formalized medical training. The medical certification of these individuals runs from emergency medical technician (EMT)-basic to licensed physicians depending on the jurisdiction, the “LEO-medics” agency involved, and the needs of the tactical team.

Washington state’s first advanced life support (ALS) level LEO-based regional TEMS unit instituted by the Vancouver, Washington police department is one such example (1). The unit officially called the South West Washington Regional TEMS Unit attached to the regional SWAT team is comprised primarily of full-time commissioned police
officers with collateral TEMS duties. This unit recently expanded its scope of practice to include other high-risk specialty police units, such as the Civil Disturbance Unit (riot squad) and the Explosive Ordinance Disposal Unit (bomb squad). Additionally, members of this unit are utilized by the police department during recruitment physical agility tests; they also conduct department-wide emergency medical aid in-services.

This model comprises EMS providers in systems where the EMS system is fire-based. Again, the level of provider in this system can vary from EMT-basic to EMT-paramedic. On some teams, tactical medics go through formal police academy training becoming certified peace officers and in others, these medics are provided tactical training, but not to the level of peace officer certification. Either way, familiarity with SWAT operations, tactics, and the wide array of equipment and weapons are essential.

Issues, advantages, and disadvantages related to fire-based TEMS teams are discussed in further detail subsequently.

Some EMS systems are so-called “third systems” (i.e., they are governmental systems, but not fire- or policebased, and some are a private entities). In these jurisdictions, TEMS providers are composed of EMS personnel who work primarily for this third service provider. This is common in many Canadian units, and also is modeled well by the Austin, Texas, tactical medics. The primary function of members of these organizations remains the provision of civilian EMS care, but a select group is trained further in tactical EMS.

This model is increasing in popularity primarily among many academic based institutions. In this model, many of the TEMS providers are physicians. Often the TEMS support will include resident physicians in training who will later be medical program director’s (MPDs) for TEMS units. This model will also incorporate other medical providers.

There are two distinct issues that should be considered in the composition of the TEMS element: What, if any, law enforcement status should unit members have and what level of medical provider is best? There are successful TEMS programs across the United States with diverse compositions. What works best in one location may not work well in another location. Each choice must be considered in a cost-benefit analysis specific to that jurisdiction.

Some teams require all of their TEMS providers to be fully sworn officers who are qualified first as tactical team members and second as medics. This approach has several benefits: (i) having a team member as the TEMS provider instills confidence in other team members and meets operational security requirements; (ii) the medic can provide his/her own security when not caring for a patient; and (iii) the medic has arrest and custodial authority, which can be very useful when caring for a prisoner. On the other hand, medical support of the team then becomes a collateral duty; continuing education and skills maintenance in both the tactical and medical arenas may become burdensome and the available manpower for this type of assignment is usually very limited. “Role confusion” (defined as individuals not knowing if they are functioning as a medic or an operator) is often cited as a disadvantage of this model. This theoretical concern appears to be perpetuated by anecdote, but has not been documented in the literature and ignores the reality that TEMS must consider both the medical and tactical situation and the medical situation together. All of these problems can be overcome in individual circumstances with adequate training and command leadership. Despite the apparent advantages of an internal system, the majority of TEMS teams in the United States remain external systems (2).

Many teams have opted to utilize fire/rescue/EMS personnel as TEMS providers. The advantage of this is that the medical support of the team is their primary function, and they are not distracted by other duties. Generally, tactical team members will have greater confidence in their medical skills compared to classroom-trained EMTs who are police officers first and have limited practical patient care experience. Continuing education and skills maintenance are also easier to achieve. It also seems that the manning for this kind of assignment is more readily available. However, in most situations, these providers have no arrest powers and will require an officer in attendance if they are treating a prisoner. In most situations, they also require the team to provide for their security at all times and represent an operational security risk if careful screening and background investigations are not accomplished before making them part of the unit. Their relative lack of tactical skills can be remedied with rigorous training and most team commanders consider it easier to train a medic in tactics than to train a tactical officer in medicine.

A few tactical teams continue to rely on “standby” coverage of their operations by conventional fire/rescue/EMS. Although this is probably the easiest type of coverage to accomplish, it delays the delivery of care to the patient and
is a grossly inadequate model for addressing tactical operational medical support. TEMS is much more than EMS in a less permissive environment. It encompasses a special set of decision-making skills, clinical knowledge, and the integration of operational and medical processes. As inferred earlier from military data, the opportunities for successful intervention in the management of casualties are greatest in the first few minutes after wounding. Any plan that delays arrival of the medical provider at the patient’s side, such as having conventional EMS on standby, will have a deleterious effect on the outcome and should be avoided whenever possible.

Law enforcement status is one important factor to consider when designing your TEMS system. Although having providers with arrest powers is beneficial, it is not essential. Many outstanding programs are running in the United States today—some use sworn officers as medics and some do not. The confidence team members have in their medical providers is probably related more to a positive experience working together over time than to any other factor. Regardless of which configuration you select as the best fit for your program, it is important to remember the “one person—one job rule.” On any given mission, a single individual tasked with the duties of more than one position (e.g., medic and point man) will perform neither as well as if he had only one job. This does not preclude team members from cross-training for a variety of roles. In fact, cross-training for multiple functions is one hallmark of a military special operations medic, but the scope of an individual’s responsibility on a specific operation should be limited to that which can be successfully accomplished by a single individual.

The medical qualifications of TEMS unit members can vary from EMT-basic to physician, and arguments can be made for each level. Again, each choice must be considered in a cost-benefit analysis specific to the individual jurisdiction. Members with basic EMT training have the requisite familiarity with the prehospital environment and often work closely with law enforcement personnel on a daily basis. They are readily available at a modest cost, can maintain their skills and certifications with minimal clinical opportunities, and have adequate skills to provide lifesaving interventions during care under fire (basic airway maintenance, hemorrhage control, and rapid extraction). The down side is their limited scope of practice, their inability to initiate advanced interventions, their requirement for medical control, and their limited ability to liaison with the medical community.