Tactical EMS

A special weapons and tactics team arrives at a hostage situation. Shots are fired. “Officer down” is broadcast on the radio. Medical personnel at the scene treat the officer, and he survives what otherwise would have been a fatal injury. 

This is the world of Tactical Emergency Medical Services/Support. TEMS is designed to provide emergency medicine in a situation that places caregivers in harm’s way, such as barricaded suspect situations, warrant service or a terroristic event. The Association of the United States Army describes these situations as “Good Medicine in Bad Places.” 

Background

In 2016, 135 law enforcement officers were killed in the line of duty. Similarly, in 2015, 58,000 assaults are reported, resulting in more than 17,000 injuries annually. SWAT members are at an increased risk for injury and assault. According to the United States Park Police, SWAT teams have a casualty rate of 9 per 1,000 officer-missions. 

TEMS is not a new concept. There is documentation of medical treatment being performed on the battlefield as far back as 1500 B.C. The basic idea of triage and providing care on the battlefield originated during the Napoleonic War from Dr. Dominique Jean Larrey.  Larrey is credited with the first modern field treatment and evacuation system. The Korean War saw the first deployment of hospitals close to the front lines called Mobile Army Surgical Hospital, according to John Campbell, Lawrence Heiskell, Jim Smith and John Wipfler in their book, “Tactical Medical Essentials.”

In civilian law enforcement, the Los Angeles Police Department is widely recognized as creating the first SWAT team in the United States. Former LAPD Chief Daryl Gates is credited with organizing and fostering the team. In a policemag.com article, Paul Clinton discusses how the LAPD SWAT team formed in response to the Watt’s Riots and the University of Texas Clock Tower shooting. These events highlighted law enforcement’s need for a new methodology to control crowds and shooters.

Training

The United States Park Police Service started a Counter Narcotics and Terrorism Operational Medical Support training program in 1990. The goal of the CONTOMS program was to provide an evidence-based medical training course coupled with a continuous quality improvement program. The program also offers certification as an Emergency Medical Technician-Tactical and has become a national standard. This program serves as the model for most other TEMS training offered by other agencies and institutions. 

The CONTOMS training consists of the following components: 

• Medical threat assessment
• Downed officer rescue
• Care under fire
• Special equipment and kits
• Toxic hazards
• Medical support of specific operations

The weeklong training consists of 56 hours of didactic and practical education leading to certification as an EMT-Tactical. There also is a medical director’s course and a 24-hour Advanced EMT-Tactical course leading to certification.

The U.S. Department of Defense also has a course called Tactical Combat Casualty Care. Conducted by the National Association of Emergency Medical Technicians, it is very similar to CONTOMS training. Another training is the Tactical Emergency Casualty Care course.

Structure

There are two main types of TEMS. The first type is EMTs, paramedics, nurses or physicians being deployed with SWAT teams during call-ups. Sometimes the members are sworn officers, armed and with the team at all times. In other situations, the TEMS member is unarmed but still in close proximity to the SWAT team. There are other variations of this imbedded model. The other main type of TEMS structure is municipal ambulance service being staged at a safe location and called to the scene only if needed. 

A 2009 case study presented by Jeffery Metzger, Alexander Eastman, Fernando Benitez and Paul Pepe, documents a SWAT officer who was shot in the neck by a .45 caliber weapon. The bullet entered the right side of his neck, hitting the pharynx and spine at vertebrae C4-C5. He instantly was rescued and transported to two TEMS physicians who were with the team. They began treatment, which consisted of bleeding control and airway control via a surgical cricothyroidotomy. The local ambulance service also responded within eight minutes. The officer survived with intact neurological functioning and speech, and is able to perform most activities of daily living. It is likely that this officer would not have survived his injuries without TEMS members being present. There are countless similar stories indicating TEMS’ effectiveness.

In a 2013 TEMS overview article, Jim Morrissey documented a military casualty fatality rate decline from 19.1 percent in World War II to 9.4 percent in the Iraq/Afghanistan conflicts due to the TCCC training and imbedding medics in the field. It is logical to infer that imbedding medical providers in the civilian SWAT domain also would decrease the casualty rate. 

However, this writer was unable to locate specific data that shows a reduction in the casualty rate following TEMS involvement. In 2012, William Bozeman, Benjamin Morel, Timothy Black and James Winslow provided statewide data on the increase in TEMS units, but did not report casualty reduction. Further research is warranted. To this end, a TEMS registry similar to the CARES registry for data collection and analysis could produce an evidence-based national study.  

New model

Given the recent terroristic events in Brussels; Paris; San Bernardino, Calif.; and Orlando, Fla., TEMS will continue to be an integral part of law enforcement. However, a proposed third model would include a fully-independent TEMS that can function within the active threat area without drawing resources away from law enforcement activity. This would consist of a five-member team that can defend itself if they encounter a threat, and also provide appropriate medical treatment to victims, and extract/rescue victims to a triage location in an active shooter, terrorist bombing or ambush event.  

This team would need to have all the same training as the current TEMS members and more. One option is a modified police academy in which defensive tactics, handcuffing, use of force, firearms training, ballistic shields, weapon retention, and alike are taught. This training would be in addition to the medical training and CONTOMS, TCCC or TECC training.

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Available Course

Dr. Dariusz Wolman, assistant professor in Eastern Kentucky University’s College of Justice and Safety, is offering the Law Enforcement/First Responder Tactical Casualty Care course on May 19*, 2017 from 9 a.m. to 5 p.m. The cost is $50 per participant.
*Please note this is a date change from the article in the published Spring 2017 issue of KLE magazine.

Law Enforcement/First Response Tactical Casualty Care is continuing education offered through National Association of Emergency Medical Technician’s Pre-Hospital Trauma Life Support program. It teaches public safety first responders the basic medical care interventions that will help save an injured responder’s life until EMS practitioners can safely enter a tactical scene. 

Course participants will learn life-saving medical actions such as bleeding control with a tourniquet, bleeding control with gauze packs or topical hemostatic agents, and opening an airway to allow a casualty to breathe. 

Upon completion of the course participants will:

• Understand the rationale for immediate steps for hemorrhage control (including external hemorrhage control, direct pressure and wound packing, early use of tourniquet for severe hemorrhage, internal hemorrhage control by rapid evacuation, and transportation to major hospital/trauma center.
• Demonstrate the appropriate application of a tourniquet to the arm and leg.  
• Describe the progressive strategy for controlling hemorrhage.
• Describe appropriate airway control techniques and devices.
• Demonstrate the correct application of a topical hemostatic dressing (combat gauze).
• Recognize the tactically relevant indicators of shock.

For more information, email EKU Professor Dariusz Wolman or call (859) 622-2067.