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Tactical Medicine in Transition

The role of TEMS specialists is expanding, but you will still find them training with and supporting SWAT.

July 15, 2014  |  by - Also by this author

Photo courtesy of Chris Felski/ATF
Photo courtesy of Chris Felski/ATF

Combat is the crucible of trauma medicine. That's been true since the earliest days of medical practice, and it remains true today. The reason that combat plays such an important role in the advancement of medicine is that—with the possible exception of motorized vehicles—nothing conceived by mankind has its body-rending capability.

So it's no surprise that the tactical medic concept now in use by numerous law enforcement agencies is derived from the combat medic deployed by the world's military organizations since before World War II and specifically from the Special Forces medic concept developed by the U.S. Army in the Vietnam War. And it's also no surprise that the experience of American medical personnel in Iraq and Afghanistan is pushing the greatest evolution of tactical medicine since its inception.

In the 21st century, we generally think all advancements in every field to be the benefits of high technology. But contemporary tactical medicine is now evolving because of a simple tourniquet, a tactical medical device that was known to the armies of Alexander the Great, not by some device made of flash memory chips and lasers.

For decades, Americans have been taught not to use tourniquets to stop bleeding from extremity wounds for fear of causing tissue to die, which could necessitate amputation of the affected limb. Trauma doctors now say that fear was exaggerated, tissue death takes much longer to occur than previously believed, and regardless, it's more important to save the person's life than his or her leg or arm. This new yet ancient wisdom about tourniquets is credited with saving the lives of scores of American and allied military personnel.

And the successful use of tourniquets for hemorrhage control in war zones has led to a rethinking of hemorrhage control response in American law enforcement. Which is also leading to a rethinking and expansion of the role of tactical medics within law enforcement agencies.

Officer Response

Law enforcement tactical emergency medical support (TEMS) personnel in law enforcement assume many roles, but one of their most critical missions has always been to provide trauma care to officers, bystanders, and even suspects wounded or injured during SWAT operations. Agencies are now learning that TEMS, like the SWAT units they work with, may be arriving too late at the scenes of some incidents to do any good.

Ineffective response to the Columbine High School mass murders 15 years ago led to a rethinking of law enforcement tactics at critical incidents, especially active shooting incidents. After Columbine, patrol response to active shooters transitioned from the old "contain and call for SWAT" model to a new model that encourages the first responding officers to enter and engage the threat.

Now a similar sea change is occurring in tactical medicine doctrine. After the Aurora, Colo., movie theater massacre in 2012, emergency medical and law enforcement leaders began pushing for a nationwide adoption of tactical medical response training and individual hemorrhage control kits for first responders, including police officers.

Last April—just two weeks before the Boston Marathon attacks that once again proved police were on the front line of emergency medical response—the FBI and the American College of Surgeons organized a summit of trauma medicine and EMS specialists to discuss what could be done to improve the survival rate of victims wounded in active shooter attacks. Because they met in Hartford, Conn., the panel and its report have come to be known as the "Hartford Consensus." Their conclusion can basically be summed up in a few words: The best way to improve the survival rate of active shooting victims is to stop the bleeding as quickly as possible, and the most effective way to achieve this goal is to provide responding law enforcement with hemorrhage control training and gear.

Of course, some officers are not happy with the idea that they may now be tasked with neutralizing the active threat and then treating the wounded, but resistance is likely waning because of the ancillary benefits of having officers trained in hemorrhage control and issuing them tourniquets. Some agencies that have bought into the hemorrhage control concept report their officers have saved their own lives, lives of badged comrades, and the lives of civilians when they have used the training and tourniquets to stop bleeding after serious wounds to their extremities. Which means more agencies will soon be adopting hemorrhage control training and equipment policies.

So if emergency medical response during critical incidents is now going to be performed by patrol officers and individual SWAT operators, do law enforcement agencies still need tactical medical support? The experts say yes and for a variety of reasons.

Education

In the new TEMS model, which was outlined in a position statement last fall by the National Tactical Officers Association (NTOA), the mission for tactical medics is expanding to include instructing officers in basic medical intervention. "The role for the tactical medic is a medically trained specialist who is supporting the law enforcement operations," says Dr. Kevin Gerold, NTOA's TEMS chairman. "Today the new opportunity presented to that person is to serve as the medical trainer for the patrol officers."

Gerold, a senior medical officer at the Johns Hopkins Center for Law Enforcement and a special deputy U.S. Marshal, says the new model for TEMS is following a similar trend in SWAT. "Historically in law enforcement there was patrol and there was SWAT," Gerold explains. "But now we are teaching SWAT tactics to patrol officers so they can better respond to active shooters. There's also a need to teach tactical medical response to patrol officers because there is definitely an opportunity for patrol officers to intervene medically before the arrival of EMS units." Gerold adds that just because officers will have some hemorrhage control training that doesn't make first aid their primary mission. "We want you to push past everything to deal with the threat then move into potential lifesaving mode."

Many agencies that are introducing hemorrhage control gear and training require that officers keep their medical response kits on their person or in their cars. Gerold believes one of the first things tactical medics need to teach their fellow officers is that a tourniquet must be at hand in order to have any benefit. "Every officer needs to have a tourniquet and a pressure bandage on his or her person," he says. "If you are back behind a building and somebody shoots you, a first-aid kit in your car is not going to do you a bit of good. When you put on your gun and badge, you should have a tourniquet as well."

Gerold adds that despite decades of Boy Scout education about tourniquets, you can't effectively improvise a tourniquet out of a belt or a bandana. "You need a commercially available tourniquet; you need a tourniquet that works," he says.

More Than First Aid

So does the addition of officer education duties change the primary mission for a TEMS unit? The experts say absolutely not.

The role of TEMS in law enforcement medical operation is multifaceted, explains Dr. Lawrence Heiskell, an emergency medical specialist, a longtime tactical physician for the Palm Springs (Calif.) Police Department, and the founder of the International School of Tactical Medicine.

Heiskell points to a California POST tactical medicine standardized training program that was developed in coordination with the state's Emergency Medical Services Authority (EMSA) as a good guideline for defining the mission of an agency's tactical medical unit. That POST/EMSA program, which has been adopted by other states, lists numerous areas of responsibility for a tactical medical unit, including: tactical team health management, operational medical support such as treating of casualties, medical equipment acquisition and maintenance, medical direction, and pre-event planning.

According to Heiskell, more and more agencies in the United States and in Europe are adding tactical medical assets to their capabilities, and he believes that trend will continue. "Upper management in these agencies is now recognizing the real value of having medical for any tactical operation," he says. "Tactical operations are dangerous and people get hurt."

Heiskell says he is not concerned that agencies will want to drop their tactical medical units as more officers receive training in hemorrhage control and are issued tourniquets. "Rank and file has come to expect that full medical support will be provided for them [during tactical operations]," he says. "Would you want to go into battle without a medic?"

NTOA's Gerold agrees. "I think the tactical medicine model is still very much intact, even though it's expanding to include emergency medical education for patrol officers. You still need that trained medical provider to coordinate the medical response for high-risk tactical law enforcement operations," he says. 

Tags: Tactical Medicine


Comments (7)

Displaying 1 - 7 of 7

Dr. Rushdi Cader @ 7/17/2014 3:42 PM

I concur with Dr. Heiskel & Dr. Gerold and would add that POST should look to the implementation of a basic 1 day trauma training segment within all Police academies. In the 1 day training course put on by STAT Inc. (www.swattrauma.com), we use the T.E.A.C.H. approach: Tactics / Threat First, External bleeding, Airway, C.O.R.E. Care, and Hospital. Having a simple and standardized approach makes a huge difference when moments count. The Hartford consensus also utilizes a similar simpler acronym. The bottom line is there are two essential components: having the right supplies at hand and regular training that incorporates tactical medical scenarios. In this line of work, "preserving life takes practice", and "every day could be game day".

Dr. Rushdi Cader M.D., F.A.C.E.P.
Medical Director, SLO Regional SWAT
CEO, STAT Inc.

TJiNY @ 7/17/2014 5:29 PM

While there is a need to address the injured in tactical situations, bringing medics directly onto the "battlefield" is not the answer.

It goes against the basic principal of police tactics. You do not allow or introduce additional innocents into a deadly situation. Doing creates additional concerns for tactical teams and could lead to additional injuries or deaths.

There is nothing wrong with having EMS staged nearby. Swat/tactical officers can apply tourniquets or other measures to stop bleeding, and remove the victim to a safer area for more sophisticated treatment.

From everything I have heard on this subjects EMS Providers want to be right up front, that is not a good idea. No one will be providing medical treatment under fire.

I am truly surprised and dismayed at how some law enforcement agencies seem to be caving into what EMS wants and ignoring their own protocol.

Scott McCowan @ 7/30/2014 12:31 PM

Sir, while in part I do agree with what your saying about bringing EMS providers into an potentially unstable situation, but when TEMS providers are properly trained and educated there can be a smooth(er) intrigation into a dangerous environment. As a TEMS provider I am provided the proper equipment and trained to function in a dangerous environmeny. I feel when an officer is injured one of the last thing you need to do is to remove a second officer from a tactical environment. We have addressed this by having an officer provide self-aid and minimal buddy aid so as not to distract from the tactical situation. No one will /should provide indepth care in the hot zone. I dont think of as LEO "caving in" we all have to adapt to thinking outside the box during unuseual events. I dont know about your area where your work but an safe scene will be different that what EMS calls safe. Do you really want a properly educated individual to be down the street or outside the front door?

Brian @ 9/20/2014 5:24 PM

I agree with both Dr Rushdi and Scott, advanced medical training needs to be provided to all officer cadets and followed up semi annually at a minimum once on the force. The idea of a medic will respond within the 5-8 minute mark is outdated when it comes to tactical situations. Having a trained medics on every team is the way of the future, for those still fighting the idea should research where TEMS medics have saved lives and provides the tactical officer and their families piece of mind knowing somebody is there to help immediately. Be safe...

Skip Kirkwood @ 9/24/2014 7:03 AM

Some things seem to have become lost over the years. The role of the Tactical Medic is to take care of the SWAT team members - to be right there when an officer becomes injured (or sick). It is not to care for victims of crime, or bad guys, unless and until all the tactical officers are secure. MOST of that care is administered during training - not during actual SWAT operations. The role is much the same as that of a Navy corpsman or Army medic.

OTHER medics are supposed to take care of civilian casualties. Those are the ones that work with patrol officer rescue teams in mass shootings, etc.

I would not call what should be provided to officers "advanced medical training." Use of a tourniquet and sealing a chest wound is very basic stuff, taught to 18 year old infantry soldiers every day.

Bill Ellison @ 9/24/2014 10:10 AM

As a TEMS provider for many years and a current police academy trainer, I think it is totally appropriate to teach the 'Care Under Fire' phase of TCCC to basic police. It is easy to learn, involves adding minimal extra gear to the duty belt or vest, and we know from the GWOT it saves lives. We get a lot of vets coming through our state academy and all continue to carry TQ's and an IFAK. We have added it to our ConSims curriculum and feedback has been very positive from all students. That said, in a tactical setting there is still a place for TEMS providers for the more aggressive treatments that occur during the 'Tactical Field Care' phase, etc. of TCCC.

Steve @ 9/24/2014 2:40 PM

I am cross trained as both and recently became certified to teach Rapid Deployment. This year in the State of NC, There is a Mandatory 4 hour in-service that Officer take called The First Five Minutes. It covers it all. Our Tactical Guys just trained about 800 Officers in our county. On the other note, The one thing that I find our current rapid deployment is missing is that of an integrated EMS Team in the mix. We are not designed to go in for contact. We are part of the second phase. My Chief has been forward thinking and gotten our medics Kevlar. All of us. Chief is right, as TEMS people, we are dedicated to our teams. We have had Rapid Response Trained Medics that go into a warm zone to stop the bleeding, open the airway, and handle the pneumos. If I am the officer going in, the last thing I want to be doing is placing a tourniquet on someone when I should be protecting others and engaging the threat. I teach an EMS Academy and we have integrated it into every academy now.

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