The scene is a fixture in many war movies. A wounded soldier cries out, “Medic!” then another soldier, one who carries a medical kit and not a weapon, crawls out from his foxhole and braves the fury of a firefight or an artillery barrage to render aid to his wounded buddy.

Medics and corpsmen have been officially assigned to American Army and Marine units since World War I. And with good reason. Research shows that 90 percent of all battle deaths occur in the field, prior to any medical intervention. In a landmark review of wounds and death in battle, retired Army colonel Ronald F. Bellamy noted that many combat deaths were potentially preventable, including deaths caused by blood loss from extremity wounds, deaths caused by tension pneumothorax, and deaths caused by airway obstruction.

The lessons of Bellamy’s research were not lost on the U.S. military. They also haven’t been lost on American law enforcement agencies, as many now have medically trained personnel attached to SWAT teams.

Seconds Count

Before 1989, there existed great diversity in the way in which emergency medical care was provided during law enforcement tactical operations. Most law enforcement agencies relied on regular civilian EMS providers who staged at a safe location removed from the area of operation. Some simply called 911 to request paramedics when officers or civilians were wounded.

From an operational standpoint, these agencies were taking advantage of an established pre-hospital care system. It made sense.

Medically speaking, however, this practice left a lot to be desired. The first five minutes are critical in the care of a seriously wounded person. So the time that it took to transport wounded officers to safe areas for treatment could often lead to tragic results.

Today, more and more police tactical teams have added emergency medical personnel. For example, some have trained full-time SWAT officers as EMTs or paramedics. Others have trained medical personnel in tactical police operations.

Principles of Tactical Medicine

Tactical medical care can be provided by EMTs, paramedics, registered nurses, mid-level providers (such as physician assistants and nurse practitioners), or even physicians who serve on police tactical teams. The tactical medic’s level of training will determine what actions he or she can take in the field. For example, mid-level providers and physicians traditionally have training in advanced surgical and medical procedures beyond what is normally allowed for traditional EMS personnel. Regardless of the tactical medic’s professional standing, he or she will quickly learn that medical care in a tactical environment can be extremely challenging.

Traditional EMS doctrine maintains that rescuer and scene safety are first priorities, and that patient care is a secondary concern. What sets tactical EMS apart from standard EMS is the ability to render immediate care in the operational area.

When a SWAT team relies on traditional EMS personnel to provide medical care and an operator or civilian is acutely injured during the mission, the EMS unit must wait until either the victim is brought out to a safe area or until the entire scene can be secured by law enforcement before moving to the patient. When a tactical medic is participating in the operation, care can generally be rendered to the victim in a more timely manner.

However, it should be understood that both traditional EMS and tactical EMS have their place. Tactical medics cannot carry all the equipment into the field that a traditional paramedic has access to in his or her vehicle. Access to equipment is just one of the limitations faced by tactical medics. They also must work under difficult and potentially fluid conditions. For example, a tactical medic may have to render aid to a wounded officer or civilian while maintaining light or sound discipline.

Team Health Management

Although rendering aid under combat conditions is what most officers envision when they think about the role of tactical medics in law enforcement, such actions are really only part of the job.

The primary goal of tactical medicine is to assist a tactical team in accomplishing its mission. This is achieved primarily through team health management, which means keeping the tactical team members healthy before, during, and after operations.

One of the duties of a tactical police medic is to make sure that each member of his or her team maintains the conditioning necessary for effective SWAT deployment. A comprehensive plan of proper nutrition and exercise must be established and maintained.

SWAT conditioning should include a balance of aerobic exercise, anaerobic exercise, and stretching. Cardiovascular workouts such as running or swimming are excellent for cardiovascular fitness. Circuit weight resistance training is excellent for strength training, but it must be a total body workout. Many tactical operators train some parts of their bodies, but ignore others. This can lead to buff-looking operators who aren’t really as fit as they seem, and it can result in injuries.

In addition to his or her role as conditioning coach, the team medical officer essentially becomes the family physician for the tactical unit and should be prepared for this role. Regardless of his or her professional qualifications, the team medic will likely become the medical advisor for his or her tactical unit.

The tactical medic should be prepared to act in this capacity because it is one of the greatest benefits that he or she can provide to the team. As medical advisor, the tactical medic can foster better team health overall. He or she can persuade officers to maintain their health with regular physical exams and treatment where appropriate. Smoking cessation, alcohol and drug counseling, and stress management are also health issues that the team’s medical officer is in position to address.

In his or her role as team “physician,” the tactical medic is well advised to take a cue from other medical providers and keep detailed records. Records should be stored for a minimum of 10 years. This is both for benefit of the patient and the protection of the medic. Such records have proven to be indispensable as defense documents in several anti-police liability lawsuits. Without a medical record, there is no proof that appropriate medical care was given to the team members.[PAGEBREAK]

Medical Threat Assessment

One of the most important duties of the tactical medic is to create a formal medical threat assessment (MTA) for each training and operational deployment. A typical MTA includes consideration of issues such as environmental conditions, fatigue, nutritional issues, plant and animal threats, and a plan for extrication and transport of patients.

Medical intelligence should be gathered prior to or during the mission. This assessment includes details such as who is involved, ages of those involved, medical history, background, any pre-existing medical conditions, geographical location, and even the weather. The MTA is not just essential for the tactical medic’s operations; it is also a critical tool for the team commander as he plans the mission. SWAT commanders consider information from many sources when they create a tactical plan for a mission, including manpower, building layouts, street layouts, support equipment, nature of the mission, available weaponry, and the reliability of the sources of intelligence. The team medic’s assessment should be part of this analysis and planning.

It is the responsibility of the tactical medic to provide a concise and accurate medical briefing to the commander. Medical threat assessment forms should be used on every mission to ensure a systematic approach to the assessment process because only a systematic approach ensures complete assessment of the situation.

Lawrence E. Heiskell, M.D., FACEP, FAAFP, is a practicing emergency physician, a reserve police officer, and a tactically trained SWAT team physician with the Palm Springs (Calif.) Police Department, as well as a member of the Police Advisory Board.

Tactical Medics and Weapons Handling
Tactical medics have to be more than just emergency medical personnel; they have to be tactically aware and well versed in the weaponry used by their teams.

Tactical medics can be sworn officers whose primary duties are as an operator on the unit or they can be medical professionals who work with the team. Either way, tactical medics are going in harm’s way, and they should be qualified to carry arms so they can protect themselves.

Even if your medic is a civilian who is not permitted to carry a weapon during your operation, he or she needs weapons training. One of the duties of a tactical medic is to take charge of an officer’s weapon when his condition requires that he be disarmed. For example, if the officer becomes disoriented, he may become a danger to himself and anyone around him if he is left in charge of his weapon. In this case, the medic needs to take charge of all of the officer’s weapons and render them safe.

A tactical medic should be familiar with every handgun, shotgun, rifle, submachine gun, assault rifle, chemical launcher, and less-lethal weapon used by his or her team. All tactical team members, whether providers or not, should be able to use any weapon a team member carries and render it safe.


Injuries From Breaching Charges and Flash-Bangs
When developing a medical threat assessment for his or her team, a tactical medic should consider not just the threats presented by the bad guys but also injuries that can occur from the use of SWAT tools, including breaching and distraction charges.

Before each mission, the medic should consult with the team’s breaching expert regarding the types of explosives he plans to use and the blast forces that may be encountered.
 
Some of the medical problems that can be caused by flash bangs and breaching explosive even when they are used properly include:

• Burns, both minor and major.
• Smoke-induced bronchospasm.
• Vestibular dysfunction.
• Transient visual disorientation.
• Emotional upset and anxiety.
• Eardrum rupture has not been reported in general use, but it is possible.