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.