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Since the mass shooting at Columbine High School in 1999, the paradigm for responding to an active shooter has shifted from a reactive to a proactive response to stop the killing (by stopping the shooter or shooters) and stop the dying (by stopping external hemorrhage and treating other life-threatening injuries). To prevent the dying, trained first responders with the correct equipment and the courage to use it must be present at the point of wounding, almost immediately, to stop the bleeding. While this may be the principal responsibility of a tactical medic, there is much more involved to be effective in this role.
The Role of a Tactical Medic
The American College of Emergency Physicians describes Tactical Medical Providers (TMPs) as those who “render medical care during training and at high-threat deployments where normal EMS and Fire personnel cannot safely respond.” Today, tactical emergency medical care has evolved into a highly specialized discipline within the field of prehospital emergency medical care. The Vietnam War demonstrated the value of rapidly transporting casualties to higher echelons of care via helicopter. Furthermore, the global war on terrorism – with combat operations in Iraq and Afghanistan – has confirmed the lifesaving effects of tourniquets and hemostatic agents. Although there has been and continues to be ongoing development in new and better ways to kill in combat, there are also improved ways to treat combat injuries with higher survivability rates. As a result, casualty fatality rates have decreased by almost 10%, from 19.1% in WWII to 9.4% in the Iraq and Afghanistan conflicts.
Tactical medicine plays a significant role in reducing deaths associated with active assailant incidents.
Unfortunately, the wounding patterns previously seen primarily on the battlefield now occur in neighborhood streets, subways, busses, and schools. Mass shootings and active assailant attacks have become frequent headlines in the daily news. Further, there is the ever-present threat of a chemical, biological, radiological, nuclear, or high-yield explosive (CBRNE) attack. As a result, tactical medicine has become a discipline and specialty within EMS and law enforcement circles using the principles of tactical combat casualty care (TCCC) and tactical emergency casualty care (TECC), now widely taught to first responders.
When the U.S. Department of Defense realized that the leading cause of preventable death on the battlefield was exsanguination due to bleeding from an extremity, it and the Uniformed Services University of the Health Sciences reevaluated battlefield trauma care. From 1993 to 1996, a three-year study produced the TCCC guidelines. TCCC is a set of evidence-based, best-practice prehospital trauma care guidelines and the standard taught to the members of the U.S. military. TCCC is the standard taught to the members of the U.S. military. Medical personnel (MP), such as U.S. Navy Hospital Corpsman, U.S. Army Medics, and U.S. Air Force Pararescuemen, receive 16 hours of TCCC-MP training. Nonmedical personnel deploying in support of combat operations receive 40 hours of combat lifesaver (CLS) training (TCCC-CLS). All service members (ASM) receive 7 hours of TCCC-ASM. The civilian version is 16 hours of classroom training (TECC). Both TCCC and TECC emphasize:
· Bleeding control, using tourniquets high and tight on the extremity, over the clothing, and wound packing with hemostatic gauze;
· Airway and breathing control with needle decompression and surgical airways;
· Techniques for removing a patient from a vehicle; and
· Assessment and treatment of the patient in a nontraditional environment (e.g., under or behind cover, in low light, no light, or under night vision).
Lack of Standardization
There is no national standard on what training or certification must be considered to become a tactical medic. They may or may not have tactical training, be sworn law enforcement officers, or even be armed. However, several organizations offer training or certification in tactical medicine:
· The Counter Narcotics and Terrorism Operational Medical Support (CONTOMS) course, which has existed since 1990;
· The Tactical Paramedic-Certified (TP-C), offered by the International Board of Specialty Certifications;
· Emergency Medical Technician-Tactical (EMT-T) certification, offered by Rescue Training Incorporated;
· The TCCC and TECC courses, offered by the National Association of EMTs.
In addition to these classes, prehospital trauma life support (PHTLS), advanced trauma life support (ATLS), and the trauma nurse core course (TNCC) offer valuable education for the tactical medic. Tactical medics practice the full scope of prehospital paramedical care. So, while these instructional programs focus on trauma, an officer can just as quickly die from an exacerbation of his underlying asthma. Therefore, it is critically important for the tactical medic to stay current on their knowledge, skills, and abilities to recognize and treat medical conditions.
Tactical medical skills are perishable. They require many hours of direct patient care experience and regular exercises to maintain competency and proficiency, like any other medical skill. A full-time tactical medic assigned to the tactical team would train officers or agents in the basics of self-care and buddy care, focusing on bleeding control. A 12-month training calendar would include periods of classroom instruction, clinical rotations at the local trauma center, cadaver and live tissue labs, and operating room time to maintain their airway skills and techniques. In addition, the agency must allocate funds in the annual budget to support attendance at local and national professional development and training conferences.
There is currently no nationwide standard practice for how law enforcement and EMS agencies integrate tactical medics. For example, some law enforcement agencies have tactical medics assigned to their tactical teams full-time, while others utilize them part-time for callouts. In some cases, the tactical medic is a sworn police officer, but they are not required to have full police powers. Additionally, there are times that transport capabilities exist, such as an ambulance staged inside the hot zone. But there are other circumstances in which that capacity does not exist.
Many law enforcement agencies depend on the local civilian EMS agency to provide EMTs or paramedics and the transport vehicle. However, relying on civilian EMS agencies poses several challenges. For example, the EMT or paramedics may or may not have tactical medical training and may not be familiar with the tactical team’s techniques, procedures, or equipment. Additionally, it is standard practice for civilian EMS to stage in the cold zone with the ambulance. While this keeps the civilian EMTs and paramedics safe, it requires precious time for them to be brought up to the injured officer or bring the wounded officer to the ambulance.
Some jurisdictions opt to use a hospital car or “h-car,” which is a police car that takes an injured police officer to the hospital. As reported in a January 25, 2021 article from the Penn Medicine News, Philadelphia Police transport as many as two-thirds of penetrating trauma victims to the hospital using their police cars. While this may be a practical way to get an injured person to definitive care, there is little to no lifesaving en-route care.
Additional Benefits of TMPs
A vital part of any tactical medic program is medical control. If a civilian EMS agency supplies the tactical medic, they already have medical control. However, if the tactical medic is organic to the law enforcement agency, they would most likely fall under the operational medical control of the same doctor directing the local civilian EMTs and paramedics – but would most likely need some kind of agreement between the law enforcement agency the medical director. Getting medical control could be as simple as a memorandum of understanding or a memorandum of agreement with the local hospital or authority having jurisdiction.
Law enforcement agencies with tactical medics should use them to maximize their value to the team. When taking part in a pre-planned event or callout, the tactical medic could be consulted or personally author the medical plan. They could assist in identifying the vehicle(s) used for transport and the primary and secondary evacuation routes to the nearest trauma center. Part of the contingency planning for any event should also be identifying where the landing zone would be. The tactical medic should go with an officer to the hospital to provide en-route care, be the medical advocate for the officer, and liaise between the hospital and law enforcement agency. When attending training or at high-threat deployments, the tactical medic can provide value when not directly participating in the training or deployment – for example, distributing bottles of water to keep the officers hydrated or monitoring for weather extremes in heat or cold to help the officers avoid hyperthermia or hypothermia. The tactical medic is also trained in canine medicine and provides medical support in remote or austere environments such as a fugitive hunt.
The tactical medic can provide emergency medical contingency planning and administrative support when not deployed on a tactical operation. Medical contingency planning, more commonly known as the behind-the-scenes work, is an often-overlooked and underappreciated aspect of tactical medicine until an officer is wounded. They can help buy medical supplies, create a budget for medical equipment, training, and resources, and provide medical and logistical support. They should advocate for policy standardizing the contents and location of the individual first aid kit (IFAK). While commercial off-the-shelf (COTS) IFAKs can be well-stocked, the tactical medic can add value by customizing them for their officers, including pre-sized nasal pharyngeal airways. Officers should be required to carry their IFAK on their support side, opposite their handgun, so that other officers know where to locate the device in an emergency.
Tactical training is traditionally a high-risk training event, which carries a higher risk of injury to the participating officers. A tactical medic on-site during training allows them to provide immediate lifesaving care if needed. It also enables the tactical medic to gain a basic understanding of movement and tactics. Another administrative procedure is creating a medical file for each officer, tactical or not. This file could be a laminated index card listing the past medical history, known allergies, next of kin contact information, and medications. The tactical medic can reference this card if the officer cannot speak or is unconscious. Officers should keep this on their persons in a pre-determined location, for instance, in the breast pocket on their support side.
With the increased awareness and threat of CBRNE attacks, the tactical medic can train officers to identify the signs and symptoms of a nerve agent attack and use a nerve agent antidote kit. With the rise of Fentanyl-related calls and reported exposures, the organic tactical medic can provide officers with procedures to screen for exposure and immediate care if necessary. They can also give the officers current and accurate procedures and practices to screen for actual exposure and coordinate with the local fire department or hazmat team to provide appropriate decontamination. The agency’s public relations can be bolstered by having the tactical medic teach CPR and Stop the Bleed® classes to the public. With the rise in violence, it is prudent for law enforcement leaders to work with EMS leaders to codify how they will integrate tactical medics within their ranks before the next active shooter opens fire or the terrorist pushes the plunger.