Tactical Emergency Medical Support and Urban Search and Rescue
Tactical Emergency Medical Support
Law enforcement agencies in the 21st century face an increase in terrorist threats and new challenges, including organized opposing forces, military-type weapons, direct fire, hostage and barricade situations, and potential toxic hazards. As these threats have increased, so has the recognition of the need for integrated medical support of tactical operations.1 Tactical emergency medical support (TEMS) is the specialty of emergency medical services (EMS) established to maintain safety, health, and welfare for combat medical units and special operations civilian law enforcement units, such as special weapons and tactics (SWAT) teams, hostage rescue teams, and special emergency rescue teams.1 These specially trained teams are composed of highly trained and specially equipped personnel who are tasked with mitigating and responding to many different high-risk situations.2–5 Events such as the World Trade Center bombings and hurricane Katrina have demonstrated the need for many nonhospital health care personnel to use some of these current military out-of-hospital medical strategies.
Tactical Medical History
In the civilian setting, snipers, mass demonstrations, riots, and fire bombings gained notoriety as new forms of urban conflict in the United States during the late 1960s and early 1970s, which led to the formation of the first SWAT unit. In 1996, there were more than 5000 SWAT teams in the United States supporting local, state, and federal agencies. Essentially today, more than 90% of municipalities with a population greater than 50,000 have a SWAT team.5 With the evolution of these specialized law enforcement tactical teams, the need for military-style EMS support began to emerge.
Because of the dangerous environment, SWAT team members are at high risk for injury, with a casualty rate of 33 injuries per 1000 officer missions. Suspects are injured at the rate of 18.9 injuries per 1000 officer missions, and bystanders are injured at the rate of 3.2 per 1000 officer missions. It was recognized that traditional EMS providers were not properly trained or equipped to enter these unique and sometimes remote austere environments to care for casualties. In fact, basic EMS training still emphasizes that personnel should wait until the “scene is safe” before rendering medical care to patients. Past incidents, such as shootings at Columbine High School in Littleton, Colorado, Ruby Ridge in Idaho, the University of Texas in Austin, and the Mormon Library in Salt Lake City, proved that sequestering of medical personnel far from the area of operations leads to delays in definitive trauma care, with potentially higher morbidity and mortality.6 The tactical environment necessitates that the medical provider possess a unique training and skill subset to use a different set of field assessment and treatment priorities and strategies for monitoring and sustaining health maintenance. Provision of tactical medical care has now become an integral part of preplanning for federal, state, and local tactical teams in response from lessons learned.1,2
The principles of tactical combat casualty care (TCCC) have been refined and now applied on today’s battlefield7–10 as well as in most civilian TEMS teams.1,11–13 TCCC is a set of guidelines that aim to prevent further casualties, to accomplish the tactical mission, to save the maximum number of lives, and to minimize morbidity of the injured. These guidelines are developed by the Committee on Tactical Combat Casualty Care, which falls under the U.S. Defense Health Board. The TCCC guidelines are based on treatment of the leading preventable causes of combat death, which include hemorrhage from a compressible site, tension pneumothorax, and airway compromise.11–13 In the most recent TCCC guidelines, attention to hypothermia prevention, intravenous access, improved en route care, closed head injury, and pain management techniques are also addressed.11 Whereas TCCC is widely accepted in the military combat setting and has largely been extrapolated to the civilian environment, there are some data that question the applicability of TCCC to the civilian environment.12
Goals of Tactical Emergency Medical Support
In the early years of development, TEMS focus was on care and evacuation of wounded. This role has now evolved to include more emphasis on mission planning, primary care, preventive medicine, and emergency care of illness and injury. Although the primary goal of TEMS is to enhance the law enforcement mission, the tactical medical role involves a continuum of care that includes maintenance of team health; reconnaissance of environmental and situational aspects of the mission; coordination of local emergency medical support; creation of evacuation plan and routes; and assessment of future medical needs of the team, perpetrators, bystanders, and possible hostages.1,14 Implementation of an effective tactical medical support program is directed at achievement of several important goals (Box 192-1).
Tactical Team Structure, Training, and Integrated Medical Support
SWAT team and combat TEMS structure and size vary throughout the United States according to location and purpose. The typical team is composed of assault teams, which make initial contact with suspects, and arrest teams, which support the assault team. There are also rescue teams, backup teams, and hostage and negotiation teams. A unit commander supervises the operation from a command post.2
The TEMS component of a tactical unit, like team structure, varies widely throughout the United States. Some SWAT teams use “standby” EMS personnel, whereas others have physician-only TEMS providers. Much like the military Special Forces, many civilian tactical law enforcement agencies are now integrating medical support into the tactical team to enhance mission success.2
Law enforcement agencies using integrated medical support have varying medical qualifications. The use of an emergency medical technician for medical coverage has the advantage of availability and modest cost. Medical directors may be able to train basic providers with an enhanced skill set to provide appropriate medical care for tactical support. However, the increased skill set possessed by advanced nonhospital providers makes them favorable in a TEMS environment.2,11 In a small number of jurisdictions, emergency physicians and residents provide medical oversight for TEMS units and are also deployed as medical operators in the tactical environment.2,4 Although physician providers offer a broader scope of practice and do not require direct medical control, they usually have limited out-of-hospital experience and also require tactical training. In addition, as the law enforcement mission takes on additional roles overseas, there is a growing need for forward surgical teams similar to military forward surgical teams that can function in remote areas. The Georgia Health Sciences University has developed one such surgical resuscitation team that has been deployed in support of law enforcement operations (www.georgiahealth.edu/ems/COM/Tactical/).
Training Issues
The tactical environment is different from the traditional EMS environment. Traditional EMS doctrine taught personnel to ensure that the scene is “safe” before attempting to render care.11 This principle is not possible in some tactical situations. Tactical training needs to take into account team tactics and movement; cover and concealment; equipment issues; nuclear, biologic, and chemical training; rappelling; weapons familiarity; and noise and light discipline training.2 Also, routine training needs to be done in basic rescue tactics, tactical room entries, open area rescues and tactics, movement under fire, cover and concealment, officer down drills, and, in some systems, firearm training (Fig. 192-1). Furthermore, many teams are now training all team members in medical management for lifesaving interventions.
In the military and operational environments, there is a significant increase in the number of penetrating traumatic injuries (e.g., gunshot, fragmentary, and blast propellant wounds).13–15 Because of the increased complexity and number of combat casualties and the possibility that civilian TEMS providers may be exposed to such, additional training and knowledge of the TCCC guidelines are important for the operational and tactical medic. Although advanced trauma life support may be applicable to the emergency department management of trauma patients in both civilian and military hospitals, it was not created for combat or tactical out-of-hospital medicine.11,16 The three goals of TCCC are to treat the casualty, to prevent additional casualties, and to complete the mission.6 TCCC is divided into three distinct phases to provide the correct medical interventions at the correct time in the continuum of out-of-hospital care (Box 192-2).
Care under Fire.: In terms of medical delivery in the civilian tactical environment, the area is usually divided into three zones—cold, warm, and hot. These zones are based on tactical environment, threat level, and treatment options, which are based on a risk-benefit ratio relative to the medical provider and patient. The cold zone is a safe environment with no threat to injury. This zone is outside the inner perimeter, and regular EMS treatment principles usually apply. In the warm zone, threat is not considered immediate but still exists. Finally, the hot zone is characterized by possible direct exposure to hostile fire.
As such, care under fire refers to care being rendered in the hot zone. In this zone, the medic and casualty are under direct effective hostile fire. Care in this phase is limited but not nonexistent. When care may be rendered, airway management, the first medical priority in routine out-of-hospital medicine, is best deferred until the tactical field care phase because of difficulty in maintaining the airway during evacuation under direct fire. Also, cardiopulmonary resuscitation and cervical spine immobilization have little or no role in the treatment of penetrating injuries in this phase and are not a priority in the combat environment.16–18 Recommended care is limited to mitigation of threat (i.e., suppressive fire), placement of the casualty in rescue position if possible, tourniquet use, and evacuation of the casualty to a safer “zone” or “phase” of care if possible.
Because uncontrolled extremity hemorrhage was the leading cause of preventable battlefield death, a large portion of research and training was directed toward hemorrhage control.13,19 During the current conflict in Iraq and Afghanistan, newer tourniquets, hemostatic agents, and dressings and intravenous therapies have been developed, researched, and fielded by the military with unprecedented speed, reducing morbidity and mortality for compressible, extremity hemorrhage.19 During the care under fire phase, extremity hemorrhage control is ideally gained through the use of tourniquets. Although shunned for many years, tourniquets have re-emerged as the standard of care in this environment because of low complication rates, ease of use, rapid application, and effectiveness in stopping blood loss.6,19–24 Improvised tourniquets such as rubber surgical tubing are not recommended and should not be used unless commercial tourniquets are unavailable.23 Several studies have found that tourniquet use on the current battlefield has not resulted in increased limb loss or permanent disability even among patients thought to have had tourniquets applied unnecessarily and has resulted in a reduction in mortality with application before onset of shock and in the prehospital environment.6,19,21
Many types of extremity tourniquets are presently available for both civilian and military use. Two tourniquets currently used on today’s battlefield by the U.S. Army are the Combat Application Tourniquet (C-A-T) and the Special Operations Forces Tactical Tourniquet (SOFT-T).19,24 On the basis of current literature, both the U.S. and the Israeli military, the International Committee of the Red Cross, and civilian agencies in the United States have embraced tourniquets as an initial hemorrhage control option during the care under fire phase as well as for uncontrolled extremity hemorrhage to achieve rapid control of bleeding.11,21 The current TCCC recommendation is for liberal use of appropriate tourniquets for uncontrolled extremity hemorrhage in the tactical environment.
Tactical Field Care.: The second phase of care, tactical field care, is medical treatment rendered in the warm zone. This phase consists of medical care that is delivered while the medic and casualty are still under threat of injury but not under direct, effective hostile fire. Simply by dragging a casualty 5 feet around the corner of a building could transition the medic from care under fire to tactical field care. Care in this phase focuses on several areas that have been shown to increase morbidity and mortality in tactical environments if they are not addressed.17 Airway establishment and maintenance are first addressed in this phase of treatment. Next, breathing issues, such as tension pneumothorax and open pneumothorax (sucking chest wound), may need to be addressed in this phase of care. Circulatory issues, such as tourniquet replacement with direct pressure dressings or advanced hemostatic agents and fluid therapy, are then addressed. Intravenous or interosseous access needs to be established. Hypothermia prevention, adequate analgesia, prophylactic antibiotics, and appropriate use of cardiopulmonary resuscitation are also addressed in this phase.13
Advanced Hemostatic Agents.: The ideal out-of-hospital hemostatic agent ideally would require little training; be nonperishable, durable, flexible, and inexpensive; adhere to the wound only; pose no direct risk of disease; not induce a tissue reaction; and effectively control hemorrhage from arterial, venous, and soft tissue bleeding. There is no single ideal advanced hemostatic agent that currently meets all of these criteria for either military or civilian use. However, many hemostatic agents have been used successfully for uncontrolled hemorrhage on today’s battlefield and have contributed to reduced morbidity and mortality in penetrating combat trauma.25–30
Although many hemostatic agents are approved by the U.S. Food and Drug Administration (FDA) and have been used in both the civilian and military environments, the agent currently recommended by the Committee on Tactical Combat Casualty Care is Combat Gauze. Combat Gauze, a mineral-based dressing containing a kaolin coating, is thought to function by activation of clotting factors. More recent dressings with fine-mesh poly-rayon gauze and chitosan impregnation have been demonstrated to be at least as efficacious as Combat Gauze in a porcine model.29
Point Compression Devices and Trunk Tourniquets.: The rapid development and fielding of tourniquets and hemostatic agents on today’s battlefield have greatly reduced morbidity and mortality from previously uncontrolled hemorrhage, particularly from isolated extremity injuries. However, exsanguination-related mortality still exists. Anatomic areas that are not amenable to tourniquet application, referred to as junctional areas (i.e., neck, groin, axilla), have now become the focus of hemostatic research.31 In fact, the current combat epidemiology reports that junctional injury and bleeding is now the most common “potentially survivable” combat injury. Because junctional injuries continue to be a challenge to hemorrhage control in the tactical setting, newer devices are being developed to control these injuries in the field setting to allow the casualty time to have surgical control in an operative setting.30–32 One of the newer devices has been approved by the FDA for control of proximal femoral artery injuries, the Combat Ready Clamp (CRoC, Combat Medical Systems). This is a large C-clamp that is placed over the femoral vessels to provide direct compression. Another device under development is the abdominal aortic tourniquet, which is a pneumatic tourniquet that externally compresses and occludes the abdominal aorta at its bifurcation. This device has been shown to occlude the abdominal aorta in a pig model for up to 60 minutes without evidence of bowel ischemia or hyperkalemia and is pending FDA approval for the indication of hemorrhage control of proximal femoral and pelvic vascular injuries.33
Tension Pneumothorax.: Another leading cause of potentially preventable battlefield death is tension pneumothorax, accounting for up to 3 or 4% of all fatal injuries.14,34 McPherson and colleagues34 studied radiologic and autopsy examinations of 978 fatalities from the Vietnam conflict; 15 of the casualties with identified tension pneumothorax lived long enough to be treated by a medic, but none underwent needle decompression and all of them died.
Although needle thoracostomy is a controversial procedure in the civilian trauma setting for adults, current TCCC guidelines recommend consideration of needle decompression in casualties with chest trauma and progressing respiratory distress.17,34 The current recommendation is to use a 14-gauge or larger 3.25-inch needle. This recommendation is based on computed tomography evaluation of the chest wall, which indicted that a standard 2.0-inch needle would penetrate the pleural space in only 75% of causalities.35
Airway Management.: Airway compromise is also a potentially preventable cause of battlefield death.36 Historically, airway compromise is responsible for approximately 1% of fatal injuries on the battlefield and is due to facial or neck trauma causing obstruction. These data are consistent with a more recent review of fatal airway injuries from Operation Enduring Freedom and Operation Iraqi Freedom, which demonstrated an airway fatality rate of 1.8%, with 100% having penetrating injuries to the face or neck.36
