Airway & Respiratory, Operations, Training

Tactical Training Proves Beneficial for EMS

Issue 5 and Volume 37.

>> Tac Team Alpha: I’ve got visual on barricaded subject with hostages.

>> Command: Acknowledge Alpha. Maintain visual and advise of any change in behavior or position.

>> Tac Team Alpha: Subject appears increasingly disoriented.

Sounds of multiple shots are heard fired from the subject’s location.

>> Tac Team Alpha: I’ve got visual on wounded hostage.

>> Command: Copy Alpha on wounded hostage.

>> Command to Tac Team Delta: Go for entry; go for entry.

>> Tac Team Delta: Going entry.

>> Tac Team Delta: Subject secured. Repeat, subject secured. But officer down! Officer down! Operator care initiated.

>> Command: Medics up.

Paramedic Tango reaches the downed officer, finding blood on the ground next to a large, mid-thigh gunshot wound in his right leg. The bleeding is already controlled by a tourniquet applied by another tactical operator involved in the initial team entry that occurred 65 seconds before Tango made patient contact. The patient is awake, alert and complains of thigh pain. He denies any other injury, and none is found on a quick but thorough physical exam.

Paramedic Ocean reaches the wounded hostage at the same time Tango reaches the downed officer. Ocean finds three gunshot wounds in the hostage’s chest and abdomen. This patient is awake, talking, anxious and diaphoretic, and he has an increasingly rapid radial pulse. Ocean applies an occlusive seal over the largest wound, which is to the right of the sternum. He finds no exit wounds during the remainder of his exam, and he calls for rapid extrication.
A physician and paramedic await the patients at the tactical command post. They have vascular access supplies ready and aeromedical helicopter resources responding with an estimated arrival time of five minutes. The wounded law enforcement officer and the wounded hostage arrive for tactical field care within six minutes of sustaining their wounds.

Tactical Training
On the day the events described above occurred, they happened only in training. But the Oklahoma Highway Patrol (OHP) EMS Unit state troopers are well aware that events such as these can occur on any day at any time.

This knowledge, coupled with a commitment to safety for all Oklahomans, including their fellow troopers, has guided OHP leaders in developing an increasingly sophisticated cadre of all-hazard medical teams for tactical, special event, mass casualty and natural disaster response throughout the state. In addition to OHP’s progressive leadership, many strategically placed building blocks exist that allow for law enforcement-related medical emergency success.

Within OHP and other states’ police organizations, specialized law enforcement teams meet the extraordinary operational challenges in tactical, riot, explosive ordinance and disaster situations. These officers may be dedicated to full-time service on such teams or accept these additional roles beyond their daily police duties. The presence of specialized operational teams, with specific training, tasks and capabilities, creates a strong infrastructure in which to introduce and advance medical emergency capabilities, not only within existing teams, but also for specialized EMS response teams.

Above & Beyond
Just like their EMS and fire colleagues, law enforcement officers are hard-wired for public service. Within an agency the size of the OHP, a call for troopers interested in new medical duties will typically result in a competitive process, yielding top-flight EMT and paramedic candidates and graduates.

EMS professionals willing to think outside their usual environments and roles are often conduits for exciting changes. Leaders within the University of Oklahoma Department of Emergency Medicine (OUDEM) were approached by OHP with hopes of gaining medical oversight support for troopers trained and in training as EMTs and paramedics.

Select OUDEM physicians and paramedics who expressed interest in participating in the program were screened for their medical knowledge, law enforcement duty awareness, physical abilities and teamwork attributes. They were also required to complete extensive security background checks. Next came an extensive process that included exhaustive database queries and character references for each candidate.

After the OHP special team orientation, the selected physicians and paramedics received special “boots on the ground” training and emergency response
experiences statewide before being approved to serve on OUDEM’s Special Operations Medical Oversight and Support (SOMOS) group. Each physician and paramedic has a formal affiliation with OHP, which provides them with protection from claims while they’re on duty in special assignments and allows for medical liability protection and worker’s compensation for injuries through OUDEM.

The physicians and paramedics work together to ensure coverage is available for statewide response around the clock, using response vehicle assets secured under the Department of Homeland Security funding or responding with a state trooper in a patrol vehicle.

Specialized Equipment
“High speed/low drag” is the catch-phrase for expedient, effective operations. Equipment carried on each person and in team support vehicles is evaluated and implemented with this mantra. Medical equipment primarily designed for emergency department (ED) and/or daily EMS use often fails this specialized operations requirement. Anything bulky can become an unintentional “target,” and heavyweight items impede rapid movements often needed in access and egress maneuvers.

All team members, law enforcement officers and medical support specialists carry individual first aid kits, for more about IFAKs, see “Beyond the Tape,” pp. 38–40. In general, active operational area equipment is kept to necessary, but effective, “minimums.”

In addition to the IFAKs each officer carries, space- and weight-efficient extraction devices are also available during all operations. These devices are specifically designed to allow for rapid patient movement by a minimum number of law officers and paramedics. This often includes devices capable of being used by a single-operator, such as drag straps/pulls and sleds.

Tactical field care—the next echelon of care—is planned and carried out at strategic locations using larger medical kits containing additional hemorrhage control agents, hemostatic dressings and gauze, as well as more advanced airway and pharmaceutical supplies. IV and intraosseous fluids are carried with a constant balancing of physical weight of fluid against anticipated clinical needs based on probable patient conditions and times to definitive
trauma destinations.

Sustained Operations & Care
SOMOS members are also equipped with 72-hour go bags to allow faster deployment to large events that may advance to extended operations. The “go bags” have prepacked personal items, such as uniforms, safety glasses, additional protective equipment, multiple flashlights with extra batteries, foul weather gear, safety gloves and self-heating meals. The special bags also include members’ personal medications, back up contact lens/glasses and other specific daily required products.

Disaster-specific equipment, designed to address a multitude of casualties, is carried in a dedicated trailer assigned to OHP in the state’s regional EMS system disaster plan. Typical mass casualty supplies for triage, treatment area set-up, basic medical care and extrication devices and patient removal equipment are efficiently organized throughout the trailer. Although the trailer is designated for primary use in one of Oklahoma’s eight health regions, it can be mobilized throughout the state as conditions may warrant.

Depth of Training
Putting the right equipment in the hands of motivated professionals is a good place to start, but it’s a poor destination. Routine training for the “non-routine” response is integral to nearly any special operations team’s success when it matters most.

Training exercises and didactics that support effective operations primarily address the following three major medical missions:
>> Injured law enforcement care and medical advice on how to minimize the risk of these injuries;
>> Civilian care in special law enforcement operations settings with coordination and support for local EMS agencies; and
>> Civilian care in statewide disaster settings while working alongside local EMS agencies.

The training schedule consists of two mandatory days per month, a yearly one-week exercise, and additional training as it becomes available from local, state and federal organizations, such as Basic Disaster Life Support and Homeland Security exercises.

All medical specialists are trained and certified as EMT-Tacticals or equivalent, with a strong basis in tactical combat casualty care (TCCC) philosophy and methodology. Many members are instructors certified in trauma specific disciplines (Prehospital Trauma Life Support, International Trauma Life Support and Advanced Trauma Life Support), which serve as good fundamental trauma support courses; although modifications in application are necessary in the tactical environment.

The axiom, “Good medicine can get you or someone else killed” is often applied to training drills. For instance, definitive airway management could be desirable, but intubating in the line of sight of an active shooter isn’t going to end well for either the intubator or the intubatee. All team members, including primary law enforcement operators, are trained to proficiencies in performing basic medical/trauma assessment, controlling bleeding, using tourniquets and hemostatic agents, sealing open chest wounds, and performing simple airway management techniques and patient evacuation.

Advanced certification medical specialists (e.g., paramedics and physicians) are additionally proficient in airway management, including surgical cricothyrotomy, vascular access and tension pneumothorax decompression. Bomb technicians at OHP are invaluable instructors in explosive ordinance awareness level training and bomb suit access training. Trauma shears are useless in the access, assessment and care of an explosive ordinance technician, and operators and medical support specialists must know the proper methods for bomb suit removal and blast-related injury care.

As it is for any special operations team, the training is rigorous, in-depth and designed to push members to mental and physical extremes. Just as special operations medicine was new to the troopers, working in the hot/warm zones of law enforcement special operations was eye-opening to the physicians and paramedics. The mutual respect is immeasurable, with everyone remaining engaged, supportive and enthusiastic for new information and skills.
Although textbooks and medical literature is being absorbed by everyone involved, the medical director has found benefit in dedicated weight room “learning” as well.

FrontLine Training
A specialized tactical casualty care course was designed and delivered to the tactical team operators. The operators are instructed to “get off the X,” which means getting to a place of increased safety before implementing any detailed medical care. After the operators are in an area of concealment, and preferably cover, their training in bleeding control, chest seal application and basic airway control with nasal or oralpharyngeal airways is designed to save lives and minimize injuries. The training and teamwork ensures that the tactical law enforcement operators rapidly incorporate medical support for their peers in tactical operations drills and actual situations.

Taking it to the Street
Because of the praise from the law enforcement officer tactical operators, the training has also been extended by the medical team to road patrol troopers and additional staff at the OHP training center. The same approach to simple, non-invasive assessment and aid that makes lifesaving differences was a success in the pilot course that now serves as the template for ongoing courses.

Practical scenarios making the didactics come to life play an important role in this training curriculum’s effects. With more than 400 state troopers interested in training, the schedule looks filled for an exciting future. Everyone is feeling the crunch of budget limitations at best and cutbacks at worst. To mitigate this issue, all avenues of financing are actively considered. Examples of successful funding to date include U.S. Department of Homeland Security grants, criminal activity forfeiture money, and corporate and private donations, in addition to line-item OHP budgeted items.

The Sustainable Future
Early intervention for controlling bleeding, minimizing chest trauma, and improving oxygenation and ventilation can make the difference in life or death in the special operations environment. Applying the concepts from law enforcement to additional areas managed by law enforcement officers and medical support specialists can offer many benefits, namely reducing civilian casualties and treating patients injured in disaster situations. A realistic training program design and remarkable enthusiasm will enable the OHP to offer new and expanded medical capabilities throughout the state that will benefit officers and citizens alike.

The benefits of a tactical program are simple, yet profound. Law enforcement officers assigned special operations tasks know onsite medical specialists “have their back” when they need it most. Civilians exposed to the dangers of law enforcement special operations similarly benefit from immediately available aid with expertise. The state’s disaster plan is additionally strengthened by an additional cadre of medical professionals equipped to respond for effective medical aid and scene control. This article originally appeared in May 2012 JEMS as “Prepared for the Worst: Tactical training offers many benefits for EMS.”