Major Incidents, Training

TEMS Readiness Goes Beyond Active Shooter Response

Issue 40 and Volume 41.

Throughout the United States, police agencies have developed specialized teams of officers commonly known as special weapons and tactics (SWAT) teams. SWAT teams are challenged with a variety of high-risk tasks such as: hostage or barricade incidents, high-risk warrant service, civil disturbances, dignitary and executive protection, explosive ordnance disposal, and homeland security missions.1,2 Specially trained tactical emergency medical support (TEMS) providers are often embedded with these teams to provide medical support for law enforcement operations.

TEMS operations require more than simply providing immediate emergency medical and trauma care when called upon; the pattern of TEMS training is centered on dynamic tactical movements, rapid extrication methods and hemorrhage control techniques practiced by performing exercises known as immediate action drills.

It’s early in the evening and TEMS providers arrive for a scheduled training session. They don their ballistic protective equipment and proceed to the immediate action drill. “Officer down!” The TEMS providers shout out, “Seek cover! Provide self-care! Return fire!” Then a rescue plan is formulated. TEMS providers gain access to the downed officer with the use of a ballistic shield and armed cover from law enforcement. They control major hemorrhage to a simulated arterial bleed of the left leg with a tourniquet, then perform rapid extrication using webbing, or a commercially available drag strap, to a location of cover and concealment. These actions are repeated in a variety of situations, using a variety of tactical formations and different extrication methods. The team talks about the mechanics of doing these exercises, and discuss what’s working, what’s not working, and how they can improve. Then the team members go home until the next scheduled drill.

If this sounds like your TEMS training sessions, they need to change. There’s no doubt that mastery of care under fire, bleeding control and rapid extrication techniques are a cornerstone of TEMS and imperative for optimal survivability in penetrating trauma cases; however, this is a very small segment of a TEMS provider’s responsibility.


Today’s current advancements and recommendations on treating traumatic injuries have been heavily influenced by the lessons learned on the battlefields in Iraq and Afghanistan over the past 15 years.3,4

The Committee on Tactical Combat Causality Care (CoTCCC) recognized that there are many ways combat medicine could be adapted to serve civilian populations. This is especially true in events such as mass shootings, terrorism or high-threat pre hospital environments such as SWAT operations.4

In 2010, the Committee for Tactical Emergency Casualty Care (C-TECC) was formed, and the lessons learned from U.S. and allied military forces were adapted and modified to meet the specific needs of civilian populations.4 The main points of C-TECC are: establish goals, principles, current guidelines and skill sets needed to improve survivability of victims in high-threat situations.5 It provides clear delineation as to what treatments are appropriate in various degrees of threat providers and victims could be exposed to.

In April 2013, following a series of mass casualty shootings, medical, law enforcement, fire/rescue and EMS communities felt a duty to respond. This led to the formation of a group known as the Hartford Consensus, which focused on five major points to increase survivability: threat suppression, hemorrhage control, rapid extrication to safety, assessment by medical providers and transport to definitive care. The five critical actions ensured a continuum of care that offered victims the greatest opportunity for survival.6

In July 2013, the committee met again. A call to action was made that became known as Hartford Consensus II. The strategy focused on achieving the objectives of the first Hartford Consensus. It was no longer considered acceptable for fire, rescue or EMS to stage and wait for casualties to be brought to the perimeter, but to function in areas of mitigated risk. Hartford Consensus II suggested that a responsibility exists to ensure all responders have training in hemorrhage control techniques, including tourniquet use, pressure dressings and hemostatic agents, and that TECC concepts should be incorporated into the EMS/fire/rescue training in order to increase survivability.7 This recommendation has made tactical EMS and TEMS a ubiquitous term among civilian EMS communities today.


The influences from the Hartford Consensus and C-TECC have guided TEMS units to focus a great amount of time mastering three main areas of focus:

  1. Tactical movements and casualty extraction techniques such as drags and carries;
  2. Hemorrhage control techniques such as tourniquet application, pressure dressings, wound packing, application of hemostatic agents, and even the use of junctional tourniquets; and
  3. Airway management techniques such as surgical cricothyrotomy, needle thoracentesis and supraglotic airway devices.

Paradoxically, the time focused on this kind of training for a TEMS unit is often disproportionately weighted, and the remainder of the skill set ignored. In actuality, the most common practices of a TEMS unit aren’t those needed in direct threat care scenarios, such as an active shooter incident. Units are more likely to call upon the numerous ancillary skills required of and expected of a TEMS provider.

This isn’t to say that threat mitigation strategies, hemorrhage control techniques and rapid extrication methods should be ignored, but rather that TEMS training must also include some combination of additional key components: prevention, health monitoring, sound mission planning, sick call and minor injuries, strategic risk reduction and education. Some of these elements such as mission planning, risk identification and reduction strategies could be juxtaposed with immediate action drills.

A retrospective analysis of data collected from 1,042 tactical missions over a five-year period with the Maryland State Police showed that the majority of patient encounters during high-risk operations were for the treatment of members of the law enforcement tactical team; this comprised 67% of total patient encounters. Injuries were most prevalent during training activities seconded by high-risk warrant service, with the most common complaint being musculoskeletal pain or injury.8


Ben Franklin’s axiom “an ounce of preparation is worth a pound of cure” couldn’t hold truer for TEMS units. Although this quote was initially geared for his argument for fire protection, it’s very applicable for medical providers in the tactical environment. One sure way to save lives and reduce injuries is to avoid injuries in the first place. Implementation of injury and illness prevention programs can be as simple as offering annual influenza vaccinations or having tetanus vaccinations made available to those who need them. Teams can implement a physical fitness program or facilitate annual physicals by a physician. TEMS providers can even implement policies on pre-training or pre-deployment stretches to help prevent muscle strains and sprains, for example.

Commanders of SWAT teams are engaged and focused on swiftly mitigating a particular situation using legal, sound tactics in the most appropriate manner. It’s the job of TEMS to identify the areas of risk for the team’s health and well-being. Environmental conditions, health, nutrition or underlying medical conditions could adversely affect personnel performance and decision-making skills, thus jeopardizing the success and safety of a given mission.8 During missions lasting more than several hours, TEMS providers should be calculating required caloric intake based on the degree of activity members are engaged in. Atmospheric temperatures and conditions should be continuously monitored and team members should have clothing adjustments and oral hydration adjustments based on this information. Knowledge of the health history of your individual team members will help to monitor them for specific warning signs or symptoms that could be exacerbating underlying medical conditions and impact performance or safety.


Excellent mission planning is an indispensable skill of a TEMS team. It’s the blueprint and foundation of successful missions.

The ability to create a sound, comprehensive medical mission plan and threat assessment isn’t possible without practice and training. It’s the responsibility of TEMS to create a medical threat assessment that’s robust and multifaceted. The team should consider variables that include: mission objectives, degree of inherent risk of mission, duration, time of day, weather conditions, hospital locations and capabilities, medical air evacuation ability and capabilities, landing zone locations, location of 24-hour veterinarian clinics, heat indexes and recommended fluid intake, anticipation of the use of gas, distraction devices, less lethal munitions, establishment of casualty collection points, and routes of ingress and egress.

Patient injuries that are typically not life-threatening include musculoskeletal pain, fatigue, sleep deprivation, respiratory symptoms, and nasal congestion or rhinorrhea—many of which can be alleviated by administering over-the-counter medications.8 Some states have already approved, or are working toward establishing, an expanded scope of practice, protocols and medication lists to be utilized in the tactical arena. Addressing these types of complaints could require additional training and education of TEMS units.

In addition to expanding medications made available to TEMS— including second-generation antihistamines, decongestants, anti-inflammatory medications, antacids, anti-diarrheal and topical creams such as steroid, antibiotics and antifungal creams—some models also advocate education in procedures such as wound closure, dislocation reduction, wound irrigation and proper taping of joints.

An alternative solution is positioning a physician, physician assistant or nurse practitioner on site during training sessions or in close proximity of a command post during lengthy missions.

TEMS has a large role in the implementation of risk reduction strategies. This begins by thoroughly analyzing tactical operational plans and creating a medical threat assessment, identifying areas within these plans that present a potential risk for preventable injury as well as providing suggestions for eliminating or minimizing them.

Officers and SWAT team members need to be well-versed in self-care and buddy aid. It’s not uncommon for law enforcement officers to feel very uncomfortable around even the suggestion of something that resembles practicing medicine, but because a person can hemorrhage to death in a matter of minutes, it’s imperative that every member on a tactical team be trained and equipped to stop bleeding in themselves or a teammate. It’s the tactical medic’s responsibility to teach the team to feel confident and become competent in this lifesaving measure.

This responsibility extends to community outreach, such as teaching educators and school administrators to develop emergency plans for active shooter incidents and provide basic bleeding control measures.


The documented pattern of injuries and illnesses associated with tactical missions, as well as the expectations and position that law enforcement agencies have on TEMS, has become the standard in operational safety and mission success. TEMS is much more than care under fire, and ongoing training should reflect its complexity by challenging typical models of training with creativity and innovation. Doing so will refine the vast skill-set needed to meet the expected role of today’s tactical medics.


1. Kraska PB, Kappeler VE. Militarizing American police: The rise and normalization of paramilitary units. Social Problems. 1997;44(1):1–18.

2. Tang N, Kelen GD. Role of tactical EMS in support of public safety and the public health response to a hostile mass casualty incident.Disaster Med Public Health Prep. 2007;1(1 Suppl):S55–S56.

3. National Highway Traffic Safety Administration. (August 1996.) EMS: A historical perspective. National Association of EMTs. Retrieved July 11, 2015, from

4. TECC Overview. (n.d.) The Committee for Tactical Emergency Casualty Care. Retrieved June 26, 2015, from

5. 2014 Tactical Emergency Casualty Care (TECC) guidelines. (2014.) The Committee for Tactical Emergency Casualty Care. Retrieved June 26, 2015, from

6. Joint Committee to Create a National Policy to Enhance Survivability from Mass-Casualty Shooting Events, Jacobs LM, McSwain NE, et al. Improving survival from active shooter events: The Hartford Consensus. Bull Am Coll Surg. 2013;100(1 Suppl):32–34.

7. Joint Committee to Create a National Policy to Enhance Survivability from Mass-Casualty Shooting Events. (2013.) Active shooter and intentional mass-casualty events: The Hartford Consensus II. American College of Surgeons. Retrieved June 26, 2015, from

8. Levy MJ, Smith R, Gerold KB, et al. Clinical encounters in tactical medicine: A mission-specific analysis of the Maryland State Police experience. J Spec Oper Med. 2014;14(2)98–104.

9. Gerold K. (n.d.) TEMS position statement. National Tactical Officers Association. Retrieved June 26, 2015, from