“˜Any Call Has the Potential to Become Violent’

Over the years, the EMS and law enforcement industries have seen changes ranging from their ballistic protection and equipment to training and response procedures. Unfortunately increases in violence, mental instability, drugs, gangs, lack of attention and desperation have forced people in both occupations into combat situations. The result has been more high-risk tactical incidents for law enforcement that ultimately involve EMS. Increased attacks on both professions have resulted in injury and death to responders.

Fairfax County (Va.) Police Department Second Lieutenant Robin Davis, NREMT-P, a 25-year police veteran, urges responders to change their basic training. “Any call has the potential to become violent. Providers need to increase their awareness. When law enforcement becomes involved in critical tactical operations, they require highly trained EMS personnel who can work in austere and unstable environments, at times under fire. A working knowledge of not only emergency medicine but law enforcement procedure is critical,” he says.

Looking at statistics in both EMS and law enforcement, there’s obviously a problem.(1,2) Although there’s no national database on EMS deaths associated with law enforcement activities, a 1992—1997 study published in the December 2002 Annals of Emergency Medicine determined that 114 EMTs and paramedics were killed on the job. That’s an estimated 12.7 fatalities per 100,000 EMS workers–more than twice the national average.(3) As for law enforcement officers, their deaths are tracked and categorized annually. The past 10 years averaged 161.2 officers killed each year, with an average of 54.2 as a result of gunfire.(2)

From the Columbine High School shootings to the 9/11 attacks on the Pentagon and World Trade Center, EMS and law enforcement are increasingly becoming targets of violence. This is partially due to similarities in the professions and partially due to lack of awareness and training.

Tactical operations in law enforcement require special skills and training of everyone involved, including EMS responders. Knowing the exact role that’s to be assumed is critical, but just as critical is the ability to change roles within seconds if the situation changes. EMS is a crucial part of every tactical operation. Only those with specialty training and the mental ability to remain calm and focused when chaos ensues will ever find themselves attached to a tactical team. Most will remain on standby in a cold zone or in a safe casualty collection point until the scene has been deemed safe and secure by law enforcement or the patient has been brought to them.

According to Tac-Med, LLC Tactical Medicine Coordinator Sgt. Leon Jaskuta, “tactical EMS members must meet the same physical and mental requirements of law enforcement team members. They need to be proficient and knowledgeable in basic tactical procedures while also operating in austere, unpredictable environments. During call-outs, tactical EMS providers often assume the role of medical command from the law enforcement incident commander while serving as a liaison with civilian EMS units,” he says. “In this role, they must ensure prompt treatment of injured and ill law enforcement officers, civilians and suspects. Efficient evacuation of patients can involve establishing landing zones for medical helicopters and contacting hospitals advising them of potential trauma cases. Those in the warm and hot zones of hostile environments are specially trained to watch the back of their fellow tactical team members. They treat injured members while under fire ultimately within four minutes.”

Start of Tactical EMS
The military is well aware of the successes of treating and evacuating the wounded, so it has established mobile army surgical hospital (MASH) units to treat wounded soldiers close to or inside the battlefield. These have recently been replaced by combat support hospitals, allowing for even more advanced medical treatment close to the front lines. The principals of quick care established by the military have served as a foundation for Counter Narcotics and Terrorism Operational Medical Support (CONTOMS) to meet the needs for specialized training to support law enforcement special operations. CONTOMS has established the first EMT-Tactical (EMT-T) certification.(4)

Supported by the National Tactical Officers Association, the National Association of EMTs (NAEMT) and the National Association of EMS Physicians (NAEMSP), CONTOMS has trained more than 7,000 emergency personnel from 50 states. More than 75 local, state and federal law enforcement agencies seek this certification-based training for their tactical medics.(4)

David Neubert, MD, deputy regional EMS medical director for Montgomery County, Pa., and medical director for Tac-Med, LLC, has more than 17 years’ experience in prehospital care and has worked in trauma centers in New York and Pennsylvania. He says, “reports from Somalia and the Iraq wars on tactical combat casualty care (TCCC) played a key role in pushing the concept of tactical medicine from the military into the civilian law enforcement sector.”

According to Lawrence Heiskell, MD, founder of the International School of Tactical Medicine, “they are an approved school for tactical medicine by the U.S. Department of Homeland Security Office of Domestic Preparedness.” Based at the Palm Springs (Calif.) Police Department Training Center since 1996, they have graduated more than 1,600 students from 750 agencies and now teach tactical medicine worldwide.(5) The West and East coasts of the U.S. set different standards for EMS and law enforcement, so it’s imperative that students ensure the course they choose has been recognized by the proper authorities in their state for oversight and curriculum.

Tac-Med, LLC provides regional training in the northeastern U.S., and coordinates with local, state, and national EMS and law enforcement resources to provide tactical medical training based on the guidelines established by the tactical section of the American College of Emergency Physicians.

The Boonshoft School of Medicine at Wright State University in Dayton, Ohio, also maintains a division of tactical emergency medicine course as a way to lead the nation in determining and disseminating best evidence and practices for tactical medical education and clinical care.(7)

Faced with an unpredictable environment, tactical EMS providers are now training to venture into hostile fire side-by-side with law enforcement as medical providers for injured team members. Basic medical training for tactical operators include hemorrhage control, basic and advanced airway management, casualty evacuation, triage, movement, basic toxicology, preventative medicine, medical intelligence, pain control, basic team movements, ballistics and explosives injuries, as well as sports medicine and K-9 care.

Since tactical EMS providers may be armed–a controversial move in some states–and operate in an unpredictable environment, these providers should carry only enough items to stabilize a patient’s condition. Neubert suggests that a kit include tourniquets, combat gauze/hemostatic dressing, an occlusive dressing, naso pharyngeal airway, 14-gauge long needle for chest decompression or needle cricothyroidotomy, colored markers for triage purposes, 4-by-4 and 5-by-9 gauze pads, kling and a good pair of shears. More advanced care can be provided once they are moved to a safer casualty collection point for transport to the hospital via ambulance or helicopter.

Davis, former assistant chief with the Sterling (Va.) Volunteer Rescue Squad, says that whether a department assigns EMS to work with tactical teams or trains police officers as paramedics to operate in the hot zone, one thing is sure. “High-risk operations warrant special focus and training of all members. But day-to-day interactions between EMS and law enforcement are critical, too. The more EMS and law enforcement understand one another at the ground level, the better and safer operations will be for all involved,” he says.

1. Dubay D. (January 2012). EMS in the Line of Duty Deaths.In Dave’s EMS Headquarters. Retrieved Jan. 6, 2012, from www.davesems.com/LODD.html.
2. Cosgriff C.( January 26, 2012). The Officers- Current Year Deaths. In Down Memorial Page. Retrieved from www.odmp.org/search/year/2012.
3. Maguire BJ, Hunting KL, Smith GS, et al. occupational fatalities in emergency medical services: A hidden crisis. Ann Emerg Med. 2002;40(6):625—632.
4. FitzGerald D. (n.d). CONTOMS: The CCRC tactical medicine program. American College of Emergency Physicians. Retrieved Jan. 23, 2012, from www.acep.org/content.aspx?id=31880.
5. Tactical Medicine (1996). Do you have what it takes? In International School of Tactical Medicine. Retrieved Jan. 23, 2012 from www.tacticalmedicine.com/files/brochure_2011.pdf.
6. Brown JE. (n.d). Division of tactical emergency medicine. In Boonshoft School of Medicine, Wright State University. Retrieved Jan.10, 2012 from www.med.wright.edu/em/dtem. 

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