Special Responses, Special Medics

Late one night in a remote location in the Midwestern United States, a team of law enforcement agents is seeking the arrest of individuals suspected of narcotics trafficking. Armed with a search warrant, the special weapons and tactics (SWAT) team approaches the target residence. They announce their presence by knocking loudly on the door. Their verbal announcements are met with a shotgun blast that injures the officer closest to the door. He is bleeding badly from a gunshot wound. As the SWAT team reacts to the crisis with well-rehearsed immediate action, the call goes out, "Medic up!"

Law enforcement remains a dangerous occupation. During the past 10 years in the United States, there has been an average of one law enforcement officer death every 53.4 hours, or 164 a year. On average, more than 57,000 law enforcement officers are assaulted each year, resulting in some 17,000 injuries. Given this sobering reality, the U.S. Department of Health and Human Services and the U.S. Park Police, in cooperation with the U.S. Department of Homeland Security and TRUE Research Foundation for the Advancement of Military Medicine, sponsor the Counter Narcotics and Terrorism Operational Medical Support (CONTOMS) program. For nearly 20 years, CONTOMS has provided nationally recognized evidence-based courses in tactical medical support of law enforcement and military operations.

Law enforcement and the military services have long recognized that medical support of special operations can enhance the probability of mission success. This type of support requires a unique additional expertise complementary to the basic qualifications of prehospital healthcare providers. Community emergency medical services systems in the United States and abroad were developed to respond to the needs of individual patients in controlled situations. However, in some locales, emergency medical technicians trained for EMS roles have been pressed into service to support counterterrorism, drug interdiction and other law enforcement activities, without any additional training. These activities have become increasingly specialized in nature, characterized by prolonged operations, organized opposing forces, use of military-type weapons and increasing death and injury among law enforcement officers, perpetrators and innocent citizens.

The CONTOMS provider course, also called EMT-Tactical, is a 56-hour program that offers a foundation for medical personnel providing such support to special response teams. The basic school integrates didactic, practical and field exercises to provide students with the essentials of tactical emergency medical support (TEMS). Successful completion of the course results in certification of special competence. Course topics include:

• Patient extraction and medical care in the tactical environment;
• Forensic evidence collection;
• Medical threat assessment and intelligence;
• Wounding effects of weapons and booby traps;
• Special equipment for medical support;
• Preventive medicine to ensure unit health.

Training in the CONTOMS program integrates and distills contemporary military, law enforcement and prehospital practice into a guide for TEMS providers. When looking at the training required for a medical provider to support a special response team, it is ultimately more about methodology than advanced skills, new technology or unique topics. The provider must learn how to think "outside the box," methodically yet flexibly. The provider must learn how to be proactive in applying basic medical skills in different ways to adapt to dynamic threat environments. In this regard, it is as much about the "when" and the "why" as it is about the "what" or the "how" in the delivery of medical support. It is this insight and judgment that helps the TEMS provider respond with maximum effect in highly unstructured settings.