Maintenance Medicine: Maryland's Tactical EMS Protocols Aimed at Keeping the Cops Online

     In this era of dangers numerous and unknown, the use of law enforcement special operations teams has proliferated, and with it the need for tactical medical support. The specialty of tactical EMS has consequently grown, but without, in many cases, much of a specific medical framework to underpin it.

     With the creation last year of specialized protocols for EMS supporting law enforcement operations, Maryland became the first state to take official steps to remedy that lack. Its tactical EMS protocols are now being piloted by the Maryland State Police's Tactical Medical Unit, and could be embraced elsewhere soon.

     What they amount to is basically occupational medicine: keeping tactical operators healthy and intact during unpredictable, often-violent, sometimes-lengthy operations.

     "The challenge was, how do we keep officers, who are elite-trained folks-and there are very few of them-in service for days at a time?" explains state EMS medical director Richard Alcorta, MD, FACEP. "In the past, we've had standoff situations that have lasted multiple days. And during those, we have to rotate personnel in and out, and some of those personnel can have injuries or illnesses that need to be addressed. So it's a protocol that allows EMS personnel who are cross-trained as law enforcement officers to essentially provide occupational medicine to their colleagues, to keep them in service."

     The idea originated with two doctors, Kevin Gerold and Don Alves, who provide medical direction for the MSP's tactical unit. They approached officials at the Maryland Institute for EMS Systems (MIEMSS) about developing a set of protocols to assist their officers under the unique circumstances of special operations. Alcorta and MIEMSS' protocol committee set to work, tapping the expertise of law enforcement. They eventually produced both BLS and ALS versions.

     An obvious consideration was the safety of the EMS providers themselves. "We can't really project personnel into the special operations environment, because it increases the risk," Alcorta says. "So what we really addressed was just keeping tactical personnel functional."

     That means medics won't be venturing into hot zones, opening chests and removing bullets. Rather, they'll be in the cold or warm zones, performing maintenance and minor repairs. And while the new protocols are designed for the benefit of law enforcement operators, the providers using them will of course treat all comers, including hostages, bystanders and even bad guys.

     The tactical protocols differ in a few ways from the state's regular medical protocols. They permit the use of adhesives and stapling to close wounds, and include steps for the removal of darts from electro-conductive weapons like Tasers. They include medications for minor injuries and over-the-counter products (e.g., ibuprofen, cimetidine, Mylanta, NoDoz) to help keep operators online.

     The idea was to supplement, not replace, the state's existing medical protocols. To participate, memoranda of understanding are required between involved providers, their local EMS medical director and the tactical team's medical director, if different. Providers have to be trained, and each time the protocols are used, they're to file a quality assurance report and notify both medical directors. A copy also goes to Alcorta's office.

     In January, the MSP further bolstered the program by announcing a tactical physician component. Under this, docs from the Johns Hopkins University Department of Emergency Medicine will deploy with tactical operators in high-risk situations and assist in on-scene care.

     The protocols were first deployed last September, and as of early January, there had been around a dozen utilizations of them. Find the state's medical protocols, including the tactical component, at http://miemss.umaryland.edu/MdMedProtocols2006.pdf.John Erich, Associate Editor