How to Develop Tactical EMS Protocols
In civilian law enforcement situations such as active shooters, barricaded subjects and hostage takers, specially trained teams of officers (i.e. SWAT) carry out the mission so as to ensure success.1 These missions are some of the most dangerous responsibilities of civilian law enforcement agencies, with injuries occurring in upward of one-third of tactical operations and related training.2 However, law enforcement tactical teams, trained to respond to these events, are typically not prepared to treat the casualties of these potentially violent encounters.
Recent years have seen a surge in violent crimes across the world. Notable events, such as Columbine, Beslan, Virginia Tech and many others, have influenced the development of a concept known as tactical emergency medical support (TEMS). This concept has been formally evolving since 1989 and is steadily gaining acceptance.3,4 Evidence now shows that integration of tactically trained paramedics can improve the outcome of tactical operations.5 As a result, the tactical medic has become an “integral team member in specialized law enforcement operations.”6 Further, there is a potential liability faced by any tactical team that conducts operations without the ability to provide immediate medical intervention.7
Paramedics operating in this unique prehospital specialty face many challenges which cannot be resolved through the application of standard prehospital protocols. Paramedics functioning in the tactical environment must be prepared to deal with limited resources, delayed transport and a higher occurrence of penetrating injuries.8 Further, the tactical paramedic must overcome these challenges while dealing with the complexities of a potentially hostile environment. While there are strong guidelines in place for care in today’s combat tactical environment, care in the civilian tactical environment is sometimes lacking direction. This area of medical care falls in a gray area between combat medicine and standard prehospital care, where neither is fully appropriate.
Policy or position statements published by organizations such as the American College of Emergency Physicians (ACEP), the National Association of EMS Physicians (NAEMSP) and the National Tactical Officers Association (NTOA) all support the concept of TEMS, with ACEP describing TEMS as an “essential component” of tactical law enforcement teams.9 Feldman, Schwartz, and Morrison (2006) concluded that every civilian tactical law enforcement unit should utilize a TEMS program modeled on the military system of Tactical Combat Casualty Care (TCCC).2 It is for this reason that this review of the literature focuses on relevant topics that may serve as the basis for TEMS protocol development.
Tactical Combat Casualty Care
Trauma care in the combat tactical setting has been revolutionized by the concept of TCCC.10 This project was initiated by the Naval Special Warfare Command and has since been continued by the U.S. Special Operations Command (USSOCOM). The ultimate goal of TCCC is to keep the tactical operator in a condition capable of continuing to fight.11 This is not possible without integrated, tactically trained paramedics. While the TCCC concept was designed for the combat tactical environment, many of its aspects are applicable to the civilian tactical environment.12, 13 The similarities between the military and law enforcement tactical environments allow TEMS to bridge the gap between combat medicine and conventional civilian prehospital EMS.14
The TCCC guidelines depict three phases of tactical care. These phases are known as Care Under Fire (CUF), Tactical Field Care (TFC) and TACEVAC. Potential cover, concealment, terrain, distance to threat, sniper coverage and effective firepower delineate these zones of care and provide guidance for which interventions are appropriate based on the potential threat.10
Care Under Fire. The CUF phase of TCCC is characterized by the presence of an immediate direct threat and is the most dangerous time to deliver care. During this phase, the tactical operator (i.e. specially trained law enforcement officer) should be expected to remain engaged with the enemy if possible. The tactical medic should attempt to keep the casualty from sustaining further injury. Life threatening hemorrhage should be addressed; however, airway management is best deferred until the tactical field care phase.10
Tactical Field Care. Once protected from the immediate threat of hostile fire, the tactical field care phase begins. In this setting, limited Advanced Life Support (ALS) measures may be appropriate. Airway management should begin with Basic Life Support (BLS) maneuvers but may ultimately proceed to surgical intervention if those measures are unsuccessful. Sucking chest wounds should be sealed, and any tension pneumothorax should be addressed. During this phase of care, wounds may be bandaged, fractures splinted and hypothermia should be prevented.
TACEVAC. This phase rounds out the TCCC concept with more traditional EMS interventions as the focus shifts to transport to definitive care. Interventions at this stage encompass the full spectrum of ALS maneuvers. Chest tubes should be placed if indicated and wounds should be reassessed for the potential discontinuation of tourniquets. Advanced airway management is appropriate as indicated during this phase as well. Further TACEVAC care includes the administration of analgesics and antibiotics.11
Scene safety is one of the basic tenets of conventional EMS.15 This typically results in EMS units staging in a safe area until the scene has been secured by law enforcement. The National Association of Emergency Medical Technicians (NAEMT) reported that 12% of all EMS calls for service involved a delay in providers reaching a patient as a result of potentially unsafe scenes. NAEMT also reported that tactical law enforcement missions could result in even longer delays.15
Even in an urban setting with hospitals in close proximity, tactical medics may find themselves in a position that does not allow for evacuation of their patient to definitive care. In this regard, clinical protocols for the tactical medic must allow for advanced care while respecting safety and equipment limitations imposed by their theater of operation.10 Medical protocols for the tactical medic must focus on hemorrhage control and be geared toward keeping the tactical operator in a condition capable of continuing toward their mission objectives.11 In this setting, simplicity is golden and critical thinking is paramount.
While medicine historically focuses on the concept of primum non-nocere (First, do no harm), we must recognize that we have a duty to act and inaction in itself may be harmful.16 We must not accept delays in care due to the inherent dangers of tactical operations, but must make appropriate risk/benefit determinations in regards to scene safety and the need for medical intervention. Since civilian EMS systems have different resources and transport times, not all suggested protocol topics are relevant for all systems. Individual medical directors must make the determination as to which protocol topics are appropriate for their tactical medics.
Tactical Supportive Care
A supportive care protocol should be adopted by any agency operating in the tactical environment. This protocol should address topics such resuscitation decision-making, the concept of remote assessment, the challenges of triage and the dangers of introducing oxygen into the tactical environment. It is important to address here the impracticality of spinal motion restriction (SMR) during most phases of TCCC and the opinion that SMR is not necessary for penetrating trauma.10
Cardiopulmonary Resuscitation. Performing cardiopulmonary resuscitation (CPR) in the tactical environment is likely not to be practical. This must be evaluated on an individual basis while giving consideration to the available resources and access to definitive care. It is, however, widely accepted that battlefield victims with explosives trauma or other penetrating trauma with no signs of life should not be subjected to resuscitation attempts.10
Remote Assessment. The tactical environment has many inherent challenges for the tactical medic. Effective incoming fire may prevent the tactical medic from reaching the patient, and thus the tactical medic may need to assess a potential patient and determine the patient’s viability from a distance.2 This concept, known as remote assessment, may be accomplished with the use of binoculars, spotting scopes, riflescopes, or night vision goggles. It may also be necessary for the tactical medic to coordinate with negotiators during a hostage situation involving sick or injured hostages.2
Triage. Tactical operations have the potential to involve a significant number of casualties. The process of sorting through these casualties and quickly determining the extent of their injuries is known as triage. The goal of this process is to do the greatest good for the greatest number of people. In the tactical setting, this process might be complicated by the need to extract patients from an area where care cannot be safely rendered.17
Tactical situations have the potential to become mass casualty incidents (MCI) but local resources may be able to mitigate the situation. This was the case at the Columbine school shooting. While there were a great number of patients to be triaged, there were adequate resources available to treat and transport the injured.18
Oxygen. Oxygen may be an essential therapy in conventional EMS, but it has very little use in the tactical environment. Among the dangers is the risk of explosion of an oxygen cylinder if struck by a bullet. For this reason, oxygen should remain in the cold zone.19
Spinal Motion Restriction. Despite traditional EMS teachings that indicate the need to perform SMR with most blunt and penetrating trauma, this practice requires bulky equipment and multiple providers. We must recognize the low incidence of cervical spine (c-spine) injuries associated with penetrating trauma, the leading cause of combat injury.14 SMR is not likely to be practical in the tactical environment. For these reasons, the TCCC and Prehospital Trauma Life Support (PHTLS) curricula recommend deferring SMR until the patient can be safely extracted to the cold zone.15
The most common cause of preventable battlefield death is exsanguination from a wound of the extremity.16 These are wounds in which hemorrhage could have potentially been controlled with the use of a tourniquet. During the care under fire phase, control of hemorrhage is the top priority.13
Tourniquets. Tourniquets in the prehospital setting can be safe and effective.13 There is also a lack of evidence supporting the use of limb elevation or pressure points to control extremity hemorrhage when direct pressure is not effective.16 For this reason, the tactical medic might utilize a tourniquet earlier than would be considered in a conventional EMS setting.15 The temporary use of tourniquets in the tactical environment frees the rescuer’s hands for other tasks including self-defense.14 When tourniquets are applied in the CUF phase, in order to conduct an extraction, the bleeding site should be reassessed and tourniquet removal considered as circumstances permit.20
Hemostatic Agents. Not all hemorrhage can be controlled with the use of direct pressure or the application of a tourniquet. Such potentially complicated sites of hemorrhage include the most proximal aspect of the extremities, the axilla, groin, torso and neck.14 ACEP also places the face and scalp in this category.21 In such situations, consideration should be given to the use of hemostatic agents.16 These unique dressings possess properties that contribute to clot formation through alternative means (e.g. mobilization of clotting components) and should be used in addition to direct pressure and pressure bandages.8
Shock management has been researched for decades and significant breakthroughs have come about as a result of lessons learned in Operation Iraqi Freedom (OIF).22 Following control of hemorrhage in the trauma patient, the management of shock becomes paramount. This should be accomplished through fluid administration when indicated.
Fluid resuscitation in the tactical environment takes a “hypotensive resuscitation” approach.10 Fluid should be administered in individuals with an altered level of consciousness secondary to hypovolemia. Additionally, the absence of a palpable radial pulse is an indication for fluid administration with the return of palpable radial pulses as an endpoint.14
The standard of care described by ACEP distinguishes between controlled and uncontrolled hemorrhage when considering fluid resuscitation. ACEP recommends the administration of 20 ml/kg of normal saline (0.9% NaCl) following control of hemorrhage. In the event that hemorrhage has not been controlled, ACEP recommends limiting fluid administration to a quantity capable of maintaining peripheral perfusion.21
Airway dysfunction occurs less frequently in the tactical setting than in a conventional EMS setting.15 Studies indicate that airway adjuncts are often effective, in the absence of traumatic airway obstruction, and the need for an advanced airway is less common. Consideration should also be given to the decreased ability to monitor a patient during the CUF and TFC phases. Very few patients in this setting experience a primary life-threatening airway or breathing problem.13
Pneumothorax. Tension pneumothorax is the second-leading cause of reversible and preventable combat death. Tactical medics must be prepared to effectively seal any open chest wound. Less importance is placed on the use of a relief valve as paramedics are trained to recognize and treat any tension pneumothorax that may subsequently develop.14
Tactical medics must maintain a high index of suspicion when managing penetrating trauma to the chest, and a diagnosis of pneumothorax should be made in any case involving progressive respiratory distress following penetrating or blunt chest trauma.16 The typical clinical indicators of tension pneumothorax can be difficult to appreciate in the tactical environment. Thus care in the tactical environment dictates more aggressive treatment for this condition. For this reason, needle decompression should be performed in the presence of torso trauma with respiratory distress, regardless of progression.10 This differs from many civilian prehospital protocols that require clinical signs of hemodynamic instability prior to performing needle decompression.
Advanced Airway Options. An analysis of combat fatalities found that only a small percentage of combat deaths were attributable to airway compromise, with most of those cases being associated with significant maxillofacial trauma.23 Intubation was found to be extremely difficult during these situations. Additionally, the white light emitted during laryngoscopy could potentially give away one’s position when working in low ambient light conditions. If a more definitive airway is necessary, many experts recommend surgical cricothyrotomy as the procedure of choice.14 Endotracheal intubation should only be considered in the tactical environment when a patient is experiencing a respiratory compromise directly associated with airway obstruction as a result of trauma.15
An additional challenge of placing an advanced airway in the tactical environment is confirming tube placement. It is not practical to carry expensive equipment in this environment but simple colormetric devices may work.24 While these devices are suitable for confirmation of intubation, they are not acceptable for physiologic monitoring.
Another option for airway management in the tactical environment is the use of blind insertion airway devices. The American College of Surgeons recommends the use of a multi-lumen esophageal airway device, such as the Combitube™, or a laryngeal tube airway, such as the King LT™.13 These devices can be inserted without violating light discipline, and their correct placement can more easily be confirmed.
Much of what has been learned in battlefield medicine can be applied to the civilian prehospital setting. It is ineffective, and potentially dangerous, to attempt to apply standard prehospital practices to the civilian tactical environment. For civilian tactical medics to operate successfully in this unique environment they must have TEMS-specific protocols in place to justify their actions. These protocols can be effectively designed based on the TCCC guidelines with modifications to accommodate jurisdictional and environmental considerations. While further evaluation may be needed prior to the implementation of these protocol topics, they serve as a good foundation for the creation of new TEMS protocols.