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 as many as 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 that 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 Authors Michael Feldman, Brian Schwartz and Laudie Morrison 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