At 0430 hours we meet at the station to check and double-check all our equipment, including our tactical gear. Our personal protective equipment (PPE) is loaded: ballistic vests with gear attached—not with weapons but with life-saving tactical medical gear at the ready. EMS, fire and police radios are included.
We drive to the briefing location and join the SWAT team to review elements of the incident action plan (IAP). The IAP discloses all the potential dangers of the operation (e.g. guns, drugs, gang suspects or all three), and the tactics the team plans to use. As medics, we factor in which hospitals, trauma centers and landing zones can be utilized given the location of the operation. Two of us roll to the operation location with the SWAT team in the Armored Response Vehicle (ARV), while the third medic follows in the ambulance as part of the caravan. Our primary purpose is to ensure the operators are safe given all the potential dangers. On site, medics stay in the ARV and the team makes entry.
We follow the operation on the radio for possible problems. We are prepared, but this operation, like most, lasts about 10 minutes with no injuries and suspects detained. In every operation there is always the potential for significant combat-type injuries, but the immediate presence of tactical medics allows for the best chance of survival to every member of the operation.
Tactical paramedicine is certainly not new, especially in California. Going back to the ‘70s, the Los Angeles County Sheriff’s tactical team included law enforcement paramedics on their full-time team. However, tactical paramedicine has come more into prominence over the last decade, especially from paramedics and other emergency responders outside of law enforcement. This progress has been bolstered by evidence-based advances in tactical emergency casualty care born out of a decade of combat, as well as the establishment of guidelines for scope of practice, as well as the initial and continuing education in this specialized area. Through the hard work of schools like the International School of Tactical Medicine (ISTM) and organizations like the Committee for Tactical Emergency Casualty Care (C-TECC), tactical medicine has been greatly advanced and has been made more readily available to emergency care providers. The result is that across the country, highly trained paramedics, EMTs, RNs, MDs and PAs are supporting tactical teams.
The San Mateo County Tactical Emergency Medical Services (TEMS) team is a unique and highly trained group comprised of responders from both the local private ambulance service, American Medical Response (AMR), and the fire department of San Mateo County, Calif. The team serves and responds with the county’s four SWAT teams and its Terrorism Counter Assault Team (TCAT). The 20 paramedics and EMTs on the team undergo the same physical fitness requirements as the SWAT teams and are required to attend an 80-hour tactical medic school. They are also required to attend monthly trainings and adhere to the training matrix that is set from the tactical medic guidelines in “California POST/EMSA Tactical Medicine Operational Programs and Standardized Training Recommendations” (2008). This is in addition to the training requirements of their home agencies for their routine positions as firefighters/paramedics.
In San Mateo County, tactical medics have been responding with SWAT teams for more than ten years. The development of the San Mateo County TCAT following the 9/11 attacks brought to the forefront the concept of protecting our SWAT operators as they respond to more complex and coordinated events. This eventually extended to the four tactical teams as a means to give them the best possible care in the most timely fashion. San Mateo County Sheriff Captain Mark Wyss states, "We can't imagine sending our SWAT teams out without our medics. They play a crucial and important role in team health and survival."
The public/private partnership of the team is a recent development. Just a few years ago there were two tactical medic teams in the county: a fire department-based team and a private provider-based team. In 2012 the county law agencies requested one consolidated team with an easily requested, standardized, consistent and expeditious response for SWAT operations. Because both teams understood the importance of the mission, the consolidation was seamless. After some team-building exercises and common SOPs, 2013 saw the official birth of San Mateo County TEMS.
In 2013 the TEMS team responded to 23 events with county SWAT teams as well as with other specialized teams, such as the gang task force, narcotics task force, FBI SWAT, DHS, San Francisco SWAT and the USSS. Team co-commander Mike Marsh says, "We earned the privilege of working with these allied agencies as a result of the team's reputation for high-level service and professionalism.”
The joint team is not without challenges. Because the majority of tactical operations do not generate revenue, it can potentially strain budgets both in the private and public sectors, especially with ever-reduced cost recovery and reimbursements. However, Brad White, AMR’s general manager for San Mateo and San Francisco counties, says that, "We are committed to the highest level of service to our communities and our law enforcement partners." This sentiment is echoed by Central County Fire Chief Mark Ladas, who says, "The concept of a tactical medic team was initially created to support our regional SWAT team; to us it was a natural extension of what the fire service does that was aided by a few motivated individuals and our excellent relationship with our law partners."
Since working with SWAT teams in austere environments requires a specific temperament, prospective team members go through rigorous vetting and mentoring before they are allowed to respond on callouts (in addition to the training described earlier in this article). The tactical medic team does not carry firearms and operates in the non-direct threat area with force protection. This clarifies our TEMS mission of saving lives and reducing injuries, but requires embedding concepts and stringent training in order to keep the team safe.
The San Mateo County TEMS team medical doctor, Dr. Dan Huie, who is also a reserve officer with the Hillsborough, Calif. police department and a tactical medic, brings the point home. He comments, "Our goal is to save lives in critical incidents. This TEMS program is designed to provide appropriate medical care at the earliest opportunity and the rapid transition of casualties to higher levels of care as soon as feasible. The San Mateo program brings together law enforcement, fire department and EMS agencies into a cohesive task force to accomplish this mission."
As state and local EMS agencies provide the framework and policies for tactical emergency care, providers and teams now have a legitimacy that was not previously widespread. In California this has been spearheaded by the state Emergency Medical Services Authority (EMSA), Chief Deputy Director Dan Smiley and also by the late Ken Whitman, who held the role of Special Consultant Homeland Security Training Program for Police Officer Standards for Training (POST). The partnership between EMSA and POST led to the development of a groundbreaking document, "California POST/EMSA Tactical Medicine Operational Programs and Standardized Training Recommendations," which gives our state tactical paramedics clear direction for their programs and practices.
One future opportunity we see in our county, is that as combat veterans return and integrate into fire, EMS and law positions, they can be utilized as subject matter experts in tactical care concepts. Every solider has learned the essentials of Tactical Combat Casualty Care (TCCC), especially as it pertains to hemorrhage and airway control. These care guidelines have now been adopted by the civilian counterpart of Tactical Emergency Casualty Care (TECC).
Moving forward, our goal is to make the San Mateo County TEMS team sustainable both from a financial and equipment perspective, and increase discipline and proficiency by having stringent evidence-based practices and guidelines. Our goals are to eliminate preventable deaths and keep our SWAT teams functioning at the highest level. We want to ensure that at the end of every operation, every SWAT operator and medic goes home safely.
Kolman JA. A Guide to the Development of Special Weapons and Tactics Teams. Springfield, IL: Charles C Thomas, 1982.
California POST. Tactical Medicine Operational Programs and Standardized Training Recommendations, post.ca.gov/Publications/TacticalMedicine.pdf.
Committee for Tactical Emergency Casualty Care, c-tecc.org.
Callaway DW, Smith ER, et al. Tactical Emergency Casualty Care (TECC): Guidelines for the Provision of Prehospital Trauma Care in High Threat Environments. Journal of Special Operations Medicine, 2011, 11(3): 104-22.
John Kammeyer is a division chief assigned to the Central San Mateo County Training Division. He is the San Mateo County regional tactical medical team commander.