Sunday, January 23, 2011

Tactical Emergency Medical Services-Docs with glocks?

The concept of physicians and paramedics working with tactical teams is relatively new. Tactical teams, known variously as special weapons and tactics (SWAT), special response units, rapid response units, or hostage rescue teams, were first established in 1968 in Los Angeles. SWAT teams often utilize paramilitary tactics and respond to a variety of emergencies that ordinary police units are ill equipped to deal with. The possibility of injury to team members, hostages, and suspects and the need for integrated operational security led to the incorporation of medical elements within these teams. Tactical emergency medical services/support (TEMS) has now become standard (and in states like California, codified) and the role of the physician has evolved beyond simple direct support of a tactical team. The need for such medical support has been clearly illustrated by incidents where their presence effected a positive outcome as well as when their absence has led to preventable poor outcomes: the 2002 Moscow theater siege that resulted in 169 fatalities (139 hostages) and hundreds more hospitalized or the 1993 breach of operational security at the Branch Davidian complex in Waco Texas that led to the deaths of 82 Davidians and 4 ATF agents.  
TEMS providers are often employed either part time or on a volunteer basis as the frequency of SWAT call outs combined with the necessity to maintain their medical acumen makes full time activity impractical. Training for TEMS is also variable, most departments require a minimum of attendance at a tactical EMS school such as CONTOMS (Counter Narcotics and Terrorism Operational Medical Support) school or the former HK school (now known as the International School of Tactical Medicine.
These 1-2 week courses familiarize medics with tactical operations and their role in a tactical team. They typically also provide familiarization with the common weapons used by SWAT teams: Glock pistols, MP5 submachinguns, M-4/AR-15 carbines, and tactical shotguns. The level of weapons training varies from being able to clear and safe these weapons to full qualification. Other training specific to TEMS includes tactical team movement, armored operations, helicopter operations, night operations, chemical agent training, weapons retention and combatives, patient packaging and movement, and emergency medical procedures in zero visibility environments.  Most of this training focuses on preparing the provider to work in the extremely austere tactical environment and follows the treatment guidelines outlined in the military combat casualty care (TCCC) curriculum.  Very active departments commonly choose to send their medical providers to a full SWAT school so that their TEMS officers are cross-trained in all facets of tactical operations. 

The role of the medical provider varies by locality. Some TEMS providers are sworn, armed, fully integrated members of a tactical team. These providers are able to provide for their own security during entry scenarios and are able to tactically engage suspects if the need arises. Other providers are posted at the tactical perimeter ready to make entry as soon as the need arises. While the former is preferable, the latter may be necessary due to training limitations or political considerations. Large units often have a medical provider that makes entry with the team while another provider, acting as medical commander, remains in the command post to advise the SWAT commander. Whatever the model, attending standardized training and regular training with the SWAT team is an absolute necessity if the medical provider is going to become an active and trusted team member. At the physician level the role of tactical medical support has expanded to include medical threat assessment, large event medicine, VIP/protective and government security services, and press relations.   

The tactical environment has many unique challenges that is beyond the training and capabilities of pre-hospital medical providers. Medical support for tactical operations is now seen as an essential component for any tactical team. Physician medical directors represent the most specialized application of medical care, and are ideally positioned to act as facilitators of tactical-civilian integration and advocates of standardized training for TEMS providers. With the expanding role of physicians in operational and tactical settings its clear that the future will hold many exciting possibilities that push the boundaries of "traditional" emergency medicine and may one day be considered an EM sub-specialty in its own right. 

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