Tactical Medicine: When SWAT Dials 911

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Tactical Medicine When SWAT Dials 911

• Philip Yoon, MD
• Associate Professor, Depts. of Family Medicine
  Emergency Medicine
• University of Alberta Hospital

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Disclosure

• I do not have an affiliation (financial or
  otherwise) with any commercial organization that
  may have a direct or indirect connection to the
  content of my presentation.

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Acknowledgements

• Palm Springs Police Department
• United States Navy
• Rising Sun Tactical (Edmonton, AB)
• Canadian Forces
• Canadian Tactical Operational Medical Solutions
  (CTOMS) Inc.
• Edmonton EMS
• Edmonton Police Service Tactical Unit

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Phil - a Jack Bauer wannabe?
ABSOLUTELY!
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Case Example

• 0315 One or more armed masked assailants enter a
  24-hr convenience store demanding money from the
  clerk. The clerk refuses, activates the silent
  alarm, and is shot once in the upper left
  abdomen.
• 0318 Police officers arrive at the scene and
  secure the perimeter. The clerk lying on the
  ground can be seen through the windows. It is
  unknown if the perpetrator(s) are still on the
  premises. Tactical and EMS are called.

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Case Example

• 0322 EMS arrive and can see the clerk through
  the window on the ground in a pool of blood
  making head movements. Police Staff Sergeant on
  scene does not allow EMS to enter the store. EMS
  notifies trauma centre and Trauma Team activated.
• 0330 Tactical Unit arrives and a decision is
  made to make a covert entry in the rear of the
  store.
• 0400 The scene is finally cleared and EMS is
  permitted to enter the building and attend to the
  clerk.

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Case Example

• 0410 EMS arrives to the ED with a 24 year old
  male with a single GSW to the LUQ with VSA and
  CPR in progress.
• 0412 Resuscitative efforts are terminated.

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Learning Objectives

• To provide an introduction to the discipline of
  Tactical Medicine.
• To outline the components, training aspects, and
  environmental characteristics of Tactical EMS
  operations.
• To briefly review some current controversies in
  Tactical Medicine.

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Presentation Outline

• Tactical Medicine concepts
• History, goals, and role
• TEMS components
• TEMS characteristics
• Training
• Medical Threat Assessment
• Zones of Care
• Tactical Medicine controversies

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Tactical Emergency Medicine Support (TEMS)

• TEMS is a term referring to non-military EMS
  services that have been modified for the
  realities of the tactical environment (It) is
  emerging as a new sub-specialty with nationwide
  application in prehospital care.
• Heiskell, LE, Carmona, RH Tactical Emergency
  Medical Services An Emerging
• Subspecialty of Emergency Medicine, Ann Emerg Med
  199423778-785.

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TEMS

• Comprehensive medical support of law enforcement
  special operations
• Baseline medical preparations (standard operating
  procedures)
• Deployment pre-planning
• Operational support
• Medical advocacy
• Out of hospital care in austere environments -
  The best care in the worst places.

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A Brief History of TEMS

• Napoleons surgeon-in-chief introduced
  battlefield cart ambulances
• US Civil War - Union nurse (and founder of the
  American Red Cross) Clara Barton pioneered the
  treat the soldiers where they lay concept
• Military Medicine - more formalized from WW II on
  - intrinsic medical capabilities required for
  special operations
• Civilian law enforcement operations - Special
  Weapons and Tactics (SWAT)

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TEMS in Canada
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TEMS in Canada

• At the end of 2008, there were 9 agencies with a
  TEMS unit (Ottawa, Toronto, Montreal, Sherbrooke,
  Edmonton, Hastings-Quinte, Calgary, York, Peel)
• No tactical paramedics are armed
• No tactical physicians
• TEMS not as advanced or established as in the US

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TEMS Misconceptions

• Not Docs with Glocks
• TEMS members are not SWAT operators

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Goals of TEMS

• To accomplish the operation without injury or
  death resulting from the teams intervention
• Reduce morbidity and mortality among law
  enforcement members, victims of violence,
  bystanders, and other parties
• Improve position against liability
• Diminish disability costs and lost productivity
  to law enforcement organizations
• Maintain good team morale
• Contribute to public safety

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Role of TEMS

• An integrated unit within the local or regional
  EMS system
• Maintains a working relationship with law
  enforcement organization(s)
• Specializes in pre-hospital care customized to a
  tactical environment and special operations

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Conventional vs. Tactical EMS

• Standby ambulance model
• Delayed response
• Delayed transport
• External to law enforcement operations
• EMS staff without customized equipment

• Integrated into law enforcement operations
• Rapid response
• Rapid / delayed transport
• EMS staff familiar with LE operations and use
  customized equipment
• Operational security maintained

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Tactical Medicine

• Good medicine can be bad tactics
• Bad tactics can get you or others injured or
  killed
• The worse the tactics, the more medicine that
  will be required
• A single casualty qualifies as a mission failure
• Tactical medicine is about the proper
  intervention at the right time
• ABCs are different!

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Phil at SWAT School
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Like playing Doom
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Civilian TEMS vs. Military Medicine

• Civilian Tactical Medicine
• Police procedures
• Protection of the community
• Life saving mission
• Suspect apprehension
• Casualties are unacceptable

• Military tactics
• Elimination of the enemy
• Search and destroy missions
• Render enemy dead or ineffective
• Acceptable casualty rate

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Can TEMS make a difference?

• Demonstrated need for immediate, life saving
  interventions
• Greater than 80 of those fatally wounded by a
  bullet die within 30 minutes of injury
• Pope A, French G, Longnecker DE, eds. Fluid
  Resuscitation State of the science for treating
  combat casualties and civilian injuries.Washington
  , DCNational Academy Press1999.
• Rapid response for the Big Three
• Airway obstruction
• Tension Pneumothorax
• Hemorrhage

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Unique Attributes of TEMS

• Care under fire
• Weapons safety
• Hazardous materials
• Barricades / dangerous obstacles
• Specialized equipment
• Familiarity with less than lethal munitions
• Forensic evidence preservation collection
• Crime scene management
• Integration with a tactical law enforcement team

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TEMS Unique Skills

• Medical threat assessment
• Casualty collection, triage, and evacuation
• Remote assessment methodology
• Sensory deprived / overloaded assessment
• Tactical movement with light and noise discipline
• Weapons management
• Environmental assessment
• Medicine across the barricade
• Hazmat decontamination procedures
• Canine medicine

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Equipment Personal Protection

• Helmet
• Eye protection
• Body armor
• Gloves
• Gas masks
• Versatile clothing
• Joint pads
• Environment-specific

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Tactical Medical Equipment

• Mission specific
• Versatile
• Portable
• Durable
• Easily deployable
• Simple
• Includes communication devices

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TEMS Personnel

• Tactical Paramedic
• Tactical Nurse
• Tactical Physician
• Emergency Medicine
• Surgery

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Edmonton TEMS Training
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Edmonton EMS
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Tactical Medicine Training

• SWAT school
• Physical conditioning
• Weapons training
• Weapons management
• Armed vs. unarmed
• Close quarters battle/combat
• Field Medicine
• Pre-hospital medicine
• Environmental / wilderness medicine
• Combat medicine
• Critical care / trauma care
• Canine medicine

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Tactical Medicine Training

• Chemical munitions and deployment techniques
• Distraction devices and effects
• Booby traps and unconventional or improvised
  weapons
• Weapon systems and management
• CBRNE

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Medical Threat Assessment

• A comprehensive assessment of medical issues of
  the people involved, the available resources, and
  integration of EMS operations with various other
  agencies (police, fire, city, hospitals, etc.)

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Remote Assessment

• Assessing viability
• Call to cover
• Instructions for self care
• Risk / benefit ratio

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Spot the imposter
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Drop the frackin camera
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Zones of Care

• Personal safety is of primary importance
• Hot Zone Care under fire
• Warm Zone
• Cold Zone

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Hot Zone

• Care under fire
• Best defense is SUPERIOR FIREPOWER
• Very limited or non-existent assessment and
  temporizing measures
• Priority is protection of self and patient
• Emphasis on extraction scoop and run

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Warm Zone

• Sufficient cover / concealment from threats
• Possible area of vulnerability
• BLS for immediately life-threatening problems
  Airway management, needle decompression,
  hemorrhage control
• C-spine control may be a luxury

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Cold Zone

• Standard EMS protocols
• ALS procedures
• More comprehensive survey
• Coordination of patient triage and transport

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Common Injuries

• Most common injuries are bruises, sprains, and
  simple lacerations
• Injuries to suspects are most commonly due to
  falls
• Heat and cold injuries
• Rarely, penetrating trauma

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TEMS Unique Circumstances

• Warrant service
• Barricaded suspect
• Hostage situation
• Active shooter in a populated building
• Clandestine drug labs
• Armed suspects
• Clandestine drug labs
• Mass gatherings / protest demonstrations
• Riots
• Dignitary protection

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Tactical Medicine Controversies

• Conducted Electrical Weapons
• Excited Delirium
• In-Custody Medical Clearance
• Field Hemorrhage Control
• Armed Tactical Medics

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Conducted Electrical Weapons

• Taser use by law enforcement
• Physiological effects of Taser use
• High profile public inquiries

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Excited Delirium

• A poorly understood syndrome involving physical
  struggle and cardiorespiratory failure in
  in-custody individuals
• Involvement of law enforcement use of force
  techniques (physical restraint, less-than-lethal
  weapons, Taser)

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In-Custody Medical Clearance

• Requests from law enforcement to provide medical
  clearance of individuals heading to a
  correctional centre
• Lack of national standards for pre-hospital and
  ED evaluation of newly arrested individuals

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Field Hemorrhage Control

• Tourniquet use indications and safety
• Hemostatic dressings

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Armed Tactical Medics

• Tactical Paramedics / Physicians carrying
  firearms?
• Care-giver and law enforcement officer role
  conflict?

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Final Acknowledgement
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Questions?
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I need a tactical barf bag