A confluence of domestic incidents in the mid-1960s of unprecedented violence and scale demonstrated to law enforcement agencies in the United States the necessity of increased preparedness and specialized response capabilities. Law enforcement agencies in the United States today have near-immediate access to highly trained individuals and special equipment to respond to high-threat and operationally complex situations. Often referred to as special weapons and tactics (SWAT) teams, police tactical units are tasked with responses to high-threat crime and violence, including the prevalence of military grade weapons, taking of hostages, and organized terrorist activities.

National leaders within law enforcement, emergency medicine, and emergency medical services (EMS) have supported the development of dedicated medical support for tactical teams. Position papers from the National Tactical Officers Association (NTOA), National Association of EMS Physicians (NAEMSP), and American College of Emergency Physicians (ACEP) all support tactical emergency medical support (TEMS) as an essential component to help maintain the health and safety of law enforcement personnel, suspects of crime, and the general public. Today, the breadth of law enforcement tactical missions commonly includes hostage or barricade situations, high-risk warrant service, active shooter incidents, violent felon apprehension, civil disturbances, dignitary and executive protection, maritime and dive operations, and explosive ordnance disposal.

Tactical emergency medical support is now viewed as an essential adjunct to law enforcement operations and public safety. ^, Professional medical engagement in the area of TEMS continues to attain formal recognition and physician competency is an established requirement of subspecialty certification in emergency medical services (EMS). The efficacy of tactically trained medical providers and their roles have been described in a growing number of unconventional prehospital scenarios including responses to national disasters and national special security events (NSSE).

Tactical medicine augments high-threat law enforcement operations through medical threat assessments, delivering immediate emergency medical care, and promoting the safety and health of law enforcement personnel. Tactically trained medical personnel achieve their objectives through mission preplanning, clinical practices developed or adapted specifically for law enforcement operations, and establishing critical interfaces between police, conventional EMS, and the emergency health care system.

The broad goals of TEMS are to facilitate the overall success and safety of law enforcement missions during all phases of a tactical operation through the delivery of preventive, urgent, and emergency medical care. The basic approaches used by tactical medicine providers were initially developed by the military for small unit operations and have been widely applied to civilian law enforcement. In the operational setting, TEMS provides medical risk surveillance, injury and illness prevention, resource identification and coordination, and rapid access to emergency medical care.

A fundamental tenet of tactical medicine is that the medical support mission may be subordinate to the overall requirements and constraints of the law enforcement mission. In contrast to conventional EMS and in-hospital practices, where the sole consideration is typically the health and welfare of individual patients, the essential priority in a tactical mission is the success of the law enforcement objective. When a casualty occurs during a tactical operation, medical providers may be directed to delay or modify medical interventions until the tactical commander determines that rendering care will not jeopardize the overall mission.

A key consideration in TEMS concerns the level or type of medical provider to be deployed for operational medical support. Most commonly, tactical medicine is rendered by experienced emergency medical personnel with EMS backgrounds, trained at either the basic life support (BLS) or advanced life support (ALS) level. BLS providers are generally more plentiful, with fewer requirements for initial and ongoing training, whereas ALS providers are typically fewer, more difficult to train, and costly to maintain. Larger law enforcement agencies may deploy a mix of BLS and ALS personnel. True multitiered programs in TEMS are rare, not accounting for the potential operational role of tactical physicians or the agency medical director.

Jurisdictional EMS standards typically dictate many or all of the interventions commonly found within the ALS scope of practice. Nevertheless, intensively trained BLS providers with focused expansions of clinical practice have demonstrated effectiveness in providing operational medical support for federal law enforcement. TEMS medical directors maintain the authority to train BLS providers with judiciously enhanced medical skill sets deemed essential for care in the tactical environment.

Given that the overall volume of patient encounters in tactical medicine is relatively low, TEMS-specific protocols and training paradigms have historically been developed with a paucity of data and often based on anecdotal evidence. Although the impetus for the development of many tactical medicine programs was the risk of traumatic injuries during law enforcement operations, opportunities to provide more comprehensive medical support beyond the narrow scope of trauma care have emerged. There has been increasing evidence to justify broadened medical training, protocols, and expanded clinical skills sets for tactical medics.

Two distinct subsets of encounters occur in TEMS—low-frequency/high-acuity (e.g., gunshot wounds or falls from height) and high-frequency/low-acuity (e.g., sprains and strains or environmental exposures). Management of low-frequency/high-acuity patient encounters requires proficiency in complex lifesaving interventions; however, advanced clinical skills are difficult to maintain in low-volume EMS systems. Because TEMS providers typically also serve as law enforcement officers, resources including time, funding, and opportunities to maintain clinical skills are often insufficient.

By contrast, high-frequency/low-acuity patient encounters are not medically emergent or even urgent in many cases. Because patient populations encountered in TEMS are very often law enforcement officers, the impact of even these low-acuity medical issues on overall tactical team performance, capacity, or time can be significant. Unfortunately, the assessment and management of low-acuity medical complaints are often out of the scope of training and clinical practice of conventional EMS providers. The challenge for medical directors and law enforcement agencies is to ensure that protocols, training, and ultimately provider capabilities are sufficiently adept to manage the breadth of anticipated clinical encounters in TEMS.

As a subspecialty area of prehospital medicine and law enforcement operations, TEMS programs carry special administrative and medical oversight requirements. Qualified physician leadership and medical control, as in conventional EMS, is an essential component of tactical emergency medical support. Unique qualifications and expanded responsibilities exist for tactical medical directors. The ability to thoughtfully and proactively manage enhanced provider scopes of practice, adjuncts to conventional EMS interventions, and integration with existing health system and public safety infrastructures are equally important.

The successful integration of emergency medicine into law enforcement operations is a complex process that mandates effective medical leadership. All fundamental tenets of medical director accountability in EMS apply to tactical emergency medical support programs. The added challenges of directing care in the law enforcement arena and potential need for augmented capacities of TEMS providers call for additional qualifications of physicians responsible for such programs. Of foremost significance, the TEMS medical director must understand the central mission of the law enforcement agency. TEMS medical directors must formulate and implement clinical policies, protocols, and training sufficient for TEMS providers to deliver effective preventive, urgent, and emergent medical care in the dynamic law enforcement environment. Additionally, they must be proficient in the formulation of operational medical plans and have a superior understanding of special operations and tactical procedures.

Tactical combat casualty care (TCCC) originated as a project within naval special warfare, and tactically appropriate battlefield trauma care guidelines were published in 1996. These were later continued by the US Special Operations Command and used today throughout the Department of Defense. TCCC adapted civilian ALS principles to provide medical care during a hostile force encounter. These combat trauma care guidelines combine advanced trauma care with good small-unit tactics, balancing the need to treat casualties against the risks of providing such treatment within the context of an ongoing operation. The three major goals of TCCC are to treat the casualty, prevent additional casualties, and complete the mission.

The treatment principles of TCCC were developed based on the recognition that preventable deaths in combat scenarios occur from uncontrolled hemorrhage due to extremity wounds, tension pneumothorax, and airway compromise from maxillofacial trauma. TCCC recognizes that the tactical objective of neutralizing a hostile threat generally takes precedence over providing definitive medical care. TCCC divides the level of medical care provided during a hostile force encounter into three phases—care under fire (CUF), tactical field care (TFC), and combat casualty evacuation care (CASEVAC).

Care Under Fire

CUF is the first phase of casualty care that is rendered while tactical operators are under direct hostile fire ( Fig. e16.1 ). CUF encourages the casualty to remain engaged in the operation, seeking cover and concealment, and returning fire, if possible. Immediate lifesaving maneuvers that may be rendered by a casualty (“self-aid”) or a nearby tactical operator (“buddy aid”) are emphasized in this phase. Because uncontrolled hemorrhage from extremity wounds is a leading cause of preventable battlefield deaths, CUF emphasizes control of life-threatening bleeding with early use of a tourniquet. Airway management while under fire is preferentially deferred until the TFC phase. Both CPR and cervical spine immobilization are usually contraindicated in the presence of an ongoing hostile threat.

Care under fire—direct threat phase of care.

Courtesy Nelson Tang, with permission.

Tactical Field Care

TFC begins once operators, who remain at risk of injury, are no longer under direct hostile fire and is most often rendered by trained medical providers. Assessment and treatment priorities include assessing the casualty for unrecognized hemorrhage and controlling all sources of bleeding, and treating through the use of tourniquets and topical hemostatic agents ( Fig. e16.2 ). Attention is directed toward establishing or maintaining an unobstructed airway by using simple maneuvers, such as inserting a nasopharyngeal airway and/or placing the casualty in a recovery position. Casualties with unilateral blunt or penetrating chest trauma in respiratory distress are rapidly evaluated for tension pneumothorax or sucking chest wounds and undergo needle decompression when indicated, or are treated with an occlusive dressing, as necessary. When possible, intravenous (IV) or intraosseous access is established to administer fluids and/or medications. Grossly contaminated wounds, open fractures, or penetrating abdominal trauma may receive empirical IV antibiotics, especially if evacuation and transport times are prolonged. The need to perform a complete physical examination (secondary survey) is balanced against the risk of hypothermia, which should be actively managed using layered coverings and warmed IV fluids.

Tactical field care—indirect threat phase of care.

Courtesy Nelson Tang, with permission.

Combat Casualty Evacuation Care

CASEVAC is the care rendered while the casualty is being evacuated by ambulance or helicopter to undergo definitive care at a prestaged landing zone or casualty collection point ( Fig. e16.3 ). Interventions and therapeutics during the CASEVAC phase most closely approximate conventional EMS care and include continued ALS while en route to receiving facilities, most often trauma centers. The situational need for medical care, severity of specific injuries, numbers of casualties, and local system practices determine whether the TEMS provider accompanies an injured law enforcement officer to the hospital to act as the patient’s advocate, as well as a liaison to tactical command.

Combat casualty evacuation care—evacuation phase of care.

Courtesy Nelson Tang, with permission.

Committee for Tactical Emergency Casualty Care

Whereas TCCC is widely accepted in the military combat setting, it is not directly applicable to the civilian environment. Recognizing this, a diverse group of first responders, law enforcement leaders, and tactical medicine experts convened in May 2011 to create the Tactical Emergency Casualty Care (TECC) guidelines, a set of best practice recommendations for casualty management during high-threat civilian tactical and rescue operations. Based on principles originally derived from its military analog, TECC guidelines consider key differences in the civilian environment, including resource allocation, patient population, and scope of practice. TECC is applied in three phases—direct threat, indirect threat, and evacuation care. The Committee for Tactical Emergency Casualty Care (C-TECC) meets formally twice per year to critically evaluate emerging evidence and update its consensus open-access guidelines.

Direct Threat Care

To meet the specific operational scenarios and terminology used in the civilian sector, the first phase of care under TECC is termed direct threat care . The priorities of direct threat care emphasize mitigating the threat, moving the wounded to an area of relative safety, and managing hemorrhage using tourniquets. Emphasis is placed on the importance of various rescue and patient movement techniques, as well as rapid airway opening and positioning techniques, if operationally feasible. Treatment and operational requirements are the same for all levels of providers during this phase of care.

Indirect Threat Care

Indirect threat care can be initiated once the casualty is in a relatively safe area, with proper cover and less chance of rescuers being injured or patients sustaining additional injuries. Similar to TCCC, assessment and treatment priorities in this phase focus on the preventable causes of death. Four different levels of providers are assigned to scope of practice and skill sets based on level of training and certification—law enforcement officer, emergency medical responder (or equivalent), emergency medical technician (EMT), and advanced EMT-paramedic.

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