Chapter 39 David K. Tan, William P. Bozeman, and Denis FitzGerald Law enforcement is an inherently dangerous occupation with 1,487 peace officers killed and 625,260 assaulted in the line of duty from 2000 to 2010. This does not include 72 officers who lost their lives during the September 11, 2001 terrorist attacks [1–6]. Members of special weapons and tactics (SWAT) teams are at even higher risk, sustaining an injury rate of approximately 33 per 1,000 officer-missions [7]. Although beginning as medical support to SWAT teams, tactical emergency medical support (TEMS) now encompasses the provision of preventive, urgent, and emergency medical care during such high-risk, extended-duration, and mission-driven law enforcement special operations [8]. The military has long recognized the value of early and definitive medical care in areas of operations. The success of its approach to embedded medical support has resulted in expansion to units other than special operations [9,10]. Although they encountered situations similar to their military counterparts, tactical units in civilian law enforcement underrecognized the benefit of medical support, and its establishment remained underdeveloped until 1989 and 1990 when national, multidisciplinary conferences promoted the provision of medical support to civilian tactical teams [11–13]. Today, the National Tactical Officers Association “… endorses and supports the incorporation of a well-trained and equipped Tactical Emergency Medical Support (TEMS) element into all tactical teams” [14]. An early survey of SWAT commanders found that the most common form of medical support for their team was a civilian ambulance on standby at a predesignated location with a crew that had no training in tactical movement or medicine. These findings suggested a need for established TEMS protocols, medical oversight, and specialized training, for several reasons [15]. First, hostile conditions commonly encountered in the tactical arena place standard prehospital care providers at risk. Unprepared and unequipped to deal with these dangers, traditional EMS providers may become patients rather than caregivers. Second, entry into the operational area will be controlled, and access may be denied to non-law enforcement personnel. Also, typical EMS protocols prohibit entry of providers into unsecured environments, preventing timely medical evaluation and treatment of casualties in a tactical situation. Third, although the operational scene may be located in an urban setting, the treatment environment can be functionally austere. Recent military combat experience demonstrated improved survival with specially trained providers, with a 44% improvement in battle casualty survival despite a 46% greater rate of casualties sustained [16]. Fourth, planning for medical contingencies requires knowledge of the planned operation of the tactical team, but law enforcement officials are reluctant to share details of their operational plan due to security concerns [17]. Thus, a more integrated TEMS structure preserves the security of sensitive information while allowing for better planning and improved communication. An understanding of the unique TEMS environment and the proper training to operate in that environment are essential to a successful tactical medical support program to enhance mission accomplishment, avoid liability, diminish disability costs, and maintain team morale [18]. The medical support of law enforcement tactical operations creates an environment with unique attributes (Box 39.1). Medical oversight enhances the development of appropriate protocols and teaching of additional skills (Box 39.2). The areas of operation for a tactical mission are usually based on the threat level. Traditionally, terms such as inner and outer perimeter have been used. While the concept of static inner and outer perimeters is useful in planning tactical operations, its application to tactical medical support is limited because as the incident evolves, areas of safe refuge or egress may rapidly change. Stratifying the medical areas of operations based on risk better reflects the dynamic process of treating the injured in the tactical arena. The area with the greatest risk is the hot zone, where an immediate threat is present. This risk may be secondary to a known threat or to hazardous conditions. Medical priorities in the hot zone must be limited to patient extraction or applying a tourniquet for life-threatening hemorrhage. Even these procedures may be delayed because of the potential risk for further injury to both the patient and the rescuer. The cold zone is the area with neither significant danger nor threat. Medical care in this area parallels that in the routine EMS world. The warm zone is the area of potential or indirect threat. Medical care provided in this zone is dictated by weighing the risk/benefit ratio and the perceived level of threat. Thinking in terms of graduated zones provides a basis to critically analyzing medical treatment options in a highly dynamic environment [19]. The military, in its Tactical Combat Casualty Care paradigm, has developed a similar classification that also divides the area of care into three zones. “Care under fire” is analogous to the hot zone. Preventing further injury, tourniquet application, and retreating to safety are the only acceptable interventions. “Tactical field care” is similar to the warm zone and includes airway management, breathing and circulation intervention. Needle thoracostomy, vascular access, and other immediately life-saving procedures are part of this phase. “Tactical evacuation care,” or TACEVAC, includes more definitive management as the patient is evacuated away from the threat by any available means and is analogous to the cold zone [20]. Tactical emergency medical support providers should be familiar with the specific weapons of the tactical team’s arsenal, along with their associated medical risks and appropriate treatment strategies for patients exposed to them. Basic training in weapon handling is a minimum requirement for the TEMS provider since casual or improper handling can have tragic consequences. Handling of unfamiliar weapons poses an even greater threat, and a protocol for the safe transfer of such a weapon to a tactical team member is encouraged. Weapons designed to incapacitate suspects while minimizing the risk of death or serious injury are known as less lethal weapons (LLWs). They include chemical irritants, kinetic impact projectiles, noise/flash diversionary devices (NFDDs), and conducted energy weapons (CEWs). The term “less lethal” indicates that lethal effects are less likely than with traditional firearms but that death is possible. Chemical irritant agents are a common tool used for incapacitation and crowd control. They are usually highly effective, though some subjects are able to resist their effects. The most common agent used is oleoresin capsicum (OC) derived from hot peppers and commonly known as pepper spray. Ortho-chlorobenzylidene malononitrile is a synthesized chemical irritant commonly known as “tear gas” and abbreviated as CS. The agents are chemically unrelated but produce similar effects, with intense burning sensations on exposed skin and mucous membranes within moments of contact. Ocular pain, lacrimation, and blepharospasm are prominent effects. Rhinorrhea and dyspnea are also common although true bronchospasm is rare. Incapacitating symptoms last 10–15 minutes and resolve over 30–60 minutes. Medical treatment should include removal of contaminated clothing and irrigation with water (OC) or moving air (CS). Formal medical evaluation is rarely needed for either of these agents. Kinetic impact projectiles, fired from specialized launchers, include “rubber bullets,” wood, plastic, and foam batons, and flexible fabric containers containing small metallic beads (“beanbags”). Kinetic impact projectiles are larger and heavier than traditional bullets and travel more slowly. They present a large surface area which distributes the force of impact, making them less likely to penetrate skin. Impact sites from these weapons should be evaluated carefully for unintentional penetration and for serious underlying injuries. Fatalities can occur with head, neck, and precordial impacts [21,22]. Noise/flash diversionary devices are designed to surprise and temporarily disorient subjects in their vicinity by producing a bright flash and loud explosion. NFDDs are typically activated and placed by hand though launched projectiles are also used. NFDDs can produce major blast trauma, tympanic membrane rupture, and burns if they explode in tightly enclosed spaces or in close proximity to or in contact with a person. In addition, they are an ignition risk and can cause fires. Although electrical stun gun weapons have been available for decades, modern CEWs are a relatively recent addition to the police arsenal of LLWs. CEWs are similar to pistols in appearance and deliver a series of brief electrical pulses that produce pain and involuntary muscular contractions. The low-current, high-voltage pulses are delivered either by direct contact with the weapon or via a pair of insulated wires attached to sharp metal probes that are fired by compressed gas and are designed to puncture and remain imbedded in skin or clothing to allow completion of an electrical circuit. The most commonly used CEW is the TASER, an acronym for Thomas A. Swift’s Electric Rifle of storybook fame. The electrical pulses of the TASER X26 CEW each contain approximately 0.36 joules of energy at variable voltage up to 50,000 volts. Nineteen pulses per second are delivered for a period of 5 seconds, and the discharge can be truncated or repeated by the operator [23]. Common risks of CEWs include puncture wounds from the sharp probes and blunt trauma from resulting falls, although the overall injuries from CEWs are very low. A large multicenter trial found that 99.7% of real-world suspects exposed to CEWs had mild injuries or none at all [24]. Vertebral compression fractures from intense muscular contraction and ignition of flammables by electrical arcing have been reported [25]. Great debate exists regarding the risk of ventricular dysrhythmias. Current research suggests a very low risk, at one in 2.5 million exposures [26–29]. However, due to ongoing concerns about deaths in police custody associated with CEW exposure, its safety remains under active investigation [30]. Clandestine labs pose a special problem for both law enforcement and TEMS providers. Many of the materials used to produce illicit drugs are flammable or explosive, increasing the possibility of burn and blast injuries from ignition due to weapons fire, CEW deployment, or even light switches. Acute and chronic health effects from toxic exposure must be considered since illicit drug operations rarely use safe materials or practice safe handling procedures. Additionally, booby traps are a known hazard of clandestine operations with the potential to cause routine and unusual wounding patterns. Loss of evidence because it was unrecognized, disturbed, improperly stored, or not maintained in a chain of custody can damage an investigation. One study concluded that emergency care providers often overlooked, lost, or discarded forensic evidence [31]. The TEMS physician must have knowledge of the principles and procedures used to maintain evidence integrity. The patient care report should also document forensic findings, including evidence that may be lost in transport or continuing care of a patient, such as firearm soot on clothing or skin. Tactical medical providers may be faced with pediatric, geriatric, and/or chronically ill individuals with special medical needs. In addition, it may be difficult to determine if acute medical conditions are contributing to the behavior of some patients. An example that has received a great deal of attention in the professional and lay press is excited delirium.
Tactical EMS
Introduction
History of tactical teams and TEMS
The TEMS environment and limitations of traditional EMS response
Unique attributes of TEMS
Zones of care
Weapons safety and less lethal weapons
Chemical agents
Kinetic impact projectiles
Noise/flash diversionary devices
Conducted energy weapons
Hazardous materials
Forensic evidence collection
Special patient populations and excited delirium
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