Chapter 25 Tactical Medicine*

Lawrence E. Heiskell, Bohdan T. Olesnicky, Sydney J. Vail

Tactical medicine can be defined as both emergency and nonemergency care provided to victims of illness or injury related to law enforcement or military operations, often in a hostile environment.⁵⁴ Tactical medicine in the early years was often referred to as tactical emergency medical support (TEMS). The emergency medical services (EMS) and prehospital community called it tactical EMS, and the U.S. military coined the phrase combat casualty care. Numerous law enforcement agencies now have tactical medical teams composed of physicians and prehospital care providers. Because many law enforcement agencies throughout the United States and branches of the U.S. military have embraced this concept, it is now commonly known as tactical medicine.

Before 2001 there was a perception of professional separation between physicians in traditional medical practice and the tactical medicine physicians involved in law enforcement. This was probably related to what might be seen as competing priorities for physicians when dealing with sick or injured patients who are suspects in a law enforcement investigation.

No other subspecialty in emergency medicine has experienced the growth rate of tactical medicine. In the past 20 years, more than 200 publications addressing tactical medicine issues have been written. Tactical medicine educational programs have trained thousands of emergency medical technicians (EMTs), paramedics, and physicians, who have responded to the call to provide on-scene emergency medical care to members of the law enforcement community or active duty military ⁵⁰ (Figure 25-1). Tactical medicine is very similar for both military and civilian tactical providers. Techniques, strategies, protocols, and equipment are all virtually identical, with few differences. The military tactical medical provider must deal with long deployment times, therefore incurring a significant preventive medicine requirement. Although routine medical care and performance enhancement (e.g., conditioning, nutrition, and rest) are important for both civilian and military tactical teams, they take on a longer-term function for the military tactical medicine provider. A civilian tactical operation typically takes hours to days. (The Waco and Ruby Ridge incidents were exceptions, more in concert with a military-style length of engagement.) A typical tactical military operation may take days to months, and other aspects—such as disease and nonbattle injury—have become as important as the tactical medical care (Table 25-1).

FIGURE 25-1 Police tactical medic administers intravenous fluids to a downed officer.

(Courtesy International School of Tactical Medicine.)

TABLE 25-1 Nonbattle Conditions Encountered by Tactical Medical Personnel (Spring 2003)*

Primary ICD-9 Disease Category	n	% of Total
Digestive	44	17.4
Symptoms ill defined	38	15.0
Mental disorders	29	11.5
Musculoskeletal	29	11.5
Genitourinary	21	8.3
Nervous system sense organs	17	6.7
Skin	15	5.9
Supplemental	15	5.9
Infectious and parasitic	10	4.0
Circulatory	10	4.0
Endocrine, nutritional	8	3.2
Neoplasms	6	2.4
Respiratory	5	2.0
Pregnancy	3	1.2
Congenital	3	1.2
Total	253	100.0

ICD, International Classification of Diseases.

* Navy/Marines Operation Iraqi Freedom from March 21 to May 15, 2003.

Tactical medicine has been a mainstay of military operations since the beginning of modern warfare. The hospital corpsman, or combat medic, was deployed on the front lines with the warriors to provide basic medical care. This care was often provided under fire, sometimes in the harsh environments of the jungle, desert, ocean, high mountains, and other austere conditions. As the science of medicine improved, the need to deliver higher levels of care further toward the forward edge of the battle area was recognized. During Operation Iraqi Freedom, shock trauma platoons, composed of emergency physicians and support staff, were sent to the front lines to provide advanced resuscitative support. These units could be fully operational and caring for patients in less than 30 minutes. Mobile surgical teams and forward resuscitative surgical teams developed the technology to put trauma surgical teams within minutes of the location of a combat casualty. These teams have evolved to become fully mobile and able to set up or dismantle in 30 minutes, use tent shelters or shelters of opportunity within which to perform operations, and provide lifesaving damage-control surgery to multiple patients under the extreme conditions of modern warfare. During civilian law enforcement tactical operations, the tactical medic can be deployed within seconds to care for an injured officer (Figure 25-2).

FIGURE 25-2 Forward resuscitative surgical team tactical medics evaluate an injured tactical team member.

(Courtesy International School of Tactical Medicine, Lawrence E. Heiskell, MD.)

Tactical medics are trained to resuscitate, treat, and transport patients in extreme hot or cold temperatures, over rough terrain and hostile territory, while protecting the patient from further injury. The capabilities are such that a critical patient can be pharmacologically paralyzed and intubated, while wounds are still open and attempts are made to prevent the hypothermia, dehydration, and coagulopathy inherent in postsurgical patients (Figure 25-3).

FIGURE 25-3 Injured tactical officer being extracted from the hot zone.

(Courtesy International School of Tactical Medicine, Lawrence E. Heiskell, MD.)

Tactical medicine has advanced to anticipate and react to changes in combat strategy, which translates directly to law enforcement. For instance, during Operation Iraqi Freedom, the most serious injury patterns were primarily high-velocity penetrating wounds—that is, mostly gunshot wounds (Figure 25-4 and Table 25-2).²⁹ As the war against terrorism has progressed, the weapon of choice of the insurgents has become the improvised explosive device (IED).⁷⁷ This weapon produces significantly more trauma, including shrapnel, blast, and thermal injuries. It has also required a change in protective body armor because the injury patterns have changed to include more devastating extremity and head-and-neck wounds than torso wounds (Figure 25-5).²⁸ The IED has also continued to cause problems with torso injuries, because the blast patterns cause shrapnel to angle up under traditional body armor and through arm openings. This has promoted development of armor that better helps protect these areas.

FIGURE 25-4 A high-velocity gunshot wound to the left arm.

(Courtesy International School of Tactical Medicine, Lawrence E. Heiskell, MD.)

TABLE 25-2 Battle Conditions Encountered by Tactical Medical Personnel (Spring 2003)*

Mechanism of Injury	n	% of Total
Gunshot wound	76	24.1
Shrapnel/fragmentation	65	20.6
RPG (handheld antitank grenade-launcher)/grenade	39	12.4
Motor vehicle accident	28	8.9
Fall	17	5.4
Explosion	16	5.1
Unknown/not recorded	16	5.1
Land mine	14	4.4
Mechanical/machinery	13	4.1
Blast	11	3.5
Other	10	3.2
Multiple (NOS [not otherwise specified])	4	1.3
Blunt	3	1.0
Debris	3	1.0
Total	315	100.0

* Navy/Marines Operation Iraqi Freedom from March 21 to May 15, 2003; wounded in action.

FIGURE 25-5 Anatomic location of injury (wounded in action [WIA] only).

(Courtesy Naval Health Research Center.)

Suspects may also sustain penetrating injuries during tactical operations (Figure 25-6). The terrorist attacks of September 11, 2001, and events such as the 1999 Columbine High School shootings, heightened our nation’s awareness of the real threats of terrorism and violence on U.S. soil and diminished some of the resistance to medical providers being actively and closely involved in law enforcement special operations. Today, hundreds of fire and EMS agencies provide tactical emergency medical support to federal, state, and local law enforcement special operations teams.

FIGURE 25-6 Suspect sustained a self-inflicted gunshot wound to the chest moments before a dynamic entry.

(Courtesy International School of Tactical Medicine, Lawrence E. Heiskell, MD.)

Law enforcement special operations, often referred to as SWAT (special weapons and tactics) teams, are intended to deal with a wide range of high-risk criminal problems and threats.⁶⁷ These include, but are not limited to, hostage rescues, terrorist acts, barricaded suspects, violent and suicidal suspects, take-over bank robberies, high-risk warrant services, and active shooter situations. Tactical medics must train and prepare for these types of difficult situations^17,^43,⁴⁴ (Figure 25-7, A).

FIGURE 25-7 A, Tactical medics train for active shooter situations. B, Preservation of evidence is a critical component of tactical medicine.

(Courtesy International School of Tactical Medicine.)

Patient advocacy, with priorities of ensuring the best possible quality of care and patient confidentiality, can be at cross-purposes with a law enforcement officer trying to gather important facts in an investigation to ensure public safety and justice. Tactical medicine providers must respect both patient rights and mission goals. Medics during tactical operations must have a constant awareness of evidence preservation while operating in the tactical environment (Figure 25-7, B).

SWAT teams are found in most midsize and larger law enforcement departments throughout the United States. In some areas, a number of small departments have banded together to form multijurisdictional or regional SWAT teams.¹⁵ Harsh environmental conditions, including what many regard as wilderness situations, will increasingly provide a backdrop for incidents requiring tactical efforts and the ongoing need for field medical support. Regardless of the scale of the program, tactical medicine has grown into a multifaceted specialty.

History of Tactical Medicine

Much of the training and tactics of civilian SWAT teams is based on the experience of military special operations teams. Such military teams have their origins in the U.S. Office of Strategic Services and the British Special Air Service during World War II. Some of the earliest military special operations teams incorporated tactical medical components.

German Fallschirmjäger (paratroopers) incorporated a well-organized medical support team with physicians. Dr. Heinrich Neumann jumped with the unit during the invasion of the island of Crete in 1942.³⁶ During the Normandy invasion of June 6, 1944, at Pegasus Bridge on the Orne River, the British, led by Major R. J. Howard, landed with medical support, accompanied by a physician, Captain J. Vaughan of the Royal Army Medical Corps.² The U.S. Armed Forces during World War II also incorporated physicians in their assault on fortressed Europe. Dr. Robert Franco and Dr. Daniel B. McIlvoy both parachuted into Sicily with the 82nd Airborne Division in April 1943 and jumped into Normandy in June 1944.²⁵

During the 1950s, the Army Special Forces (77th Special Forces Group) was formed. As U.S. Special Operations teams evolved, other specialized teams, such as DELTA, America’s elite counter-terrorist force, were formed.³⁵ Each of these special operations units has a plan for tactical medical support. The growth of terrorism in the 1970s resulted in the formation of other special operations groups worldwide. The Germans established a special unit within their border police, later presented to the world as the GSG9 (Grenzschutzgruppe-9).⁹⁶ This unit emerged after the 1972 tragedy at the Olympic Village in Munich, Germany. The French formed the Groupe d’Intervention de la Gendarmerie Nationale in 1974, and many other countries have since developed similar units.

Medical providers in the combat environment were traditionally taught to perform with the principles of the traditional hospital-based Advanced Trauma Life Support (ATLS). Although this training was instrumental in decreasing morbidity and mortality of trauma victims in the noncombat scenario, it fell short of providing appropriate care for the patient and the combatant team members on the field of battle. Numerous reviews of past and recent conflicts have noted inadequacies of this approach to battlefield medical care.^6,^8,^14,⁹⁹

Ninety percent of battle deaths occur in the field, before any medical intervention. Bellamy did a landmark review of wounds and death in battle.^7,⁷¹ In this study,⁷ he noted that 31% of battlefield deaths resulted from penetrating head injury, 25% from surgically uncorrectable torso trauma, 10% from potentially correctable torso trauma, 9% from exsanguinating extremity wounds, 7% from mutilating blast trauma, 5% from tension pneumothorax, 1% from airway obstruction, and 12% from various wounds (sepsis and shock off the battlefield) (Figure 25-8). Potentially preventable battlefield causes of deaths include bleeding to death from extremity wounds, tension pneumothorax, and airway obstruction.⁵³

FIGURE 25-8 A, How people die in ground combat. CNS, Central nervous system; DOW, died of wounds; KIA, killed in action. B, Tactical medics establish an airway during a training exercise.

(Courtesy International School of Tactical Medicine; A courtesy Colonel Ron Bellamy; B courtesy Lawrence E. Heiskell, MD.)

These statistics have proved true in today’s conflicts in the global war on terrorism and in most tactical medical scenarios. They gave rise to questions about the pure application of the basic advanced life support precepts of airway, breathing, and circulation (ABC) for battlefield and tactical situations. In 1993, led by the Naval Special Warfare Command, a multiagency working group (Committee on Tactical Combat Casualty Care), including special operations physicians, medics, corpsmen, and operators, began a 2-year study of this issue. This led to the guidelines titled Tactical Combat Casualty Care in Special Operations.¹⁴ The committee meets regularly and reviews new equipment, practices, and current operations for lessons learned and then revises the guidelines as appropriate. These guidelines, which evolved from the special operations community, are currently being evaluated and implemented in most combatant units of the U.S. military and of many other countries.¹³

The need for civilian SWAT teams in the United States evolved from high-profile criminal acts that resulted in shocking losses of human life. The seminal incident involved a sniper at the University of Texas at Austin. On August 1, 1966, Charles Whitman shot and killed 16 people and wounded 31 others.⁶⁸ In the midst of this tragedy, it became apparent that the law enforcement agencies called out were ill equipped to deal with the threat, hampered by inadequate weaponry and not trained to respond in a timely and optimal fashion. After this incident, many law enforcement agencies began developing specially trained and equipped tactical units to respond rapidly to such threats to public safety.³⁰ The Los Angeles Police Department and the Los Angeles County Sheriff’s Department were among the first law enforcement agencies in the United States to organize and develop full-time tactical units specifically trained to handle high-risk incidents.

Before 1989, there existed great diversity in the ways emergency medical care was provided during law enforcement tactical operations. Early on, most law enforcement agencies relied on regular civilian EMS providers staged at a safe location removed from the area of operation, or they simply dialed 9-1-1. Although this took advantage of an established prehospital care system, care for injured officers could be significantly delayed.⁹⁸

Other agencies trained full-time SWAT officers as EMTs or paramedics. This concept of getting medical care “close to the fight” was also realized in the Gulf War, and the military put this new concept in place during Operation Iraqi Freedom. Information obtained from interviews with military emergency physicians who served in Iraq has suggested success of the new model of battlefield care.

Shared Principles of Military Tactical Combat Casualty Care and Civilian Tactical Medicine

Tactical combat casualty care (TCCC) varies from ATLS in several distinct ways, primarily because in a TCCC situation, the victim and medical provider are not in a safe environment. In addition, medical care of the victim may not be the highest priority, and the team may be operating in the open under extreme environmental conditions, hours from higher levels of care.

The premise of TCCC is to do the right things at the right times. Underlying this basic statement is the suggestion that good hospital-based medicine is often not good battlefield medicine,¹³ as logically follows from these three statements:

1 Good medicine can be bad tactics.

2 Bad tactics can get everyone killed.

3 Bad tactics can cause the mission to fail.

The ultimate goals of TCCC are the following:

1 Treat the casualty.

2 Prevent additional casualties.

3 Complete the mission.

TCCC is divided into three main stages of care:¹³ care under fire, tactical field care, and combat casualty evacuation care. These are defined in the following paragraphs.

Care Under Fire

Sometimes care is rendered by the medic or corpsman at the scene of the injury while still under effective hostile fire. Medical equipment is limited to what the individual operator or the corpsman or medic can carry in the medical pack. The most effective medical care during this stage of TCCC is fire superiority—that is, winning the battle, or at least keeping enemy heads down and reducing hostile incoming fire. The medical provider (and the casualty if able) must work to suppress hostile fire and eliminate the threat as directed by the mission commander, and, if possible, to protect the injured fighter from further harm.

For many reasons, this is undoubtedly the most difficult phase of TCCC. First, the traditional provider, trained to be a “medic first,” may find it hard to direct attention to the threat and not maneuver to respond to the casualty. Second, this phase usually occurs in the most exposed environment, where the provider cannot use normal assessment tools. For example, during nighttime the provider cannot use a light, because it could draw fire, and listening for lung sounds with a stethoscope in an explosion-rocked firefight is useless. In earlier conflicts, it was noted that many medics and corpsmen who responded to casualties, instead of suppressing gunfire were wounded or killed, and that a significant number of the victims that they were trying to rescue were already dead. The priorities for the provider during this phase of care therefore are as follows:¹³

1 Return fire as directed or required.

2 Try to keep yourself from getting shot.

3 Try to keep the casualty from sustaining additional wounds.

4 Stop any life-threatening external hemorrhage with a tourniquet.

5 Take the casualty with you when you leave.

Airway and breathing problems are not addressed during this phase. The key action is to stop exsanguinating hemorrhage. A tourniquet is the primary means to stop the bleeding on an extremity (Figures 25-9 to 25-12). The tourniquet can be applied and left in place by the injured operator or medic, who can then return fire in support of the team. If a tourniquet cannot be placed because of the location of the wound, then direct pressure and a hemostatic dressing are recommended as the appropriate actions.

FIGURE 25-9 CATSSOF (combat application tourniquet system).

(Courtesy International School of Tactical Medicine and Tactical Medical Solutions, Inc, Lawrence E. Heiskell, MD.)

FIGURE 25-10 Mechanical advantage tourniquet.

(Courtesy International School of Tactical Medicine, Lawrence E. Heiskell, MD.)

FIGURE 25-11 Chitosan QuikClot Combat Gauze Vacuum Packed and Z-Folded hemostatic dressing.

(Courtesy International School of Tactical Medicine, Lawrence E. Heiskell, MD.)

FIGURE 25-12 Emergency bandage.

(Courtesy International School of Tactical Medicine, Lawrence E. Heiskell, MD.)

As soon as possible, the casualty is moved to a safer location, and the next phase of TCCC is instituted. This movement is performed with techniques dictated by the tactical situation. It can be done by, for example, vehicles, buddy lifts, or dragging. Another departure from traditional ATLS teaching is that cervical spine protection is not routinely provided in this phase of care. Studies of penetrating neck injuries in Vietnam demonstrated that only 1.4% of patients with penetrating injuries would have benefited from cervical spine immobilization.⁴ Although not all combat-related injuries are penetrating, the complexities of moving a patient in an environment where the patient and provider are under fire often preclude even rudimentary cervical spine immobilization.

Tactical Field Care

The tactical field care phase consists of care rendered once the medic and the casualty are no longer under effective hostile fire. It also applies to situations in which an injury has occurred on a mission but there has been no hostile fire. Available medical equipment is still limited to that carried into the field by mission personnel. Time before evacuation to a medical treatment facility may vary considerably.

In this phase, the medic has a short time to evaluate and treat the wounded. The medic assesses injuries, performs medical care as able (equipment still limited to what was carried onto the battlefield), and then informs the mission commander of the findings. The mission commander then determines what action will be taken (evacuate, abort, continue). This again may be a major departure from nontactical medical care, in that the medical provider is not the ultimate authority on patient disposition. The mission commander decides how much time is taken to care for the casualty in any phase of the operation, if and when medevac will occur, and what assets will be allocated from the primary mission toward care of the injured.

Step 1: During this phase, the provider must assume not only that hostile fire may occur at any time but also that any injured team member with altered mental status may become a threat. The provider must therefore disarm the team member, an action that most warriors resist.

Step 2: Address airway compromise. Airway actions are usually rendered as follows: if the victim is unconscious without obstruction, use a nasopharyngeal airway (better tolerated and less likely to become dislodged with movement)¹ and a rescue position if able. If airway obstruction is present and cannot be alleviated with these maneuvers, the next recommended treatment is to move directly to a surgical cricothyrotomy. Endotracheal intubation is not recommended at this level of care for several reasons: (1) It requires the medic to carry onto the battlefield equipment that has no other purpose; (2) the medic must practice regularly to maintain his or her skills; (3) success rates under austere conditions are believed to be significantly less than those done in a controlled or semicontrolled setting; and (4) the laryngoscope light may compromise team safety on the field.^81,^93,⁹⁴ Emergency cricothyrotomy is the best option in this phase of TCCC. Because of distorted anatomy, it is the best way to protect the airway of a patient with maxillofacial wounds. Blood and tissue in the airway preclude visualization of the cords and make endotracheal intubation difficult or impossible.^13,⁸⁹

Step 3: Treat breathing difficulties. Any severe progressive respiratory distress is assumed to be due to a tension pneumothorax (the number-two cause of preventable battlefield deaths). One cannot wait for the classic signs (which are unreliable at best and most often impossible to ascertain on the battlefield) of diminished breath sounds, hyperresonance, and tracheal deviation to make this diagnosis.⁷⁴ Therefore, faced with victims in increasing respiratory distress and with unilateral penetrating chest trauma, the medic will go directly to a needle thoracostomy. This is the definitive procedure in this phase. A chest tube is not usually needed, it is difficult to perform on the battlefield, and it would only further complicate patient care, transportation, and mission completion.¹³

Step 4: Readdress bleeding. The medic rapidly locates uncontrolled hemorrhage and any wounds where a tourniquet has been placed. If possible, a hemostatic dressing is placed; the tourniquet may be discontinued if the wound and tactical scenario permit. Even if the bleeding appears controlled, further “rough” evacuation may necessitate keeping a tourniquet in place to prevent rebleeding. Each action that the medic takes is designed to save life with minimal further care by the medic. For example, a medic who is holding pressure on a bleeding wound cannot return fire, take care of other casualties, or perform other procedures on this patient. The patient is not optimally prepared for transportation, which may consist of being thrown over someone’s back and carried out. Thus a tourniquet that would be a last-ditch effort in a noncombat environment becomes the method of choice in the tactical combat situation. Each operator in the field carries, and knows how to use, at least one tourniquet that can be self-applied. This allows the operator to self-administer lifesaving bleeding control and then continue with the fight until treatment by the medic is possible.

Step 5: The medic should determine whether an intravenous (IV) line or a saline lock is beneficial. The advantages would be that the patient could receive fluid resuscitation and IV antibiotics. Disadvantages include a probable delay in transportation, the additional equipment required (and the bulky apparatus that could become dislodged or tangled during evacuation), and difficulty in placing a line under austere tactical conditions. If an IV is deemed necessary but cannot be expeditiously placed, the intraosseous route is used. Several devices can be used to achieve this, including large-bore hypodermic needles, traditional intraosseous needles, and devices such as the FAST1 Intraosseous Infusion System and BIG (Bone Injection Gun), which quickly and accurately place the needle in the sternum or in another appropriate location.

Step 6: Determine whether fluid resuscitation is required. In general, if the patient is not in shock (the best indicators of shock in the field are altered mental status in the absence of head injury, and weak or absent pulses), then no IV fluids are necessary. If the patient is conscious, oral rehydration is permissible and preferred in many tactical scenarios. If the patient is in shock, the medic can give Hextend ⁶⁵ as a 500-mL bolus and reassess after 30 minutes. If the victim is still in shock, the Hextend is repeated once. Usually no more than 1000 mL of Hextend is given, and further efforts at resuscitation are determined by the tactical scenario. If the patient has a traumatic brain injury and is unconscious and pulseless, fluid resuscitation is given to restore the pulse. This protocol maximizes survivability of the patient and limits the amount of equipment necessary to be carried onto the battlefield.

Step 7: Inspect and dress known wounds. The medic locates and appropriately treats wounds already identified but not yet treated because of tactical considerations and then proceeds with a quick but thorough head-to-toe assessment for additional wounds. This is analogous to the secondary survey of ATLS, with a couple of notable exceptions. First, the patient is not exposed. This is because the patient may have to be moved quickly if the tactical situation changes and because the patient must be kept warm and protected from further injury for a much longer time than in an urban setting. The medic often does this examination by feel to avoid using white light, to keep the victim’s body armor as intact as possible, and to avoid cutting off protective clothing that may be required during evacuation.

Step 8: Assess for pain control. Analgesia is administered in this phase of care with the following considerations. If the victim is able to fight, non-narcotic preparations are used. These do not affect mental status, allowing the victim to remain armed and responsive. If the victim is unable to fight, morphine and promethazine, IV or intramuscular (IM), are given as needed.

Step 9: If not already done, fractures are splinted and neurovascular status is rechecked.

Step 10: Consider early administration of antibiotics for open combat wounds, which significantly reduces the rate of infection.¹¹ Oral medication is preferred if the patient is conscious. Gatifloxacin has been shown to be highly effective with minimal risks. Gatifloxacin is a broad-spectrum fluoroquinolone that is active against gram-positive and gram-negative microbes, aerobes, anaerobes, and freshwater and saltwater pathogens; is a once-a-day drug; and has a long shelf life. If the victim is unable to take oral medication or has significant abdominal trauma, IV/IM antibiotics are used, with cefotetan being the current drug of choice. In many units, the operators are given a “wound pack,” consisting of an antiinflammatory, acetaminophen, and gatifloxacin, and instructed to take the entire pack as soon as possible after being wounded.

Step 11: Continue to communicate with the victim, giving encouragement, explaining the care given, and giving updates on the tactical scenario if appropriate.

Traumatic cardiac arrest is treated on the battlefield just as it is in the civilian setting. If the victim is pulseless, apneic, and has no sign of life, resuscitation is not attempted. After these measures have been taken, or if medical evacuation is now available, the last phase of TCCC, combat casualty evacuation care, is entered.

Combat Casualty Evacuation Care

This phase of care is rendered once the casualty (and usually the rest of the mission personnel) has been picked up by an aircraft, land vehicle, or boat. Additional medical personnel and equipment that have been prestaged in these assets should be available at this stage of casualty management. The management plan aligns closely with that of the tactical field care phase, with the addition of more equipment and perhaps higher levels of medical providers. This phase is also the phase most similar to ATLS, although it may occur in the back of a moving conveyance and is still somewhat limited by available equipment and the tactical scenario. The basic medical plan for combat casualty evacuation care is as follows:

1 Airway management: Same as for tactical field care, with the addition of laryngeal mask airway/Combitube/endotracheal intubation for definitive airway management before cricothyrotomy if the operators are trained and the patient can be endotracheally intubated (e.g., has no midface injuries). Spinal immobilization is still not deemed necessary for casualties with penetrating trauma for the reasons stated earlier.

2 Breathing: Same initial considerations as for tactical field care. A chest tube can be placed if needle thoracostomy has produced no improvement in breathing, or if long transport is anticipated. Most combat casualties do not require oxygen, but its administration may be of benefit in the following situations: low oxygen saturation by pulse oximetry, injuries associated with impaired oxygenation, unconscious patient, and traumatic brain injury (to maintain oxygen saturation >90%). Sucking chest wounds should be treated with petroleum gauze applied during expiration, covering it with tape or a field dressing, placing the victim in the sitting position, and monitoring for development of a tension pneumothorax. Asherman seals are also ideal for quickly securing chest tubes and for sucking chest wounds.

3 Bleeding: Same as for tactical field care.

4 IV line: Same as for tactical field care.

5 Fluid resuscitation: Same as for tactical field care, with blood and/or lactated Ringer’s solution possibly available.

6 Monitoring, wound care, reinspection for additional wounds, analgesia, reassessment of fractures, antibiotics: All the same as for tactical field care.

A main precept of TCCC is to move medical care from being the sole responsibility of the combat medic, to involve each operator and each level of leadership. Each fighter carries a tourniquet that can be self-placed. Each fighter is trained in basic combat lifesaving skills so that the effects of wounds can be minimized (within defined limits) and fire can be returned until the medic can arrive and perform the appropriate advanced medical care. Each leader, from the squad level up, is trained to evaluate medical concerns as an integral part of the mission execution and is able to decide when to abort the mission, when to continue, and when to alter the plan, based on the mission objective and the issues that the injured team member or members bring to the fight.

Principles of Tactical Medicine

The tactical environment presents unique challenges to law enforcement officers, and the same is true for personnel providing EMS medical support in that environment. Tactical medical care providers must have an understanding of and consideration for law enforcement tactics and mission-specific objectives when planning and providing medical support (Figure 25-13).⁵² Most comprehensive law enforcement tactical medicine programs require medical providers to attend some formal law enforcement training. Before deployment, further training in SWAT school will most likely also be required to familiarize the tactical medic with basic and advanced tactics. This extensive training may result in reserve police officer status for the medical provider if there is a reserve program in existence at the law enforcement agency where the program is based. The operator then enters a true hybrid role between medicine and law enforcement.

FIGURE 25-13 Tactical medics discuss placing a suspect under arrest during a tactical operation operational preplan during a training exercise.

(Courtesy International School of Tactical Medicine, Lawrence E. Heiskell, MD.)

Traditional EMS doctrine maintains that rescuer and scene safety are first priorities, and that patient care is a secondary concern.⁷⁶ The nature of tactical operations requires that law enforcement officers and tactical medical personnel operate in unsecured environments and situations with significant potential for violence and injury (Figure 25-14).⁷² Tactical scenes are rarely safe from the civilian standpoint, but tactical medical personnel are trained to conduct concise and limited medical evaluations and interventions in potentially threatening areas.⁸²