PART 3 The TEMS Advantage

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PART 3The TEMS Advantage
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TEMS, a definition

• Tactical Emergency Medical Support is a term
  referring to nonmilitary EMS that has been
  modified for the realities of the tactical
  environment and is emerging as a new
  sub-specialty with nationwide application in
  prehospital care.
• It can be defined as the spectrum of services
  necessary to establish and maintain the health,
  welfare and safety of Special Operations law
  enforcement providers.
• TEMS refers to tactical emergency medical
  SUPPORT, rather than tactical emergency medical
  SERVICES, recognizing the broad spectrum of
  health services beyond acute care.

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TEMS History

• Military has long recognized the value of early
  medical
• care in areas of operations. Unconventional
  warfare resulted
• in development of Special Forces units able to
  operate outside the normal realm of military
  operations. They are unique in the sense their
  operations put them remote from supporting
  elements for prolonged periods. This also meant
  they are required to provide their own medical
  treatment to sustain their operational
  effectiveness. Specialized medical support was
  required. Specially trained medics were developed
  and deployed with these teams to meet the need.
• Development of SWATcivil unrest and disorder of
  the 1960s saw the advent of tactical units as a
  part c civilian law enforcement. The Texas Tower
  Incident was a pivotal event. In August 1,1966,
  Charles Whitman kills 15 and wounds 31 from the
  top of the 28-story administration building at
  the University of Texas. Police administrators
  around the country assess their ability to
  respond to such an incident.

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History cont.

• National conferences held in 1989 and 1990
  Representatives from law enforcement, emergency
  medicine and EMS developed consensus relating to
  the provision of medical support to tactical
  teams.
• In 1990 the Counter Narcotics Operational Medical
  Support (CONTOMS) course is introduced. It is
  based at Uniformed Services University and
  supported with DoD counter-drug funding. To date,
  near 80 classes conducted, over 4,000 students
  trained, from over 700 agencies and four
  countries.
• In fall 1993 the National Tactical Officers
  Association (NTOA) publishes a position statement
  in support of TEMS. The provision of TEMS has
  emerged as an important element of tactical law
  enforcement operations... In January 1999,
  National Association of EMS Physicians forms TEMS
  task force to look at TEMS issues

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The Need for TEMS

• There are high risks associated with law
  enforcement. In 1998, 61 law enforcement officers
  were killed and 18,198 injured by assaults in the
  line of duty. Members of Special Weapons and
  Tactics (SWAT) teams at increased risk with 33
  injuries per 1,000 officer-missions.
• Law enforcement activities take place in volatile
  and dangerous environmentsthat are growing more
  dangerous every month. Some of the more specific
  hazards include
• Organized opposing forces
• Military type weapons
• Hostage taking
• Barricaded subjects
• Toxic hazards/clandestine drug labs

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the need continued.

• Provision of medical support may take place under
  austere conditions. The medical care providers
  must have an understanding of and consider the
  law enforcement mission when planning the medical
  support. Conventional EMS is inadequate for this
  role.
• Most common medical support is civilian ambulance
  on standby (69). There is no medical direction
  for TEMS in 78 of situations. And 23 of the
  time there is no EMS preplan.
• What we do know is that there is a demonstrated
  need for immediate, life-saving interventions in
  penetrating trauma. Twenty percent of those
  fatally wounded by penetrating trauma die from
  readily treatable causes
• 10 Tension pneumothorax
• 9 Exsanguinating peripheral hemorrhage
• 1 Airway obstruction
• Fifteen percent die within 30 minutes of
  wounding.

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The current TEMS role

• This is a dynamic and innovative field. It is in
  a constant state of change. There are military
  medical special operations conferences like SOMA
  in Tampa that now welcome law enforcement TEMS
  operators. The NTOA fully recognizes and supports
  the TEMS concept and is actively encouraging
  SWAT/SRT teams around the country to incorporate
  a TEMS solution into their teams capabilities.
• There are now National and International
  associations for TEMS providers (ITEMS). Several
  states (e.g. FL, CA, IL) have statewide
  organizations.
• In MississippiTEMS operators are coming together
  to form a State wide organization this year.
• More money is becoming available for equipment
  and training for TEMS operators in organizations
  from the federal to local levels.

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Goals of TEMS

• Enhance Mission Accomplishment
• Reduce death, injury and illness and related
  effects among officers, innocents and
  perpetrators.
• Improve agencys posture in liability prone
  circumstances
• Reduce line of Duty injury and disability costs
  to the agency
• Reduce lost work time for specially trained,
  hard-to-replace officers
• Maintain good team morale when true concern for
  members goo health is realized

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Key TEMS Concepts

• The TEMS delta
• TEMS operator as a technical expert
• Full integration
• A job description

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The TEMS deltaor the change from EMS to TEMS

• A change in focus TEMS is secondary to the
  tactical mission. Render aid only when directed
  and when the tactical situation warrants, and do
  so under low light conditions often with
  attention to noise and light discipline.
• A change in environment You are now on a crime
  scene. A knowledge of chain of evidence is
  imperative. You are also in a more dangerous
  environment.
• A change in roles not only are you there for the
  patient, but you are also a part of the tactical
  solution. You are the medical eyes, ears and
  hands for the tactical commander.
• A change in equipment you must carry all or most
  of what you need on your personyou cant always
  run back to the truck. You must also wear
  ballistic protection (vests and helmets) as well
  as eye protection.
• A broadening of responsibilitiesentry work is a
  small part of the equation. Medical preplan,
  health surveillance, training/educating...
• A change in the application of medical
  aidBleeding is the most important issue in the
  tactical arena. So in TEMS, its not the ABCs its
  the CABs, circulation/bleeding is first.

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The TEMS Operatora technical expert

• The responsibility for the success or failure of
  a mission rests with the Commander. The Commander
  relies upon various technical experts in
  achieving mission success. Weapons, vehicles, and
  equipment must be maintained and appropriately
  used if they are to function reliably. The
  Commander is also responsible for the maintenance
  and appropriate use of his people. However, he
  will most likely not have a background in, nor be
  readily conscious of the importance of health
  maintenance, injury control or medical
  pre-planning. Yet these components are vital to
  mission success. The EMT-T must be the technical
  expert in health maintenance of the units
  personnel. In this capacity, the tactical medic
  functions as the Commanders medical
  conscience, preventing him from unwittingly
  and/or unnecessarily sacrificing his own people.
• A TEMS operator is a key element to any tactical
  solution. We believe they are a specialists just
  like any other specialist on a team (i.e. EOD,
  Sniper)this however does not always play out
  because of a lack of

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Full integration

• Face timeTEMS operators should be integrated
  with the team. It is all about spending time with
  a team. It is not enough to have an individual
  who stands back in the distance and available if
  needed. The reality is that TEMS operator is
  needed and not just during an action. The TEMS
  operator should be training with the tactical
  team, spending time with other members of the
  unittrust is built with time.
• The TEMS operator should be familiar with the
  tactics and individuals on the team. There are
  those in the TEMS community that argue that TEMS
  providers should know their operators well enough
  to provide a psychological evaluation on each
  man.
• The bottom line is timeto commit to TEMS is to
  commit to time with your team.

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So what exactly does a TEMS operator do?

• Educate/Advise team and team commander on medical
  issues, buddy care and essential first aid
• Immediate Action Drills and Officer Down
  scenarios
• Extended operations medical oversight (rest/duty
  cycles)
• Special equipment needs
• Provide care under fire
• Toxic Hazards
• Safety review (equipment, SOPstraining and
  operationally)
• Wound ballistics, IEDs, Booby traps, DDs
• On scene forensics
• Medicine across the barricade
• Online and offline medical control

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Training Topics

• Medical Threat Assessments - prioritized
  gathering of medical intelligence having an
  impact on the the physiological and psychological
  well-being and performance of the tactical team.
  This includes weather conditions, environmental
  hazards, knowledge of local medical facilities,
  air assets, etc. and putting it together in a
  concise form usable to the commander. It usually
  fulfills a role in the mission briefing.

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Training Topics cont

• Medical Aspects of Extended Operations
• CONOPS - Continuous Operations - around the clock
  work scheduling for days or weeks at a time.
• SUSOPS - Sustained Operations - individuals
  working continuously on shifts longer than 12
  hours, often non-stop.
• Average length of tactical operations is 6 hours,
  35 minutes. Some can go for weeks.

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Training Topics cont

• Management of Dental Injuries
• Care under Fire - ABCs in the Tactical
  Environment (or CABs)
• Noise and Light Discipline
• Sensory Deprived or Sensory Overloaded Patient
  Assessments
• CPR in the Tactical Environment
• Surgical and Non-Surgical Airway Techniques
• Chest Decompression

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Even more training topics

• Remote Assessment Methodology - assessing a
  patient from a safe location initially and only
  exposing the provider if medically indicated
• Hostage Survival
• Weapons and their Effects
• Incendiary Devices, Booby Traps, and Distraction
  Devices
• Basic Forensic Examination of GSWs
• Medicine Across the Barricade - medical
  assessment and treatment via phone, radio, or
  other method, through a care-giver who is on the
  other side of the barricade.
• Officer Rescue

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Case Studies in the Application of TEMS

• Vancouver
• Baltimore County

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Case 1

• Vancouver, WA - SouthWest Regional SWAT Team
  responded to a barricaded subject who was armed
  and suicidal, and had been indiscriminately
  firing her weapon at officers prior to SWATs
  arrival. Accompanying the SWAT team was a
  tactical paramedic, who is a full-time
  commissioned officer and stages in the inner
  perimeter.

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Duties of the Paramedic

• Soon after arrival, the paramedic briefs
  assisting fire and private ambulance personnel on
  tactical medical procedures.
• Paramedic coordinated aeromedical evacuation (to
  include GPS coordinates for landing sites and
  staging area, as well as multiple patient
  scenarios and triage) with the fire department
  helicopter and crew.
• Due to the warm temperatures and the potential
  for an extended operation, the Red Cross and
  additional fire department assets were requested.

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Shots Fired

• During negotiations, the subject fires upon a
  negotiator. Counter-sniper responds with a .308
  round, striking the subject in the neck/upper
  chest. Paramedic was at the subjects side
  within 20 seconds of the last shot fired.
  Subject was conscious and hysterical. Rapid
  Trauma Assessment (RTA) revealed a large amount
  of blood on and near patient with GSW to left
  lateral neck just above chest. Wound was
  bleeding profusely and an exit wound was
  discovered under the left armpit, also bleeding
  profusely. V/S revealed patient to be tachypnic,
  tachycardic, and severely hypotensive.

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Treatment

• Air asset was immediately activated
• Direct pressure was applied to both wounds and
  bleeding eventually controlled.
• C-Spine immobilization.
• High-flow O2 delivered by mask.
• Two IV lines established
• Cardiac monitor and pulse oximeter were applied

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Resolution of Case 1

• Patient was monitored and periodic V/S
  reassessments were conducted until patient turned
  over to air asset
• Patient arrived at a Level One trauma center 39
  minutes after being shot. Post-action review
  held with medical control suggested that a needle
  thoracentesis should have been considered due to
  the proximity of the wound to the airway and the
  pending air transportation. Bullet affected no
  vital areas and patient made full recovery.

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Case 2 Baltimore County, MD

• Police Tactical Unit responded to a hostage
  incident involving subject who had recently been
  arrested for domestic violence. Upon being
  released from custody, subject, who had a lengthy
  criminal history, kidnapped his girlfriend and
  killed the couple she had been staying with. A
  passerby, who attempted to aid the girlfriend,
  was also killed.

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Bad gets worse

• Two more people were shot, including a two year
  old boy and a pregnant mother who later died at a
  local hospital, as the subject attempted to
  carjack passing motorists. Later, the kidnapped
  girlfriend escaped. However, in an attempt to
  re-capture the girlfriend, the subject broke into
  the apartment occupied by the girlfriends
  mother, and took the mother, the mothers
  boyfriend, and the boyfriends son hostage. The
  SWAT team soon arrived at the residence and a
  perimeter established.

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TEMS support

• TEMS support provided by a fire
  captain/paramedic who had been trained as a
  tactical medic. The team also had five members
  who had EMT training, but no practical experience
  in field medical care. Later in the
  incident(which would last over 100 hours) the
  Maryland State Police and the Federal Bureau of
  Investigation would provide tactical medical
  personnel to support the operation as well. As
  the incident progressed a special operations
  physician for the Maryland State Police responded
  to provide sick call for the personnel on-scene.

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Medical Considerations

• Aeromedical support in Maryland is provided
  statewide by the Maryland State Police. A
  staging area was set up near the crisis site and
  remained during the entire operation.
• Due to the extended nature of the operation,
  rest/work schedules were needed to maintain
  operator effectiveness. Medics had to be on
  alert for signs and symptoms of fatigue and sleep
  deprivation. Medics also were affected by this
  and had to provide for sufficient medical
  assistance around the clock.

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Medical Considerations cont.

• Due to the violent nature of the subject, three
  ALS units were staged at a local fire station for
  a rapid response. This was coordinated by the
  tactical medics on the scene. Medics also
  coordinated medical plans with local hospitals.
• Since tactical team health and well-being is
  paramount for the tactical medic, issues such as
  sanitation, nutrition and hydration became an
  issue (in spite of rumors, tactical teams cannot
  live on pizza and donuts indefinitely). Bathroom
  facilities had to be located, as well as
  available drinking water. Sanitation even
  included the removal of a vicious dog that had to
  be destroyed early in the operation in one of the
  tactical team staging areas.

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Treating the routine

• In extended operations, the routine medical
  problems also have to be addressed. Headaches,
  diarrhea, allergies, colds, parasites (in this
  case, ticks encountered in a wooded area near the
  target location ) all were encountered during
  this operation and had to be treated by the
  tactical medics on scene.

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Resolution of Case 2

• The situation was resolved after the mother and
  the boyfriend escaped from the apartment, leaving
  the twelve year old boy behind. In an attempt to
  rescue the boy, the tactical team entered the
  building. The subject reached for a weapon and
  was shot numerous times by tactical team members.
  The subject was pronounced dead at the scene.

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Lesson learned

• For long term incidents, TEMS and other EMS
  resources can quickly be strained (e.g. the 3 ALS
  units, the air assets, and the shortage of TEMS
  providers over the course of the mission). Also,
  the duties of the tactical medic will more than
  likely be maintaining the health of the tactical
  operators rather than treating the trauma
  associated with violent confrontations.