Tactical Emergency medical services (TEMS) is out-of-hospital care given in hostile situations by specially trained practitioners. Tactical support provided through TEMS can be applied in either the civilian world, generally with special law enforcement teams such as SWAT and SERT, as well as with military special operations teams. Tactical EMS providers are paramedics, nurses, and physicians who are trained to provide life-saving care and, sometimes, transport in situations such as tactical police operations, active shooters, bombings, and natural disasters.[1] Tactical medical providers (TMPs) provide care in high risk situations where there is an increased likelihood for law enforcement, civilian, or suspect casualties. TEMS units are also deployed in situations where traditional EMS or firefighters cannot respond. 

Tactical medicine has been in existence long before it was officially termed 'tactical EMS.' Tactical medicine has its origins on the battlefield. Since human beings have been fighting in wars, tactical medicine has been applied to those wounded in combat. Early kings had personal medics to care for them in the event that they were injured in battle, while the Spartans utilized persons from lower ranking classes, Helots, to tend to their injuries so they could continue fighting. During World War II as well as the Vietnam War, the need for a higher standard of battlefield medicine became increasingly apparent as up to 20% of soldiers wounded in combat would die from their wounds. It was found that the majority of deaths occurred from exsanguination (bleeding to death) or compromised breathing, usually related to a collapsed lung or airway obstruction. Exsanguination in combat was mitigated by the widespread training of military personnel on tourniquet use. Deaths due to airway compromise and other breathing issues were decreased once medics were trained in Basic life support procedures such as inserting airways and using Bag valve masks. Not surprisingly, many of the same injuries such as penetrating trauma, blast injuries, and airway compromise are sustained by law enforcement in their line of duty. Following the widely publicized active shooter situations such as the Columbine High School massacre, Virginia Tech shooting, and others, major changes took place in law enforcement protocol regarding emergency medical support in the field. One of these changes involved training officers in proper care of their own wounds and the wounds of their partners/teammates through interventions such as properly applying a Tourniquet. Many agencies have also put their officers through Emergency medical technician training to obtain additional medical knowledge. An additional option, which most closely resembles tactical EMS, is utilizing a person previously trained as a medical practitioner to provide medical support for law enforcement by either integrating them into the team itself or allowing them to treat casualties in a warm zone (a location that is deemed to be a mild risk for sustaining injuries). Presently, many law enforcement agencies across the nation have recognized the benefit of training a medical professional as a tactical officer and utilizing them in situations where there is a higher risk of sustaining casualties.

TECC - UH Sponsored training class

The 2nd edition of NAEMT's Tactical Emergency Casualty Care (TECC) course teaches EMS practitioners and other prehospital providers how to respond to and care for patients in a civilian tactical environment.

The course presents the three phases of tactical care and integrates parallel EMS nomenclature:

• Hot Zone/Direct Threat Care that is rendered while under attack or in adverse conditions.

• Warm Zone/Indirect Threat Care that is rendered while the threat has been suppressed but may resurface at any point.

• Cold Zone/Evacuation Care that is rendered while the casualty is being evacuated from the incident site. 

The 16-hour classroom course includes all new patient simulations and covers the following topics:

• Hemorrhage control including immediate action drills for tourniquet application throughout the course;

• Complete coverage of the MARCH assessment;

• Surgical airway control and needle decompression;

• Strategies for treating wounded responders in threatening environments;

• Caring for pediatric patients;

• Techniques for dragging and carrying victims to safety; and

• A final, mass-casualty/active shooter event simulation.

TECC vs TCCC

Tactical Emergency Casualty Care (TECC) is a set of evidenced-based and best practice trauma care guidelines for civilian high-threat pre-hospital environments.  The TECC guidelines are built upon the critical medical lessons learned by US and allied military forces over the past 15 years of conflict and codified in the doctrine of Tactical Combat Casualty Care (TCCC). Using the military TCCC guidelines as a starting point, the Committee creates the civilian high threat medical guidelines through a process of literature research, evidence evaluation, expert discussion, and civilian best practices review. The TECC guidelines are built upon the foundations of TCCC but are different to meet the unique needs of the civilian medical and operational environments.  The differences address civilian specific language, provider scope of practice, population, civilian liability, civilian mission and operational constraints, logistics, and resource acquisition. 

CONTOMS

The COUNTER NARCOTICS AND TERRORISM OPERATIONAL MEDICAL SUPPORT (CONTOMS) Program was started in 1990 to meet the need for specialized medical training to support law enforcement special operations. EMT-Tactical (EMT-T), the cornerstone of the program, is a 1-week, 56-hour continuing education module for medical personnel supporting special response teams.

The goal of the CONTOMS Program is to offer a nationally standardized curriculum, certification process, and quality improvement procedure to meet the needs of those EMTs, paramedics, and physicians who operate as part of a law enforcement team. Additionally, the Program tracks data to ensure that the educational efforts are evidence-based, so that it meets the dynamic needs of the law enforcement and EMS communities. Finally, the program faculty is available for consultation to Federal, State, and local agencies to help meet immediate requirements, solve urgent problems, or conduct needs assessments.

Rescue Task Force

The RTF principal  involves placing EMS providers in forward positions, protected by law enforcement, to provide emergency medical intervention immediately while efforts to secure the scene continue 

OHIO RTF Requirement

Effective April 1, 2019, all Ohio EMS providers (EMR, EMT, AEMT, and Paramedic) are required to view the Rescue Task Force Awareness Training Module (RTF) as part of the continuing education (CE) necessary for Ohio EMS certificate renewal. Ohio’s fire service and law enforcement officers are also encouraged to take the course.

• The RTF awareness training module must be completed only once, either through an EMR or EMT initial course completed after September 1, 2019, or online through the Public Safety Training Campus during your first renewal period starting on or after April 1, 2019.

• You should maintain a copy of your certificate of completion after completing the RTF module. If your certificate is audited, you will need to provide proof that the RTF module was completed.

DIRECT THREAT CARE (DTC) / HOT ZONE Guidelines:

1. Mitigate any immediate threat and move to a safer position (e.g. initiate fire attack,

coordinated ventilation, move to safe haven, evacuate from an impending structural

collapse, etc). Recognize that threats are dynamic and may be ongoing, requiring

continuous threat assessments.

2. Direct the injured first responder to stay engaged in the operation if able and

appropriate.

3. Move patient to a safer position:

a. Instruct the alert, capable patient to move to a safer position and apply self-aid.

b. If the patient is responsive but is injured to the point that he/she cannot move, a

rescue plan should be devised.

c. If a patient is unresponsive, weigh the risks and benefits of an immediate rescue

attempt in terms of manpower and likelihood of success. Remote medical

assessment techniques should be considered to identify patients who are dead or

have non-survivable wounds.

4. Stop life threatening external hemorrhage if present and reasonable depending on the

immediate threat, severity of the bleeding and the evacuation distance to safety.

Consider moving to safety prior to application of the tourniquet if the situation

warrants.

a. Apply direct pressure to wound, or direct capable patient to apply direct pressure to

own wound and/or own effective tourniquet.

b. Tourniquet application:

i. Apply the tourniquet as high on the limb as possible, including over the

clothing if present.

ii. Tighten until cessation of bleeding and move to safety.

5. Consider quickly placing patient, or directing the patient to be placed, in a position to

protect airway.

TXA - How it works

TXA is a synthetic reversible competitive inhibitor to the lysine receptor found on plasminogen. The binding of this receptor prevents plasmin (activated form of plasminogen) from binding to and ultimately stabilizing the fibrin matrix.

Current protocol for use is in situations with hemorrhage withing 1 hour of onset with signs and symptoms of shock - HR>120 and SPB<90. This is AFTER BLS hemorrhage control as been utilized. The dose is 2 grams given over 10 mins. This can be a slow push or it can be put in a bag of D5 (or NS) and run over 10 mins. It is normally supplied as 1 gram (1000mg) in 10ml vials. 

CPR

Penetrating trauma - CPR may be indicated in specific situations

Blunt trauma - CPR futile

Zones of danger

• The Hot Zone is the direct area in which there is an ongoing hazard—such as a building where there is an active shooter.

• The Warm Zone is the perimeter immediately around the Hot Zone. It may include areas that police have cleared but not necessarily secured, such as a portion of a building in which they are still working to neutralize a suspect.

• The Cold Zone is the area beyond the perimeter where there is no known threat. It may include former Hot or Warm zone areas that police have both cleared and secured.

Differences between type of clotting agents - how they work

Hemostatic agents such as Celox, QuikClot and Hemcon are designed to promote rapid blood coagulation in the event of a traumatic wound involving an arterial bleed. Hemostatic gauze products are now widely available to EMS professionals and first responders, and approved for all levels of training in some areas. These products have saved many lives on the battlefield and are now also being used to stop traumatic bleeding in workplace, motor vehicle, and at-home accidents. 

QuikClot was the first hemostatic agent adopted by the United States Military. QuikClot Combat Gauze is still favored by much of the US Military. Later developments led to chitosan-based products such as Celox, which are proven safe and effective. Celox granules are preferred in some instances, such as in the event of a scalp evulsion, where impregnated gauze products would have to be later removed, meaning the flap would need to be lifted. This may not be necessary if Celox granules are used, as they are readily metabolized. Gauze-based products are more suited for wound-packing a penetrating injury. The use of Celox hemostatic granules and chitosan-impregnated gauze can quickly and safely stop blood flow from potentially lethal wounds. Hemostatic gauze dressings using the active ingredient chitosan include Celox, Chito-SAM and Hemcon. CoTCCC (the Committee on Tactical Combat Casualty Care) has long recommended QuikClot Combat Gauze as the hemostatic agent of choice for all branches of the US Military. 

NIJ LEVEL I BODY ARMOR

The original NIJ Level - now out of commission

The Level I protection rating was created in the 1970s and is now obsolete. If you come across a Level I vest, consider it either memorabilia or junk.

NIJ LEVEL IIA BODY ARMOR

The current lowest level of protection

Level IIA armor is the lightest and most flexible armor available today but largely out of date. Usually soft armor, it's easily concealed beneath clothes.

LEVEL IIA PROTECTS AGAINST:

• .9mm FMJ (Full Metal Jacket) at 1165 feet per second (ft./s)

• .40 S&W (Smith & Wesson) FMJ at 1065 ft./s

 NIJ LEVEL II BODY ARMOR

"HANDGUN ARMOR," DEFEATING UP TO .357 MAGNUM ROUNDS

Level II vests are still relatively light, flexible, and easily discrete under clothes, but can defeat a higher range of ammunition than Level IIA. They also offer more blunt force protection than IIA.

LEVEL II PROTECTS AGAINST:

• all handgun rounds, up to and including .357 magnum jacketed soft point (JSP)

NIJ LEVEL IIIA BODY ARMOR

Good all-round for concealable, lightweight protection

Level IIIA is the most common protection level you'll see when browsing for soft body armor.

Found in everything from bulletproof vests to bulletproof backpacks, it's a bit heavier than Level IIA or II but still largely concealable.

LEVEL IIIA PROTECTS AGAINST:

• 9 mm rounds traveling at speeds of up to 1400 ft./s.

• .44 magnum rounds.

LEVEL IIIA+

Some suppliers offer level IIIA+ vests that protect against shotgun rounds, 9 mm Civil Defense rounds, and FN 5.7. While such vests aren't officially certified by the NIJ, it's becoming a popular option for niche use.

NIJ LEVEL III BODY ARMOR

Rifle-defeating armor

Level III body armor is the first level that protects against rifle rounds. This armor usually consists of hard plates as opposed to soft plates, so it's not concealable.

Hard armor is also heavier than soft armor, but with that weight comes greater protection.

LEVEL III IS DESIGNED TO HANDLE:

• Six shots from a 7.62x51 NATO round traveling up to 2780 ft./s

LEVEL III+ BODY ARMOR

Like Level IIIA+, III+ isn't an official NIJ rating. However, it's used by some manufacturers to indicate that this armor has the same protective capacity as Level III but can handle extra threats like M855 "green tip" ammo or M193.

Level III+ is becoming a popular option for those who face additional threats.

NIJ LEVEL IV BODY ARMOR

Top level protection

Level IV body armor is the highest basic level. It consists of hard plates as opposed to Level IIIA plates and below. Level IV armor achieves this standard by stopping a single bullet as opposed to Level III's six, so it isn't always better than a Level III armor.

LEVEL IV IS DESIGNED TO HANDLE:

• One hit from 7.62MM armor piercing rifle (APR) bullet with a velocity of 2880 ft./s.