BUILDING A TEMS TEAM

Martin J. Greenberg, M.D.
Chief, Section of Hand Surgery
Illinois Masonic Medical Center            
Tactical Physician, Cook County Sheriff's Police
 Chicago, Illinois

E. John Wipfler, III, M.D., FACEP
Attending Emergency Physician
Clinical Assistant Professor, Univ. of IL College of Medicine 
 OSF St. Francis Medical Center
 STATT Medical Director;  Peoria City Police Dept. SRT Unit 
  and Peoria County Sheriff's Dept. Aux. Deputy
 Peoria, Illinois

Initially published in ITOA News Summer 2002
Excerpts printed with permission for ACEP TEMS Newsletter

Tactical Emergency Medical Support (TEMS) serves an increasingly important role for tactical teams across Illinois and our nation. As tactical teams strive to incorporate TEMS into their structure, a number of basic technical questions arise. This article will attempt to answer these questions with templates that may be evaluated, used, or modified by fledgling TEMS teams. The most frequently asked questions include, "What type of agreement should the TEMS team have with the tactical team; and what medical gear does the TEMS team need?"

PART I: THE MEMORANDUM OF UNDERSTANDING (MOU)

The responsibilities of both the TEMS provider and the law enforcement agency should be clearly defined prior to TEMS team activation. An agency entrusts its most valuable resource to the Tactical Medic. With lives at stake, the agency naturally wishes to understand and approve of all aspects of TEMS activity performed in their behalf. Alternatively, the medics wish to clarify their role within the tactical team.  The agreement outlining these mutual responsibilities is termed the Memorandum Of Understanding (MOU). This written agreement is mandatory to avoid misunderstandings. It is also required by the Illinois Department of Public Health (IDPH) in order for pre-hospital medical personnel to register and function as a prehospital medical agency within the Emergency Medical Services (EMS) system in the State Of Illinois. The MOU is then submitted to the Illinois Department of Public Health (IDPH) along with a standard EMS agency application form. Three TEMS agencies are currently registered as non-transport EMS agencies in Illinois. Each agency must decide upon the level of Life Support Service they provide: Basic (BLS), Intermediate (ILS), or Advanced Life Support (ALS). Additionally, the TEMS agency must clarify if they will be a "transport" or "non-transport" agency (i.e. have their own ambulance and transport patients or interface with existing transport units. The costs and administrative paperwork rises considerably for transport units. TEMS units in Illinois have so far been non-transport ALS agencies. Municipal fire fighter paramedics/EMTs may possibly more easily arrange for transport options. The MOU provides a description of the medical services provided. Written approval from the local area EMS Medical Director is also required. The regional EMS office is familiar with these documents and will be helpful in getting the TEMS unit registered. The benefits of joining the EMS system are numerous.They include receiving radio guidance from the Resource Hospital (often mandatory if physicians are not physically present at the call-out), replacing outdated medications, obtaining state contract pricing on needed supplies, and training support. A TEMS team in Illinois is legally bound to enter the State EMS system when they enter into a written agreement with a law enforcement agency.

A sample outline of one type of Memorandum of Understanding (MOU) has been included in this newsletter. It is meant to serve as a starting point for discussion between these parties and should be modified in any manner they see fit. The MOU sample outline summarizes the salient aspects of a successful relationship between the TEMS and tactical teams. It is a basic framework meant to simplify the development of TEMS MOUs. The authors and the Illinois Tactical Officer's Association take no responsibility for the use of this outline by any party, and recommend that local legal counsel review any agreement between a TEMS Team and a law enforcement agency.

PART 2: TACTICAL EMS MEDICAL UNIFORM AND EQUIPMENT

The following is a general description of TEMS medical officer uniform, equipment and medical supplies.

Medical Officer Uniform

• appropriate agency uniform for training and call-out missions
• boots (good ankle support, good all-around traction, and waterproof which will be somewhat protective against blood born pathogens (Gortex, etc.)
• cold weather clothing, such as hats, gloves, insulated clothing, parkas, and boots
• wet weather gear : poncho, raincoat, Gortex garments
• appropriate cooler clothing if hot weather is present

(Note: the exterior uniform/helmet should allow others at a scene to immediately identify the TEMS provider as a "medic;" i.e., subdued red cross on uniform/gear;. Some in this field, however, feel that this may jeopardize the medics, as terrorists may intentionally 'target' medical personnel. This is controversial.)

Personal Protective Equipment

• ballistic vest (Level III preferred)
• helmet (Kevlar)
• black balaclava, fireproof (Nomex) to protect identity at scene, and prevent facial burns
• eye protection (polycarbonate lenses to protect from flying debris/trauma)
• ear protection (foam plugs, shooting muffs)
• gloves (rubber gloves - Nitrile is ideal), and possibly leather or Nomex gloves
• medical protective PPE gear: face mask/shield, gloves, HazMat gear, if needed
• knee pads (to protect knees, especially when treating patients while kneeling with glass/blood on the floor)
• gas mask (may be issued by commander if conditions warrant; i.e., expected deployment)
• NBC protective filter for gas mask (a must have item, for terrorist threats, and only $35.00 each)
• Camelback brand water hydration system or canteen

TEMS Medical Equipment/Supplies
The medical gear/medications to provide medical support may be carried in many different ways…each unit does it differently. Our unit has adopted the simple philosophy in which "if it's not attached to you when the (expletive deleted) hits the fan, you won't have it there when you need it." We currently have a three-level system. Two of these remain with the TEMS officers at all times, while the third (large advanced medical bag) typically remains locked up in a secure, stable temperature environment in our hospital, and then is brought to the call-out scene and remains locked in a secure vehicle, or remains under direct control at the Tactical Operations Center. An Automatic External Defibrillator (AED) is carried by our TEMS unit. It is not carried personally with us during call-outs, but is left nearby in the unit vehicles in case it is needed, and is within a one minute response time from wherever training or call-outs are held. In the past several years, several SWAT officers have died from sudden cardiac death at annual qualification exercises. Sadly, had a defibrillator been immediately present during these unfortunate incidents, the outcome may have been different. Immediate defibrillation in the first four minutes of a potentially fatal arrythmia (abnormal heart beat) has a fairly good survival rate. Defibrillation after eight minutes, even with CPR given immediately, results in a much poorer outcome. Keep the AED/defibrillator close at hand!

The three-level system will now be explained. Please keep in mind that there are several ways to structure the medical gear for a TEMS unit… this is only one explanation.

I) Tactical Medical Vest with Belt, Holster, Airway (leg) pack. Contents may include:

• stethoscope, Nitrile rubber gloves, face mask with eye shield
• airway management kit - cricothyroidotomy hook, scalpel, mouth-mask valve, Cook pneumothorax kit, hemostats, ET tube (6.5 and 7.5), stylet, oropharyngeal airway, laryngoscope with #3 blade
• compression trauma bandages (3), cloth tape, small roll of duct tape
• Asherman penetrating chest trauma seal (2)
• minor wound medical kit: Steri-strips, benzoin, betadine, neosporin ointment, band-aids, 2x2 bandages
• Tylenol/Advil tablets (acetaminophen and ibuprofen, for minor pain/headaches)
• personal I.D./wallet/Sheriff or Police badge
• handcuffs, holster and defensive weapon (pistol), ammo, extra magazine
• trauma scissors, knife, folding style/utility, paratool
• cellular phone
• portable radio with tactical headset; access to all tactical law enforcement frequencies
• flashlights (multiple)
• binoculars; consider night vision monocular/headset
• pen and pad of paper for notes
• camera and film (for evidence preservation,documentation, interesting cases)
• ASP expandable baton
• metal detector (hand held, vibratory type, for identifying hidden weapons, cuff keys)
  II) Tactical Medical Backpack
• second advanced airway management kit which includes second set of above airway supplies, and Magill forceps, laryngoscope #1 and #3 blades, full assortment of ET tubes
• large curved hemostats, scalpels
• two one-liter IV LR fluid bags/IV starter kits with two blood tubing IV lines/pressure IV bag
• disposable hot pack (to keep IV fluid warm in cold weather operations)
• seven French change-out catheter set (used for cut-downs/IV access)
• additional trauma dressings, gauze bandages
• collapsible one-man stretcher
• two SAM splints
• universal protection supplies (gloves, masks)
• disposable flash camera (documentation/forensic evidence)
• list of each team member's medical history/allergies
• 50 feet of 400-lb parachute cord
• emergency thermal blanket
• second flashlight
• medicines: Tylenol, Advil
• GPS unit (for use in rural location to guide air medical transportation assistance)
• ACLS medications: atropine, epinephrine, lidocaine
• MARK I NAAK kits, optional (providing atropine and 2-PAM for nerve agent exposure)

III) Tactical Medical Advanced Emergency Medication Pack. 
NOTE: This pack is kept locked in a controlled environment at the base hospital. The contents includes narcotics, which must be properly stored and controlled under federal guidelines. In addition, it is important to prevent exposure to high heat due to the sensitive medications contained (PO and IV antibiotics, paralytics, and other medications). Our hospital will "restock" this bag every six months, thus, recycling the medications prior to expiration, allowing net "cost" to be  very low. Listed below is what is contained in our advanced kit.

ADVANCED EMERGENCY MEDICATION PACK
(for use under the direction of a physician)

COLD/FLU SYMPTOMS

• Cough drops
• Entex PSE decongestant, # 20
• Neosynephrine nasal spray, # 1 bottle

MINOR PAIN CONTROL

• Ibuprofen 400 mg tablets, #30
• Tylenol 500 mg tablets, #30

SEVERE PAIN CONTROL

• MSO4 for IM/IV use (30 mg total)

ALLERGY/ANAPHYLAXIS

• Epinephrine 1:1000, #3 2-cc ampules
• Benedryl 25 mg, #20 capsules
• Prednisone 20 mg, # 10 tablets
• Albuterol inhaler, # 1 (used for asthmatics also)

GI AILMENTS

• Immodium tablets #20 tablets
• Peptobismal tablets # approx 20
• Mylanta tablets # approx 20

ITOA News - Summer 2002 39

UNRESPONSIVE PATIENTS

• Ammonia capsules, # 2
• Dextrose 50%, # one 50 cc syringettes
• Oral glucose syrup, # one tube
• Narcan, # two 2-mg ampules

ACLS DRUGS

• Lidocaine 1%, # two 10cc syringettes
• Atropine, # two syringettes
• Epinephrine 1:10,000 # four 10-cc syringettes

SEIZURE CONTROL

• Diazepam for IV/IM use, # one 10 mg vial

RSI MEDS

• Diazepam 10 mg vial
• Ketamine for IM/IV use, # 1 bottle
• Vecuronium (Norcuron) 10 mg powder
• Rocuronium (Zemuron) two 5 cc vials
• Normal Saline 25 cc bottle (to reconstitute Norcuron)

EAR EYE AILMENTS

• Gentamycin ophthalmologic ointment, # 2 tubes
• Gentamycin opth. Drops #2 bottles
• Cortosporin otic suspension, # 1 bottle

SKIN AILMENTS

• Lotrizone cream 10 gm, # 3 tubes
• Triamcinolone 0.1% cream 10 gm, # 3 tubes
• Sun screen, 30-SPF, 1 tube

INFECTION TREATMENT

• Cephalexin 500 mg tablets (10)
• Ancef (2 gm, IV/50cc bag)
• Rocephin (2 gm, IV/50 cc bag)

OTHER MEDICATIONS

• Nitroglycerine spray, one container
• Oragel (dental analgesic), one tube

Consider additional MARK I NAAK kits. Additional items included in the Advanced Medical Supply Kit include the following:

• syringes and needles, alcohol wipes
• suture kits (2) and minor surgical emergency supplies, such as gauze, basin, sterile gloves, suture material, betadine swabs, etc.
• Dermabond skin laceration tissue glue
• additional IV fluid and IV lines, IV starting kits
• Anderson Blast Gauge
• sterile saline (2 bottles) for irrigation/cleaning wounds
• dental kit: mirror, dental floss, clove oil, topical anesthesia, tongue
• blades, stoma wax, temporary filling material
• additional trauma supplies: antiseptic towelettes, compression elastic bandage, trauma pads, eye dressing, Q-tips, SAM splints, triple antibiotic ointment, band-aids, tape, non-stick gauze, gauze pads, moleskin/blister kit, irrigation syringes/solution, Betadine and Hibaclens scrub brushes, cold packs, heat packs, cling wrap, two Cook Pneumothorax kits
• extra stethoscope, pen light, trauma scissors, knife/paratool
• gloves latex, sterile and nonsterile; face mask/shield
• pencil marker, waterproof paper, medical records of unit members
• patient I.D./triage tags, emergency thermal blankets (2), strobe light
• medical waste bags, disposable sharps hard plastic container
• thermometer

In summary, the medical gear that is utilized by a TEMS unit can be simple and cost-effective, or can be very advanced. The actual use of this medical gear is very infrequent. Are these medical supplies "too expensive and too much hassle?" Remember that a
traumatic full arrest victim has less than 1 in 1,000 chance of survival. If medical providers take immediate action, preventing full arrest, survival is much improved.
With planning, such as rotating medical supplies prior to expiration, budgets can handle an ALS level prehospital emergency response.

ABOUT THE AUTHORS

Martin J. Greenberg, MD, FACS, FAAOS is Chief, Section of Hand Surgery at the Illinois Masonic Medical Center, in Chicago, Illinois. He is an Assistant Clinical Professor of Orthopedic Surgery at the University Of Illinois College Of Medicine. Marty is also an Executive Committee Member of the Illinois Mobile Emergency Response Team, as well as TEMS Committee Co-Chair for the Illinois Tactical Officers Association. He is a Reserve Police Officer for the Village of Tinley Park, Illinois, and is the Training Director for the STATT Team, South Suburban Police Emergency Response Team.

E. John Wipfler, III, MD, FACEP is an Attending Emergency Physician at OSF St. Francis Medical Center. He is a Clinical Assistant Professor in the Department of Surgery/Emergency Medicine at the University of Illinois College of Medicine, and is also a TEMS Committee Co-Chair for the Illinois Tactical Officers Association John is the Medical Director of the STATT Tactical EMS Unit, supporting the Peoria County Sheriff 's Department STAR Unit and Peoria City Police Department SRT Unit. He is an Auxiliary Deputy Sheriff with the Peoria County Sheriff 's Department.