Tactical Ten for Medical Integration
The evolution of tactical medicine is rooted in military medicine throughout history (Bulter, FK, et al. 2016). Some of the most important civilian medical practices today were born on the battlefield (Mott, JC, et al., 2013). This is necessary, progressive, and imperative to the preservation of life at major traumatic events with multiple injuries, for both for tactical operators and innocent civilians.
Active shooter and mass casualty events are present and not declining. Civilian medical providers arrive rapidly to a major event with multiple injuries, but due to factors outside their control, the first patient contact may not occur for an extended period of time. Medicine in a tactical environment has evolved rapidly as lessons learned from the military make their way to our police, fire, and EMS providers in the United States.
Several factors affect the integration of civilian medical personnel into the tactical environment. Innovation is complicated, and every team will face its own hurdles. The following are 10 suggestions based on my own experience while aiding in the establishment of a tactical medicine unit for a major metropolitan police department over a five-year period.
- Unfortunately, the creation of the Tactical Medical team is violent event-driven. Proactivity in team creation can take away urgency, and choosing the right personnel for tactical medical providers is a must. These providers must be intelligent, tactically savvy, self-aware, independent, in fighting shape, multitaskers, and have the humility to take criticism with grace. This is especially important where tactical medicine has not existed in the past and there will be resistance to change. Nothing will kill the forward progress of integrating tactical medicine faster than choosing the wrong personalities. How do you choose the medics that you think with reasonable certainty will put their own lives in danger to begin treatment before a scene is declared a safe “cold zone”?
- Tactical situations are very regimented. It is imperative to train with the tactical team before running a real-life mission. Knowing how to move, when to move, where to move, and when to speak are considerations that must be planned. Planning for these situations is multifaceted, and a broad-brush approach will only create confusion. Staging of personnel and equipment, along with communication and coordination with medical personnel outside the perimeter, are planned and must be practiced prior. Medics should be integrated as much as possible into the overall plan, and not considered external or ancillary support. Any time there is scheduled tactical training, there should be a medical scenario incorporated.
- Speaking of training, trust is built in the training environment. Every single rep is an opportunity to self-identify your weaknesses or have them pointed out to you. Ego has no place on a smooth-running team, including medical personnel. No operator or medic is perfect, and you will make mistakes in the training environment. If mistakes are not identified and improvements recommended, it may be due to lack of training intensity, lack of training complexity, or lack of observer/controllers that have more or varying experiences than those completing the reps. Ego will fracture a team. Medics benefit from learning to be grateful for teammates that care enough about them to point out their missteps. There are lives at stake. Medics should be comfortable saying they don’t know and shouldn’t operate out of their skill set. They should also ensure they mentally walk through a variety of patient care scenarios at every opportunity. As the team is training, the medic can evaluate at every still frame what their role would be if a teammate should go down. Plan for the psychological stress of treating a brother or sister, but no one can never accurately replicate that level of pressure in a training environment. Having an after-action plan for critical incidents could mitigate the stress that will inevitably result.
- The hierarchy of the team should be clear, and the medic should know the team's standard operating procedures, if they are available. Even if medics don’t make an entry with their team, they MUST know how they move, communicate, and their terminology to formulate an evac and/or medical plan. Once any threats are mitigated and the scene is safe enough for medical, medics will be expected to make decisions. Everyone on the team should know everyone else’s responsibilities. Medics should know their decisions have consequences and what the positive and negative consequences of those decisions are. The first two breakdowns of any operation before its execution involve trust and communication. Train these two factors as much as possible. Multitasking is a non-negotiable part of what we do.
- Gear familiarity is important. Medics should know their equipment first, and then learn the equipment of the team members. How to take off equipment quickly is imperative when seconds count. Most tactical vests have quick releases to dump the equipment quickly. Medical personnel should know how to do this. Equally important is knowing when not to do this. Some casualties have to be moved through a warm or hot zone, and they need their protective gear placed back on/over them. For example, the medic may have to unfasten a team member's vest, throw on a chest seal and replace the vest for movement. Moving a civilian wearing civilian clothes into an ambulance on a stretcher is a completely different ball game than moving an operator in full gear into the back of a waist-high armored vehicle. Integration of these skills into training scenarios will save minutes when seconds are precious.
- Medical equipment must be compact. Medics won’t have the room or energy to stand on a scene for ten hours if their pack is not well-thought-out. Spread equipment throughout the team into individual first aid kits. Be familiar enough with the medical treatment goals to improvise the equipment they need should they run out. Knowledge of how to improvise tourniquets, chest seals, and stretchers are a minimum skill set. Have multiple lights on you and make sure you have nonwhite light sources. Medics should be familiar with their equipment in low and red lights. Noise discipline is important for the approach to a scene, so gear should be secure where it doesn’t rattle. Radios should be turned down and earpieces used with possible. If a medic has one radio, they should train how to switch it from the operating channel to medical.
- A medic’s knowledge is wasted if they don’t share it with their team. Every member of the team should have a good working knowledge of basic medicine. Sharing information with the team is a measure of the success of the medical provider. The people you train may be the first people on the scene of an active shooter, and the training they provide will have a ripple effect of improved survivability. Empower the team to be confident in their medical skills and practice with them as much as possible. Encourage them to study multiple sources and get all the training they can.
- Improvement of survivability on a tactical scene depends on the operators being able to quickly and efficiently execute their mission. “The best battlefield medicine is fire superiority.” In other words, tactics come first and then medicine. Know when it's time for each, and know that it could change in seconds.
- Study trauma medicine and know how to reduce the effects of the trauma triangle in the tactical environment. Hypothermia, Acidosis, and Coagulopathy; How can we mitigate these three as much as possible in a prehospital tactical situation? Do we have the necessary equipment to do so? Bleeding control is the primary focus at the point of injury. Every officer should know about bleeding control and evacuation. Make sure your team knows they have the rest of the patient’s life to control life-threatening bleeding. Practice how and when to move patients while the tactical team conducts a secondary clear, or how to set up a casualty collection point. Move fast and efficiently and don’t let the medicine get in the way of life-saving. It is imperative to study and train the necessary skills to evaluate vital signs and patient conditions without the luxury of a stethoscope, blood pressure cuff, or monitor (i.e. palpable radial pulse, hands-on evaluation of your patient, mucous membrane condition, etc.).
- Despite our skill set outside a tactical environment, every provider on a tactical scene should be an expert in, if not an instructor of, Tactical Emergency Casualty Care (TECC) (Callaway, DW, et al., 2011). The survivability of casualties on active scenes depends on the medical provider becoming an absolute master of the basics. Every police officer and every person with access to a tactical scene should be TECC trained at a minimum. Medical providers on the scene would greatly benefit from instructor-level credentialing. TECC takes the guesswork out of tactical medicine as they are constantly revamping recommendations based on the work of military medicine. While all recommendations and skills may not be applicable depending on the medical direction of the team, the basic skills in this course are the foundation of any medicine intended to save lives outside the brick-and-mortar clinical environment. Training should focus on the skill set suggested by TECC with a special focus for the medical personnel on improvisation, casualty collection points, and triage.
Tactical medicine teams are a valuable addition to, or asset of, any current EMS system. These teams will save lives in mass casualty situations, improve community relations, and improve the chances of survival of our first responders.
Butler FK Jr, Hagmann J, Butler EG (2016): Tactical combat casualty care in special operations. Mil Med 161 (Suppl):3–16.
Callaway, DW, Reed S, Shapiro, Geoff, et al (2011). The Committee for Tactical Emergency Care (C-TECC): Evolution and application of TCCC guidelines to civilian high threat medicine. Journal of Special Operations Medicine 11:2.
Mott, JC, Hill, BW, Parsons, DL: Tactical Combat Casualty Care Handbook: Observations, insights, and lessons. Center for Army Lessons Learned. April 2013.
Intro Picture Details:
This article is a summary of the key points made during the presentation on March 15, 2022, by Officer Brandi Kamper and Dr. Jeffrey Mott.
For further details, see the description in the Chair's Letter April 29, 2022.
Thank you Brandi and Jeff for your excellent lecture and 10 important things to remember. Our physicians really learned a lot, and your summary of the 10 key lessons to remember are very insightful and helpful.