On October 2, 2017, we woke up to the grim news of another mass shooting. The night before, a man in Las Vegas had opened fire on a crowd of concert fans, discharging high-powered weapons from the 32nd floor of the Mandalay Bay hotel, killing 58 people and injuring over 800. Police stormed the hotel but found the gunman had already committed suicide, thus ending the siege after leaving a morbid path in his wake.
Increasingly, EMS providers find themselves responding to protracted scenes of violence. They must be trained to work alongside law enforcement in high-risk scenarios, where a conventional approach to emergency response may not be feasible. Thus, tactical medicine has evolved.
The Goals of Tactical Medicine
Tactical Emergency Medical Support (TEMS)1 builds upon the principles of numerous disciplines, primarily from military medicine, disaster response, and urban search and rescue. Its goal is to devise a system of medical care that supports law enforcement missions, to reduce casualties while minimizing threats to responders.
TEMS aims at optimizing the health, safety, and welfare of law enforcement officers and the communities they protect. It is broken down into two primary functional components:
- Operational – special operations law enforcement missions, maritime medicine, hazardous materials incidents, explosive ordnance disposal, and executive protection.
- Supportive – medical intelligence and mission planning, medical consultation, occupational health, and veterinary support.
By providing specialized medical support, TEMS not only allows special operations teams to function with increased safety, but it also improves the probability of mission success in a number of ways: reducing morbidity and mortality, improving team morale, minimizing incident liability, and providing on-site medical care that reduces the number of prisoner transfers to medical facilities.
Zones of Care
During tactical missions, law enforcement will divide the target area into zones of operation, with inner and outer perimeters providing static boundaries for their operations. TEMS divides these areas of operation into three Zones of Care:
- Hot Zone – care is provided under fire
- Warm Zone – tactical field care is provided
- Cold Zone – tactical evacuation takes place
TEMS practice guidelines define the rescue activities that occur within each zone. Certain treatments are limited, based on the level of risk within each zone, and include these guidelines:
- Care Under Fire – Hot Zone
- Cover and concealment: prevent further injury to casualty or rescuer
- Neutralize the threat as soon as possible
- Use tourniquets for life-threatening extremity hemorrhage
- Avoid invasive airway procedures, CPR, or strict cervical spine precautions
- Tactical Field Care – Warm Zone (X-A-B-C-D-E)
- EXsanguinating: hemorrhage control (tourniquet, hemostatic, and pressure dressings)
- Airway: clear obstructions, NPA, supraglottic or endotracheal tube, and surgical airway
- Breathing: treat sucking chest wounds and tension pneumothoraces
- Circulation: assess for shock
- Disability: splint major fractures, immobilize cervical spines for high-risk injuries
- Exposure: protect from hypothermia and consider heat, chemical, or toxic exposures
- Tactical Field Evacuation – Cold Zone
- Conventional EMS and transport care
- Ensure clear routes of egress
- Consider staging requirements
- Remain alert for secondary devices and unconventional threats (flood, crowds, fire)
Suction Considerations During Tactical Medical Events
The high probability of traumatic injuries resulting from tactical medical scenarios ensures the need for suction. Gunshot wounds, blast injuries, or toxic exposures will produce bleeding and respiratory threats, all of which may require suction. But like other tactical gear, your portable suction unit must be designed with certain specifications in mind:
- Portability – the unit must be small enough to fit within a trauma bag and lightweight, for ease of carry.
- Durability – the suction unit must be able to withstand the rigors of tactical environments, which may include extreme temperatures and weather patterns.
- Reliability – steadfast battery power must be provided, along with replacements, for extended incidents.
- Functionality – the unit must supply the necessary negative pressure needed for multi-system trauma, while still meeting the physical requirements of tactical gear.
Tactical medical scenarios can be long-term, large-scale incidents that require special training, extensive preplanning, and a tailored approach to emergency care. Be sure your portable suction units are up to the task.
Prehospital Trauma Life Support, American College of Surgeons, Committee on Trauma, MOSBY JEMS, Elsevier.