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TACTICAL EMERGENCY MEDICAL SUPPORT
Posted by: Write My Essay on: February 8, 2018

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Abstract

This paper examines current policies and guidelines that establish the framework for the roles and responsibilities of the tactical medic in the hot zone of the active shooter environment. It is pertinent to know the proper and most effective policies and procedures for tactical medical team deployment to ensure safety and survivability. The propagation of active shooter incidents and the resulting casualties of these events have compelled emergency responders to adjust their response modes. This response change is an attempt to reach the wounded and dying more rapidly to affect more positive outcomes. .  [“Write my essay for me?” Get help here.]

Images retrieved from  911 Tactical Medicine
Entry teams regularly train as a single discipline with a single objective–to suppress the threat. Emergency medical responders, typically non-law enforcement, are attached to threat suppression teams as they make entry into the hot zone. The addition of a medical component possesses benefits and complexities that need to be weighed. Objective evaluation of the tactical medic function will be accomplished through communication with law enforcement, fire departments, labor unions and risk managers to understand the tactical medical role, its feasibility, and the added danger of unarmed responders inside the hot zone.

The active shooter environment is kinetic, uncertain and dangerous. Tactical medics must be highly trained, coordinated, and have guiding documents that direct the limits of their response.  Evaluating the integration of multiple disciplines into a single response team that is expected to move and communicate in a common language will assist with establishing controlling policy and standard operating guidelines.

Definitions
Hot
A “Hot Zone” is defined as being a location where terrorists or other perpetrators are present. This could be in the form of them roaming around or in cases where they are engaged by homeland security or other law enforcement.

Warm
A “Warm” zone is determined to be an area that has been cleared, and no identifiable suspects or threats are believed to be in the area.

Cold
In Cold Zones, no suspects are present. Cold Zones often serve as a patient transfer area and a transportation point. It could also be a casualty collection point, staging area, the location of a command post, or a tactical operations center.

Tactical Methods (overview)
Hot
In “hot” zones, no Emergency Medical Service personnel are permitted to operate.

Warm
“The exhaustive process of declaring an area “Cold” would be prohibitive as these exigencies, so firefighters and EMS personnel will be expeditiously placed for life safety operations, under close Law Enforcement escort, facilitating rescue initiatives and treatment of the injured in established Warm Zones (). Medics can wear ballistic protection in these zones. Operations in the Warm Zones are largely targeted towards repair of the damaged area or the disabling of standpipes and routing of a bypass water system to facilitate more supply. At this point, medics may treat and transport any victims out of the warm zones. It should be noted that Warm Zones might be considered to be existing without pockets of the Hot Zones. [Need an essay writing service? Find help here.]

Cold
Medics do not require ballistic protective gear at this point.

Current Policies and Guidelines
Introduction
As the recent Dallas sniper attack has shown, active shooter incidents can impact both civilians and police personnel thereby requiring emergency medical services to apply immediate assistance. Nearly 90 percent of all preventable active shooter related deaths occur before a casualty can reach a nearby hospital or medical treatment center. Ranging from hemorrhaging from wounds on their extremities, airway obstruction, to tension on their pneumothorax, these are the primary preventable causes of death that can be handled by an adequately trained medical support unit. However, since civilian EMS agencies do not provide the necessary training for their personnel to operate in an active shooter hot zone, there is a concern for their safety since police personnel are more likely to actively safeguard them, thereby putting themselves at risk, due to their designation as inexperienced civilians. < Click Essay Writer to order your essay >

As a result of the necessity of personnel that have up-to-date knowledge on SWAT and police department operations as well as training in emergency medical assistance, TEMS (Tactical Emergency Medical Support) personnel are the most suitable for active hot zones. It is based on this that this section will examine the current polices and guidelines that establish the framework for the roles and responsibilities of TEMS personnel in active shooter environments. Through this examination, the effectiveness of the current SOP (Standard Operating Procedure) will be evaluated leading to a better understanding of its purpose, functionality and potential areas where improvements can be implemented.

Current Changes in TEMS Policies and Guidelines
Before proceeding, it is necessary to take note of the current shift in TEMS policies and guidelines which focus on providing individual hemorrhage control kits as well as emergency medical response training to police officers and other first responder personnel (Polun, Hsu, Yuann-Meei, Yiing-Yiing, I-Ching, and Wei-Fong 2004 230). Previously, the doctrine for TEMS focused on police officers, SWAT, and other first responders waiting for a tactical medic to arrive on the scene to provide the necessary assistance to an injured civilian or on-site responder. However, as a result of recent mass shootings such as the movie theater massacre that occurred in Aurora, Colorado, the inherent weakness of this reactive doctrine has been revealed. In the aftermath of these incidents, there were numerous identified casualties who had preventable deaths (ex: hemorrhaging). The problem, in this case, is not the response time of TEMS personnel; rather, it is the lack of sufficient knowledge and capability by first responders on the scene to give emergency medical care.

It is argued that if the first responders had the necessary knowledge and equipment to help stabilize victims for further medical assistance during active shooter incidents, this could have resulted in more lives being saved. While it can be stated that this adds an additional burden for police officers, SWAT personnel and first responders since they have to neutralize a threat as well as treat the wounded, the fact remains that this shift in the policies and guidelines surrounding TEMS is likely to result in more lives being saved which is the goal of any operation involving civilian casualties in a hot zone with an active shooter. Most of the injuries involving active shooters are external hemorrhages due to being hit by a bullet or shrapnel. It is actually a myth perpetuated by Hollywood that a shot to the body can instantly kill a person. While this can temporarily immobilize them and cause significant amounts of pain, they are still alive and can be treated. However, while the bullet may not have killed them, the resulting hemorrhage can due to the blood loss that occurs that can lead to shock. In these situations, the most important action that can be done is to stabilize the patient by stopping the bleeding as quickly as possible (Danielsson and Alm 2012, 3456). To bring this sort of resolution about, law enforcement personnel would need to undergo proper hemorrhage control training as well as be given kits that are specifically designed to counter the blood loss that occurs. Through these actions, the primary component behind preventable deaths during active shooter incidents can be addressed resulting in more lives being saved.

This is not to say that this shift in TEMS policy and guidelines would make tactical medics obsolete; rather, it is more of a change in which this type of EMS personnel will operate in active shooter hot zones. Even if law enforcement officers are provided the needed training and field equipment to handle hemorrhages, this does not mean that they would possess the knowledge, skill, and equipment to handle more complex cases or know how to further stabilize a shooting victim to ensure that they would have fewer complications during recovery. In the next section, the implications of this shift in policies and guidelines for TEMS personnel will be examined.

Impact of the Changes in TEMS
The new approach to TEMS by law enforcement personnel does not make a tactical medic redundant nor does it radically change the current model that they operate under; rather, it is more accurate to state that the shift in existing policies and guidelines helps to address weaknesses that were inherent in the previous SOP. Tactical medical units attached to police or SWAT teams engaged in an active hot zone are still placed under the same responsibilities of treating casualties, implementing medical support, ensuring proper health management of the team, obtaining the necessary medical supplies and creating a plan of operations prior to a breaching or suppression event where there is the possibility of injury. What the current changes do is help take the pressure of a tactical medic on the field so that they can concentrate on cases that require more advanced medical assistance. As seen in the Dallas sniper incident and the Aurora massacre, there can be multiple casualties of an active shooter at any incident. Since there are limited amount of tactical medical units assigned per team, this results in the potential for preventable deaths to go unaddressed due to the inherent personnel limitations (Young, Sena, and Galante 2014, 39). This is why the new TEMS model focuses on the tactical medic acting as a field medical supervisor when it comes to emergency medical assistance that all law enforcement personnel are expected to participate in.

The previous policy and guideline for active shooter incidents focused on threat suppression then medical care by a tactical medic on the field. This SOP was considered the best strategy for preventing the medic from being injured by stray gun fire as well as maximizes the potential for survival for the victim that was being treated (Jenkins 1996, 481). However, the problem with the old model was that it mostly resulted in personnel waiting for the medic to appear for assistance to be rendered. The new design focuses on the tactical medic educating officers beforehand regarding the type of injuries they are likely to encounter, inform them of the proper procedure for treatment and coordinate their efforts on the field once the threat has been dealt with. This follows the same initial policies and guidelines when it comes to neutralizing an active shooter in a hot zone but adds the additional action of coordination from the tactical medic resulting in first responders and other law enforcement personnel also rendering medical assistance. The addition of TEMS training also helps to offset instances where an officer is injured yet the tactical medic cannot reach their position. In these cases, if another officer is present or the individual that was shot is still conscious, they could administer treatment to the wounded area via hemorrhage kits that they brought on the field. By knowing how to apply a triage kit correctly, this helps to prevent cases where a tactical medic will risk their life to reach an injured officer.

Policies and Guidelines For TEMS Unit Deployment
TEMS deployment procedures are considerably different than their civilian EMS counterparts since good medicine in a hot zone can lead to wrong tactics which can get people killed. It is due to this that the current policies and guidelines for tactical medical units focus on not only treating the casualties of an active shooter incident but preventing further losses due to improper medical intervention (Vogel, Cohen, Habib, and Massey 2004, 42). It is based on this that TEMS deployment utilizes the following stages of care when it comes to deployment, each with its own policies and guidelines that influence the actions of the tactical medic:

a.) Care Under Fire (Hot Zones)
In certain cases, a field medic would need to provide on-site medical assistance to a law enforcement officer while they are still fired upon by a shooter that has not been suppressed. This stage is considered the most hazardous given the potential for death or serious injury. The general guidelines during this juncture of TEMS consist of the following:

1.) Returning fire as needed – if the medic is trained to handle a weapon or is accompanied by law enforcement personnel, it is at times necessary to lay down suppression fire. This is to make the shooter more cautious about exposing their themselves to potential retaliation which enables the tactical medic to reach the victim.

2.) Focus on preventing yourself from getting hurt – if the tactical medic is injured during the process of rendering assistance, this creates two casualties that would need to be retrieved from the hot zone. Situations like this add more danger to an already hazardous situation since provisioning medical care and extracting the additional victim could result in even more casualties (Delir Haghighi, Burstein, Zaslavsky, and Arbon 2013, 1197). As such, the tactical medic needs to ensure their own safety and not take unnecessary risks.

3.) Prevent the victim from receiving more injuries – in active shooter hot zones, there is a high chance that a casualty on the field could receive more injuries due to the shooter intentionally targeting downed civilians or law enforcement personnel. It is the responsibility of the tactical medic to move the patient to a location with sufficient cover to prevent this situation from occurring.

4.) Prevent an external hemorrhage from getting worse – once a casualty has been sufficiently transferred behind a protective barrier, it is necessary to immediately stop their wounds from bleeding out. Even if an injury may initially appear to be non-life threating, the blood loss can cause them to enter into shock, and this can lead to death. A tourniquet or a HemCon Bandage would be necessary to stop the wound from bleeding out before transferring the patient.

5.) Extracting the casualty – the last step in this procedure is extracting the victim. This involves laying down sufficient suppressive fire to distract the shooter and coordinate with other members of on-scene local law enforcement to assist in retrieving the victims.

b.) Tactical Field Care (Warm Zones)
This phase of deployment under the policies and guidelines of TEMS consists of providing medical assistance when a tactical medic is no longer in danger of being injured by hostile fire. This occurs when an area transitions from a hot zone to a warm zone since the active shooter on the scene has been incapacitated or killed. However, even if the immediate danger of the assailant has been addressed, this does not mean that the lives of the casualties are out of danger. Further medical assistance needs to be provided, but this is based on the approval of the mission commander in charge since it is still uncertain whether all threats in the warm zone have been adequately dealt with. In this phase, the tactical medic is required to utilize the following guidelines when it comes provisioning medical care:

1.) Acknowledge the potential for conflict occur – as the Virginia Tech Shooting has shown, there is the possibility that an active shooter may have a similarly armed accomplice. Even in a zone that has shifted from “hot” to “warm” there is still the potential for a hidden assailant to be present. Aside from this, there is also the possibility of injured law enforcement personnel to be in a state of delirium due to blood loss and, as a result, they may actually utilize their weapons under the belief that they are being attacked (Shakespeare-Finch, Rees, and Armstrong 2015, 555). It is necessary for a tactical medic to evaluate the potential danger of a hidden assailant and to disarm a casualty of any weapons they may have to prevent an escalation in the number of injured people on the scene.

2.) Addressing potential airway blockages – with a reduced threat level, tactical medics can proceed with more complex procedures when it comes to resolving cases involving preventable deaths. Blocked airway passages of incapacitated victims during shooting incidents are one of the leading causes of preventable death. To address this issue, medics normally have to utilize a nasopharyngeal airway or even attempt on-site surgery in the form of a cricothyrotomy to get fresh air into the lungs. Either of these methods is only possible if the location has been deemed sufficiently safe due to the potential of worsening a victim’s injuries if the tactical medic is exposed to danger in the middle of the procedure. This step also includes examining cases where a patient is conscious but has difficulty breathing, in such instances, it may be necessary to utilize a chest tube if the patient is unable to breathe properly for an extended period.

3.) Addressing Bleeding and Determine the need for Fluid Resuscitation – in some cases it would be necessary for a tactical medic to reassess the emergency medical procedures that were implemented to prevent a patient from bleeding out. Determining whether a tourniquet needs to be removed or if fluid resuscitation is necessary are all aspects of ensuring that a casualty in a shooting incident is sufficiently stabilized so that they can be moved to a medical facility that can provide more extensive treatments.

c.) Combat Casualty Evacuation (Cold Zones)
This is the final phase in TEMS unit deployment and focuses on the policies and guidelines surrounding what to do with a casualty once they have been sufficiently extracted from a warm zone to a cold zone. In this case, the focus centers on stabilizing the patient so that they can be transported safely. Depending on the severity of the injury, a tactical medic may opt to recommend that a patient be brought to a medical center via emergency air transport or for less severe and more stable cases, a motor vehicle would suffice. The same steps in tactical field care are implemented in this final phase, but the focus is more on ensuring that the patient survives the transit from the conflict area to a hospital.

Benefits and Cost
What has been presented in this analysis are the current policies and guidelines when it comes to the deployment of tactical medical units in an active shooter environment, their procedures in dealing with casualties and the changes that have been implemented to address identified weaknesses. It has been shown that the proposed changes in TEMS procedures for law enforcement personnel create a greater likelihood of increased survivability of casualties during active shooter incidents. When comparing past policies and guidelines for TEMS deployment compared to the proposed progressive changes, it can be seen that TEMS procedures were centered primarily on the medic. However, as this report has shown, centering the provisioning of medical care via a single unit can result in preventable deaths occurring. This is why the new procedures can be considered as a blend of medical attention and military tactics since it prevents compartmentalization related deficiencies in performance.

As mentioned in this report, good medicine can result in the implementation of wrong tactics which can get people killed; however, the same can be said about good tactics resulting in preventable deaths occurring. What was needed was to bridge the gap between the policies and guidelines between the models of action in such a way that it addresses the problems each has when it comes to the implementation of their standard operating procedure (Rasmussen, Tolsgaard, Dieckmann, Issenberg, Østergaard, Søreide, Rosenberg, and Ringsted 2014, 1728). The new TEMS action model does this by ensuring that role specialization is not a detriment towards accomplishing the goal of the mission.

The primary purpose of any police action in a hot zone during an active shooter incident is to safeguard the lives of civilians. While this can be accomplished by neutralizing the shooter, the fact remains that more lives could be lost through inaction (i.e. due to the preventable deaths). It is based on this that the main benefit of educating law enforcement personnel regarding the standard medical procedures for hemorrhages, which are the most common external injury during an active shooter incident, and by providing them anti-hemorrhage kits, is that this results in more lives being saved. However, it should be noted that while several states have already implemented the new TEMS model, there is still considerable resistance to change in several police districts. This problem stems from the perceived budgetary increase needed to train law enforcement personnel in the required medical practices as well as the cost of outfitting an entire police force with anti-hemorrhage kits. They argue that by just eliminating the active shooter as quickly as possible, this ensures that emergency medical personnel can be brought in that much faster while tactical medics can handle on-site injuries (Gildea and Alan Janssen 2008, 412).

This report has shown through the policies and guidelines for TEMS is that that the old model creates needless exposure to danger for a tactical medic and enforces a system where limited personnel are available to handle preventable deaths. The result are people potentially dying or ending up with a more complicated health issue compared to a situation where they received immediate emergency medical assistance. Taking this into consideration, the new TEMS model is more applicable to the mandate of law enforcement agencies since it focuses on saving lives while allowing local police officers to perform their duties.

Evaluation of Tactical Medic Function
The problem with evaluating the current function of tactical medics is that they differ widely depending on the region that they operate in. For example, tactical medics in the West Coast, in addition to their training in emergency medicine, have also been trained in police and military tactics via various reserve programs. By having formal training in law enforcement, this allows a tactical medic to understand the different operational guidelines that influence police tactics in the field during an active shooter incident and plan accordingly. Formal training and their induction into a police program also makes police departments more willing to work with a tactical medic due to the reduced civil liability in the event of an injury or death and the fact that having someone know about all the necessary operational guidelines when it comes to operating in a hot zone makes it far easier to reach a compromise when it comes to reaching affected victims.

On the other end of the spectrum, tactical medics from the East Coast are frequently sourced from local fire departments and EMS agencies. Unfortunately, they are often not part of the local reserve force and are treated more as a potential liability than a much-needed resource. After going over the policies and guidelines impacting the actions of tactical medics in the field and why they were put in place, it can be stated that the practice of “borrowing” emergency medical practitioners from local fire departments and EMS is an inappropriate and even dangerous prospect given the potential dangers that untrained personnel can bring to an active shooter environment.

A tactical medic’s role is to provide medical assistance to law enforcement officers while at the same time being cognizant of their role in the mission parameters. This helps them to understand what operational procedures are going to be enacted, how a tactical medic fits into them and what they should do to minimize their interference while maximizing the chances of providing medical assistance to injured parties on the scene. The only way this can be accomplished is if the medic in question is intimately familiar with police procedures via direct training. Merely borrowing an individual from a non-law enforcement agency and placing them in the role of a tactical medic creates the potential for them to become another victim.

In this report, it was discussed that one of the possible methods of increasing the survival of shooting victims is to educate law enforcement personnel on EMS procedures for external hemorrhages and to provide them with the necessary kits to stop the bleeding. This is a practical crossover of roles since giving on-site medical assistance via an emergency procedure is better than the alternative of not giving it at all. However, the same cannot be said about providing a medic from a fire department or EMS a briefing on their role in an active shooter hot zone and expect them to be able to perform adequately. They are not used to the same pressures and dangers that law enforcement personnel are exposed to and, as a result, are more likely to cause further injury or be a victim than they are to provide medical assistance.

The function of a tactical medic is not supposed to be limited to medicine alone; rather, they are also expected to contribute to the operation via knowledge on how to use weapons and the tactics used to suppress active shooters. This allows tactical medics to operate independently of a squad of police officers and allows them to instantly evaluate a situation and implement their police training to ensure not only their safety but those of the shooting victim as well. This is why the practice of East Coast law enforcement agencies can be considered as dangerous since it exposes untrained personnel to the dangers of a hot zone and expects them to provide proper medical assistance despite the entirely new and extremely stressful environment they are exposed to.

Conclusion
This report has investigated the current policies and guidelines that establish the framework for the roles and responsibilities of the tactical medic in the hot zone of the active shooter environment. What has been presented in this analysis are the methods utilized in the deployment of tactical medical units in an active shooter environment, their procedures in dealing with casualties and the changes that have been implemented to address identified weaknesses.

The main problem that has been identified is that civilian EMS agencies do not provide the necessary training for their personnel to operate in an active shooter hot zone, there is a concern for their safety since police personnel are more likely to actively safeguard them, thereby putting themselves at risk, due to their designation as inexperienced civilians. As such, it is recommended that only TEMS medics that have undergone police training are to be utilized in any hot zone with an active shooter. However, this action does not reduce the problem of the inherent limitations in TEMS operations wherein a medic cannot be in several locations at the same time. This shows the importance of the current shift in TEMS policies and guidelines which focus on providing individual hemorrhage control kits as well as emergency medical response training to police officers and other first responder personnel.

Previously, the doctrine for TEMS focused on police officers, SWAT, and other first responders waiting for a tactical medic to arrive on the scene to provide the necessary assistance to an injured civilian or on-site responder. Through the new approach, individual law enforcement personnel are given the capabilities and the tools to assist both civilians and other police officers if they are hit by bullets in a hot zone. The new approach to TEMS by law enforcement personnel does not make a tactical medic redundant nor does it radically change the current model that they operate under; rather, it is more accurate to state that the shift in existing policies and guidelines helps to address weaknesses that were inherent in the previous SOP.

The new design focuses on the tactical medic educating officers beforehand regarding the type of injuries they are likely to encounter, inform them of the proper procedure for treatment and coordinate their efforts on the field once the threat has been dealt with. This follows the same initial policies and guidelines when it comes to neutralizing an active shooter in a hot zone but adds the additional action of coordination from the tactical medic resulting in first responders and other law enforcement personnel also rendering medical assistance. Overall, what this report has revealed is that positive change has been occurring in TEMS policy; however, there are still areas of improvements necessary as seen in the difference between West Coast and East Coast TEMS.

Recommendation
Based on the information presented in this report, the key recommendation for change in the current policies and guidelines impact TEMS operations is to immediately stop the practice of borrowing medical personnel from fire departments and EMS so that they can be placed in a tactical medical position. The problem with the method has already been discussed, and it has been shown that it is not feasible in the long term given the potential adverse outcomes.

Instead, this report recommends that the program of teaching basic medical procedures to address external hemorrhages be expanded and made into a requirement by all law enforcement agencies within the country. This helps to address the immediate need for “borrowing” medics during active shooter incidents by enabling police officers to administer emergency care before more extensive treatment options can be implemented.

Aside from this, future researchers examining this topic may want to look at the reasons behind the resistance to change seen in East Coast law enforcement departments when compared to their West Coast counterparts when it comes to the practices used in obtaining tactical medics for hot zone operations. This distinct regional difference is unusual and could be the result of either the police culture in East Coast cities or the different approach to active shooter incidences. An examination of such an issue is warranted given the impact this has on the number of lives that could be saved.

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Shakespeare-Finch, Jane, Amanda Rees, and Deanne Armstrong. 2015. “Social Support, Self-efficacy, Trauma and Well-Being in Emergency Medical Dispatchers.” Social Indicators Research 123, no. 2: 549-565.

Vogel, Juliet M., Alan J. Cohen, Mandy S. Habib, and Brian D. Massey. 2004. “In the Wake of Terrorism: Collaboration Between a Psychiatry Department and a Center for Emergency Medical Services (EMS) to Support EMS Workers and Their Families.” Families,           Systems & Health: The Journal Of Collaborative Family Healthcare 22, no. 1: 35-46

Young, Jason B., Matthew J. Sena, and Joseph M. Galante. 2014. “Physician Roles in Tactical Emergency Medical Support: The First 20 Years.” Journal Of Emergency Medicine (0736-4679)46, no. 1: 38-45

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