Birth of TEMS
Battlefield medicine got its origin from the Spanish in the Siege of Malaga. The injured troops were carried off of the battlefield in wagons, although they were not picked up until the end of the battle. During the Civil War, surgeons attached to the Union army understood the need to bring the hospital to the war, and set up aid stations at the regimental level. This helped speed up the triage and treatment of injured soldiers, resulting in a decrease in casualties.
In 1993, the Battle of Mogadisu prompted the military command to take a look at how medics were being taught and deployed with special operations forces. Two years later, a paper titled “Tactical Combat Casualty Care in Special Operations” set out a new standard for training special operations medics. This paper became the backbone of what has now become the military standard, and is transitioning to the civilian standard for tactical medics. The main focus of the paper was to understand how to treat “preventable death.” This meant injuries that could have been treated properly, but lack of treatment resulted in death.
During the 90s on the civilian side, medics were generally not integrated with tactical teams. Many police departments were combating the war on drugs, and they were just getting their SWAT teams established. Medics who understood that rapid treatment made the most difference began asking to be attached to the SWAT teams. At first, this was simply being on the scene, many times standing back at the command post or warm zone. As the medicine was proven to make a significant difference, they began moving farther forward to the hot zone.
Police departments started to see the value of having a medic integrated with the tactical team. Just as a sniper is a specialist, a medic brings a different specialty that has a need in the tactical setting. In these situations the mission comes first and the medicine comes second.
Tactical Medic vs. Street Medic
Why was there a delay in getting the tactical medics into the hot zone? Many times a medic is not someone who has that tactical experience. SWAT scenes can be dynamic and it takes training to understand how to operate on those scenes. Staging on calls does not give a medic the opportunities to understand those concepts on even simple calls.
Many times trust is a huge component of integrating a medic on a tactical team. The SWAT officers train for these calls and trust their teammates to cover them in a high threat situation. When someone from outside the police department is now placed on the team, it takes time to build that trust with the medic. Many times that trust comes from the physical conditioning and ability to train with the team. SWAT calls can be physically demanding, so if a medic cannot perform during training, they won’t perform in the real call.
Once the trust is established, how does the tactical medic differ from the street medic? Many times this answer comes in looking into the medical bag, or “kit,” they carry. The military began to prove that tourniquets had their place in rapid control of hemorrhaging, so many tactical medics began utilizing tourniquets before they gained acceptance back on the ambulance. With limited space, airway management ends up being simplified: NPA or surgical airway. Next, a tool for needle decompression addresses care of a pneumothorax. These three main tools address the injuries that cause “preventable death.” Other equipment for the tactical medic is developed to save space or weight. For example, a BVM that collapses down to a small footprint is preferred over the regular BVM from the ambulance.
After tools, tactical medics also have a few treatment differences. A tactical medic is going to start treatment in the hot zone where there is no ambulance. Bright lights, space and plenty of supplies don’t exist in the hot zone. There may also be a delay moving a casualty from a hot zone to even a warm zone, then to an ambulance. This means that tactical medics need to be part critical-care medic to take care of those patients during the delay.
High Threat Healthcare
So what exactly does a Tactical Emergency Medicine Specialist (TEMS) learn? The backbone of the education is treatment of major traumatic injuries. Understanding the pathophysiology of what occurs to the body is important to understand the best treatment options. The TEMS medic has to understand how to integrate the medicine into the mission.
The principles of Tactical Combat Casualty Care (TCCC) help to understand how to get the most effective medicine on the battlefield at the proper time. The “preventable death” injuries need to be treated in order of most lethal to least lethal, which doesn’t necessarily follow the ABC assessment everyone learned in EMT-B school. Time becomes a critical factor, and understanding which injuries can cause death quickest helps focus treatment on the correct injury.
Other aspects of the tactical environment become part of the education. Less lethal tools such as CS or OC gas, Tasers, or different types of shotgun rounds can all have considerations for treatment that aren’t seen on an ambulance. Explosives, chemicals or biological threats may also be present on scenes and need to be treated in very specific ways. What can be routine on a tactical call may not ever be encountered while riding an ambulance, so TEMS medics need to understand those differences.
Finally, TEMS medics need to understand and practice procedures they will be utilizing on tactical calls. This can range from chest tubes, fluid resuscitation with options besides normal saline or canine care. The normal procedures that they use on the ambulance now get performed in environments with low lights and loud sounds, which can be sensory overload to someone who’s not trained.
Medic of Many Hats
While high threat medicine can sound exciting, there are other aspects of tactical medicine that can get overlooked in a TCCC class. In planning stages, medics can play an integral part. Mission threat assessment helps the medic prepare for threats that may be on a scene. This ranges from weapons that have been reported on scene to the weather, and plays a huge part in preventative medicine.
On scenes, the medics may be responsible for moving the patient from the hot zone to the warm zone to meet an ambulance crew. To be successful, medics have to learn technical rescue techniques to effectively move patients. This can be a detailed skill on a scene when the threat is still present, so hasty techniques become utilized to do more with less. TEMS medics have to understand how to apply those technical rescue components to their situation.
Preventative medicine is where the TEMS medic makes the difference for his or her team most often. SWAT officers may go on scenes dozens of times without getting shot, but problems like hyperthermia, hypothermia or dehydration can sneak in without notice. Also, medical problems can present on scene to someone who may appear healthy and fit. Medical monitoring and routine health screens become tools in the TEMS medic’s pocket next to a Bougie.
“Sick call” or simple primary healthcare quickly becomes a role that the TEMS medic plays after trusts are built with the team. Those who carry Tylenol always report back that it is the most-used medication for the simple ailments or ortho injuries. This falls back to the 80/20 rule. Eighty percent of the injuries take 20 percent of our focus, and 20 percent of the injuries take 80 percent of our focus. A good TEMS medic will go through a few bottles of Tylenol before they use his or her first tourniquet.
Finally, a TEMS medic will also play the role of educator. The other members of the team should be seen as “force multipliers” to help the medic in his or her role. TEMS medics can teach team members the basics of tactical medicine such as how to place a tourniquet. If the SWAT officer is closer to a patient than the medic, the officer can utilize his or her own tourniquet to get treatment started.
Once someone decides they are ready to become a TEMS medic, what’s the next step? Find a true TEMS course. While departments may be budget-sensitive, this is not a place you want to cut corners on with training. Taking a TEMS class from a knowledgeable and competent program could be the difference in life or death for a SWAT officer later. Also, taking that TEMS class from a program with proper resources can be a better learning environment than having the “seasoned” medics of the team teaching the new medics in-house.
A proper TEMS program should stay on top of recent developments in medicine, equipment or tactics to teach their students. If a department or agency is committed to putting medics on a tactical team, this should come with the commitment to properly train and support the medics as well.
While a TCCC certification is a great start for a TEMS medic, the education in TCCC really scrapes the tip of the iceberg. TEMS will cover non-medical topics that will help TEMS medics understand what is happening on a SWAT scene. This is critical for a TEMS medic to be fully integrated into the team. Maintaining certifications in both should be seen as a standard.
After going through TEMS, the next step is to train with the team. Integrate “downed officer” drills into routine training. While snipers spend time working on proficiency, medics should also be given specific time and opportunities during tactical training. It’s best to make mistakes during training to find deficiencies in equipment or tactics that can help make the team stronger. Since these are not situations that happen routinely on an ambulance, the medical training needs to occur frequently for a TEMS medic to stay proficient. Training with the team can help the officers practice self-aid/buddy-aid to be effective force multipliers.
When given the opportunity, train with other TEMS medics around the region. This can help troubleshoot techniques when one team has practiced something specific that another team has had trouble overcoming. Threats are always evolving, and tactics/medicine should always evolve as well.
To stay on top of overall tactical medicine evolution, a TEMS medic should stay on top of his or her education. This can be achieved by going back through a TEMS program periodically, reading journals such as the Journal of Special Operations Medicine, or training opportunities provided by the Department of Homeland Security. Protocols and products are always evolving as the military continues to research. When a TEMS medic gets complacent with education, they may find that the tools they utilized have been overtaken by something they are not proficient in or their tools are no longer supplied.
The final step a TEMS medic can make in training is to prepare and pass the Certified Tactical Paramedic (TP-C) exam by the Board of Critical Care Transport Paramedic Certification. The TP-C exam is a challenge, but maintained by those who are dedicated to providing the best medical care in tactical environments.
From the outside, it may be difficult to see all the things that a tactical medic does on a call. These highly dedicated medics are involved in providing care during high stress and high threat environments. TEMS has evolved to meet the needs in training those professionals to perform their best under those challenges.