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Tactical Medicine for Police First Responders, Part I:
Assimilating Military Medical
Lessons into Civilian Law Enforcement
By Joshua A. Jones, MA/BA, CHS-II

Online Introduction

As criminal mass casualty events continue to occur in the United States, police first responders are called upon to mitigate threats and prevent unnecessary loss of life. Uniformed officers are often the first and only responders on scene to render aid to injured victims in an active threat environment.

Abstract

As criminal mass casualty events continue to occur in the United States, law enforcement personnel are called upon to mitigate threats and prevent unnecessary loss of life. It is impractical for police first responders to wait for tactical teams and emergency medical service support personnel before contacting violent assailants. Often, uniformed police officers are the first and only responders available to render aid to victims in active threat environments. Case studies have demonstrated that patients in these scenarios can succumb to trauma that may have been survivable with timely basic interventions. However, police operators in the field must balance the tactical efficacy of threat mitigation against that of rendering aid to fellow officers, bystanders, and suspects. By adapting the U.S. military’s Tactical Combat Casualty Care (TCCC) doctrine, this paper identifies the need to train civilian law enforcement officers in basic medical skills that are practically applicable to tactical situations.

Keywords: tactical medicine, TCCC, casualty care, crisis response, mass casualty incidents

LearningObjectives:

  1. Explain the origin and evolution of the Tactical Combat Casualty Care (TCCC) system.
  2. Identify important documents and reports relevant to civilian tactical medicine.
  3. Identify the three most common causes of preventable combat death.

ABCHS® approves this activity for 1 Continuing Education credit. All certified members are required to complete 30 hours of approved Continuing Education credit in their 3 year recertification period to maintain their certification.

TargetAudience:

Police officers; security professionals; first responders

ProgramLevel:

Basic – Prior emergency or tactical medical training is beneficial.

Introduction

In the United States, a felonious assault is carried out against a police officer every nine minutes. Annually, 53 officers are murdered while on duty and more than 14,500 sustain serious injuries as a result of interpersonal violence. Ambush was the leading cause of on-duty death among sworn law enforcement personnel in 2014. These injuries and deaths are most often the result of penetrating trauma and exsanguinations from wounds associated with firearms or, to a lesser extent, edged weapons. Regardless of these harsh facts and figures, there is currently no institutionally accepted medical training program which prepares police first responders to manage injuries amid an active threat (National Law Enforcement Officers Memorial Fund, 2015; Sztajnkrycer, 2010a). Though nearly all state and local law enforcement academies dedicate about 24 hours of training to basic first aid and cardiopulmonary resuscitation (CPR), very few offer any form of tactical medicine training (Reaves, 2009). Moreover, given the broad law enforcement role within the emergency response system, the need for this training extends beyond officer safety. Citizens rely on their sworn officers to assist and protect them during life threatening and otherwise dangerous situations which may involve traumatic injury.

There is a conspicuous need for tactical medical training among law enforcement first responders. The expansion of the occupational expectations of police officers amid the threat of death and serious bodily injury in an era of increasingly common mass casualty events requires individual officers to be prepared to respond to all manner of emergency situations which may involve traumatic injuries. In active threat environments, uniformed officers are often the first and sometimes only responders on scene to render aid to injured victims. Unlike in traditional emergency medicine, the specific tactical situation is likely to dictate medical treatment priorities.

How can tactical medical training benefit law enforcement first responders in the performance of their duties and prevent unnecessary loss of life? As they are often the first on scene to medical calls for service, active shooter events, and other mass casualty incidents, as well as in the best position to aid wounded suspects and victims following officer involved shooting incidents, police responders should be capable of administering basic life-saving medical interventions, such as hemorrhage control, that could result in death within minutes if left untreated (Jacobs, et al., 2013). When confronted with performance degrading and life-threatening injuries to themselves and others, it is impractical and ill-advised for police officers to merely stand by and wait for paramedics to arrive on scene (McArdle, 2012). These first responders must be trained to deliver effective care within the context of their unique work environment without compromising other objectives. The basic medical interventions that have proven effective in treating the injury patterns most commonly associated with preventable death in active threat scenarios are codified in the Tactical Combat Casualty Care (TCCC) protocols originally created by the U.S. military for use in Special Forces missions (Butler, et. al., 2007; Center for Army Lessons Learned, 2012). These same principles, when modified appropriately, can inform civilian crisis response doctrine to improve survivability in high risk emergency scenarios (Glassberg, et al., 2014; United States Department of Homeland Security, 2015).

In order to be effective, tactical medical training must focus on those specific skills and competencies that have the potential to prevent unnecessary injury and death in situations that police officers are likely to encounter in the field (Sztajnkrycer, 2010b). In situations wherein ambulance and critical care transports are likely to be prolonged, interrupted, or blocked due to manmade or natural threats, officers must be competent enough in trauma assessment and treatment to provide basic medical care to themselves and others at the site of injury (Judge, 2012). As the occupational requirements of policing continue to expand in an increasingly dangerous work environment, the hard-learned lessons codified in the U.S. military’s TCCC doctrine can benefit civilian law enforcement professionals in protecting themselves and preserving life. Through modification and adaptation of military combat casualty management principles, this paper identifies the specific medical skills and competencies that can benefit police first responders and the communities they serve.

The Emergence of Tactical Medicine

The concept of integrating emergency medical personnel into law enforcement missions pre-dates the development of modern tactical casualty care guidelines, though the preponderance of research has focused on specialized medical support roles for tactical law enforcement operations. McArdle, Rasumoff, and Kolman (1992) illustrated the emergence of “tactical medics” within the ranks of police Special Weapons and Tactics (SWAT) teams. Forward thinking law enforcement agencies recognized and responded to the hazards inherent to apprehending especially dangerous suspects through the creation of highly trained para-military SWAT units. Over time, it became increasingly common for these teams to incorporate prehospital care providers, generally by investing the time and money to train sworn officers up to the level of emergency medical technician (EMT) or, to a lesser extent, paramedic level. The authors noted that tactical situations necessitate treatment prioritization that can contradict traditional training for civilian medical responders and present unique situations wherein care must be withheld due to the risk of creating additional casualties. Ergo, there was an obvious need to train medics capable of providing adequate care in this environment.

Carmona (2003b) explained that, up until the early 1990s, progress in the field of tactical medicine was isolated and not unified by any professional organization nor legitimized under a codified body of knowledge. Developments were fragmented and the process of identifying best practices was especially problematic due to a lack of evidence based protocols. The concept of civilian tactical medicine finally gained traction with police administrators and medical practitioners through the efforts of respected professionals such as Captain John Kolman of the Los Angeles County Sheriff’s Department, who was one of America’s first SWAT commanders and went on to found the National Tactical Officers Association (NTOA). Kolman and his colleagues at the NTOA utilized this nation-wide network as a platform to champion the idea to formalize SWAT team medical support operations. Still, few law enforcement agencies recognized medical care as being within their occupational scope.

Advanced Care Providers in Tactical Emergency Medical Support

Modifications to the traditional EMS system necessitated in tactical law enforcement response emerged as a unique emergency medicine subspecialty, though studies relevant to the effectiveness of tactical medicine were sparse and advanced care providers had few opportunities to build competencies in this area. To address this gap, Bozeman and Eastman (2002) presented a one day Counterterrorism Operations Medical Support (CONTOMS) awareness course to 39 emergency physicians. Through anonymous surveys administered before and after the program, the authors concluded that the course increased provider comfort levels with tactical medicine concepts and that knowledge was retained for several months following the training. Though the study was small in scope, and less than half of the CONTOMS participants completed four month follow-up surveys, the results indicated that advanced care providers could be trained to support tactical EMS missions.

Some well funded police agencies chose to adopt the recommendations of the National Association of EMS Physicians through the implementation of Tactical Emergency Medical Support (TEMS), a flexible system which incorporated highly trained physicians and advanced care providers for on-scene assistance to law enforcement tactical situations (Heck & Guillermo, 2001). This concept was assessed by Metzger, Eastman, Benitez, and Pepe (2009), who noted that, since the formal inception of TEMS, support for specialized tactical medics increased significantly among law enforcement and emergency medicine professionals. The authors found that TEMS provided more immediate higher level medical treatment to wounded officers, victims, and suspects, as well as reduced unnecessary hospital transports through on-scene medical assessment. In one notable case study analyzed by the authors, TEMS physicians saved the life of a police officer who had suffered a massive hemorrhage and airway obstruction from a gunshot wound to the neck. The two physicians who had been integrated into the tactical team controlled the bleeding and opened a surgical airway, which resulted in the officer’s condition improving slightly prior to arriving at the hospital. Within 12 hours, the patient was alert and oriented with purposeful movements. Subsequent review by medical quality assurance personnel determined that the actions of the TEMS physicians were inarguably life-saving in this case.

Law Enforcement Medical Competencies

The tactical medic role is a highly specialized discipline which requires substantial education and training. Nonetheless, the demand for these professionals has expanded significantly, along with the responsibilities of modern SWAT units and crisis intervention teams. Operational commanders recognized their utility in crisis and hostage negotiations, as well as myriad other tactical situations which carry the risk of performance degrading traumatic injury; making them a vital element of police special operations (Carmona, 2011; Greenstone, 1998). However, administrators in many police departments began to regard the development of specialized tactical teams and providing advanced medical training as being outside of their budgetary reality (Sharp, 2011). Moreover, in recent years, senior law enforcement leaders and trainers have been reevaluating the traditional response model wherein patrol officers secure hazardous scenes and await the arrival of a specialized tactical team. Instead, modern officer are empowered with the knowledge and basic tactical training to enter active threat situations and move to contact the assailant(s) during the interim (Blair, Nichols, Burns & Curnutt, 2013). As the occupational scope of law enforcement now places patrol officers in situations wherein they are presented with medical emergencies amid hostile threats, the need for tactical medical training at this level is obvious and pressing. Nonetheless, few researchers have examined medical competencies among law enforcement professionals.

Kilner and Hall (2005) conducted an analysis of triage decision making abilities among firearms trained police officers in Britain. Notably, unlike in the United States, only a small percentage of specialist officers are authorized to carry firearms in the United Kingdom. Nonetheless, these officers generally receive little or no medical training beyond basic first aid.

The authors recruited 82 firearms officers to participate in a tactical medicine course, which consisted of a paper based triage exercise wherein respondents were asked to assess the clinical priority of 30 patients (20 adults and 10 children) involved in a hypothetical mass casualty event. The officers were put through the same scenario twice; first with and then without supplied decision making assistance materials. When referencing the materials, even though they were not given guidance on how to use them, respondents demonstrated a significant increase in correct responses to triage prioritization questions. The most notable result was a reduction in under triage of less conspicuous severe injuries. Not surprisingly, prior tactical medical training was significantly associated with higher scores. The authors concluded that specialist firearms officers would be able to make more appropriate clinical priority decisions in mass casualty scenarios and assess injury severity in individual patients when provided with decision support materials and minimal training.

Ciccone, et al. (2005) argued that tactical operations place law enforcement personnel at increased risk of injury and are often conducted in environments which limit access to emergency medical care. Nonetheless, training programs for traditional EMTs and paramedics to deliver tactical medical care in these high threat environments are exceedingly rare and most often require extensive previous experience in the field. The authors examined the Special Agent Emergency Medical Technician (SAEMT) training curriculum, which was specifically designed for federal agents with prior tactical operations experience, but no previous medical training. The 181.5-hour program, which consisted of the EMT-Basic curriculum with additional tactical operations planning topics and weapons training, was delivered to agents of the Drug Enforcement Agency (DEA). Of the 95 agents who completed the program, 88 percent also successfully passed the National Registry of EMTs-Basic examination within two attempts. The authors concluded that the SAEMT program provided a useful template with which to meet the demands of law enforcement agencies in need of tactically proficient medics.

Few studies have independently assessed the need for casualty management training or relevant competencies among field level law enforcement officers who are not members of tactical teams or similarly specialized units. Sztajnkrycer, Callaway, and Baez (2007) surveyed 97 American officers in one county jurisdiction to grade their responses on nine injured officer scenarios. Their study revealed that, while 68 percent of the police respondents were trained to the Emergency Medical Responder (EMR) level, their tactical medical decision making competencies were suboptimal. Higher scores were achieved by those trained to the EMT or paramedic level. Interestingly, prior military experience had no impact on the test results and tactical unit assignment was paradoxically associated with lower scores, which may be indicative of medical training being perceived as a low priority at the institutional level or at least within the subculture of police special operations. Nonetheless, 92 percent of respondents expressed an interest in additional law enforcement specific medical training. The authors concluded that in the post-9/11 era, the development of tactical medical programs for front-line police officers was appropriate and necessary in order for the profession to evolve with the expanding demands of public service.

Much of the available research continues to focus on the demand for specially trained medics to support law enforcement tactical team missions, with comparably little attention paid to basic medical competencies among individual police officers. Importantly, the competency based training matrix for TEMS personnel, developed by the National Tactical Officers Association (NTOA) in cooperation with the American College of Emergency Physicians, focuses on 18 educational domains specifically adapted to each of four audiences; operator, medic, team commander, and medical director (Schwartz et al., 2011). Accordingly, metrics were already in place to improve the competencies of individual officers without investing months or even years in additional medical training. Moreover, a pantheon of nationally respected police administrators, instructors, and tactical operators have argued for the assimilation of tactical casualty care principles to the civilian law enforcement community; not merely in the form of specialized medics, but regarding every police officer as a tactical medical responder (Dickinson, 2014; French, 2009; National Tactical Officers Association, 2013).

McArdle (2012) explained that, in the traditional organization of the public safety network, police, paramedics, and firefighters are each responsible for distinct elements of a common mission, with limited overlap. In line with this model, emergency medical care has been conventionally regarded as being within the purview of fire / rescue departments and ambulance services. Even though police work routinely places officers in situations which carry the risk of serious traumatic injury, the unique medical concerns of these professionals are not adequately addressed in most communities. Many law enforcement agencies simply rely on local EMS personnel, as opposed to empowering police officers with the training to improve their own survivability in the field.

Adapting Lessons from the Battlefield

With specific modification made to address civilian trauma care, military combat care principles can inform public safety response and improve survivability in active threat scenarios. Professional law enforcement agencies have become increasingly accepting of incorporating police first responder. Tactical medical personnel are still generally expected to hold licensure at the paramedic, registered nurse, physician or other advanced provider level (Heck & Guillermo, 2001). While some jurisdictions authorize the use of experienced EMTs based on individual needs assessments, others require extenuating circumstances, as well as approval from both the designated TEMS Medical Director and Tactical Commander, to utilize providers licensed below the paramedic level (California Commission on Peace Officer Standards and Training, 2010; Illinois General Assembly, 2014; Ohio Tactical Officers Association, 2012). Nonetheless, many law enforcement professionals have recognized the need to expand the operational scope and definition of tactical medicine.

In order to identify the need for emergency casualty care training throughout the law enforcement community, it is necessary to understand the origins of the modern Tactical Combat Casualty Care (TCCC) system created by the U.S. military and its gradual assimilation into civilian emergency medical service (EMS) protocols. Moreover, stakeholders must comprehend the evolution and expansion of the occupational requirements of law enforcement first responders in an era of mass casualty and active shooter incidents to appreciate the utility of applying combat medicine doctrine to civilian crisis response. The move away from traditional EMS-based protocols to address the needs of operators on the battlefield is instructive of how civilian police officers can benefit from basic casualty management training. Heeding these military medical lessons as a matter of policy will empower police first responders with the skills and abilities to better protect life in the performance of their duties.

Evolution of Tactical Casualty Care in the U.S. Military

The history of death and injury among American service members is long and bloody. Prior to the World War I, the prognosis for virtually all wounded soldiers was bleak. Nevertheless, amid the carnage, researchers uncovered teachable moments that would be used to save the lives of future soldiers. Military leadership embraced new technological advancements and introduced casualty management principles to the battlefield in order to save lives and improve overall combat effectiveness (Holmquist & Barnett, 2002). However, lacking a more appropriate model, military medicine was effectively a forward deployed copy of the civilian healthcare system, albeit in a more austere operational environment.

As Lavery, et al. (2000) explained, the protocols used to reduce mortality on the battlefield required constant revision and adaptation as the nature of warfare evolved over time. Technological advancements, specifically in transportation, meant that more soldiers were being placed in combat more frequently. This reality was brutally illustrated in casualty figures. After-action assessments of U.S. conflicts demonstrated that timely on-scene interventions and rapid extraction to advanced care substantially decreased mortality and disability following serious injuries. The combination of battlefield medics trained in basic first aid and improved evacuation procedures was responsible for the considerable improvement in survival rates for wounded soldiers between World War II and Vietnam. Nevertheless, even as medical technology grew by leaps and bounds, delivering effective care to forward deployed troops became exceedingly problematic.

Following the costly and eye opening 1993 Battle of Mogadishu in Somalia, U.S. Special Forces commanders were the first major professional body to propose the need to identify improvement opportunities in emergency medical response to tactical situations. At that time, up to 90 percent of battlefield deaths occurred prior to the patients reaching a medical treatment facility (F. K. Butler, Haymann, & E. G. Butler, 1996; Eastridge, et. al., 2012). This trend compelled the command staff to investigate battlefield prehospital care. Emergency medical training for Special Operations Forces (SOF) field medics taught at the 18 Delta Medical Sergeants Course was then based on civilian Advanced Trauma Life Support (ATLS) guidelines. While ATLS was proven effective at treating trauma patients in the civilian setting, its utility in tactical situations was called into question by the senior leadership of the Naval Special Warfare Command. Concern was also voiced by the U.S. Special Operations Command (USSOCOM), which ultimately funded a two-year study on combat casualty care techniques. The results of the USSOCOM study were presented by F. K. Butler, Haymann, and E. G. Butler (1996), who identified significant shortfalls in the ATLS-based training standard. The authors contended that the delivery of medical care in an active threat environment necessitated modifications to the curriculum in order to address tactical factors such as hostile fire, equipment availability and limitations, variations in evacuation times, and casualty transportation concerns. Additionally, since most battlefield deaths were caused by penetrating injuries, a comparably rare occurrence to civilian EMS, a greater emphasis on this type of trauma was needed in provider training curricula.

The USSOCOM study was especially significant because it presented a basic tactical casualty management plan which divided care into three distinct phases. Each phase recognized medical care as an aspect of overall tactical flow wherein treatment priorities were dependent upon the situation. This notion represented a departure from traditional medical philosophy wherein all conceivable and available resources are summoned to provide the highest level of care possible for every patient. Therein, “Care Under Fire” was identified as treatment rendered at the scene of injury, while both the patient and provider may be receiving effective enemy fire. In this scenario, equipment would likely be limited to what the individual operators had carried into the fight on their persons and certain interventions, such as airway management, may be inadvisable as they could expose additional responders to injury. Depending on the scenario, a patient may be required to rely on self-aid while maintaining threat suppression as a priority. “Tactical Field Care” begins once the threat has been eliminated or no longer poses a direct hazard. More responders may be able to assist, though equipment availability may not be ideal and evacuation times could vary dramatically. Moreover, the resurgence of a threat can force the responders to transition back into Care Under Fire. Lastly, “Combat Casualty Evacuation (CASEVAC) Care” is delivered once the patient has been picked up by some mode of transport with pre-staged medical equipment and trained personnel. In the military setting, this generally consists of helicopter CASEVAC transport to a field hospital (F. K. Butler, Haymann, & E. G. Butler, 1996). These study results and recommendations laid the foundation for what would evolve into the U.S. military’s Tactical Combat Casualty Care (TCCC) system. It also initiated a discussion wherein emergency medical professionals and tactical operators began to recognize that effective medical care could inadvertently compromise good tactics and create unnecessary casualties (King, Filips, Blitz, & Logsetty, 2006).

As explained by Butler, et al., (2007), the tactical trauma care guidelines outlined in the USSOCOM study findings were rapidly adopted throughout the U.S. Armed Forces. The authors contended that TCCC had saved lives on the battlefield and improved tactical flow in situations wherein casualties could have otherwise unnecessarily bogged down mission tempo or exposed additional troops to injury. Consequently, the Department of Defense endeavored to provide TCCC training to all U.S. combatants. The Committee on TCCC (CoTCCC) was charged with reviewing and periodically updating the protocols based on contemporary medical literature and field reports from combat first responders. The overarching mission of the CoTCCC is to offer a cogent trauma management plan without sacrificing sound tactics. Its guiding objectives are to treat casualties while preventing additional injuries and accomplishing the prescribed tactical mission.

Preventable Combat Death

Casualty data collected from the Vietnam War and into the early phases of the Global War on Terrorism affirmed that exsanguinations from external hemorrhage were by far the leading reasons for -related death. Various researchers have concluded that as many as 25 to 60 percent of these fatalities could have been prevented with aggressive hemorrhage control through the application of a tourniquet (Butler & Blackbourne, 2012). Since modern soldiers wear more advanced ballistic armor, torso injuries have become less common than were observed in previous conflicts. Subsequent research, particularly the Wound Data and Munitions Effectiveness Team (WDMET) study of casualty figures among U.S. troops during Operations Enduring and Iraqi Freedom (OEF/OIF), revealed that the three primary causes of preventable combat death were uncontrolled hemorrhage from extremity wounds, tension pneumothorax, and airway obstruction (Gerhardt, Mabry, DeLorenzo, & Butler, 2012). Accordingly, the TCCC doctrine provides immediate responders with practically applicable interventions for each of these types of injury patterns.

Butler, Holcomb, Giebner, McSwain, and Bagian (2007) noted that the primary focus of tactical medical research from the military has been bleeding control, specifically from extremity wounds. Accordingly, one of the most significant revisions to the TCCC guidelines has been the inclusion of the Combat Application Tourniquet (CAT), which can be applied one handed and was endorsed by the U.S. Army Institute of Surgical Research as completely effective at occluding blood flow to extremities. As of 2006, the military was also heavily involved in ongoing research to test the practicality of hemostatic agents, such as QuikClot, which are designed as another viable option to control severe hemorrhage with the application of chemicals that encourage blood clotting. Importantly, these conclusions were adopted by the military at a time when direct pressure was virtually the only accepted form of hemorrhage control taught to civilian first responders.

Backed by continual evidence based research and field reports, the Committee on TCCC has significantly expanded its recommendations for casualty management since the original guidelines were published in 1996. By the early 2000s, the military began juxtaposing the effectiveness of various airway management interventions and reconsidered the focus on treating tension pneumothorax from traumatic injuries. Moreover, the treatment of hypothermia and hypovolemic shock in the field was eventually addressed with the release of the third set of protocols, which is important given that recent studies have affirmed that hypothermia is an independent contributor to mortality, especially during casualty evacuation (Butler, et. al., 2007). Research and subsequent revision to the TCCC protocols are in continual review.

In their two-year analysis of more than 1,000 patients treated at six forward operating American surgical facilities in Afghanistan, Lairet, et al. (2012) affirmed that the most common mechanisms of injury were the result of explosions, penetrating and blunt trauma, and burns. The life-saving emergency interventions most often performed in the prehospital field setting were hemorrhage control and hypothermia prevention. The authors noted a high rate of effective tourniquet application, but revealed a trend in missed opportunities in airway management and the prevention of tension pneumothorax. Though there may always be room for improvement, combat casualty management in the field has improved dramatically in the era of TCCC.

Modern Application to Civilian Crisis Response

Arreola-Risa, et al. (2000) argued that the prehospital care phase is of critical importance in reducing patient mortality. In their study of operational EMS improvements in a Latin American city, they affirmed that, in conjunction with other low cost logistical changes, the introduction of additional multi-system trauma training for field providers via the Prehospital Trauma Life Support (PHTLS) course could improve patient outcomes. In the six months following the implementation of the training, providers were more capable of identifying the need for interventions such as spinal immobilization and airway devices without increasing the amount of time spent on scene. Most importantly, the percentage of transported patients who died in route to the hospital decreased significantly from 8.2 to 4.7 percent. Some of the improvements in mortality rates were attributable to an increase in the number of ambulance dispatch sites, though the advanced trauma training provided in the PHTLS course was also directly responsible.

McArdle, Rasumoff, and Kolman (1992) noted that trauma management training for civilian first responders focuses primarily on blunt force injuries and mitigating occupational risks associated with accidents and public health issues such as infection control. Treating penetrating trauma injuries amid a hostile threat is not taught in traditional curricula. To provide medical care in such an environment, medical providers must possess a unique skill set and knowledge base. Nonetheless, researchers have concluded that the professional judgment of field-level emergency medical providers is just as accurate as objective scoring systems used in prehospital trauma triage (Emerman, Shade, & Kubincanek, 1991; Mulholland, Gabbe, & Cameron, 2005). Accordingly, it is reasonable to contend that adequately skilled responders with tactical training could be expected to recognize the most common injury patterns associated with hazardous scenarios and render the appropriate interventions.

Upon publication, the TCCC guidelines gained widespread attention from civilian emergency medicine professionals. The doctrine was formally legitimized in 1999 when it was incorporated into the first chapter on military medicine ever added to the Prehospital Trauma Life Support (PHTLS) Manual. Glassberg, et al. (2014) proposed that, while combat casualty care requires unique protocols given the challenges inherent to battlefield medicine, it shares general concepts with civilian trauma management. The authors conducted an extensive review of available literature on combat casualty care to identify improvements in treating causes of preventable death, such as hemorrhage control and airway management, as well as streamlined evacuation procedures. The study concluded that, though military medical practices are specifically aligned with the unique mission of combatants, they may also have the potential to prevent unnecessary loss of life in civilian scenarios.

In recent years, EMS professionals have recognized the applicability of TCCC protocols to civilian trauma care. Facilitating this assimilation has become a popular topic in emergency medicine trade journals. Erich (2013) noted that the injury patterns observed among the civilian victims of four high-profile mass casualty incidents overlapped in notable ways with those suffered by modern soldiers. The author supported the opinion of retired U.S. Navy Medical Corps Captain Frank Butler, Jr., in that these events should at least prompt civilian public safety agencies to adopt some fundamental principles from the military, such as maintaining a sufficient stock of commercially manufactured tourniquets and issuing an individual first aid kit to every responder. Additionally, in his recommendations for medical directors in developing tactical EMS protocols, Carhart (2012) opined that the TCCC concept of the three Stages of Care was useful in a broad range of civilian incidents.

Rathbun (2003) discussed the unique difficulties and situational dynamics that impact medical care in tactical environments. The author specifically analyzed how tactical emergency medicine differs from traditional EMS operations with regard to the decision making process at the provider level. Whereas codified protocols generally guide civilian EMS providers, tactical situations dictate care delivery options based upon operational flow, prior training, suspect behavior, resource availability, and myriad other fluid considerations in a highly stressful rapidly evolving environment. One principle difference in tactical scenarios is that law enforcement tactical priorities may at times supersede those of the medical mission in order to protect responders and bystanders from unnecessary harm. Unlike in traditional evidence based medicine, tactical medics may find that treatment priorities are determined by situational factors completely outside of the provider’s scope of influence.

A key development in the recent history of civilian tactical medicine, as explained by Callaway, et al. (2011), was the creation of the Committee for Tactical Emergency Casualty Care (C-TECC), which was established for the purpose of facilitating the transition of the Military Casualty Care doctrine to Civilian Crisis Response. The C-TECC is a separate civilian body that is modeled after the military Committee on TCCC, which provides guidance for the TECC program. The TECC guidelines are therefore based upon TCCC principles, but adapted for casualty management in high threat civilian operations. While the TECC doctrine is founded in military medical protocols, it recognizes the pitfalls in direct assimilation of military medicine and has been modified to address differences in civilian EMS, such as patient populations and demographics, scope of practice, and resource allocation issues. Though not universally accepted, the TECC initiative is indicative of a demand for standardization in civilian tactical medicine protocols.

Emergency Medical Response in Active Threat Environments

The acceptance of military medical lessons by civilian EMS providers must be discussed in context to understand their applicability to the roles and responsibilities of law enforcement professionals. As illustrated by Mell and Sztajnkrycer (2004), the nation was collectively shocked by a horrific mass casualty incident that took place in Littleton, Colorado in 1999. Therein, two students at Columbine High School utilized home-made explosives and small arms to kill 15 people and seriously wound an additional 24. In total, emergency responders triaged some 160 persons subsequent to the attack. Several important lessons were revealed in the aftermath of the Columbine shooting. Many first responders were faced with significant risk of bodily harm; partially due to the fact that EMS crews arrived on scene and began triage while the attack was still underway. As is the case in many criminal mass casualty events, the overlapping missions of law enforcement, EMS, and fire / rescue needed to be addressed simultaneously. Nonetheless, interfacing police and EMS operations proved especially problematic. Two years prior, following a series of high-profile domestic bombings, a national survey of 800 Police Chiefs and Sheriffs had affirmed that the majority of police administrators advocated for additional medical training and expanded roles for law enforcement personnel within the EMS system (Alonso-Serra, et. al., 1997).

The Federal Bureau of Investigation (FBI, 2014) conducted a study of 160 reported active shooter events that occurred in the United States between 2000 and 2013 in order to inform law enforcement policies regarding best practices for incident response. The results indicated a steady rise in mass killings over the time period analyzed. Not including the shooters, a total of 1,043 casualties (486 killed, 557 wounded) were attributed to these events. The data provide insight into the types of targets commonly selected by assailants and clarified in which instances police responders were most at risk. Importantly, the study revealed that more than half of the active shooter incidents were completed prior to law enforcement arrival; generally because the suspect(s) had either fled the scene or committed suicide. However, in the remaining cases, police officers were required to engage the assailant(s), resulting in nine officer deaths and 28 injuries.

The United States Department of Homeland Security (DHS, 2015) noted that, in order to improve survivability for victims and first responders to active threat scenarios, traditional emergency protocols were in need of revision. The DHS guidelines utilized evidence-based strategies employed by the U.S. military to manage mass casualty events and incorporated best practices taken from numerous real world incidents in the U.S. and abroad to inform civilian crisis response strategies. The first and arguably most important element of these guidelines was the emphasis on early and aggressive hemorrhage control. Borrowing from the TCCC and TECC doctrines, the DHS response guide lists specific tactical medical interventions that are directly applicable to civilian trauma care in these scenarios.

Jacobs, et al. (2013) discussed which procedural changes in the law enforcement, EMS, and fire / rescue communities have the potential to mitigate further loss of life in the wake of mass casualty incidents. The authors introduced the Hartford Consensus; a document released by the committee convened by the American College of Surgeons to promote policies in public safety that can improve survivability during these events. Isolation of assailants and early hemorrhage control were identified as the primary areas of concern wherein additional training and improved policies have the greatest potential to preserve innocent life. The paper specifically noted the inherent problems in the traditional response model wherein law enforcement goals supersede other response missions. An improved response must therefore address multiple objectives simultaneously. The authors specifically contended that hemorrhage control and basic emergency medical interventions should be regarded as core competencies for law enforcement professionals. The group codified the integrated active shooter response concept with the THREAT acronym; Threat suppression, Hemorrhage control, Rapid Extraction to safety, Assessment by medical providers, and Transport to definitive care.

Piecemeal Progress in the Field

No single tactical EMS configuration can adequately support the unique needs and abilities of every police agency without making individualized modifications based on their specific mission and operating environment (Carmona, 2003a). Judge (2012) examined whether or not police officers across jurisdictions could benefit from the military medical lessons codified in the TCCC guidelines. The author’s primary contention was that departments should endeavor to create medical training programs for their officers based upon the unique needs of the communities they serve, with considerations made for available assets and resource allocation. Just as the military utilizes information gleaned from soldiers in the field, law enforcement agencies must consider the individual officer’s work environment, access to medical care, and which mechanisms of injury are most likely to be encountered. Accordingly, law enforcement medical training should focus on life-saving interventions in scenarios wherein traditional EMS procedures may be inadequate.

The tragic outcome of the 1993 Branch Davidian compound raid in Waco, Texas compelled the Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF) to make significant operational changes. For more than 20 years now, the ATF has trained an elite group, approximately 3 percent of its sworn agents, to become EMTs or paramedics and embedded them within its Special Response Teams (SRTs). More recently, this program gained praise after an ATF medic was captured on film as he provided life-saving care to Dzhokhar Tsarnaev following a SWAT stand-off and gunfight. Tsarnaev lived to face federal charges related to his suspected involvement in the Boston Marathon bombing and killing of Massachusetts Institute of Technology (MIT) police officer Sean Collier (Clinton, 2013).

As explained by Keim, Reiser, Shetty, and Ranger-Moore (2009), the United States Border Patrol (USBP) has been one of the most proactive and forward leaning law enforcement agencies with regard to tactical medicine. As far back as 1999, USBP began standing up specialized Border Patrol Search, Trauma and Rescue (BORSTAR) units, which are now assigned to every U.S. border sector. These teams are comprised of USBP law enforcement agents who receive additional training in search and rescue, as well as emergency and tactical medicine. These teams conduct backcountry wilderness rescue operations, which overlap with the agency’s law enforcement mission. For instance, under-prepared foreign nationals often become disoriented and lost when attempting to cross the U.S. border with Mexico. BORSTAR agents obtain medical training at USBP advanced academies to become certified EMTs or paramedics. Following graduation, they are required to complete continual in-service training and pass quarterly competency assessments to develop and hone their tactical EMS skills. Other federal agents who operate in remote and rural locations have also recognized the utility of employing skilled tactical medics. The National Park Service (2015; 2011), for instance, has adopted the Counter Narcotics and Terrorism Operational Medical Support program and publishes a tactical emergency medical services field manual to support the law enforcement operations of its Park Police and Rangers.

The lessons documented in the success stories of federal tactical medics have trickled down into lower jurisdictions as well. Manifold, Wampler, and Smith (2013) reported that the San Antonio Police Department (SAPD) modeled its own tactical medic program after BORSTAR. Therein, 40 officers were trained to the level of EMT-Basic and instructed in military medical strategies derived from the TCCC guidelines. Interestingly, SAPD has expanded the role of these police medics beyond SWAT team and warrant service support, to include medical standbys during firearms, defensive tactics, and physical fitness training at the local police academy, as well as inclusion in executive protection details. In 2010, SAPD tactical medics were charged with training every officer and cadet in their Self-Aid Buddy Care / Tourniquet Program, which they had adapted from the TCCC doctrine. In January of the following year, SAPD traffic officer Michael Thornton lost his leg after being struck by a drunk driver. The responding officer utilized his department issued tourniquet to save Thornton’s life. After being fitted for prosthesis, Thornton returned to full duty.

Sztajnkrycer, Peterson, and Clayton (2010) illustrated the development and implementation of a law enforcement tactical casualty care training program delivered to the Rochester, Minnesota Police Department. The Basic Tactical Casualty Care (BTCC) course consisted of eight training hours dedicated to lectures in rapid casualty assessment, bleeding control, chest trauma, airway management, and the survival mindset, which concluded with evaluated scenarios. In line with the tactical emphasis on hemorrhage control, it reversed the traditional Airway, Breathing, Circulation (ABC) paradigm of assessment in favor of an emphasis on external bleeding and chest trauma over airway management. The course materials were streamlined with pertinent practical information and little focus on theory. Importantly, the scenario training identified lessons and unexpected findings specifically relevant to law enforcement medical training. For instance, officers without prior tactical medicine competencies tended to perform trauma sweeps in a manner consistent with a scripted “pat down” to search suspects in custody and thus failed to recognize minor penetrating injuries in patients. The program revealed that a law enforcement tactical medical training program can be delivered without a significant resource investment and identify potential issues in scene management that can be addressed before an officer finds him or herself in a similar real-world situation.

One of the most popular tactical medicine courses among police professionals is the Law Enforcement and First Response Tactical Casualty Care (LEFR-TCC) course, which was developed by the PHTLS Committee and National Association of EMTs (NAEMT, 2015) in partnership with the Committee on TCCC to combine the lessons of military medicine in a manner applicable to civilian trauma management in accordance with the recommendations of the Hartford Consensus. The LEFR-TCC program incorporates traditional lecture with skills stations and scenario training with a specific focus on hemorrhage control, pneumothorax identification, and airway management. Pons (2014) reported that, as of September, 2014, more than 2,600 practitioners had received this training. One student, who deployed to Syria a week after finishing the class, reported back to his instructors that he was involved in a mortar attack which amputated the leg of a nearby teen-age girl. Remembering his training, he immediately applied a tourniquet and the girl survived. Another graduate who served as a local police officer stated that, while responding to a call for service, he was ambushed and suffered a gunshot wound to his arm. He credited the LEFR-TCC manual skills stations with building the confidence and knowledge that prompted him to treat his injury while remaining tactically effective.

Conclusion

The demand for tactical medics and support for law enforcement centered medical training are conspicuous in the literature. However, the policing profession as a whole has not embraced a standardized medical training program for individual officers in active threat environments (Sztajnkrycer, Callaway, & Baez, 2007). As an institution, law enforcement does not regard tactical medical skills as core competencies. Nonetheless, the maverick administrators and vocal operators who embrace this concept are becoming more numerous and influential. Scores of field reports and professional journal articles commend the efforts of individual departments in implementing tactical medical principles into their training programs and expanding the role of field-level police officers in the EMS system.

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About The Author

Joshua A. Jones, MA/BA, CHS-II, is a Law Enforcement Ranger and EMT with the National Park Service. He is a U.S. Marine Corps veteran who served in both Iraq and Afghanistan as an enlisted infantryman, with subsequent experience in private security and investigations. Joshua received his BA in Criminal Justice and MA in Emergency & Disaster Management from American Military University. He is currently pursuing graduate studies in Recreation Management at the University of Illinois. He also volunteers as a search & rescue aircrew member for the Civil Air Patrol, where he is assigned as a squadron level Emergency Services and Public Affairs Officer.

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