Introduction
In recent years, several high-profile police incidents have resulted in law enforcement and civilian injury, prompting the development of tactical emergency medical support (TEMS). This concept was adapted from the military. During World War I, nonmedical personnel were assigned to the trenches to treat wounded service members. In World War II, these personnel were placed directly into combat and evolved into the combat medic role recognized in the modern military. This combat medic framework was subsequently adapted for civilian police teams. The Tactical Combat Casualty Care (TCCC) guidelines used by the military were first modified for the civilian environment in 2011. (Source: Callaway, 2017)
TEMS teams are trained to adapt to evolving hostile environments and deliver care under such conditions. (Source: Granholm, 2024) In addition to basic emergency medical services (EMS) skills, providers require proficiency in multiple disciplines, including wilderness medicine, chemical, biologic, radiologic, nuclear, and explosives (CBRNE) exposures, hazardous material exposure, casualty evacuation, medical evacuation, and additional operational skills.[1] Care and evacuation in the TEMS setting differ substantially from practices in the civilian EMS realm.[2][3][4]
Issues of Concern
Tactical emergency care practitioners must evaluate environmental and situational threats and determine which procedures provide the greatest benefit to injured individuals. TEMS care often involves delayed intervention in harsh conditions with limited supplies and delayed transport.[5][6][7]
Zones of care provide a framework for risk assessment and guide intervention selection based on threat level. The 3 zones of care are designated as hot, warm, or cool.
The hot zone is the area of immediate danger. This zone may also be referred to as the “red zone” or “Care Under Fire.” Only self-care and rapid extraction are appropriate in the hot zone.
The warm zone is the area where danger remains possible but not immediate. This zone may also be designated the “yellow zone” or “Tactical Field Care.” In the warm zone, TEMS providers must balance the risks of evacuation with delayed intervention against the risks of persistence in a potentially hazardous environment to provide immediate care.
The cool zone is the area where no imminent danger exists. This zone may also be referred to as the "green zone" or "Tactical Evacuation Care" (Tac-Evac).
The rapid and remote assessment methodology (RRAM) is an algorithmic approach to scene assessment, designed to maximize patient benefit while minimizing risk to the TEMS provider. Under this philosophy, TEMS providers are not exposed to risk when the potential benefit to the patient is minimal. The guidelines below illustrate the application of the principles of the rapid and remote assessment methodology:
The situation should be assessed from a safe location, and entry into an area where danger is possible or likely should be undertaken only if medical needs dictate.
Only critical procedures should be performed when under fire. Normal stabilization and extraction must be weighed against the risk to TEMS providers.
The security of the area should be confirmed following the occurrence of an injury.
A determination should be made regarding whether the injured party is the perpetrator and, therefore, poses a potential danger. To accomplish this assessment, the patient should be CLEARed—Confirm identity, Look for weapons, Evaluate injuries, Acquire intelligence (if feasible), and Retain familiarity with weapons.
Injury severity should be evaluated. If the patient is stable, self-care instructions should be provided from a safe area. If the patient is unstable, the risk to TEMS providers should be evaluated and compared with the potential patient benefit.
When the risk to the provider is high, attempts to reach the patient should be delayed until safe extraction is possible. Efforts to make patient contact may proceed when the risk is low.
In high-risk situations, only critical resuscitation should be administered until the patient is moved to a safer area. Resuscitation should be completed on-site when provider risk is low.
Environmental conditions dictate TEMS provider actions. Exposure of the provider's position increases the risk of targeting. Noise must be controlled through the use of hand signals and soft speech. Supplies should be secured to prevent rattling. Upon reaching the patient, both provider and patient should be moved to cover. Low-light sources should be employed to protect the provider's location and preserve night vision in darkness or at night.
The TEMS primary survey is based on the XABCDE approach to trauma. First, an exsanguinating hemorrhage must be identified. A tourniquet should be applied to injuries suitable for tourniquet use, and combat gauze should be employed for other sites. Studies have demonstrated that tourniquet application improves hemodynamic control and shock indices at receiving facilities.[8]
Airway management is challenging in a tactical environment. Standard airway management techniques are applied, but low-light conditions, limited airway supplies, and a shortage of additional personnel often complicate their use. A rescue airway, such as a supraglottic airway, may provide the most feasible advanced airway in a tactical situation. A surgical airway may be required if the patient presents with a clenched jaw, airway obstruction, cervical spine injury, or severe maxillofacial trauma, and airway patency cannot be maintained by upright positioning.
Breathing should be assessed for conditions affecting oxygenation and ventilation. For large chest wounds, a chest seal or occlusive dressing should be applied with close observation to prevent a “sucking” chest wound. Tension pneumothorax should be identified rapidly and treated with needle decompression. Circulation should be supported through fluid administration. Permissive hypotension should be maintained in patients with penetrating torso injuries. Peripheral 18-gauge intravenous lines are acceptable for resuscitation, and an intraosseous line may be placed if intravenous access cannot be obtained. When no pulse is detected, cardiopulmonary resuscitation is not performed in unsecured areas and has minimal utility in secured areas, as it is generally ineffective in traumatic arrest.
Disability should be evaluated by assessing neurologic status as soon as feasible. Pupillary response should be noted, and mental status should be assessed. The Glasgow Coma Scale (GCS) may be applied, although its use may be limited in tactical environments. The AVPU (Awake, Verbal, Pain, Unresponsive) assessment may provide a more practical alternative. Exposure should be performed when possible to allow full evaluation. Measures should be taken to prevent hypothermia. Studies indicate that active versus passive warming techniques do not significantly alter core body temperature.
Extraction and Evacuation
Extraction is the movement of a patient from the site of injury to an area of relative safety. Various methods are employed depending on the tactical situation. Training in extraction is essential to ensure that these techniques can be performed instinctively under intense tactical conditions. Injured Special Weapons and Tactics (SWAT) team members should attempt self-extraction to a safe area. Once in a safe area, life-saving self-care, such as tourniquet application, should be administered. If self-care is feasible, evacuation may be delayed until the scene is secure, avoiding additional risk to others. In cases of penetrating torso injury or other severe trauma, self-extraction and self-care may be impossible, necessitating manual extraction by rescuers.
Manual extraction is the movement of a patient by carrying or dragging. The patient should be moved as delicately as possible, preferably after a rapid assessment for injuries is completed. In many cases, an injured SWAT officer must be moved before assessment or treatment, as the risk to rescuers outweighs the risk of aggravating the injury. When immediate extraction is required, the patient should be moved only as far as necessary to reach hard cover and exit imminent danger. Multiple methods for extraction exist. Rescuers must perform these techniques safely and according to a plan, protecting themselves from muscle strains and operating within their physical abilities.
The simplest and safest method to move a patient to hard cover may be dragging. Dragging should occur along the long axis of the body to maintain spinal alignment. Grabbing the interior of the SWAT officer’s vest allows the neck to be supported with forearms during the drag. Commercially manufactured drag systems with webbing and ankle loops may also be employed. Caution is required when dragging a patient downstairs, as gravity can cause rapid movement. A 2-rescuer approach for stair drags is generally safer and more effective. Rigid or semirigid stretchers may be used to provide additional spinal protection during stair extrication. Soft stretchers may be employed on smooth surfaces with 1 rescuer or on rough surfaces with 2 or more rescuers. Additional extraction methods include the thrown rope drag and manual carries by 1 or 2 rescuers.
Armored SWAT vehicles may be deployed to shield the officer from fire, allowing medical care to be provided on-scene before further extraction. Simulation studies indicate that “firefighters worn” and “flexible tarp” devices are the most appropriate for manual extraction.[9]
Evacuation is the movement of a patient from a cool zone to a location where transportation can occur. This process is often accomplished through coordination with a civilian EMS ambulance staged outside the outer perimeter, where no danger exists. The ambulance transports the patient, frequently accompanied by tactical medical providers, to the hospital. Skills most commonly employed by evacuation teams include blood transfusion, pressor infusion, and mechanical ventilation.[10]
In cases involving a severely injured officer, tactical medical programs may transport the patient in a SWAT vehicle or patrol car to an appropriate facility if no advanced life support ambulance is immediately available. Air medical transport may also be utilized for evacuation during operations in remote areas or cases when ground transport is delayed. Such transport should be prearranged, with the helicopter placed on standby and provided with Global Positioning System (GPS) coordinates for the nearest landing zone.
Clinical Significance
Effective communication with civilian EMS during SWAT events is essential. The radio frequency and, if available, the mobile phone number of the standby EMS unit should be identified. Radio communications should be as sterile as possible, avoiding sensitive information, including patient names. Mobile communication is preferred when feasible. The standby EMS crew should be kept updated on operational events to facilitate patient care. Communication with the receiving facility, including details of the injury and estimated time of arrival, assists in expediting definitive treatment. If a medical card is available for the injured SWAT officer, the information it contains may be invaluable to the receiving facility when planning management.
