Tactical Medicine: Providing Care in the Urban Battlefield

Tactical Emergency Medical Services (TEMS) was first recognized during the Civil War and in World Wars I and II. Rapid care of injured soldiers and transport to a hospital provided a better chance of surviving. On the civilian side, the emergency medical services (EMS) system originated in 1966 with the publication of “Accidental Death and Disability: The Neglected Disease of Modern Society.”¹ The Los Angeles Watts riots of 1965, which left more than 1,000 wounded and 34 dead, and the University of Texas clock tower shooting in 1966, which killed +14 people and wounded 34 civilians, both influenced the first Special Weapons and Tactics unit by the Los Angeles Police Department in 1967.² SWAT units were composed of law enforcement officers trained to handle high-risk incidents. The benefit of TEMS to SWAT units was first presented in national conferences in 1989 and 1990 with representatives from law enforcement, emergency medicine, and EMS.^3,4 By 1994, the National Tactical Officers Association (NTOA) released its position statement recommending that “special operations teams (SWAT, Special Emergency Response Team, etc.) [should] include properly trained tactical emergency providers.”⁵

The Golden Hour
The concept of the “Golden Hour” was first described by R. Adams Cowley from his experiences in combat and providing helicopter transport for injured patients in Baltimore.⁶ He recognized that the sooner the patient reached definitive care, the more likely their survival. Throughout the years, it has been debated whether 60 minutes is truly the Golden Hour; currently, the standard of care is rapid transit to the hospital.⁷ However, with the integration of physicians as tactical medical providers (TMPs) supporting SWAT units, potentially lifesaving care can be offered on-scene in the urban battlefield.

Primum non nocere
Hippocrates said physicians must be able “to do good or to do no harm.”⁸ But this can been seen as contradictory for the physician carrying a weapon with the potential to take someone’s life. In truth, not every tactical physician member of a SWAT unit carries a firearm. Those who are sworn officers and carry firearms are bound by the oath of “protect and serve.” With a comprehensive approach, the physician generally provides more to the team than just immediate medical care during callouts. They offer preventative care as the team physician and perform occupational health duties during long.term operations. Kevin Gerold, DO, JD, MSEd, FCCM, FCCP, described the tactical physician best, as a “hybrid of occupational health, emergency medicine, sports medicine, and [acting as] a health and safety officer.”⁹

Not Just ATLS in the Field
One might assume the extensive training during residency and daily role of managing resuscitations and performing life-saving procedures would prepare the average emergency physician for a medical emergency in the tactical environment.¹⁰ Rather, a different mindset and training is required to perform Tactical Combat Casualty Care (TCCC). TCCC was first introduced by the U.S. military’s special operations community in the 1990s as a set of guidelines for the treatment of injured operators in the battlefield. With revisions, the guidelines have become the new standard of care in pre-hospital battlefield medicine.¹¹ TCCC divides care into 3 phases based on the location relative to the threat:

1. Care Under Fire: Taking place in the “hot zone,” this is essentially casualty care under fire. It is limited to tourniquet placement for hemorrhage control and extrication from burning vehicles or buildings.
2. Tactical Field Care: Taking place in the “warm zone,” this represents care rendered while not under direct fire. The mnemonic MARCH describes warm zone considerations: Massive hemorrhage, Airway, Respirations, Circulation, Head injury. Interventions include wound management, application of hemostatic agents, intubation, needle decompression, fluid resuscitation, analgesia, and packaging the patient for evacuation.
3. Tactical Evacuation Care: Taking place in the “cold zone,” this involves all of the interventions necessary until definitive care is reached. This includes advanced monitoring, transfusion of blood products, placement of chest tubes, and ventilator management.

Tactical Medical Assessment
The difference between ATLS and TCCC begins with the medical assessment of the patient. The mnemonic X-ABC (eXsanguinate, Airway, Breathing, Circulation) replaces the mnemonic of ABC used in ATLS. X, which can have many meanings, typically takes place during care under fire.

The X Factor
The first step can often mean eliminating the target, designated “X.” This would occur if the tactical medic is operating on the front line in the hot zone. Before any medical assessment can be performed, all threats must be eliminated. Alternatively, another TMP or SWAT member can protect the position and neutralize any incoming threats while the provider delivers tactical emergency medical care to the patient. In some situations, eliminating the target could mean to simply hold the position and continue the firefight, as the goal is to minimize the number of casualties.

The second step continues with abolishing any potential indirect threats before providing tactical medical care. This means to decrease any possible threats from other operators, including their distraction devices, pepper spray, smoke and gas grenades, and weapons. The confused operator may think the medical provider is a hostile entity and act against him or her. This also means to decrease any risk of secondary explosion, including risk of injury from hazardous materials after an explosion. Finally, any risks from seemingly innocent individuals may be mitigated by performing a thorough search involving a metal detector.

The third step is reaching the patient, and the fourth step is finally evaluating for any life-threatening exsanguination. Remember, the priorities for a tactical provider are:¹² 

1. Return fire as directed or required
2. Avoid becoming a patient
3. Keep the patient from sustaining additional wounds
4. Stop any life-threatening external hemorrhage with a tourniquet
5. Complete the mission

Once threats are stopped and the patient is behind cover, the provider can continue assessing X-ABC. Re-assess for any external extremity bleeding by applying a tourniquet or compression bandage and perform a rapid scan of major external bleeding. If the patient is unconscious, sweep from head to toe, stopping periodically to look for blood.

ABC
Evaluate for patency of the airway and respiratory compromise. If necessary, facilitate efforts with airway adjuncts or provide an advanced airway. If signs of shock are present, obtain rapid IV or IO access for fluids or blood products. If extraction to a point of safety is possible, life-saving care can efficiently be provided there.

Operating in a Hostile Environment
Imagine adding a level of intensity, now performing the initial assessment in a low-lit environment. Most callouts occur at night or in complete darkness, as light is avoided to prevent enemies from knowing the operators’ location. Now add another level of complexity including smoke, flashing lights, and gunfire.

There are 2 important patient assessment skills that most training programs include. These are sensory-deprived physical assessment (SDPA) and sensory-overload physical assessment (SOPA). In SDPA, operators are blindfolded and required to perform a complete primary and secondary exam using senses other than vision. Typically, these assessments can be performed on full-scale human patient simulators in military settings or portable SimMan in civilian settings.¹³ In SOPA, distractions are simulated to overload the visual and auditory senses using smoke from dry ice, strobe lights, loud music, gunfire, and explosions via an audio system. The reality is that operators will need to perform an assessment in the dark, in a prone position, with weapons firing, while communicating with incident commander. All the while, the operator must be vigilant with a 360-degree sphere of awareness of incoming threats. This emphasizes the importance of proper training for TEMS.

The tactical provider may also render care from a distance by either direct visualization of the patient or by phone communication. This is known as remote assessment medicine. With the use of binoculars or a rifle scope, the provider may assess situations and communicate with the incident commander to determine if immediate rescue is necessary based on signs of life or injury.²

The role of the tactical physician can vary, but it almost always involves preventive medicine, medical intelligence, and operational assistance. These skills make the physician an indispensable part of the team.¹⁴

A Look into the Future
The Committee for Tactical Emergency Casualty Care (C-TECC), comprising a broad range of operational and academic leaders in multidisciplinary prehospital medicine, was formed in May 2011 to create TECC guidelines. Modeled after TCCC, this guide translates military lessons into the civilian high-threat, prehospital community with an emphasis on terminology, trauma care recommendations, and operations. C-TECC accounts for differences in the civilian environment, resource allocation, patient population, and scope of practice.¹⁵

Learn More
There are many ways to learn more about tactical medicine:

• Join the ACEP Tactical Emergency Medicine Section at https://www.acep.org/tacticalsection/.
• Read Tactical Medicine Essentials by Campbell JE, Wipfler EJ, Heiskell LE.
• Take FEMA courses online.
• Consider taking the Tactical Combat Casualty Care course.
• Visit c-tecc.org.
• Contact a local fire/EMS or police medical director to get involved.

References
1. Division of Medical Sciences, Committee on Trauma and Committee on Shock (September 1966), Accidental Death and Disability: The Neglected Disease of Modern Society, Washington, D.C.: National Academy of Sciences-National Research Council.
2. Wipfler E.J. Tactical Medicine Essentials. (2012). American College of Emergency Physicians.
3. Carmona R, Brennan K. Tactical emergency medical support conference (TEMS): A successful joint effort. Tactical Edge 1990;8(3):7.
4. Rasumoff D. EMS at tactical law enforcement operations seminar a success. Tactical Edge. 1989;7(4):25–29.
5. National Tactical Officers Association. NTOA position statement: Inclusion of tactical emergency medical support (TEMS) in tactical law enforcement operations.” Tactical Edge. 2007;25(3):10.
6. Cowley RA, Hudson F, Scanlan E, et al. An economical and proved helicopter program for transporting the emergency critically ill and injured patient in Maryland. J Trauma. 1973;13(12):1,029–38.
7. Eisele C. The Golden hour. JEMS. 2008.
8. Jone DA. The Hippocratic Oath III: Do no harm, withdrawal of treatment, and the mental capacity act. CMQ. 2007;57(2):15-23
9. Gearon CJ. Medics enter the “hot zone.” The Washington Post. 2007.
10. Ramirez ML, Slovis CM, (2010) Resident involvement in civilian tactical emergency medicine. J Emerg Med. 2010;39(1);49-56.
11. Montgomery HR, Butler FK, Kerr W, Coklin CC, et al. TCCC guidelines comprehensive review and update. JSOM. 2017;17(2):21-38.
12. Heiskell LE, Olesnicky BT, Welling LE. Tactical Medicine and Combat Casualty Care. In: Auerbach PS, ed. Wilderness Medicine. 2007:552-573.
13. Nicholes A, Rupert R, Bond W, McCarthy JF. When man meets machine: Using computerized human patient simulators in tactical scenarios. JEMS. 2006.
14. Young JB, Sena MJ, Galante JM. Physician roles in tactical emergency medical support: The first 20 years. J Emerg Med. 2014;46(1):38-45.
15. Committee for Tactical Emergency Casualty Care.