Todd Burke, Jim Weiss and Mickey Davis
Having a solid medical component integrated into your tactical team is not just an option. According to the National Tactical Officers Association’s (NTOA’s) list of “best practices” in 2003, it is a standard.
Sixteen years before the NTOA’s best practices were presented, the “Tactical EMS School” was created by four active police paramedics who recognized the need to deliver true medical support into the inner perimeter. The school offered a way to bring this advanced life support – Tactical Emergency Casualty Care – to the hot crisis zones of the SWAT, EMS and law enforcement worlds. Taught were immediate care techniques for mass attacks and “care under fire” for incidents such as the Boston Marathon or the First Baptist Church in Sutherland, Texas. These are high risk solutions in dangerous environments, often similar to environments where military combat medics can be found.
The original program lasted three days. In 1993, it was expanded to five days and became residency-based, including lodging and meals in the price of tuition. It also gained accreditation by the American College of Emergency Physicians (ACEP).
In 1995, the course moved to Camp Ripley, MN, which offered more suitable remote and private facilities, and took training away from populated areas and unnecessary distractions.
In 2014, the school was endorsed by the Committee for Tactical Emergency Casualty Care (C-TECC) for delivering “approved educational content”
In 2015, it was accredited by the International Board of Specialty Certifications for those seeking to recertify this specialty under their auspices. The Tactical EMS School offers continuing medical education units formatted to meet National Registry guidelines and the program is approved in many states for POST credits.
In 2017, the program celebrated its 30th anniversary.
Cadre of Coaches
The staff is made up of 20 coaches, all of whom have significant operational experience. Each brings special and unique skills to the table and most are veteran paramedics within a police or fire department. The medical director is an orthopedic surgeon with an extensive background in military battlefield medicine and has ties to the U.S. Special Operations Command (USSOCOM). There is also a tactically trained veterinarian who is part of the FEMA USAR Task Force system responsible for assessing and approving USAR K9s, prior to the dogs being approved for deployments. K9s are utilized throughout the week during the course.
Schedule for the Week
Training days begin at 0600 with stretching/injury prevention and problem solving team initiatives which provide a healthy workout in the context of pure teamwork.
This experience runs for 77 hours over six days, including evening operations which might extend past midnight. An average day is 13 hours; however, team members have their kits squared away for possible middle of the night callouts. Additional evening sessions are optional for those wanting additional experience handling firearms, learning how to make a personal rescue harness with webbing, or practicing airway techniques.
A weeklong course cannot adequately cover everything a tactical medic needs to learn; however, training time and team building are maximized by keeping team members together for the entire week during training, deployments and meals. Team members begin the day with injury prevention, team initiatives, a team breakfast, and training in simulated conditions by making the training ground resemble a battle zone as much as possible.
Training begins with personal introductions; concepts and philosophy; occupational medicine (which is a large part of what Tactical Emergency Medical Support [TEMS] is about); roles and responsibilities; and firearms and weapons familiarization.
There isn’t a live-fire component in this program. Being able to handle and render tactical firearms safely is an essential skill which is taught during the week – learning how to fight with a firearm belongs in another specialized training session.
The class is separated into four teams (red, white, blue, and gray) and participants are given corresponding colored shirts, with coaches wearing black shirts. Teams remain intact all week and work through over 20 different operational exercises and team initiatives, some as brief as 15 to 30 minutes, while full mission profiles last six to eight hours.
Whether a participant is a basic life support first responder or an emergency physician, each scenario is designed and managed in a variety of ways, depending upon individual skill level and licensure. It is a common occurrence to discover that, at some point during training, each person is the weakest link on their team and, at another point, the strongest asset.
First responders, nurses, physicians, surgeons, and other professionals are distributed over the four teams to emphasize the importance of the team dynamic and how their individual talents contribute to the team. Attitude and behavior are deemed more important than any rank or title, and knowing when to follow is just as important as knowing when to lead.
Tactical concept exercises include weapons familiarization; casualty collection points; concealment and camouflage; arrest and control; team movement with a medical package; lawful use of force; the psychology of hostage taking; medicine across the barricade; and immediate action drills
Medical concept labs include the medic’s role; wound packing; chest seals and decompression; tourniquets; tactical medical preplanning; patient packaging; extended orthopedics; stress management; salt triage; and new threats, such as the drug, carfentanil.
Practical exercises include airway management; hemorrhage control; sensory deprivation; chemical agents; remote patient assessment; officer down rescue; patient movement; adjuncts for rescue; K-9 medical and trauma; and full mission profiles.
The Burrito Wrap Technique – This technique is taken from wilderness medicine and search and rescue disciplines. It utilizes a Reflexcell™ blanket to wrap the patient, a Thermolite® pad underneath, a regular tarp, and a SAM® Splint to create a head wrap and visor. A length of utility rope laces it all together so that the patient can be carried long distances. A Burrito Wrap can be particularly useful when rescuers anticipate an extended evacuation time or the patient cannot readily be evacuated by vehicle.
First, the patient is medically stabilized with whatever treatments need to be performed (tourniquet, wound pack, IV placement, etc.) or adjunct devices placed (splints, pelvic stabilizers, etc.). A 75 to 100 foot piece of utility or rescue rope is laid out in a back and forth cascading line. An 8′ x 10′ poly tarp is then placed on top of this for the final covering before the patient is laced into the wrapped package.
For the patient, the first consideration is to remove/replace as much wet clothing as possible. Adding an adult hygiene garment can be a big plus for the injured person who needs to void while the overland carry is in progress since they are notably packaged and stopping to unwrap for a break would not be practical.
Effecting Rescue – The original 1996 Tactical Combat Casualty Care postulates state that the priorities of care are: 1) self aid, 2) buddy aid, and 3) medic aid. In the tactical environment, performing the correct medical intervention in the wrong place or at the wrong time can get team members killed. This is one of the main reasons every person is tourniquet equipped and skilled. Other members of the team may be engaged in an active gunfight while you are involved with stopping your own blood loss after taking a round.
It is also essential for the medical rescue team members to communicate well with the tactical team leadership and understand that the team leader remains in charge. This means treatment of a casualty may be interrupted, or not occur, until the team moves to a better and more defensible position.
In one of the many scenarios practiced, medics begin to perform care on a downed officer after the team runs 100 yards to reach him, with the tactical element providing over watch. After 60 seconds of treatment, the team takes incoming fire. Blanks and Noise and Flash Diversionary Devices (NFDDs) are discharged, smoke is thrown, people are yelling, and the tactical officers are burning expending magazines. Placing medics in this situation during training goes a long way to reinforce the adage that few plans survive first contact with the bad guys.
Sensory Deprivation and Overload – There is also value in suppressing or overstimulating students’ senses to push the learning curve and demonstrate that something can be done differently or in an unconventional way.
For example, airway management is a staple for medical responders, but doing this upside down, in darkness, or when your hands are so cold you can’t feel them may offer a degree of reality. Prior to performing an airway procedure on a mannequin, participants are required to run up and down four to six flights of stairs and then plunge their hands into a five gallon bucket of ice water for 60 seconds. Afterwards, they are required to perform the technique.
At another skill station, all participants wear gas masks which are taped over so they can’t see. Students then have to move to an injured operator and perform a physical exam according to the Tactical Emergency Casualty Care (TECC) “MARCH” (Massive bleeding, Airway, Respirations, Circulation, Hypothermia/head injury) principles. When they discover a firearm on a brain injured, mind altered, or unconscious operator, they have to take control of it, keep the muzzle pointed in a safe direction and render it safe. This emphasizes that, while medics may not need to qualify or perform with every firearm and tool in their team’s inventory, they must be able to handle them safely and take charge in all conditions.
Tear Gas – Students practice how to don, clear, doff, and store/carry their gas masks. Afterwards, the face pieces are blacked out and they perform simple medical tasks to overcome their sensory deprivation, reinforcing that they don’t necessarily have to see to solve the problem.
Additionally, there is a static and controlled exposure to a CS agent (tear gas). Students remove their masks, clear them and remain in the gas environment. The objective of the drill is not to prove that CS is unpleasant, but rather to recover a mask which has been pulled from their face, regain a seal and continue the job while in the gas.
Finally, an unexpected exposure is introduced while a medical rescue is in progress, with the instructors causing the operators to experience a mask failure. While very unpleasant, focusing on the medical interventions necessary to save the life of a teammate helped to overcome fear and the strong urge to flee or panic. This was a profound learning opportunity for many.
The 2018 Tactical EMS School is scheduled for September 23-28, 2018, at Camp Ripley, MN. For more information, go to http://tactical-specialties.com/tactical-ems-school/.
Todd Burke is a 35 year decorated veteran of the emergency services as a police officer, firefighter and paramedic. He holds a variety of instructional certifications in multiple disciplines and has been the director of the Tactical EMS School for the last 24 years (www.tactical-specialties.com).
Jim Weiss is a retired Brook Park, Ohio, Police Department lieutenant.
Mickey Davis is an award winning author and a senior volunteer member of a California fire department.