“One dictum I had learned on the battlefields of France in a far distant war: You cannot save the world, but you might save the man in front of you, if you work fast enough”
Diana Gabaldon, Ph.D, Author, “Outlander”
In the late 1700s, Napoleon Bonaparte appointed Dominique-Jean Larrey to develop an echeloned model of military medicine for the French army. The realization that prolonged suffering, increased morbidity and mortality on the battlefield occurred as a matter of course, Larrey was determined to provide early medical interventions in the field by designing and deploying the ambulance volante, or flying ambulance, a carriage staffed with medical personnel.
Based on Larrey’s concept and principles, Dr. Jonathan Letterman further expanded field emergency medical care during the Civil War by designing horse-drawn ambulance trains to provide transport from the field to definitive medical care at local hospitals. Caregivers, such as Clara Barton, also rendered medical aid to the wounded on the battlefield, during transport and at forward medical facilities. In later wars and armed conflicts, combat medicine and rapid medical evacuation to rear echelon medical facilities played an essential role in optimizing survival from battlefield trauma.
The foundation and forerunner of our current day emergency medical systems has been combat-tested military medicine and the subsequent lessons learned. In addition, basic and applied biomedical research on trauma and combat casualty care has led to a more profound understanding of trauma pathophysiology and more effective trauma care in both military and civilian environments.
Furthermore, military force health protection efforts, including the R&D and educational/training activities conducted at military research institutes, such as the prestigious US Army Medical Research Institute of Infectious Diseases (USAMRIID), the US Army Medical Research Institute for Chemical Defense (USAMRICD), the US Army Institute for Surgical Research (USAISR), and the Armed Forces Radiobiology Research Institute (AFRRI), have provided a treasure trove of translational research data, medical countermeasures, techniques and protocols that may be applied to civilian medical care in the CBRNE context.
Tactical Emergency Medical Support (TEMS) refers to medical support for law enforcement operations. TEMS is not military medicine, however, it draws heavily on principles, practices, lessons learned, and equipment used in modern military medicine. TEMS concepts, principles and practices are really adaptations and modifications of military Special Operations Forces (SOF) medical support that are applicable to civilian tactical assets, such as S.W.A.T.
The National Association of EMS Physicians (NAEMSP) defines TEMS as “the spectrum of services necessary to establish and maintain the health, welfare, and safety of special operations law enforcement providers”. TEMS involves the overall support of mission success and the preservation of life safety, team health and wellness, gathering medical intelligence and providing medical threat assessments, providing acute medical care in austere and hostile operational environments to team members, suspects, hostages, and civilian bystanders.
The advent of prolific civil unrest and the use of tactical ultraviolence prompted law enforcement agencies to create specialized tactical teams to deal with high risk situations. The concept of the civilian “tactical medic” came into play based upon mission operational needs and hazards, and a national database that catalogued the injury mechanisms and patterns sustained by both law enforcement personnel and civilians. This national database created by the Casualty Care Research Center in collaboration with various other agencies, such as the U.S. Park Police and the U.S. Department of Defense (DoD),resulted in the development of the Counter Narcotics and Terrorism Operational Medical Support (CONTOMS) course, as the flagship, gold-standard curriculum in TEMS.
While the “stock and trade” of tactical medicine has been ballistic trauma /gunshot wounds, blast trauma, blunt trauma, along with contusions, abrasions and other physical injuries, heat stress and complications/exacerbations of pre-existing conditions in perpetrators and victims, the asymmetric, non-conventional threat environment has created a pressing need for tactical and special response teams to become fully trained and equipped to engage in operations involving CBRNE and other HAZMAT threats; some of them are clandestine drug laboratories, environmental crime scenes, and even stealth attacks on the petroleum, chemical and nuclear power generation sectors.
Tactical units may have to provide tactical overwatch, hostage rescue, room clearing, close quarter take-downs, and render-safe operations in a dynamic, extremely hostile and unstable environment. Entry teams must be able to wear the appropriate levels of personal protective equipment (PPE) and conduct sampling and monitoring to assess and characterize toxic airborne hazards, oxygen deficient atmospheres, flammability/explosivity hazards, corrosive environments, radioactivity, and the presence of militarized/weaponized agents, such as nerve agents, eg. sarin or vesicants, eg. sulfur mustard (HD) or other chemical weapon agents (CWAs) or biological warfare /bioterrorism agents (BWAs/BTAs), eg. ricin.
Concurrently, in an incident or event involving criminal or terrorist activity, after suppressing armed threats, the team must be able to determine the presence of secondary devices/booby traps, conduct render-safe operations, if able, recognize unstable threats such as runaway exothermic reactions or impending structural collapse, and collect and preserve forensic evidence as per established protocols. The team may encounter a contaminated suspect(s) that must be subdued and taken into custody, or may require to engage in fire discipline to avoid creating a chemical release or explosive event. TEMS providers must be fully prepared to conduct medical threat assessments and recommendations to preserve the health and safety of team members, victims, hostages, collateral responders and civilian by-standers.
In addition, TEMS personnel, as well as the rest of the team, must maintain constant vigilance and situational awareness, and the TEMS provider as an integrated medical, health and safety professional needs to provide continual reassessment of the risk-benefit ratio between medical treatment and extraction.
Operational security (OPSEC) is essential, and must not be compromised. The TEMS provider must possess a high level of knowledge and skill sets in the medical planning and response to terrorism and HAZMAT incidents in order to properly treat officers down and other victims of a CBRNE event or HAZMAT incident. TEMS providers must be able to:
1. Recognize clinical signs and symptoms that are suggestive of exposure and toxicity related to CBRN agents.
2. Utilization of appropriate levels of PPE based on hazard risk assessments .
3. Knowledge of time to onset of signs and symptomatology, as well as functional capacity likely after CBRN/HAZMAT exposures, is vital post-exposure to provide optimal medical, health and safety decision-making for all tactical operators and continued viability of the mission.
4. Provision of best available medical and environmental intelligence to team commander, and ultimately to the overall Incident Commander.
The TEMS provider should be prepared for the administration of antidotal therapy for nerve agent and cyanide/systemic asphyxiant toxidromes, recognition and treatment of irritant gas/pulmonary agent toxidromes resulting from toxic inhalation of gases, such as chlorine, anhydrous ammonia, phosgene, and isocyanates, assessment and treatment of chemical burns, explosive blast and incendiary trauma, and radiological exposure. As an integral and vital component of the medical and safety management of CBRN and HAZMAT events, TEMS providers and all tactical team members must be thoroughly familiar with decontamination protocols and procedures.
The principles of preventive medicine and public health are of paramount concern to TEMS providers and medical directors. These functions cover all aspects of team health and wellness, including appropriate medical monitoring and surveillance for occupational exposures, hydration, nutritional status, behavioral health, vaccination status and needs, selection, donning, doffing of appropriate and adequate PPE, including appropriate threat level body armor, exercise tolerance/fitness, and other aspects. Team health, wellness and safety are tantamount to successful mission completion because degraded team performance from any cause may result in death and disability of team members, victims and compromise mission continuity and completion.
Non-conventional threats utilizing CBRNE and HAZMAT are a clear and present danger, which have significant and recent historical precedents. The response of specialized tactical teams with CBRNE/HAZMAT capabilities, and their medical support elements, are essential to mission success in non-conventional threat-CBRNE and HAZMAT events.