Page 74 - Journal of Special Operations Medicine - Summer 2014

this represents the “warm zone” of operations, inside a more aggressive approach toward providing prehos-
the perimeter. The third phase is evacuation, which is pital care in a mass casualty incident may be beneficial.
typically staged in the cold zone of law enforcement op-
erations, typically outside the perimeter where there is Preplanning will be critical in providing medical support
no threat. in a riot. Medical threat assessment and planning should
be done, when possible, to identify munitions used by
While the ideal situation is to have paramedics trained to both the police and the rioters, appropriate hospitals
work in the hot zone (direct threat); unfortunately, this for victim treatment, access routes, alternative methods
is not always administratively possible, or not enough of victim transport (buses, for example). This would be
tactically trained medics may be available to handle necessary to anticipate the most likely types of injury pat-
multiple simultaneous incidents (Mumbai-type event), terns anticipated in a riot. In the case of Singapore’s Little
or the tactically trained paramedics may be delayed in India Riot, some of the perpetrators were intoxicated and
arriving at the scene. In these situations, an alternative dehydrated after heavy alcohol consumption. Appropri-
plan needs to be developed. ate medical management would also be required in man-
aging such casualties once they have been apprehended.
Since the number one cause of preventable battlefield
death has been shown to be hemorrhage, stopping hem- The approach to tactical medicine varies from country
orrhage becomes the obvious priority. If law enforce- to country; within the United States it varies among the
ment officers (LEOs) are the only personnel in the hot states and the different local jurisdictions within the
zone, then it becomes their responsibility to manage and same state. Thus each jurisdiction must develop an ac-
transport the casualties to the medical personnel. This ceptable approach to providing medical care in the tac-
requires excellent communication between all personnel, tical environment. For Singapore, this will most likely
requires that LEO personnel carry medical supplies and involve training tactical medics to operate in the warm
be trained in their use, and that an abundance of LEO zone initially. Urgent lifesaving techniques (hemorrhage
personnel be available since the LEO is now responsible control) and patient transport in the hot zone will ini-
for patient treatment and transport to the medics wait- tially be provided by specially trained law enforcement
ing in the cold or warm zones, and for actively pursuing officers. During this period of transition and for all fu-
and suppressing the threat. ture incidents, integrated training between EMS, tactical
medics, and law enforcement must be performed so that
In situation of civil unrest, the LEO will deal with casu- operational conditions are replicated as closely as pos-
alties initially until specially designated tactical medics sible with excellent interoperability.
(likely from the SPF) attached to the Special Operations
command and Gurkha Contingent units mobilize to dis- It has been demonstrated (Tucson, Arizona, shooting)
perse the riot. The tactical medics will designate CCPs that properly trained LEOs will play a major role in the
in strategic locations, usually the warm zone where in- initial management of casualties because they are the
jured personnel can be stabilized (if necessary) with us- first group of uniformed personnel to arrive at the scene
ing TECC Indirect Threat care guidelines before moving and are also able to operate in a tactical environment.
them to the cold zone where ambulances and non-tacti- Hence, their training should include the ability to pro-
cal medical providers and paramedics are located. In the vide hemorrhage control via the use of tourniquets and
hot zone, LEO first responders and anti-riot LEO will the extrication of the casualties from the hot zone via
be involved in basic management of the casualties with different carrying techniques. They must be deployed op-
severe bleeding and be responsible for their extrication, timally before the specialized anti-riot LEO and Tactical
using dedicated rescue teams, to the planned CCP in the Medics take over the management and evacuation of the
warm zone which is manned by tactically trained med- casualties. Likewise the specialized anti-riot LEO must
ics. Transport of casualties from the warm to the cold also be trained in hot zone first responder care just as the
zone would be done by tactical medics and additional street level patrol office is trained to provide initial hem-
LEOs. During this process, the principles of TECC orrhage control. As for the Tactical Medic, they have to
would be followed with hemorrhage initially addressed be trained for medical management of casualties in both
in the high threat tactical environment and other medi- hot and warm zones, setting up of CCP’s and managing
cal conditions treated in the warm and cold zones. casualties who have injuries ranging from conventional
trauma to non-lethal munitions used. Depending on the
types of riot control devices used and the type of weap-
Lessons Learned, Future Plans
ons used, decontamination may also need to be pro-
Although the outcome of treating casualties was satis- vided. A Mass Casualty Incident can be expected if a riot
factory in the Little India riot, analysis of the medical escalates. Therefore triaging and mass casualty incident
events surrounding the incident seemed to indicate that management should be included in the training as well.

64 Journal of Special Operations Medicine Volume 14, Edition 2/Summer 2014