Page 130 - Journal of Special Operations Medicine - Summer 2015

contacts, the incidence of use of force was 1,269 per 69% of tactical operations involved conventional EMS
1.56 million interactions. In contrast, injury rates assets on standby at a pre-designated location. Ninety-
16
5
during tactical operations for civilians, law enforce- four percent of the providers had no specialized train-
ment personnel, and suspects are reported to be as ing in tactical operations and could not operate within
high as 3.2, 1.8, and 18.9 per 1,000 officer missions. a “hot” or “warm” zone of care. Although the study by
3
A more recent survey of physician involvement in tac- Vainionpaa et al. uses the term TEMS, the EMS support
4
tical incidents found that 16.5% of tactical incident model in that study used the on-duty supervisor and the
events resulted in injury, while 4.5% resulted in fatali- closest available ambulance. This model is quite different
ties. A retrospective study of 120 tactical incidents in from the US TEMS concept, and more analogous to a
6
Helsinki, Finland, identified four (3.3%) fatalities on nonintegrated standby response.
scene and 28 (23.3%) patients. 4
The current study was unable to distinguish between
Firearms accounted for nearly 15% of all injuries in conventional EMS standby response and TEMS re-
the current study. Five percent of patient encounters sponse. However, some data suggest that the majority
in the current study involved cardiac arrest, of which of tactical incident EMS activations were attended by
more than three-quarters underwent field resuscitation. conventional EMS rather than by TEMS personnel.
A total of 133 (3.4%) patients were declared dead on Thirty-seven percent of incidents were coded as occur-
scene. Of patients with documented outcomes, nearly ring on streets or roads. While tactical operations have
one-quarter of patients transported to the hospital suc- involved vehicle assaults, this finding more likely reflects
cumbed to their injuries in the ED (Figure 3). This may the location of EMS staging and first patient encounter.
reflect the greater proportion of firearms injuries in this TEMS providers may not have transport capacity and
study compared with the Helsinki study. However, the so may be dependent upon conventional EMS assets for
4
Helsinki study evaluated all tactical incidents. This study casualty evacuation. TEMS also may not participate in
only involved incidents in which EMS agencies partici- NEMSIS. In part due to these reasons, the current data
pating in NEMSIS were deployed, therefore biasing the likely do not represent the specialty care provided by
severity of outcomes. Since outcome is a non-mandatory TEMS units across the United States.
field, more severe outcomes are likely to be documented.
The US military revolutionized the approach to medical
Approximately 55% of EMS providers in this study op- care under fire with the development of Tactical Combat
erated at the BLS level (Figure 1). Significantly fewer Casualty Care (TCCC). This data-driven approach,
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tactical incident activations resulted in ALS Level 1 re- focused upon limiting possibly preventable deaths and
sponse compared with total NEMSIS activations. Given preventing further injuries, has proven remarkably suc-
the potential for significant injury in tactical events, and cessful and continues to save lives in combat. 26,27 In the
the severity of injury noted in the current analysis, the civilian arena, the Committee on Tactical Emergency
lack of ALS availability was surprising and may pro- Casualty Care (CTECC) has developed specific man-
vide an opportunity for care improvement. However, in agement guidelines for law enforcement medical care
the setting of penetrating trauma, there is an increas- under conditions of ongoing threat. Both TCCC and
28
ing body of data to suggest that rapid transport is more CTECC identify specific skills essential for medical care
beneficial than ALS-level interventions. 17–20 Based upon under these circumstances, including tourniquet place-
the available data, the most common interventions were ment for exsanguinating extremity hemorrhage, hemo-
blood glucose analysis, pulse oximetry, extremity intra- static agent application, recognition and management
venous access, and cardiac monitoring. of tension pneumothorax, and limited airway manage-
ment. In the current study, no tactical incident patient
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The majority of publications on EMS response to law en- was documented as receiving a tourniquet, hemostatic
forcement tactical operations focus upon Tactical Emer- agent, or needle thoracostomy; 17 patients received na-
gency Medical Support (TEMS). 6,8–10,21–23 TEMS has been sopharyngeal airways. This may reflect issues with chart
defined as “the mission-preplanning, preventative care documentation, as procedures performed by TEMS per-
and medical treatment rendered during mission driven, sonnel prior to patient hand-off to conventional EMS
high-risk, large-scale, and extended law enforcement assets might not be captured by NEMSIS. Alternatively,
operations.” The National Tactical Officers Associa- it may reflect different injury patterns among military
2
tion recommends law enforcement tactical teams include and law enforcement operations. 30
properly trained tactical emergency medical provid-
ers. The State of California states that tactical medicine Limitations
should be fully integrated into law enforcement tactical
operational programs. Despite this, a previous survey This study has limitations and biases inherent in any ret-
24
of EMS response to US tactical operations indicated that rospective study, including the potential for miscoding or

120 Journal of Special Operations Medicine Volume 15, Edition 2/Summer 2015