Page 77 - 2020 JSOM Winter

FIGURE 2 Portland Fire & Rescue RRT medics conduct operations such as 2-chlorobenzalmalononitrile (CS) gas. Here, the CDU
during a riot in May 2017. medic must think outside the military-grade chemical, biolog-
ical, radiological, and nuclear defense (CBRNE) box and con-
sider chemical threats commonly encountered at protests, such
as riot control agents, toxic smoke from burning material, and
toxic fumigants (seen in rodent smoke bombs thrown at law
enforcement). Biohazards, such as urine, blood, and feces, are
also known to have been thrown at law enforcement and are
obvious concerns. Additionally, but particularly troubling, is
the use of hydrofluoric acid (HF) as a weapon. HF has been
used for vandalism during protests, and its insidious patho-
physiology demands that the medic be particularly vigilant for
any liquid that is splashed on others. Medics must prepare for
likely HAZMAT threats by having ready access to detection
equipment such as pH paper, gas detectors, and dosimeters.
The ability to confirm or deny the presence of HAZMAT and
potentially begin the process of identifying an unknown sub-
Source: Oregonian/OregonLive Mark Graves stance, is an important capability for the CDU medic.

Mass Casualty Triage
crowd or withdrawing from a particular location are common
tactics of experienced CDUs. The medic must be aware of these As described above, one of the key distinctions between the
tactics and their interplay with patient care. For example, if a concept of operations for CDU medics and their SWAT col-
medic assumes care of a person with minor injuries, but the leagues is the potential for an MCI. In a gathering of thousands,
tactical situation changes and law enforcement determines the the competency of mass casualty triage is especially relevant.
best course of action is to disengage, the medic cannot aban- Just as CDU medics must plan for numerous extrication and
don the patient. This is a dilemma: medics may see a patient ambulance exchange points, so too must they predesignate ca-
with injuries for which they have a duty to respond (another sualty collection points throughout the potential protest area.
reason to sharpen remote assessment skills), but responding to In the event of an intentional mass casualty incident such as
the patient may create a tactical problem. As with other issues a shooting or bombing, rapid sorting of dozens of casualties
described previously, the key here is good communication with is daunting. Triage is an art, not a science, and dynamics of a
leadership. First, the CDU medic’s employing agency and med- civil disturbance make triage here especially complex. CDU
ical director must clearly communicate their expectations for medics are well advised to practice triage methods that are
responding to emergencies in a civil disturbance. Written guid- simple and expedient, as this will reduce their cognitive load
ance is important in the event of post-event litigation. Second, and facilitate the most important work of moving patients
CDU medics must communicate the situation, resource needs, quickly to definitive care.
and an estimated scene time to their tactical leaders whenever
the medic assumes patient care. This will help in determining Tactical Familiarization
tactics while the medic is actively treating the patient. Finally,
operational leadership must aggressively coordinate the move- The tactical familiarization competency is in many ways the
ment of transport resources in and out of the threat area in cornerstone of effective TEMS. The competency compels the
order to rapidly transition patient care from the CDU medic medic to move across disciplines and be familiar with tactical
to ambulance-based personnel. operations, team structure, command structure, tactical move-
ment, communications, equipment, and other unique facets of
Closely related to awareness of legal issues is awareness of a tactical team. CDU TEMS is no different, but again, the issue
public perception. CDU medics will be operating in full view of scale is at the forefront. CDU medics must be equipped and
of the public they serve. Medics must conduct themselves with trained to communicate vertically to all levels of the chain of
utmost professionalism. Protesters and groups are not only ac- command, as well as horizontally to other emergency respond-
tive in the streets; they are prolific users of social media and ers, dispatchers, and other team medics. This is far easier said
missteps by medics can go viral in seconds. Uniforms must be than done given the seemingly intractable difficulties with
clearly marked to identify the medics role but not so different communication interoperability. Medics must be intimately
that the medic becomes a potential target. Medics should not familiar with CDU tactics and objectives to avoid becoming
interact with the public at all unless for patient care. And pa- a hindrance to their team and to maintain their own safety.
tient care, usually conducted in a somewhat private setting, Awareness of the tactical situation and an understanding of
will now occur in view of thousands in person and online. His- potential outcomes also keeps the medic aware of potential
tory taking and treatment must be exemplary and professional. threats, which in turn helps with injury prediction and med-
ical planning. Tactical familiarization then, is the thread that
weaves many of the competencies together, both for “normal”
Hazardous Materials (HAZMAT) Management
TEMS and for the civil disturbance environment.
The HAZMAT competencies are well suited to the CDU medic.
Their emphasis on hazard identification, mission planning, Operational Rescue and Casualty Extraction
PPE, decontamination, and treatment are all relevant to civil
disturbances. In fact, the HAZMAT competencies are particu- For a SWAT medic, patient drags and carries are basic skills.
larly relevant, given law enforcement use of riot control agents The ability to move a colleague out of harm’s way is as

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