Page 78 - 2020 JSOM Winter

fundamental a skill as tourniquet application. In a civil dis- Conclusion
turbance, however, the rescue and extraction of a casualty is
one of the most confounding problems. Large, tense crowds TEMS is a maturing discipline of pre-hospital care. It has stan-
complicate not only accessing a patient but simply locating dards and a strong culture. TEMS in the civil disturbance en-
them. Just as with remote assessment, CDU medics must vironment is not new, but it is minimally described in medical
leverage other resources including elevated police observers, and tactical literature. Yet, protests and riots occur commonly
aircraft, and even streaming social media when attempting around the world. The medical threats in this environment
to locate potential patients. Once the decision has been made are not unique, but managing them is uniquely complex. The
to transport a patient, logistics become even more complex. TEMS competencies, while not designed for CDU TEMS,
Ambulances must be given safe routes to approach and stage, are well suited to describe the discipline. Their applicability,
and the medic must be skilled in moving a patient by both however, must be viewed through the lens of conducting oper-
standard and improvised methods. Lifting tarps, ATVs, and ations in massive, unruly crowds and include a deliberate con-
even stretchers towed by bicycle should be considered. Civil sideration of the unique aspects of this environment. Patient
disturbances are at best mass gatherings in which the sheer access and egress are key concerns, as is a constant focus on
number of people in the streets will complicate access and the crowd as a potential MCI, and the accompanying actions
egress. At worst, civil disturbances are hostile, denied areas in case the worst occurs.
where patient movement is more appropriately described as
exfiltration. Staffing an ambulance with tactically trained re- Civil disturbance TEMS represents an emerging discipline that
sponders, dedicated to exfiltration of patients from the protest may be one part tactical medicine and one part mass gathering
area, is a valuable resource that leaders should consider. Here medicine. Mass gathering medicine, also called event medicine,
again, CDU TEMS is not inventing new skills, but is reimag- is a younger discipline than TEMS and its focus is largely on
ining tactical fundamentals through the lens of large, hostile peaceful mass gatherings, such as music festivals. The October
crowds and the complexities that accompany them. 2017 massacre in Las Vegas, however, is an example of how a
happy mass gathering can become a tactical medical ordeal in
an instant. Arbon et al. have described factors that may assist
in predicting patient presentation and transport rates at large
public events. These factors, coupled with law enforcement
4
threat assessments and medical intelligence, may be useful for
medical planning around civil disturbances. Research on inju-
ries and illnesses encountered during civil disturbances could
be valuable in building CDU TEMS as a professional subspe-
cialty of tactical medicine.

Note From the Authors
This piece was completed in January 2020. In late May 2020,
nightly protests began occurring in Portland. At the time of
this writing, the protests had continued uninterrupted for
more than 150 days. Many of the protests involved violence,
and the Portland Fire & Rescue RRT medic program has
treated dozens of patients during this time. As might be ex-
pected, the program’s tactics and policies have been adjusted
in response to lessons learned. The doctrine described in this
article, however, has held up well, and the authors believe it
still represents best practices.

Disclosures
The authors have nothing to disclose.
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Assault Aid Bag Prolonged Field Care Field Aid Station

76 | JSOM Volume 20, Edition 4 / Winter 2020