By Brendalyn Val Bilotti

Tactical Medicine is a rapidly growing area in law enforcement. This focus on advanced pre-hospital medicine in a tactical or austere environment is the result of the current risks associated with law enforcement activities and the ever-growing war on terrorism. Furthermore, the Federal Bureau of Investigation has released the “2017 Law Enforcement Officers Killed and Assaulted” report online. This report states that 60,211 officers assaulted while performing their duties. They also reported that 46 law enforcement officers were feloniously killed in the line of duty, as well as an additional 47 law enforcement officers died as the result of accidents that occurred in the line of duty.

As TEMS (Tactical Emergency Medical Support) has grown in popularity, so have the number of programs offering instruction for this specialty. The challenge has been in the varied ways these programs are conducted. With a lack of a nationwide standardized competency-based program, such as is used with Pre-Hospital Trauma Life Support (PHTLS), the programs that do exist are producing a wide range of understanding, capabilities, and expectations of performance.

One of the most challenging areas of establishing consistent delivery of TEMS resources is the significant variation that TEMS providers come from. Due to the nature of the physical demands of the tactical environment as well as the increased risk to the provider, TEMS providers are almost always volunteers. They are physicians, physician assistants, nurses, paramedics and EMT's. The problem arises not just in their scope of practice and what they can do, but also the autonomy with which they are able to provide this support. A physician may act independently, but a nurse and physician's assistant need to operate under the auspices of a physician. Paramedics and EMT's can only provide care within the state guidelines, and must also be certified by the local county to provide this care.

Given the variation in what care is provided, the questions that individual departments need to ask include:

1. What competencies are required of each TEMS operator? The basis for most trauma care is adapted or adopted from The Committee on Tactical Combat Casualty Care, and The Committee on Emergency Casualty Care outlines the best practices for trauma care in a tactical environment. It is not all inclusive of all the needs of a law enforcement operation. In addition, the California Emergency Medical Services Agency (CAEMSA) and Police Officer Standardized Training (POST) have released a collaborative “Guidelines for Tactical Medicine.” It is from this position a course can be developed for all deputies, and from that course, advanced courses can quickly grow.
   
   
2. Medical equipment should each operator carry? As in any job, the tools you take with you dictate how much one can accomplish while completing the job assigned to you. To have impractical tools, impractical tools or the wrong tools not only inhibit but impedes mission completion. Therefore, deciding what tools a TEMS operator carries indicates how independent they are and how effective they are while providing medical care. Equipment including tourniquets, chemical hemorrhagic control agents, pressure dressing and airway support equipment all need to be evaluated.
   
   
3. How often should each TEMS operator be required to perform these skills in a training environment? Professional licenses and certifications have to be renewed every 2-6 years, depending on a provider’s level of training and licensure. No standard currently exists for tactical medicine. It is well documented that skill degradation occurs without practice, and this area needs to be addressed. Insight for this can be garnered from air ambulance programs, which have a broad scope of practice and regimented training schedules. This would include a focus on the non-medically trained patrol officer who is on the front line of any law enforcement activity, from a traffic stop to those whose job puts them at greatest threat, such as Explosive Ordinance Disposal (EOD) or Special Response Unit (SRU).

Licensing
Licensed professionals have a scope of practice defined and often limited by the licensing body. Example are the American Medical Association (AMA), California Board of Registered Nursing (BRN), and the CAEMSA as defined by Title 22 of the State of California, as well as the First Responder course which is a non-licensed certification whose scope of practice is defined by the United States Department of Transportation (DOT).

These licensing and certification bodies have standards of practice, assessments, procedures and tests that each level of licensure is required to prove competence in through written and skills testing — providing certification at each level: Tactical Emergency Medical Support (TEMS; for a contracted and trained EMT/paramedic/nurse, providing care under fire in the hot zone) and the Tactical Medical Doctor (TMD; for the physician serving as the tactical team's medical director and medical team leader). With these different and well-defined levels of care, both the tactical team leader, the medical team leader and all tactical team members have clear expectations of services provided at each level, thereby furthering legitimization of the TEMS and TMD providers and their integration into the tactical program and environment.

Training 
When inquiries have been made of law enforcement officers regarding the tactical medicine courses they have taken, one similar concern was voiced: programs seemed to be often geared toward medical personnel with no law enforcement or military background, and not toward experienced law enforcement officers. This subtle yet profound difference means that many program's curricula include topics such as weapons, tactics and range time. Officers stated they did not need nor want these topics because these were covered in their academies, SWAT schools and were governed by their specific agency's policies. Some programs did not delineate between licensed and not licensed students, and students attended classes in skills that they could never use.

Suggestions included the following:

• Develop a visionary and forward-thinking curriculum that approaches the topic of tactical medicine from the view of law enforcement officers.
• Law enforcement leaders need to be at the forefront in advocating for and ensuring that the expertise, training, and equipment to support our first line of defense is available.
• Law enforcement agencies need to define the qualification requirements for all officers.
• Periodic formal and informal meetings among law enforcement and medical leaders are essential for unit cohesion and clear communication before an incident.

The suggestions listed above provide a useful framework for creating a Tactical Medicine Program for law enforcement.

On a micro-level, this provides the law enforcement community an alternative to the currently available method of having an ambulance on standby unavailable to provide immediate casualty care, thereby delaying care to wounded officers, civilians or suspects.

On a global scale, this type of program provides incredibly valuable alternatives to current training programs that are tactical and weapons focused in training, and further providing a medically focused and competency-based program, as opposed to one based only in theory or one that his focused on licensed personnel with an advanced scope of practice.  It is essential to convey the importance of offering a quality standard based curriculum that includes a specific performance-based standard that is divided by the performance level of function.

The publication concluded with several additional recommendations. The following is a summary of several of the key recommendations provided for law enforcement:

• Law enforcement needs to learn more about the available resources of the communities they serve as well as the capabilities of other agencies involved in emergency response.
• Law enforcement leaders must develop relationships and networks with medical and EMS agencies before a crisis occurs.
• Law enforcement leaders must assure a strong institutional commitment to officer safety and providing resource allocation to provide the necessary skills and equipment.

The information in the publication was comprehensive and covered a breadth of information. This article covers just a few of the specific decisions that each agency must make. Just like corporate culture, each agency defines the roles and responsibilities of its officers, as well as expectations of basic training standards and operational expectations.

The information provided in this article is intended as a starting point for law enforcement and medical leaders to develop a collaborative, proactive and problem-solving approach to combat future knowledge deficits and ensure a well-trained and well equipped first line of defense.

This basic outline provides a solid starting point for developing a tactical medical program. As this program becomes developed and the instructor cadre solidifies, a program can be expanded to teach all law enforcement self-aid and buddy aid. These skills reduce the severity and long-term impact of the line of duty injuries.

An individual who has completed a Tactical Medicine training program may or may not be competent to perform any number of medical procedures. Issues such as licensure, state and county laws, and the broad background that TEMS operators come from, beginning at the certified First Responder, including licensed personnel such as EMT's, paramedics and nurses, and ending by encompassing the physician level make the solutions complex. Currently, a certificate is not a validation of competence. It is this gap that should be addressed and with current movements toward standardization. In the article “Tactical Medicine-Competency-Based Guidelines” the framework to develop a standardized program is outlined.

It is from this launching point that a program can be used to develop a program. With slight modification, it can be offered to other affiliated public safety agencies, such as fire departments, the county contracted ambulance provider. A program is unique in the provision of medical care in the tactical environment geared towards experienced law enforcement officers and experienced medical providers.