These patients require rapid extrication, advanced resuscitation, and transport by a dedicated RTF component; they cannot be attended to solely by tactical medics.Recently, RTF has become a “buzz word” that first responder departments use to demonstrate their effectiveness in tactical events. However, the role and implementation of such teams varies markedly from agency to agency. In practice, interoperability must continue to be emphasized by both command and ground-level units, and it must be practiced on a recurring basis to prevent confusion of operational objectives. On the day of the San Bernardino shooting only three fire agencies in the county had active RTF programs in place. Communication between these units was extremely strained by existing systems and the varied understanding of RTF concepts. Ensuring cohesive and coherent medical education across agencies will not only provide law enforcement with understanding of medical priorities, but also familiarize EMS with the tactical priorities of their law enforcement partners.As many law enforcement agencies begin to deploy their own medical assets, it is critical that EMS medical directors recognize the tactical medical resource as separate from but augmenting the overall medical profile. This position falls outside the realm of the medical branch of the incident command system because of its integration with operational teams. Thus, a law enforcement medical coordinator may provide a conduit to both EMS and fire assets as well as providing operational input to the incident commander. The LEMC would then provide the commander with critical information that may be overlooked by the traditional medical branch of the ICS. First, the ability to conduct an in-depth, plant grow table medical-threat assessment using operational data gathered by law enforcement and combined with EMS resources will provide on-scene commanders with a much better perspective on potential threats and limitations to operational plans.
Secondly, this position will provide improved integration between the tactical elements of the response and the force protection and rescue elements of the task force. Creating a LEMC position ensures proper allocation of both human and medical assets. Because SWAT medics operate within the law enforcement branch and not the medical branch, there is potential for duplication of efforts and general disorganization. This occurred in San Bernardino. Despite the traffic management by the SBPD, local resources pouring into the area of the shooting caused an obstacle to staged EMS assets. Medical resources were also being dispatched in duplicate with their respective law enforcement teams. Consolidated coordination of these assets would improve law enforcement support as well as integration for agencies less experienced with the RTF model. Ideally this position would be filled by an active or former tactical medical provider – preferably a physician with knowledge of both the tactical and EMS functions. The benefits include continuous evaluation of the medical threat from law enforcement assets in the hot zone as well as EMS and fire in the warm/cold zone. Additionally, the LEMC would oversee resource need and distribution among the operational teams. Designating one individual streamlines the process and enables the SWAT medic to focus solely on providing emergent aid within the hot zone, while knowing that coordination is being managed by a professional who understands the scene, its evolution, and their needs. Further, because of the uncertain nature of these operations, agencies must be prepared for extended operations.This possibility was understood by several teams present at the IRC event because they had recently been involved in the manhunt for Christopher Dorner, the disgraced Los Angeles Police Department officer who went on a shooting spree throughout Southern California. As the duration of that event extended several hours teams began to lack the basic necessities such as food and water, and experienced a shortage of personnel needed for the rotation system in order to sustain a high operational tempo.
Though the logistics branch of the ICS is theoretically tasked with procurement of supplies for an operation, law enforcement team health remains under the purview of the tactical medic. Therefore, a LEMC would be the ideal person to ensure proper allotment of resources regardless of the duration of operations.Law enforcement and fire departments have adapted quickly to minimize the loss of life in high-threat incidents through improved integration and education. Training for these scenarios is more often practiced as isolated events and less frequently combined. As a result, medical directors often outfit their teams in relation to the perceived threat, with PPE and medical equipment designed to protect from handguns and treat the “preventable causes of death.” Despite this traditional mindset, it has been repeatedly demonstrated that modern terrorists coordinate complex attacks, using multiple detonations to “drive” response and inflict maximal damage. Although many of the victims of the San Bernardino terrorist event were shot numerous times, it has been well documented that there were unexploded IEDs in the immediate vicinity of both survivors and rescuers. In the face of multiple, armed attackers using high-powered rifles and multiple explosive devices, the typically-issued PPE is inadequate and the available medical supplies could quickly be exhausted, particularly when treating individuals with blast injuries. Further, as active-shooter incidents have evolved, the push to incorporate Tactical Emergency Casualty Care guidelines by first-responder agencies has accordingly focused on ballistic injuries. This approach emphasizes the need for hemorrhage control but overlooks both the likelihood of encountering victims with multiple amputations and the complications of blast injury not seen by a penetrating injury. Medical directors and medical assets should update their education programs to re-emphasize treatment of blast vs. ballistic injury. In addition, focused, mass-casualty management will help agencies and designated LEMCs as to the care and coordination necessary for adequate resource planning.
In light of the threats now faced by our society, merely supplying one tourniquet, one chest seal and one dressing may no longer be sufficient. We recommend that ALL responders carry tourniquets,hydroponic table while SWAT team members should carry several. In addition, designated law enforcement medical elements should wear the same PPE as their colleagues on patrol. The development of a portable medical kit for active shooter/suspected terrorist events should be encouraged. Should extra equipment become necessary, this kit should contain multiple tourniquets, triage tape, combination dressing/ bandages and large quantities of gauze for hemostasis/wound packing. Contrary to conventional thinking, establishment of an airway is not of primary concern in these types of events, eliminating the need for multiple advanced airway kits. Most public buildings follow standard security practices, and medical directors and tactical medics should accordingly make basic changes in their response profiles. When the sprinklers were activated in the IRC building, medical assets were unprepared for operations in a wet environment. Moving forward, medical directors should educate and plan for the electrical shock hazards and biological hazards posed to responders in that environment. Rescue equipment should include waterproof triage tags , and teams should have the tools to circumvent difficulties with building access as part of the rescue plan. In the current environment, all tactical teams must have such access. Finally, agency training can no longer accept notional acknowledgment to the presence of IEDs. The actual procedures for IED, complicated, active shooter incident events should now be the standard, practiced scenario.Additionally, the complex and critical nature of injuries seen in these events and the challenge of accessing patients wounded by explosions, demonstrate the necessity for bystander care at the scene of the incident. Municipal and county agencies should consider training communities in TECC First Care Provider guidelines.Similarly, as the community has accepted the placement of automated external defibrillators in high-traffic areas, trauma/MCI equipment stations should also be pre-positioned in such areas and co-located with the AED.Stresses from these critical incidents may be reversed or halted through adaptive responses. Recognition that PTS is a likely outcome to mass casualty events should stimulate medical directors and team medics to create mechanisms for early recognition and practice of adaptive responses both for the individual and the collective. While individual stress is the focus of therapy, shared trauma or group stress remains a possible outcome. This shared trauma may unconsciously change processes within the group, affecting operational capabilities.Restricting access by non-essential personnel to victims remains the most basic process for decreasing stress in all groups. Additionally, there is a marked difference to the responses expected by responding patrol units and organized SWAT units. While specialized teams may have the infrastructure to address PTS, including their own medical assets, individuals involved in the initial response may find it difficult to participate in departmental programs because they fear stigmatization.
Avoidance of formal services may isolate and cause development of maladaptive responses that incur significantly higher risk for long-term pathology.Formal gatherings of team members and peer groups should be initiated very early to begin discussion of what has been witnessed and to prevent isolation by those most affected. However, support services must remain flexible and available to individuals reaching out to medical directors and team medics. Moreover, these gatherings must be protected from rules of discovery; fostering unguarded discussion/ conversation is crucial to this process, and fear of retribution may destroy this process. Finally, team medics may themselves need assistance following a crisis. It is imperative that medical directors or medical coordinators, as well as team leaders, allow for small-group or peer discussions in the aftermath of a critical event.As part of their standard training, each participant received a standardized irritant exposure and completed a training evolution.They were then required to complete a series of tasks to simulate control and apprehension of a combative criminal suspect. This training sequence lasted approximately 1½-2 minutes. Military trainees wearing protective gas masks were placed in an enclosed structure that was then saturated with CS gas. Gas masks were removed and each trainee was exposed to the tear gas for approximately 10 seconds. They were then required to perform a series of training tasks and safely exit the multi-story structure. This training sequence also lasted approximately 1½-2 minutes. After irritant exposure and completion of their training sequence, all subjects proceeded to a decontamination area and were allowed to irrigate their eyes and skin ad lib with water. Participants were randomized to a control group and intervention group. The intervention group was provided a cup containing a unit “dose” of 15cc of Johnson’s® baby shampoo and instructed to apply it liberally to their head, neck, and face. Repeat shampoo “doses” were available ad lib to this group. Irrigation was provided by a garden hose for police trainees exposed to OC and by a custom-made, multi-station irrigation device for military trainees exposed to CS. This device was constructed of two PVC pipes supported horizontally three feet off the ground and connected to a fire hydrant. Water flow was adjusted to produce an approximately 48-inch column of water from each of 20 holes drilled in each PVC pipe at offset angles. Oleoresin capsicum or “pepper spray” is an oil-based extract from pepper plants of the genus Capsicum. The chemically active ingredient is capsaicin, a fat-soluble phenol. OC causes its effect by stimulating type C unmyelinated nerve fibers that cause the release of substance P along with other neuropeptides, causing neurogenic inflammation and vasodilation.These neuropeptides also produce protective reactions of mucus secretion and coughing.Clinically this results in a painful burning sensation of the skin and mucous membranes, blepharospasm , and shortness of breath. Although OC causes a prominent subjective sense of dyspnea due to mucosal irritation, research has shown no objective change in respiratory function.OC has been estimated to be 90% effective in stopping aggressive behavior.A prior review of ED visits for OC exposure found the most common symptoms to be burning, erythema and local irritation to exposed areas.“Tear gas” is a lay term used to describe a group of irritant chemicals that cause lacrimation. The most commonly used agent by law enforcement is CS. CS is actually a crystalline solid, not a gas, making the term “tear gas” a misnomer; it is insoluble in water and has a small solubility in alcohols.It is aerosolized by multiple techniques including dissolving it in an organic solvent, micro-pulverization into a powder or in use with a thermal grenade that produces hot gases.