Tactical EMS a pointless waste of time and resources?

[Dustdevil]

Having thoroughly trashed Helicopter EMS, Dr. Bledsoe may now be turning his attention to this running joke we call "Tactical EMS." Here is an interesting abstract he recently posted (but did not author) to another forum.

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Effectiveness of Tactical Emergency Medical Support (TEMS): A

Systematic Review

Michael J. Feldman, Laurie J. Morrison, Brian Schwartz,

Sunnybrook-Osler Centre for Prehospital Care, Toronto, Ontario

Introduction: Tactical law enforcement operations pose an increased

risk of injury or death to civilians and officers. As many as one third of

missions result in injuries. There are no current systematic reviews of the

effectiveness of TEMS.

Objective: To systematically review the evidence for the effectiveness

of TEMS on patient outcomes.

Methods: Medline (1966-2005) and EMBASE (1980-2005) were searched

for citations indexed using one of the subject headings "emergency medical

services," "police," "law enforcement," or the keyword "tactical." Three blinded

authors independently conducted a hierarchical selection based on title and

then abstract. Agreement between reviewers was calculated at each level of the

review. In addition, a hand search of The Tactical Edge, the official publication

of the National Tactical Officers Association, was conducted for 1989-2005 for

all articles on TEMS. Articles were selected for inclusion if they pertained to

outcomes, effectiveness, best practices, or guidelines in civilian TEMS.

Results: The literature search yielded Medline 184 citations and 135 from

EMBASE. Of these, 15 articles were selected for full review. An additional 18

articles were identified in the hand search. The kappa statistic between the

authors was 0.51 ± 0.03 for titles and 0.63 ± 0.04 for abstracts selected.

Study quality was limited. Only four studies examined outcomes, and none

were randomized or blinded. One evaluated tactical awareness training for

emergency physicians, and three reported outcomes in psychiatric patients

to which police responded. There were three position statements by major

U.S. or international organizations. The remaining articles reported on

standard practices in specific areas of TEMS, team configurations, and

training. No articles specifically addressed tactical considerations for disasters,

and only one discussed issues pertaining to terrorism or hazardous materials

events.

DISCUSSION: A large body of TEMS literature exists, which describes

team configuration, training, planning, preventative and emergency care,

communication, weapons safety, specialized equipment, hazardous materials,

terrorism, evidence preservation, considerations for austere environments,

medicine across the barricade, medical intelligence, response to psychiatric

emergencies, and postmission support. Despite this, there is little evidence

on effectiveness of TEMS.

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In other words, the Tactical EMS community and concept are analogous to a Democratic politician. A lot of big talk, promises, and pectoral puffery, but when it comes right down to it, the Emperor has no clothes.

[somedic]

Bledsoe should have attacked this subject way before now. I like the Analogies there Dust! You got a real skill with that.

This fad will end one day not not until departments waste a lot of money.

Somedic

[Peter Paramedic]

Do you have a link to the other forum.

Thanks

[PRPGfirerescuetech]

Bledsoe should have attacked this subject way before now. I like the Analogies there Dust! You got a real skill with that.

This fad will end one day not not until departments waste a lot of money.

Somedic

it will thrive til insurance companies stop dropping liability coverages for adding TEMS units to tacticasl response teams

[PRPGfirerescuetech]

Regarding the article, it doesnt specify if TEMS "is or is not working".

It states theres no research to determine that.

...just keeping to the facts.

PRPG

[somedic]

firesrescuetec: You are correct. It may take a long time to gather any reliable data for research so who wants to waste money and time researching something anecdotal that boosts the ego, provides ninja suits, guns and flash bangs to so-called "tactical medics".

Somedic

[AnthonyM83]

I'll give Tactical EMS the benefit of doubt for now, as it'd make sense to have EMS on standby for situations that have high risk in GSWs.

A question I'd ask is: Is there a difference in effectiveness among different levels of medical providers?

[PRPGfirerescuetech]

firesrescuetec: You are correct. It may take a long time to gather any reliable data for research so who wants to waste money and time researching something anecdotal that boosts the ego, provides ninja suits, guns and flash bangs to so-called "tactical medics".

Somedic

Likely the same people who researched "research articles" on TEMS, just to prove scientifically there isnt enough research.

[somedic]

PRPG: Good point.

Anthony: As a "tactical medic" in the civilian and military arena, I see no need for Paramedics in the hot zone. A good first responder with "tactical" training will serve the purpose as well as any Paramedic in a care under fire scenario. In my military team EVERYONE is exceeds the normal Combat Life Saver certification course. These guys are not EMS providers but are better than any egotistical "tactical medics" I deal with on the civilian side. I also know how they will react when bullets and RPGs start trying to find us.

The civilian"tactical medics" I deal with will/have pissed themselves over way less excitement..........

[seastrat]

Having been a police officer assigned to a high-risk law enforcement team just outside NYC for the past 5+ years, both before and after we had medics assigned to us I have to disagree with the idea that TEMS is a "pointless waste of resources."

Often, people who aren't involved with these kinds of operations don't understand what high risk law enforcement teams really do, which is why they think TEMS or more accurately TOMS (Tactical Operational Medical Support) is a waste of time. I'll try to lay out for you some of the reasons TOMS is a good thing:

First, there is the peace of mind factor. It is much easier for me to go in after a badguy knowing that if things go south I'm not going to be waiting around for who-knows-how-long for a 911 ambulance to show up. And even if we have a unit on standby, there is a small question about what crew is working that day. I'll spout more on this a little later, but as far as peace of mind is concerned, I'm confident that the medics assigned are the cream of the crop -- I'm not getting the rookie medic who just got out of class and is going to be a bundle of nerves when he's treating me. On our team, the medics have been background checked and vetted by both the EMS side and the law enforcement side, and they are full time professional paramedics with years of experience. I'm not suggesting that the police deserve a higher level of care than the average citizen (as a matter of fact, better than 80% of the patients treated by our medics have been innocent civilians or suspects), it's just that tactical scenes tend to be highly charged events, and being able to choose quality personnel who have been through the grinder a bit ahead of time is a great advantage.

Which brings me to the main thing that the medics on my team do: they plan ahead. Most of what SWAT does is plan ahead. We will sometimes take a two or three days to develop intel on what seems on the outside to be a "basic" narcotics warrant. SWAT is expected to be able to deal with pretty much whatever comes up. After a job, we can't say "Well, we never really expected THAT to happen." And we'd prefer not to have to think up a plan on the spot when things don't go by the numbers: we'd rather know what plan B, plan C, and plan D is so we can seamless switch gears without calling a Time Out. Having the medics give their two cents at the planning stage is essential -- something we didn't even realize we were missing until we started including them. The Team Leader has a million things to worry about and he can't remember everything, the operators are focused on their individual missions and learning the plans & contingencies, and the high brass are wondering if they should bring an extra mocha latte to the scene if we are going to be a while. For my team, it is essential that we have people there who can think about those million little details that will "get" you if you don't consider them: what hospital is "open," what a good LZ might be & if any kids are playing soccer on it, what the local traffic and weather conditions are, whether we'll need Child Services if there are minors in the target, and during extended operations, food/hydration & work cycles: it's all kinds of stuff like that that the medics think about in their preplan. I can tell you a horror story about a night where a cop got shot, his buddies threw him in the back of a patrol car and drove him to a hospital that was on trauma divert because the CT was down for maintenance. That night right there justified our TOMS preplan 100%.

The medics know our plan ahead of time, so there is no confusion about what may be a safe place for them to work and what is probably not a safe place. And, at the risk of too many "war stories," I can tell you about a day when two medics strolled right though the middle of a gunfight because no one told them what was happening, where the bad guy was, anything. Our medics know the plan, know the target, have maps and diagrams, understand what the geometry of cover is likely to be (that is, where they can "hide" if things go badly, and what kind of safe "shadow" a given piece of cover is likely to give them). And that's just not information we'd be willing to share ahead of time with medics that we hadn't done backgrounds on. Waco, Texas came unraveled in part because ATF asked for help from the local volunteer ambulance, they told the mailman, he told Branch Davidian and lots of people died.

Planning ahead goes beyond just doing the mission preplans: The medics on my team know how to get me out of my gear quickly (Our vests have a million buckles and straps and unclipping is faster than cutting), and they practice keeping c-spine with my helmet on. Everybody knows what a pain in the neck getting a motorcycle helmet off is, if you haven't practiced with a kevlar helmet and a radio headset you don't want to do it for the first time with blood all over the place and a bunch of cops with machine guns screaming at you to get to the hospital with their buddy. (Especially if you are that rookie medic.) We also make our medics "weapons familiar." Once upon a time I was in an ambulance when the crew discovered a gun on their patient (he was an unconscious off-duty cop). When the .38 in it's holster fell on the floor of the ambulance the crew froze -- not their fault, none of them had ever seen a gun up close before. Our medics know that they can pick up a gun, make it safe (in a number of ways) and keep doing their job without freaking out. TEMS naysayers often suggest that there should always be a police officer assigned to babysit any patient the medics are treating, but that just isn't realistic: You have one (maybe two?) guys from the entry team shot up, plus you are going to strip two more guys to babysit them...how many guys are left to go get the badguy -- remember, the bad guy? THe one shooting at the police? Instead, our medics can render the weapons safe, stow them in a compartment in their truck, tape off flashbangs, smoke & gas, and move on with treatment.

My team knows and respects the medics and their decisions. Tactical decisions are made by the Team Leader, but he defers to them on treatment/transport questions. Remember my guy who was transported by patrol car to the wrong hospital? There was a paramedic unit less than a block away when that happened, but the unforms "didn't think they could wait." On my team, the guys know that if the medics need another minute, another 5 minutes, we don't rush them, because they've got work to do before moving the patient. Yes, all SWAT teams are supposed to be well-disciplined, but it can be quite challenging to maintain that discipline if your best friend looks like he's dying and two guys you've never seen before look like they are dilly-dallying on the scene.

And there is an added benefit. Here on the East Coast, medics are underpaid, under-appreciated and under-recognized for their service generally. The medics on my team have definitely helped to bridge the gap between services. Some guys on my team never knew the difference between a paramedic and an EMT, even though the entire county is staffed by paid ALS flycar paramedics and volunteer BLS EMT ambulances. Now, the even the paid medics who are not members of the team enjoy a certain "co-professional" status in the county (and for the first time the cops have come out on the side of the medics with regards to salary and benefits).

We take great pains to weed out the "wannabes," so we don't have guys who think they are cowboys. I'm not saying those people aren't out there, but from what I've seen, they generally don't last too long if they are actually assigned to a team. Our medics are cool, calm, almost mellow guys & girls who are anything but the TEMS nuts people like to talk about. I interact with the medics from other nearby counties, and I'd have to say the same about them: the nuts get thrown out in interview, initial training or their first few missions.

Although we don't train anybody to do major ALS "care under fire" but there may be times when you want ALS to "push" into a structure. To best explain this, I have to site everybody's favorite TEMS justification: Columbine. Teacher Dave Sanders was shot before 11:30. He didn't die until 15:00. Even if evacuation was tactically impossible, if medics could have pushed in to that room, he might have had a better chance. Yes, what he really needed was surgery, but to wait 3 and a half hours with no care really reduced his chances for survival. And it made the responders seem helpless: The famous "1 bleeding to death" sign in the window where he was dying was a call for help that went unanswered. Would Dave Sanders have died anyway? Who knows, but he survived without any meaningful care for more than 3 hours, so I'm guessing his chances might have been pretty good. Please note: this is not a crack on Littleton Fire or Denver General: that was the first time we saw something like this. Almost no one would have been prepared, it was just bad luck for them that they were first. But whoever is next (and there have been plenty) will be judged to have been irresponsible for not considering that someone might need medical attention in a tactical environment. Not having medics capable of treating someone while "bunkered down" will likely be considered negligent.

Well, I guess that's a little more than two cents worth, but I hope it clears up some questions for the folks out there who don't think TEMS/TOMS is a worthwhile venture.