Introduction

Providing medical support to law enforcement, specifically to tactical teams, can be time-consuming and daunting. The results and outcomes, however, can be some of the most rewarding a medic or physician sees in their career. Professionals say that there is nothing like being directly involved in the heat of battle and knowing that their efforts, expertise, and capabilities may save the life of someone who has experienced a traumatic injury. Being involved in tactical field operations differs dramatically from a quasicontrolled environment such as the emergency department or a relatively "routine" medical emergency run.[1][2][3]

Minus the initial response to an active violence incident, tasks associated with tactical operations are methodical, tedious, and time-consuming. Tactical physicians and emergency medical service (EMS) personnel may be sidelined in the warm zone (see zones of care) as a safety precaution. There is a more frequent integration of medical providers into entry teams or more frequent positioning close to the fight to provide the quickest possible intervention should something go wrong and the need for emergency medical care become necessary. Medical providers should expect significant training and practice if integrated into the entry team. This activity focuses on tactical team movements, operations, and communication dynamics.

Issues of Concern

Terms like "fatal funnel," "projecting," and "telescoping" are not a good thing. "Cover" and "concealment" are good things (for example, a cover is something that can likely stop projectiles such as bullets, and concealment is something that may hide and prevent professionals from being seen). Law enforcement refers to the fatal funnel as a doorway where one can be easily seen but is difficult to move out of in the case of incoming projectiles. A police officer never stands in front of a doorway, especially an open door, during a high-risk incident. The unknown is one of the most dangerous aspects of the tactical environment, similar to unsearched areas or the other side of the doors. Additionally, walls afford some cover and concealment from the 3 "Bs:" bombs, bullets, and bad guys. Open doors afford none. Since movement is paramount in a tactical environment, slow and methodical movements are necessary but can be extremely uncomfortable and challenging. Another aspect of the tactical movement is to avoid projecting presence. This is where terms like "slicing the pie" and "quick peeks" come into play. Slicing the pie is used to look into open doorways, gaining a perspective for as much of the space on the other side of the door by looking from different angles. Whatever cannot be viewed by slicing the pie may be viewed by conducting "quick peeks." This is when an officer lines up on the wall adjacent to the door and quickly looks inside the doorway to the left and right without telescoping their head. Officers have their firearms in hand, and the shooting hand penetrates the doorway simultaneously with their heads. This allows them to address a threat if necessary.

Zones of Care

The "hot zone" is the area where the action is happening. In a tactical environment, this is where the bombs, bullets, and bad guys are located and where the highest threat level exists. Generally, only life-threatening injuries to responders should be addressed in the hot zone. In the "warm zone," some mitigation efforts have generally been taken to minimize the risk. This is generally where EMS and tactical support personnel work. In active violence scenarios, for example, this can be searched for threats, and once deemed likely safe, this is where the casualty collection point is located. Law enforcement brings the injured here for their initial assessment and treatment of life-threatening injuries. While EMS work in the warm zone, law enforcement is assigned to do nothing except provide overwatch and security for medical personnel. The "cold zone" is where there is no actionable intelligence or indication of a threat. This area is far enough away from the hot zone that a threat is not likely present. Incident command posts, media staging areas, and outer perimeter are in the cold zone. Triage and ambulance staging areas should also be in the cold zone.

In 21st-century policing, active violence and tactical responses are changing significantly and constantly. After every major event, first responder agencies modify their response, training, and capabilities. For example, following events such as the Aurora, Colorado theater shooting and the Pulse Nightclub shooting, among others, many law enforcement officers throughout the country are being trained in tactical, emergency, and casualty-care interventions. Interventions include tourniquet application, hemostatic gauze, nasopharyngeal airways, and the application of pressure dressings, among others. Law enforcement, however, is instructed to focus on neutralizing the threat before rendering any aid. At no time should rapid movement to the threat or exercising good tactics be jeopardized or hindered due to providing medical aid to casualties. Law enforcement officers are taught to come back and address casualties during "warm zone" operations when there is no additional credible intelligence of additional threats. However, the building or area may not have been completely "cleared." The term "clear" has been used interchangeably with other law enforcement terms such as "search," "check," "safe," and others. When a room, building, or area has been "cleared," every possible area where a person could be hiding or concealed is checked and verified that no one is there. Once completed, the room, building, or area is designated a "cold" zone. With the integration of rescue task force principals, more non-law enforcement EMS providers are being integrated into tactical teams that rapidly enter warm zones before the areas have been completely "cleared." This is a relatively new principle based on battlefield medicine and casualty statistics. The faster a medical provider can be at the side of a traumatically injured patient, the better the chances for survival. Completely clearing a normal-sized building often takes 1 to 2 hours, whereas trauma patients need intervention within minutes.

Medical providers should know current threats and trends affecting law enforcement and first responders. This directly impacts the ability to provide effective medical treatment. Currently, immediately dangerous to life and health (IDLH) drugs are a substantial threat to the safety and well-being of those who respond to and handle those incidents. Secondary and tertiary exposures have become a real threat, and appropriate personal protective equipment is imperative for law enforcement and medical providers who may be in the field during clandestine lab tactical operations. Medical providers should also become familiar with field decontamination procedures, including technical and rapid-emergency decontamination for those experiencing medical emergencies after operating in a hazardous tactical environment.

Lastly, field EMS and medical providers must understand the tools, weaponry, and equipment law enforcement uses in the field. Providers should become familiar with their local tactical teams and law enforcement agencies, the tools and weapons they carry, effects when used, interventions to treat injuries and illnesses, and how to provide effective medical treatment without hindering criminal investigations whenever possible.

Clinical Significance

To safely work with law enforcement, physicians and emergency medical personnel must understand team movements, operations, tactics, tools and equipment, and communication to effectively assist in providing healthcare if needed. Additionally, it is incumbent on EMS and medical providers to understand the rapidly changing field measures being introduced to minimize the number of casualties resulting from criminal and terrorism-related tactical events. The threats to public safety are evolving rapidly in the 21st century. Professionals must work together and communicate new intelligence as it is presented.[4]