Introduction
Providing medical support to law enforcement, specifically to tactical teams, can be time-consuming and daunting. However, the outcomes can be some of the most rewarding a medic or clinician encounters in their career. Healthcare professionals believe that nothing compares to being directly involved in the heat of action, understanding that their efforts, expertise, and capabilities may save someone who has suffered 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]
Apart from 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 as a safety precaution (Please refer to "Zones of Care" in the Issues of Concern section for more information). Medical providers are more frequently integrated into entry teams or positioned closer to the action to ensure rapid intervention if emergency medical care is needed. 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
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Issues of Concern
Terms such as fatal funnel, projecting, and telescoping are not favorable. In contrast, cover and concealment are beneficial. For instance, cover refers to objects that can effectively stop projectiles, such as bullets, whereas concealment involves measures that may hide healthcare professionals, preventing them 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. In addition, walls afford some cover and concealment from the 3 Bs—bombs, bullets, and bad guys. In contrast, open doors offer no protection. As movement is essential 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. Terms such as slicing the pie and quick peeks come into play here. 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. In this technique, the 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 positioning allows them to address a threat if necessary.
Zones of Care
Tactical environments are divided into 3 zones of care based on the level of threat:
- Hot zone: The hot zone is 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.
- Warm zone: The warm zone is an area where risk has been mitigated to some extent. This zone is generally where EMS and tactical support personnel operate. In active violence scenarios, the warm zone is searched for threats and, once deemed reasonably safe, serves as the location for the casualty collection point. Law enforcement brings the injured individuals to this area for their initial assessment and treatment of life-threatening injuries. Although EMS personnel provide medical care in the warm zone, law enforcement is assigned to do nothing except provide overwatch and security for medical personnel.
- Cold zone: The cold zone is an area with no actionable intelligence or indication of a threat, positioned far enough from the hot zone to make the presence of a threat unlikely. Incident command posts, media staging areas, and the 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 theater shooting in Colorado and the Pulse nightclub shooting in Florida, 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. However, law enforcement is instructed to neutralize 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 assistance 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 further threats. However, the building or area may not have been completely cleared. The term cleared 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 for no hidden individuals. Once the area has been cleared, 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 approach 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, as 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 used by law enforcement in the field. Providers should be familiar with their local tactical teams and law enforcement agencies, the tools and weapons they carry, and the effects when used. Providers should be equipped to treat injuries and illnesses caused by these tools while ensuring that medical interventions do not interfere with ongoing criminal investigations whenever possible.
Clinical Significance
To safely work with law enforcement, clinicians and emergency medical personnel must understand team movements, operations, tactics, tools and equipment, and communication protocols. This knowledge is crucial for effectively providing healthcare when needed. In addition, EMS and medical providers must stay informed about the rapidly changing field measures aimed at minimizing the number of casualties resulting from criminal and terrorism-related tactical events. The threats to public safety are evolving rapidly in the 21st century. Healthcare professionals must collaborate and communicate new intelligence as it is presented.[4]
References
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Hunt AP, Tofari PJ, Billing DC, Silk AJ. Tactical combat movements: inter-individual variation in performance due to the effects of load carriage. Ergonomics. 2016 Sep:59(9):1232-41. doi: 10.1080/00140139.2015.1132780. Epub 2016 Mar 28 [PubMed PMID: 27677344]
Haddock CK, Poston WS, Heinrich KM, Jahnke SA, Jitnarin N. The Benefits of High-Intensity Functional Training Fitness Programs for Military Personnel. Military medicine. 2016 Nov:181(11):e1508-e1514 [PubMed PMID: 27849484]
Nindl BC. Physical Training Strategies for Military Women's Performance Optimization in Combat-Centric Occupations. Journal of strength and conditioning research. 2015 Nov:29 Suppl 11():S101-6. doi: 10.1519/JSC.0000000000001089. Epub [PubMed PMID: 26506171]