Introduction

Emergency medical service (EMS) practitioners are exposed to many potential dangers on a daily basis. Proper safety measures should be followed at all times to ensure the safety of EMS providers, the team, and patients. During tactical EMS situations, the EMS practitioner has the additional responsibilities of promoting team and public safety while enhancing the probability of special operations mission success. Tactical EMS providers are responsible for implementing the tactics and procedures necessary to protect team members, victims/hostages, bystanders, and perpetrators.  Pre-mission team planning and management are crucial for mission success but often is overlooked.[1][2][3]

Issues of Concern

The level of risk faced during SWAT/combat scenarios makes pre-mission planning vital to mission success. Tactical EMS practitioners must create a more detailed plan for each situation and scenario to maximize safety.  Pre-mission planning and medical threat assessment can include operational planning, reconnaissance missions, medical intelligence, team education, and training.  The degree of pre-mission planning is dependent on mission frequency and the time available to prepare. For example, when team training occurs regularly at the same location, a standing tactical EMS plan can be developed.  Modifications to the pre-mission plan would only occur when different hazards may be encountered.  

Planning should take into account the duration and exposure to the elements.  The temperature and potential duration of exposure can guide the team in their preparation of appropriate clothing and resuscitation equipment.  If the mission duration is expected to be longer than 24 hours, the tactical medic should prepare a sleep cyclings schedule and doses of chronic medication for all participating personnel.

Tactical EMS practitioners must quickly assess scene safety and institute the necessary safety measures to mitigate possible hazards. Tactical EMS works collaboratively with other public safety agencies such as the police and fire department to address hazards and ensure that the appropriate resources are readily available.  Scene security is a top priority. Tactical EMS providers need to rapidly assess the scene and determine if ancillary services and support should be activated to protect team members and patients.

The care provided depends on the risk and hazards present at the scene.  In high-risk scenarios, where there is imminent danger or a confirmed active shooting, the care provided should be adjusted to account for the level of threat.  Each team member should carry a minimal amount of medical gear on their persons and be well versed in its use. Tourniquets are life-saving and should be carried by all providers, regardless of their involvement in a mission. Immediate access to life-saving equipment is key.  Tourniquets, needle decompression, or other equipment in a team member kit may have to be used before a tactical EMS provider can assess the victim or individual. There is often a limited window for intervention.

Wearing the proper protective equipment for the environment is the first step. Though scene safety is one of the mantras of EMS, the tactical situation makes it more challenging. Proper protective gear includes tactical and medical gear—the chaotic prehospital environment of increases the risk of blood-borne exposure and injury. The risk can be mitigated by wearing the proper combat protective gear for the threat (e.g., body armor) and assessing whether environmental factors require additional equipment such as gas masks, face masks, or specialized protective clothing. Team compliance with proper safety equipment is a major responsibility of the tactical EMS provider.  Pre-mission planning should include consideration of the appropriate gear needed and understanding of the scene to maximize the chance of a successful mission.

EMS practitioners utilize specialized equipment for the assessment, evaluation, and transport of patients. Ensuring that the correct equipment is used, in proper working order, and is prepared for deployment is the responsibility of the EMS leader. It is important to remember that the tactical environment may require specialized equipment since an ambulance and lighting may be unavailable. Given the need for all equipment to be carried by the team, weight and mobility restrictions can limit what is immediately available on the scene. Equipment should be lightweight, rugged, and easy to use regardless of dexterity and ambient temperature. Every member of the team should be trained sufficiently on safe usage of all EMS and police equipment. A critical skill for the emergency medicine provider is the knowledge and skill to put on safe all possible weapons that the team uses in case the gun needs to be removed from the team member at the time of treatment.[4][5][6]

Clinical Significance

EMS practitioners are responsible for assessing a patient’s condition, determining the immediate interventions necessary, and the need and ability for scene extraction for further medical care. Additional equipment, personnel, or resources are obtained at the discretion of the EMS provider before proceeding.

The mental and physical demands of the tactical EMS practitioner require that they are at their best each day. Maintaining a level of excellence in the workplace is highly dependent on the degree of wellness outside of the work environment. Avoiding practitioner fatigue is important to ensure that each one will be capable of making the best decisions consistently and safely. All of the steps, pre-mission planning, and preparation will help to ensure the safest environment for all team members and patients.[7][8][9]