Back in the olden days, the world operated a little differently than it does now. We have veterans still working among us who will tell you how it used to be 30 years ago. Literature around the fire station describes about how things were done a hundred years ago. It is no secret that the heritage of the fire service is long and honorable and our veterans paved the way for what we now enjoy as the standard of our industry.
The early days were full of new ventures, and each passing year, fire departments broke new ground on operational techniques and the guys who performed them. Without that foundation we wouldn’t be where we are today. We still have many lessons to learn.
Years ago, when I started in the new EMS field, encountering a person shot was limited to military experience and the occasional robbery gone bad. My first shooting call was in 1984 when a loving couple had a tremendous fight and someone grabbed a handgun. The story made the newspapers and my unit was the talk of the service, since everyone wanted to know the details of the death.
Trauma has been studied a great deal, but the growth of domestic violence in our modern society has changed our patient care methods. Canned programs like Basic Trauma Life Support (BTLS) illustrate the impact proper medical care can have on the victim’s survival. Responders must perform many more tasks for the patient beyond just throwing them in the unit and taking them to the hospital. The victim of a violent act could literally bleed to death if proper care is not rendered immediately. We know that bleeding to death from trauma is a fixable problem.
Trauma studies from the Vietnam War have led us to understand the soldier who received wounds in combat could literally bleed to death if a highly trained (and motivated) combat medic does not stop the bleeding. Although we understood that fragment or bullet wounds in the torso require surgical intervention to stop blood loss completely, the extremity wound posed a correctable problem that could be handled in the field. Death from extremity wounds in Vietnam resulted in 2,500 soldiers killed in action (KIA). This was listed as the number one preventable cause of death on the battlefield and is a real threat to modern Special Weapons and Tactics Team (SWAT) operations.
These high numbers correlate directly to the treatment plans of prehospital medicine professionals today and clearly illustrate that we can save more people from trauma by rapid intervention, especially those who are shot in the arms or legs. A gunshot wound in the leg could mean certain death if not treated within minutes. This has become a crucial understanding for law enforcement agencies, whose officers are placed in high-threat areas. Rapid and concise medical care matters.
Most fire rescue personnel operate either on the fireground or on urban streets, where we may be called to respond to a person shot. We can also anticipate that most firefighters want medical care readily available during active fire engagement in the event of injury. Few departments today fail to send a medical unit to the fire scene, as much for civilian as for responder injuries. Most firefighters hope they stay safe, but they realize that burns, falls, and structure collapses are part of the job. Paramedics who show up should be well-versed in caring for these types of fireground injuries.
Police officers want that same care for their personnel when mitigating crime scenes. Some calculate that there are as many as 50 officer injuries for every 1,000 SWAT call-out operations. Although these scenarios are somewhat different than that of fireground, it is essential to know that trained medical responders are standing by. This goes for the routine police call as well SWAT team calls.
A police SWAT team is comparable to a fire service special team, such as a heavy rescue or hazardous materials response unit. Although they may not respond for every call, they are available when we need them. Increased violence, most conspicuously in crises such as the 1999 Columbine High School attack, has changed the way public safety agencies respond to events. Society now demands that responders not wait for bleeding victims to drag themselves out the front door to be rescued by far-off staging units. Those who depend on us in a house fire also depend on us in this type of situation.
The responders at Columbine were brave and faced an event that few would have anticipated and perhaps few had actually ever trained for. As a result of what was learned in the handling of this crisis, we are responsible to place fire EMS personnel on police SWAT teams and spearhead patient care operations from within the structure.
Tactical paramedics are the assets whose time has come. Highly trained paramedics and emergency medical technicians (EMTs) are now routinely placed in tactical operations and perform their skills with the police department. In 1993, the National Tactical Officers Association (NTOA) endorsed the use of the tactical emergency medical specialist (TEMS) team as a necessity for special response teams in violent circumstances. “The provision of TEMS has emerged as an important element of tactical law enforcement operations…” It is imperative that the fire rescue services of today get on board with law enforcement agencies in a concerted effort to reduce the death rate to our officers and the civilians that could be victims of violence.
We have come to expect that a crew will don a Level-A suit and pierce the hot zone of a chemical spill. We fear for their safety while they go downrange to perform these dangerous tasks. We track them with our eyes as they disappear inside a structure where we know that many things can go wrong. We wait patiently for them to reappear with a “thumbs up” sign that all is well and assist them doffing their gear and mopping up. We must all understand that the team downrange depends on the personnel in staging, just as the individual hazmat team members depend on the person next to them in that other Level A suit. The same holds true for the tactical paramedic: The gear they put on and the training they undergo ensure a safe operation for all involved.
The police SWAT officers depend upon the tactical medical team just like our soldiers count on their medics. The tactical medic carries with him all the knowledge derived from working in a hostile environment. Admittedly, guns and bombs or clandestine labs are not what a traditional fire rescue person was about, but we must acknowledge that times have changed: the public may come to need a paramedic in the hot zone dragging them to safety as bullets fly overhead.
We hope that tragedies like Columbine will not occur again, but we must learn from such events to preserve life when called to do so. Knowledge is as much a tool as a set of irons. If we fail to prepare for the next call it may come back to haunt us. The lessons learned from benchmark fire events such as Coconut Grove forever changed how the fire service does things. We must use hindsight to plan ahead for the next crisis.
More violence in our communities, such as the Fulton County Courthouse shootings in Atlanta and the Virginia Tech shootings, suggest that crises like this will continue to occur. We cannot handle the calls of today with the mentality of yesterday. We cannot sit and wait for bleeding victims to come to us. We must now go to them.
During the writing of this article, another violent tragedy occurred at an Omaha, Nebraska, shopping mall. Consider who had to respond to that particular call and imagine how your neighbors would react if it was right down the street from your house. Who will risk everything to go in and help those in danger? We must train as we will act and then act as we have trained.
Getting started on a tactical medical team requires leadership to acknowledge that paramedics need to be assigned with police forces. We admit that paramedics with military background can lead the way. But a tactical emergency medical service (TEMS) team can be comprised of veteran public safety personnel who can work in austere conditions with limited support. After all, there will not be as many hands inside the hot zone as there are on the street when you work the routine gunshot wound victim. Police chiefs and fire chiefs need to examine this new arena of operations, decide if this program can be supported, and determine what it will take to establish it.
The DeKalb County (GA) Fire Rescue EMS team began simply as a medical support team for bomb squads during the 1996 Olympics here in Atlanta. That group of volunteers staged with local, state, and federal agencies that felt having paramedics around during their bomb responses sounded like a good plan. That evolved into the tactical response team that is still in action today. Our team now proudly serves our local urban police force and their SWAT teams (with police for urgent responses and the sheriff’s SWAT team for high-risk warrants).
Our connections in those early days in a secret hangar staging with EOD bomb units eventually paid off. Now we are the single tactical provider for the Georgia State Patrol (the state’s anti-terrorist task force) and the Atlanta FBI SWAT. Because of our training and reputation we now provide dignitary protection for the Governor at certain events, as well as for other high-profile visitors.
We see action across the entire state of Georgia, but the mentality is the same. A highly trained fire rescue paramedic can operate within a SWAT team to provide urgent medical care to anyone who needs it. We are part of those teams; we train with them and we care for them before, during, and after the operation. None of our officers take a step inside a high-threat area without knowing their paramedic is with them. Such service is invaluable to the community. You can also log numerous National Incident Management System (NIMS) training hours as interagency cooperation begins to grow and expand.
Our team operates as a part of the overall service, but we have a separate standard operating procedure that governs what we can do under adverse conditions. We have approved the tactical combat casualty care plan (TCCC) for our field use, which was commissioned by the Naval Special Warfare on April 9, 1997, by Rear Admiral Tom Richards. It is endorsed by the American College of Surgeons Committee on Trauma and the National Association of EMTs. This can serve as your practice guidelines and, once authorized by your medical director, it could serve as a treatment plan for your TEMS operators. It includes topics on using tourniquets; bleeding control packets, and other high-end procedures used in major trauma care for combat situations. It is backed by extensive research in the military and adopts current trauma trends in EMS.
Our team also operates on a 2:1 response plan. This means we page and send three paramedics out on each call. Two medics work the inside hot zone (one carries a shield and the other carries a trauma bag) and the third works as the liaison on the outside within the command post for the police agency. That position coordinates the regular EMS transport activities and can be called inside the structure as needed.
Your paramedics will need to go through approved tactical classes that teach them how to perform their street skills in the combat situation. There are many excellent TEMS classes around the country and it establishes how a team will treat victims with limited help and in austere conditions. Besides the tactical medicine aspect of training, we encourage your newly trained tactical paramedics to go through your local police agency’s SWAT I class. It will build team spirit and increase members knowledge of how a police response team works, how it uses its special weapons, and what its tactics are.
There are many roads to follow as you initiate the conversation about whether to have a tactical medical team. Know that the community may not understand the scope of your duties, but they will be glad that you respond to remedy the crisis. Also realize that when you sign up for this job, you are among yet another group of professionals that cares about relieving suffering and rendering aid when needed most. Although we may hope that another school or mall shooting never takes place again, the future may prove us wrong. A single child held hostage by a drugged-out parent or a botched robbery may be cause to activate your local SWAT team. Be prepared and train in the event it does occur. After all, your community needs your help.
Kevin Johnson has been a Georgia-certified paramedic and firefighter since 1983. He serves with DeKalb County (GA) Fire Rescue and is also a tactical emergency medical service specialist (TEMS), who has spent the past eight years responding with local, state and federal law enforcement SWAT teams from the Atlanta area. Johnson holds a master’s degree in executive fire service leadership and is co-owner of a public safety consulting firm in Atlanta.
