Tactical Emergency Medical Service in Salt Lake City as Provided by. the Salt Lake City Fire Department

Transcription

1 Tactical Emergency Medical Service 1 Tactical Emergency Medical Service in Salt Lake City as Provided by the Salt Lake City Fire Department Karl Lieb Salt Lake City Fire Department Salt Lake City, Utah

2 Tactical Emergency Medical Service 2 CERTIFICATION STATEMENT I hereby certify that this paper constitutes my own product, that where the language of others is set forth, quotation marks so indicate, and that appropriate credit is given where I have used the language, ideas, expressions, or writings of another. Signed:

3 Tactical Emergency Medical Service 3 ABSTRACT The integration of Tactical Emergency Medical Services into law enforcement special operations is becoming more common throughout this country. These personnel are often drawn from fire department ranks given their common public safety responsibility, their training in emergency medicine, and their experience in providing emergency care in various environments. Such programs allow emergency medical responders prompt access to patients who may be in need of immediate medical intervention. The Salt Lake City Fire Department currently has no established program to provide tactically trained emergency medical personnel (EMS) to SWAT members, patrol officers, or members of the public in SWAT or active shooting incidents. In the interest of public safety, Salt Lake City Fire Department needs to provide trained tactical medical personnel as an integral element to any Salt Lake City Police Department tactical operation. The purpose of the following research was to identify and provide both Salt Lake City Police and Salt Lake City Fire with a practical means to provide tactical EMS service to police department operations during these types of responses. Action research will be used to answer the following questions: A. How do other agencies effectively integrate tactical EMS (TEMS) into their operations? B. What are the parameters of the training? C. What are the common obstacles to such programs? D. What type of TEMS program would be most beneficial to Salt Lake City? A simple survey was used to generate data regarding the existence of such programs and their basic organization. Public safety organizations of similar size to Salt Lake were solicited to provide relevant data that was valuable in the development of a program for Salt

4 Tactical Emergency Medical Service 4 Lake City Fire Department. The results indicated a significant percentage of public safety organizations integrate the two disciplines in varied models. Recommendations incorporated this data into a practical two-phase plan that would address the need for both SWAT medics and TEMS trained firefighters who may be the first responders to this type of incident.

5 Tactical Emergency Medical Service 5 TABLE OF CONTENTS Abstract... page 3 Table of Contents... page 5 Introduction... page 6 Background and Significance... page 8 Literature Review... page 13 Procedures... page 25 Results... page 28 Discussion... page 31 Recommendations... page 35 References... page 43 Appendices Appendix A: Survey... page 46 Appendix B: Standard Operating Guideline... page 47

6 Tactical Emergency Medical Service 6 INTRODUCTION No two incidents involving a mass shooting/active shooter are the same. It appears that the "bad guys" (criminals and terrorists) are more determined, more violent, and more heavily armed than ever before. Many of these types of events cannot be peacefully resolved or negotiated and crisis situations such as "mass killings" appear to be occurring with alarming frequency (Vernon, 2010a). Public safety organizations today have to be prepared for virtually any type of emergency. The "all-hazard" approach now applies to police, as well as fire departments throughout the country. The fire industry has evolved to become a primary resource for emergency medical service in many urban locations in the United States. As such, they must be integrated into some of the tactical operations conducted by police departments in times of immediate need. One such type of immediate need is "active shooting incidents". In these instances, police personnel are focused on mitigating a threat that will continue to utilize deadly force on innocent civilians until such threat is terminated either by police intervention or suicidal action. History has shown that an active shooter will wound, kill, or otherwise incapacitate any civilian in his/her path in a premeditated effort to cause maximum impact on society's norms while leaving a tremendous toll on human life. Often there may be medical need inside the perimeter long before the scene is safe. It is the TEMS provider who may provide this care (Carmona, 2003) This is where fire/emergency medical service (EMS) personnel become invaluable. In those first few minutes that an individual sustains such a wound, their chance for survival is exponentially increased with immediate emergency medical intervention. This is what many Fire Departments across the country provide to their respective police/swat teams; an ability to

7 Tactical Emergency Medical Service 7 address civilian casualties and operational injuries on-scene during an active shooting incident. This service is a necessary by-product of our current culture; where individuals maximize shockvalue by demonstrating little or no regard for human life. That being said, the challenge for most fire departments is the integration of their resources with those of the Police department. Our missions are quite different, and given the diverse training that each entity provides, it is not surprising to encounter obstacles in the development of multidepartmental logistics, resources, program design, costs, standards, and policy. Salt Lake City Police Department currently has no established program to provide tactically trained emergency medical personnel (EMS) to SWAT members, patrol officers, or members of the public in SWAT or active shooting incidents. In the interest of public safety, Salt Lake City Fire Department needs to provide trained tactical medical personnel as an integral element to any Salt Lake City Police Department tactical operation. The purpose of the following research is to identify and provide both Salt Lake City Police and Salt Lake City Fire with a practical means to provide tactical EMS service to police department operations during these types of responses. Action research will be used to answer the following questions: A. How do other agencies effectively integrate tactical EMS (TEMS) into their operations? B. What are the parameters of the training? C. What are the common obstacles to such programs? D. What type of TEMS program would be most beneficial to Salt Lake City?

8 Tactical Emergency Medical Service 8 BACKGROUND AND SIGNIFICANCE March 21, 2005: Red Lake, Minnesota Indian Reservation; 16 year old active shooter kills 5 students, 1 teacher, and a guard before killing himself October 2, 2006: Lancaster, Pennsylvania community college; active shooter kills 5 students then himself. April 16, 2006: Virginia Tech University; active shooter kills 31 people while moving from dormitory to classroom. This is the most lethal active shooter in U.S. history. May 26, 2007: Moscow, Idaho courthouse; sniper kills one police officer, wounds another before killing himself. December 5, 2007: Omaha, Nebraska; active shooter kills eight people and wounds 5 others in a shopping center. February 8, 2008: Baton Rouge, Louisiana: A nursing student kills two and then herself at Louisiana Technical College. February 14, 2008: DeKalb, Illinois: Active shooter kills seven students and wounds 15 others in a classroom at Northern Illinois University before killing himself (Vayer, 2003). These are just some of the incidents that have led to a collaboration of fire and police resources to meet the service need for emergency medical service on-scene of such events.

9 Tactical Emergency Medical Service 9 These incidents are not, however, exclusive to "other cities". In Salt Lake City alone, we have seen active killing incidents first-hand: April 15, 1999: Family History Library; 71-year active shooter kills a security officer, patron, and wounds five others (including a police officer) before being shot by police (Gunman in Salt Lake City, 1999). February 12, 2007: Trolley Square Mall; 18-year old active shooter kills 5 patrons and wounds 6 before being shot by police (Trolley Square Shooting, n.d.) The latter of these two incidents remains very fresh on the minds of Salt Lake City public safety and city officials to this day. The event has been analyzed and studied extensively to provide better understanding and knowledge of what police can expect in such an incident, as well as how the fire department can be of greater value during the police operation. Although accurately recognized for their professional and prompt mitigation of the incident, personal testimony from multiple public safety officers confirm the fact that this incident precipitated for nearly 30 minutes. "We have six fatalities and multiple victims at hospitals. They were found throughout the mall", said Sergeant Robin Snyder of the Salt Lake City Police Department (Gunman Kills Five, 2007). Lt. Josh Scharman, one of the first patrol officers on scene, reported that "As we entered the mall, we saw the wounded and began to move towards the sound of gunfire. We made the conscientious decision right then and there that we were going to bypass the wounded and try and eliminate the ongoing threat". Scharman went on to say that "This mass-casualty experience was unique for us. The 'grab and drag' model wasn't going to work he would continue to shoot, so we established a areas within the building that we felt were

10 Tactical Emergency Medical Service 10 secure enough to bring in EMS within 15 minutes" (Personal Interview, 2011). Patrons in the mall at the time of the shooting corroborate this timeline; "I saw a woman's body face-down at the entrance to Pottery Barn Kids. I locked myself and four others inside a storage room for about 40 minutes, but I was still able to hear the violence" said mall patron Mike Lund (Gunman Kills Five, 2007). Incidents such as these demonstrate the methodical nature of active shooters and the time it may take to locate and safely mitigate the suspect. Traditional role limitations present a basic problem for a rapid response to these incidents: police departments do not normally employ paramedic or emergency medical technicians (EMT's). Thus the reliance on an EMS organization or fire department is necessary. Traditionally, fundamental differences in objectives exist among the different public safety entities. For instance, although law enforcement, fire, and EMS all share the same basic life safety priority in live-shooting events, the first priority for police is to terminate the threat, whereas the first priority for fire/ems is normally to establish that the scene is secure. Firefighters do not normally carry weapons during routine operations within their jurisdictions. They are trained to protect themselves by remaining aware of their surroundings and utilizing all information at their disposal. This often means waiting for police to "secure the scene" and ensure that fire personnel are in no immediate danger of any threat. This is a standard protocol for operations within the Salt Lake City Fire Department and has worked effectively for those patients who intend to inflict harm on themselves or are victims of assault where the assailant may still be in the area (Salt Lake City Fire Department, Policy #03-23).

11 Tactical Emergency Medical Service 11 Unfortunately, this standard may deny those in immediate need of life-saving intervention that they may need while in the hazard zone - a zone that may be rendered "secure" for the purpose of a tactically-trained EMS providers under the watchful eye of a SWAT-trained "cover team". In an active shooting incident, the first priority for police is to identify the threat, but moving targets within a building present a particular challenge depending on the size of the structure and the number of rooms or areas contained within its walls. Analysis of these incidents indicate that there is time for EMS providers to enter such a scene tactically and render rapid life-saving aid to victims while the "contact team" actively pursues the shooter (Weiss, 2007). Traditionally, police departments have utilized EMS in three distinct ways: 1. "If we need you, we'll call you:" Ineffective given that law enforcement officials may not realize in advance that they may need EMS. 2. Stand-alone EMS unit assigned to staging: Less than ideal given that the scene must be "secured" or patients must be evacuated with valuable care time lost. 3. Incorporation of EMS into the tactical police operation (TEMS): Most effective given that EMS responders are within the tactical zone ensuring time-sensitive emergency care for police, civilians, and suspects (Rooker, 1992). The value of immediate medical care has been clearly established in medical journals and studies. In fact, the time for effective first aid is very limited. A review of the Vietnam wound data reveals that greater than 80% of those fatally wounded by a bullet die within a few minutes

12 Tactical Emergency Medical Service 12 of injury (New Castle County, 1999). In addition, airway management is integral to the management of trauma patients. Cerebral oxygenation and oxygenation of other parts of the body provided by adequate airway management and ventilation remains the single most important component of pre-hospital patient care (McArdle, Rasumoff, and Kolman, 1992). With greater police enforcement of drug-related, criminal activity, there now is more contact between police and heavily armed felons. The availability of mind-altering substances, the increased reliance on outpatient psychiatric services, the increase in gang activity, and the availability of assault-type weapons, individually and the concert, underlie the increased demand for an ability to provide medical care on the home battlefront (McArdle, et al, 1992). If there is a possibility that lives can be saved during these types of incidents, we have an obligation as public servants to develop the education, resources, and training to provide this service to the citizens of Salt Lake City. This topic is directly related to the Executive Analysis of Fire Service Operations and Emergency Management Course in that a Tactical EMS program is integral to the safe and effective response to active shooting/mass killing events that have become more common throughout the United States. These incidents represent an emerging issue that can occur in metropolitan, urban, suburban, and rural environments nationwide. SWAT team missions are often hazardous, unconventional, and immediate. Incorporating tactical EMS personnel into these operations is appropriate and necessary in an effort promote a risk-reduction plan requiring fire department participation. It is incumbent on operations Chiefs and Emergency Managers to ensure that the appropriate coordination and training occur to prioritize life safety for both public safety officers and the citizens they serve.

13 Tactical Emergency Medical Service 13 LITERATURE REVIEW There is a direct line between from the evolution of medical support for military special operations forces in the United States of America after World War II, to what is now recognized as TEMS in civilian law enforcement and public safety. From these military experiences came the determination that the traditionally trained "medic" was inadequately prepared to operate with these units without additional training in several disciplines (Llewellyn, 2003). Today, the use of local fire department personnel on tactical teams has become an increasing trend within the tactical and fire service communities. Yet, most police departments do not have dually-certified Police Officer Standards and Training individuals with emergency medical training. Thus, police organizations still attempt to bring medical provider's as close to the scene as possible while respecting their inability to defend themselves in a hazard zone. For years Miami-Dade Fire Rescue shadowed Miami-Dade Police Department personnel for warrant services, potentially violent arrests, and raids. Rather than a formal TEMS agreement, however, they essentially operated autonomously of the Police Department in that they responded in their own vehicles, worked within their own protocols, and had minimal communication with their public safety cohorts while "standing by" to intervene if a police officer or civilian was injured and either brought to the safe zone or the scene was secured by police personnel. The rescue units would stand by at a safe distance while attempting to monitor events within the "hot zone". Both Fire and Police realized there were gaps in the system. Onduty firefighter crews were often not notified of the impending response until minutes before the actual operation. Since many of these operations took several hours to complete, the

14 Tactical Emergency Medical Service 14 fire department would realize a negative impact on their response times and district coverage (Palestrant, 2010). There is also a financial cost associated with this type of operational. The deployment of a TEMS unit often eliminates the need to hold an engine on scene for hours, and this cost can be measured (Evans, 2009). The byproduct of such an arrangement was felt often times by the victims and responders alike. Although each public safety entity prioritized life safety, this independent response model led to reductions in efficiency and positive medical outcomes. In military environments, fast triage and evacuation of casualties is imperative. Ninety percent of combat deaths occur before patients reach medical treatment facilities; some 15-20% of these are probably preventable, coming from causes like bleeding extremities, collapsing lungs and airway obstructions (Weiss et al, 2007). Many of the wound patterns seen in recent military conflicts are also seen in the civilian tactical arena. Domestically, there have been incidents all over the country where police and victims have bled out because help was not able to get to them due to the danger of the situation. In a 1999 incident, two officers in Cobb County, Georgia, were killed in a hostage situation, and another officer was wounded. Medics were there but were unable to do anything to help the officers until the police cleared the area (Weiss and Davis, 2006). Studies have shown that more than 60% of SWAT officers' injuries suffered during showdowns with criminals involve excessive bleeding, often from gunshot or knife wounds. Downed officers wait for an ambulance to arrive at the incident, then for police officers to deem the area safe for paramedics to enter and administer treatment delay that increased the risk that

15 Tactical Emergency Medical Service 15 injured officers would bleed to death (Roberts, 2010). Other medical professionals put it more succinctly: "The current standard of fire/ems departments staging during an active shooter incident while waiting for police to "secure the scene" is inherently flawed: While waiting for police to clear the entire area, those injured inside the building aren't receiving care and are dying from their injuries" (Smith, Iselin and McKay, 2009). Yet even with such compelling arguments, controversy regarding such programs does exist. As with the implementation of most new programs, there will undoubtedly be honest differences of opinion between knowledgeable and experienced professionals. TEMS has been no different. However, "The differences have been more challenging since there is very little evidence base available to us to clearly develop policy, procedures, and guidelines. Much like emergency medicine itself as it developed, TEMS practice is founded on anecdote and /or extrapolation of related scientific information." (Carmona, 2003). Many "old school" fire departments resist the idea of firefighters with guns or training with police. The perception stems from the stereotype that firefighters fight fire and police officers fight crime. I have heard it myself many times; "if you want to carry a gun, then be a cop." Opponents will use the assertion that this role is not part of a firefighters job. But proponents of the concept assert that TEMS personnel must be able to defend themselves, if need be. This issue is prominent for many departments trying to resolve the issue of arming their medics or not. Some administrator's (and union leaders) oppose arming medics because they feel providing medics with weapons is counterintuitive to their training to support life. In addition, some argue that it is difficult for one individual to devote the time and training necessary to

16 Tactical Emergency Medical Service 16 maintain both medical skills and weapons skills. Other considerations are that it is unknown how an armed (or unarmed) TEMS provider will react to a stressful high-risk situation or what their perception of threat will be in a given situation. Their perception is what ultimately determines the appropriate level of force to be used by an officer (Carmona, 2003). Advocates of arming medics point to the need for TEMS personnel to be able to operate safely in an environment much different than what they are accustomed to; an environment where they could get shot (Myers, 1997). It is essential to prepare medics for a stressful environment that differs from normal EMS calls. Many medics are used to being in control of the environment, for example, arriving to a residential structure, taking a patient out on a stretcher and putting him in the back of an ambulance for transport to a hospital. But it's different with SWAT teams. "In tactical-medic operations, we're going into an environment not built for us. It's hostile." (Roberts, 2010). Lt. Mike White of Tampa Fire Department stated "When I met with leaders of our SWAT team and our fire department, and addressed this issue of being armed, I did it with the idea that if we are unarmed, we actually have the potential to being a detriment to the team" (Essex, 2002). White went on to say that the members of his team have not had difficulty maintaining competency in all their skills and that arming medics puts them on the same footing with the rest of the team, which he feels is vital to developing a cohesive unit. If then, the determination is made that TEMS personnel will be armed, there is also the concern of providing firefighters with the ability to utilize deadly force. "If the TEMS personnel are going to be armed, the fire department should consider sending them through a lawenforcement academy for liability purposes. The possibility of shooting, killing, or seriously wounding a suspect is very real, and the scrutiny of a shooting review board or a defense

17 Tactical Emergency Medical Service 17 attorney will put the operation at risk in the absence of proper training and credentialing" (Evans, 2009). The benefit of providing this training to personnel, however, is that it provides justification for these team members to operate under the authority of the police department and creates an atmosphere on the team of mutual understanding and credibility. Many believe EMS personnel would operate safer with tactical training. "Far too often, EMS crews walk into crime scenes with little or no information on what is occurring and find themselves in the middle of an unsafe situation" (Smith, 1999). Another concern is that the risk accepted by a tactical medic is beyond the risk accepted by firefighters. But is it? A firefighter's first tactical priority is life safety, and this priority is balance against existing risk. Many believe this is simply an extension of this objective in a different role. There are risks every time a firefighter enters a burning building, treats a patient who has a communicable disease or rescues a person from the heat of a wildfire. These are inherent risks associated with the job of a firefighter. Rendering aid at the scene of a active shooting incident should be no different (Palestrant, 2010). There is also ample discussion regarding whether police officers should be trained to a medical competency (EMT/Paramedic) or if firefighters/ems should be trained to police/swat standards. Proponents of training police to a medical standard will say that this maintains the close bond necessary for an effective team. This is the case in many departments, with little or no compromise in the tactical ability of the team. However, it is becoming more apparent that the opposite model is more common; firefighters trained in police operations. Critics to the former point out the logistical challenges of a full-time police officer attending some 1,000 hours

18 Tactical Emergency Medical Service 18 of medical training, not including emergency department time and riding an ambulance for a minimum of 160 hours? Most importantly, where will they obtain hands-on experience (Essex, 2002). "The vast majority of cities do not have the call volume to maintain the proficiency of a tactical medic assigned to a law-enforcement unit, Moreover, the skill proficiency needed for IV's and advanced air way control makes it more feasible for experienced firefighters/paramedics to fill this role" (Evans 2009). Most law enforcement personnel are trained only to the level of American Red Cross First Aid and cardiopulmonary resuscitation (CPR). Usually, there is no provision for medical procedure to psychomotor skill retention, other than annual recertification. In many jurisdictions, patrol officers are discouraged from providing medical care even though they are often the first emergency personnel to arrive at the scene of an incident. With a few exceptions, they lack the training and experience to assess and provide triage for patients rapidly (McArdle etal, 1992). Firefighters simply know EMS better than police officers ever will. The converse may also be true, but it is simply more practical to train a firefighter/paramedic in basic police SWAT movement than vice-versa. For many, the issue of liability has become a point of contention regarding any TEMS team. Some law enforcement agencies will directly employ TEMS providers, either as sworn officers or civilians. Many other TEMS programs rely on agreements between the law enforcement agency and a government (eg, fire department) or private (eg., hospital) agency. These agreements are usually documented as a Memoranda of Understanding (MOU) or Letters of Agreement (LOA) between the two agencies and are essential to assuring the protection of all

19 Tactical Emergency Medical Service 19 parties as well as the citizens served by them. These documents address the issues of function and process as well as liability, disability, and other legal matters (Vayer and Schwartz, 2003). Interestingly enough, if the liability issue is addressed from a victim's standpoint, it appears to be more of a proponent of integrated SWAT teams than an obstacle to the programs. As Lieutenant White said: "It was a huge liability to take my partner and me out of our rescue truck five blocks down the road and say 'grab your bags and follow me'. We were not trained, we didn't have a clue. It took two or three of their SWAT team members just to protect us. Any one of their people you draw from just to babysit a paramedic is taking away from their law enforcement resources. If you take the same two people you just grabbed out of that rescue truck and you train them, equip them, and give them the right tools to operate, your department's liability is lessened" (Essex, 2002). Some organizations circumvent this issue by combining police and fire into a simple, but role-specific Rescue Task Force (RTF) model. This model removes the TEMS personnel from the SWAT team and instead places them with two police officers who act as security as they enter the building immediately after the SWAT team identifies the need for EMS. As the SWAT team continues to "move toward the sound of shooting" initial RTF's are providing care to the wounded in the hot zone while additional RTF's are formed in the safe zone. The goal of this response is to get medical resources to the patient's side within minutes of being wounded while continuing to mitigate provider risk. "We felt our tactical medics were limited by their primary role of working directly with our SWAT team and would likely be delayed in their deployment to the scene." (Smith, et al, 2009). The RTF's then, like the police response to active shooters, must be implemented almost immediately.

20 Tactical Emergency Medical Service 20 Lastly, there is no consensus on what type of EMS certification is appropriate for TEMS personnel. It is generally regarded that most injuries occurring within the "hot zone" of a tactical incident are of the Basic Life Support (BLS) variety; blunt trauma, excessive bleeding, airway obstructions, etc. Based on data from more than 8,000 gunshot wounds of American serviceman of every means, we have learned that proper and effective ALS care in a combat zone (hot zone) is unsafe. Instead, a wounded soldier is first provided "buddy care" which addresses his immediate life-threatening wound. He is then rescued and removed to a nearby safe zone where more advanced intervention and stabilization may occur. The victim usually receives BLS care first, followed by ALS care in a different location (Rasumoff, 1995). Given that algorithm, BLS (EMT's) personnel could make up the entirety of the TEMS program. If BLS is utilized, then there should be mechanisms immediately available to access ALS care and patient transfer, when needed. Usually this does not require and special considerations since all EMS have those processes in place (Carmona, 2003). On the other hand, Paramedics have the knowledge, experience, and training to perform more extensive interventions, particularly when the scene time becomes extended or the environment becomes isolated (Vayer et al, 2003). In some jurisdictions, TEMS candidates must have at least three years of experience as certified paramedics in order to be considered for the program in addition to seven years service as firefighters (Roberts, 2010). It is clear that these types of programs prioritize only experienced EMS responders for this type of duty. Ideally, from a patient's perspective, physicians would fulfill the role of TEMS providers. Although this would allow for the greatest scope of practice and medical control, they often have

21 Tactical Emergency Medical Service 21 little experience in pre-hospital care. In addition, they are certainly more costly to retain and have limited availability for no-notice emergency response due to their routine commitments to clinical care (Vayer et al, 2003). Tactical medicine is more like combat medicine than that practiced by even the fire department in everyday emergencies. The most common are penetrating injuries and wounds with massive bleeding (Weiss et al, 2006). The training of TEMS personnel can be quite intense, given the variety of possible tactical situations. These fall into three general categories, and TEMS personnel must be prepared for each: 1. Barricaded suspect individual(s) have created defensible space with unknown dangers. 2. High-risk warrant service arresting a dangerous suspect or raiding a dangerous location. 3. Hostage situation armed and dangerous suspect detaining, threatening, or killing civilians (Rooker, 1992). SWAT Medics are unlike other paramedics and EMT's both in their training and in their demeanor. They must be high performance, competitive individuals because high stress and physical fitness are part of the job. Their spot on the team is earned through extensive assessments. SWAT medics must be able to function under physical and mental stress and still deliver life saving medical procedures quickly and accurately (Weiss et al, 2007). Many new members fail to recognize the time commitments to a tactical team as well as their standard EMS responsibilities. First and foremost is the family consideration. The support and understanding of the medics' family remains key to retaining team members. Several teams

22 Tactical Emergency Medical Service 22 point out that they have lost members due to family pressure. The amount of unscheduled time away from the family and the uncertainty of the teams location and its missions take a toll on each members home life (Smith, 1999). Essential to the team's effectiveness is its make-up. The importance of having the right kind of people on the team cannot be overemphasized. They must be physically fit and pass the same performance tests as police officers on the team. Even more importantly, they have to have the right personality and attitude about their position on the team. As Brad England, Executive Director of Cyprus Creek EMS states "We are looking for people who want to be Paramedics, not people who may lose their focus on their role and get involved in the police aspects of the team" (Smith, 1999). "Their job is to provide medical support to police officer, civilians, and in some cases criminals. They should not be considered part of the direct assault force" (Essex, 2002). For Calgary, Alberta, paramedics who want to become members of the TEMS program, desire alone isn't enough. Recruits with a minimum of two years on the job are put through a challenging 8-step process including high angle rescue, confined space operations, tactical movements, weapon training, psychological tests, and physical training (D'Amour, 2005). Although not the only training course available, a large number of organizations use the Counter Narcotics Tactical Operations Medical Support (CONTOMS) program for their initial training curriculum. This program, located in the Uniformed Services University of the Health Sciences (USUHS), has been in operation since 1990 and has produced more than 4,000 qualified tactical medics since then through its five-day course (Davis, 2001). "The program was

23 Tactical Emergency Medical Service 23 built out of necessity", says Joshua Vayer, CONTOMS Course Director. "There's more to understand about providing tactical EMS than 'oh, there's bad guys and there shooting at me and I'm at risk." There are whole elements of medicine in the austere tactical environment that need to be understood." he said. Public safety organizations throughout the country are trying to accomplish the same objective: integrated medical care, without disruption of tactical lawenforcement procedures. But without any kind of national standard, each agency had its own approach and local EMS systems varied. Consistent national TEMS standards were sorely needed, and the CONTOMS program identified three goals: 1. To establish a standardized TEMS curriculum and certification process nationwide. 2. To collect and data to ensure the curriculum is up to date. 3. To provide consultation to public safety agencies for operational planning (Rasumoff, 1995). The original 1989 curriculum included fundamentals on EMT support and survival how to operate within the tactical medic environment. Organizations often developed ongoing training within their own SWAT team customized to their own specific needs. Now, the current EMS tactical program includes an in-depth section on the psychology of hostages and hostage takers, lectures on the effects of heat and cold on performance, and how TEMS personnel can prepare and support a team for extended operations. In addition, there is specialized training in triage, sports medicine (sprains and strains), blunt trauma, entry planning, and the development of a detailed Medical Threat Assessment (MTA) which identifies the capabilities of local hospitals,

24 Tactical Emergency Medical Service 24 local EMS, and other medical resources (Davis, 2001). Basic knowledge of potential HazMat exposure is mandatory as well as the ability to conduct primary and secondary patient surveys silently and in the dark (Rooker, 1992). Agencies with very limited budgets should look at local or state program s on self-aid, buddy-aid, or "officer down" training to initiate development of a TEMS program (Vernon, 2010b). Lastly, equipment and training costs may be an issue for potential TEMS providers. Budgets remain one of the biggest stumbling blocks. Who will pay for the program? Typically police and EMS split the equipment responsibility. The police provide the tactical equipment, such as ballistic vests, uniforms and helmets. EMS provides the necessary medical equipment and supplies. However, personnel comprise the highest cost. Even relatively inactive teams must train on a regular basis (Smith, 1999). Particularly in today's challenging economic times, the financial burden associated with tactical EMS can be a significant obstacle to any new program. Tactical Medics need the same protective outfits that the SWAT teams have, including bulletproof vests and military-style Kevlar helmets. The equipment required for a TEMS provider will depend on two factors: The level of training of the provider and the role of the TEMS provider with the team. As a frame of reference, the average cost for equipping a LOS Angele County Sheriff's Department Tactical Medic is about $6840 (Vayer et al, 2003). Law enforcement can often times pay for some of this equipment with seized money if policy allows. In addition, law enforcement grants are more numerous than fire/ems grants. (Evans, 2009). There are many factors involved in the selection of training for TEMS personnel. These factors include, but are not limited to, course availability, team mission, TEMS provider skill level, role of the TEMS provider within the team, and the cost of the training. While there are multiple

25 Tactical Emergency Medical Service 25 courses available, some have limited availability due to lack of federal funding. Those that are available may be too costly for many public safety agencies (Vayer et al, 2003). PROCEDURES The basis for the vast majority of original research for this project is a survey. The survey itself will ask specific questions regarding the existence and type of TEMS program relative to the purpose statement of the research. It will be created to yield clear and valid results which may be useful in the development of an effective TEMS program for Salt Lake City. The success or failure of such a program relies, in some part, on the design, composition, and sustainability of other programs that have addressed the challenges and pitfalls of such an undertaking. It is accepted that many of these programs across the country may be in various levels of design, development, and operation. Still, utilizing the knowledge and experience gained from those departments who have already initiated the basic building-blocks of an effective program should make the Salt Lake City initiative just that much more practical. The action research designed for this work will incorporate a simple survey designed to present little or no obstacle to rapid completion. This is imperative given that the recipients of the survey are undoubtedly busy, and the complexity and length of the document may have an inverse effect on completion rate. The survey will consist of six basic questions designed and formulated to solicit objective information on the existence, type, and success of any TEMS program currently implemented by the public safety organization. One hundred-twelve total survey's were distributed electronically to various departments nationwide who met the participatory criteria. Sample size was selected based on the researcher's estimate of a

26 Tactical Emergency Medical Service 26 reasonably representative data pool for comparable cities to Salt Lake. Consideration was also given to a reasonable sample size for analysis. The agencies receiving the survey were selected based on population served of between 100, ,000 (U.S. Cities, 2008), and a violent crime rate greater than the national average (Crime Statistics, 2007). It was assumed that these cities would be comparable to Salt Lake City Fire Department's size and relative run volume. The above average risk for violent crime criteria would hypothetically indicate greater potential for the use of TEMS. Special consideration was also made to include those cities/regions within established criteria where previous active shooting/mass casualty incidents had occurred (Vayer et al, 2003). A survey was also sent to the corresponding law-enforcement agency of each Fire Department selected to participate. This was done to determine if different perspectives could be identified within the same program. The respondents were provided the studies' purpose and scope, but were not informed of any predetermined hypothesis or intent. Questions were mixed between open-ended and closed-ended to maintain some uniformity without limited valuable feedback. Finally, all survey recipients were informed or their participation in a research study for the National Fire Academy and agreed to respond willingly. The questionnaire could be returned anonymously. The survey questionnaire is as follows: 1. Do you currently have a Tactical Emergency Medical Services program and how is it designed? 2. If yes, what are the key benefits to your department?

27 Tactical Emergency Medical Service If no, why not? 4. Are your Paramedics/EMT's armed? 5. Do you utilize EMT's or Paramedics for your Tactical EMS program? 6. How are your TEMS personnel trained? (Appendix A) The questionnaire was directed to the SWAT Commander of the respective law enforcement agency as well as the Medical Director of the corresponding fire department. The following cities were requested to participate in survey: Boise, ID Norfolk, VA Santa Rosa, CA Lakewood, CO Des Moines, IA Chandler, AZ Oceanside, CA Dayton, OH Fayettville, NC Madison, WI Rancho Cucamonga, CA Sunnyvale, CA Akron, OH Lubbock, TX Ontario, CA Mesquite, TX Aurora, IL Durham, NC Tempe, AZ Pasadena, CA Fontana, CA Glendale, AZ Lancaster, CA Savannah, GA Augusta, GA Hialeah, FL Pembroke Pines, FL Fullerton, CA Little Rock, AK Scottsdale, AZ Cape Coral, FL Newark, NJ Glendale, CA Irving, TX Sioux Falls, SD Buffalo, NY Huntington Beach, CA Irvine, CA Elk Grove, CA West Valley City, UT Tallahassee, FL Spokane, WA Salinas, CA Lincoln, NE Newport News, VA Arlington, VA Pasadena, TX Cedar Rapids, IA Knoxville, TN Provo, UT Paterson, NJ Santa Clara, CA Rochester, NY Torrance, CA St. Petersburg, FL Fort Wayne, IN

28 Tactical Emergency Medical Service 28 The limitations to this research method were as follows: 1. The relatively small sample size of cities surveyed. 2. The relatively small number of organizations returning the survey. 3. The confirmed accuracy of information provided. RESULTS The survey questionnaire returned 58 individual responses (52%) of 112 requests for information within two weeks. Responses were mixed between Fire/EMS (34) and law enforcement (24). The following data was specific to the Survey Questions: Question 1: 36 of 58 (63%) respondents confirmed that they had some form of TEMS program. 24 of the 36 (66%) had incorporated the program into their SWAT team in some manner. Question 2: 28 of 36 (78%) respondents reported immediate patient access (or similar) as the number 1 benefit of integrated TEMS. 17 of 36 (47%) respondents reported reduced liability (or similar) as the number 2 benefit of integrated TEMS. 10 of 36 (28%) of respondents reported a better working relationship (or similar) as the number 3 benefit of integrated TEMS.

29 Tactical Emergency Medical Service 29 Question 3: 18 of 22 (82%) respondents reported cost (or similar) as the number 1 reason they did not have a TEMS program. This included equipment and training. 8 of 22 (36%) respondents reported no compelling need (or similar) as the number 2 reason they did not have TEMS program. 5 of 22 (23%) respondents reported they did not know how to implement (or similar) a TEMS program as the number 3 reason they do not have a TEMS program. Question 4: 15 of 36 (43%) respondents have armed their EMT's/Paramedics within their TEMS program. Question 5: 25 of 36 (69%) of respondents use some combination of EMT's and Paramedics in their TEMS program. 11 of 36 (30%) respondents use paramedics exclusively for their TEMS program. Question 6: 25 of 36 (69%) of respondents use some form of "in-house" training exclusively to certify their TEMS personnel. This would include SWAT training and any specialized EMS training. 18 of 36 (50%) of respondents use a combination of "in-house" and "outside" schools to train their TEMS personnel. This would also include P.O.S.T. training and/or CONTOMS or similar. 6 of 36 (17%) of respondents reports the use of "outside" schools only to train their TEMS personnel.

30 Tactical Emergency Medical Service 30 In summation with regards to the research questions: Of the 52% who responded to the questionnaire: 63% had some form of Tactical EMS program in place within their tactical response unit. 37% denied having a Tactical EMS program. Of these 63% that responded affirmatively to the question regarding having a TEMS program: 69% of departments had imbedded them in some form within their respective SWAT teams. Of these 69%, 39% had provided standardize training outside of their department (P.O.S.T, CONTOMS, or similar). Of these 63% that responded affirmatively to the question regarding having a TEMS program: 61% had provided internal training only to their personnel; both medical specific and/or SWAT. 43% of those with a TEMS program have armed their personnel in some manner. 69% of those with a TEMS program use EMT's and/or Paramedics. 31% of those with TEMS programs use Paramedics exclusively. Of the 38% who responded negatively to the question regarding having a TEMS program: 87% of respondents listed "cost" as the primary obstacle to implementing a TEMS program. 48% noted lack of training or "liability" as an obstacle to a TEMS program. 27% listed lack of interest or need as an obstacle to a TEMS program.

31 Tactical Emergency Medical Service 31 DISCUSSION It is clear that Tactical EMS programs are becoming more prevalent throughout the United States. Literature and Results have identified a compelling argument for the programs; faster delivery of emergency medical care in the "hot or hazard" zone to those who need it on scene. This is in direct contradiction to the previous (or current) standard of maintaining medical providers in the "cold zone" and having the tactical team evacuate patients to them. While this is safe for the TEMS providers, it does not meet the needs of the team or the casualty (Vayer et al, 2003). Over one-half of the respondents had some form of TEMS program, and it appears that number may continue to grow. Some case law is beginning to develop and show that tactical medics are beginning to be seen as standard of care. This may be the greatest impetus for the development of the concept in the future (Smith, 1999). Of those organizations that have implemented TEMS programs, almost three-quarters of them have done so within their SWAT teams on the law-enforcement side. This indicates that most policymakers and administrators believe that the value of having EMS on scene on or near the front line outweighs the potential liability of keeping the EMS group out of the danger zone until the scene can be completely secured. This supports the trend as indicated in the literature review that for those willing to make the commitment, full tactical integration is the best solution to the challenge of bringing EMS providers to the front line. It appears that TEMS is gaining nationwide acceptance in both EMS and law enforcement agencies because many TEMS providers have made a positive impact during tactical law enforcement operations (Rasumoff, 1995)

32 Tactical Emergency Medical Service 32 How, exactly, this integration is accomplished remains mixed from the results. Although the data indicates an increasing trend of bringing TEMS personnel into the fold of tactical operations, it also indicates that just over one-half of those have achieved law enforcement status eg: P.O.S.T. Certification. Of those departments that do mandate P.O.S.T. certification, they identified two common benefits: 1. The medic can provide for his/her own safety without the necessity of dedicating a tactical resource to him/her (this infers armed and trained in police tactics). 2. The medic now has arrest powers, authority to detain, and full "confidence" of the remainder of the team (Essex, 2002). In fact, of those departments that have TEMS program, less than half have utilized "outside" training in any form to prepare their personnel. This means that many of those acting in a TEMS capacity are neither P.O.S.T. certified nor CONTOMS trained. Interestingly, over one-half of those agencies with TEMS programs are relying independently on in-house training to bring their TEMS programs on-line. This indicates that although arrest powers, for instance, may be beneficial in some cases, it is not viewed as essential. This may also indicate a prevalent feeling from administrators that "role confusion" may have be a factor in the effectiveness of the team. It is essential to remember the "one person one job rule". "On any given mission, a single individual tasked with the duties of more than one position (eg, medic and point man) will perform neither as well as if he had only one job" (Vayer et al, 2003). Across the United States there are successful TEMS programs with quite diverse composition. What works best in lone

33 Tactical Emergency Medical Service 33 location may not work well in another location. Each choice must be considered in a costbenefit analysis specific to the jurisdiction (Vayer, 2003). The data also supports the literature review on the question of equipping TEMS personnel with guns; with the results mixed. Close to one-half of the respondents with TEMS programs have made the commitment to arming their TEMS personnel for either self-defense or the ability to terminate an immediate threat to the patient or other team members. As discussed earlier, this is a major point of contention for those who do not believe that EMS personnel with guns is the most appropriate way to accomplish the TEMS objectives. Ultimately, both the armed and unarmed approaches have advantages and disadvantages and the individual team must make their own decision based o their state laws, mission, and team composition (Vayer et al, 2003). Although the data indicates there may be some means of providing TEMS personnel with the ability to carry firearms without completing P.O.S.T. training, the means for this process remains unclear and inconclusive. As for the appropriate medical certification, it appears clear that very few department's utilize (or are capable of providing) paramedics exclusively for TEMS activation. The data indicates that almost three-quarters of those departments with TEMS are utilizing a combination of both EMT's and Paramedics. This may be due to the preponderance of EMT's as opposed to representative of the personnel available for such duty department-wide. Often, the pool of paramedics alone is not sufficient to support the program. In addition, it is clear from the literature that BLS providers (EMT's) are sufficient to fulfill most of the responsibilities of TEMS. "Since the goals are to provide immediate care necessary to support life airway