EMS, Tactical Medical Threat Assessment and Protection


Article Author:
Jeff Thurman


Article Editor:
Timothy Price


Editors In Chief:
Alexandra Caley
Sameh Boktor


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
8/22/2019 3:16:45 PM

Introduction

A medical threat assessment is a vital part of pre-mission planning that attempts to identify all potential medical threats to the team. Completing a medical threat assessment and discussing the findings with the mission commander is an integral part of the responsibilities of a Tactical Emergency Medical Services (TEMS) provider. Attempts should be made to mitigate all reasonable threats identified in the pre-mission stage. During the mission, the TEMS provider should continue to assess for medical threats as it is often not possible to foresee all medical hazards before team deployment. The TEMS provider should participate in the development of standard operating procedures to mitigate common medical hazards likely to be encountered on tactical missions.

Issues of Concern

Pre-Mission Health:

 Medical threat mitigation begins before the planning stage of any specific mission. Team members should have access to a physician for routine health screening and prevention/treatment of common medical issues. Each member of the team should maintain a medical card covering medical conditions, medications, and allergies. This information should be securely stored but readily accessible by the Tactical Emergency Medical Service (TEMS) provider to accompany a team casualty to the hospital. Each team member should be up to date on immunizations, particularly to tetanus and hepatitis. Additional immunizations may be recommended for team members as determined by anticipated potential encounters with less common pathogens in the operational jurisdiction.[1] Physical fitness standards are essential to ensure that team members can overcome any reasonably anticipated physical challenge.

Routine Threats:

Tactical teams must identify and attempt to mitigate medical threats that are likely to be encountered on every mission. Threats warranting consideration include gunfire, injury to vision/hearing, musculoskeletal injuries, and bloodborne pathogen exposure. These threats are best countered by proper protective equipment. Each team member, including medical personnel, should be outfitted with ballistic protective gear. For most missions, this will include a ballistic vest and helmet. The level of ballistic protection must be sufficient to protect from the type of weapons the team is likely to encounter on the given mission. Team members should wear vision and hearing protection. Musculoskeletal injuries are common while operating in a tactical environment and usually are not entirely preventable.[2] However, team members should wear protective gear such as long sleeve shirt and pants, knee/elbow pads, abrasion-resistant gloves, and sturdy footwear. Wearing gloves, eye protection, long-sleeved shirt, and pants will also help to protect team members from bloodborne pathogen exposure. Each team member should also include a set of medical gloves in their kit in case they need to provide care to a casualty. The TEMS provider must assist the command staff in making sure that each member of the team is wearing the required items.

Environmental Concerns:

 An assessment of the environmental conditions should take place before every mission. On days with moderate temperatures and little chance of rain, significant changes to the operational plan are unnecessary. However, the team will frequently be required to operate in less than ideal conditions. Extreme heat poses a difficult problem because the team cannot wear less than the minimum necessary protective clothing and equipment; this will limit the ability to dissipate heat. To the extent possible, team members should keep equipment weight low and wear clothing that allows for effective sweat evaporation. Cold environments are slightly more manageable as team members can simply add layers to decrease heat loss. Team members do have to layer efficiently to avoid overheating or a decrease in mobility. Each individual must feel comfortable with their layering system prior to starting the mission. Upon initiation of the mission, there is not likely to be an opportunity to add or remove layers safely. Rain gear should be issued and worn if there is a significant chance of rain, and is especially true in cold environments to prevent hypothermia. In the event of prolonged operations, plans must be in place to allow individuals to rotate out of harsh conditions and gear down. Food and hot/cold drinks should also be available. Ideally, the gear down area will be in an environmental and temperature-controlled building or vehicle such as a bus, which will help prevent the development of hyper/hypothermia.

Chemical Hazards:

 Chemical hazards are common considerations for tactical teams. The team must be prepared to identify and counter a variety of chemical threats. Many chemical hazards can be reasonably anticipated, and thus, mitigation incorporated into the operational plan. However, the team must also be ready to handle unanticipated chemicals. Contingency plans should be in place for mobilization of a dedicated HazMat team. Individual team members should have HazMat training sufficient to ensure that they can appropriately identify when a HazMat team is needed. If the team carries chemicals for deployment, such as oleoresin capsicum (OC) or tear gas (CS), individuals should have comprehensive training in the use, storage of, and possible physiologic consequences of the agents. In addition to the other protective equipment carried, team members should have rapid access to a gas mask. Cartridges for the gas masks need to protect from riot agents and an array of unknown agents. Given the high prevalence of opioids, it is reasonable for teams to carry naloxone to treat exposures.  Generally, the risk of toxicity to officers from accidental external exposure is greatly exaggerated in law enforcement circles. If the pre-mission assessment identifies a high risk of exposure to a specific agent, each operator or the TEMS provider should carry appropriate antidotes.

EMS Staging/Transport:

 Due to the high risk of injury during operations, tactical teams must build contingencies for rapid extrication of casualties into the operational plan. The TEMS provider is typically the team member who will provide the link to the civilian EMS system. Reliable communications are a high priority. A dedicated EMS unit should have a staging area at a predetermined location. Staging locations must be far enough away from the operational area that the EMS crew is not at risk from stray gunfire. The unit should also be out of visual sight of the target location to maintain operational security. These considerations need to be balanced with the ability of the medical unit to respond rapidly to the scene if necessary. The TEMS provider needs to be aware of the capabilities of local hospitals so that casualties can be transported to the nearest appropriate facility.

Medical Training/Equipment:

 Recent military operations have shown a reduced mortality rate when all individuals receive training in Tactical Combat Casualty Care (TCCC) principles[3][4] A reasonable extrapolation of these findings to the civilian setting suggests that there is a benefit to all team members having the skills to provide life-saving self/buddy-aid. Team members need to have the ability to render life-saving aid to themselves or others.[5] In addition to appropriate medical training, team members need to carry life-saving medical equipment as part of their kit. During hostile fire, the TEMS provider may be unable to reach a casualty. It is the responsibility of the TEMS provider to help team commanders select appropriate medical equipment to be carried by each individual.

Planned vs. Unplanned Missions:

 Most missions have the advantage of being planned, and typically, there is sufficient time to perform a full medical threat assessment. To the extent that is possible, these threats can then be minimized or countered. Tactical teams are often called to respond with no advanced warning. During these operations, the TEMS provider must begin the medical threat assessment as soon as is practical.

Clinical Significance

Teams operating in a tactical environment face many challenges. Incorporating medical threat assessments into routine mission planning can help to anticipate threats to the health and safety of the team. It is the job of the TEMS provider not only to treat but prevent casualties and ensure a favorable mission outcome.


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EMS, Tactical Medical Threat Assessment and Protection - Questions

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A medical threat assessment provides information on which of the following?



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What are the main components of Force Health Protection?



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Which of the following individuals should be evaluated by the team/unit physician?



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A 35-year-old male presents to his team commander asking to be returned to duty. He is a member of a small special operations team. The team was involved in a mission that suffered several casualties. Three of the operators were critically injured and one was killed. The team commander request that you perform an assessment and provide a medical recommendation. A review of his medical history shows no pre-existing comorbidities. His vitals are within normal limits. A physical exam is negative for acute findings. He has difficulty falling sleeping and feelings of guilt that he was unable to save his teammate. Which of the following is the next best step?



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A tactical medical threat assessment and protection coverage is being provided for a SWAT team that has been on-scene for 4 hours surrounding the house of a barricaded subject. The team members are preparing to rotate back to the staging area to gear down and eat. The team calls upon the medical provider to assess the sniper. His team states that the sniper was found lying in the snow in a concealed position and is confused. On assessment, a 31-year-old male who is sluggish to answer the questions is seen who has to be frequently redirected. He is unable to give a detailed account of the last several hours of the mission. His pulse is 105/min, and respiratory rate is 23/min. There is no obvious trauma. His medical card lists no medical problems or medications. What could the team have been done to prevent this condition?



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During pre-mission planning, the SWAT commander asks for medical opinion on an anticipated chemical threat. The team is preparing for an operation into the house of a suspect thought to be involved in an act of domestic terrorism earlier that day. A weaponized gas attack was carried out in a public area. The victims had symptoms of seizures, confusion, vomiting, diarrhea, salivation, bradycardia, and bronchorrhea. Which medication(s) is/are most appropriate for the team to carry?



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EMS, Tactical Medical Threat Assessment and Protection - References

References

Toffoli CA, Optimizing Mission-Specific Medical Threat Readiness and Preventive Medicine for Service Members. U.S. Army Medical Department journal. 2018 Jan-Jun;     [PubMed]
Nindl BC,Williams TJ,Deuster PA,Butler NL,Jones BH, Strategies for optimizing military physical readiness and preventing musculoskeletal injuries in the 21st century. U.S. Army Medical Department journal. 2013 Oct-Dec;     [PubMed]
Butler FK Jr,Hagmann J,Butler EG, Tactical combat casualty care in special operations. Military medicine. 1996 Aug;     [PubMed]
Butler FK Jr, Tactical medicine training for SEAL mission commanders. Military medicine. 2001 Jul;     [PubMed]
Callaway DW, Translating Tactical Combat Casualty Care Lessons Learned to the High-Threat Civilian Setting: Tactical Emergency Casualty Care and the Hartford Consensus. Wilderness     [PubMed]

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