In a departure from routine civilian medical care, medical care in the tactical environment has unique constraints and requirements which may alter the manner and location of provided treatments. Initial treatment of a casualty may be minimal at the site of injury and while under effective fire. During this “Care Under Fire” stage, removing the casualty from harm and ending the threat is of primary importance. Expanded care is performed after the provider and casualty are no longer under direct threat but only with equipment which can be carried by the medic. Care begins to resemble routine civilian medicine once evacuation has begun, and definitive care is undertaken well removed from the threat environment. Full description of the tactical role of the medical element is a large topic, and readers should seek instruction from a number of dedicated texts and courses on the subject for full operational methods.
Tactical operations can expose the medical provider to a wide range of possible illness and injury patterns. Criminal activity is not limited to a particular time, location, or environment, and, therefore, SWAT operations must be carried out across any possible spectrum of circumstances. This requires the medical support element to be prepared and experienced in the treatment of a very broad set of possible maladies in both officers and civilians. In addition to the expected traumatic injuries possible during any violent physical encounter, persons in a tactical environment are prone to heat and cold stress, a host of medical illnesses, chemical and biologic agents, as well as some unique injury patterns from specialized tools used by SWAT teams.
Regardless of the possible suspect danger encountered by the tactical team, the environment in which they operate is a significant and constant threat to both their operational readiness and health. While the key maneuvers in ending a potentially violent situation may last only several seconds, the overall time of deployment is hours to even days. During this time, officers will be exposed to the elements in full tactical equipment likely consisting of a Nomex or similar suit, heavy body armor, helmet, APR mask or respirator, ammunition loadout, and specialized breaching tools. This equipment can weigh in excess of 40 lb and does not allow effective evaporative cooling. In some situations, officers may be wearing occlusive chemical suits, which severely limit their homeothermic mechanisms. These factors make heat illness a very real threat to the team members. Dehydration, heat cramps, heat exhaustion, and even heat stroke can affect team members even in seemingly inactive duties. Medical staff should reinforce oral hydration guidelines and be vigilant for any suggestion of early heat illness. Oral hydration requirements can reach 0.5 to 1 L/h with moderate activity in hot and humid environments.10 Adequate rest-work cycles should also be ensured during prolonged deployments to help avoid both environmental and mental stresses. CBRNE environments mandate rotation of personnel to ensure a minimum amount of time is spent in chemical/biologic occlusive suits and respirators, and medics should provide pre and postentry medical exams to ensure operators are fit to return to duty. Full protocols are beyond the scope of this text; however, suggested standards can be found in OSHA hazardous material operations and NFPA regulations.11 While heat illness is often the more common malady faced by team members, cold injury is also a significant threat. Much of a deployment may be spent outside in a concealed position awaiting a moment of entry. Wet conditions greatly accelerate heat loss due to water's significantly greater heat capacity and conductance compared to air. In addition, adaptive responses are less effective and hypothermia becomes more profound if the rate of cooling is slow. This is especially critical with marksmen/observers who may be in a fixed position for prolonged periods of time and must maintain a high degree of mental activity. Uniform selection must take into account these factors and hypothermia must be avoided. Decreased body temperature has significant detrimental effects on critical thinking, reaction time, muscle power, coordination, and morale.12-15 All these effects can seriously decrease the capability of the tactical element. Lastly, dehydration is still a threat in cold environments due to a combination of decreased perceived need for fluids as well as increased renal filtration from peripheral vasoconstriction.
The tactical environment poses a number of traumatic threats to police, suspects, and civilians. Lacerations and puncture wounds are common and come from a number of possible sources. Broken glass, metal, and debris created during the breaching and entry to the area pose a threat. Additionally, animal bites both from civilian animals and police working dogs can occur. In addition to the visible lacerations and punctures caused, bites also raise the possibility of infectious complications such as cellulitis, myositis, abscess formation, and tetanus, as well as localized rhabdomyolysis and compartment syndrome caused by the prolonged powerful bite of a police dog which is subduing a suspect. Falls with associated blunt trauma are likewise a threat in this environment. Rappelling and helicopter operations may be a part of agency tactics and can increase the risk of closed head injury and significant deceleration injury.
The act of engaging with potentially violent suspects presents an obvious threat to officers and civilians. Criminals and terrorists can use a variety of possible weapons against police and civilians. Edged weapons such as ice picks and knives can inflict serious wounds, even though soft ballistic armor. The medical element must be skilled in treating ballistic injuries, and these may range from low-velocity small-caliber handgun munitions to high-velocity large-caliber rifle and shotgun projectiles. Despite the formidable protection offered by modern body armor, vulnerable areas do exist and officers are not immune to ballistic injury. Significant injuries can be sustained to the face, neck, and proximal extremities. Additionally, there is substantial energy transferred to the wearer of soft body armor during a gunshot. This is known as “behind armor blunt trauma” and can cause serious injury. A .357 magnum handgun round defeated by soft ballistic armor delivers five times the energy of a major league fastball to the wearer, and the vest can deform up to 4.4 cm against the wearer by NIJ standards. This can break ribs, lacerate solid organs, and cause commotio cordis and resulting in ventricular arrhythmia. Tactical medical providers should have the capacity for defibrillation to treat this eventuality.
Military data have shown that the largest proportion of potentially salvageable injuries involves airway loss, extremity hemorrhage, and tension pneumothorax,16 and modern tactical casualty care has involved ways of rapidly and effectively dealing with these injuries while under austere conditions. Airway loss secondary to trauma is a significant threat in this environment and one of the prime responsibilities of the medical element (Figure 66-2). While EMT-paramedic and physician level providers are adept at endotracheal intubation for airway control, the time and setup needed is sometimes not practical in a high threat environment. In addition to intubation, providers should become proficient with blind airway devices and techniques for cricothyroidotomy to rapidly secure an airway. Effective techniques have been developed by military and other groups to allow rapid field cricothyroidotomy even using night vision goggles under little to no light.17 Needle decompression for treatment of tension pneumothorax is well within the scope of practice of readers of this text and should be available and practiced.
A tactical medic and physician work to manage an airway. (Photo by Ray Kemp * 9-1-1 Imaging.)
Hemorrhage control is another pillar of tactical medical care. Many of the hemorrhage control techniques used in an emergency room setting are not applicable in the tactical environment, where equipment at the site of injury will be minimal, access to the casualty will be limited due to hostile individuals, and mission goals must be met to prevent further loss of life. In this environment, the tourniquet has reemerged as a simple, potentially lifesaving piece of equipment. Military experience and research has shown that correct application of a proper modern tourniquet provides rapid control of extremity hemorrhage while still under direct threat and may even allow operators to remain mission capable. There are several modern tourniquets available, and reviews of their ease of application, weight, occlusion effectiveness, and subjective use can be found in a number of military and civilian sources for those looking to choose a product for field use.18,19 Regardless of the model chosen, they should be carried by each officer, be readily available for self-application, and be trained with regularly to ensure proper use. Another evolving technology for use in rapid hemorrhage control under austere conditions is the hemostatic dressing. These have undergone significant civilian and military testing to stop arterial and venous bleeding which is not amenable to tourniquet placement. The literature on individual dressings is widespread, and while several have proven effective on stopping significant animal models of proximal extremity hemorrhage, there have been a number of problems including excess heat production, burns, significant embolism/thrombosis, and local tissue damage which have caused some dressings to fall from favor.20 Medical directors should be familiar with this volume of literature prior to choosing a dressing for use in the field.
Further trauma can be a result of burn and blast injury both from deliberate incendiary devices as well as accidental ignition of environmental hazards. Improvised explosives and deliberate fires are common tools of terrorist and criminal suspects. In addition, the manufacture of many drugs of abuse and chemical weapons produce flammable and potentially explosive environments which may be entered by tactical teams while executing warrants or other high-risk entry work. These vapors can be ignited from routine sparks caused during forced entry or by the muzzle flash of a weapon, resulting in fire or explosion.
Aside from traumatic injury, there are a number of other hazards facing those in tactical operations. The constellation of chemical, biological, radiologic, and nuclear (CBRN) threats are all part of the tactical arena. Chemical agents ranging from simple irritants to sophisticated nerve agents must be planned for by the medical element. Treatment of these agents is covered elsewhere in this text; however, the tactical medical element should be familiar with the available treatments and antidotes to chemical weapons. Biologic agents and low-grade nuclear dispersal devices (“dirty bombs”) may also be encountered.
Police and tactical teams work on a force continuum to control suspects, which ranges from verbal commands to lethal force. Between these two extremes, several tools have emerged which allow control of potentially dangerous suspects without resorting to deadly force. These are known as less lethal technologies, and they present specialized injury patterns which must be handled by the tactical medical team. Of those agents commonly encountered and used by law enforcement, oleoresin capsicum (OC) and CS/CN gases will be some of the most frequently utilized. Oleoresin capsicum, or “pepper spray,” is an extract of the common pepper species. It causes Substance P–mediated pain, erythema, and edema to skin, as well as lacrimation, injection, and blepharospasm of the eyes. Corneal abrasions can occur in a significant minority of those exposed, 7% in one study,21 but this appears to be due to rubbing of the eyes rather than direct chemical erosion.22 Respiratory irritation and bronchospasm in those with reactive airway disease may occur. Pain relief is primarily time dependent, and other agents such as milk, Maalox, topical lidocaine, and baby shampoo were not found superior to water irrigation for pain relief.23 CS and CN gases produce similar skin burning and mucosal irritation with shorter length of effect. Treatment is generally supportive and decontamination is carried out with water primarily.
Conducted electrical devices (CEDs) are another less lethal option for law enforcement officers. Most widespread in use is the TASER, which uses a charge of 50,000 V at 20 cycles/s, causing tetany of major muscle groups. While its primary control is through this resultant incapacitation, it can also be quite painful. This is delivered in repeatable 5-second durations through a pair of barbs attached to 35 foot wires. It is in use with over 17,800 law enforcement agencies with an estimated 2,370,000 human deployments in the field.24 TASER use avoids other pain compliance measures and can spare the use of lethal force. It has been shown to significantly reduce the odds of both officer and suspect injuries in retrospective studies of 24,000 use-of-force incidents in 12 departments.25 It has also shown to reduce the incidence of injury compared to physical control measures by over sixfold.26 CEDs have been associated with less than 1% of in-custody deaths.27 However, concern has been raised for their safety, particularly their potential ability to cause cardiac injury. This has led to a volume of available literature on safety, including over 20 published studies and an AAEM position paper.28 Bozeman et al found no evidence of arrhythmia during ECG monitoring of 84 subjects during TASER deployment.29 Ho and colleagues have studied a number of deployment scenarios designed to mimic real world use and have found no evidence of EKG, electrolyte, or cardiac biomarker abnormalities in a series of studies.30,31 In a prospective trial of 426 consecutive TASER deployments by a major metropolitan SWAT team, Eastman showed that use spared lethal force in 5.4% of situations. There was only one serious injury, which was a delayed death 12 hours after deployment. The suspect's condition was consistent with excited delirium with altered mental status, hyperthermia, and bizarre behavior.32 A prospective multicenter observational trial by Bozeman et al33 characterized the injury patterns seen in over 1200 uses. Most suspects had no injury (78.1%), though mild injuries such as contusions, painful puncture wounds and chipped teeth were seen in 21.6%. There were two closed head injuries from falls, and two delayed deaths consistent with excited delirium.
Treatment of CED injuries should focus on the specifics surrounding the deployment and monitoring for significant symptoms. Excited delirium and toxicologic illness are common causes for CED use, and they should be monitored and treated. Special attention should be given to the fall caused by the momentary incapacitation and the mental status of the patient following. Barb extraction techniques mirror methods used for fish hook removal, and can usually be accomplished in the field, though barbs to the face, neck, and genitalia should be treated as impaled objects. Most CED deployments do not result in significant injury, with most requiring no specialized medical care. Serious injury or admission is rare.26 Existing evidence does not support routine screening tests or admission for observation in asymptomatic persons.28 However, symptoms such as chest pain should be investigated considering the patient's underlying risk factors and history. Medical review after CED deployment can help refine departmental usage policy.
Impact weapons are another law enforcement tool for controlling violent suspects. These can range from simple batons to rubber and bean bag munitions fired from shotguns or 37-mm launchers. These are generally a last resort prior to lethal force, and while considered less lethal, they can cause significant injury. Bean bag munitions are generally fired at the legs and abdomen and deliver energy equivalent to a major league fastball. Pain and bruising are the common result, but serious injuries such as hemo/pneumothorax, splenic rupture, cardiac contusion, solid organ contusion, and penetrating fatal chest injury have been reported in the literature.34
Noise flash diversionary devices, commonly termed flash bangs, are a common tool of the tactical team to distract and disorient potentially violent suspects. These devices burn rapidly to emit a loud noise and bright flash, which allows a tactical team a precious few seconds' advantage when confronting suspects. Their roughly 2 million candle power flash is enough to temporarily blind those in close proximity without causing permanent damage. The device produces a 200-dB concussion and 15 psi overpressure at the site of ignition. This is louder than a jet engine and equivalent to an extra atmosphere of pressure. This is enough to cause TM rupture and pulmonary overpressure injury. However, the pressure wave decays exponentially and is below the threshold for injury at a distance of 5 ft which is their minimum deployment distance. Injuries are rare, but officers or suspects exposed at close proximity can experience significant blast injury similar to any other overpressure device.