In our cities and towns across the country, our communities have come to depend on the expertise and protection of first responders. Firefighters. Law enforcement. SWAT. Marine units. Hazardous materials specialists. Canine-supported search and rescue. Drug enforcement. There are many unique disciplines and specialties filled by trained men and women who come to our aid when the worst happens. To help us, to protect us and to always be there for us, 24/7/365.
In addition to being exposed to the hazards of their core jobs, first responders often perform in high-risk environments with extreme conditions. They may face an active shooter situation in a hospital. They may have to search and recover drowning victims in sub-zero temperatures through unpredictable ice. They may have to conduct a raid in a meth-lab home where children or elderly are living. They face being attacked, shot, stabbed, bitten, burned, suffocated or exposed to toxic gas.
And yet they still go in. They still perform as teams of experts in any weather, any condition and face these extreme hazards to save lives.
These are extreme, yet unfortunately common scenarios first responders face every day they suit up. Although trained and prepared to deal with most tactical situations, when they happen, the risk is still high for permanent injury or mortality. When we think of the dangers associated with these high-risk jobs we also need to ask, who supports and cares for our first responders? Who helps them stay healthy so they can perform at their best? Who treats them and any peripheral casualties on-scene when these tactical situations occur?
An Evolving EMS Subspecialty
Tactical EMS (TEMS), which falls under a wider encompassing discipline of Operational Medicine, has evolved into a critical component of first responder support. This support places specially trained and certified paramedics in the field with first responders to provide advanced life support medical care to all sick or injured parties involved within a zone of police activity not accessible to a local EMS provider, regardless of their involvement in the situation.
These paramedics train and deploy with regional police tactical teams on special operations and provide for the physical wellbeing of the officers involved in these operations. Many communities have embedded TEMS paramedics on staff within these first response departments, and some partner with local providers for an on-call or on-demand deployment of first responder medical support.
Quincy's First 24/7 TEMS Project
Brewster Ambulance Service has established an Operational Medicine unit of TEMS-trained paramedics to support the City of Quincy's first responders and public works professionals including Quincy fire, law enforcement, dive team and marine unit, and SWAT. The team provides 24/7/365 support and participates in training as well as planned and unplanned events with Quincy's first responders. The TEMS team is embedded on a dedicated non-transport vehicle outfitted for first responder care with critical care medical equipment and supplies. This special vehicle, in addition to the 9-1-1 advanced life support ambulances already serving emergency calls in Quincy, provide ample coverage and additional support to the TEMS unit.
Over the last year, Brewster Ambulance, in cooperation with the Quincy Police Department (QPD), designed a TEMS plan that included the best operational medicine platform to support their law enforcement personnel. This Brewster Ambulance/QPD TEMS plan is in accordance with the Massachusetts Department of Public Health Statewide Treatment Protocols Appendix U Tactical EMS Principals stating that tactical EMS personnel may only provide care for predefined service members in this manner; any other persons presenting for care, or any service members who present with an acute medical issue, are to be considered patients under the definition of 305 CMR. Such care will be provided in accordance with the State Treatment Protocols. Also M.G.L c. 111C, 105 170.333: Duty to Operate in Accordance with Laws, Regulations, Protocols and Other Requirements. Each service shall operate and ensure its agents operate in accordance with M.G.L. c. 111C, 105 CMR 170.000, and in accordance with all other applicable laws and regulations, the Statewide Treatment Protocols, where relevant, administrative requirements of the Department, and the services' established policies and procedures consistent with 105 CMR 170.000.
Tactical gear, armor and uniforms for the TEMS paramedics was funded by the Urban Area Security Initiative federal grant. This tactical gear had to achieve or exceed certain standards for deployments. The team has been training side-by-side with the Quincy first responders to practice mock drills and exercises to standardize how the team deploys with the first responders (more detailed information regarding the TEMS gear to come).
Examples of how these fully-capable paramedics will be supporting first responders include advocating for general team health as well as preparation and planning for deployments whether active incidents, planned raids or warrants. Many teams design around gunshot wounds, violence, stabbings or injuries resulting from the tactical situation or environment. What is also taken into consideration is any pre-existing medical conditions that the first responder may have such as asthma, heart disease or diabetes. The goal being overall team health and wellness so they can perform safely and effectively.
In addition, the medicine can also be delivered to any casualties, injuries to suspects, peripheral people in the home such as children or elders. For example, there could be a situation where a diversionary device is deployed in the home that elderly aren't used to. Care and deployment plans take into consideration these factors. Missions range in scope and intensity from missing person searches to the resolution of critical incidents involving armed barricaded individuals, hostage situations or civil unrest.
training that's Vital to Team and Peripheral Survivability
The most important factor to the success and safety of these operations is trust. First responders—whether SWAT, fire, law enforcement or marine unit-trained—must have the trust of their medical support team. By obtaining familiarity with these high-risk incidents and missions, both medics and responders develop a mutual care bond that withstands active tests in the field. To build this trust and collaborative cooperation, TEMS paramedics work with QPD responders to conduct mock drills ranging from active shooter, warrant service, home raids, bomb threats, marine search and rescue, barricades, hostage situations and other tactical situations requiring response.
Medics have clinical experience and knowledge, however, when entering tactical situations handled by expertly trained first responders, they require additional training that exposes them to hazards, tactical weapons, operational strategies and other aspects primarily the domain of these special operations tacticians. The first responders also learn how to work with the medics not only for preparedness in integrating medical support, but to provide medical care for situation injuries and for their overall health and well being.
The Multi-faceted Challenge of Quincy
The City of Quincy is unique in that it has specialty services and significant maritime presence. It operates four patrol boats, pier and bridge inspections, a harbormaster capacity workload which responds to vessels in distress, medical emergencies on the water, port security, escorting large vessels and cargo ships, fuel spills and other maritime hazardous emergencies. Quincy also has a twenty-member dive team that does evidence preservation and collection from the water, body recoveries, vessel and pier inspections. The TEMS paramedics are also assigned to the Quincy marine unit to provide medical response support and wellness care to the team operating in and around the coastal area of Quincy.
With an average of fifteen years of experience, these specially trained and equipped paramedics have an integral role within the QPD team. Many also have backgrounds with the military, fire service, law enforcement and air medical programs within the local area. TEMS paramedics are certified as nationally registered EMT-paramedics in the state of Massachusetts with credentials in:
- Basic trauma life support (BTLS)
- Advanced trauma life support (ATLS)
- Fundamentals of critical care support (FCCS)
- Pediatric advanced life support (PALS)
- Neonatal advanced life support( NALS)
Education for TEMS paramedics includes:
- Continuous education and a 48-hour advanced life support refresher
- Advanced cardiac life support (ACLS)
- Cardiopulmonary resuscitation (CPR) mandated by the DPH-OEMS
- TCCC (Tactical Combat Casualty Care)
TEMS paramedics attend sixteen hours of monthly training with QPD SWAT elements. This training provides an education platform for procedures, weapons use and tactics used by law enforcement during activations. Additional educational includes hazmat, weapons of mass destruction, K9 medical treatment, traumatic ballistic injuries, hostage rescue and emergency evacuation. Brewster Ambulance Services will remain responsible for the care and transportation of civilian casualties as well as law enforcement. QPD TEMS will comply with the following DPH laws and regulations within the Commonwealth of Massachusetts:
- 170.355: Responsibility to Dispatch, Treat and Transport
- 170.335: Non-Discrimination
- 170.357: Point-of-Entry Plans
- 170.360: Responsibility to Provide Appropriate Personnel During Transfer
- 170.380: Medical Communications
- 170.390: EMS Vehicle Readiness
- 170.400: Supplies
- 170.840: Emergency Medical Technician - Paramedic
- 170.470: Class V
Planning for all outcomes
TEMS paramedics take over the medical part of tactical missions so first responders can focus on the tactical side. The TEMS paramedics work with the first responders to prepare for and plan missions. Planning for incidents includes identifying local hospitals and trauma centers, listing pre-exposed hazards (dogs, etc.), weapons or explosives. For example, powdered fentanyl can aerosolize upon entry which has the potential to poison people in the house as well as responders. Peripheral assets such as K9 support require local 24-hour vet service for canine EMS. Officer dogs can be assaulted, shot or stabbed, and dogs trained to detect narcotics can overdose.
Planning also includes creating evacuation routes and casualty collection points for a safe haven of victims whether peripheral or responder to get them out of the line of fire. There are pre-staged ambulances in key locations for planned missions, so transport is already activated and the teams are not waiting.
Communication in Real Time
Emergent response requires the teams to be more dynamic with planning. To enhance the communications, the teams designed electronic briefings (e-briefings) that transmit directly to each team member's smart phone. It includes GIS mapping, target locations, hazards, local trauma centers and any information critical to the mission—even weather forecasts. Once the teams are deployed, they have contacts, resources and mission-critical information on their phones. When changes are made on the fly, they get the information they need instantly.