Tactical paramedicine is the provision of prehospital medicine within a hostile environment, that requires knowledge of tactics, special equipment, and specialized personalized protective equipment (PPE). The PPE and the training, is really what separates this team from regular operations.
Ben is an Acting Superintendent currently assigned to Special Operations and has been a Paramedic for 21 years in Ottawa. He has served on multiple specialty units including the Paramedic Bike Unit and Paramedic Support Unit. Ben is currently a 14 years member of the Paramedic Tactical Unit where he serves as a unit lead and is involved in Special Operations competency maintenance including the selection and intake of new members. Ben has had multiple deployments with municipal, provincial and federal partners, fulfilling many roles. His most dynamic activation to date was assuming tactical command within Parliament Hill during the October 22nd terrorist attack where he led paramedic tactical assets, internal CCP and was integral to the unified command structure. Ben has also been instrumental in developing and writing the City of Ottawa’s Hostile Event response plan, encompassing the Rescue Task Force model. This has brought him to serve on both the City of Ottawa’s and the International Public Safety Association’s Rescue Task Force committees.
PPE includes ballistic vests and helmets, as well as advanced respiratory protection for CBRNE deployments. Canadian tactical paramedics are NOT armed, as they are only paramedics and not sworn peace officers. The United States operates with different models including armed officers cross trained as EMTs/Paramedics.
Tactical Police arose from the Texas Tower Incident, where a student began shooting at other students. TEMS knowledge and skills originally comes from our military colleagues before it was transferred to the civilian side.
From a Canadian perspective, Toronto started the first Canadian Tactical Paramedicine program. Locally, the 1999 OC Transpo incident where a gunman shot 6 people and killed 4 was the catalyst for creating a local team, which occurred in 2001 when the City amalgamated.
From a training standpoint, the key is understanding mechanisms of injury, the arsenal of weapons, efficiency of care, and police tactics. Additionally, the Paramedics Chiefs of Canada have outlined 38 competencies that Tactical Paramedics should have.
The role of TEMS, is for “everyone” – police, suspect, or anyone in between. In terms of where the team is situated is very much dependent on the situation. The goal is to support the operation, not be the operation. In addition to warrant executions, the team will be involved in anything “high threat” (e.g. barricaded situations, emotionally disturbed persons, anything with weapons involved, etc.).
Medics take part in Tactical Emergency Casualty Care (TECC), while the military version is Tactical Combat Casualty Care (TCCC). TECC differs from TCCC by providing training for all age spectrums and co-morbidities.
Direct threat care is the first concept of TECC, indirect threat care (have some time, distance, shielding from the threat) is the next concept.
The treatment hierarchy should be M-A-R. Massive hemorrhage, airway, respirations. Then extricate with hypothermia management.
If the patient is exhibiting signs of a tension pneumothorax, a chest needle decompression should be used. Anterior axillary, 5th intercostal space is the new standard location.
MCI (massive casualty incidents), K-9 care, Immediate Action Rapid Deployment (IARD) is also part of the team training. A symbiotic training relationship also exists with the Canadian Armed Forces – the military was looking for more medical training, while the Tactical Unit was looking for more trauma training.
Additional Equipment Carried
- Ballistic PPE
- Additional medications when on Federal deployments
- Sports Medicine
- Hypothermia control
- Which is tremendously important to combat the Trauma Triad of Death
- Patients still get hypothermic in hot conditions
- It was the 2nd most common cause of death in Afghanistan in the summer temperatures
- Turn on the heat in the ambulance even on hot days
- Don’t infuse cold saline into your patient
- The NaCl is also acidotic in nature, which only perpetuates this cycle
- Strip and flip and re-cover
CBRNE – Chemical, Biological, Radiological, Nuclear, Explosive
- Ottawa has a combined team, but many other jurisdictions have a split team
- Level B suit (level A fully encapsulates your breathing apparatus while level B exposes it)
- Air purifying respirator (APR)
- Tyvek and Tychem (used for splash when not concerned about vapours)
- Nerve agent, organophosphates, irritants (pepper spray, CS), cyanide kit, hydrofluoric acid kit
- The cyanide kits will be used more frequently during fire/inhalation calls, as the combustion of the new materials in the home often produces cyanide
Rescue Task Force (RTF)
The 2008 Columbine Incident changed police response mentality on its head. Beforehand, the police response mentality was Contain-Isolate-Negotiate.
From Columbine, IARD – Immediate Action Rapid Deployment – was developed. During the Columbine response, 2000 police officers showed up, and contained. IARD was thus developed to train officers to go in, hunt the killers, and terminate the situation. The goal is thus to stop the killing. The number 1 way to save lives is to prevent further killing.
In 2012, as a result of the Virginia Tech Shooting, Rescue Task Force (RTF) was developed. RTF, the goal is embedding paramedics and fire fighters within a police element to go and provide care to an injured victim.
During an IARD deployment, you will have 3 different teams responding. Contact teams are teams of officers going in to try and find the suspect and stop the killing. The RTF team will try and stop the dying. A variety of other RTF teams will deploy, and sometimes just firefighters, to stop the destruction. This allows for a full and complete response. Fire fighters are force multipliers (trained in first aid and tourniquet use), and also bring specialized equipment. Rescue Task Force teams or Rescue teams (Police officers only) will then extricate victims to awaiting transport units or casualty collection point.
These teams will be deployed to any MCI with weapons or threats involved. The criteria are that: someone has shown propensity for violence, there are victims, and they have access to more victims. Examples are active killer situations, edged weapons attacks, vehicle borne incidents, fire as a weapon events etc.
Generally, there are 3 types of RTF makeups:
- Specialized Teams Approach
- Paramedic Tactical Unit & Paramedic Support Unit. Both units carry ballistic PPE, that are personal issued.
- These teams are out doing regular calls, and if a RTF call comes in, they can deploy quickly (already equipped and trained).
- Forward Deploy Model
- People who are designated each day, and would get stocked PPE, or it would be placed on an MCI vehicle or with a superintendent, and would be handed out as teams arrive on scene.
- Advantages: doesn’t matter who shows up, everyone is trained. This may be more feasible on smaller services.
- All Hands on Deck
- Nobody is issued any PPE, and the first arriving vehicle moves with the officers in response
Statistically speaking, 2/3 of these incidents are done (arrest, suicide, threat neutralized) in the first five (5) minutes.
Having said that, police have a plus 1 rule, and the incident is not wrapped up until everything is checked and that there isn’t 1 extra person there. For example, the 2014 Parliament Hill Attack was “over” in only a few minutes, but the incident lasted 13 hours.
Stop The Dying – Hemorrhage Control
A very common reason for out of hospital death is hemorrhage. Exsanguinating from major vasculature can occur in 3-6 minutes. Paramedic response is often more than that.
The Hartford Consensus, created after the 2012 Sandy Hook Shooting by the American College of Surgeons, is a protocol for national policy to enhance survivability from active shooter and intentional mass casualty events.
The Consensus also validated that the #1 cause of death is non-compressible hemorrhage, so they created Stop the Bleed to assist the public.
How do I identify life threating hemorrhage? The obvious one is the “eye brow test”…if there’s objectively a lot of blood, that’s a hemorrhage. If you suspect a massive hemorrhage, you will never be wrong putting on a tourniquet (TQ). The less obvious ones are the intramuscular bleeding.
Proper TQ application technique:
- High and tight over clothing is the fastest and easiest way
- If you have some time (i.e. not in a direct threat environment), then optimally: 2-4 cm above the wound, directly on skin
- It should “hurt” the victim. For a TQ to be effective, it must be tight
- The success of the TQ is how tight the band is before it’s closed off.
- Pull it as tight as possible before you begin to turn the rod
- You want to occlude arterial bleeding. If it’s not tight enough, it only occludes venous blood flow. This can cause compartment syndrome.
- You need approx. 300 mmHg of pressure to occlude arterial blood flow
- Give appropriate analgesia
- Put it on if you’re concerned
- 2nd TQ
- Should be applied if the 1st isn’t effective
- Place above (proximal) to the 1st TQ
- Don’t take it off
For the lay person, take whatever you have and put it in the wound. The technical way would be to try and find the source(s) of bleeding, occlude it with your fingers, and remove as much debris as possible. “Knead” the packing into the wound without losing pressure until it is fully packed. The packing creates pressure within the wound. Wound packing is very effective in areas that you can’t apply a TQ. You should never pack into the chest and abdominal cavity as well as the cranial vault or airway.