Providing medical support to law enforcement, specifically to tactical teams, can be a time consuming and daunting initiative. The results and outcomes, however, can be some of the most rewarding a medic or physician see in their career. Professionals say that there is nothing like being directly involved in the heat of battle and knowing that their efforts, expertise, and capabilities may save the life of someone who has experienced a traumatic injury. Being involved in tactical field operation is dramatically different from that of a quasi-controlled environment such as the emergency department or a relatively “routine” medical emergency run.[1][2][3]

Minus the initial response to an active violence incident, tasks associated with tactical operations are methodical, tedious, and time-consuming. Tactical physicians and emergency medical service (EMS) personnel may be sidelined in the warm zone (see zones of care) as a safety precaution. There is a more frequent integration of medical providers into entry teams or more frequent positioning close to the fight to provide the quickest possible intervention should something go wrong and the need for emergency medical care becomes necessary. If integrated into the entry team, medical providers should expect a significant amount of training and practice. This training will focus on the dynamics of the tactical team movements, operations, and communication.

Terms like “fatal funnel,” “projecting,” and “telescoping” are not a good thing. “Cover” and “concealment” are a good thing (for example, a cover is something that will likely stop projectiles such as bullets and concealment is something that may hide and prevent professionals from being seen). The fatal funnel is what law enforcement refers to doorways where one can be easily seen but difficult to move out of in the case of incoming projectiles. A police officer will never stand in front of a doorway, especially an open door, during a high-risk incident. The unknown is one of the most dangerous aspects of the tactical environment, similar to unsearched areas or the other side of the doors. Additionally, walls will afford some cover and concealment from the 3 “Bs:" bombs, bullets, and bad guys. Open doors will afford none. Since movement is paramount in a tactical environment, slow and methodical movements are necessary but can be extremely uncomfortable and challenging. Another aspect of the tactical movement is to avoid projecting presence. This is where terms like “slicing the pie” and “quick peeks” come into play. Slicing the pie is the method used to look into open doorways, gaining a perspective for as much of the space on the other side of the door by looking via different angles. Whatever cannot be viewed by slicing the pie may be viewed by conducting "quick peeks." This is when an officer lines up on the wall adjacent to the door and without telescoping their head, quickly looks inside the doorway to the left and right. Officers will have their firearms in hand, and the shooting hand will penetrate the doorway simultaneously with their head. This will allow them to address a threat if necessary.

Zones of Care

The "hot zone" is the area where the action is happening. In a tactical environment, this will be where the bombs, bullets and bad guys are located, and where the highest level of threat exists. As a general rule, only life-threatening injuries to responders will be addressed in the hot zone.  In the "warm zone," generally some type of mitigation efforts have been taken to minimize the risk. This is generally where EMS and tactical support personnel will work. In active violence scenarios, for example, this will be searched for threats and once deemed likely safe, this will be where the casualty collection point is located. Law enforcement will bring the injured here for their initial assessment and treatment of life-threatening injuries. While EMS work in the warm zone, there will be law enforcement assigned to do nothing except provide overwatch and security for medical personnel. The "cold zone" is where there is no actionable intelligence or indication of a threat. This area is far enough away from the hot zone; it is not likely a threat will present in this area. Incident command posts, media staging areas, and outer perimeter will be located in the cold zone. Also located in the cold zone will be triage areas, ambulance staging areas, among others.

In 21st-century policing, active violence and tactical responses are changing significantly and constantly. After every major event, first responder agencies across the country modify their response, training, and capabilities. For example, following events such as the Aurora, Colorado theater shooting, the Pulse Nightclub shooting, among others, many law enforcement officers throughout the country are being trained in tactical, emergency, casualty-care interventions. Interventions such as tourniquet application, hemostatic gauze, nasopharyngeal airways, application of pressure dressings, among others. Law enforcement, however, is instructed to focus on neutralizing the threat before rendering any aid. At no time should rapid movement to the threat or exercising good tactics be jeopardized or hindered due to providing medical aid to casualties. Law enforcement officers are taught to come back and address casualties during "warm zone" operations when there is no additional credible intelligence of additional threats although the building/area may not have been completely "cleared." The term "clear" has been used interchangeably with other law enforcement terms such as "search," "check," "safe," and others. When a room, building, or area has been "cleared," every possible area where a person could be hiding or concealed is checked and verified that no one is there. Once completed, the room, building, or area is designated as a "cold" zone. With the integration of rescue task force principals, more non-law enforcement EMS providers, are being integrated into tactical teams who make rapid entry into warm zones before the areas have been completely "cleared." This is a relatively new principal based on battlefield medicine and casualty statistics. The faster a medical provider can be at the side of a traumatically injured patient, the better the chances for survival. Completely clearing a normal sized building, often takes 1 to 2 hours; whereas, trauma patients need intervention within minutes.

Medical providers should be aware of current threats and trends affecting law enforcement and first responders. This will have a direct impact on the ability to provide effective medical treatment. Currently, immediately-dangerous to life and health (IDLH) drugs are a substantial threat to the safety and well-being of those who respond and handle those incidents. Secondary and tertiary exposures have become a real threat, and appropriate personal protective equipment is imperative, not only for the law enforcement but also for those medical providers who may be in the field during clandestine lab tactical operations. Medical providers should also become familiar with field decontamination procedures to include technical decontamination and rapid-emergency decontamination of those experiencing medical emergencies after operating in a hazardous tactical environment.

Lastly, it is imperative for field EMS and medical providers to understand the tools, weaponry, and equipment being utilized by law enforcement in the field. Providers should become familiar with their local tactical teams and law enforcement agencies, the tools and weapons they carry, effects when used, interventions to treat injuries and illnesses, and how to provide effective medical treatment without hindering criminal investigations whenever possible.

To safely work with law enforcement, physicians, and emergency medical personnel must have an understanding of team movements, operations, tactics, tools and equipment, and communication to effectively assist in the provision of healthcare if it is needed. Additionally, it is incumbent on EMS and medical providers to understand the rapidly changing field measures being introduced to minimize the number of casualties resulting from criminal and terrorism-related tactical events. The threats to public safety are evolving at a rapid pace in the 21st century. It is imperative that professionals work together and communicate new intelligence as it is presented.[4]