CALIFORNIA TACTICAL MEDICINE GUIDELINES POST and EMSA TREXPO WEST 2010 March 29, 2010

POST/EMSA TACTICAL MEDICINE PROGRAM Daniel R. Smiley Chief Deputy Director EMERGENCY MEDICAL SERVICES AUTHORITY Kenneth L. Whitman Special Consultant COMMISSION ON POST

POST Operational Guidelines for SWAT (2005)  POST Operational Guidelines for SWAT (2005) identified the need for tactical medicine as an integral part of the law enforcement tactical team. Chapter 5 – Planning section of the SWAT Guidelines states:  5.5 … SWAT teams should incorporate medical emergency contingency planning as part of the SWAT operational plan.  Where resources allow, consideration should be given to integrating Tactical Emergency Medical Support (TEMS) personnel within the structure of the SWAT team.

POST Operational Guidelines for SWAT (2005)  Additionally, a Basic SWAT Team Operational Component has been identified as “medical support” under the Command and Control Element in the guidelines.  This guide is also meant to serve as a companion document to the POST Operational Guidelines for SWAT (2005). It describes the critical role that tactical medical planning and threat assessment plays in the overall contingency planning as part of the SWAT operational plan.

POST/EMSA TACTICAL MEDICINE PROGRAM “TACTICAL MEDICINE IS DEFINED AS THE DELIVERY OF MEDICAL SERVICES FOR LAW ENFORCEMENT SPECIAL OPERATIONS”

TACTICAL MEDICINE PROGRAM GOALS ENSURE TACTICAL TEAMS IN CALIFORNIA HAVE AN APPROVED TACTICAL MEDICINE SUPPORT COMPONENT AVAILABLE DURING ALL RESPONSES PROVIDE A STANDARDIZED TRAINING COURSE FOR TACTICAL MEDICAL TEAMS DEVELOP CORE COMPETENCIES FOR TACTICAL MEDICINE PROVIDE ADDITIONAL TRAINING AND UPDATES AS NEEDED

WHY WAS THIS NEEDED ?  Varying levels of training ranging from hours  No standardized curriculum  No standardized core competencies  No standardized written or skills testing  Not integrated with EMS system  Sometimes practicing without medical direction or oversight

I am a “Tactical Medic?”  What does that mean?  What do you know?  What training do you have?  What medical skills can you do?  What equipment should you have?  Are you integrated with the EMS system?  Are you part of a program with medical oversight?

POST/EMSA TACTICAL MEDICINE PROGRAM DEVELOPMENT WORKGROUP CALIFORNIA AMBULANCE ASSOCIATION CALIFORNIA FIRE CHIEFS ASSOCIATION CALIFORNIA EMS MEDICAL DIRECTORS ASSOCIATION CALIFORNIA EMS ADMINISTRATORS ASSOCIATION CALIFORNIA EMERGENCY MEDICAL SERVICES AUTHORITY COMMISSION ON PEACE OFFICER STANDARDS AND TRAINING STATE OF ILLINOIS DEPARTMENT OF PUBLIC HEALTH EMS COUNCIL INTERNATIONAL SCHOOL OF TACTICAL MEDICINE (ISTM) LAW ENFORCEMENT TACTICAL EXPERTS (LASD, LAPD, CHP, SDPD, SJPD, SFPD, PSPD)

POST/EMSA TACTICAL MEDICINE PROGRAM PROGRAM DEVELOPMENT PHASE ONE COMPLETED TACTICAL MEDICAL GUIDELINES, APPROVED BY POST COMMISSION (JULY 2009) AND EMSA COMMISSION (DECEMBER 2009 FINALIZING REGULATIONS/PROCEDURES TO BE INCLUDED IN THE CALIFORNIA CODE OF REGULATIONS (CCR) 1084 AND SUBJECT TO APPROVAL BY THE OFFICE OF ADMINISTRATIVE LAW (OAL)

POST/EMSA TACTICAL MEDICINE PROGRAM PHASE TWO DEVELOPING 40-HOUR REFRESHER COURSE (FALL 2010) DEFINE TACTICAL MEDICAL CARE TRAINING LEVELS ESTABLISH ANNUAL COURSE REVIEW PROCEDURES

POST/EMSA TACTICAL MEDICINE PROGRAM TACTICAL MEDICINE COURSE PALM SPRINGS POLICE DEPARTMENT INTERNATIONAL SCHOOL OF TACTICAL MEDICINE (ISTM) MODULE A – 40 HOURS MODULE B – 40 HOURS (ESTABLISHED IN 1996) STATE & FEDERAL APPROVALS POST-CERTIFIED FOR CPT CREDIT EMSA APPROVED DHS APPROVED—3 YEAR REAPPROVAL IN PROCESS (USE OF FEDERAL GRANT FUNDS)

POST/EMSA TACTICAL MEDICINE PROGRAM REMEMBER COMPLETION OF THE TACTICAL MEDICINE TRAINING COURSE DOES NOT AUTOMATICALLY QUALIFY YOU TO BECOME A SWAT TEAM MEMBER LAW ENFORCEMENT AGENCY POLICY WILL DICTATE HOW TRAINED TACTICAL MEDICAL TEAM MEMBERS WILL BE DEPLOYED OR UTILIZED

THE TACTICAL MEDICINE GUIDELINES

WHAT IS IN THE GUIDELINES DOCUMENT?  1.0 Definition of Tactical Medicine  2.0 Tactical Medicine Operational Programs  3.0 Tactical Medical Planning and Threat Assessment  4.0 Tactical Medicine Operational Equipment Recommendations  5.0 Tactical Medicine Training Programs  6.0 Tactical Medicine Required Course Content Description  7.0 Tactical Medicine Clinical Core Competencies – Psychomotor  8.0 Tactical Medicine Scenarios  9.0 Tactical Medicine Final Competency Testing  10.0 Tactical Casualty Care Assessment and Treatment Model

Two Parts to the Guidelines  Description of Tactical Medicine Operational Programs  Standards for Approved Tactical Medicine Training Programs

Tactical Medicine Operational Programs At the Law Enforcement Agency Level

KEY INTRODUCTORY POINTS  The public safety agency developing a tactical medicine operational program should conduct a needs assessment to determine the level of emergency care required by the SWAT team to support the mission and operations.  The operational program should consider the need for medical oversight and coordination with the local EMS agency, medical direction, use of Emergency Medical Technicians (EMTs), paramedics and other advanced life support personnel, and minimum training and equipment standards.

KEY INTRODUCTORY POINTS  The agency should develop policies and procedures for medical support during tactical operations.  The assignment and/or deployment of any emergency medical support personnel during a tactical response shall be at the sole discretion of the agency or department in accordance with established policies and operational procedures.

KEY INTRODUCTORY POINTS  Legal authority and proper training to carry a firearm is a prerequisite to arming emergency medical support personnel.  Armed medical support personnel must have statutory authority to carry a firearm and should be trained and tested to the standard for law enforcement personnel.

Formation of Tactical Medicine Operational Programs  LE Agencies should develop policies regarding the use of firearms by tactical medical personnel.  It is recommended that tactical medical team members should minimally obtain reserve peace officer status.  Reserve peace officers that are members of the tactical medical team should maintain proficiency levels with all firearms deployed by SWAT, as determined by the LE Agency.

And Now EMSA’s turn …  For the Medical Aspects  Yes, Tactics before Medicine

Formation of Tactical Medicine Operational Programs  Tactical Medicine programs and their medical personnel shall be integrated into the local EMS system, in coordination with the local Emergency Medical Services (EMS) Agency.  This shall be in accordance with applicable statutes and regulations found in Health and Safety Code 1797 et seq.

Formation of Tactical Medicine Operational Programs  Optimally, each Tactical Medicine program should have a Medical Director, who shall be a physician currently licensed in California, to provide medical direction, continuous quality improvement, medical oversight, and be the lead for medical contingency planning.  The Medical Director shall acquire and maintain competency in tactical medicine, and may also serve as the program director.

Formation of Tactical Medicine Operational Programs  All personnel who are tactical medical providers shall be minimally certified at the EMT level.  Tactical medical programs should utilize personnel licensed at the advanced life support level. This may include physicians, mid-level providers, registered nurses, paramedics, and Advanced EMTs operating under their authorized scope of practice.  All personnel must have tactical medical training, as defined within the POST and EMSA guidelines.

Tactical Medicine Operational Program Domain

Medical Oversight  Medical oversight refers to advice and direction provided by the program director and the Medical Director to trained tactical medical personnel who provide medical care in all aspects of tactical operations.  Each tactical medical program shall ensure medical oversight is available.

Medical Contingency Planning  Medical Contingency Planning is the inclusion of medical personnel in pre-event planning and preparation.  Tactical medical personnel should participate in the development phase of mission planning and risk assessment to ensure appropriate assets are in place for the identified mission parameters.  Considerations should include appropriate resources and trained medical personnel, and may include, but are not limited to ground ambulance standby, air ambulance availability, and transport to specialized hospital facilities, including trauma centers.

Operational Support (TEMS)  TEMS refers to Tactical Emergency Medical Support, which is the operational support component of the discipline of Tactical Medicine.  If available, tactically trained medical personnel should be deployed and utilized during SWAT operations, at the direction of the LE Agency.  This operational unit is a designated group of medical personnel, preferably at the advanced life support level, specifically selected, tactically trained, and equipped to provide medical care during critical law enforcement incidents.

Quality Improvement and Post Incident Analysis  Quality improvement is the ongoing and active review of all medical involvement in tactical operations for the purpose of improved patient care and operational outcomes.  Tactical medical personnel should participate in post-incident analysis and debriefings.

Team Health Management  Team health management is the supervision and implementation of the general health and well-being of all members of the tactical team.  Team health management strives to maintain and enhance the total well being of the SWAT team member through physical conditioning, diet, mental health and preventive care.  Overall health assessment and fitness evaluation should be conducted on a regular basis.  In conjunction with the tactical medicine program, it is incumbent on tactical team members to meet the physical fitness standards set by their LE Agency, in accordance with POST SWAT guidelines.

Training and Education  Tactical Team members should not be deployed in the role of tactical medical provider until successful completion of an approved Tactical Medicine Course,  AND  Сompletion of any additional requirements as set forth by the law enforcement agency.

Medical Equipment Acquisition and Maintenance  Tactical medical providers should be equipped to meet the mission identified by the LE Agency.  The tactical medical provider should be equipped with the necessary basic and advanced medical supplies and equipment for their level of licensure.  Medical equipment used by the tactical medical providers should be agency-issued and approved by the program director and/or Medical Director, including any modifications, additions, or attachments.  Equipment shall be maintained regularly to ensure it is in good working order prior to deployment. Expiration of supplies, including medications, should be checked regularly.

Tactical Medicine Training Programs At the Training Program Level

Tactical Medicine Training Standards  Minimally, the Tactical Medicine Course shall be 80 hours in length and conform to the core competencies.  An Alternate method to complete, is a 40 hour course, when ALL students have prerequisites of 80 hour Basic SWAT Course, EMT or above, WMD training, and Current LE/Public Safety designation.

APPROVAL OF THE TACTICAL MEDICINE COURSE  The course of instruction shall be jointly approved by the Commission on Peace Officer Standards and Training (POST) and the California Emergency Medical Services Authority (EMSA).  60 Days Prior to Course Advertisement and commencement.

REFRESHER TRAINING  Tactical medical providers should successfully complete a minimum of 24 hours of POST-certified tactical medicine refresher training every 3 years to maintain competency and proficiency.

Full Tactical Medicine Course - 80 Hours Admin and Safety1 Hour Medical Classroom Skills (9 Skill Stations) 28 Hours 6 Hours Tactical Classroom Skills (6 Scenarios) Firearms 6 Hours 16 Hours TacMed Scenarios (18 Scenarios)9 Hours Testing Written Skills (12 Scenarios) 2 Hours 6 Hours TOTAL 80 Hours

Alternate Tactical Medicine Course - 40 Hours (Prereqs SWAT Basic, EMT, WMD training, + LE) Admin and Safety1 Hour Medical Classroom Skills (9 Skill Stations) 20 Hours 6 Hours Tactical Classroom Skills (6 Scenarios) Firearms 0 Hours TacMed Scenarios (18 Scenarios)9 Hours Testing Written Skills (6 Scenarios) 1 Hours 3 Hours TOTAL 40 Hours

Clinical Core Competencies: Cognitive  Medical –Patient Assessment in Tactical Environment –Airway Management, Bleeding Control, Shock Management, WMD, etc. –Advanced Care  Tactical –General Topics to Operate as part of Tactical Team –Team Movement –Safety and Integration

Clinical Core Competencies: Psychomotor  Safety and Personal Protective Equipment (PPE)  Tactical Assessment and Treatment (TC2)  Basic Airway and Ventilation Techniques  Advanced Airway and Ventilation Techniques (N/A for BLS personnel)  Wound/Hemorrhage Control  Intravenous Access Techniques (N/A for BLS personnel)  Medication Administration Techniques  Cardiac and Circulatory Support  Patient Extraction and Evacuation

Tactical Casualty Care Assessment and Treatment Model  Modeled after TCCC but adapted for the Civilian Environment –Basic Management Plan for Care, Situational Awareness, and Scene Safety (Care Under Fire) –Basic Management Plan for Assessment, Evaluation, and Tactical Field Care (Tactical Field Care) –Extraction, Evacuation, and Transportation (Tactical Evacuation)

Tactical Casualty Care Assessment and Treatment Model

Tactical Medical Scenarios Practice  Basic Scenarios (6) –Tactical Casualty Care –Assessment and Basic Treatment –Operating as part of/with Tactical Team  Advanced Scenarios (12) –Advanced Life Support Care in Tactical Environment –Special Cases (WMD, Environmental, Low Light, Conditions, etc) –Refinement of Tactical Medical Operations

Competency Testing  Cognitive Written Test –Designed to test Knowledge  Psychomotor Skills –9 Medical Clinical Core Competencies  Tactical Medicine Skills Testing (6) –Integrative Skills Evaluation

DEFINING TACTICAL CASUALTY CARE TRAINING LEVELS

 Confusion over terminology  Training standards for various levels  Scope of Practice (basic life support vs. advanced life support)  Redefined into 3 levels –Tactical First Aid –Tactical Life-Saver –Tactical Medicine

TACTICAL CASUALTY CARE TRAINING LEVELS Course TitleAudienceHours of Training Tactical First AidLaw Enforcement Officer8 Tactical Life-SaverSWAT team member or other specialty team member (non- EMT) 24 Tactical Medicine or Tactical Medic Medical Component as part of SWAT team at BLS or ALS level 80, or 40 hours if EMT and prior SWAT Basic school

TACTICAL CASUALTY CARE TRAINING LEVELS Course TitleTraining TopicsScope of Practice Tactical First Aid **No ALS procedures “Care Under Fire” Principles Basic Hemorrhage Control Basic Airway Management Extraction and Movement of Patients Tourniquet Emerg Trauma Dressing Extraction Basic Airway Treat for Shock Tactical Life-Saver **No ALS procedures As above plus, Tactical Casualty Care Model Basic “Tactical Field Care” Principles --Naso-Pharyngeal Airway (NPA) --Sucking Chest Wound Basic Team Movement Scenarios As above plus, Tactical Casualty Assessment Airway plus NPA Occlusive Dressings Tactical Medicine or Tactical Medic As indicated in POST and EMSA approved Tactical Medicine Guidelines. As indicated in Guidelines, plus; Current certification or licensure, Approved EMS provider, and Local Accreditation

Summary  “Goal” is to protect the public and law enforcement personnel  Design Tactical Medicine program and have reproducible, standardized training  Continue to look to the Future to ensure standard programs and training that set high quality standards

Questions?