[Scan-DC] 'Tactical Medicine'

[Alan Henney]

http://www.washingtonpost.com/wp-dyn/content/article/2007/04/20/AR2007042001792.html

Medics Enter The 'Hot Zone'
'Tactical Medicine' Reaches Victims Even Before Perpetrators Are
Caught

By Christopher J. Gearon
Special to The Washington Post
Tuesday, April 24, 2007; HE01

Teresa Hughes is sure about what saved her life on the winter night in
2004 when her boyfriend shot her in the face: It was the emergency
medical care she received from the specially trained team of Maryland
State Police officers who broke into her house to rescue her. Falling
in and out of consciousness, she heard one trooper say, "Oh my, we're
going to get you some help, sweetie, we're going to get you help." He
and his colleagues stabilized her and got her to a waiting helicopter
that whisked her to the shock trauma center in Baltimore.

The treatment Hughes received that night on the floor of the couple's
Taneytown, Md., home is on the front line of emergency medicine and
freshly under the spotlight because of the shootings at Virginia Tech.
Under traditional emergency medical services (EMS) protocol, medical
first responders wait outside a crime scene, or "hot zone," until it
is deemed safe by the police. That can take precious minutes or even
hours -- and can mean the difference between life and death. But in
Hughes's case, the SWAT team included troopers who had been trained as
paramedics and were able to give her immediate care, despite fears
that her boyfriend might be barricaded inside the house.

Maryland State Police (MSP), along with police in Fairfax and
Montgomery counties, the U.S. Park Police and some divisions of the
Virginia State Police, are among the agencies that have embraced
so-called tactical medicine, embedding paramedics and even physicians
into special operations teams in the hope of saving lives, not only in
the kind of domestic attack that Hughes suffered but in mass killings
and school shootings like last week's rampage at Virginia Tech.

Since the mid-1990s, the MSP Tactical Medical Unit -- consisting of
seven advanced-trained paramedics and three Johns Hopkins emergency
care physicians -- has been providing medical support to SWAT teams on
their high-risk missions. "We are deploying physicians to the scene,
and that is not the standard of practice in this country for EMS,"
said Nelson Tang, one of the Hopkins doctors.

Now, in one of the few pairings between law enforcement and an
academic medical institution, MSP and Hopkins plan to expand the role
of out-of-hospital emergency care. The state police will train medical
residents and other physicians in special operations while Hopkins
will help assess the value of tactical medicine, which so far rests
largely on theories drawn from battlefield medicine.

A Model Program

Prompted by the killings in Waco, Tex., and at Columbine High School
in Colorado, these innovations attempt to save the lives of victims,
of members of the SWAT teams and even suspects.

One man behind the thinking is former U.S. surgeon general Richard
Carmona, who served in the Army Special Forces in Vietnam. "We were
never deployed without a medic on the team," said Carmona, who
introduced that concept to police work in the 1980s when he was a
deputy sheriff while also serving as director of Tucson Medical
Center's Trauma Services. "The Maryland State Police is really one of
the model programs nationally," he said.

Across the country, law enforcement agencies have been developing
similar programs, though most rely on fire department emergency
technicians or paramedics to support SWAT teams rather than following
Maryland's model. In the view of Lt. Mark Gibbons, a police commander
and tactically trained paramedic who helped start the MSP unit, it is
an approach worth pursuing. "When law enforcement needs assistance,
special operations is the 911 for cops," Gibbons said, explaining that
frontline medical support tells officers and the public "that you care
about them." Still, tactical medicine is not without controversy,
including whether caregivers (especially physicians) should carry
firearms. MSP's tactical paramedics do carry guns, as they are also
sworn state troopers; the physicians, who stay outside the hot zone,
do not.

'A Phone Call Away'

Those physicians were called out on almost half of the more than 250
missions the tactical medical unit responded to in Maryland last year.
Typically, the doctors provide consultation and logistical support and
give medical care to victims once they have been moved by paramedics.
Under an arrangement by which they hold part-time positions with the
state police, "the physicians are always a phone call away, if they
are not actually on the scene," said Sgt. Keith McMinn, one of the
tactical paramedics.

In recent years, the physicians have joined teams serving high-risk
warrants and dealing with hostage situations; they have supported the
bomb squad, been called to the University of Maryland at College Park
when there has been a risk of crowd violence after basketball games,
and they have helped protect the governor in large gatherings.

Much of the doctors' focus is on the troopers: "A lot of tactical
medicine is keeping a special operations team self-sustained," Gibbons
said. That can mean monitoring the troopers' work-rest cycles on
long-term missions such as hostage incidents; it can involve stapling
non-threatening wounds that might otherwise keep them out of a
mission; and it can even involve advising troopers not to overdo it in
training.

"It's a hybrid of occupational health, emergency medicine, sports
medicine and [acting as] a health and safety officer," said Kevin
Gerold, a Hopkins doctor who is MSP's tactical medical director.

Operating in the Dark

Medical knowledge plays an important role before a mission begins:
"Planning is the most important part . . . to plan for when things go
bad," McMinn said. Members of the medical unit figure out such details
as the location of the nearest hospital and the likelihood of the
presence of hazardous materials. They may also try to determine
whether a suspect has a mental illness or whether a hostage has a
medical problem, such as diabetes, that could affect the outcome of a
case.

Sometimes a mission requires a SWAT member to be deployed in the woods
for hours on a January day or night, even if he's suffering from a
cold or diarrhea. In such cases, "we need that sniper to be focused on
the mission" rather than his own discomfort, McMinn said. Tactical
paramedics can provide medical supplies and some drugs.

Last summer Maryland expanded the scope of its tactical paramedics.
Now they can staple or superglue the wounds of troopers on high-risk
missions, dispense some prescription drugs and provide other care to
keep special operations officers in the fight.

"Functionally, it gives them outstanding flexibility," said Don Alves,
another tactical physician.

Providing emergency care in dangerous settings is very different from
operating in a hospital. "Stealth may be critical to both the success
of the mission as well as the safety of officers and providers,"
Hopkins doctor Tang said.

Light is often a hazard, for example. So rather than relying on sight
to perform a critical procedure such as inserting a breathing tube in
someone's windpipe, Tang said, "we teach a procedure called digital
intubation, where the fingertips are inserted into the mouth and used
to feel for the correct placement."

Similarly, sirens, gunfire and noise from traffic may limit the
physician's ability to use a stethoscope, Tang continued, so "we teach
using hands on both sides of the chest to feel for chest rise."

When there is a gunman at large, the paramedics and physicians may
have to work while lying flat alongside a patient. "The hands can be
used to sweep down a body to feel for moisture that is likely to be
blood, Tang said. "Again, hands on chest to verify breathing.
Alternately, a small mirror can be held up to the face to check for
'fogging' that indicates breaths."

Field Training

With the sound of bombs exploding in a stand of woods outside
Chantilly one day in late March, third-year Hopkins emergency medicine
resident Kiernan DeAngelis got a taste of the challenges facing
medical personnel who work with SWAT teams.

It was training day for DeAngelis and for the MSP unit, which was
joining Fairfax County police and fire departments in three exercises
designed to provide medical support to a bomb squad.

"I realized just how difficult that job is," DeAngelis said, "and how
many factors you have to consider."

DeAngelis has trained with the MSP medical unit in simulations of
terrorist attacks and school hostage scenarios. Soon, Hopkins
residents will have opportunities to join MSP physicians on the
perimeter of high-risk missions. "It's a fairly hot area out there in
medicine," said Lars Thestrup, another Hopkins resident who, like
DeAngelis, had a background in EMS before going to medical school. And
it's a crucial part of the mission, Tang said, "to train the future
leaders of emergency medicine and tactical casualty care."

Prepared for Threats

The scale of the tragedy at Virginia Tech might have overwhelmed the
best of strategies, according to members of the MSP unit. Two Virginia
State Police SWAT teams, one from Salem and one from Culpeper,
responded to the incident, one of which had a tactical paramedic.

But images of wounded students being dragged or carried out of
buildings to a safe location where care could be given evoke the very
challenges the MSP unit is trying to address. "The ability to access
casualties and render aid while an active shooter situation is still
evolving" is a major goal for tactical medicine, Tang said.

"We're seeing very-high-risk threats in our schools, in our malls and
in our airports," Tang said. And on the day of the Virginia Tech
shootings, the MSP unit was training -- at a soon-to-open high school
north of Baltimore -- to respond to just such an incident. ·

Christopher J. Gearon last wrote for the Health section on how
government health agencies troubleshoot TV medical dramas.
Comments:health at washpost.com.