seastrat

Medic 5880: I hear you that it costs a lot, (I do the budgets every year. All togeter the medics cost about $40k last year) and it may be sort of like taking an paramedic unit to & from the doctor's office for a distant "what if"...however from the law enforcement side, we look at it from the angle that we are potentially using some pretty heavy duty force, and the only reason we're using that force is to make the world a safer place. If we might create a serious problem for someone, we'd best have a pretty good plan to fix that problem. We're all about the safety of everyone involved (otherwise, why would we wait outside the single suicidal barricaded gunman's house trying to talk him out?) I think an understanding of police "Use of Force" rules might help. Contrary to what many seem to think, in fact, we (the police) don't shoot to kill. We shoot to stop -- that is: shooting to stop the suspect from engaging in whatever criminal behavior they are involved in, where the use of deadly force is authorized & for which there is no more peaceful solution. Don't mix this up with "shoot him in the leg" thinking: if we pull the trigger, the behavior has to be bad enough that we are willing to kill. The reality is that aiming and accurately firing a gun is quite difficult under stress, so we only aim at "center mass of the target offered." (This means if I can see all of you I will aim in the middle of your chest. If I can only see your hand, I will shoot at the middle of your hand.) There are some small exceptions for snipers shooting at weapons to disarm suspects and taking out hostage holders, but 99.9% of the time the 1:Shoot to Stop, 2: Aim Center Mass, 3: Only Fire if You are Willing to Kill rules apply. We don't shoot to disable, but more importantly, we are never shooting with the intent to kill. We just want the badguy to stop what he's doing and we are out of other options, or our other options would clearly be ineffective. This not-shooting-to-kill thing is an important distinction. What does this Use of Force stuff have to do with Tactical Medicine? The medics come into play as soon as that trigger press is released. The primary function of any team is to make an area safe for others. As soon as that suspect stops engaging in the behavior that earned him a gunshot wound, the responsibility of SWAT is to make the area safe even for the suspect. We are obligated to make the place safe for him by ensuring that he has adequate care. It may be expensive for us to bring high tech & high speed medics with us every time, but mere expense is an argument would also have you stripping my M-4 of its night vision scope just because the chances of my shooting someone at night are pretty low and I haven't had to do it yet. For that matter, I've never had to shoot anyone even with my pistol, so under the expensive-and-not-often-used argument, I'd probably have to ditch those, too. Actually, I'd have to ditch the guns before the medics: my medics treated a couple of dozen patients last year (a couple were even critical) and my team didn't even fire a single shot (well, except for that accidental discharge in the roll call room, but that's a story for another thread). Since we rarely go to an assignment with less than 1,000 rounds of ammo total, we'd have a tough time asserting in court that we didn't have some idea that we might be involved in something where somebody got hurt. Plus, our average is that there is an injury or sudden illness on 1 out of every 3.5 missions or so, and a critical injury at least once per year. Clearly we should expect to need our medics when we head out. If we deployed without them, we'd be opening ourselves up almost no matter what the cost to have them tag along. And considering that a jury will likely hold me highly accountable if I shoot a bad guy (or worse I miss and hit a good guy accidentally) and he dies without care from a GSW that he would have survived if he'd had rapid care & transport, I'm more than happy to see a chunk of my team budget going to protect, among other things, my financial assets from a needless lawsuit. "Surviving" a shooting means more than coming out the other end still breathing. I'm confident that my medics stand ready to keep me safe beyond just keeping my blood pressure from falling below 120/80 if I spill some of my blood in the street. They'll also help keep my blood pressure from going over 220/180 by keeping me from the stress of getting sued if I spill somebody else's blood, too. And that's worth a lot to me.

I hope I didn't come across as trashing the "regular" EMS in my area (they are great) it's just that they don't see a ton of GSWs, and there is a varied level of experience on the average unit. We tend to pick "seasoned" medics who have worked in nearby big city systems and have seen tons of bad penetrating trauma. The day I get shot, I want the medic working on me to almost be bored with my injury she's seen it so many times. It would be a lot to ask a rookie medic to do well in a super high stress situation like that, especially if his unit was split and he was solo. And as far as the security issue of sharing our info with the "regular" medics, we tend to be a little paranoid (not always a bad thing in our world), and we don't even always tell the local police what we are doing sometimes until minutes before we do it. Not that we don't trust "regular" cops & medics...but we don't trust them. We've executed on targets that involved both EMS personnel and local police officers, so we kind of tend to stick to ourselves with our info. Having TOMS on the inside just gives us the edge there, because we know we can trust "our guys:" we've backgrounded the hell out of them, we see them every month at training, and they are putting themselves in the risky places right along with us. Operational security is part of their "everyday" because they don't want to get hurt any more than any of us. A couple of years ago we had patrol assist us when we executed a narcotics, gambling, prostitution and weapons search warrant on a night club that turned up empty when we got there...cigar smoke lingering in the room, drinks and cards on the table, one chair overturned, recently flushed toilets: you get the picture. Without revealing details, suffice to say Internal Affairs had their hands full with that one, and issued lots of subpoenas to cell phone carriers. Since then we collect cell phones from non-team personnel (including patrol cops and D.A.s) on senstitive ops before mission briefing starts. Our medics, on the other hand, keep their phones. And you are 100% right about that Preventive Medicine Mission, Former Lt. Our guys do a full physical with our MD on every team member and file a baseline 12 lead on each guy. It's pretty personal: they ask about every hang nail you ever had and how many times you pee at night. The bonus is that when you have to make a trip to the ER, you have all the answers available. If you take one in the vest, there's a baseline EKG so you can see the changes from a cardiac contusion. Last year, they found a bundle branch block on of our guys he never knew he had. And with the advent of all this chem/bio stuff (we are now mandated to train for CBRN events), we know that there are two guys who are allergic to Cipro (so no anthrax for them), and one guy has a mild eye pressure issue (so cautious use of Atropine in him during the organophosphate event, because Atropine increases ocular pressure). No way we'd know any of that stuff about our guys without our medics, and indiscriminate use of one of those 2-Pam/Atropine autoinjectors kits might make one of our guys blind -- not exactly a "win" for us. And since they maintain those records, we have them store all the emergency contact data, too -- they get pretty detailed there, too, & include info like where my wife works and what police department covers that area (and their number), so we can call them and ask them to send a car to get her & zip her out to the trauma center if the day turns out badly. They also do rehab and 'fix" minor injuries that otherwise might take an operator off line. We have 34 guys which sounds like a lot, but really isn't if you have a barricade/hostage. We need every guy functioning 100% to do that job right (containment, sniper/observer, entry, rescue, etc.). A guy who maces himself accidentally might be done for the day -- but with our medics it's two drops of Tetracaine, a serious chops-busting and he's back in the game. It's really just a lot of "little" stuff that will catch you off guard that our medics help prevent against.

Having been a police officer assigned to a high-risk law enforcement team just outside NYC for the past 5+ years, both before and after we had medics assigned to us I have to disagree with the idea that TEMS is a "pointless waste of resources." Often, people who aren't involved with these kinds of operations don't understand what high risk law enforcement teams really do, which is why they think TEMS or more accurately TOMS (Tactical Operational Medical Support) is a waste of time. I'll try to lay out for you some of the reasons TOMS is a good thing: First, there is the peace of mind factor. It is much easier for me to go in after a badguy knowing that if things go south I'm not going to be waiting around for who-knows-how-long for a 911 ambulance to show up. And even if we have a unit on standby, there is a small question about what crew is working that day. I'll spout more on this a little later, but as far as peace of mind is concerned, I'm confident that the medics assigned are the cream of the crop -- I'm not getting the rookie medic who just got out of class and is going to be a bundle of nerves when he's treating me. On our team, the medics have been background checked and vetted by both the EMS side and the law enforcement side, and they are full time professional paramedics with years of experience. I'm not suggesting that the police deserve a higher level of care than the average citizen (as a matter of fact, better than 80% of the patients treated by our medics have been innocent civilians or suspects), it's just that tactical scenes tend to be highly charged events, and being able to choose quality personnel who have been through the grinder a bit ahead of time is a great advantage. Which brings me to the main thing that the medics on my team do: they plan ahead. Most of what SWAT does is plan ahead. We will sometimes take a two or three days to develop intel on what seems on the outside to be a "basic" narcotics warrant. SWAT is expected to be able to deal with pretty much whatever comes up. After a job, we can't say "Well, we never really expected THAT to happen." And we'd prefer not to have to think up a plan on the spot when things don't go by the numbers: we'd rather know what plan B, plan C, and plan D is so we can seamless switch gears without calling a Time Out. Having the medics give their two cents at the planning stage is essential -- something we didn't even realize we were missing until we started including them. The Team Leader has a million things to worry about and he can't remember everything, the operators are focused on their individual missions and learning the plans & contingencies, and the high brass are wondering if they should bring an extra mocha latte to the scene if we are going to be a while. For my team, it is essential that we have people there who can think about those million little details that will "get" you if you don't consider them: what hospital is "open," what a good LZ might be & if any kids are playing soccer on it, what the local traffic and weather conditions are, whether we'll need Child Services if there are minors in the target, and during extended operations, food/hydration & work cycles: it's all kinds of stuff like that that the medics think about in their preplan. I can tell you a horror story about a night where a cop got shot, his buddies threw him in the back of a patrol car and drove him to a hospital that was on trauma divert because the CT was down for maintenance. That night right there justified our TOMS preplan 100%. The medics know our plan ahead of time, so there is no confusion about what may be a safe place for them to work and what is probably not a safe place. And, at the risk of too many "war stories," I can tell you about a day when two medics strolled right though the middle of a gunfight because no one told them what was happening, where the bad guy was, anything. Our medics know the plan, know the target, have maps and diagrams, understand what the geometry of cover is likely to be (that is, where they can "hide" if things go badly, and what kind of safe "shadow" a given piece of cover is likely to give them). And that's just not information we'd be willing to share ahead of time with medics that we hadn't done backgrounds on. Waco, Texas came unraveled in part because ATF asked for help from the local volunteer ambulance, they told the mailman, he told Branch Davidian and lots of people died. Planning ahead goes beyond just doing the mission preplans: The medics on my team know how to get me out of my gear quickly (Our vests have a million buckles and straps and unclipping is faster than cutting), and they practice keeping c-spine with my helmet on. Everybody knows what a pain in the neck getting a motorcycle helmet off is, if you haven't practiced with a kevlar helmet and a radio headset you don't want to do it for the first time with blood all over the place and a bunch of cops with machine guns screaming at you to get to the hospital with their buddy. (Especially if you are that rookie medic.) We also make our medics "weapons familiar." Once upon a time I was in an ambulance when the crew discovered a gun on their patient (he was an unconscious off-duty cop). When the .38 in it's holster fell on the floor of the ambulance the crew froze -- not their fault, none of them had ever seen a gun up close before. Our medics know that they can pick up a gun, make it safe (in a number of ways) and keep doing their job without freaking out. TEMS naysayers often suggest that there should always be a police officer assigned to babysit any patient the medics are treating, but that just isn't realistic: You have one (maybe two?) guys from the entry team shot up, plus you are going to strip two more guys to babysit them...how many guys are left to go get the badguy -- remember, the bad guy? THe one shooting at the police? Instead, our medics can render the weapons safe, stow them in a compartment in their truck, tape off flashbangs, smoke & gas, and move on with treatment. My team knows and respects the medics and their decisions. Tactical decisions are made by the Team Leader, but he defers to them on treatment/transport questions. Remember my guy who was transported by patrol car to the wrong hospital? There was a paramedic unit less than a block away when that happened, but the unforms "didn't think they could wait." On my team, the guys know that if the medics need another minute, another 5 minutes, we don't rush them, because they've got work to do before moving the patient. Yes, all SWAT teams are supposed to be well-disciplined, but it can be quite challenging to maintain that discipline if your best friend looks like he's dying and two guys you've never seen before look like they are dilly-dallying on the scene. And there is an added benefit. Here on the East Coast, medics are underpaid, under-appreciated and under-recognized for their service generally. The medics on my team have definitely helped to bridge the gap between services. Some guys on my team never knew the difference between a paramedic and an EMT, even though the entire county is staffed by paid ALS flycar paramedics and volunteer BLS EMT ambulances. Now, the even the paid medics who are not members of the team enjoy a certain "co-professional" status in the county (and for the first time the cops have come out on the side of the medics with regards to salary and benefits). We take great pains to weed out the "wannabes," so we don't have guys who think they are cowboys. I'm not saying those people aren't out there, but from what I've seen, they generally don't last too long if they are actually assigned to a team. Our medics are cool, calm, almost mellow guys & girls who are anything but the TEMS nuts people like to talk about. I interact with the medics from other nearby counties, and I'd have to say the same about them: the nuts get thrown out in interview, initial training or their first few missions. Although we don't train anybody to do major ALS "care under fire" but there may be times when you want ALS to "push" into a structure. To best explain this, I have to site everybody's favorite TEMS justification: Columbine. Teacher Dave Sanders was shot before 11:30. He didn't die until 15:00. Even if evacuation was tactically impossible, if medics could have pushed in to that room, he might have had a better chance. Yes, what he really needed was surgery, but to wait 3 and a half hours with no care really reduced his chances for survival. And it made the responders seem helpless: The famous "1 bleeding to death" sign in the window where he was dying was a call for help that went unanswered. Would Dave Sanders have died anyway? Who knows, but he survived without any meaningful care for more than 3 hours, so I'm guessing his chances might have been pretty good. Please note: this is not a crack on Littleton Fire or Denver General: that was the first time we saw something like this. Almost no one would have been prepared, it was just bad luck for them that they were first. But whoever is next (and there have been plenty) will be judged to have been irresponsible for not considering that someone might need medical attention in a tactical environment. Not having medics capable of treating someone while "bunkered down" will likely be considered negligent. Well, I guess that's a little more than two cents worth, but I hope it clears up some questions for the folks out there who don't think TEMS/TOMS is a worthwhile venture.