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Ch 11. Subspecialty: Tactical EMS

Tactical medicine comprises out-of-hospital medical services and supports for civilian law enforcement operations, typically SWAT operations.

What Does a SWAT Team Do?

SWAT (Special Weapons and Tactics) teams are law enforce- ment units with specialized training suitable for high-risk assign- ments. They can be local, state, or federal. Occasionally, these teams may be called something other than SWAT, like Special Response Teams (SRT).

  • Assignments frequently include:
  • High-risk warrant service
  • Active shooter response
  • Barricaded suspects
  • Hostage situations
  • Clandestine drug lab interdiction
  • Domestic terrorism
  • Riots or civil unrest

Common Terms in the Tactical Environment

Cold zone: Outer-most perimeter of a tactical scene where risk is lowest.
Warm zone: Moderate risk area of the tactical scene where medical decision-making is most influenced by the dynamics of the tactical scene.
Hot zone: Inner perimeter of the tactical scene where risk is highest (ie, area of active fire).
Breach: To open or port a structure by force, usually with a tool.
Entry: The act of entering a structure with the intent to neu- tralize a known threat and/or clear the structure of additional or unknown threats.
Cover: Any structure on the tactical scene suitable to protect one from danger; not to be confused with “concealment.”
Concealment: The state of being out of the visual field of the threat; not to be confused with “cover.”
Operator: A law enforcement officer (LEO) who is a SWAT team member.

Stack: The term used for the entry team, based on its formation.

What is the role of the Tactical Medical Provider (TMP)?

TMPs can be paramedicine professionals, nurses, physician assistants, or physicians. Sometimes, a TMP is a sworn law en- forcement officer with a medical background. The role of the TMP includes, but is not limited to:

  • Providing team health and preventive care.
  • Performing medical pre-planning for tactical operation.
  • Attending to injury or illness during training and operations.
  • Self-aid/buddy aid education for LEOs.
  • Medical evaluation of a suspect prior to incarceration.
  • Acting as liaison between the tactical team and medical community.

Challenges of the Tactical Environment

The tactical scene differs from the conventional pre-hospital environment because of the challenges presented. Frequent and focused training optimizes the ability of TMPs to work in this environment. Challenges include:

Presence of an active, unpredictable threat to safety.

  • Low light conditions.
  • Sound impediments.
  • Restrictive, bulky nature of protective gear.
  • Chemical munitions.
  • Limited field resources.
  • Extraction and evacuation.
  • Logistics of sustained operations.
  • Preservation of evidence.

Medical Threat Assessment

The medical threat assessment (MTA) is the cornerstone of tactical medical support. It is the method by which the TMPs collect and document information for the medical pre-planning of an operation. This information is to be shared with the tacti- cal commander for consideration when planning an operation. At a minimum, the MTA document should attempt to include the following information:

  • Type of operation.
  • Number of operators.
  • Number of civilians and suspects on scene, and any pre- existing conditions they may have.
  • Nearest ED, trauma center, and burn center.
  • Any public works or other obstacle that would impede transport to definitive care.
  • Nearest landing zone for air medical transport.
  • Canine threats on scene.
  • Emergency veterinary care.
  • Fresh water source on scene.
  • Weather and environmental conditions.


For tactical operations, the positioning and movement of TMPs are at the discretion of the tactical commander and can vary widely from team to team. Some TMPs will line up in the “stack” and make entry with operators. Others may remain in the “warm zone” behind hard cover or in the “cold zone.” Safety is paramount.

PPE for the TMP:

  • Body armor and ballistic helmet
  • Eye protection
  • Ear protection (unless it interferes with communication)
  • Knee pads
  • Medical PPE
  • Air-purifying respirator (APR)
  • Hydration system

Medical Care in the Tactical Environment

The medical treatment paradigms for civilian tactical opera- tions are extrapolated from military medicine models. Based on military data, the 3 most common causes of preventable battle- field death are:

  1. Extremity hemorrhage.
  2. Tension pneumothorax.
  3. Airway obstruction.

Tactical Combat Casualty Care (TCCC) is the military model for battlefield trauma care and is the most commonly used mod- el for the civilian tactical environment. The 3 phases of care un- der TCCC are:

  1. Care Under Fire: The phase of care rendered under hostile fire or while the threat is still active. Depending on the structure of the tactical team or the dynamics of the scene, the first responder may be an operator, and medical equipment may be limited to the contents of the operator’s individual first aid kit (IFAK).
    • Contrary to conventional civilian trauma treatment models, emphasis is placed on hemorrhage control before airway management. The MARCH acronym is frequently used:
      • M — Massive hemorrhage
      • A — Airway
      • R — Respiration
      • C — Circulation
      • H — Head injury/hypothermia
  2. Tactical Field Care: Care rendered when the first responder is no longer under hostile fire. It may also refer to care for the injured on a scene in the absence of antecedent hostile fire. Care may be more detailed and comprehensive, but is still limited by conditions and equipment. Multiple casualties should be triaged accordingly. Delay to definitive care should be minimized.
  3. Tactical Evacuation Care: Care rendered once the casualty is en route to definitive care. Additional medical equipment and personnel may be present, but conditions are still a limitation.

Medical Equipment

Tactical medical kits vary based on the level of the provider, medical protocols, and practice environment. Many teams em- ploy a “modular” system, where the medical kit is organized based on convenience, type of operation, length of operation, and other considerations. Though an exhaustive list of kit contents and formulary medications are beyond the scope of this reference, all kits should include the basic equipment necessary to address the 3 most common causes of preventable battlefield death. This includes:

  • Tourniquets
  • Compression bandages
  • Nitrile gloves
  • Gauze
  • Nasopharyngeal airway
  • Chest seals
  • Large bore needles
  • Shears


  • Campbell JE, et al. Tactical Medicine Essentials. Sudbury, MA: Jones & Bartlett Learning, 2012.
  • Schwartz, Richard B., John G. McManus, and Raymond E. Swienton. Tactical Emergency Medicine. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2008.
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