EMT-Basic Exam: The Basics of Operations - Tactical Emergency Medical Support

In extremely dangerous or violent emergencies, a tactical emergency medical support (TEMS) team may be called in to deal directly with anyone involved in the threat. TEMS crews are comprised of specially trained EMS workers who are responsible for the care of patients during a traumatic event. Even if you never serve on a TEMS team, it’s important for you to understand the duties that individual crew members perform. In addition, you may encounter some questions regarding TEMS teams on the EMT-Basic exam.

1. TEMS Responsibilities
A TEMS team may be called on in a variety of dangerous situations. Their support is often requested during hostage negotiations and raids on drug laboratories. Members of the TEMS squad are responsible for assessing and treating anyone who is injured or becomes ill during the operation. In the field, TEMS members commonly encounter and treat the following conditions:
- Gunshot wounds
- Penetrating trauma (stab wounds)
- Pepper spray or tear gas exposure
- Premature pregnancy
- Cardiac or respiratory arrest
- Heat stroke
- Hypothermia
- Hazardous material exposure
- Explosion injuries or burns

As always, this specialized team is led by a knowledgeable and dependable EMS worker. This person, called the tactical leader, is responsible for performing a medical threat assessment (MTA) before other units arrive on the scene. An MTA prepares the EMS crews for the scene and ensures that they know what medications, equipment, and protective gear to bring with them. In some situations, firearms or other weapons may be necessary. Remember, you should never handle a firearm or any other weapon unless you have specialized training. Once EMS crews arrive, the tactical leader will schedule team deployment, rotations, and hydration breaks.

Tip: Preparation for TEMS calls begins before an event takes place. Team members should always be physically and mentally prepared to deal with the stress of the emergency.

2. Field Care and Triage
The tactical leader, along with his or her team members, creates three zones at the scene: the cold zone, the warm zone, and the hot zone. The cold zone is an area where EMS workers and patients are safe from any threats. The warm zone is the outer perimeter of the scene. In this area, contact with perpetrators is unlikely, but injury is still possible. The hot zone, or inner perimeter, is where a persistent or unknown threat still exists. Before establishing these zones, TEMS providers and basic life support (BLS) providers must size up the scene.

a. Scene Assessment
The mnemonic device ACE helps TEMS providers remember how to assess a scene in a tactical environment. ACE stands for assessment, cover and concealment, and evacuation.
As TEMS providers perform their scene assessment, they must always consider the risk of injury or illness to themselves, their team members, bystanders, and patients. These risks include environmental conditions such as extreme heat or cold, scene-specific risks such as stray bullets from a gunman, or any uncommon problems or issues at the scene.
While searching for risks, TEMS providers need to simultaneously determine the boundaries of the hot, warm, and cold zones. These zones must be selected according to the safety they will provide patients and emergency personnel. Ideal zones will provide both concealment, which keeps TEMS providers and patients hidden from perpetrators, and cover, which protects both parties from attack using some kind of physical barrier. TEMS providers use their specialized training to spot protected locations for these zones.
As part of the MTA, the tactical leader will identify locations for helicopter landing zones and EMS contact points before anyone steps foot on the scene. Knowing where these points are is vital and reaching them is challenging. Moving patients from the hot zone to the warm zone and then into the cold zone is called evacuating. In case an evacuation route is blocked or compromised, you must be aware of alternate routes. Once in the cold zone, you may begin advanced medical interventions.

b. Medical Care
In a tactical emergency, the level of care you can provide a patient with depends on the zone in which you are working. The hot zone is constructed along the innermost perimeter of the scene and the safety level is either unknown or nonexistent. In this zone, the perpetrator or threat may still be nearby. To ensure the safety of the emergency personnel and the patients, very few medical interventions are performed in the hot zone. Performing an intervention such as CPR could draw the attention of a perpetrator, putting the responders and the patients in great danger. In certain situations, tactical leaders may direct TEMS providers who have specialized BLS training to treat life-threatening conditions in the hot zone.
Occasionally, TEMS providers may need to treat injured coworkers in the hot zone. When approaching a TEMS provider who has been injured, follow these steps:

1. Identify yourself as an EMT-Basic or TEMS provider and verbalize your intent to help.

2. If you’re under fire and have the proper training, return fire and allow your patient to return fire. If you’re not under fire, disarm the patient.

3. If the patient is hemorrhaging, attempt to intervene using a tourniquet or direct compressive dressings.

4. Evacuate the patient to the warm zone for further care using a fireman’s carry, one-person drag, or one-to-two person lift, depending on your patient’s injuries. If the patient can walk, help support his or her weight.

Remember to communicate with your patient throughout your approach, treatment, and evacuation. If you approach a patient who appears deceased, don’t attempt rescue until the area is declared safe. Doing so would only put your life, and possibly the lives of your coworkers, at risk.
Although the warm zone is usually a safe distance from the threat, workers in this zone must always be aware of their surroundings. The risk of injury from explosions and hazardous materials still exists in this zone. Workers in the warm zone are able to provide a higher level of patient care because there is a lower risk of injury. If a threat from an assailant with a dangerous weapon is verified, workers must follow noise and light restrictions to avoid attracting additional attention to themselves and their patients. Workers may need to treat or assess patients in nontraditional and uncomfortable positions to avoid giving away their position.

When a patient comes to you for medical assistance in a warm zone, follow these steps:

1. If patient has a weapon, disarm him or her and confiscate all secondary weapons.

2. Assess the patient’s airway, breathing rate, and circulation.

3. Place the patient in the recovery position.

4. Inspect the patient for additional injuries, including those from contact with hazardous materials.

5. Splint any fractures.

Continue communicating with the patient as you move, paying close attention to any changes in mental status. Patients who are confused, unresponsive, in shock, or who have sustained a life-threatening wound should be evacuated to the cold zone as soon as possible.

Tip: Never perform CPR on your patient in the warm zone; your actions may give away your position.

The cold zone is an area located far enough away from the event that all workers and patients are no longer at risk of injury or contamination. Regular standards and rules regarding trauma, triage, and transport apply in the cold zone. Advanced life support (ALS) and advanced trauma life support (ATLS) providers are positioned in this zone and will tend to any serious injuries before transport.
Minor injuries such as contact with pepper spray or tasers should be treated in the cold zone. Before patients can be transferred, the emergency responders must disarm them, determine their priority, and decontaminate them. If the patient is a member of an emergency response team, it is recommended that a TEMS provider accompanies the patient to the hospital. This allows the TEMS provider to communicate any changes in the patient’s condition to the team onsite.

Related Topics You Should Review:
- Basic principles of tactical field care and triage
- Working with BLS providers, ALS providers, and other support teams
- Lifts/carries used during evacuations or extrications
- Performing rapid circulatory assessments
- START method