AOHC April 2012 Medical Support of SWAT Teams Fabrice Czarnecki, M.D., M.A., M.P.H., FACOEM I have no disclosures to make. Police Tactical Teams History of SWAT Watts riots 1965 University of Texas tower incident 1966 Summer Olympics in Munich 1972 Summer Olympics in Munich 1972 Ma alot school attack 1974 1
History of SWAT NYPD Emergency Service Unit 1920 LAPD Special Weapons and Tactics1967 LASD Special Enforcement Bureau 1970 GIPN (France) 1972 GSG9 (Germany) 1973 Roles of SWAT Barricaded subjects Emotionally disturbed persons High risk warrants (arrest and search) Hostage rescue Active shooters Protection (persons and events) Capabilities Entry team Containment team Less lethal equipment Entry tools Explosive breaching HazMat / WMD Snipers 2
Capabilities TEMS Canine Explosive ordnance disposal Air assets Hostage negotiators Equipment Body armor (level IIIA or above, with trauma plate) Handgun Longgun Ballistic shield Respirator Gloves (fire retardant) Boots Uniform (fire retardant) TEMS Tactical Emergency Medical Support 3
TEMS Providers SWAT officer Officer/EMT ( EMT Tactical ) Paramedic TEMS Medical Director Tactical Combat Casualty Care Tactical Combat Casualty Care (TCCC) Current US military model of tactical medicine First publication in 1996 (Military Medicine) 3 phases of care: Care under fire Tactical field care Tactical evacuation care http://www.naemt.org/education/phtls/tccc.aspx Care Under Fire 1. Return fire and take cover. 2. Direct or expect casualty to remain engaged as a combatant if appropriate. 3. Direct casualty to move to cover and apply self aid if able. 4. Try to keep the casualty from sustaining additional wounds. 4
Care Under Fire 5. Casualties should be extricated from burning vehicles or buildings and moved to places of relative safety. Do what is necessary to stop the burning process. 6. Airway management is generally best deferred until the Tactical Field Care phase Care Under Fire 7. Stop life threatening external hemorrhage if tactically feasible: Direct casualty to control hemorrhage by self aid if able. Use a CoTCCC recommended tourniquet for hemorrhage that is anatomically amenable to tourniquet application. Apply the tourniquet proximal to the bleeding site, over the uniform, tighten, and move the casualty to cover. Tactical Field Care 1. Casualties with an altered mental status should be disarmed immediately. 2. Airway Management a. Unconscious casualty without airway obstruction: Chin lift or jaw thrust maneuver Nasopharyngeal airway Place casualty in recovery position 5
Tactical Field Care 2. Airway Management b. Casualty with airway obstruction or impending airway obstruction : Chin lift or jaw thrust maneuver Nasopharyngeal airway Allow casualty to assume any position that best protects the airway, to include sitting up Place casualty in recovery position If previous measures unsuccessful: Surgical cricothyroidotomy (with lidocaine if conscious) Tactical Field Care 3. Breathing a. In a casualty with progressive respiratory distress and known or suspected torso trauma, consider a tension pneumothorax and decompress the chest on the side of the injury with a 14 gauge, 3.25 325inch needle/catheter unit inserted in the second intercostal space at the midclavicular line. Ensure that the needle entry into the chest is not medial to the nipple line and is not directed towards the heart. Tactical Field Care 3. Breathing b. All open and/or sucking chest wounds should be treated by immediately applying an occlusive material to cover the defect and securing it in place. Monitor the casualty for the potential development of a subsequent tension pneumothorax. 6
Tactical Field Care 4. Bleeding a. Assess for unrecognized hemorrhage and control all sources of bleeding. If not already done, use a CoTCCC recommended tourniquet to control lifethreatening external hemorrhage that is anatomically amenable to tourniquet application or for any traumatic amputation. Apply directly to the skin 2 3 inches above wound. Tactical Field Care 4. Bleeding b. For compressible hemorrhage not amenable to tourniquet use or as an adjunct to tourniquet removal (if evacuation time is anticipated to be longer than two hours), use Combat Gauze as the hemostatic agent of choice. Combat Gauze should be applied with ihat least 3 minutes of direct pressure. Before Bf releasing any tourniquet on a casualty who has been resuscitated for hemorrhagic shock, ensure a positive response to resuscitation efforts (i.e., a peripheral pulse normal in character and normal mentation if there is no traumatic brain injury (TBI)). Tactical Field Care 5. Intravenous (IV) access 6. Fluid resuscitation 7. Prevention of hypothermia 8. Penetrating Eye Trauma 9. Monitoring 10. Inspect and dress known wounds 11. Check for additional wounds 12. Provide analgesia as necessary 7
Tactical Field Care 13. Splint fractures and recheck pulse 14. Antibiotics: recommended for all open combat wounds 15. Burns 16. Communicate with the casualty if possible 17. Cardiopulmonary resuscitation (CPR) 18. Documentation of Care Tactical Evacuation Care 1. Airway Management (advanced airways) 2. Breathing 3. Bleeding 4. Intravenous (IV) access 5. Fluid resuscitation 6. Prevention of hypothermia 7. Penetrating Eye Trauma Tactical Evacuation Care 8. Monitoring 9. Inspect and dress known wounds if not already done 10. Check for additional wounds 11. Provide analgesia as necessary 12. Reassess fractures and recheck pulses 13. Antibiotics: recommended for all open combat wounds 8
Tactical Evacuation Care 14. Burns 15. Pneumatic Antishock Garment 16. Documentation of Care TCCC: Limitations Great training tool Critical concept of prioritization of tactical over medical Military protocols, not adapted dto domestic law enforcement (tourniquets rarely needed) Roles of the Medical Director 9
NTOA Statement The N.T.O.A. believes the general duties of a medical officer should include: Before a Mission 1) Preventive Medicine/Health Maintenance/Injury Control 2) Mission planning (medical aspects)/medical Threat Assessment 3) Research of Pertinent or Topical Medical Issues 4) Recommendation of Internal Policies related to TEMS or General Health Issues NTOA Statement During a Mission Direct Medical Care Medical Control of certified prehospital care providers Advisement/Consultation for Incident Commanders, Team Leaders Liaison with local EMS system officials, local hospitals, officials from other public safety agencies NTOA Statement After a Mission Incident review Review of all medical records relevant to operational or training missions Data collection and analysis Recommendations based on review and analysis The Tactical Edge, Spring 1994 10
Medical Threat Assessment Medical Threat Assessment Type of mission Expected duration of mission Hostile subjects: prior violent history, weapons, number of subjects Haz Mat / Clandestine drug lab / WMD Animal threats Booby traps Expected medical needs (number & type of potential patients) Medical Threat Assessment Environment: Weather (temperature, wind, precipitations, humidity) d ffi if i k f h i j Need to rotate officers if risk of heat injury Hydration alone does not prevent heat injuries Use Wet Bulb Globe Temperature 11
Hospital Survey Hospital capability? Trauma / Burn / Decontamination Time of Day? (staffing) Divert? Helicopter pad? Transport Survey How do we get injured to the hospital? Call 911? Ambulance transport (response time?) Pre arranged ambulance BLS or ALS Non ambulance Police car, SWAT vehicle Police SUV Air assets Landing zone Transport Survey How do we get injured to the hospital? Maps GPS Traffic Road closures Planned evacuation routes 12
During a Mission Roles of the Medical Director During a mission: Liaison with local EMS and hospitals Advise SWAT commander Ensure performance of officers (sleep deprivation, cold injury ) Supervise TEMS providers Direct medical care Performance Caffeine pills to fight sleep inertia? Hydration / Food If operation > 12 hours: Establish work sleep cycles Medications? Naps Food safety (gastroenteritis?) 13
Performance: Medical Issues Medical director s decision to restrict officers during an operation (eg, toothache) Medication i use immediately prior or during operation? Preventive Medicine Roles of the Medical Director Compliance with ACOEM LEO guidance Wellness program CAD i d ik d ti CAD screening and risk reduction Medical screening Education: first aid, bloodborne pathogens, nutrition, supplements, shift work, health maintenance (routine and during operations) 14
Roles of the Medical Director Ensuring the physical fitness and emotional health of the team Regular physical training Proper rest bf before scheduled doperations (no off duty job, court appearance, on purpose overtime) Surveillance Programs Hearing (firearms, explosives, distraction devices) Respirator Lead Copper? Immunizations Routine immunizations (verify records) Travel immunizations as needed 15
Medical Records Accessible to the medical director, if possible Tape information inside body armor (medical history, medications, i allergies) Personal Protective Equipment Body armor Footwear Eye protection Hearing protection (especially in training) Helmet Gloves (fire retardant) distraction devices Uniform (fire retardant) HazMat PPE Respirator Body Armor Levels (NIJ Standard) IIA [tested with 9 mm and.40 S&W] II [tested with 9 mm and.357 Magnum] IIIA [tested with.44 Magnum and.357 SIG] III [hard armor, tested with 7.62 x 51 mm] IV [hard armor, tested with 30 06] Trauma plate 16
Team Training Issues Roles of the Medical Director Attend training: Source of most injuries Integration Education of medical director Education of officers Training Injuries 11 deaths in police training in 2010 (US) Heat stroke: Physical activity + PPE/body armor + lack of work/rest cycles Rhabdomyolysis Dilutional hyponatremia Cardiac issues Have an AED on scene Trauma Access to care from training site? 17
Heat Injury Prevention Acclimatization Work/rest cycles (according to Wet Bulb Globe Temperature) Hydration (but risk ikof hyponatremia) Add 20 F to Wet Bulb Globe Temperature if wearing body armor 18