15
T ACTICAL MEDICINE—COMPETENCY -BASED GUIDELINES Richard Bruce Schwartz, MD, John G. McManus, Jr., MD, MCR, John Croushorn, MD, Gina Piazza, DO, Phillip L. Coule, MD, Mark Gibbons, Glenn Bollard, MD, David Ledrick, MD, Paul Vecchio, E. Brooke Lerner, PhD ABSTRACT Background. Tactical emergency medical support (TEMS) is a rapidly growing area within the field of prehospital medicine. As TEMS has grown, multiple training programs have emerged. A review of the existing programs demon- strated a lack of competency-based education. Objective. To develop educational competencies for TEMS as a first step toward enhancing accountability. Methods. As an ini- tial attempt to establish accepted outcome-based competen- cies, the National Tactical Officers Association (NTOA) con- vened a working group of subject matter experts. Results. This working group drafted a competency-based educational matrix consisting of 18 educational domains. Each domain included competencies for four educational target audiences (operator, medic, team commander, and medical director). The matrix was presented to the American College of Emer- gency Physicians (ACEP) Tactical Emergency Medicine Sec- tion members. A modified Delphi technique was utilized for the NTOA and ACEP groups, which allowed for additional expert input and consensus development. Conclusion. The resultant matrix can serve as the basic educational standard around which TEMS training organizations can design pro- grams of study for the four target audiences. Key words: tactical medicine; tactical combat casualty care; hemorrhage control PREHOSPITAL EMERGENCY CARE 2011;Early Online:1–15 INTRODUCTION Over the course of the last 40 years, law enforcement units have identified the need for specialized teams Received February 26, 2010, from the Department of Emergency Medicine (PLC) and the Center of Operational Medicine (PV), Medi- cal College of Georgia (RBS, GP), Augusta, Georgia; the Department of Emergency Medicine (JGMcM, JC), Brooke Army Medical Center, Fort Sam Houston, Texas; the National Tactical Officers Association (MG), Baltimore, Maryland; the Department of Emergency Medicine (DL), Saint Vincent’s Mercy Medical Center, Toledo, Ohio; the De- partment of Emergency Medicine (EBL), Medical College of Wiscon- sin, Milwaukee, Wisconsin; and TEMS Section (GB), American Col- lege of Emergency Physicians, Irving, Texas. Revision received June 17, 2010; accepted for publication June 22, 2010. The authors report no conflicts of interest. The authors alone are re- sponsible for the content and writing of the paper. Address correspondence and reprint requests to: Richard Bruce Schwartz, MD, Medical College of Georgia, 1120 15th Street, Au- gusta, GA 30912. e-mail: [email protected] doi: 10.3109/10903127.2010.514092 to deal with unique problems. 1 These teams have de- veloped a variety of subject matter experts in nego- tiations, weapons, explosives, and medicine. Those who provide medical support during tactical opera- tions represent a unique segment of prehospital care providers, working in hazardous and austere environ- ments. This type of prehospital medicine, known as tactical medicine, is an evolving discipline. Tactical medicine is broad based and includes care provided not only by traditional medical providers (emergency medical technicians [EMTs], physicians, physician assistants, and nurses), but also by the op- erators themselves. Additionally, it impacts the tacti- cal and medical command structure in which the unit operates. The goal of effective tactical medicine sup- port is to enable law enforcement to operate more ef- ficiently, more effectively, and with reduced risk. Tra- ditional emergency medical services (EMS), nursing, and medicine require practitioners to undergo stan- dardized testing and licensure procedures. In addi- tion, various standardized educational curricula have been developed for aspects of medical care such as the use of Advanced Cardiac Life Support (ACLS) for the management of cardiac arrest. No such standardized curricula exist for tactical emergency medical support (TEMS). There is a need for defined and consistent skill competencies that are expected for TEMS providers. The lack of a tool of this nature has limited standard- ization through our nation’s law enforcement organi- zations. Consistency with regard to core competencies would provide standards from which training and pro- tocols could be developed. The provision of trauma care in the tactical envi- ronment has been guided by the U.S. Defense Health Board Committee for Tactical Combat Casualty Care (TCCC). This committee comprises military and civil- ian subject matter experts in tactical medicine. The committee meets regularly to update and incorporate battlefield experience and research into best practices for traumatic casualty care in the tactical environment. The American College of Surgeons (ACS) and the Na- tional Association of Emergency Medical Technicians (NAEMT) have endorsed the military’s guidelines for TCCC. This set of best practices for military care on the battlefield is published in the manual PHTLS: Prehos- pital Trauma Life Support, sixth edition. 2 The guide- lines specify the trauma care to be delivered in a hostile environment to mitigate the risks inherent in combat and are utilized as a base for most tactical medicine 1 Prehosp Emerg Care Downloaded from informahealthcare.com by Medical College of Wisconsin on 09/24/10 For personal use only.

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Page 1: Tactical Medicine-Competency-Based Guidelines

TACTICAL MEDICINE—COMPETENCY-BASED GUIDELINES

Richard Bruce Schwartz, MD, John G. McManus, Jr., MD, MCR, John Croushorn, MD,Gina Piazza, DO, Phillip L. Coule, MD, Mark Gibbons, Glenn Bollard, MD, David Ledrick, MD,

Paul Vecchio, E. Brooke Lerner, PhD

ABSTRACT

Background. Tactical emergency medical support (TEMS)is a rapidly growing area within the field of prehospitalmedicine. As TEMS has grown, multiple training programshave emerged. A review of the existing programs demon-strated a lack of competency-based education. Objective.To develop educational competencies for TEMS as a firststep toward enhancing accountability. Methods. As an ini-tial attempt to establish accepted outcome-based competen-cies, the National Tactical Officers Association (NTOA) con-vened a working group of subject matter experts. Results.This working group drafted a competency-based educationalmatrix consisting of 18 educational domains. Each domainincluded competencies for four educational target audiences(operator, medic, team commander, and medical director).The matrix was presented to the American College of Emer-gency Physicians (ACEP) Tactical Emergency Medicine Sec-tion members. A modified Delphi technique was utilized forthe NTOA and ACEP groups, which allowed for additionalexpert input and consensus development. Conclusion. Theresultant matrix can serve as the basic educational standardaround which TEMS training organizations can design pro-grams of study for the four target audiences. Key words:tactical medicine; tactical combat casualty care; hemorrhagecontrol

PREHOSPITAL EMERGENCY CARE 2011;Early Online:1–15

INTRODUCTION

Over the course of the last 40 years, law enforcementunits have identified the need for specialized teams

Received February 26, 2010, from the Department of EmergencyMedicine (PLC) and the Center of Operational Medicine (PV), Medi-cal College of Georgia (RBS, GP), Augusta, Georgia; the Departmentof Emergency Medicine (JGMcM, JC), Brooke Army Medical Center,Fort Sam Houston, Texas; the National Tactical Officers Association(MG), Baltimore, Maryland; the Department of Emergency Medicine(DL), Saint Vincent’s Mercy Medical Center, Toledo, Ohio; the De-partment of Emergency Medicine (EBL), Medical College of Wiscon-sin, Milwaukee, Wisconsin; and TEMS Section (GB), American Col-lege of Emergency Physicians, Irving, Texas. Revision received June17, 2010; accepted for publication June 22, 2010.

The authors report no conflicts of interest. The authors alone are re-sponsible for the content and writing of the paper.

Address correspondence and reprint requests to: Richard BruceSchwartz, MD, Medical College of Georgia, 1120 15th Street, Au-gusta, GA 30912. e-mail: [email protected]

doi: 10.3109/10903127.2010.514092

to deal with unique problems.1 These teams have de-veloped a variety of subject matter experts in nego-tiations, weapons, explosives, and medicine. Thosewho provide medical support during tactical opera-tions represent a unique segment of prehospital careproviders, working in hazardous and austere environ-ments. This type of prehospital medicine, known astactical medicine, is an evolving discipline.

Tactical medicine is broad based and includes careprovided not only by traditional medical providers(emergency medical technicians [EMTs], physicians,physician assistants, and nurses), but also by the op-erators themselves. Additionally, it impacts the tacti-cal and medical command structure in which the unitoperates. The goal of effective tactical medicine sup-port is to enable law enforcement to operate more ef-ficiently, more effectively, and with reduced risk. Tra-ditional emergency medical services (EMS), nursing,and medicine require practitioners to undergo stan-dardized testing and licensure procedures. In addi-tion, various standardized educational curricula havebeen developed for aspects of medical care such as theuse of Advanced Cardiac Life Support (ACLS) for themanagement of cardiac arrest. No such standardizedcurricula exist for tactical emergency medical support(TEMS). There is a need for defined and consistent skillcompetencies that are expected for TEMS providers.The lack of a tool of this nature has limited standard-ization through our nation’s law enforcement organi-zations. Consistency with regard to core competencieswould provide standards from which training and pro-tocols could be developed.

The provision of trauma care in the tactical envi-ronment has been guided by the U.S. Defense HealthBoard Committee for Tactical Combat Casualty Care(TCCC). This committee comprises military and civil-ian subject matter experts in tactical medicine. Thecommittee meets regularly to update and incorporatebattlefield experience and research into best practicesfor traumatic casualty care in the tactical environment.The American College of Surgeons (ACS) and the Na-tional Association of Emergency Medical Technicians(NAEMT) have endorsed the military’s guidelines forTCCC. This set of best practices for military care on thebattlefield is published in the manual PHTLS: Prehos-pital Trauma Life Support, sixth edition.2 The guide-lines specify the trauma care to be delivered in a hostileenvironment to mitigate the risks inherent in combatand are utilized as a base for most tactical medicine

1

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2 PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2011 VOLUME EARLY ONLINE / NUMBER 1

training programs. These TCCC best practices couldbe developed into competency-based TEMS educa-tion programs; however, they are limited and do notaddress other areas that are considered to be es-sential for the delivery of a comprehensive TEMSprogram.1,3–10 Therefore, a more broadly defined com-petency base is needed for TEMS training curricula.

Currently many well-experienced providers andeducators share the desire to see best practicesbrought into this aspect of prehospital emergencycare. Several tactical medicine training courses ex-ist. However, the educational model has been basedon a process-oriented educational model ratherthan a competency-based, outcome-oriented educa-tional model. Competency-based training is describedas a way to produce reliable and reproducibleroles and responsibilities.11,12 Process-oriented train-ing is focused on the delivery of material, whereascompetency-based training focuses on the attain-ment of specific educational objectives. For instance,process-oriented training would assign credit for at-tending a one-hour lecture on hemorrhage control. Al-ternatively, a competency-based program would focuson the student’s ability to demonstrate the identifica-tion of hemorrhage, the proper application of a tourni-quet, and the application of combat gauze to a woundwith life-threatening hemorrhage. It is essentially thedifference between receiving a card or certificate forcourse attendance after attaining a certain level of per-formance on a written test and receiving a card or cer-tificate for course completion after the demonstrationof skills in a simulated environment. When no demon-stration of skills or knowledge is required, the attendeemay or may not have gained the ability to performthe skills that were taught. As an example, in train-ing physicians, the Accreditation Council for Gradu-ate Medical Education (ACGME) recently adopted sixcore competencies to ensure that residents in trainingconformed to uniform guidelines. This transition tocompetency-based education has changed the focus ofeducation from course or process completion to task orcompetency completion.

Competency can be broadly defined as the habitualand judicious use of communication, knowledge, tech-nical skills, clinical reasoning, emotions, values, andreflection in daily practice for the benefit of the indi-vidual and community being served.13 Competencyis context dependent. A physician’s rank in medicalschool, a pilot’s rank in flight school, or an officer’sstanding at a military academy will not predict how heor she will perform with a given patient, during an in-flight emergency, or in a unique tactical situation. At-taining acceptable grades on a normative test or com-pletion of a course of study alone does not necessar-ily prove that the practitioner has the needed skills.Rather, a demonstration of mastery of a set of crite-ria forms the basis for qualification and the mark of a

competent provider. Competency-based training mayallow for greater standardization of training with a fo-cus on outcomes.11–13

The National Tactical Officers Association (NTOA)and its academic partners assert that tactical medicineprograms should be developed utilizing competency-based, outcome-oriented education programs. Further,if accountability is to be enhanced, objectives, stan-dards, and criteria must be clearly stated and openfor inspection by colleagues, administration, experts,and students.14 The goal of this project was to de-velop educational competencies for TEMS as a firststep toward enhancing accountability. The same ap-proach was taken by the ACGME in 1999 through itsOutcomes Project.15

METHODS

To meet this need, the NTOA assembled an 11-memberworking group of subject matter experts to review ex-isting course curricula, to identify gaps, and to assem-ble a competency-based educational framework forTEMS curricula. This working group was made up offour physicians, one physician assistant, and six out-of-hospital providers (Appendix 1). All members ofthe working group had previously collaborated in thedevelopment of national level TEMS curricula (NTOATEMS curricula and the Tactical Operator Care [TOC]curriculum that was developed for the Federal Bu-reau of Investigation [FBI]). The working group wasselected by the leadership of the NTOA based on theirnational reputation and to ensure that there was rep-resentation from all stakeholder groups (physicians,EMS, law enforcement, military, fire rescue). The TEMSexperience of the group included military as well aslocal, state, and federal civilian law enforcement. Themembers of the working group are listed in Appendix1 along with the individual expertise of each member.

Prior to initiating their work, the members of theworking group reviewed the Core Competencies forHealth Professionals in a Disaster developed by theAmerican Medical Association (AMA) under a grantfrom the Assistant Secretary for Preparedness andResponse (ASPR) as an example of how to developcompetencies for selected population groups.16 Theworking group then drafted a TEMS competencymatrix utilizing a similar methodology as the priorAMA work. They incorporated the practices from theTCCC guidelines into the matrix along with additionalcompetencies relevant to the civilian law enforcementenvironment. The draft TEMS competency matrixwas then reviewed by the American College ofEmergency Physicians (ACEP) Tactical EmergencyMedicine Section using a modified Delphi procedure.The Delphi procedure is a method for obtaininggroup consensus by making revisions to a list ordocument based on group feedback until all agree

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Schwartz et al. TACTICAL MEDICINE COMPETENCY-BASED GUIDELINES 3

that the final list or document is complete or a setnumber of feedback cycles are completed. The Delphiprocedure is based on the assumption that the con-sensus from a structured group is more accurate thanthat from an unstructured group. A “mini” Delphiprocedure (also called talk estimate talk) has beendeveloped for use during face-to-face meetings. Thisproject used a modified Delphi procedure by utilizingboth the traditional Delphi procedure (ACEP TEMSleadership and general membership) and the miniDelphi procedure (NTOA working group).

The specific steps for this project are provided in de-tail. An initial draft of the competencies was developedby a single author (RBS), who then acted as the facilita-tor for the modified Delphi review. The competencieswere provided in written form to the NTOA workinggroup and they had a face-to-face meeting where sev-eral rounds of review were facilitated until consensuson the competencies was achieved.

The revised competency document was then pro-vided to the leadership of the ACEP TEMS Section.The leaders of the TEMS Section reviewed the docu-ment and provided suggested revisions. The facilitator(RBS) reviewed the recommendations and integratedthem into the competency document. The revised doc-ument was provided to the leaders of the TEMS Sec-tion for a review and approval that that version shouldbe sent to the general membership of the ACEP TEMSSection for review. Once the revised document was ap-proved by the section leaders, it was provided via e-mail to the general membership the ACEP TEMS Sec-tion, which consists of 275 physicians. All feedbackwas reviewed by the facilitator (RBS) and integratedinto the document. The revised document was sent tothe general membership of the section for review andconcurrence that consensus was established. The doc-ument was then circulated among the NTOA workinggroup for a final review, and there was agreement thatthe document was complete.

RESULTS

The initial draft document included 11 competency do-mains along with 30 separate core crosscutting com-petencies. The core crosscutting competencies were in-tended to apply to all levels of TEMS providers. Theinitial draft document also included 184 specific com-petencies for TEMS providers. These were competen-cies that would apply to a given target audience. Thespecific target audiences were operator/agent/officer,medical provider, team commander, and medical di-rector.

The expert NTOA working group utilized the miniDelphi procedure to modify the initial draft document.They increased the number of competency domains to14. They also increased the core crosscutting compe-tencies to 43, and the specific competencies to 285.

TABLE 1. The 18 Identified Competency Domains

1. Tactical Combat Casualty Care Methodology2. Remote Assessment and Rescue/Extraction3. Hemostasis4. Airway5. Breathing6. Circulation7. Vascular Access8. Medication Administration9. Casualty Immobilization

10. Medical Planning11. Human Performance Factors/Health Surveillance12. Environmental Factors13. Explosions and Blast Injuries14. Injury Patterns and Evidence Preservation15. Hazardous Materials Management16. Remote/Surrogate Treatment17. Less Lethal Injuries18. Special Populations

The leadership of the ACEP TEMS Section used theDelphi procedure and increased the number of com-petency domains to 17, along with the number of corecrosscutting competencies to 46 and the number ofspecific competencies to 314.

Finally, on review by the ACEP TEMS Section gen-eral membership, using the Delphi procedure, one ad-ditional domain was added, along with two core cross-cutting competencies and 44 specific competencies.

The final TEMS competency matrix includes 18competency domains (see Table 1), 48 core cross-cutting competencies, and 358 specific competencies.As shown in Table 2, the specific competencies aredefined for each level of TEMS provider: opera-tor/agent/officer, medical provider, team commander,and medical director.

The competencies were defined to represent basictasks and information for which the different providertypes are responsible. In some instances, the tasks per-tain to medical procedures and skills. For the comman-der and medical director, unique tasks address specificcommand functions. For example, one role defined forthe commander is ensuring that key equipment andtraining are available. Recurring medical director tasksinclude ensuring competency in the performance ofmedical skills by operators and medical providers, cre-ating medical protocols, and advising the team com-mander.

DISCUSSION

This competency-based matrix represents the initialversion of a dynamic document meant to change andgrow with the evolution of medical technology, as wellas with the collective experience of those who practicemedicine in this unique environment. The matrix rep-resents a framework on which training curricula andmedical protocols can be based.

There is an inherent inability to routinely em-ploy traditional assets (i.e., ambulances, EMTs, and

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edic

aid

bags

toal

low

for

appr

opri

ate

TAC

EV

AC

care

1.3.

5Su

mm

ariz

eth

efi

eld

tria

gepr

oces

san

dev

acua

tion

prio

riti

es

1.3.

11E

nsur

em

edic

com

pete

ncy

inm

edic

alsk

ills

requ

ired

inth

eTA

CE

VA

Cph

ase

ofT

CC

C1.

4D

emon

stra

tepr

ofici

ency

inth

eus

eof

TC

CC

asa

syst

emin

the

tact

ical

envi

ronm

ent

1.4.

1D

escr

ibe

the

proc

ess

ofca

sual

tyex

trac

tion

and

evac

uati

on

1.4.

3D

escr

ibe

the

impo

rtan

ceof

trai

ning

the

oper

ator

sin

the

unit

topr

ovid

eim

med

iate

lifes

avin

gin

terv

enti

ons

1.4.

5D

escr

ibe

the

use

ofop

erat

or-l

evel

first

resp

ond

ers

and

med

ical

prov

ider

sin

the

scop

eof

TC

CC

and

the

prop

erpl

acem

ento

faC

CP

and

its

secu

rity

1.4.

7E

valu

ate

each

oper

atio

nal

plan

,ass

ess

the

med

ical

thre

ats,

and

mak

ere

com

men

dat

ions

toth

eco

mm

and

eron

the

mos

tap

prop

riat

epo

siti

onin

gan

dal

loca

tion

ofm

edic

alas

sets

1.4.

2D

escr

ibe

the

com

pone

nts

ofth

eIF

AK

and

thei

rpr

oper

appl

icat

ion

tech

niqu

es

1.4.

4D

escr

ibe

the

com

pone

nts

ofth

eIF

AK

and

the

med

icai

dba

g1.

4.6

Cre

ate

and

eval

uate

polic

ies

that

incl

ude

med

ical

trai

ning

and

med

ical

scen

ario

sas

apa

rtof

the

unit

’spr

epar

edne

ss

2.R

emot

eA

sses

smen

tand

Res

cue/

Ext

ract

ion

2.1

Dem

onst

rate

profi

cien

cyin

rem

ote

asse

ssm

ent

met

hod

olog

y(R

AM

)

2.1.

1Pe

rfor

ma

rem

ote

asse

ssm

ento

faca

sual

ty2.

1.2

Perf

orm

are

mot

eas

sess

men

tofa

casu

alty

2.1.

3D

escr

ibe

RA

Man

dit

sro

lein

mis

sion

plan

ning

and

exec

utio

n2.

1.4

Ens

ure

the

com

pete

ncy

ofop

erat

ors

and

med

ics

inR

AM

2.1.

5A

dvi

seth

eco

mm

and

eron

the

inte

grat

ion

ofth

ere

mot

eas

sess

men

tfind

ings

into

the

tact

ical

plan

2.2

Dem

onst

rate

profi

cien

cyin

high

-thr

eate

xtra

ctio

nte

chni

ques

2.2.

1Pe

rfor

mIA

Ds

and

high

-thr

eate

xtra

ctio

nte

chni

ques

2.2.

2Pe

rfor

mIA

Ds

and

high

-thr

eate

xtra

ctio

nte

chni

ques

2.2.

3D

escr

ibe

the

impo

rtan

ceof

IAD

s,hi

gh-t

hrea

text

ract

ion,

and

the

need

for

spec

ializ

edeq

uipm

enta

ndsk

ills

2.2.

5D

escr

ibe

the

impo

rtan

ceof

IAD

s,hi

gh-t

hrea

text

ract

ion,

and

the

need

for

spec

ializ

edeq

uipm

enta

ndsk

ills

2.2.

4E

nsur

eth

ateq

uipm

enti

sav

aila

ble

toex

ecut

ehi

gh-t

hrea

tex

trac

tion

2.2.

6R

ecom

men

deq

uipm

entt

obe

used

for

high

-thr

eat

extr

acti

on2.

3D

emon

stra

tepr

ofici

ency

inca

sual

tyex

trac

tion

utili

zing

full

360◦

mul

tid

imen

sion

alta

ctic

alsp

ace

2.3.

1D

escr

ibe

the

mul

tid

imen

sion

alta

ctic

alsp

ace

and

met

hod

sfo

rex

trac

tion

,infi

ltra

tion

,and

exfi

ltra

tion

2.3.

2D

escr

ibe

the

mul

tid

imen

sion

alta

ctic

alsp

ace

and

met

hod

sfo

rex

trac

tion

,in

filt

rati

on,a

ndex

filt

rati

on

2.3.

3D

escr

ibe

the

utili

zati

onof

alte

rnat

ein

filt

rati

on,b

reec

hing

,ex

filt

rati

on,r

outi

neex

trac

tion

,an

dca

sual

tyex

trac

tion

and

the

equi

pmen

treq

uire

dfo

rea

ch

2.3.

4Pr

ovid

ean

awar

enes

s-le

vel

brie

foft

heco

ncep

tof

mul

tid

imen

sion

alta

ctic

alsp

ace

and

its

impl

icat

ions

for

succ

essf

ulca

sual

tyex

trac

tion

2.3.

5R

ecom

men

deq

uipm

entt

obe

used

for

casu

alty

extr

acti

on

(Con

tinu

edon

next

page

)

5

Preh

osp

Em

erg

Car

e D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

edic

al C

olle

ge o

f W

isco

nsin

on

09/2

4/10

For

pers

onal

use

onl

y.

Page 6: Tactical Medicine-Competency-Based Guidelines

TA

BL

E2.

The

18C

ompe

tenc

yD

omai

nsan

dth

eSp

ecifi

cC

ompe

tenc

ies

inth

eFi

eld

Tact

ical

Em

erge

ncy

Med

ical

Supp

ortM

atri

x

Dom

ain

Com

pete

ncy

Ope

rato

rM

edic

alPr

ovid

erTe

amC

omm

and

erM

edic

alD

irec

tor

3.H

emos

tasi

s3.

1D

emon

stra

tepr

ofici

ency

inco

nven

tion

alhe

mor

rhag

eco

ntro

l,in

clud

ing

dir

ectp

ress

ure,

wou

ndpa

ckin

g,w

ound

dre

ssin

g,an

dpr

essu

red

ress

ing

3.1.

1Pe

rfor

mhe

mor

rhag

eco

ntro

ltec

hniq

ues

for

self

-aid

,for

bud

dy-

aid

,and

toas

sist

am

edic

alpr

ovid

er

3.1.

2Pe

rfor

mhe

mor

rhag

eco

ntro

lat

your

leve

loft

rain

ing

and

eval

uate

adeq

uacy

ofhe

mor

rhag

eco

ntro

ldon

eby

oper

ator

s

3.1.

3D

escr

ibe

conv

enti

onal

hem

orrh

age

cont

rolt

echn

ique

san

dth

eir

role

inm

issi

onpl

anni

ng

3.1.

5E

valu

ate

and

trai

nop

erat

ors

and

med

ics

inco

nven

tion

alhe

mor

rhag

eco

ntro

l

3.1.

4E

nsur

eth

atop

erat

ors

are

equi

pped

wit

hIF

AK

san

dm

edic

sar

eeq

uipp

edw

ith

IFA

Ks

and

med

icai

dba

gs

3.1.

6E

nsur

eco

mpe

tenc

yin

med

ical

skill

sre

quir

edin

conv

enti

onal

hem

orrh

age

cont

rol

3.2

Dem

onst

rate

profi

cien

cyin

the

iden

tifi

cati

onof

life-

thre

aten

ing

hem

orrh

age

3.2.

1D

escr

ibe

the

prin

cipl

esin

iden

tifi

cati

onof

life-

thre

aten

ing

and

non–

life-

thre

aten

ing

hem

orrh

age

3.2.

2Id

enti

fyan

dre

asse

ssca

sual

ties

who

requ

ire

hem

orrh

age

cont

rol

3.2.

3D

escr

ibe

the

pote

ntia

lim

pact

oflif

e-th

reat

enin

ghe

mor

rhag

eco

ntro

lon

mis

sion

plan

ning

and

com

plet

ion

3.2.

4E

nsur

eth

atm

edic

san

dop

erat

ors

are

adeq

uate

lytr

aine

dto

iden

tify

life-

thre

aten

ing

hem

orrh

age

3.3

Dem

onst

rate

profi

cien

cyin

the

appl

icat

ion

ofa

tour

niqu

et(T

Q),

com

mer

cial

and

impr

ovis

ed

3.3.

1Pe

rfor

mse

lf-a

pplic

atio

nof

anef

fect

ive

TQ

inbo

tha

light

and

dar

ken

viro

nmen

t,on

each

extr

emit

y,w

ith

one

hand

3.3.

4Pe

rfor

mse

lf-a

pplic

atio

nof

anef

fect

ive

TQ

inbo

tha

light

and

dar

ken

viro

nmen

t,on

each

extr

emit

y,w

ith

one

hand

3.3.

9D

escr

ibe

the

impo

rtan

ceof

TQ

sin

the

cont

rolo

fext

rem

ity

hem

orrh

age

3.3.

11M

ake

reco

mm

end

atio

nto

com

man

der

son

effe

ctiv

eT

Qs

for

IFA

Ks

and

med

icai

dba

gs

3.3.

2Pe

rfor

map

plic

atio

nof

aco

mm

erci

alT

Qon

aca

sual

tyin

both

alig

htan

dd

ark

envi

ronm

ent

3.3.

5Pe

rfor

map

plic

atio

nof

aco

mm

erci

alT

Qon

aca

sual

tyin

both

alig

htan

dd

ark

envi

ronm

ent

3.3.

10E

nsur

eth

atIF

AK

san

dm

edic

aid

bags

are

equi

pped

wit

hef

fect

ive

TQ

s

3.3.

12E

valu

ate

oper

ator

s’an

dm

edic

s’ab

ility

toco

ntro

llif

e-th

reat

enin

ghe

mor

rhag

e

3.3.

3Pe

rfor

map

plic

atio

nof

anef

fect

ive

impr

ovis

edT

Q3.

3.6

Perf

orm

appl

icat

ion

ofan

effe

ctiv

eim

prov

ised

TQ

3.3.

13C

reat

em

edic

alpr

otoc

ols

for

oper

ator

san

dm

edic

sth

atin

clud

eth

eap

plic

atio

nof

TQ

sut

ilizi

ngT

CC

Cpr

inci

ples

3.3.

7A

sses

sa

TQ

for

adeq

uacy

ofap

plic

atio

n3.

3.14

Cre

ate

med

ical

prot

ocol

sfo

rop

erat

ors

and

med

ics

that

incl

ude

the

rem

oval

ofT

Qs

3.3.

8A

sses

sca

sual

tyfo

rT

Qre

mov

al3.

4D

emon

stra

tepr

ofici

ency

inth

eap

plic

atio

nof

adva

nced

hem

osta

tic

agen

ts

3.4.

1D

escr

ibe

the

ind

icat

ions

and

cont

rain

dic

atio

nsfo

rth

eus

eof

adva

nced

hem

osta

tic

agen

ts

3.4.

3D

escr

ibe

the

ind

icat

ions

and

cont

rain

dic

atio

nsfo

rad

vanc

edhe

mos

tati

cag

ents

3.4.

6D

escr

ibe

the

use

ofad

vanc

edhe

mos

tati

cag

ents

inth

eco

ntro

lof

life-

thre

aten

ing

hem

orrh

age

3.4.

8C

reat

em

edic

alpr

otoc

ols

for

oper

ator

san

dm

edic

sth

atco

nsid

erth

eus

eof

adva

nced

hem

osta

tic

agen

ts3.

4.2

Perf

orm

the

prop

erap

plic

atio

nof

adva

nced

hem

osta

tic

agen

ts

3.4.

4Pe

rfor

mth

epr

oper

appl

icat

ion

ofad

vanc

edhe

mos

tati

cag

ents

3.4.

7E

nsur

eth

athe

mos

tati

cag

ents

are

avai

labl

eto

med

ics

and

oper

ator

sas

med

ical

prot

ocol

sd

efine

3.4.

9M

ake

reco

mm

end

atio

nsto

com

man

der

sco

ncer

ning

the

inte

grat

ion

ofad

vanc

edhe

mos

tati

cag

ents

into

the

IFA

Ks

and

med

icai

dba

gs3.

4.5

Eva

luat

eth

eef

fect

iven

ess

ofad

vanc

edhe

mos

tati

cag

ent

hem

orrh

age

cont

roli

niti

ated

byop

erat

ors

6

Preh

osp

Em

erg

Car

e D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

edic

al C

olle

ge o

f W

isco

nsin

on

09/2

4/10

For

pers

onal

use

onl

y.

Page 7: Tactical Medicine-Competency-Based Guidelines

4.A

irw

ay4.

1D

emon

stra

tepr

ofici

ency

inca

sual

typo

siti

onin

g(r

escu

e,ch

in-l

ift,

jaw

-thr

ust)

and

basi

cai

rway

clea

ranc

ete

chni

ques

(Hei

mlic

h,d

irec

tvis

ualiz

atio

n)

4.1.

1Id

enti

fyai

rway

com

prom

ise

4.1.

3Id

enti

fyai

rway

com

prom

ise

4.1.

5D

escr

ibe

the

prin

cipl

esre

late

dto

casu

alty

posi

tion

ing

4.1.

6C

reat

em

edic

alpr

otoc

ols

for

oper

ator

san

dm

edic

sth

atad

dre

ssca

sual

typo

siti

onin

g

4.1.

2Pe

rfor

mpr

oper

posi

tion

ing

ofan

inju

red

casu

alty

(wit

han

dw

itho

utai

rway

com

prom

ise)

4.1.

4Pe

rfor

mpr

oper

posi

tion

ing

ofan

inju

red

casu

alty

(wit

han

dw

itho

utai

rway

com

prom

ise)

4.2

Dem

onst

rate

profi

cien

cyin

plac

emen

tofa

naso

phar

ynge

alai

rway

(NPA

)

4.2.

1D

escr

ibe

the

ind

icat

ions

and

cont

rain

dic

atio

nsfo

rus

eof

anN

PA

4.2.

3D

escr

ibe

the

ind

icat

ions

and

cont

rain

dic

atio

nsfo

rus

eof

anN

PA

4.2.

5D

escr

ibe

the

tact

ical

appl

icat

ions

ofN

PAus

age

4.2.

7C

reat

em

edic

alpr

otoc

ols

for

oper

ator

san

dm

edic

sfo

rth

eus

eof

NPA

s

4.2.

2Pe

rfor

mpl

acem

ento

fan

NPA

4.2.

4Pe

rfor

mpl

acem

ento

fan

NPA

4.2.

6E

nsur

eth

atN

PAs

are

avai

labl

eto

oper

ator

san

dm

edic

sas

med

ical

prot

ocol

sd

efine

4.2.

8M

ake

reco

mm

end

atio

nsto

com

man

der

sre

gard

ing

type

sof

NPA

sto

bein

clud

edin

the

IFA

Ks

and

med

icai

dba

gs4.

2.9

Ens

ure

the

com

pete

ncy

ofop

erat

ors

and

med

ics

inth

eus

eof

NPA

s4.

3D

emon

stra

tepr

ofici

ency

inpl

acem

ento

fasu

prag

lott

icai

rway

(SG

A)d

evic

e

4.3.

1D

escr

ibe

the

ind

icat

ions

for

use

ofan

SGA

dev

ice

4.3.

2D

escr

ibe

the

ind

icat

ions

for

use

ofan

SGA

dev

ice

4.3.

4D

escr

ibe

the

role

ofan

SGA

dev

ice

4.3.

6C

reat

em

edic

alpr

otoc

ols

for

med

ics

for

the

use

ofSG

Ad

evic

es

4.3.

3Pe

rfor

mpl

acem

ento

fan

SGA

dev

ice

4.3.

5E

nsur

eth

atSG

Ad

evic

esar

eav

aila

ble

tom

edic

sas

med

ical

prot

ocol

sd

efine

4.3.

7M

ake

equi

pmen

tre

com

men

dat

ions

toco

mm

and

ers

rega

rdin

gSG

Ad

evic

es4.

3.8

Ens

ure

the

com

pete

ncy

ofm

edic

sin

the

use

ofSG

Ad

evic

es4.

4D

emon

stra

tepr

ofici

ency

inen

dot

rach

eal(

ET

)in

tuba

tion

4.4.

1D

escr

ibe

ET

intu

bati

on4.

4.2

Des

crib

eth

em

edic

alin

dic

atio

nsfo

rpe

rfor

min

gE

Tin

tuba

tion

4.4.

5D

escr

ibe

the

role

ofE

Tin

tuba

tion

4.4.

7C

reat

em

edic

alpr

otoc

ols

for

med

ics

for

ET

intu

bati

on

4.4.

3D

escr

ibe

tact

ical

cons

ider

atio

nsth

atm

ayre

nder

ET

intu

bati

ond

ange

rous

4.4.

6E

nsur

eth

ateq

uipm

entf

orE

Tin

tuba

tion

isav

aila

ble

tom

edic

sas

med

ical

prot

ocol

sd

efine

4.4.

8M

ake

reco

mm

end

atio

nsto

com

man

der

sre

gard

ing

equi

pmen

tfor

ET

intu

bati

on4.

4.4

Perf

orm

ET

intu

bati

on4.

4.9

Ens

ure

the

com

pete

ncy

ofm

edic

sin

perf

orm

ing

ET

intu

bati

on,i

nclu

din

gin

low

-lig

htan

dno

-lig

htsi

tuat

ions

and

othe

rau

ster

een

viro

nmen

ts

(Con

tinu

edon

next

page

)

7

Preh

osp

Em

erg

Car

e D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

edic

al C

olle

ge o

f W

isco

nsin

on

09/2

4/10

For

pers

onal

use

onl

y.

Page 8: Tactical Medicine-Competency-Based Guidelines

TA

BL

E2.

The

18C

ompe

tenc

yD

omai

nsan

dth

eSp

ecifi

cC

ompe

tenc

ies

inth

eFi

eld

Tact

ical

Em

erge

ncy

Med

ical

Supp

ortM

atri

x

Dom

ain

Com

pete

ncy

Ope

rato

rM

edic

alPr

ovid

erTe

amC

omm

and

erM

edic

alD

irec

tor

4.5

Dem

onst

rate

profi

cien

cyin

esta

blis

hmen

tofa

surg

ical

airw

ay(c

rico

thyr

oid

otom

y)

4.5.

1D

escr

ibe

the

use

ofa

surg

ical

airw

ayan

dho

wto

reco

gniz

ew

hen

itm

ight

bene

eded

4.5.

2D

escr

ibe

the

ind

icat

ions

for

plac

emen

tofa

surg

ical

airw

ay4.

5.4

Des

crib

eth

ero

leof

asu

rgic

alai

rway

4.5.

6C

reat

em

edic

alpr

otoc

ols

for

perf

orm

ing

surg

ical

airw

ays

4.5.

3Pe

rfor

mpl

acem

ento

fasu

rgic

alai

rway

usin

gco

mm

erci

ally

avai

labl

ean

dim

prov

ised

tech

niqu

es

4.5.

5E

nsur

eth

ateq

uipm

entf

orsu

rgic

alai

rway

plac

emen

tis

avai

labl

eto

med

ics

asm

edic

alpr

otoc

ols

defi

ne

4.5.

7M

ake

reco

mm

end

atio

nsre

gard

ing

equi

pmen

tfor

surg

ical

airw

aypl

acem

ent

4.5.

8E

nsur

eth

eco

mpe

tenc

yof

med

ics

tope

rfor

msu

rgic

alai

rway

proc

edur

es

5.B

reat

hing

5.1

Dem

onst

rate

profi

cien

cyin

reco

gnit

ion

ofop

enpn

eum

otho

rax

and

tens

ion

pneu

mot

hora

x

5.1.

1Id

enti

fyth

efin

din

gsas

soci

ated

wit

hop

enan

dte

nsio

npn

eum

otho

raxe

s

5.1.

2Id

enti

fyth

efin

din

gsas

soci

ated

wit

hop

enan

dte

nsio

npn

eum

otho

raxe

s

5.1.

3U

nder

stan

dth

atop

enan

dte

nsio

npn

eum

otho

raxe

sar

epr

even

tabl

eca

uses

ofd

eath

inco

mba

tand

law

enfo

rcem

ent

oper

atio

ns

5.1.

4E

nsur

eth

eco

mpe

tenc

yof

oper

ator

san

dm

edic

sin

the

reco

gnit

ion

ofop

enan

dte

nsio

npn

eum

otho

raxe

s

5.2

Dem

onst

rate

profi

cien

cyin

plac

emen

tofa

need

leth

orac

osto

my

5.2.

1D

escr

ibe

wha

tane

edle

thor

acos

tom

yis

and

whe

nit

mig

htbe

need

ed

5.2.

3D

escr

ibe

the

ind

icat

ions

for

perf

orm

ing

ane

edle

thor

acos

tom

y

5.2.

6D

escr

ibe

the

role

ofne

edle

thor

acos

tom

y5.

2.8

Cre

ate

med

ical

prot

ocol

sfo

rm

edic

sto

perf

orm

ane

edle

thor

acos

tom

y5.

2.2

Ass

ista

ppro

pria

tely

trai

ned

med

ical

pers

onne

lin

the

plac

emen

tofa

need

leth

orac

osto

my

5.2.

4D

escr

ibe

need

leth

orac

osto

my

“tro

uble

shoo

ting

”

5.2.

7E

nsur

eth

atne

edle

thor

acos

tom

yeq

uipm

enti

sav

aila

ble

tom

edic

sas

med

ical

prot

ocol

sd

efine

5.2.

9E

nsur

eth

eco

mpe

tenc

yof

med

ics

inpe

rfor

min

gne

edle

thor

acos

tom

y

5.2.

5Pr

oper

lype

rfor

ma

need

leth

orac

osto

my

5.3

Dem

onst

rate

profi

cien

cyin

the

plac

emen

tofa

ches

tsea

l(co

mm

erci

ally

avai

labl

ean

dim

prov

ised

)

5.3.

1D

escr

ibe

the

ind

icat

ions

for

use

ofa

ches

tsea

l5.

3.4

Des

crib

eth

ein

dic

atio

nsfo

rus

eof

ach

ests

eal

5.3.

7D

escr

ibe

the

use

ofth

ech

est

seal

and

its

role

intr

eati

ngon

eof

the

prev

enta

ble

caus

esof

dea

thfr

omtr

aum

a

5.3.

9C

reat

em

edic

alpr

otoc

ols

for

oper

ator

san

dm

edic

sfo

rth

eus

eof

ches

tsea

ls

5.3.

2Pe

rfor

mpl

acem

ento

faco

mm

erci

alan

dan

effe

ctiv

eim

prov

ised

ches

tsea

l

5.3.

5Pe

rfor

mpl

acem

ento

faco

mm

erci

alan

dan

effe

ctiv

eim

prov

ised

ches

tsea

l

5.3.

8E

nsur

eth

ateq

uipm

entf

orpl

acem

ento

fan

effe

ctiv

ech

est

seal

isav

aila

ble

toop

erat

ors

and

med

ics

asm

edic

alpr

otoc

ols

defi

ne

5.3.

10E

nsur

eth

eco

mpe

tenc

yof

med

ics

inth

eus

eof

ches

tsea

ls

5.3.

3A

sses

sth

ead

equa

cyof

ach

ests

eala

fter

plac

emen

t5.

3.6

Ass

ess

the

adeq

uacy

ofa

ches

tsea

laft

erpl

acem

ent

6.C

ircu

lati

on6.

1D

emon

stra

tepr

ofici

ency

inas

sess

ing

adeq

uacy

ofci

rcul

atio

n

6.1.

1D

emon

stra

teth

eab

ility

tod

oa

basi

cas

sess

men

toft

head

equa

cyof

circ

ulat

ion

6.1.

2D

emon

stra

teth

eab

ility

tod

obo

tha

basi

can

dan

adva

nced

asse

ssm

ento

fthe

adeq

uacy

ofci

rcul

atio

n(e

.g.,

mon

itor

ing,

phys

ical

exam

inat

ion)

6.1.

3D

iscu

ssth

ed

iffe

renc

esin

asse

ssm

enti

nth

eva

riou

sph

ases

ofT

CC

C

6.1.

4D

escr

ibe

the

basi

can

dad

vanc

edm

etho

ds

ofas

sess

ing

the

adeq

uacy

ofci

rcul

atio

n

6.1.

5E

nsur

eth

epr

ofici

ency

ofte

amm

embe

rsin

the

asse

ssm

ento

fthe

adeq

uacy

ofci

rcul

atio

nin

both

tact

ical

and

nont

acti

cale

nvir

onm

ents

6.2

Dem

onst

rate

profi

cien

cyin

trea

tmen

tof

circ

ulat

ory

com

prom

ise

6.2.

1D

emon

stra

tepr

ofici

ency

inba

sic

trea

tmen

tof

circ

ulat

ory

com

prom

ise

6.2.

2D

emon

stra

tepr

ofici

ency

inba

sic

and

adva

nced

trea

tmen

tof

circ

ulat

ory

com

prom

ise

(eg,

CPR

,AE

D)

6.2.

3D

escr

ibe

the

basi

can

dad

vanc

edm

etho

ds

totr

eat

circ

ulat

ory

com

prom

ise

6.2.

4C

reat

em

edic

alpr

otoc

ols

rela

ted

totr

eatm

ento

fci

rcul

ator

yco

mpr

omis

e

8

Preh

osp

Em

erg

Car

e D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

edic

al C

olle

ge o

f W

isco

nsin

on

09/2

4/10

For

pers

onal

use

onl

y.

Page 9: Tactical Medicine-Competency-Based Guidelines

7.V

ascu

lar

Acc

ess

7.1

Dem

onst

rate

profi

cien

cyin

the

esta

blis

hmen

tofa

nin

trav

enou

s(I

V)s

alin

elo

ck

7.1.

1D

escr

ibe

the

pote

ntia

lne

edfo

rIV

acce

ss7.

1.2

Des

crib

eth

ein

dic

atio

nsfo

r,an

dta

ctic

alco

nsid

erat

ions

of,

obta

inin

gIV

acce

ss

7.1.

4D

escr

ibe

the

pote

ntia

lnee

dfo

rIV

acce

ss7.

1.6

Cre

ate

appr

opri

ate

trea

tmen

tpro

toco

lsfo

rIV

acce

ss

7.1.

3D

emon

stra

tepr

ofici

ency

inob

tain

ing

IVac

cess

7.1.

5E

nsur

eth

ateq

uipm

entf

orpl

acem

ento

fIV

acce

ssis

avai

labl

eto

med

ics

asm

edic

alpr

otoc

ols

defi

ne

7.1.

7E

nsur

eth

eco

mpe

tenc

yof

med

ics

inIV

acce

sste

chni

ques

inro

utin

ean

dta

ctic

alen

viro

nmen

ts7.

2D

emon

stra

tepr

ofici

ency

ines

tabl

ishm

ento

fan

intr

aoss

eous

(IO

)dev

ice

7.2.

1D

escr

ibe

the

pote

ntia

lne

edfo

rIO

acce

ss7.

2.2

Des

crib

eth

ein

dic

atio

nsfo

rat

tem

ptin

gIO

acce

ss7.

2.4

Des

crib

eth

epo

tent

ialn

eed

for

IOac

cess

7.2.

6C

reat

eap

prop

riat

etr

eatm

entp

roto

cols

for

IOac

cess

7.2.

3D

emon

stra

tepr

ofici

ency

inob

tain

ing

IOac

cess

7.2.

5E

nsur

eth

ateq

uipm

entf

orth

ese

curi

ngof

IOac

cess

isav

aila

ble

tom

edic

sas

med

ical

prot

ocol

sd

efine

7.2.

7E

nsur

eth

eco

mpe

tenc

yof

med

ics

inIO

acce

sste

chni

ques

8.M

edic

atio

nA

dm

inis

trat

ion

8.1

Dem

onst

rate

profi

cien

cyin

IV/

IOfl

uid

resu

scit

atio

n

8.1.

1D

escr

ibe

the

pote

ntia

lne

edfo

rIV

/IO

flui

dre

susc

itat

ion

8.1.

2D

emon

stra

tepr

ofici

ency

inIV

/IO

flui

dre

susc

itat

ion

8.1.

3D

escr

ibe

the

risk

san

dbe

nefit

sof

IV/

IOfl

uid

resu

scit

atio

nto

mis

sion

com

plet

ion

8.1.

5C

reat

eap

prop

riat

eIV

/IO

flui

dre

susc

itat

ion

prot

ocol

s

8.1.

4E

nsur

eth

atIV

flui

dis

avai

labl

eto

med

ics

asm

edic

alpr

otoc

ols

defi

ne

8.1.

6E

nsur

eth

eco

mpe

tenc

yof

med

ics

inIV

/IO

flui

dre

susc

itat

ion

8.2

Dem

onst

rate

profi

cien

cyin

the

adm

inis

trat

ion

ofan

alge

sia

8.2.

1D

escr

ibe

the

need

for

anal

gesi

a8.

2.2

Dem

onst

rate

profi

cien

cyin

anal

gesi

aad

min

istr

atio

n8.

2.3

Des

crib

eth

eri

sks

and

bene

fits

ofan

alge

sia

tom

issi

onco

mpl

etio

n

8.2.

5C

reat

eap

prop

riat

epr

otoc

ols

for

anal

gesi

a

8.2.

6M

aint

ain

appr

opri

ate

cont

rola

ndd

ocum

enta

tion

ofal

lsch

edul

ed

rugs

8.2.

4E

nsur

eth

atIV

anal

gesi

am

edic

atio

nis

avai

labl

eto

med

ics

asm

edic

alpr

otoc

ols

defi

ne

8.2.

7E

nsur

eth

eco

mpe

tenc

yof

med

ics

inan

alge

sia

adm

inis

trat

ion

8.3

Dem

onst

rate

profi

cien

cyin

the

adm

inis

trat

ion

ofem

erge

ncy

anti

biot

ics

for

trau

mat

icw

ound

s

8.3.

1D

escr

ibe

the

pote

ntia

lne

edfo

rem

erge

ncy

anti

biot

ics

topr

even

twou

ndin

fect

ions

8.3.

2D

emon

stra

tepr

ofici

ency

inan

tibi

otic

adm

inis

trat

ion

for

trau

mat

icw

ound

prop

hyla

xis

8.3.

3D

escr

ibe

the

risk

san

dbe

nefit

sof

anti

biot

icad

min

istr

atio

nto

mis

sion

com

plet

ion

8.3.

5C

reat

epr

otoc

ols

for

emer

genc

yan

tibi

otic

adm

inis

trat

ion

for

trau

mat

icw

ound

s8.

3.4

Ens

ure

that

IVan

tibi

otic

sar

eav

aila

ble

tom

edic

sas

med

ical

prot

ocol

sd

efine

8.3.

6E

nsur

eth

eco

mpe

tenc

yof

med

ics

inan

tibi

otic

adm

inis

trat

ion

8.4

Dem

onst

rate

profi

cien

cyin

appr

opri

ate

and

safe

use

ofov

er-t

he-c

ount

er(O

TC

)med

icat

ions

inth

eta

ctic

alse

ttin

g

8.4.

1D

escr

ibe

the

ind

icat

ions

for

use

and

adve

rse

sid

eef

fect

sof

com

mon

lyus

edO

TC

med

icat

ions

and

the

pote

ntia

lben

efits

and

dan

gers

they

crea

tein

the

tact

ical

envi

ronm

ent

8.4.

2D

escr

ibe

the

ind

icat

ions

for

use

and

adve

rse

sid

eef

fect

sof

com

mon

lyus

edO

TC

med

icat

ions

and

the

pote

ntia

lbe

nefit

san

dd

ange

rsth

eycr

eate

inth

eta

ctic

alen

viro

nmen

t

8.4.

4D

escr

ibe

the

ind

icat

ions

for

use

and

adve

rse

sid

eef

fect

sof

com

mon

lyus

edO

TC

med

icat

ions

and

the

pote

ntia

lbe

nefit

san

dd

ange

rsth

eycr

eate

inth

eta

ctic

alen

viro

nmen

t

8.4.

5C

reat

epr

otoc

ols

for

the

adm

inis

trat

ion

ofO

TC

med

icat

ions

gene

rally

cons

ider

edsa

fefo

rus

ein

the

tact

ical

envi

ronm

ent

8.4.

6C

reat

epr

otoc

ols

for

med

ics

toex

clud

epe

rson

nelf

rom

oper

atio

nsbe

caus

eof

adve

rse

med

icat

ion

sid

eef

fect

s

(Con

tinu

edon

next

page

)

9

Preh

osp

Em

erg

Car

e D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

edic

al C

olle

ge o

f W

isco

nsin

on

09/2

4/10

For

pers

onal

use

onl

y.

Page 10: Tactical Medicine-Competency-Based Guidelines

TA

BL

E2.

The

18C

ompe

tenc

yD

omai

nsan

dth

eSp

ecifi

cC

ompe

tenc

ies

inth

eFi

eld

Tact

ical

Em

erge

ncy

Med

ical

Supp

ortM

atri

x

Dom

ain

Com

pete

ncy

Ope

rato

rM

edic

alPr

ovid

erTe

amC

omm

and

erM

edic

alD

irec

tor

8.4.

3D

emon

stra

tepr

ofici

ency

inse

lect

ing

OT

Cm

edic

atio

nsth

atar

ege

nera

llyco

nsid

ered

safe

for

use

inth

eta

ctic

alen

viro

nmen

t

8.4.

7E

nsur

eth

atm

edic

atio

nsar

epr

oper

lyst

ored

and

asse

ssed

ona

sche

dul

efo

rex

pira

tion

and

dam

age

8.5

Dem

onst

rate

profi

cien

cyin

the

iden

tifi

cati

onan

dco

nsid

erat

ion

ofm

edic

atio

nal

lerg

ies

8.5.

1D

escr

ibe

the

impo

rtan

ceof

iden

tify

ing

and

repo

rtin

gm

edic

atio

nal

lerg

ies

tom

edic

alsu

ppor

t

8.5.

3D

emon

stra

tepr

ofici

ency

inth

eid

enti

fica

tion

and

doc

umen

tati

onof

med

icat

ion

alle

rgie

s

8.5.

5D

escr

ibe

the

impo

rtan

ceof

iden

tify

ing

and

repo

rtin

gm

edic

atio

nal

lerg

ies

tom

edic

alsu

ppor

tand

prov

ide

inpu

tint

oth

ere

port

ing

SOP

8.5.

6C

reat

eap

prop

riat

em

echa

nism

sfo

rid

enti

fyin

gan

dre

port

ing

med

icat

ion

alle

rgie

sto

med

ical

supp

ort

8.5.

2D

escr

ibe

reco

gnit

ion

ofan

alle

rgic

reac

tion

toa

med

icat

ion

8.5.

4D

escr

ibe

reco

gnit

ion

ofm

edic

atio

nal

lerg

ies

and

prop

ertr

eatm

ento

falle

rgic

reac

tion

s

8.5.

7C

reat

epr

otoc

ols

for

the

trea

tmen

tofa

llerg

icre

acti

ons

tom

edic

atio

ns

9.C

asua

lty

Imm

obili

zati

on9.

1D

emon

stra

tepr

ofici

ency

inth

em

anag

emen

tof

susp

ecte

dce

ntra

lner

vous

syst

em(C

NS)

orsp

ine

inju

ries

9.1.

1D

emon

stra

tepr

ofici

ency

inth

ere

cogn

itio

nof

com

mon

mec

hani

sms

ofC

NS/

spin

ein

juri

es

9.1.

4D

emon

stra

tepr

ofici

ency

inth

ere

cogn

itio

nof

com

mon

mec

hani

sms

ofC

NS/

spin

ein

juri

es

9.1.

7D

escr

ibe

the

impo

rtan

ceof

the

man

agem

ento

fsus

pect

edC

NS/

spin

ein

juri

es

9.1.

9C

reat

epr

otoc

ols

for

the

prot

ecti

onof

CN

S/sp

ine

inju

ries

9.1.

2D

emon

stra

tepr

ofici

ency

inpr

ovid

ing

basi

cC

NS/

spin

epr

otec

tion

9.1.

5D

emon

stra

tepr

ofici

ency

inpr

ovid

ing

adva

nced

CN

S/sp

ine

prot

ecti

on

9.1.

10E

nsur

eth

eco

mpe

tenc

yof

oper

ator

san

dm

edic

sto

prot

ect

CN

S/sp

ine

inju

ries

9.1.

3D

emon

stra

tepr

ofici

ency

inba

sic

neur

olog

icas

sess

men

t

9.1.

6D

emon

stra

tepr

ofici

ency

inad

vanc

edne

urol

ogic

asse

ssm

ent

9.1.

8E

nsur

eth

atsu

pplie

sar

eav

aila

ble

toop

erat

ors

and

med

ics

toal

low

them

tost

abili

zean

dpr

otec

tCN

S/sp

ine

inju

ries

asm

edic

alpr

otoc

ols

defi

ne

9.1.

11R

ecom

men

deq

uipm

entf

orop

erat

ors

and

med

ics

topr

ovid

eC

NS/

spin

epr

otec

tion

9.2

Dem

onst

rate

profi

cien

cyin

frac

ture

splin

ting

and

extr

emit

yne

urov

ascu

lar

asse

ssm

ent

9.2.

1D

emon

stra

tepr

ofici

ency

inba

sic

splin

ting

9.2.

3D

emon

stra

tepr

ofici

ency

inba

sic

and

adva

nced

frac

ture

man

agem

ent,

incl

udin

gsp

lint

appl

icat

ion

and

trac

tion

splin

ting

9.2.

5D

escr

ibe

the

prin

cipl

esof

splin

ting

9.2.

7C

reat

epr

otoc

ols

for

frac

ture

splin

ting

for

oper

ator

san

dm

edic

s

9.2.

8E

nsur

eth

eco

mpe

tenc

yof

oper

ator

san

dm

edic

sin

basi

csp

linti

ngte

chni

ques

9.2.

2D

emon

stra

tepr

ofici

ency

inex

trem

ity

neur

ovas

cula

ras

sess

men

tbef

ore

and

afte

rsp

linti

ng

9.2.

4D

emon

stra

tepr

ofici

ency

inex

trem

ity

neur

ovas

cula

ras

sess

men

tbef

ore

and

afte

rsp

linti

ng

9.2.

6E

nsur

eth

atsu

pplie

sar

eav

aila

ble

toop

erat

ors

and

med

ics

for

splin

ting

and

extr

emit

yne

urov

ascu

lar

asse

ssm

enta

sm

edic

alpr

otoc

ols

defi

ne

9.2.

9E

nsur

eth

eco

mpe

tenc

yof

oper

ator

san

dm

edic

sin

extr

emit

yne

urov

ascu

lar

asse

ssm

ent,

incl

udin

gbe

fore

and

afte

rex

trem

ity/

join

tm

anip

ulat

ion

and

splin

tap

plic

atio

n9.

3D

emon

stra

tepr

ofici

ency

inth

eem

erge

ntre

duc

tion

ofjo

intd

islo

cati

ons

9.3.

1D

escr

ibe

the

risk

san

dbe

nefi

tsof

join

tdis

loca

tion

red

ucti

onto

mis

sion

com

plet

ion

9.3.

3D

escr

ibe

the

risk

san

dbe

nefi

tsof

join

tdis

loca

tion

red

ucti

onto

limb

salv

age

and

mis

sion

com

plet

ion

9.3.

6D

escr

ibe

the

risk

san

dbe

nefi

tsof

join

tdis

loca

tion

red

ucti

onto

mis

sion

com

plet

ion

9.3.

8C

reat

epr

otoc

ols

for

join

td

islo

cati

onan

dfr

actu

red

islo

cati

onre

duc

tion

s

9.3.

4D

emon

stra

tepr

ofici

ency

injo

intd

islo

cati

onan

dfr

actu

red

islo

cati

onre

duc

tion

sas

med

ical

prot

ocol

sd

efine

10

Preh

osp

Em

erg

Car

e D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

edic

al C

olle

ge o

f W

isco

nsin

on

09/2

4/10

For

pers

onal

use

onl

y.

Page 11: Tactical Medicine-Competency-Based Guidelines

9.3.

2D

emon

stra

tepr

ofici

ency

inex

trem

ity

neur

ovas

cula

ras

sess

men

tbef

ore

and

afte

rjo

intd

islo

cati

onre

duc

tion

(per

form

edby

appr

opri

ate

med

ical

pers

onne

l)

9.3.

5D

emon

stra

tepr

ofici

ency

inex

trem

ity

neur

ovas

cula

ras

sess

men

tbef

ore

and

afte

rjo

intd

islo

cati

on/

frac

ture

dis

loca

tion

red

ucti

on

9.3.

7E

nsur

eth

atsu

pplie

sar

eav

aila

ble

toop

erat

ors

and

med

ics

for

join

tdis

loca

tion

red

ucti

onan

dbe

fore

and

afte

rre

duc

tion

and

man

agem

enta

sm

edic

alpr

otoc

ols

defi

ne

9.3.

9E

nsur

eth

eco

mpe

tenc

yof

med

ics

inem

erge

ntre

duc

tion

ofjo

intd

islo

cati

ons/

frac

ture

dis

loca

tion

,inc

lud

ing

extr

emit

yne

urov

ascu

lar

asse

ssm

entb

efor

ean

daf

ter

red

ucti

on

10.M

edic

alPl

anni

ng10

.1D

emon

stra

tepr

ofici

ency

inm

edic

alpl

anni

ngan

dan

alys

isof

med

ical

inte

llige

nce

10.1

.1U

nder

stan

dth

ero

leof

med

ical

plan

ning

and

its

impo

rtan

cefo

rin

div

idua

lhe

alth

and

mis

sion

com

plet

ion

10.1

.2D

efine

the

com

pone

nts

ofa

med

ical

plan

for

tact

ical

oper

atio

ns

10.1

.4D

escr

ibe

the

role

ofm

edic

alpl

anni

ngan

dit

sim

port

ance

for

ind

ivid

ualh

ealt

han

dm

issi

onco

mpl

etio

n

10.1

.6Pr

ovid

eov

ersi

ghti

nm

edic

alpl

anni

ng

10.1

.3D

efine

the

inhe

rent

risk

sin

mis

sion

exec

utio

n(t

oin

clud

ein

filt

rati

on,a

ctio

nsat

the

obje

ctiv

e,an

dex

filt

rati

on)a

ndth

eir

impa

cton

med

ical

plan

ning

10.1

.5D

escr

ibe

the

inte

grat

ion

ofin

form

atio

nfr

omm

edic

alpl

anni

ngin

tom

issi

onpl

anni

ng

10.1

.7E

nsur

eth

eco

mpe

tenc

yof

med

ics

inid

enti

fyin

gri

sks

and

plan

ning

for

mit

igat

ing

step

s(t

oin

clud

ead

equa

tePP

Ese

lect

ion

and

use)

11.H

uman

Perf

orm

ance

Fact

ors/

Hea

lth

Surv

eilla

nce

11.1

Dem

onst

rate

profi

cien

cyin

mon

itor

ing

wor

k/re

stcy

cles

11.1

.1D

escr

ibe

appr

opri

ate

wor

k/re

stcy

cles

base

don

oper

atio

nala

nden

viro

nmen

talc

ond

itio

nsan

dth

eir

impa

cton

hum

anpe

rfor

man

ce

11.1

.2M

onit

oren

viro

nmen

tala

ndop

erat

iona

lcon

dit

ions

11.1

.5D

escr

ibe

the

impo

rtan

ceof

wor

k/re

std

uty

cycl

esan

dsl

eep-

cycl

ead

just

men

t

11.1

.7C

reat

epr

otoc

ols

conc

erni

ngw

ork/

rest

cycl

esba

sed

onen

viro

nmen

tala

ndop

erat

iona

lcon

dit

ions

11.1

.3M

ake

reco

mm

end

atio

nsto

com

man

der

for

wor

k/re

stcy

cles

11.1

.8C

reat

epr

otoc

ols

for

the

safe

and

appr

opri

ate

adm

inis

trat

ion

ofm

edic

atio

nsto

adju

stth

esl

eep

cycl

eof

pers

onne

lin

volv

edin

sust

aine

dan

dco

ntin

uous

oper

atio

ns11

.1.4

Mak

esa

fean

dap

prop

riat

eus

eof

med

icat

ions

for

slee

p-cy

cle

adju

stm

ento

fpe

rson

neli

nvol

ved

insu

stai

ned

and

cont

inuo

usop

erat

ions

11.1

.6D

escr

ibe

the

impo

rtan

ceof

usin

gin

putf

rom

med

ical

pers

onne

lto

inte

grat

ew

ork/

rest

cycl

esin

tom

issi

onpl

anni

ng

11.1

.9M

ake

reco

mm

end

atio

nsto

the

com

man

der

for

wor

k/re

stcy

cles

11.2

Dem

onst

rate

profi

cien

cyin

heal

thsu

rvei

llanc

e

11.2

.1D

escr

ibe

the

impo

rtan

ceof

heal

thsu

rvei

llanc

efo

rth

ein

div

idua

land

for

mis

sion

com

plet

ion

11.2

.2Im

plem

enta

ppro

pria

tehe

alth

surv

eilla

nce

mea

sure

s11

.2.4

Des

crib

eth

eim

port

ance

ofhe

alth

surv

eilla

nce

for

the

ind

ivid

uala

ndfo

rm

issi

onco

mpl

etio

n

11.2

.6C

reat

epr

otoc

ols

toas

sist

inhe

alth

surv

eilla

nce

11.2

.7A

dvi

seth

eco

mm

and

eron

the

impa

ctof

team

mem

ber

heal

thon

mis

sion

read

ines

s11

.2.3

Ad

vise

the

com

man

der

and

med

ical

dir

ecto

ron

impa

ctof

team

mem

ber

heal

thon

mis

sion

read

ines

s

11.2

.5E

nsur

eth

atre

sour

ces

are

avai

labl

efo

rhe

alth

surv

eilla

nce

11.2

.8C

reat

epr

otoc

ols

toas

sist

inth

ed

eter

min

atio

nof

pers

onne

l’sfi

tnes

sfo

rd

uty

afte

rill

ness

orin

jury

(Con

tinu

edon

next

page

)

11

Preh

osp

Em

erg

Car

e D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

edic

al C

olle

ge o

f W

isco

nsin

on

09/2

4/10

For

pers

onal

use

onl

y.

Page 12: Tactical Medicine-Competency-Based Guidelines

TA

BL

E2.

The

18C

ompe

tenc

yD

omai

nsan

dth

eSp

ecifi

cC

ompe

tenc

ies

inth

eFi

eld

Tact

ical

Em

erge

ncy

Med

ical

Supp

ortM

atri

x

Dom

ain

Com

pete

ncy

Ope

rato

rM

edic

alPr

ovid

erTe

amC

omm

and

erM

edic

alD

irec

tor

11.3

Dem

onst

rate

profi

cien

cyin

prev

enti

vem

edic

ine

11.3

.1D

escr

ibe

the

impo

rtan

ceof

prev

enti

vem

edic

ine

for

the

ind

ivid

uala

ndfo

rm

issi

onco

mpl

etio

n

11.3

.2D

escr

ibe

the

impo

rtan

ceof

prev

enti

vem

edic

ine

for

the

ind

ivid

uala

ndfo

rm

issi

onco

mpl

etio

n

11.3

.4D

escr

ibe

the

impo

rtan

ceof

prev

enti

vem

edic

ine

for

the

ind

ivid

uala

ndfo

rm

issi

onco

mpl

etio

n

11.3

.6C

reat

epr

otoc

ols

rega

rdin

gpr

even

tive

med

icin

e

11.3

.3Im

plem

enta

ppro

pria

tepr

even

tive

med

icin

em

easu

res

11.3

.5E

nsur

eth

atre

sour

ces

are

avai

labl

efo

rpr

even

tive

med

icin

e11

.4D

emon

stra

tepr

ofici

ency

inin

jury

prev

enti

on(e

.g.,

pers

onal

prot

ecti

veeq

uipm

ent

[PPE

])

11.4

.1D

escr

ibe

the

impo

rtan

ceof

inju

rypr

even

tion

for

the

ind

ivid

uala

ndfo

rm

issi

onco

mpl

etio

n

11.4

.2D

escr

ibe

the

impo

rtan

ceof

inju

rypr

even

tion

for

the

ind

ivid

uala

ndfo

rm

issi

onco

mpl

etio

n

11.4

.4D

escr

ibe

the

impo

rtan

ceof

inju

rypr

even

tion

for

the

ind

ivid

uala

ndfo

rm

issi

onco

mpl

etio

n

11.4

.6C

reat

epr

otoc

ols

rega

rdin

gin

jury

prev

enti

on(P

PEse

lect

ion

and

use)

11.4

.3Im

plem

enta

ppro

pria

tein

jury

prev

enti

onm

easu

res

11.4

.5E

nsur

eth

atre

sour

ces

are

avai

labl

efo

rin

jury

prev

enti

on

12.E

nvir

onm

enta

lFa

ctor

s12

.1D

emon

stra

tepr

ofici

ency

inth

em

anag

emen

tofs

peci

ficth

reat

sfr

omth

een

viro

nmen

t(e.

g.,h

eat,

cold

,alt

itud

e,pl

ants

,an

imal

s,ge

ogra

phy)

12.1

.1D

escr

ibe

the

envi

ronm

enta

lthr

eats

from

heat

,col

d,a

ltit

ude,

plan

ts,

anim

als,

and

geog

raph

y

12.1

.5D

emon

stra

tepr

ofici

ency

inth

ere

cogn

itio

nof

heat

,col

d,

alti

tud

e,pl

ants

,ani

mal

s,an

dge

ogra

phic

ally

ind

uced

/re

late

dill

ness

esan

din

juri

es

12.1

.9D

escr

ibe

the

envi

ronm

enta

lth

reat

sfr

omhe

at,c

old

,alt

itud

e,pl

ants

,ani

mal

s,an

dge

ogra

phy

12.1

.11

Cre

ate

appr

opri

ate

prot

ocol

sfo

rth

etr

eatm

ento

fen

viro

nmen

tally

rela

ted

illne

sses

/in

juri

es(e

.g.,

heat

,co

ld,a

ltit

ude,

plan

ts,a

nim

als,

geog

raph

y)

12.1

.2D

escr

ibe

the

sign

san

dsy

mpt

oms

ofhe

atan

dco

ld-i

nduc

edill

ness

es/

inju

ries

12.1

.6D

emon

stra

tepr

ofici

ency

inth

etr

eatm

ento

fhea

t-an

dco

ld-i

nduc

edill

ness

esan

din

juri

es12

.1.3

Des

crib

eth

esy

mpt

oms

ofal

titu

de-

ind

uced

illne

sses

12.1

.7D

emon

stra

tepr

ofici

ency

inth

eap

prop

riat

etr

eatm

ento

fal

titu

de-

ind

uced

illne

sses

12.1

.4D

escr

ibe

the

sym

ptom

sof

som

ein

juri

esan

dill

ness

esas

soci

ated

wit

hco

mm

only

enco

unte

red

plan

ts,a

nim

als,

and

geog

raph

icfe

atur

es

12.1

.8D

emon

stra

tepr

ofici

ency

inth

etr

eatm

ento

finj

urie

san

dill

ness

esas

soci

ated

wit

hco

mm

only

enco

unte

red

plan

ts,

anim

als,

and

geog

raph

icfe

atur

es

12.1

.10

Des

crib

eth

eim

pact

ofen

viro

nmen

talt

hrea

tson

mis

sion

plan

ning

and

com

plet

ion

12.1

.12

Ens

ure

the

com

pete

ncy

ofop

erat

ors

and

med

ics

inre

cogn

izin

gan

dtr

eati

ngen

viro

nmen

tally

rela

ted

illne

sses

/in

juri

es

12.2

Dem

onst

rate

profi

cien

cyin

the

iden

tifi

cati

onan

dm

anag

emen

tofs

ever

eal

lerg

icre

acti

ons

(ana

phyl

axis

)

12.2

.1D

escr

ibe

the

sign

san

dsy

mpt

oms

ofan

aphy

laxi

s12

.2.3

Dem

onst

rate

profi

cien

cyin

the

rapi

dre

cogn

itio

nan

dtr

eatm

ento

fana

phyl

axis

12.2

.5D

escr

ibe

the

sign

san

dsy

mpt

oms

ofan

aphy

laxi

s12

.2.8

Cre

ate

appr

opri

ate

trea

tmen

tpro

toco

lsfo

rth

etr

eatm

ento

fana

phyl

axis

,in

clud

ing

the

rapi

dad

min

istr

atio

nof

epin

ephr

ine

12.2

.6D

escr

ibe

the

risk

san

dbe

nefi

tsof

trea

tmen

twit

hep

inep

hrin

efo

ran

aphy

laxi

sto

mis

sion

com

plet

ion

12.2

.2D

escr

ibe

the

impo

rtan

ceof

rapi

dtr

eatm

entw

ith

epin

ephr

ine

for

seve

real

lerg

icre

acti

ons

(ana

phyl

axis

)

12.2

.4D

emon

stra

tepr

ofici

ency

inth

era

pid

adm

inis

trat

ion

ofep

inep

hrin

efo

rse

vere

alle

rgic

reac

tion

s(a

naph

ylax

is)a

sm

edic

alpr

otoc

ols

defi

ne

12.2

.7E

nsur

eth

atm

edic

atio

nsfo

ran

aphy

laxi

sar

eav

aila

ble

tom

edic

sas

med

ical

prot

ocol

sd

efine

12.2

.9E

nsur

eth

eco

mpe

tenc

yof

oper

ator

san

dm

edic

sin

rapi

dly

reco

gniz

ing

and

trea

ting

anap

hyla

xis,

incl

udin

gth

era

pid

adm

inis

trat

ion

ofep

inep

hrin

e

12

Preh

osp

Em

erg

Car

e D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

edic

al C

olle

ge o

f W

isco

nsin

on

09/2

4/10

For

pers

onal

use

onl

y.

Page 13: Tactical Medicine-Competency-Based Guidelines

13.E

xplo

sion

san

dB

last

Inju

ries

13.1

Dem

onst

rate

profi

cien

cyin

the

reco

gnit

ion

and

trea

tmen

tof

expl

osio

n/bl

ast

inju

ries

13.1

.1D

escr

ibe

the

inju

ries

and

the

mec

hani

smof

inju

ryre

sult

ing

from

expl

osio

ns/

blas

ts

13.1

.3D

escr

ibe

type

sof

expl

osio

n/bl

asti

njur

ies

13.1

.7D

escr

ibe

the

type

sof

expl

osio

n/bl

asti

njur

ies

13.1

.10

Des

crib

eth

ety

pes

ofex

plos

ion/

blas

tinj

urie

s13

.1.4

Dem

onst

rate

profi

cien

cyin

tria

gean

din

itia

ltre

atm

ento

fex

plos

ion/

blas

tinj

urie

s

13.1

.11

Cre

ate

prot

ocol

sfo

rth

etr

iage

and

man

agem

ento

fex

plos

ion/

blas

tinj

urie

s13

.1.5

Des

crib

eth

eim

port

ance

ofpr

ompt

and

effe

ctiv

ehe

mor

rhag

eco

ntro

lfor

expl

osio

n/bl

astv

icti

ms

13.1

.8D

escr

ibe

how

expl

osio

n/bl

asti

njur

ies

can

affe

ctm

issi

onco

mpl

etio

n

13.1

.12

Rec

omm

end

equi

pmen

tth

atw

ould

allo

wop

erat

ors

and

med

ics

toop

tim

ally

asse

ssan

dtr

eate

xplo

sion

/bl

asti

njur

ies

13.1

.2D

escr

ibe

the

impo

rtan

ceof

prom

pthe

mor

rhag

eco

ntro

lfor

expl

osio

n/bl

ast

vict

ims

13.1

.6D

emon

stra

tepr

ofici

ency

inm

onit

orin

gca

sual

ties

wit

hex

plos

ion/

blas

t-re

late

din

juri

es(e

.g.,

impa

ired

hear

ing,

blas

tlu

ng)

13.1

.9E

nsur

eth

ateq

uipm

enti

sav

aila

ble

toop

erat

ors

and

med

ics

toas

sess

and

trea

tex

plos

ion/

blas

tinj

urie

sas

med

ical

prot

ocol

sd

efine

13.1

.13

Ens

ure

the

com

pete

ncy

ofop

erat

ors

and

med

ics

inth

eas

sess

men

tand

trea

tmen

tof

expl

osio

n/bl

asti

njur

ies

14.I

njur

yPa

tter

nsan

dE

vid

ence

Pres

erva

tion

14.1

Dem

onst

rate

anun

der

stan

din

gof

the

patt

erns

ofin

jury

inno

nacc

iden

talt

raum

a

14.1

.1D

escr

ibe

the

inju

rypa

tter

nsan

dth

em

echa

nism

sof

inju

ryin

nona

ccid

enta

ltra

uma

resu

ltin

gfr

omw

eapo

nry

14.1

.2D

escr

ibe

the

inju

rypa

tter

nsan

dth

em

echa

nism

sof

inju

ryin

nona

ccid

enta

ltra

uma

resu

ltin

gfr

omw

eapo

nry

14.1

.3D

escr

ibe

the

inju

rypa

tter

nsan

dth

em

echa

nism

sof

inju

ryin

nona

ccid

enta

ltra

uma

resu

ltin

gfr

omw

eapo

nry

14.1

.4D

escr

ibe

the

inju

rypa

tter

nsan

dth

em

echa

nism

sof

inju

ryin

nona

ccid

enta

ltra

uma

resu

ltin

gfr

omw

eapo

nry

14.2

Dem

onst

rate

anun

der

stan

din

gof

evid

enti

ary

conc

erns

asre

late

dto

casu

alty

care

14.2

.1D

escr

ibe

pres

erva

tion

and

colle

ctio

nof

evid

ence

asre

late

dto

casu

alty

care

14.2

.2D

emon

stra

tepr

ofici

ency

inth

epr

eser

vati

onan

dco

llect

ion

ofev

iden

cere

late

dto

casu

alty

care

14.2

.4D

escr

ibe

the

pres

erva

tion

and

colle

ctio

nof

evid

ence

asre

late

dto

casu

alty

care

14.2

.5D

emon

stra

tepr

ofici

ency

inth

epr

eser

vati

onan

dco

llect

ion

ofev

iden

cere

late

dto

casu

alty

care

14.2

.6D

escr

ibe

the

prop

erd

ocum

enta

tion

ofin

juri

esre

late

dto

nona

ccid

enta

ltr

aum

a14

.2.3

Des

crib

eth

epr

oper

doc

umen

tati

onof

inju

ries

rela

ted

tono

nacc

iden

tal

trau

ma

14.2

.7C

reat

epr

otoc

ols

that

allo

wfo

rev

iden

cepr

eser

vati

ond

urin

gpa

tien

tcar

e

15.H

azar

dou

sM

ater

ials

Man

agem

ent

15.1

Dem

onst

rate

profi

cien

cyin

the

reco

gnit

ion

ofsi

gns

and

sym

ptom

sof

expo

sure

toch

emic

al,b

iolo

gica

l,ra

dio

logi

cal,

and

/or

nucl

ear

(CB

RN

)mat

eria

lsan

dth

ere

cogn

itio

nof

risk

sfr

omha

zard

ous

mat

eria

lsus

edin

clan

des

tine

dru

gla

bora

tori

es

15.1

.1D

escr

ibe

sign

san

dsy

mpt

oms

ofex

posu

reto

CB

RN

mat

eria

ls

15.1

.3D

emon

stra

tepr

ofici

ency

inth

eid

enti

fica

tion

ofsi

gns

and

sym

ptom

sof

expo

sure

toC

BR

Nm

ater

ials

15.1

.5D

escr

ibe

the

thre

ats

from

CB

RN

mat

eria

lsin

mis

sion

plan

ning

15.1

.7D

escr

ibe

the

situ

atio

nsth

atm

ayre

pres

entC

BR

Nth

reat

s15

.1.8

Ens

ure

the

com

pete

ncy

ofm

edic

sin

the

iden

tifi

cati

onof

the

sign

san

dsy

mpt

oms

ofC

BR

Nex

posu

re15

.1.2

Dem

onst

rate

awar

enes

sof

situ

atio

nsth

atm

aypr

esen

tath

reat

from

haza

rdou

sm

ater

ials

used

incl

and

esti

nela

bora

tori

es

15.1

.4D

emon

stra

tepr

ofici

ency

inth

eid

enti

fica

tion

ofsi

tuat

ions

that

may

repr

esen

tath

reat

from

haza

rdou

sm

ater

ials

used

incl

and

esti

nela

bora

tori

es

15.1

.6D

escr

ibe

the

thre

ats

from

haza

rdou

sm

ater

ials

used

incl

and

esti

nela

bora

tori

es

15.1

.9E

nsur

eth

eco

mpe

tenc

yof

med

ics

inth

eid

enti

fica

tion

ofth

esi

gns

and

sym

ptom

sof

expo

sure

toha

zard

ous

mat

eria

lsco

mm

only

used

incl

and

esti

nela

bora

tori

es15

.2D

emon

stra

tepr

ofici

ency

inse

lect

ing

appr

opri

ate

PPE

15.2

.1D

emon

stra

tepr

ofici

ency

inse

lect

ing

appr

opri

ate

PPE

for

agi

ven

haza

rd

15.2

.2D

emon

stra

tepr

ofici

ency

inse

lect

ing

appr

opri

ate

PPE

for

agi

ven

haza

rd

15.2

.3D

escr

ibe

com

mon

haza

rdou

sm

ater

ialt

hrea

tsth

atsh

ould

bein

clud

edin

mis

sion

plan

ning

15.2

.4E

nsur

eth

eco

mpe

tenc

yof

oper

ator

san

dm

edic

sin

the

appr

opri

ate

PPE

sele

ctio

n15

.3D

emon

stra

tepr

ofici

ency

inpe

rfor

min

gfie

ld-e

xped

ient

dec

onta

min

atio

n

15.3

.1D

escr

ibe

the

proc

ess

offie

ld-e

xped

ient

dec

onta

min

atio

n

15.3

.2D

emon

stra

tepr

ofici

ency

infie

ld-e

xped

ient

dec

onta

min

atio

n

15.3

.3E

nsur

eth

atd

econ

tam

inat

ion

asse

tsar

eav

aila

ble

tote

ams,

incl

udin

gPP

Ean

dfi

eld

-exp

edie

ntd

econ

tam

inat

ion

capa

bilit

ies

15.3

.4C

reat

epr

otoc

ols

conc

erni

ngfie

ld-e

xped

ient

dec

onta

min

atio

nfr

omha

zard

ous

mat

eria

ls

(Con

tinu

edon

next

page

)

13

Preh

osp

Em

erg

Car

e D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

edic

al C

olle

ge o

f W

isco

nsin

on

09/2

4/10

For

pers

onal

use

onl

y.

Page 14: Tactical Medicine-Competency-Based Guidelines

TA

BL

E2.

The

18C

ompe

tenc

yD

omai

nsan

dth

eSp

ecifi

cC

ompe

tenc

ies

inth

eFi

eld

Tact

ical

Em

erge

ncy

Med

ical

Supp

ortM

atri

x

Dom

ain

Com

pete

ncy

Ope

rato

rM

edic

alPr

ovid

erTe

amC

omm

and

erM

edic

alD

irec

tor

15.3

.5E

nsur

eth

eco

mpe

tenc

yof

oper

ator

san

dm

edic

sin

field

-exp

edie

ntd

econ

tam

inat

ion

15.4

Dem

onst

rate

profi

cien

cyin

imm

edia

telif

esav

ing

inte

rven

tion

sfo

rth

evi

ctim

sof

CB

RN

expo

sure

15.4

.1D

escr

ibe

the

impo

rtan

ceof

anti

dot

esto

trea

tvic

tim

sof

CB

RN

expo

sure

15.4

.3D

emon

stra

tepr

ofici

ency

inse

lect

ion

and

adm

inis

trat

ion

ofan

tid

otes

for

CB

RN

expo

sure

Des

crib

eth

ein

dic

atio

nsfo

rus

ean

dap

prop

riat

eus

eof

auto

inje

ctor

anti

dot

eki

ts

15.4

.4H

ave

anaw

aren

ess

ofan

tid

otes

for

CB

RN

expo

sure

15.4

.6C

reat

epr

otoc

ols

for

the

use

ofan

tid

otes

for

CB

RN

expo

sure

15.4

.2D

escr

ibe

the

ind

icat

ions

for

use

and

appr

opri

ate

use

ofau

toin

ject

oran

tid

ote

kits

15.4

.5E

nsur

eth

atan

tid

otes

are

avai

labl

eto

med

ics

asm

edic

alpr

otoc

ols

defi

ne

15.4

.7E

nsur

eth

eco

mpe

tenc

yof

med

ics

inan

tid

ote

sele

ctio

nan

dad

min

istr

atio

n

16.

Rem

ote/

Surr

ogat

eTr

eatm

ent

16.1

Dem

onst

rate

the

skill

ofpr

ovid

ing

med

ical

care

bypr

oxy

orsu

rrog

ate

16.1

.1D

escr

ibe

the

conc

epto

fsu

rrog

ate

care

16.1

.2D

emon

stra

teth

eab

ility

tope

rfor

mas

sess

men

tof

illne

ss/

inju

ryan

dto

prov

ide

trea

tmen

tvia

asu

rrog

ate

wit

hout

the

use

ofon

e’s

hand

sor

visu

alcu

es

16.1

.3D

escr

ibe

the

bene

fitof

surr

ogat

eca

rean

dth

ero

leth

isin

tera

ctio

npl

ays

inga

ther

ing

med

ical

and

othe

rin

telli

genc

e

16.1

.4D

evel

opap

prop

riat

ere

sour

ces

toal

low

med

ics

topr

ovid

est

ep-b

y-st

epin

stru

ctio

nsfo

rsu

rrog

ates

rend

erin

gca

rein

emer

genc

ies

16.1

.5E

nsur

eth

epr

ofici

ency

ofm

edic

sin

prov

idin

gin

stru

ctio

nfo

rsu

rrog

ate-

rend

ered

asse

ssm

enta

ndca

re

17.L

ess

Let

hal

Inju

ries

17.1

Dem

onst

rate

profi

cien

cyin

the

reco

gnit

ion

and

trea

tmen

tof

illne

ssan

din

jury

asso

ciat

edw

ith

less

-let

hal

wea

pons

17.1

.1D

escr

ibe

the

risk

san

dbe

nefit

sof

usin

gle

ss-l

etha

lw

eapo

ns

17.1

.2D

escr

ibe

the

risk

san

dbe

nefit

sof

usin

gle

ss-l

etha

lw

eapo

ns

17.1

.6D

escr

ibe

the

risk

san

dbe

nefit

sof

usin

gle

ss-l

etha

lw

eapo

ns

17.1

.7D

escr

ibe

the

risk

san

dbe

nefit

sof

usin

gle

ss-l

etha

lw

eapo

ns17

.1.3

Des

crib

epo

tent

iali

llnes

san

din

jury

patt

erns

asso

ciat

edw

ith

the

use

ofle

ss-l

etha

lw

eapo

ns

17.1

.8C

reat

epr

otoc

ols

for

the

dia

gnos

isan

dtr

eatm

ento

fpo

tent

iali

njur

ies

and

illne

sses

resu

ltin

gfr

omth

eus

eof

less

-let

halw

eapo

ns17

.1.4

Dem

onst

rate

profi

cien

cyin

the

dia

gnos

isan

dtr

eatm

ento

fill

ness

esan

din

juri

esca

used

by,

orex

acer

bate

dby

,the

sew

eapo

ns

17.1

.9C

reat

epr

otoc

ols

that

iden

tify

pati

ents

who

will

requ

ire

hosp

ital

eval

uati

onaf

ter

bein

gst

ruck

wit

hle

ss-l

etha

lwea

ponr

y17

.1.5

Ad

vise

the

com

man

der

whe

nle

ss-l

etha

lwea

pons

,suc

has

cond

ucti

veen

ergy

dev

ices

(CE

Ds)

,may

beco

ntra

ind

icat

edba

sed

onm

edic

alpr

otoc

ols

17.1

.10

Cre

ate

prot

ocol

sfo

rth

em

anag

emen

toft

heag

itat

edsu

spec

t,in

clud

ing

the

imm

edia

teaf

terc

are

ofan

ysu

chsu

spec

twho

has

been

man

aged

wit

ha

CE

D

18.S

peci

alPo

pula

tion

s18

.1U

nder

stan

dth

eun

ique

aspe

cts

rela

ted

toch

ildre

n,pr

egna

ntw

omen

,fra

ilel

der

ly,a

ndth

ed

isab

led

whe

nw

orki

ngin

the

tact

ical

envi

ronm

ent

18.1

.1D

escr

ibe

the

vuln

erab

iliti

esof

spec

ial

popu

lati

ons

and

the

pote

ntia

lmed

ical

and

tact

ical

impl

icat

ions

they

pres

ent

18.1

.2D

emon

stra

tepr

ofici

ency

inpr

ovid

ing

appr

opri

ate

casu

alty

care

tosp

ecia

lpop

ulat

ions

18.1

.3D

escr

ibe

spec

ialp

opul

atio

nsan

dth

eir

impa

cton

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Page 15: Tactical Medicine-Competency-Based Guidelines

Schwartz et al. TACTICAL MEDICINE COMPETENCY-BASED GUIDELINES 15

paramedics) in law enforcement operations due to thehazardous environment and risk involved in activelaw enforcement operations. Because of these risks, itcould be argued that without tactical medicine, thestandard of care practiced in the prehospital environ-ment is not consistently applied in the tactical environ-ment. There is a pressing need to provide a mechanismby which the standard of prehospital care can be deliv-ered in this environment.

The provision of tactical medicine allows all mem-bers of our society access to the best available prac-tices of prehospital care by specially trained individ-uals, prepared and equipped for the unique hazardsof the tactical environment. Defining the roles and re-sponsibilities of these providers and creating educa-tional programs of study based on a set of competency-based standards will aid in ensuring the provisionquality care. While these competencies will allow forcompetency-based training programs, the applicationof the training is obviously also subject to appropriatestate law and local protocols.

CONCLUSION

The TEMS competency matrix presented here canprovide a structure around which competency-basedTEMS courses for four target audiences (operator,medic, team commander, and medical director) can bedeveloped.

References

1. Carmona RH. The history and evolution of tactical emergencymedical support and its impact on public safety. Top EmergMed. 2003;25:277–81.

2. Prehospital Trauma Life Support Committee of the NationalAssociation of Emergency Medical Technicians, in cooperationwith the Committee on Trauma of the American College ofSurgeons. PHTLS: Prehospital Trauma Life Support, 6th ed. St.Louis, MO: Mosby Elsevier, 2007.

3. Croushorn JM, Carmona R. Tactical medical support. TopEmerg Med, 2003;25:273–351.

4. Schwartz RB, McManus JG, Swienton RE. Tactical EmergencyMedicine. 1st ed. Philadelphia, PA: Lippincott Williams &Wilkins, 2008.

5. Vayer JS, Schwartz RB. Developing a tactical emergency medi-cal support program. Top Emerg Med. 2003;25:282–93.

6. Tang NF, Fabbri W. Medical direction and integration with ex-isting EMS infrastructure. Top Emerg Med. 2003;25:326–32.

7. Rathbun DJ. The clinical practice of tactical medicine and careunder fire: medical decision making and the role of the tac-tical emergency medical support provider. Top Emerg Med.2003;25:306–15.

8. Heck JJ. The role of preventive medicine in TEMS. Top EmergMed. 2003;25:299–305.

9. Dressler FL. Operational planning for the law enforcementmedic. Top Emerg Med. 2003;25:333–6.

10. Rinnert KJ, Hall WL 2nd. Tactical emergency medical support.Emerg Med Clin North Am. 2002;20:929–52.

11. Sullivan R. The Competency-Based Approach to Training. JH-PIEGO Policy Paper for USAID. September 1995.

12. Dubois DR, W. Competency-based or a traditional approach totraining? A new look at ISD models and an answer to the ques-tion, What’s the best approach? April 2004.

13. Epstein RM, Hundert EM. Defining and assessing professionalcompetence. JAMA. 2002;287:226–35.

14. Dilendik JR. Assumptions underlying criterion referenced as-sessment are educationally sound. Education. 2001;99(1):89–96.

15. Bradley FM. Competency-based resident education. Otolaryn-gol Clin North Am. 2007;40:1215–25.

16. Subbarao I, Lyznicki JM, Hsu EB, et al. A consensus-basededucational framework and competency set for the disciplineof disaster medicine and public health preparedness. DisasterMed Public Health Prep. 2008;2(1):57–68.

APPENDIX 1National Tactical Officers AssociationWorking Group Participants

Brent Bronson, EMT-P (18 years’ experience—EMS ed-ucation, fire rescue education, TEMS education)

Phillip Coule, MD, FACEP (23 years’experience—EMS, EMS education, federal lawenforcement, diving medicine)

John Croushorn, MD, FACEP (10 years’experience—military medicine, federal law en-forcement, aviation medicine, TEMS education)

Mark Gibbons, EMT-P (25 years’ experience—TEMSeducation, aviation medicine, EMS education, local,state, and federal law enforcement)

Sean McKay, EMT-P (14 years’ experience—fire res-cue education, TEMS education, EMS education, locallaw enforcement)

Gina Piazza, DO, FACEP (8 years’ experience—EMSeducation, TEMS education, local and federal law en-forcement)

David Rathbun, EMT-P (40 years’ experience—locallaw enforcement, TEMS education)

Richard Schwartz, MD, FACEP (20 years’experience—military medicine, local and federallaw enforcement, aviation medicine, wildernessmedicine education, diving medicine education,TEMS education)

Robert Soto, EMT-P (17 years’ experience—EMS ed-ucation, fire/rescue education, TEMS education)

Charles Studley, PA-C, 18D/18Z (29 years’experience—military medicine, federal law enforce-ment, TEMS education, diving medicine education)

Paul Vecchio, 18D/18B/18F/18Z (27 years’experience—military medicine, federal law en-forcement, TEMS education)

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https://www.researchgate.net/publication/232176602_The_Clinical_Practice_of_Tactical_Medicine_and_Care_Under_Fire_Medical_Decision_Making_and_the_Role_of_the_Tactical_Emergency_Medical_Support_Provider?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/232176602_The_Clinical_Practice_of_Tactical_Medicine_and_Care_Under_Fire_Medical_Decision_Making_and_the_Role_of_the_Tactical_Emergency_Medical_Support_Provider?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/232176602_The_Clinical_Practice_of_Tactical_Medicine_and_Care_Under_Fire_Medical_Decision_Making_and_the_Role_of_the_Tactical_Emergency_Medical_Support_Provider?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/232176602_The_Clinical_Practice_of_Tactical_Medicine_and_Care_Under_Fire_Medical_Decision_Making_and_the_Role_of_the_Tactical_Emergency_Medical_Support_Provider?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/232206984_The_Role_of_Preventive_Medicine_in_TEMS?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/232206984_The_Role_of_Preventive_Medicine_in_TEMS?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/5824976_Competency-Based_Resident_Education?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/5824976_Competency-Based_Resident_Education?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/10995249_Tactical_emergency_medical_support?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/10995249_Tactical_emergency_medical_support?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/232120690_Operational_Planning_for_the_Law_Enforcement_Medic?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/232120690_Operational_Planning_for_the_Law_Enforcement_Medic?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/232198023_Developing_a_Tactical_Emergency_Medical_Support_Program?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/232198023_Developing_a_Tactical_Emergency_Medical_Support_Program?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/232197460_Medical_Direction_and_Integration_With_Existing_EMS_Infrastructure?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/232197460_Medical_Direction_and_Integration_With_Existing_EMS_Infrastructure?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/232103375_The_History_and_Evolution_of_Tactical_Emergency_Medical_Support_and_Its_Impact_on_Public_Safety?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/232103375_The_History_and_Evolution_of_Tactical_Emergency_Medical_Support_and_Its_Impact_on_Public_Safety?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/232103375_The_History_and_Evolution_of_Tactical_Emergency_Medical_Support_and_Its_Impact_on_Public_Safety?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/298348201_Defining_and_assessing_professional_competence?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw
https://www.researchgate.net/publication/298348201_Defining_and_assessing_professional_competence?el=1_x_8&enrichId=rgreq-63e4c14f-f813-4174-bac1-1a29eaee4596&enrichSource=Y292ZXJQYWdlOzQ2MzkyNTQ0O0FTOjE5MTI0Mjc4NjY2NDQ1MEAxNDIyNjA3MjQxMzMw

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