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ABC’s of Tactical Emergency Medicine Support Part I of IIDeputy Sheriff Michael Gorham, BS, AEMT‐T 

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THE “ABC” IN TACTICAL EMS (PART 1)

PRESENTED BY MICHAEL GORHAM

• Law Enforcement • Firefighter (South Wayne Fire Department) • EMS AEMT with TEMS Endorsement #11467

• I am an Instructor in Firearms, Tactical Response, EMS, BLS

• Army ILNG/ROTC, Civil Air Patrol, US Coast Guard Auxiliary

• Instructor with Southwest Technical College, Fennimore WI

Lafayette County Sheriff’s Office WI Cuba City Area Rescue Squad US Coast Guard Auxiliary

RECOGNITION This presentation comes from the assistance of many sources:

Midwest Tactical Officer’s AssociationChad Stiles. Chris Cook, Steve Rabinovich, Shane Heilmann, Matt Savage

John Hallbrook, State of Iowa Emergency Management Milwaukee and Oak Creek Fire Departments WI

Arlington County Fire Department VA. National Tactical Officers’ Association

(Specialized Tactics Operational Rescue Medicine) Instructors: Mark Gibbons, Sean Mckay, Kevin Gerold, Phillip Carmona

North American Rescue, Brent Bronson Tactical Medical Solutions

CAVEATS

• I am a student just like you sharing my thoughts, so it if you disagree with my information, that is your right based on your experiences and training. I do not like the word expert.

• I have preferences in products however, I am not here to sell you any product or endorse one over another. (Beware of Counterfeits)

• My experience is a culmination of 30 plus years working in the military, private security, police, fire and EMS. My largest foundation comes from working in rural Southwestern Wisconsin. My second base was working in the Dane County Metro Area of Wisconsin ( Madison )

• Some pictures are graphic

RHETORICAL VERSUS PRACTICAL

The root question to most of all of public safety’s crisis’?

1. Anticipate Crisis or Problems (Reactive)

2. Why do we Plan? - Response to Crisis

3. Why do we train? - Performance in our response

4. Why do we work to get better at what we do?

- expectations; Public and Personal

“The perseveration of life is the fundamental priority of all public safety”.

There are three stages of crisis response when the situation is not prepared for

DenialDeliberationDecisive Action 

Courtesy of the ALERT Presentation

NO TRAINING OR PLANNING

Emotion And InstinctVaried Outcomes

Usually lots of complications Example:

Police Transport Shooting Victims in Aurora CO to area Hospitals

WITH PLANNING AND PREPARATION

Consider Colonel Boyd’s OODA Loop Response process

1. Observe

2. Orient

3. Decide

4. Act

Can be applied to most if not all public safety situations

REMEMBER TACTICAL EMS IS STILL EMS

The response paradigm changes

ACTIVE SHOOTER EVENT DEFINITION

An active shooter event involves one or more persons engaged in killing or attempting to kill multiple people in an area occupied by multiple unrelated individuals.

UNDERSTANDING THE PROBLEM

Active shooter incidents happen everywhere in this country, from the small town to the largest cities

• These goofs study each other and learn • Looking to Share their pain and looking for

attention.• Can cross any social economic barrier • Low cost attacks • Weapons can be obtained easily or homemade

THE FIRST RECORDED ASMCI

May 18, 1927 in Bath Township, MISchool board member Andrew Kehoe

upset over property tax increaseKilled wife and burned his barn before

driving to schoolThree explosions leaving 45 dead and

58 woundedStill the deadliest attack on a school in

U.S. history

VIRGINIA TECH - APRIL 16, 2007• Cho murders 32 with two

handguns

• 7:15 a.m. West Ambler Johnston Hall – Hilscher and Clark killed

• Returns to his apartment andreloads

• Leaves to mail pictures and video manifesto to NBC

• 9:45 a.m. Norris Hall murders

• Executions in five classrooms

• Kills 30, then himself

March 8, 2009 in Illinois

Suspect Terry Sedlacek, 27

Fatally shot pastor before stabbing himself

Two parishioners were stabbed trying to restrain suspect

Suspect developed a mental illness after contracting Lyme disease

CHURCH INCIDENTS

WISCONSIN INCIDENTS, OAK CREEK AND BROOKFIELD

Number Shot0‐45‐910+

20002000200120012002200220032003200420042005200520062006200720072008200820092009201020102011201120132013

Courtesy of the ALERT Presentation

THE SHOOTER

• No “Profile”• Revenge Mindset• Some broadcast

intentions

LOCATION OF ATTACKS

0% 10% 20% 30% 40% 50%

Other

Outdoors

Education

Commerce

How quickly the police arrive

Target availability

Number of Deaths

3 MINUTES IS THE RESPONSETIME ON AVERAGE

How long does it take to get to victims? Assess, Treat Evacuate, and Transport

THE CHALLENGE FACING EMS

National Registry standards for all levels of Medics in their training and testing, which are critical tasking

BSI Body Substance PPE Pass/Fail

Is the scene safe (safer) Pass/Fail

BULLETS VERSUS BOMBS

• IED’s are somewhat harder to acquire• Expense and skill to make IEDs • Larger chance of being detected• It does not mean IEDs are not going to be

used • Bath MI to Columbine to Boston Marathon

Bombings • Paradigms are rapidly changing

UNDERSTANDING BALLISTIC TRAUMA

RIFLED AMMUNITION Lethality increases over 2200 feet per second

CONSIDER FUTURE ISSUES TRAUMA FROM

IMPROVISED EXPLOSIVE DEVICES

WHAT CAN WE LEARN FROM

THE BIBLE OF TACTICAL COMBAT CASUALTY CARE

Following the SEAL casualties sustained during the invasion of Panama, the Navy Special Operations community conducted an extensive review of combat death and trauma care.The concept of TCCC was developed in 1996 after an extensive analysis of the Vietnam Casualty Database.Lessons from Grenada, Panama, Somalia were also applied,

TCCC

Tactical Casualty Combat Care or (T)Triple C is the military’s response to trauma on the battlefield. (Note their patients are usually 18-35 YOA males in excellent health.

Combat Lifesaver is Combat First Aid on steroids

WHERE IT BEGAN

HOW PEOPLE DIED IN GROUND COMBAT BELLAMY, RF. CAUSES OF DEATH IN CONVENTIONAL LAND WARFARE, MILITARY MEDICINE. 1984

15% of Ground Combat Deaths are Preventable

• CARE UNDER FIRE • TACTICAL FIELD CARE • CASUALTY EVACUATION

TCCC (3) Phases of Care

TCCC TRAINING

Assessment (Contact and Remote) Use of Tourniquet Use of Chest Seals Use of Nasal Airway Wound packing (Hemostatic agents) IV administrationMedications (some) Casualty Evacuation

GENESIS OF MEDICAL SUPPORT IN SWAT

Within a Decade after the formation of Specialized Tactical Units, the late (1980s) ubiquitously known as SWAT. Teams started adding in a integrated medical

support. For 25 years often larger agencies have integrated

prehospital care providers into law enforcement operations. The SWAT Medic was designed to care for

the team members much like their military cousins.

Many agencies have used integrated medical support in Search and Rescue operations

TEMS or Tactical Emergency Medical Support is usually an integrated prehospital care provider sometimes referred to as Tactical Medical Providers(TMPs).

TMPs are assigned to a SWAT team. (Models vary from First Responder to Paramedics)

TEMS Post 9/11

COMMITTEE ON TECC ADOPTS TCCC FOR PUBLIC SAFETY

The TECC website – Sean Mckay, pictured on the left Committee Member (Yoda)

TECCTACTICAL EMERGENCY CASUALTY CARE 

TECC (3) PHASES OF CARE

1. Direct Threat Care (Hot Zone)

2. Indirect Threat care (Warm Zone)

3. Casualty Evacuation (Cold Zone)

LEVELS OF CARE IN TACTICAL OPERATIONS 1. Self Aid/Buddy Aid taught to Police Officer

2. Internal Medical Support integrated into SWAT –Tactical Medic. Deployed into the Hot Zone

3. External Medical Support and the Continuum Of Care Edge of Warm/Cold Zone transport to definitive care.

4. Rescue Task Force Support, a new concept. In the event of MCIs where the event involves violence, coordinated teams of Police, Fire, EMS enter the warm zone and evacuate the treatable victims out of the zone.

TECC TRAINING (VARIES)

Assessment Contact and Remote Tourniquet Application Chest Seals Airway Management

Wound Packing (Hemostatic agents)

Generally ( No Needle Decompression) Casualty Evacuation ( Needs to comply with National Registry Scope of Practice) Addresses the issue of NREMT testing ( Is the scene safe)

TOOLS OF TECC

• Tourniquet – (Bleeding for exterimities) • Chest Seals  (Sucking Chest Wound) • Nasal Airway (Airway Management) • Hemostatic Gauze (Wound Packing) • Emergency Trauma Bandage 

All First responders in the nation should be taught TECC-Gorham

A NEW HOPE RTF is the Rescue Task Force is the 

integration of police, fire, and EMS working in concert to treat casualties in an active killer mass casualty incident or AKMCI. 

However, the principles of a RTF can be scaled down to small incidents involving 1‐4 victims   

2013 MTOA TEMS Course @ FT McCoy

MY CONTACT INFO

chiefgorham@yahoo.com563-542-3867 Facebook Michael Francis GLafayette County Sheriff’s Office 608-776-4444

PART II THE ABCS OF TEMSFor Justice Clearinghouse

PRESENTED BY MICHAEL GORHAM

• Law Enforcement • Firefighter (South Wayne Fire Department) • EMS AEMT with TEMS Endorsement #11467 • I am an Instructor in Firearms, Tactical Response, EMS,

BLS

• Army ROTC, Civil Air Patrol, US Coast Guard Auxiliary

Lafayette County Sheriff’s Office WI Cuba City Area Rescue Squad US Coast Guard Auxiliary

RECOGNITION This presentation comes from the assistance of many sources:

Midwest Tactical Officer’s AssociationChad Stiles. Chris Cook, Steve Rabinovich, Shane Heilmann Matt Savage

John Hallbrook, State of Iowa Emergency Management Milwaukee and Oak Creek Fire Departments WI

Arlington County Fire Department VA.

National Tactical Officers’ Association (Specialized Tactics Operational Rescue Medicine)

Instructors: Mark Gibbons, Sean Mckay, Kevin Gerold, Phillip Carmona

North American Rescue, Brent Bronson Tactical Medical Solutions

CAVEATS

• I am a student just like you sharing my thoughts, so it if you disagree with my information, that is your right based on your experiences and training. I do not like the word expert.

• I have preferences in products however, I am not here to sell you any product or endorse one over another. (Beware of Counterfeits)

• My experience is a culmination of 30 plus years working in the military, private security, police, fire and EMS. My largest foundation comes from working in rural Southwestern Wisconsin. My second base was working in the Dane County Metro Area of Wisconsin ( Madison )

•Why are we here?

•Active Shooter Events

•What is the Significant MOI (Mechanism of Injury)

•Bullets and IED other penetrating trauma

REVIEW OF PART 1

TCCC Military Origin Victims 18-35 Males Good health No restrictions as far as OHSA, NREMT, Etc

TECC Civilian Adaptation Wider Population Scope of Practice NREMT, OHSA, other Medical oversight

REVIEW OF PART 1

• Training?  What do I need to know • TECC can be taught to LEOs and Fire • There is no national standards or 

curriculum • However, training should follow the  

Committee on TECC guidelines 

COMMON QUESTIONS

COURSES

National Tactical Officers Association; STORM Specialized Tactics for Operational Medicine

Contoms National Association of EMTs has TCCC course

selections Wisconsin has a variety of courses Be careful what you are buying into ask questions to the

vendors Medical Background; Instructors; conforms to TECC

CAUTION WHEN PURCHASING MEDICAL KITS

• Tactical Emergency First Aid Kits are a hot topic now • With that comes a desire to address the need • We are a capitalist based economy 

CAUTION WHEN PURCHASING MEDICAL KITS

• Think about these issues• For example  If you buy 14 gauge needles for needle 

decompression; are your people trained to do that.• Does it fit within their practice  • How sustainable is it for your agency – medical 

equipment has a shelf life  (Hemostatic agents) • Is the supplier reputable and are the products vetted 

either by the military or the 

RECOOMENDED TOURNIQUETS

SOFT-T Tactical Medical Solutions CAT North American Rescue

PLATINUM 5 MINUTES AND THE GOLDEN HOUR

What happens in this time frame often dictates the patients outcome

TREATMENT PARADIGM

Stabilize injured using ACAB-E assessment and treatment

Assessment  sometimes referred to as Situation  Circulation Airway Breathing Evacuation

M assive bleeding A  irwayR  espirations C  irculation H ypothermia 

and Head out 

Threat Suppression Hemorrhage Control 

Rapid EvacuationAssessment 

Transport 

MODALITIES ACRONYMS

TIME COMPETIVE Death from Hemorrhage 1 - 3 minutes

Death from Airway compromise 4 - 5 minutes

Death via Tension Pneumothorax 10+ minutes

“Golden Hour” 60 minutes

It is pointless to treat a casualty for a developing tension pneumothorax while he is dying by strangulation from a

compromised airway or by uncontrolled bleeding.

9% KIA BLEEDING TO DEATH FROM EXTREMITY WOUNDS

Normal Blood

Volume

Death probable

9% KIA BLEEDING TO DEATH FROM EXTREMITY WOUNDS

5% KIA TENSION PNEUMOTHORAX

1% KIA AIRWAY OBSTRUCTION

Train for contingencies

What if your people don’t have the equipment for what ever reason?

“Follow P.A.C.E. methodology in medical interventions”

• Primary

• Alternate

• Contingency

• Emergency

GOOD MEDICINE MAY BE BAD TACTICS

First responsibility stop the threat

PUBLIC SAFETY RESPONSE

Police agencies have made significant changes in their response since Columbine. Police are taught to engage the threat immediately rather than wait.

Fire/EMS agencies still stand outside until the police have secured the scene.

This may lead to the injured not receiving treatment and dying from wounds they received

The Rescue Task Force is the combined resources of the public safety team to mitigate a MCI which is a law

enforcement driven incident.

TEMS is Tactical Emergency Medical Support for the SWAT Team

Both use Tactical Emergency Casualty Care, interventions

FIRE AND EMS RESPONSE GOALS

1. Provide rapid treatment to the wounded

2. Prevent those who have survivable injuries from dying

3. Use resources more efficiently and effectively

4. Evacuate the wounded to definitive care sooner

5. Provide the proper gear and security for the operators

THE REALITY

Fire/EMS needs to take a more progressive response and assume more risk to save lives.Risk is nothing new the the fire service, we are willing to enter a burning building, confined spaces, hazmat releases, etc. to save lives. The risk is mitigated by the use of SCBA, turnout gear, training, equipment, and SOP’s

THE REALITY

In the active shooter incident the risk is mitigated with the use of ballistic gear, security, equipment, SOP’s and training. The environment in an active shooter incident is more controllable then that of a building on fire.

RTF EQUIPMENT

PPI level IIIA Hornet Tactical Vest

PPI level IV Rifle Plates (Chest and Back)

PPI level IIIA Special Ops. Helmet

RTF EQUIPMENTMEDICAL - VEST MOUNTED

Tourniquet x 2

H-Bandage pressure dressing x 2

Hemostatic Gauze x 2

Chest seal x 2

NP airways x 2

14ga. 3.5” needles x 2

Tegaderms x10

THE QUESTION OF ARMING MEDICS

1. Varied Responses

2. Based on your Jurisdictional needs and resources

3. Minimally Medics should have weapons familiarization

4. Why? Disarming Downed Operators with

Altered Mental Status

IF OFFICERS ARE BROUGHT OUT OF THE FIGHT; CHECK AMS DANGEROUS IF ARMED

RTF OPERATIONS

RTF OPERATIONS

As the contact team moves through the building searching for the threat, location of wounded is relayed back to commandAfter the contact team either neutralizes the threat or contains it the RTF is deployedRTF proceeds to the location of the wounded and begins treatment

RTF OPERATIONS

RTF OPERATIONS A PARADIGM SHIFT

The RTF consists of 2 police officers and 2 medicsOfficers provide front and rear security and control movementMedics provide treatment and evac. of the woundedRTF operates in the warm zone

Arlington Fire Department VA Initiative

RTF OPERATIONS

RTF OPERATIONS

The objective of the first RTF is to triage then treat the wounded behind cover not in the line of fire. Then they switch objectives and begin evac of the wounded.The second and subsequent RTF’s begin evac of those treated until the team ahead of them runs out of equipment and then they leap frog forward to finish treatment.

RTF OPERATIONS

RTF OPERATIONS

OTHER SKILL SETS THAT ARE NEEDED

BREACHING PATIENT EXTRACATION AND EVACUATION

OTHER SKILL SETS THAT ARE NEEDED

Vehicle Platforms Pros and Cons

COMMAND AND CONTROL

• These types of incidents are very dynamic and the number of threats, victims, etc can change at any time.

• The first Fire/EMS supervisor and the first arriving PD command officer need to form a Unified Command.

• The number of RTF’s formed is based on the availability of resources both FD/ EMS and PD.

• In Rural areas consider using VFD personnel to be litter bearers

• The location of the CCP is based on the building type, number of victims, threat location, resources, and environmental conditions.

• Movement is controlled by the police element of the unified command

THIS IS A LAW ENFORCEMENT EVENT

• Medicine does not drive Law enforcement tactics

• It is a crime scene and you will need good documentation

BE A SCHOLAR AND A WARRIOR

1. What barriers are there going to be?

2. Urban versus Rural ?

3. Paid versus Volunteers?

4. Time and Resources Competitive Goals?

5. Relationships and Networking ?

•Have a plan focus on strategies not specifics •Work your plan, training isolation exercises to scenarios •Need all stakeholders on board •Study what works •Take what works in your jurisdiction; discard what doesn’t •Public safety is an Applied Science

LEADERSHIP: PLANNING

Be decisive, improvise, adapt, overcome….Gunny Highway

MENTAL PREPARATION FOR THIS EVENT

• Most Fire/ EMS are not prepared for entering into the arena of violence.

• Sometimes Providers hesitate when treating victims of traumatic violence. ( Train through this; it is an adverse reaction)

• Lt. Col David Grossman (ret) has done extensive research on interpersonal violence. There are resources available to develop body armor for the mind. (ON COMBAT) (THE GIFT OF FEAR, Gavin De Becker)

• If you find your self excited by the events and overwhelmed remember to breath. Breathing slow and deep is good for you to function properly.

RESOURCE MATERIALS

D AV I D G R O S S M A N R E T I R E D LT C

G AV I N D E B E C K E R

RESOURCES

1) COMMITTEE ON TACTICAL EMERGENCY CASUALTY CARE 2) MIDWEST TACTICAL OFFICERS ASSOCITION 3) NATIONAL TACTICAL OFFICERS ASSOCIATION 4) NATIONAL ASSOCIATION OF EMTS 5) NATIONAL REGISRTRY OF EMTS 6) NORTH AMERICAN RESCUE7) TACTICAL MEDICAL SOLUTIONS 8) QUICK CLOT 9) STATE EMS ASSOCITION (WEMSA)

MY REFERENCE MATERIALS

THANK YOU FOR DOING WHAT IT IS YOU DO“THE MEASURE OF A PERSON IS DEFINED BY THE WAY HE MAKES THE WORLD A BETTER PLACE” 

MY CONTACT INFO

chiefgorham@yahoo.com563-542-3867 Facebook Michael Francis GLafayette County Sheriff’s Office 608-776-4444