Introduction to TEMS

Tactical Emergency Medical Support (TEMS) is a term referring to pre-hospital care that has been modified for the realities of the tactical law enforcement environment (SWAT/SRT/ERT) and is a growing area of pre-hospital care. Articles have appeared in several peer-reviewed medical journals and tactical literature with a growing number of national organizations creating sections dedicated to this topic.

TEMS at its most basic level its the administration of a program designed maintain the health, welfare and safety of SWAT Operators. This involves a much broader definition of care than traditional EMS employees. There is a component of TEMS that is tied to the military concept of far forward care, however most of our mission and activity is well in advance of any operation.

Many are familiar with the military model of a "medic." Special operations forces took this concept to a new level. Being found in situations separating operators from rear echelon security and medical care necessitated new roles for the medic. This broadening of roles is mirrored in the comparison between TEMS operators and traditional EMS providers.

Following the advent of SWAT in the late 60's and early 70's. Most medical support for these high-risk operations was limited to stand by EMS and fire rigs. Several notable exceptions including the LA County Sheriff SWAT team endeavored to have a medic available for their operations. However it has only been in the last 10-12 years that TEMS has really begun to emerge as a standard of care in the tactical arena. National conferences were held in 1989 and 1990. Representatives from law enforcement, emergency medicine and EMS began to develop consensus relating to the provision of medical support to tactical law enforcement teams.

In 1990 the Counter Narcotics Operational Medical Support (CONTOMS) course was introduced. The National Tactical Officer's Association developed a TEMS curriculum. Texas A&M developed a well-defined course in TEMS. Several others including H&K have maintained TEMS courses nationwide. In 1993 the National Tactical Officers Association (NTOA) published a position statement in support of TEMS. It read in part, "The provision of TEMS has emerged as an important element of tactical law enforcement operations..." and in January 1999, National Association of EMS Physicians forms TEMS task force to look at TEMS issues.

Municipalities that employee tactical units in the application of law enforcement need to understand that these operations come at significant risk. According to national database, in 1998, 61 law enforcement officers were killed and 18,198 injured by assaults in the line of duty. Members of Special Weapons and Tactics (SWAT) teams at increased risk with 33 injuries per 1,000 officer-missions (data presented by CCRC). There is even more risk for a community if there is not a highly trained alternative to dangerous situations. TEMS endeavors to make this dangerous occupation safer for the officers, perpetrators and community.

Tactical law enforcement activities take place in volatile and dangerous environments that are growing more dangerous every day. Criminals are using more sophisticated techniques, dangerous weaponry and risky tactics (i.e. taking hostages or barricading themselves). Not to mention the recent tragedy of what is referred to as "active shooter scenarios" such as school shootings. There are also clandestine drug labs and toxic hazards associated with them.

Talk with any tactical operator and they will tell you that they desire medical back up. Unfortunately in many parts of the country a civilian ambulance on standby is still the standard of care (almost 70%). There is no medical direction for TEMS in 78% of situations, and 23% of the time there is no EMS preplan. There is also the issue of the environment that TEMS is practiced. It is without the lights and equipment a hospital Emergency Department afford nor the usual safety that traditional EMS providers operate.

Health Maintenance and Surveillance

This is a wide-ranging component to the TEMS operator's duties. Immunizations and health surveillance including Tuberculosis screening with an annual PPD are important components. Having a portable and complete medical record on each operator available for the tactical commander is another key issue. Two copies, one on the operator's person and a copy stored in a secured place available on scene. Emergency Departments can be made aware that if a tactical operator presents to their facility the information is readily available and is kept in the same location every time. We currently recommend the Medical Information Carrier System (MICS). It is a $5 identification system designed by a physician that contains all pertinent medical data and contact information.

Operational Support

Being able to assess operational risks including potentially injurious behavior or situations, environmental risks and toxic hazards are key to a tactical medic's role. Providing a medical preplan to the tactical solution is a major focus of the tactical medic. Rest/duty cycles and monitoring performance decrement during operations is also important. Hydration status, sleep deprivation, and work-rest cycles are important on extended operations.

The Benefit of TEMS to a municipality/organization

We are committed to helping agencies address the specific issues regarding to establishing a TEMS component to existing tactical operations. It has been accomplished all over the country. The first step is being able to define the true benefit of a TEMS program

  • Enhance mission accomplishment.
  • Reduce death, injury, illness, & related effects among officers, perpetrators & innocents
  • Improve the agency and/or municipality's liability posture.
  • Provide comprehensive medical support while maintaining operational security (OPSEC).
  • Provide Medical Support while maintaining chain of evidence.
  • Reduce line of duty injury and disability costs to the agency.
  • Reduce lost work time for specially trained, hard-to-replace officers,
  • Maintain good team morale.
Other questions that arise typically deal with understanding the TEMS team structure and mission, who will be on the team, whether civilians will be armed, what stage of operations will the team be involved, and insurance/liability concerns are typically the other major concerns. All are important issues and are too detailed to be adequately covered in this forum, however we do have information available for those interested in starting a TEMS unit who need the nuts and bolts of how to "make it happen."

Far-Forward Care & Care Under Fire

What is far-forward care, and what does it entail? The ability to properly assess the threat of the tactical situation and stratify the risk to benefit ratio of any treatment provided in that environment is the cornerstone of tactical emergency care.

Medics are also instructed in how to approach the assessment of each injury.

  1. Determine if the area is secured.
  2. Determine if the patient is one of the perpetrators, and therefore likely to be a threat to the providers.
  3. Determine the current level of injury/stability of the victim.
  4. Assess the benefits and risks of exposing providers in an unsecured area.
  5. Assess benefits and risks of stabilizing versus evacuating the patient.
The practice of TEMS also involves being ever aware of noise and light discipline, the importance of immediately moving themselves and their patient to a position of cover and concealment, and minimizing talking by using hand signals and whisper. We also emphasize packing our medical gear to avoid clatter.

Medical Training for Tactical Operators

We feel that a properly trained operator is one that maintains tactical medical awareness. There is a great deal of evidence that when trained in a few simple skills, lives will be saved. Other than the skills, all operators should carry some very inexpensive equipment. We have this information available without cost to all operators.

Training should also include WMD, biological and chemical hazards. What to look for and what to do if one of these agents is expected.

Knowledge regarding forensic examination & evidence collection, toxic hazards in the tactical environment, detailed medical preplan and operational Security (OPSEC) are other issues key to TEMS. Tactical Medical Operators should be held to a set of minimum standards, and all tactical teams should have a resource like this available at all times.