Foundational Tactical Training for Nationally Registered Emergency Medical Technicians by LaTrelle Walker

Draft

Abstract

The term Emergency Medical Technician (s) or EMT (s) refers to a nationally recognized group of professionally qualified personnel, trained to respond to and mitigate a variety of emergency situations. The focus of their mission is of course pre-hospital and emergency medicine. The emerging need for tactical operations for EMTs places personnel at risk. With the war on terrorism expanding, special operations involving EMTs are becoming part of standard operating procedures and occur on more regular basis. Currently, there are very few tactical medicine curriculums that are training traditional emergency medical services (EMS) providers to operate in these types of environments. The purpose of this report is to explore the possibilities and feasibility of integrating such training into the nationally recognized curriculum of the National Registry of Emergency Medical Technicians (NREMT) to provide the nations EMTs with a foundational training and enhanced capability so they can be better prepared when they respond to and mitigate such events.

Table of Contents Abstract Table of Contents Introduction Analysis Design Development Training Implementation Program Implementation Evaluation Program Management Conclusion I 1 2-3 4-10 11-13 14 15 15 16 17 18

Introduction The events of 11 September 2001 served to heighten public awareness of an expanded need for tactical operations. Tactical operations, involving Special tactics, law enforcement, and special operations teams, are challenging, inherently unsafe activities with increased risk of morbidity and mortality for operational personnel, perpetrators, hostages, and bystanders. The fundamentally hostile, austere, and often remote environment in which tactical operations occur, places limitations on the provision of medical care. Conventional EMS systems do not adequately prepare their personnel for the unique environment of tactical operations. Tactical emergency medical support (TEMS) has evolved in response to the needs of law enforcement agencies for maintaining the health, welfare, and safety of special operations personnel, as well as providing a broad range of health- and mission-specific services. Personnel often are faced with threats, including armed suspects, barricade situations, booby traps, and exposure to hazardous substances found in drug laboratories. These operations inherently are dangerous and often are conducted in remote locations. Tactical emergency medical support (TEMS) practice deviates from standard EMS practice in several important respects. Scene and provider safety are given top priority over the provision of patient care in standard EMS practice, whereas the nature of tactical operations often requires that TEMS personnel deliver care despite dangerous environments and situations. Effective emergency medical support for tactical operations requires knowledge of the tactical environment and operations plus unique skills for patient assessment and treatment of occupational, traumatic, and toxicological injuries under austere conditions.

EMS systems in the United States were developed to respond to the needs of individual patients in (semi) controlled situations. EMTs are charged with arriving onscene at any type of call and taking charge of and managing other peoples emergencies. As evidenced in the distant and not so distant past pre-hospital providers have assumed the responsibility of responding to increasingly violent incidents in the streets which include acts of terrorism and performing a wide variety of skills. Historically the standards of care applied have been based largely on patient care needs instead of survivability and operational tempo. This approach is no longer appropriate, is not optimal in its scope and should be adjusted to ensure success of emergency responders.

In the post 9/11 world with the continual threat of foreign terrorism we can no longer allow are EMTs to be so meagerly trained and expect them to respond to and manage a rainbow array of emergency events. They must expand their scope of practice, increase their capabilities and level of expertise if they wish to successfully operate in the world today, with the threat of terrorism and the growth of criminal and gang activities the definition of what an emergency responder is and does will continue grow and expand.

Analysis

Needs Analysis Triggering Circumstance: There exists a need for additional training for EMTs in the realm of tactical operations. Performance/Historical Data: Overview of the Emergency Medical Services System A. History of EMS 1. World War I: motor vehicles and volunteer ambulance squads were used. 2. World War II: trained corpsmen brought casualties to aid stations. 3. Korean conflict: further development of the field medic; casualties transported to Mobile Army Surgical Hospitals via helicopter. 4. Domestic emergency care lagged behind. 5. Into the 1960s, pre-hospital care could range from interns to individuals without training. a. The sick and injured were often transported by private vehicle. b. Staffed emergency departments were often limited to large urban areas. 6. Accidental Death and Disability (a. k. a. The White Paper) published in 1966 a. Reported the inadequacies of pre-hospital care. b. Recommended: 1. Development of training 2. Development of federal guidelines and policies 3. Adoption of the means to provide emergency care and transport 4. Establishment of staffed emergency departments 7. Highway Safety Act and the Emergency Medical Act created funding sources and development programs. 8. Early 1970s: DOT developed the first National Standard Curriculum for the training of EMTs. 9. Late 1970s to early 1980s: DOT developed a recommended National Standard Curriculum for the training of paramedics. 10. Circa 1980: EMS established in most of the United States. a. Responsibility of municipalities to provide pre-hospital care b. Recognized standards developed for training and equipment B. National Highway Traffic Safety Administration (NHTSA) 1. Technical Assistance Program Assessment Standards 1996 2. 10-point assessment criteria include: a. Regulation and policy b. Resource management

c. Human resources and training d. Transportation equipment and system e. Medical and support facilities f. Communications system g. Public information and education h. Medical direction i. Trauma system and development j. Evaluation C. Levels of training 1. Basic First Aid a. Trains individuals in the workplace, teachers, coaches, babysitters, and others b. Individuals trained in basic first aid are taught to provide necessary critical care prior to arrival of EMTs. 2. First Responder a. Trains individuals to initiate immediate care and to assist the EMTs when they arrive b. Focuses on providing immediate basic life support and urgent care with limited equipment 3. EMT-B a. Requires approximately 110 hours of training (more in some states) in the essential knowledge and skills required for providing basic emergency care in the field b. Includes skills for automated defibrillation, definitive airway adjuncts, and assisting patients with certain medications 4. EMTIntermediate (EMTI) a. Designed to increase knowledge and add skills in specific aspects of advanced life support (ALS) b. Additional skills include IV therapy, interpretation of cardiac rhythms and defibrillation, orotracheal intubation, and administration of certain prescribed drugs. 5. EMTParamedic (EMTP) a. An EMTP has completed an extensive course of training that significantly increases knowledge and mastery of basic skills and covers a wide range of ALS skills. b. Skills include IV therapy, pharmacology, and cardiac monitoring. 6. If your state differs from the national blueprint, explain the levels of training recognized.

The first TEMS training program developed in the United States (US) was the Counter Narcotic Tactical Operations Medical Support (CONTOMS) program, created in 1990 by the Casualty Care Research Center (CCRC), in cooperation with the Department 5

of Defense, Department of the Interior, United States Park Service Special Forces Branch, and the Uniformed Services University of the Health Sciences (USUHS). The CONTOMS consists of a series of courses that focus on the unique medical skills as well as law enforcement principles and techniques necessary for the successful accomplishment of tactical missions. The primary CONTOMS course prepares previously trained pre-hospital EMS personnel from a variety of backgrounds for EMTTactical certification with a one-week, 58-hour instruction course; numerous private organizations are offering training based on the model of the CONTOMS curriculum. Tactical emergency medical support providers must be able to provide care with less medical equipment, limited space, light and sound restrictions, and without contact to medical control. Remote patient assessment, the practice of triaging, evaluating, and ordering treatment for a patient without being in the patients presence may be necessary. Patients may require disarmament, render-safe activity, or removal of protective clothing. In addition to providing tactical medical care, TEMS personnel perform other functions that contribute to mission readiness and may provide strategic advantages to mission leaders including: (1) team performance monitoring (2) assessment of morale and fatigue (3) preventative health maintenance (4) pre-emptive medical reconnaissance (5) gathering of on-scene medical intelligence (6) interactions with civilian medical resources.

Tactical
Zones of operation Protective tactical equipment Light and sound discipline Zones of care

Medical

Preventive medicine/primary care Medicine across the barricade remote assessment methodologies, care provision

Rapid insertion and extrication techniques Forensic evidence preservation

Medical Threat Assessment Sensory deprived, sensory overload physical examination

Weapons handling and render safe techniques

Hazardous materials/Hasty decontamination

Table 1 Comparison of knowledge and skills required for tactical and medical personnel.

The most common approach to recruitment and training of TEMS personnel has been to provide medical personnel with additional training that includes some level of law enforcement training. The CONTOMS and other TEMS training programs require prior training using the 110-hour minimum Emergency Medical Technician-Basic: National Standard Curriculum as a prerequisite. Under certain circumstances, this approach to recruitment and training of TEMS personnel may be undesirable or impractical for several reasons. During an operational environment tactics should take precedence over emergency medical skills to ensure a missions success. Whether law enforcement personnel without prior medical experience are capable of attaining and 7

maintaining the necessary EMS knowledge and skills has not been demonstrated. In these situations, providing medical personnel with appropriate tactical training may be a more desirable alternative than providing law enforcement personnel with medical training. Roles and Responsibilities of the EMT-Basic A. Personal safety 1. Should always be the EMT-Bs top priority 2. Determined by sizing up the scene during the approach B. Safety of crew, patient, and bystanders 1. Ability to safely operate the ambulance 2. Sizing up the scene for threats C. Patient assessment 1. Should be thorough and accurate 2. Includes a SAMPLE history 3. Recognize that assessment findings will affect treatment decisions and a poorly done assessment may lead to inappropriate treatment D. Patient care based on assessment findings 1. Reaching a clinical impression and providing care 2. Identifying patients who need immediate intervention and those who will benefit from a detailed assessment E. Lifting and moving patients safely 1. Properly packaging the patient and safely moving him or her 2. Using proper lifting mechanics to protect the EMT F. Transport/transfer of care 1. Transporting the patient to the destination 2. Giving necessary radio reports 3. Giving a verbal report to health care facility staff G. Record keeping/data collection 1. Documenting patient care report 2. Completing other needed reports (ie, incident report) H. Patient advocacy (patient rights): Considers the patient as a whole and safeguards the patient's rights

Professional Attributes of the EMT: A. Professional attributes of an EMT 1. Puts patient's needs as a priority without endangering self 2. Maintains a professional appearance and manner 3. Expected to perform under pressure with composure and self-confidence 4. Treats patients and families under stress with understanding, respect, and compassion 5. Is nonjudgmental 6. Extends compassion, respect, and the best care possible to every patient, regardless of the patient's attitude 7. Respect patient confidentiality because EMS is an extension of the emergency medical care provided in the emergency department by physicians 8. Does not discuss findings or any disclosures made by the patient with anyone except those who are treating the patient or as required by law. B. Continuing education: 1. An EMT-B is required to attend a certain number of hours of continuing education (CE) each year. 2. Review state requirements for renewal. 3. An EMT-B must also maintain a current knowledge of local, state, and national issues affecting EMS. 4. Maintaining knowledge and skills is a substantial responsibility; the EMT-B must regularly practice or refresh seldom-used skills. Responsibilities of and EMT in a tactical scenario could include any or all of the following: 1. Acquiring and maintaining important medical history, immunization status and current health status of each team member. 2. Transfer of information to medical personnel during the treatment of injury or illness. 3. Developing appropriate physical fitness, psychological stress prevention, and selfaid/buddy aid programs for team personnel. 4. Monitoring the medical effects of environmental conditions on individual and team performance; including considerations such as sleep deprivation, nutritional status and heat and cold stress. 5. Providing field medical treatment to team members injured or taken ill while engaged in mission activity. 6. Ensures that team members are afforded the best possible treatment and are transferred in a timely manner to an appropriate level of care.

7. Provides humanitarian medical assistance to non-law enforcement personnel injured or taken ill during an operation until transfer to the EMS system can be safely affected. 8. Serving as the patient advocate for officers who are treated by other medical providers. 9. Establishes good working relationships with local EMS systems and with receiving medical institutions and assures appropriate integration of the teams medical program with the local health care delivery system. 10. Keeps commanding officers apprised of his findings and recommends actions, which should be taken to insure optimum outcome for the officer and the team following injury or illness. 11. Conducting Medical Threat Assessments to determine the potential impact of medical/health factors on mission outcome and serving as the Medical Intelligence Officer. 12. Serves as a health information resource for team members. These functions are an integral part of the mission planning process.

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Design This course will be instructor led and delivery will be a combination of lecture, small group discussion, practical and hands on instruction ending in a scenario based evaluation. The course consists of eight modules with a total of 197.5 hours of instruction (Table 2).
Module 1: Preparatory Introduction Basic Life Support Introduction to Human Body Vital signs, History Taking Lifting/Moving Patients Legal/Ethical Issues Module 1 Examination Module 5: Trauma Kinematics of Trauma Bleeding and Shock Soft Tissue Injuries Musculoskeletal Care Bandaging and Splinting Injuries to Head and Spine Trauma Skills Lab Clinical Rotations Module 5 Examination

3.5 hours 3.5 hours 2.5 hours 2.5 hours 3.5 hours 3.0 hours 1.0 hours

1.0 hours 1.5 hours 2.0 hours 2.0 hours 2.0 hours 2.0 hours 4.0 hours 8.0 hours 1.0 hours

Module 2: Airway Airway Didactics Airway Skills Lab Clinical Rotations Module 2 Examination Module 3: Patient Assessment Scene Assessment Patient Assessment Patient Assessment Skills Lab Focused History/Physical Exam Ongoing Patient Assessment Communications Documentation Clinical Rotations Module 3 Examination

3.5 hours 2.5 hours 4.0 hours 1.0 hours

Module 6: Infants and Children Infants and Children Didactics Infants and Children Skills Lab Module 6 Examination

2.5 hours 3.0 hours 1.0 hours

0.5 hours 4.0 hours 4.5 hours 5.5 hours 1.0 hours 1.0 hours 1.0 hours 16 hours 1.0 hours

Module 7: Operations Ambulance Operations Special Operations CBRNE Response Operations Clinical Access and Rescue Clinical Rotations Module 7 Examination

1.0 hours 1.5 hours 16 hours 3.0 hours 4.0 hours 1.0 hours

Module 4: Medical/Behavioral/Environmental/OBGYN General Pharmacology 1.0 hours Assessment and Pharmacology Lab 1.0 hours Respiratory Emergencies 2.0 hours Cardiovascular Emergencies 3.0 hours Cardiovascular/Respiratory Lab 2.0 hours Diabetic/Neurological Emergencies 2.0 hours Allergies/Poisonings/Overdoses 3.0 hours Behavioral Emergencies 1.0 hours Environmental Emergencies 2.0 hours Obstetric/Gynecological Emergencies 2.0 hours Medical Skills Lab 3.5 hours I.V. Therapy/Fluid Replacement 1.5 hours IV Therapy Skills Lab 3.0 hours Clinical Rotations 20 hours Module 4 Examination 1.0 hours

Module 8: Summary and Practical Exams Program Review Field Training Exercise Review and Preparation Medical Field Training Examinations Trauma Field Training Examinations Clinical Rotations National Registry Examination Preparation National Registry Examination

1.0 hours 1.0 hours 9.0 hours 9.0 hours 4.0 hours 1.0 hours 3.0 hours

Total 197.5 hours

Table 2 Curriculum for tactical emergency medical technician training and education IV = intravenous, Lab = laboratory and OB-GYN = obstetric/gynecological 11

Within each module, participants are provided with both didactic teaching and hands-on, field-based drills. The goal of this course is to provide tactical emergency medical training to personnel with no previous medical training and to prepare them to pass the National Registry of Emergency Medical Technician-Basic Examination. The foundation for the curriculum consisted of the standard Department of Transportation (DOT) EMT curriculum, with approximately 87 hours of training in tactical operations added to the course. Bradys Emergency Care, 9th edition was provided to participants to provide a fundamental EMT text as reference. Instructors would be required to be nationally registered EMT with at least 10 years of experience with a background in military and/or law enforcement as well. Nontactical topics, such as basic pediatrics and obstetrics were taught using the DOT standard curriculum, using lectures, slide presentations, and classroom demonstrations. All practical training scenarios would be tailored specifically to tactical, counter-narcotics tactical enforcement and other special operations. During practical rotations, an instructor to student ratio of 6:1 will be maintained. A total of 16 hours of clinical rotations will be conducted by ride-alongs with fire/rescue services in high-call volume, urban areas. This experience is supported by rotations through hospital emergency and intensive care unit settings. Student evaluations will be conducted using standard, national EMT checklists. A written and practical examination will be administered at the end of each module. During the final module, personnel participate in full-scale, tactical, role-playing scenarios simulating actual tactical operations.

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The final examination will consist of three parts: (1) National Registry of Emergency Medical Technicians Basic written examination (2) National Registry of Emergency Medical Technicians skill tests (3) Objective assessment of the students by qualified instructors/examiners in a scenariobased examination. Participants will be required to maintain perfect attendance, and an 80% pass rate in class exercises to sit for the final examination.

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Development The training will be conducted in eight hour sessions concluding in small group discussion and practical application as needed. At the start of each consecutive session there will be a review of the previously covered materials. Each course will consist of multiple learning objectives. Each learning objective will have a PowerPoint lesson plan. These lesson plans may be presented in a classroom environment or in a field setting. The lesson will start with an informal lecture. The lesson plans will use video and still photo screen shots of the actual tactical operations. By using PowerPoints automation effects you can break down the sequence of an event/task step by step to the students to ensure a good understanding, before attempting a practical or hands on application of that particular task. Each lesson will have a check of understanding as an evaluation method; at the conclusion of each objective each student will receive practical evaluation (PE). These PEs will require the learner to perform the objective in an application that is applicable to various tactical scenarios.

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Implementation The implementation process should be relatively painless all the curriculum needed to teach tactical operations to EMTs already exist as evidenced buy the multiple private agencies capitalizing on this particular market (the problem with that is the lack of standardization between organizations), as well the educational agencies, policies and procedures are also in place it is simply a matter of getting authorization to add to an existing curriculum. Prior to implementing the training the involved organizations would have to coordinate to ensure various resources are available to conduct the training. EMT programs my have to work with law enforcement academys to ensure this need is met. Once all the prerequisites that ensure successful execution of this course are fulfilled the training could begin. Training will be conducted as outlined in the development portion of the paper. Program Implementation The true measure of the effectiveness of the training will be the learners ability to perform tactical operations in a scenario driven evaluation, as well as convey understanding of the various concepts throughout the course. Course Directors will need to maintain contact with all former students and track their progress for the prescribed amount of time. The Director will solicate feedback from former students in person, by telephonic interview, or by Email. The results of this feedback will be used in the evaluation process.

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Evaluation

The designated local EMT program director will facilitate two methods of evaluation. One being data collection of test score, hands on exams and scenario based evaluations. This evaluation will determine whether the students are learning the material. The second evaluation will be a course critique from the students, this will allow for remarks that ultimately will be considered for use in improving the curriculum. This should determine whether the students grasp the concepts of tactical operations and are capable of applying those concepts in a real life scenario. Also there will be a six month and twelve month follow up contact after the conclusion of the course and an evaluation of value of this training in their work environments. The results of these evaluation tools will be utilized for the potential improvement of the courseware.

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Program Management How can the training of tactical operations to EMTs proposed in this paper be administered most effectively? The National Registry of EMTs currently drives the national standard curriculum of EMTs (accepted by the department of transportation) they define such areas as roles, responsibilities, scope of practice, training requirements, and refresher training requirements to name a few. Other stakeholders that would be involved in the process would include the State Bureau of EMS and whatever local, regional and state education entities offer EMT training. There is currently no one responsible for providing tactical operations training. This long standing divisions between various agencies (Fire, Law and EMS) and the difference of opinions on whose responsibilities are whose and what levels of training personnel should receive are eroding and now is a good time to propose such a change. By having this training integrated into the national curriculum we can fill a capability gap that has been identified for some time. The systems are already designed and in place it is simple a matter of getting the primary stakeholders to buy in and support enhancement of existing curriculum.

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Conclusion Traditionally this type of training would be the responsibility on the individual EMT, to seek out the training and assume the responsibility of tuition, lodging and travel, which would also include consuming the cost of time off without pay. Providing the training in the initial phases of EMT training will also lessons this burden as well as the burden on the EMS directors wanting or needing to provide such training to there employees and the cost savings associated with sending employees to such training. This study presents a new paradigm in the training of EMT personnel in tactical medicine. The NREMT Program will provide foundational emergency medical, tactical and special operations training to personnel. The design of this program provides a useful template to meet the expanding demand for tactical training of emergency services personnel and also provides and inherent capability of expansion or contraction as needs change.

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