Medics Enter The 'Hot Zone'
Tuesday, April 24, 2007
Teresa Hughes is sure about what saved her life on the winter night in 2004 when her boyfriend shot her in the face: It was the emergency medical care she received from the specially trained team of Maryland State Police officers who broke into her house to rescue her. Falling in and out of consciousness, she heard one trooper say, "Oh my, we're going to get you some help, sweetie, we're going to get you help." He and his colleagues stabilized her and got her to a waiting helicopter that whisked her to the shock trauma center in Baltimore.
The treatment Hughes received that night on the floor of the couple's Taneytown, Md., home is on the front line of emergency medicine and freshly under the spotlight because of the shootings at Virginia Tech. Under traditional emergency medical services (EMS) protocol, medical first responders wait outside a crime scene, or "hot zone," until it is deemed safe by the police. That can take precious minutes or even hours -- and can mean the difference between life and death. But in Hughes's case, the SWAT team included troopers who had been trained as paramedics and were able to give her immediate care, despite fears that her boyfriend might be barricaded inside the house.
Maryland State Police (MSP), along with police in Fairfax and Montgomery counties, the U.S. Park Police and some divisions of the Virginia State Police, are among the agencies that have embraced so-called tactical medicine, embedding paramedics and even physicians into special operations teams in the hope of saving lives, not only in the kind of domestic attack that Hughes suffered but in mass killings and school shootings like last week's rampage at Virginia Tech.
Since the mid-1990s, the MSP Tactical Medical Unit -- consisting of seven advanced-trained paramedics and three Johns Hopkins emergency care physicians -- has been providing medical support to SWAT teams on their high-risk missions. "We are deploying physicians to the scene, and that is not the standard of practice in this country for EMS," said Nelson Tang, one of the Hopkins doctors.
Now, in one of the few pairings between law enforcement and an academic medical institution, MSP and Hopkins plan to expand the role of out-of-hospital emergency care. The state police will train medical residents and other physicians in special operations while Hopkins will help assess the value of tactical medicine, which so far rests largely on theories drawn from battlefield medicine.
A Model Program
Prompted by the killings in Waco, Tex., and at Columbine High School in Colorado, these innovations attempt to save the lives of victims, of members of the SWAT teams and even suspects.
One man behind the thinking is former U.S. surgeon general Richard Carmona, who served in the Army Special Forces in Vietnam. "We were never deployed without a medic on the team," said Carmona, who introduced that concept to police work in the 1980s when he was a deputy sheriff while also serving as director of Tucson Medical Center's Trauma Services. "The Maryland State Police is really one of the model programs nationally," he said.
Across the country, law enforcement agencies have been developing similar programs, though most rely on fire department emergency technicians or paramedics to support SWAT teams rather than following Maryland's model. In the view of Lt. Mark Gibbons, a police commander and tactically trained paramedic who helped start the MSP unit, it is an approach worth pursuing. "When law enforcement needs assistance, special operations is the 911 for cops," Gibbons said, explaining that frontline medical support tells officers and the public "that you care about them." Still, tactical medicine is not without controversy, including whether caregivers (especially physicians) should carry firearms. MSP's tactical paramedics do carry guns, as they are also sworn state troopers; the physicians, who stay outside the hot zone, do not.
'A Phone Call Away'
Those physicians were called out on almost half of the more than 250 missions the tactical medical unit responded to in Maryland last year. Typically, the doctors provide consultation and logistical support and give medical care to victims once they have been moved by paramedics. Under an arrangement by which they hold part-time positions with the state police, "the physicians are always a phone call away, if they are not actually on the scene," said Sgt. Keith McMinn, one of the tactical paramedics.
In recent years, the physicians have joined teams serving high-risk warrants and dealing with hostage situations; they have supported the bomb squad, been called to the University of Maryland at College Park when there has been a risk of crowd violence after basketball games, and they have helped protect the governor in large gatherings.
Much of the doctors' focus is on the troopers: "A lot of tactical medicine is keeping a special operations team self-sustained," Gibbons said. That can mean monitoring the troopers' work-rest cycles on long-term missions such as hostage incidents; it can involve stapling non-threatening wounds that might otherwise keep them out of a mission; and it can even involve advising troopers not to overdo it in training.
"It's a hybrid of occupational health, emergency medicine, sports medicine and [acting as] a health and safety officer," said Kevin Gerold, a Hopkins doctor who is MSP's tactical medical director.
Operating in the Dark
Medical knowledge plays an important role before a mission begins: "Planning is the most important part . . . to plan for when things go bad," McMinn said. Members of the medical unit figure out such details as the location of the nearest hospital and the likelihood of the presence of hazardous materials. They may also try to determine whether a suspect has a mental illness or whether a hostage has a medical problem, such as diabetes, that could affect the outcome of a case.
Sometimes a mission requires a SWAT member to be deployed in the woods for hours on a January day or night, even if he's suffering from a cold or diarrhea. In such cases, "we need that sniper to be focused on the mission" rather than his own discomfort, McMinn said. Tactical paramedics can provide medical supplies and some drugs.
Last summer Maryland expanded the scope of its tactical paramedics. Now they can staple or superglue the wounds of troopers on high-risk missions, dispense some prescription drugs and provide other care to keep special operations officers in the fight.
"Functionally, it gives them outstanding flexibility," said Don Alves, another tactical physician.
Providing emergency care in dangerous settings is very different from operating in a hospital. "Stealth may be critical to both the success of the mission as well as the safety of officers and providers," Hopkins doctor Tang said.
Light is often a hazard, for example. So rather than relying on sight to perform a critical procedure such as inserting a breathing tube in someone's windpipe, Tang said, "we teach a procedure called digital intubation, where the fingertips are inserted into the mouth and used to feel for the correct placement."
Similarly, sirens, gunfire and noise from traffic may limit the physician's ability to use a stethoscope, Tang continued, so "we teach using hands on both sides of the chest to feel for chest rise."
When there is a gunman at large, the paramedics and physicians may have to work while lying flat alongside a patient. "The hands can be used to sweep down a body to feel for moisture that is likely to be blood, Tang said. "Again, hands on chest to verify breathing. Alternately, a small mirror can be held up to the face to check for 'fogging' that indicates breaths."
With the sound of bombs exploding in a stand of woods outside Chantilly one day in late March, third-year Hopkins emergency medicine resident Kiernan DeAngelis got a taste of the challenges facing medical personnel who work with SWAT teams.
It was training day for DeAngelis and for the MSP unit, which was joining Fairfax County police and fire departments in three exercises designed to provide medical support to a bomb squad.
"I realized just how difficult that job is," DeAngelis said, "and how many factors you have to consider."
DeAngelis has trained with the MSP medical unit in simulations of terrorist attacks and school hostage scenarios. Soon, Hopkins residents will have opportunities to join MSP physicians on the perimeter of high-risk missions. "It's a fairly hot area out there in medicine," said Lars Thestrup, another Hopkins resident who, like DeAngelis, had a background in EMS before going to medical school. And it's a crucial part of the mission, Tang said, "to train the future leaders of emergency medicine and tactical casualty care."
Prepared for Threats
The scale of the tragedy at Virginia Tech might have overwhelmed the best of strategies, according to members of the MSP unit. Two Virginia State Police SWAT teams, one from Salem and one from Culpeper, responded to the incident, one of which had a tactical paramedic.
But images of wounded students being dragged or carried out of buildings to a safe location where care could be given evoke the very challenges the MSP unit is trying to address. "The ability to access casualties and render aid while an active shooter situation is still evolving" is a major goal for tactical medicine, Tang said.
"We're seeing very-high-risk threats in our schools, in our malls and in our airports," Tang said. And on the day of the Virginia Tech shootings, the MSP unit was training -- at a soon-to-open high school north of Baltimore -- to respond to just such an incident. ·
Christopher J. Gearon last wrote for the Health section on how government health agencies troubleshoot TV medical dramas. Comments:firstname.lastname@example.org.