Tactical Emergency Medical Service in Salt Lake City as...

Tactical Emergency Medical Service 1

Tactical Emergency Medical Service in Salt Lake City as Provided by

the Salt Lake City Fire Department

Karl Lieb

Salt Lake City Fire Department

Salt Lake City, Utah


CERTIFICATION STATEMENT

I hereby certify that this paper constitutes my own product, that where the language of others is

set forth, quotation marks so indicate, and that appropriate credit is given where I have used the

language, ideas, expressions, or writings of another.

Signed:


ABSTRACT

The integration of Tactical Emergency Medical Services into law enforcement special

operations is becoming more common throughout this country. These personnel are often drawn

from fire department ranks given their common public safety responsibility, their training in

emergency medicine, and their experience in providing emergency care in various environments.

Such programs allow emergency medical responders prompt access to patients who may be in

need of immediate medical intervention.

The Salt Lake City Fire Department currently has no established program to provide

tactically trained emergency medical personnel (EMS) to SWAT members, patrol officers, or

members of the public in SWAT or active shooting incidents. In the interest of public safety,

Salt Lake City Fire Department needs to provide trained tactical medical personnel as an integral

element to any Salt Lake City Police Department tactical operation. The purpose of the

following research was to identify and provide both Salt Lake City Police and Salt Lake City

Fire with a practical means to provide tactical EMS service to police department operations

during these types of responses. Action research will be used to answer the following questions:

A. How do other agencies effectively integrate tactical EMS (TEMS) into their operations?

B. What are the parameters of the training?

C. What are the common obstacles to such programs?

D. What type of TEMS program would be most beneficial to Salt Lake City?

A simple survey was used to generate data regarding the existence of such programs and

their basic organization. Public safety organizations of similar size to Salt Lake were

solicited to provide relevant data that was valuable in the development of a program for Salt


Lake City Fire Department. The results indicated a significant percentage of public safety

organizations integrate the two disciplines in varied models. Recommendations incorporated

this data into a practical two-phase plan that would address the need for both SWAT medics

and TEMS trained firefighters who may be the first responders to this type of incident.


TABLE OF CONTENTS

Abstract ................................................................................................................................... page 3

Table of Contents .................................................................................................................... page 5

Introduction ............................................................................................................................. page 6

Background and Significance ................................................................................................. page 8

Literature Review.................................................................................................................. page 13

Procedures ............................................................................................................................. page 25

Results ................................................................................................................................... page 28

Discussion ............................................................................................................................. page 31

Recommendations ................................................................................................................. page 35

References ............................................................................................................................. page 43

Appendices

Appendix A: Survey ............................................................................................................ page 46

Appendix B: Standard Operating Guideline ........................................................................ page 47


INTRODUCTION

No two incidents involving a mass shooting/active shooter are the same. It appears that

the "bad guys" (criminals and terrorists) are more determined, more violent, and more heavily

armed than ever before. Many of these types of events cannot be peacefully resolved or

negotiated and crisis situations such as "mass killings" appear to be occurring with alarming

frequency (Vernon, 2010a).

Public safety organizations today have to be prepared for virtually any type of

emergency. The "all-hazard" approach now applies to police, as well as fire departments

throughout the country. The fire industry has evolved to become a primary resource for

emergency medical service in many urban locations in the United States. As such, they must be

integrated into some of the tactical operations conducted by police departments in times of

immediate need. One such type of immediate need is "active shooting incidents". In these

instances, police personnel are focused on mitigating a threat that will continue to utilize deadly

force on innocent civilians until such threat is terminated either by police intervention or suicidal

action. History has shown that an active shooter will wound, kill, or otherwise incapacitate any

civilian in his/her path in a premeditated effort to cause maximum impact on society's norms

while leaving a tremendous toll on human life. Often there may be medical need inside the

perimeter long before the scene is safe. It is the TEMS provider who may provide this care

(Carmona, 2003)

This is where fire/emergency medical service (EMS) personnel become invaluable. In

those first few minutes that an individual sustains such a wound, their chance for survival is

exponentially increased with immediate emergency medical intervention. This is what many

Fire Departments across the country provide to their respective police/SWAT teams; an ability to


address civilian casualties and operational injuries on-scene during an active shooting incident.

This service is a necessary by-product of our current culture; where individuals maximize shock-

value by demonstrating little or no regard for human life.

That being said, the challenge for most fire departments is the integration of their resources with

those of the Police department. Our missions are quite different, and given the diverse training

that each entity provides, it is not surprising to encounter obstacles in the development of multi-

departmental logistics, resources, program design, costs, standards, and policy.

Salt Lake City Police Department currently has no established program to provide

tactically trained emergency medical personnel (EMS) to SWAT members, patrol officers, or

members of the public in SWAT or active shooting incidents. In the interest of public safety,

Salt Lake City Fire Department needs to provide trained tactical medical personnel as an integral

element to any Salt Lake City Police Department tactical operation. The purpose of the

following research is to identify and provide both Salt Lake City Police and Salt Lake City Fire

with a practical means to provide tactical EMS service to police department operations during

these types of responses. Action research will be used to answer the following questions:

A. How do other agencies effectively integrate tactical EMS (TEMS) into their operations?

B. What are the parameters of the training?

C. What are the common obstacles to such programs?

D. What type of TEMS program would be most beneficial to Salt Lake City?


BACKGROUND AND SIGNIFICANCE

March 21, 2005: Red Lake, Minnesota Indian Reservation; 16 year old active shooter kills 5

students, 1 teacher, and a guard before killing himself

October 2, 2006: Lancaster, Pennsylvania community college; active shooter kills 5 students

then himself.

April 16, 2006: Virginia Tech University; active shooter kills 31 people while moving from

dormitory to classroom. This is the most lethal active shooter in U.S. history.

May 26, 2007: Moscow, Idaho courthouse; sniper kills one police officer, wounds another

before killing himself.

December 5, 2007: Omaha, Nebraska; active shooter kills eight people and wounds 5 others in a

shopping center.

February 8, 2008: Baton Rouge, Louisiana: A nursing student kills two and then herself at

Louisiana Technical College.

February 14, 2008: DeKalb, Illinois: Active shooter kills seven students and wounds 15 others

in a classroom at Northern Illinois University before killing himself (Vayer,

2003).

These are just some of the incidents that have led to a collaboration of fire and police resources

to meet the service need for emergency medical service on-scene of such events.


These incidents are not, however, exclusive to "other cities". In Salt Lake City alone, we

have seen active killing incidents first-hand:

April 15, 1999: Family History Library; 71-year active shooter kills a security officer, patron,

and wounds five others (including a police officer) before being shot by police

(Gunman in Salt Lake City, 1999).

February 12, 2007: Trolley Square Mall; 18-year old active shooter kills 5 patrons and wounds 6

before being shot by police (Trolley Square Shooting, n.d.)

The latter of these two incidents remains very fresh on the minds of Salt Lake City public

safety and city officials to this day. The event has been analyzed and studied extensively to

provide better understanding and knowledge of what police can expect in such an incident, as

well as how the fire department can be of greater value during the police operation. Although

accurately recognized for their professional and prompt mitigation of the incident, personal

testimony from multiple public safety officers confirm the fact that this incident precipitated for

nearly 30 minutes. "We have six fatalities and multiple victims at hospitals. They were found

throughout the mall", said Sergeant Robin Snyder of the Salt Lake City Police Department

(Gunman Kills Five, 2007). Lt. Josh Scharman, one of the first patrol officers on scene, reported

that "As we entered the mall, we saw the wounded and began to move towards the sound of

gunfire. We made the conscientious decision right then and there that we were going to bypass

the wounded and try and eliminate the ongoing threat". Scharman went on to say that "This

mass-casualty experience was unique for us. The 'grab and drag' model wasn't going to work –

he would continue to shoot, so we established a areas within the building that we felt were


secure enough to bring in EMS within 15 minutes" (Personal Interview, 2011). Patrons in the

mall at the time of the shooting corroborate this timeline; "I saw a woman's body face-down at

the entrance to Pottery Barn Kids. I locked myself and four others inside a storage room for

about 40 minutes, but I was still able to hear the violence" said mall patron Mike Lund (Gunman

Kills Five, 2007).

Incidents such as these demonstrate the methodical nature of active shooters and the time

it may take to locate and safely mitigate the suspect. Traditional role limitations present a basic

problem for a rapid response to these incidents: police departments do not normally employ

paramedic or emergency medical technicians (EMT's). Thus the reliance on an EMS

organization or fire department is necessary. Traditionally, fundamental differences in

objectives exist among the different public safety entities. For instance, although law

enforcement, fire, and EMS all share the same basic life safety priority in live-shooting events,

the first priority for police is to terminate the threat, whereas the first priority for fire/EMS is

normally to establish that the scene is secure.

Firefighters do not normally carry weapons during routine operations within their

jurisdictions. They are trained to protect themselves by remaining aware of their surroundings

and utilizing all information at their disposal. This often means waiting for police to "secure the

scene" and ensure that fire personnel are in no immediate danger of any threat. This is a standard

protocol for operations within the Salt Lake City Fire Department and has worked effectively for

those patients who intend to inflict harm on themselves or are victims of assault where the

assailant may still be in the area (Salt Lake City Fire Department, Policy #03-23).


Unfortunately, this standard may deny those in immediate need of life-saving intervention that

they may need while in the hazard zone - a zone that may be rendered "secure" for the purpose of

a tactically-trained EMS providers under the watchful eye of a SWAT-trained "cover team".

In an active shooting incident, the first priority for police is to identify the threat, but

moving targets within a building present a particular challenge depending on the size of the

structure and the number of rooms or areas contained within its walls. Analysis of these

incidents indicate that there is time for EMS providers to enter such a scene tactically and render

rapid life-saving aid to victims while the "contact team" actively pursues the shooter (Weiss,

2007).

Traditionally, police departments have utilized EMS in three distinct ways:

1. "If we need you, we'll call you:" Ineffective given that law enforcement officials may not

realize in advance that they may need EMS.

2. Stand-alone EMS unit assigned to staging: Less than ideal given that the scene must be

"secured" or patients must be evacuated with valuable care time lost.

3. Incorporation of EMS into the tactical police operation (TEMS): Most effective given

that EMS responders are within the tactical zone ensuring time-sensitive emergency care

for police, civilians, and suspects (Rooker, 1992).

The value of immediate medical care has been clearly established in medical journals and

studies. In fact, the time for effective first aid is very limited. A review of the Vietnam wound

data reveals that greater than 80% of those fatally wounded by a bullet die within a few minutes


of injury (New Castle County, 1999). In addition, airway management is integral to the

management of trauma patients. Cerebral oxygenation and oxygenation of other parts of the

body provided by adequate airway management and ventilation remains the single most

important component of pre-hospital patient care (McArdle, Rasumoff, and Kolman, 1992).

With greater police enforcement of drug-related, criminal activity, there now is more

contact between police and heavily armed felons. The availability of mind-altering substances,

the increased reliance on outpatient psychiatric services, the increase in gang activity, and the

availability of assault-type weapons, individually and the concert, underlie the increased demand

for an ability to provide medical care on the home battlefront (McArdle, et al, 1992).

If there is a possibility that lives can be saved during these types of incidents, we have an

obligation as public servants to develop the education, resources, and training to provide this

service to the citizens of Salt Lake City. This topic is directly related to the Executive Analysis

of Fire Service Operations and Emergency Management Course in that a Tactical EMS program

is integral to the safe and effective response to active shooting/mass killing events that have

become more common throughout the United States. These incidents represent an emerging

issue that can occur in metropolitan, urban, suburban, and rural environments nationwide.

SWAT team missions are often hazardous, unconventional, and immediate. Incorporating

tactical EMS personnel into these operations is appropriate and necessary in an effort promote a

risk-reduction plan requiring fire department participation. It is incumbent on operations Chiefs

and Emergency Managers to ensure that the appropriate coordination and training occur to

prioritize life safety for both public safety officers and the citizens they serve.


LITERATURE REVIEW

There is a direct line between from the evolution of medical support for military special

operations forces in the United States of America after World War II, to what is now recognized

as TEMS in civilian law enforcement and public safety. From these military experiences came

the determination that the traditionally trained "medic" was inadequately prepared to operate

with these units without additional training in several disciplines (Llewellyn, 2003).

Today, the use of local fire department personnel on tactical teams has become an

increasing trend within the tactical and fire service communities. Yet, most police departments

do not have dually-certified Police Officer Standards and Training individuals with emergency

medical training. Thus, police organizations still attempt to bring medical provider's as close to

the scene as possible while respecting their inability to defend themselves in a hazard zone.

For years Miami-Dade Fire Rescue shadowed Miami-Dade Police Department personnel

for warrant services, potentially violent arrests, and raids. Rather than a formal TEMS

agreement, however, they essentially operated autonomously of the Police Department in that

they responded in their own vehicles, worked within their own protocols, and had minimal

communication with their public safety cohorts while "standing by" to intervene if a police

officer or civilian was injured and either brought to the safe zone or the scene was secured by

police personnel. The rescue units would stand by at a safe distance while attempting to monitor

events within the "hot zone". Both Fire and Police realized there were gaps in the system. On-

duty firefighter crews were often not notified of the impending response until 30-60 minutes

before the actual operation. Since many of these operations took several hours to complete, the


fire department would realize a negative impact on their response times and district coverage

(Palestrant, 2010). There is also a financial cost associated with this type of operational. The

deployment of a TEMS unit often eliminates the need to hold an engine on scene for hours, and

this cost can be measured (Evans, 2009). The byproduct of such an arrangement was felt often

times by the victims and responders alike. Although each public safety entity prioritized life

safety, this independent response model led to reductions in efficiency and positive medical

outcomes.

In military environments, fast triage and evacuation of casualties is imperative. Ninety

percent of combat deaths occur before patients reach medical treatment facilities; some 15-20%

of these are probably preventable, coming from causes like bleeding extremities, collapsing

lungs and airway obstructions (Weiss et al, 2007).

Many of the wound patterns seen in recent military conflicts are also seen in the civilian

tactical arena. Domestically, there have been incidents all over the country where police and

victims have bled out because help was not able to get to them due to the danger of the situation.

In a 1999 incident, two officers in Cobb County, Georgia, were killed in a hostage situation, and

another officer was wounded. Medics were there but were unable to do anything to help the

officers until the police cleared the area (Weiss and Davis, 2006).

Studies have shown that more than 60% of SWAT officers' injuries suffered during

showdowns with criminals involve excessive bleeding, often from gunshot or knife wounds.

Downed officers wait for an ambulance to arrive at the incident, then for police officers to deem

the area safe for paramedics to enter and administer treatment – delay that increased the risk that


injured officers would bleed to death (Roberts, 2010). Other medical professionals put it more

succinctly: "The current standard of fire/EMS departments staging during an active shooter

incident while waiting for police to "secure the scene" is inherently flawed: While waiting for

police to clear the entire area, those injured inside the building aren't receiving care and are dying

from their injuries" (Smith, Iselin and McKay, 2009).

Yet even with such compelling arguments, controversy regarding such programs does

exist. As with the implementation of most new programs, there will undoubtedly be honest

differences of opinion between knowledgeable and experienced professionals. TEMS has been

no different. However, "The differences have been more challenging since there is very little

evidence base available to us to clearly develop policy, procedures, and guidelines. Much like

emergency medicine itself as it developed, TEMS practice is founded on anecdote and /or

extrapolation of related scientific information." (Carmona, 2003).

Many "old school" fire departments resist the idea of firefighters with guns or training

with police. The perception stems from the stereotype that firefighters fight fire and police

officers fight crime. I have heard it myself many times; "if you want to carry a gun, then be a

cop." Opponents will use the assertion that this role is not part of a firefighters job. But

proponents of the concept assert that TEMS personnel must be able to defend themselves, if need

be. This issue is prominent for many departments trying to resolve the issue of arming their

medics or not. Some administrator's (and union leaders) oppose arming medics because they feel

providing medics with weapons is counterintuitive to their training to support life. In addition,

some argue that it is difficult for one individual to devote the time and training necessary to


maintain both medical skills and weapons skills. Other considerations are that it is unknown

how an armed (or unarmed) TEMS provider will react to a stressful high-risk situation or what

their perception of threat will be in a given situation. Their perception is what ultimately

determines the appropriate level of force to be used by an officer (Carmona, 2003). Advocates

of arming medics point to the need for TEMS personnel to be able to operate safely in an

environment much different than what they are accustomed to; an environment where they could

get shot (Myers, 1997). It is essential to prepare medics for a stressful environment that differs

from normal EMS calls. Many medics are used to being in control of the environment, for

example, arriving to a residential structure, taking a patient out on a stretcher and putting him in

the back of an ambulance for transport to a hospital. But it's different with SWAT teams. "In

tactical-medic operations, we're going into an environment not built for us. It's hostile."

(Roberts, 2010). Lt. Mike White of Tampa Fire Department stated "When I met with leaders of

our SWAT team and our fire department, and addressed this issue of being armed, I did it with

the idea that if we are unarmed, we actually have the potential to being a detriment to the team"

(Essex, 2002). White went on to say that the members of his team have not had difficulty

maintaining competency in all their skills and that arming medics puts them on the same footing

with the rest of the team, which he feels is vital to developing a cohesive unit.

If then, the determination is made that TEMS personnel will be armed, there is also the

concern of providing firefighters with the ability to utilize deadly force. "If the TEMS personnel

are going to be armed, the fire department should consider sending them through a law-

enforcement academy for liability purposes. The possibility of shooting, killing, or seriously

wounding a suspect is very real, and the scrutiny of a shooting review board or a defense


attorney will put the operation at risk in the absence of proper training and credentialing" (Evans,

2009). The benefit of providing this training to personnel, however, is that it provides

justification for these team members to operate under the authority of the police department and

creates an atmosphere on the team of mutual understanding and credibility. Many believe EMS

personnel would operate safer with tactical training. "Far too often, EMS crews walk into crime

scenes with little or no information on what is occurring and find themselves in the middle of an

unsafe situation" (Smith, 1999).

Another concern is that the risk accepted by a tactical medic is beyond the risk accepted

by firefighters. But is it? A firefighter's first tactical priority is life safety, and this priority is

balance against existing risk. Many believe this is simply an extension of this objective in a

different role. There are risks every time a firefighter enters a burning building, treats a patient

who has a communicable disease or rescues a person from the heat of a wildfire. These are

inherent risks associated with the job of a firefighter. Rendering aid at the scene of a active

shooting incident should be no different (Palestrant, 2010).

There is also ample discussion regarding whether police officers should be trained to a

medical competency (EMT/Paramedic) or if firefighters/EMS should be trained to police/SWAT

standards. Proponents of training police to a medical standard will say that this maintains the

close bond necessary for an effective team. This is the case in many departments, with little or

no compromise in the tactical ability of the team. However, it is becoming more apparent that

the opposite model is more common; firefighters trained in police operations. Critics to the

former point out the logistical challenges of a full-time police officer attending some 1,000 hours


of medical training, not including emergency department time and riding an ambulance for a

minimum of 160 hours? Most importantly, where will they obtain hands-on experience (Essex,

2002).

"The vast majority of cities do not have the call volume to maintain the proficiency of a

tactical medic assigned to a law-enforcement unit, Moreover, the skill proficiency needed for

IV's and advanced air way control makes it more feasible for experienced firefighters/paramedics

to fill this role" (Evans 2009). Most law enforcement personnel are trained only to the level of

American Red Cross First Aid and cardiopulmonary resuscitation (CPR). Usually, there is no

provision for medical procedure to psychomotor skill retention, other than annual recertification.

In many jurisdictions, patrol officers are discouraged from providing medical care even though

they are often the first emergency personnel to arrive at the scene of an incident. With a few

exceptions, they lack the training and experience to assess and provide triage for patients rapidly

(McArdle etal, 1992). Firefighters simply know EMS better than police officers ever will. The

converse may also be true, but it is simply more practical to train a firefighter/Paramedic in basic

police SWAT movement than vice-versa.

For many, the issue of liability has become a point of contention regarding any TEMS

team. Some law enforcement agencies will directly employ TEMS providers, either as sworn

officers or civilians. Many other TEMS programs rely on agreements between the law

enforcement agency and a government (eg, fire department) or private (eg., hospital) agency.

These agreements are usually documented as a Memoranda of Understanding (MOU) or Letters

of Agreement (LOA) between the two agencies and are essential to assuring the protection of all


parties as well as the citizens served by them. These documents address the issues of function

and process as well as liability, disability, and other legal matters (Vayer and Schwartz, 2003).

Interestingly enough, if the liability issue is addressed from a victim's standpoint, it appears to be

more of a proponent of integrated SWAT teams than an obstacle to the programs. As Lieutenant

White said: "It was a huge liability to take my partner and me out of our rescue truck five blocks

down the road and say 'grab your bags and follow me'. We were not trained, we didn't have a

clue. It took two or three of their SWAT team members just to protect us. Any one of their

people you draw from just to babysit a paramedic is taking away from their law enforcement

resources. If you take the same two people you just grabbed out of that rescue truck and you

train them, equip them, and give them the right tools to operate, your department's liability is

lessened" (Essex, 2002).

Some organizations circumvent this issue by combining police and fire into a simple, but

role-specific Rescue Task Force (RTF) model. This model removes the TEMS personnel from

the SWAT team and instead places them with two police officers who act as security as they

enter the building immediately after the SWAT team identifies the need for EMS. As the SWAT

team continues to "move toward the sound of shooting" initial RTF's are providing care to the

wounded in the hot zone while additional RTF's are formed in the safe zone. The goal of this

response is to get medical resources to the patient's side within minutes of being wounded while

continuing to mitigate provider risk. "We felt our tactical medics were limited by their primary

role of working directly with our SWAT team and would likely be delayed in their deployment

to the scene." (Smith, et al, 2009). The RTF's then, like the police response to active shooters,

must be implemented almost immediately.


Lastly, there is no consensus on what type of EMS certification is appropriate for TEMS

personnel. It is generally regarded that most injuries occurring within the "hot zone" of a tactical

incident are of the Basic Life Support (BLS) variety; blunt trauma, excessive bleeding, airway

obstructions, etc. Based on data from more than 8,000 gunshot wounds of American serviceman

of every means, we have learned that proper and effective ALS care in a combat zone (hot zone)

is unsafe. Instead, a wounded soldier is first provided "buddy care" which addresses his

immediate life-threatening wound. He is then rescued and removed to a nearby safe zone where

more advanced intervention and stabilization may occur. The victim usually receives BLS care

first, followed by ALS care in a different location (Rasumoff, 1995). Given that algorithm, BLS

(EMT's) personnel could make up the entirety of the TEMS program. If BLS is utilized, then

there should be mechanisms immediately available to access ALS care and patient transfer, when

needed. Usually this does not require and special considerations since all EMS have those

processes in place (Carmona, 2003).

On the other hand, Paramedics have the knowledge, experience, and training to perform

more extensive interventions, particularly when the scene time becomes extended or the

environment becomes isolated (Vayer et al, 2003). In some jurisdictions, TEMS candidates must

have at least three years of experience as certified paramedics in order to be considered for the

program in addition to seven years service as firefighters (Roberts, 2010). It is clear that these

types of programs prioritize only experienced EMS responders for this type of duty.

Ideally, from a patient's perspective, physicians would fulfill the role of TEMS providers.

Although this would allow for the greatest scope of practice and medical control, they often have


little experience in pre-hospital care. In addition, they are certainly more costly to retain and

have limited availability for no-notice emergency response due to their routine commitments to

clinical care (Vayer et al, 2003). Tactical medicine is more like combat medicine than that

practiced by even the fire department in everyday emergencies. The most common are

penetrating injuries and wounds with massive bleeding (Weiss et al, 2006).

The training of TEMS personnel can be quite intense, given the variety of possible

tactical situations. These fall into three general categories, and TEMS personnel must be

prepared for each:

1. Barricaded suspect – individual(s) have created defensible space with unknown dangers.

2. High-risk warrant service – arresting a dangerous suspect or raiding a dangerous location.

3. Hostage situation – armed and dangerous suspect detaining, threatening, or killing

civilians (Rooker, 1992).

SWAT Medics are unlike other paramedics and EMT's both in their training and in their

demeanor. They must be high performance, competitive individuals because high stress and

physical fitness are part of the job. Their spot on the team is earned through extensive

assessments. SWAT medics must be able to function under physical and mental stress and still

deliver life saving medical procedures quickly and accurately (Weiss et al, 2007).

Many new members fail to recognize the time commitments to a tactical team as well as their

standard EMS responsibilities. First and foremost is the family consideration. The support and

understanding of the medics' family remains key to retaining team members. Several teams


point out that they have lost members due to family pressure. The amount of unscheduled time

away from the family and the uncertainty of the teams location and its missions take a toll on

each members home life (Smith, 1999).

Essential to the team's effectiveness is its make-up. The importance of having the right

kind of people on the team cannot be overemphasized. They must be physically fit and pass the

same performance tests as police officers on the team. Even more importantly, they have to have

the right personality and attitude about their position on the team. As Brad England, Executive

Director of Cyprus Creek EMS states "We are looking for people who want to be Paramedics,

not people who may lose their focus on their role and get involved in the police aspects of the

team" (Smith, 1999). "Their job is to provide medical support to police officer, civilians, and in

some cases criminals. They should not be considered part of the direct assault force" (Essex,

2002).

For Calgary, Alberta, paramedics who want to become members of the TEMS program,

desire alone isn't enough. Recruits with a minimum of two years on the job are put through a

challenging 8-step process including high angle rescue, confined space operations, tactical

movements, weapon training, psychological tests, and physical training (D'Amour, 2005).

Although not the only training course available, a large number of organizations use the

Counter Narcotics Tactical Operations Medical Support (CONTOMS) program for their initial

training curriculum. This program, located in the Uniformed Services University of the Health

Sciences (USUHS), has been in operation since 1990 and has produced more than 4,000

qualified tactical medics since then through its five-day course (Davis, 2001). "The program was


built out of … necessity", says Joshua Vayer, CONTOMS Course Director. "There's more to

understand about providing tactical EMS than 'oh, there's bad guys and there shooting at me and

I'm at risk." There are whole elements of medicine in the austere tactical environment that need

to be understood." he said. Public safety organizations throughout the country are trying to

accomplish the same objective: integrated medical care, without disruption of tactical law-

enforcement procedures. But without any kind of national standard, each agency had its own

approach and local EMS systems varied.

Consistent national TEMS standards were sorely needed, and the CONTOMS program identified

three goals:

1. To establish a standardized TEMS curriculum and certification process nationwide.

2. To collect and data to ensure the curriculum is up to date.

3. To provide consultation to public safety agencies for operational planning (Rasumoff,

1995).

The original 1989 curriculum included fundamentals on EMT support and survival how to

operate within the tactical medic environment. Organizations often developed ongoing training

within their own SWAT team customized to their own specific needs. Now, the current EMS

tactical program includes an in-depth section on the psychology of hostages and hostage takers,

lectures on the effects of heat and cold on performance, and how TEMS personnel can prepare

and support a team for extended operations. In addition, there is specialized training in triage,

sports medicine (sprains and strains), blunt trauma, entry planning, and the development of a

detailed Medical Threat Assessment (MTA) which identifies the capabilities of local hospitals,


local EMS, and other medical resources (Davis, 2001). Basic knowledge of potential HazMat

exposure is mandatory as well as the ability to conduct primary and secondary patient surveys

silently and in the dark (Rooker, 1992). Agencies with very limited budgets should look at local

or state program s on self-aid, buddy-aid, or "officer down" training to initiate development of a

TEMS program (Vernon, 2010b).

Lastly, equipment and training costs may be an issue for potential TEMS providers.

Budgets remain one of the biggest stumbling blocks. Who will pay for the program? Typically

police and EMS split the equipment responsibility. The police provide the tactical equipment,

such as ballistic vests, uniforms and helmets. EMS provides the necessary medical equipment

and supplies. However, personnel comprise the highest cost. Even relatively inactive teams

must train on a regular basis (Smith, 1999). Particularly in today's challenging economic times,

the financial burden associated with tactical EMS can be a significant obstacle to any new

program. Tactical Medics need the same protective outfits that the SWAT teams have, including

bulletproof vests and military-style Kevlar helmets. The equipment required for a TEMS

provider will depend on two factors: The level of training of the provider and the role of the

TEMS provider with the team. As a frame of reference, the average cost for equipping a LOS

Angele County Sheriff's Department Tactical Medic is about $6840 (Vayer et al, 2003). Law

enforcement can often times pay for some of this equipment with seized money if policy allows.

In addition, law enforcement grants are more numerous than fire/EMS grants. (Evans, 2009).

There are many factors involved in the selection of training for TEMS personnel. These factors

include, but are not limited to, course availability, team mission, TEMS provider skill level, role

of the TEMS provider within the team, and the cost of the training. While there are multiple


courses available, some have limited availability due to lack of federal funding. Those that are

available may be too costly for many public safety agencies (Vayer et al, 2003).

PROCEDURES

The basis for the vast majority of original research for this project is a survey. The

survey itself will ask specific questions regarding the existence and type of TEMS program

relative to the purpose statement of the research. It will be created to yield clear and valid results

which may be useful in the development of an effective TEMS program for Salt Lake City. The

success or failure of such a program relies, in some part, on the design, composition, and

sustainability of other programs that have addressed the challenges and pitfalls of such an

undertaking. It is accepted that many of these programs across the country may be in various

levels of design, development, and operation. Still, utilizing the knowledge and experience

gained from those departments who have already initiated the basic building-blocks of an

effective program should make the Salt Lake City initiative just that much more practical.

The action research designed for this work will incorporate a simple survey designed to

present little or no obstacle to rapid completion. This is imperative given that the recipients of

the survey are undoubtedly busy, and the complexity and length of the document may have an

inverse effect on completion rate. The survey will consist of six basic questions designed and

formulated to solicit objective information on the existence, type, and success of any TEMS

program currently implemented by the public safety organization. One hundred-twelve total

survey's were distributed electronically to various departments nationwide who met the

participatory criteria. Sample size was selected based on the researcher's estimate of a


reasonably representative data pool for comparable cities to Salt Lake. Consideration was also

given to a reasonable sample size for analysis. The agencies receiving the survey were selected

based on population served of between 100,000 – 350,000 (U.S. Cities, 2008), and a violent

crime rate greater than the national average (Crime Statistics, 2007). It was assumed that these

cities would be comparable to Salt Lake City Fire Department's size and relative run volume.

The above average risk for violent crime criteria would hypothetically indicate greater potential

for the use of TEMS. Special consideration was also made to include those cities/regions within

established criteria where previous active shooting/mass casualty incidents had occurred (Vayer

et al, 2003).

A survey was also sent to the corresponding law-enforcement agency of each Fire

Department selected to participate. This was done to determine if different perspectives could be

identified within the same program. The respondents were provided the studies' purpose and

scope, but were not informed of any predetermined hypothesis or intent. Questions were mixed

between open-ended and closed-ended to maintain some uniformity without limited valuable

feedback. Finally, all survey recipients were informed or their participation in a research study

for the National Fire Academy and agreed to respond willingly. The questionnaire could be

returned anonymously.

The survey questionnaire is as follows:

1. Do you currently have a Tactical Emergency Medical Services program and how is it

designed?

2. If yes, what are the key benefits to your department?


3. If no, why not?

4. Are your Paramedics/EMT's armed?

5. Do you utilize EMT's or Paramedics for your Tactical EMS program?

6. How are your TEMS personnel trained? (Appendix A)

The questionnaire was directed to the SWAT Commander of the respective law

enforcement agency as well as the Medical Director of the corresponding fire department.

The following cities were requested to participate in survey:

Boise, ID Norfolk, VA Santa Rosa, CA Lakewood, CO

Des Moines, IA Chandler, AZ Oceanside, CA Dayton, OH

Fayettville, NC Madison, WI Rancho Cucamonga, CA Sunnyvale, CA

Akron, OH Lubbock, TX Ontario, CA Mesquite, TX

Aurora, IL Durham, NC Tempe, AZ Pasadena, CA

Fontana, CA Glendale, AZ Lancaster, CA Savannah, GA

Augusta, GA Hialeah, FL Pembroke Pines, FL Fullerton, CA

Little Rock, AK Scottsdale, AZ Cape Coral, FL Newark, NJ

Glendale, CA Irving, TX Sioux Falls, SD Buffalo, NY

Huntington Beach, CA Irvine, CA Elk Grove, CA West Valley City, UT

Tallahassee, FL Spokane, WA Salinas, CA Lincoln, NE

Newport News, VA Arlington, VA Pasadena, TX Cedar Rapids, IA

Knoxville, TN Provo, UT Paterson, NJ Santa Clara, CA

Rochester, NY Torrance, CA St. Petersburg, FL Fort Wayne, IN


The limitations to this research method were as follows:

1. The relatively small sample size of cities surveyed.

2. The relatively small number of organizations returning the survey.

3. The confirmed accuracy of information provided.

RESULTS

The survey questionnaire returned 58 individual responses (52%) of 112 requests

for information within two weeks. Responses were mixed between Fire/EMS (34) and

law enforcement (24).

The following data was specific to the Survey Questions:

Question 1:

36 of 58 (63%) respondents confirmed that they had some form of TEMS program.

24 of the 36 (66%) had incorporated the program into their SWAT team in some manner.

Question 2:

28 of 36 (78%) respondents reported immediate patient access (or similar) as the number 1

benefit of integrated TEMS.

17 of 36 (47%) respondents reported reduced liability (or similar) as the number 2 benefit of

integrated TEMS.

10 of 36 (28%) of respondents reported a better working relationship (or similar) as the number 3

benefit of integrated TEMS.


Question 3:

18 of 22 (82%) respondents reported cost (or similar) as the number 1 reason they did not have a

TEMS program. This included equipment and training.

8 of 22 (36%) respondents reported no compelling need (or similar) as the number 2 reason they

did not have TEMS program.

5 of 22 (23%) respondents reported they did not know how to implement (or similar) a TEMS

program as the number 3 reason they do not have a TEMS program.

Question 4:

15 of 36 (43%) respondents have armed their EMT's/Paramedics within their TEMS program.

Question 5:

25 of 36 (69%) of respondents use some combination of EMT's and Paramedics in their TEMS

program.

11 of 36 (30%) respondents use paramedics exclusively for their TEMS program.

Question 6:

25 of 36 (69%) of respondents use some form of "in-house" training exclusively to certify their

TEMS personnel. This would include SWAT training and any specialized EMS training.

18 of 36 (50%) of respondents use a combination of "in-house" and "outside" schools to train

their TEMS personnel. This would also include P.O.S.T. training and/or CONTOMS or similar.

6 of 36 (17%) of respondents reports the use of "outside" schools only to train their TEMS

personnel.


In summation with regards to the research questions:

Of the 52% who responded to the questionnaire:

63% had some form of Tactical EMS program in place within their tactical response unit.

37% denied having a Tactical EMS program.

Of these 63% that responded affirmatively to the question regarding having a TEMS program:

69% of departments had imbedded them in some form within their respective SWAT teams.

Of these 69%, 39% had provided standardize training outside of their department (P.O.S.T,

CONTOMS, or similar).

Of these 63% that responded affirmatively to the question regarding having a TEMS program:

61% had provided internal training only to their personnel; both medical specific and/or SWAT.

43% of those with a TEMS program have armed their personnel in some manner.

69% of those with a TEMS program use EMT's and/or Paramedics.

31% of those with TEMS programs use Paramedics exclusively.

Of the 38% who responded negatively to the question regarding having a TEMS program:

87% of respondents listed "cost" as the primary obstacle to implementing a TEMS program.

48% noted lack of training or "liability" as an obstacle to a TEMS program.

27% listed lack of interest or need as an obstacle to a TEMS program.


DISCUSSION

It is clear that Tactical EMS programs are becoming more prevalent throughout the

United States. Literature and Results have identified a compelling argument for the programs;

faster delivery of emergency medical care in the "hot or hazard" zone to those who need it on

scene. This is in direct contradiction to the previous (or current) standard of maintaining medical

providers in the "cold zone" and having the tactical team evacuate patients to them. While this is

safe for the TEMS providers, it does not meet the needs of the team or the casualty (Vayer et al,

2003). Over one-half of the respondents had some form of TEMS program, and it appears that

number may continue to grow. Some case law is beginning to develop and show that tactical

medics are beginning to be seen as standard of care. This may be the greatest impetus for the

development of the concept in the future (Smith, 1999).

Of those organizations that have implemented TEMS programs, almost three-quarters of

them have done so within their SWAT teams on the law-enforcement side. This indicates that

most policymakers and administrators believe that the value of having EMS on scene on or near

the front line outweighs the potential liability of keeping the EMS group out of the danger zone

until the scene can be completely secured. This supports the trend as indicated in the literature

review that for those willing to make the commitment, full tactical integration is the best solution

to the challenge of bringing EMS providers to the front line. It appears that TEMS is gaining

nationwide acceptance in both EMS and law enforcement agencies because many TEMS

providers have made a positive impact during tactical law enforcement operations (Rasumoff,

1995)


How, exactly, this integration is accomplished remains mixed from the results. Although

the data indicates an increasing trend of bringing TEMS personnel into the fold of tactical

operations, it also indicates that just over one-half of those have achieved law enforcement status

eg: P.O.S.T. Certification. Of those departments that do mandate P.O.S.T. certification, they

identified two common benefits:

1. The medic can provide for his/her own safety without the necessity of dedicating a

tactical resource to him/her (this infers armed and trained in police tactics).

2. The medic now has arrest powers, authority to detain, and full "confidence" of the

remainder of the team (Essex, 2002).

In fact, of those departments that have TEMS program, less than half have utilized

"outside" training in any form to prepare their personnel. This means that many of those acting

in a TEMS capacity are neither P.O.S.T. certified nor CONTOMS trained. Interestingly, over

one-half of those agencies with TEMS programs are relying independently on in-house training

to bring their TEMS programs on-line. This indicates that although arrest powers, for instance,

may be beneficial in some cases, it is not viewed as essential. This may also indicate a prevalent

feeling from administrators that "role confusion" may have be a factor in the effectiveness of the

team. It is essential to remember the "one person – one job rule". "On any given mission, a

single individual tasked with the duties of more than one position (eg, medic and point man) will

perform neither as well as if he had only one job" (Vayer et al, 2003). Across the United States

there are successful TEMS programs with quite diverse composition. What works best in lone


location may not work well in another location. Each choice must be considered in a cost-

benefit analysis specific to the jurisdiction (Vayer, 2003).

The data also supports the literature review on the question of equipping TEMS

personnel with guns; with the results mixed. Close to one-half of the respondents with TEMS

programs have made the commitment to arming their TEMS personnel for either self-defense or

the ability to terminate an immediate threat to the patient or other team members. As discussed

earlier, this is a major point of contention for those who do not believe that EMS personnel with

guns is the most appropriate way to accomplish the TEMS objectives. Ultimately, both the

armed and unarmed approaches have advantages and disadvantages and the individual team must

make their own decision based o their state laws, mission, and team composition (Vayer et al,

2003). Although the data indicates there may be some means of providing TEMS personnel with

the ability to carry firearms without completing P.O.S.T. training, the means for this process

remains unclear and inconclusive.

As for the appropriate medical certification, it appears clear that very few department's

utilize (or are capable of providing) paramedics exclusively for TEMS activation. The data

indicates that almost three-quarters of those departments with TEMS are utilizing a combination

of both EMT's and Paramedics. This may be due to the preponderance of EMT's as opposed to

representative of the personnel available for such duty department-wide. Often, the pool of

paramedics alone is not sufficient to support the program. In addition, it is clear from the

literature that BLS providers (EMT's) are sufficient to fulfill most of the responsibilities of

TEMS. "Since the goals are to provide immediate care necessary to support life – airway


control, breathing support, hemorrhage control and evacuation to a secure area – the skills of an

EMT-B usually are adequate, at least in the initial minutes following an injury" (Davis, 2001).

This research leads to the question of why many departments still have no standing

TEMS agreements and many that do, do not utilize available training programs and outside

resources to certify their personnel in specific roles for TEMS. The answer is provided in the

results: Cost and liability concerns appear to be the overriding obstacles to the vast majority of

those organizations who have not yet implemented a TEMS program. First, this supports the

literature perspective from some fire and police administrators that all of the equipment and

certifications can become expensive, so much so that tactical medics may not be feasible in every

jurisdiction. In fact, many times the programs are cost-prohibitive and only work in urban

departments with a high population density and a high number of calls with potential for

violence (Roberts, 2010).

Secondly, liability concerns are also indicated by the data. Malpractice, disability, and

even liability were mentioned in the data from department's who find this to be a significant

obstacle to the development of a TEMS team. Rightly so, no agency wants to be faced with a

lawsuit only to have all the other agencies for which they thought they were working, deny

liability (Vayer et al, 2003). The decision, then, on whether or not a department commits the

necessary resources to any form of a TEMS program can largely be determined by perceived

need, which in at least for one-third of respondents, isn't there.


Lastly, there was no significant variance in the responses from fire and law-

agencies from the same jurisdiction. This indicates that although there exists many different

forms of integrated TEMS, those that have a program appear to be on the same page.

RECOMMENDATIONS

It is appropriate that any plan to implement a Tactical EMS program involving Salt Lake

City must consider three factors:

First, the political considerations of the TEMS program: Given the fact that Salt Lake

City has seen first-hand the devastating effects of active-shooting incidents and the wide-spread

impact of the event, the argument for providing this program should be minimal. City personnel

that must engage in such incidents operate in a very dangerous environment; thereby increasing

the risk for bad outcomes. Since the potential for personal injury exists, Salt Lake City public

safety has a responsibility to mitigate that risk to the greatest extent possible. Both City Officials

and local labor representatives may have concerns regarding the cost and liability of a TEMS

program, but it is clear from this research that any organized form of integration of emergency

medical support into law enforcement operations will ultimately reduce the city's potential for

liability, and in turn, be well worth the investment.

Second, the budget impact of the program to the two entities involved: Salt Lake City

Police Department (SLCPD) and Salt Lake City Fire Department (SLCFD). Any strategic

partnership must take into consideration the respective benefits provided to each department.

With such a program, the police department realizes the value of having decreased liability and

injury costs by having immediate EMS intervention available to them whenever high-risk


operations (SWAT incidents) are conducted. Thus, this researcher believes the majority of the

costs should be encumbered by the police department. The fire department realizes the benefit of

increased exposure and service to the city as an integral part of SWAT operations and

preparedness for any future "active-shooting" incident. As such, they are also a benefactor of the

program, but to a lesser extent then law-enforcement. Both entities benefit from increased

collaboration to implement this initiative and the tangible value of providing an effective and

proactive emergency response program to serve its public safety officers and the citizens of Salt

Lake.

Third, the organizational structure of the TEMS program: In 2010, the Salt Lake City

Police Department (SLCPD), in conjunction with the Salt Lake City Fire Department (SLCFD)

Investigation Unit formally inquired into the possibility of a partnership between both public

safety agencies concerning a tactical EMS team. It was proposed that that a cost and time-

effective approach to evaluating the feasibility of the program was to utilize voluntary members

of the Investigative Unit (5 individuals). This was proposed in part due to the fact that these

members were already Utah State Certified Peace Officers, thus already having basic law and

firearms skills along with Basic Life Support (EMT) medical skills (VanDongen, 2010). But this

proposal was general in nature, and not specific to many of the obstacles identified in this

research that would eventually need to be addressed. challenge the inception of any program.

the political challenges, liability issues, financial commitments, and program design and training

for the remainder of the department.


"You will find that the most successful integration of tactical medical support occurs

when a police department makes the request. Many places have had problems integrating

civilians into SWAT teams when the suggestion has come from the EMS side. When the SWAT

unit sees the need and value of close medical support, they embrace the concept." (Smith, 1999).

This was indeed the case in Salt Lake City. However, no formal agreement with SLCPD or

commitment to develop the SWAT program or a greater TEMS program for "active shooting"

incidents ever materialized. There remained concerns regarding the specific type of training

necessary for SWAT or TEMS team integration, appropriate medical certification, staffing 24/7,

job-wide interest in participation, liability, division of cost, and active opposition from the local

Union board. In addition, there was a need for a mission statement with clear objectives.

With this information in mind, this researcher proposes 2-phase model to address the current

need for both TEMS integration into SWAT operations and TEMS integration into a standard

operational model for "active-shooting" incidents. This model will be detailed in a Letter of

Agreement (LOA) in collaboration with SLCPD and with advisement from the local labor union

(Appendix B). The LOA will contain the following elements:

A. The Mission Statement, goals, and objectives of the program.

B. The number of SLCFP Firefighters trained and integrated within SLCPD SWAT team

would increase to 12. This pool of "SWAT Medics" would be used on any and all

activations of the SLCPD SWAT team.

C. SWAT medics on duty in operations would be utilized only in the event that SWAT

Medics available in day-work capacity are not available in a timely manner.


D. The SWAT Medic pool would consist of a minimum of 2 firefighter personnel trained

from each platoon (A, B, and C) of SLCFD in addition to the five (5) members of the

Investigative Unit already integrated into the SWAT program.

E. Minimum training for current and additional "SWAT Medics" would be to the

Special Function Officer* (SFO) level as provided by Utah P.O.S.T. Utah Special

Function Officers (SFO's) are sworn and certified peace officer's exercising that

spectrum of peace officer authority that has been designated by statute to the

employing agency, and only while on duty, and not for the purpose of general law

enforcement. SFO's may carry firearms only while on duty, and only if authorized

and under conditions specified by the officer's employer or chief administrator (Title

53 2011 Utah P.O.S.T. Code, n.d.). In addition to standard SWAT school training

will be provided by SLCPD and Tactical Combat Casualty Care (TCCC) training as

provided by the SLCFD Medical Division.

F. All training costs for external programs (eg SFO) will be shared equally by the

participating departments (SLCPD/SLCFD). Internal training costs (tactical and

medical) will be the responsibility of each department respectively.

G. Tactical equipment costs will be the responsibility of SLCPD and remain the property

of the SLCPD. This will include at a minimum a handgun, tactical soft body armor,

gas mask, helmet and goggles, radio equipment and pager, and cold weather gear.

Medical equipment costs (including bags/cases) will be the responsibility of the

SLCFD.


H. Staffing of SWAT medics for pre-planned tactical incidents will be the responsibility

of SLCPD. Off duty SWAT medics or SWAT medics functioning in a day-worker

capacity should receive priority for these assignments.

I. SWAT TEMS personnel will be issued a standard sidearm (as determined by SWAT)

for the purpose of self-defense within the hot-zone of any SWAT incident.

J. SWAT TEMS personnel will be trained to provide immediate medical support to

SWAT operations. It is not the intent of the program to provide SLCFD SWAT

TEMS personnel with offensive assault or entry responsibilities.

K. The minimum medical certification for participation is SWAT TEMS program is

EMT-B, given that most patient care treatment provided by TEMS personnel in the

hot-zone are traumatic or "basic" (BLS) in nature.

L. The SLCPD would retain control and oversight of the SWAT EMS component during

tactical activities and training.

This model would provide the following benefits to both entities for any SWAT-type

incident:

1. A pool of trained TEMS personnel available 24 hours a day to respond to SWAT

incident from fire stations.

2. Reduced response times due to the elimination of need for call-backs during off-

hours.

3. Reduced financial impact to SLCPD as a result of reduced call-backs.


4. Reduced financial impact to department's as a result of non-P.O.S.T. certification

mandate.

The second phase of the SLCFD model involves operational firefighters who will be the

first responders (along with Police) to an "active shooting" or "mass-killing" incident.

This phase addresses the need for fire department personnel trained in coordination with

police department personnel to provide a Rescue Task Force (RTF) function in such an

event. In the event of such an incident, police patrol officers will organize in small (2-4

person) teams as soon as they arrive on scene and move through the building bypassing

the dead, wounded, and panicked towards their objective of engaging and eliminating the

threat (Smith et al, 2009). Rescue Task Forces, made up of multiple four-person teams,

then move forward into the unsecured scene to provide stabilizing care and evacuation of

the injured. Each team consists of two police patrol officers to provide front and rear

security, and two medics to stabilize patients using Tactical Combat Casualty Care

principles. In addition to the security of armed escorts, these personnel are outfitted in

ballistic vests and helmets to further mitigate risk.

Phase Two of SLCFD's TEMS program comprises the following:

A. All fire department operational personnel (both EMT and Paramedic) will be trained in

Tactical Combat Casualty Care as provided by the SLCFD Medical Division. Captain's

will be excluded from this training.

B. All fire department personnel will be trained in the operational aspects of RTF as

provided by SLCPD.


C. Personal Protective Equipment for RTF personnel will be provided by the SLCFD.

D. Four (4) sets of RTF Personal Protective Equipment will be carried on each of the

SLCFD's Battalion Chief vehicles (B1 & B2). This will allow the equipment to be on-

scene as fire unit arrive to provide RTF support as necessary.

Each RTF PPE set contains:

1 adjustable bulletproof vest marked with Departmental patches and "RTF" on back.

1 Kevlar special operations helmet – 4 point harness to fit all sizes.

1 medical equipment shoulder bag containing:

tourniquets

pressure bandages

chest seal occlusive dressings

Hemostatic agent

Other equipment as deemed necessary

This strategic partnership between Salt Lake City Fire and Police is mutually beneficial

not only to both agencies, but to the citizens they serve. This ensures not only that SLCPD

SWAT will have a Tactical EMS component, but also that police operations throughout the city

will have the confidence in knowing that EMS providers are available to provide immediate care

to both officers and civilians in any type of emergency.


Although many law-enforcement organizations have been training in special tactics for

some times, most fire departments are not experienced in such operations. It is clear that the

addition of medical personnel to these responses is appropriate, but it does not occur without

challenges. That being the case, the collaboration of emergency medical service and law

enforcement is a complex process that requires thoughtful planning in order to benefit all parties

involved. This objective can be reached in Salt Lake City with this practical recommendation to

integrate the fire EMS service into tactical operations of the police department.


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impact on public safety. Topics in Emergency Medicine, 25, (4), 277-281.

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Davis, J.D. (2001). Tactical EMS – the cutting edge of rescue. Every Second Counts, 3, (3),

26-29.

Essex, M. (2002). Practical planning for the terrorist event. Firehouse, 27, (4), 34-38.

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APPENDIX A

The attached survey is a research tool being utilized by a participant in the National Fire

Academy's Executive Officer Program. Please complete this short questionnaire regarding a

Tactical EMS program that you may or may not have implemented in your department.

Please complete the survey in its entirety and forward the answers to:

Karl Lieb

Deputy Chief Operations

Salt Lake City Fire Department

[email protected]

1. Do you currently have a Tactical Emergency Medical Service program and how is it

designed?

2. If yes, what are the key benefits to your department?

3. If no, why not?

4. Are your paramedics/EMT's armed?

5. Do you utilize EMT's or Paramedics for your tactical EMS program?

6. How are your TEMS personnel trained?

mailto:[email protected]�


APPENDIX B

SWAT/TEMS

LETTER OF AGREEMENT

Salt Lake City Fire Department (SLCFD) and Salt Lake City Police Department (SLCPD)

Overview

The Salt Lake City Fire Department will provide trained medical personnel to support the tactical

(SWAT/TEMS) operations of the Salt Lake City Police Department.

Mission Statement

The mission of the Salt Lake City Fire Department SWAT/TEMS program is to provide

dedicated emergency medical support for the Salt Lake City Police Department during any

tactical operation or training.

Goal

The goal of the program is to reduce or prevent serious injury or death to innocent civilians,

police officers, other emergency responders, and suspects.

Objectives

1. Enhance mission accomplishment.

2. Reduce potential liability within special operations.

3. Reduce line of duty injury and disability costs to public safety agencies.

4. Reduce lost work time for public safety officers

5. Facilitate a professional working relationship between SLCFD and SLCPD

Staffing

SLCFD will provide a total of twelve (12) SWAT Medics to the SLCPD for the purposes of pre-

planned or call-out tactical operations medical support. SLCFD will also provide Tactical EMS


support in the form of on-duty firefighters for the purpose of supporting tactical operations in the

event of an "active shooter" or "mass killing" event. The twelve SWAT Medics will be drawn

from the current Law Enforcement Officers in the Investigative unit (5) in addition to seven (7)

firefighters assigned in operations. Of these, there must be at least two assigned to each of three

platoons. SWAT Medics on duty in Operations would be utilized only in the event that SWAT

Medics available in day-work capacity are not available in a timely manner.

Qualifications

1. Swat Medic candidates will hold either a Utah State Paramedic or EMT-B certificate.

2. A minimum of five (3) years as a Salt Lake City Firefighter.

3. Demonstrated, satisfactory work performance with no disciplinary action within past year

4. Successful completion of competitive process including written test, physical assessment,

and interview (process to be overseen by SLCPD in collaboration with SLCFD).

5. Ranked candidates will be selected in order from process.

6. Candidate will serve an "at will" probationary period of 6 months

Training

Minimum medical certification for either SWAT medic or Rescue Task force fire personnel will

be Paramedic or EMT – B. Minimum law-enforcement training for current and additional

"SWAT Medics" will be to Special Function Officer (SFO) level as provided by Utah P.O.S.T.

SWAT medics will be armed with a sidearm. In addition, standard SWAT school training will

be provided by SLCPD for those candidates selected for integration into the SWAT team.

Tactical Combat Casualty Care (TCCC) training will be provided to each member of the Salt

Lake City Fire Department (with the exception of Captains and Chiefs). This training will be the


responsibility of the SLCFD Medical Division. Rescue Task Force Training will be delivered to

all field personnel from both agencies in a combined SLCFD/SLCPD format.

Costs

All training costs for external programs (SFO) will be shared equally by the participating

departments (SLCPD/SLCFD). Internal training costs (tactical and medical) will be the

responsibility of each department, respectively.

Tactical SWAT equipment costs (12 sets) will be the responsibility of SLCPD and all equipment

(including SWAT sidearm) will remain the property of the SLCPD. This will include at a

minimum a handgun, tactical soft body armor, gas mask, helmet and goggles, radio equipment

and pager, and cold weather gear. RTF tactical equipment costs (8 sets) will be the responsibility

of SLCFD. This will include, at minimum, tactical soft body armor and a helmet. Medical

equipment costs (including bags/cases) will be the responsibility of the SLCFD.

Operational costs for SWAT medics for tactical incidents will be the responsibility of the

SLCPD. Every effort should be made to utilize off-duty and then "day" SWAT medics,

respectively, for pre-panned tactical operations. This will not compromise staffing numbers in

operations unnecessarily.

Tactical Command

The tactical operations commander of any SLCPD tactical operation will assume control of any

and all TEMS team(s) on scene in the absence of unified command in a rapidly developing

tactical operation. A TEMS group leader will be assumed by the SLCFD Incident Commander

on scene or assigned at his discretion immediately. The SLCFD TEMS group leader will support

the tactical commander in an active shooting or mass killing incident. Unified command

encompassing both entities will be established as soon as possible.


At no time should TEMS personnel operate in teams of less than two (2).

It is not the intent of the program to provide SLCFD SWAT TEMS personnel with offensive

assault or entry responsibilities.

Medical Command

As a unit, TEMS operations function under the medical control of SLCFD. All treatments and

standards of care provided by TEMS will follow the SLCFD standing orders and protocols,

unless specifically addressed in modified standing orders.

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