ABC’s of Tactical Emergency Medicine Support Part I of II

Deputy Sheriff Michael Gorham, BS, AEMT‐T 

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THE “ABC” IN TACTICAL EMS (PART 1)
PRESENTED BY MICHAEL GORHAM
• Law Enforcement
• Firefighter (South Wayne Fire Department)
• EMS AEMT with TEMS Endorsement #11467
• I am an Instructor in Firearms, Tactical Response,
EMS, BLS

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

Auxiliary
• Instructor with Southwest Technical College,
Fennimore WI

Lafayette County Sheriff’s Office WI

Cuba City Area Rescue Squad
US Coast Guard Auxiliary
 RECOGNITION
This presentation comes from the assistance of many sources:
Midwest Tactical Officer’s Association
Chad Stiles. Chris Cook, Steve Rabinovich, Shane Heilmann, Matt Savage
John Hallbrook, State of Iowa Emergency Management
Milwaukee and Oak Creek Fire Departments WI
Arlington County Fire Department VA.
National Tactical Officers’ Association
(Specialized Tactics Operational Rescue Medicine)
Instructors: Mark Gibbons, Sean Mckay, Kevin Gerold, Phillip Carmona

North American Rescue, Brent Bronson

Tactical Medical Solutions
 CAVEATS
• I am a student just like you sharing my thoughts, so it if you
disagree with my information, that is your right based on your
experiences and training. I do not like the word expert.
• I have preferences in products however, I am not here to sell
you any product or endorse one over another. (Beware of
Counterfeits)
• My experience is a culmination of 30 plus years working in the
military, private security, police, fire and EMS. My largest
foundation comes from working in rural Southwestern Wisconsin.
My second base was working in the Dane County Metro Area of
Wisconsin ( Madison )

• Some pictures are graphic

RHETORICAL VERSUS PRACTICAL
The root question to most of all of public safety’s crisis’?
1. Anticipate Crisis or Problems (Reactive)
2. Why do we Plan? - Response to Crisis
3. Why do we train? - Performance in our response
4. Why do we work to get better at what we do?
- expectations; Public and Personal

“The perseveration of life is the fundamental priority of all public

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

Denial
Deliberation
Decisive Action 

Courtesy of the ALERT Presentation

NO TRAINING OR PLANNING

Emotion And Instinct

Varied Outcomes
Usually lots of complications
Example:
Police Transport Shooting Victims in Aurora CO to area Hospitals
WITH PLANNING AND PREPARATION
Consider Colonel Boyd’s OODA Loop Response process

1. Observe
2. Orient
3. Decide
4. Act

Can be applied to most if not all public safety situations

REMEMBER TACTICAL EMS IS STILL EMS
The response paradigm changes
ACTIVE SHOOTER EVENT DEFINITION
An active shooter event involves
one or more persons engaged in
killing or attempting to kill
multiple people in an area
occupied by multiple unrelated
individuals.
 UNDERSTANDING THE PROBLEM
Active shooter incidents happen everywhere in
this country, from the small town to the largest
cities
• These goofs study each other and learn
• Looking to Share their pain and looking for
attention.
• Can cross any social economic barrier
• Low cost attacks
• Weapons can be obtained easily or homemade
THE FIRST RECORDED ASMCI
May 18, 1927 in Bath Township, MI
School board member Andrew Kehoe
upset over property tax increase
Killed wife and burned his barn before
driving to school
Three explosions leaving 45 dead and
58 wounded
Still the deadliest attack on a school in
U.S. history
VIRGINIA TECH - APRIL 16, 2007
• Cho murders 32 with two
handguns

• 7:15 a.m. West Ambler Johnston

Hall – Hilscher and Clark killed

• Returns to his apartment and

reloads

• Leaves to mail pictures and

video manifesto to NBC

• 9:45 a.m. Norris Hall murders

• Executions in five classrooms

• Kills 30, then himself

CHURCH INCIDENTS
March 8, 2009 in Illinois

Suspect Terry Sedlacek, 27

Fatally shot pastor before stabbing

himself

Two parishioners were stabbed

trying to restrain suspect

Suspect developed a mental illness

after contracting Lyme disease
WISCONSIN INCIDENTS,
OAK CREEK AND BROOKFIELD
 2000
2005
2001
2003
2002
2006
2004
2010
2007
2011
2009
2008
2013

Number Shot
0‐4
5‐9
10+

Courtesy of the
ALERT Presentation
 THE SHOOTER

• No “Profile”
• Revenge Mindset
• Some broadcast
intentions
 LOCATION OF ATTACKS

Commerce

Education

Outdoors

Other

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

Number of Deaths

Target availability

How quickly the police arrive
 3 MINUTES IS THE RESPONSE
TIME ON AVERAGE

How long does it take to get to victims? Assess,

Treat Evacuate, and Transport
 THE CHALLENGE FACING EMS

National Registry standards for all levels of Medics in

their training and testing, which are critical tasking

 BSI Body Substance PPE Pass/Fail

 Is the scene safe (safer) Pass/Fail

 BULLETS VERSUS BOMBS
• IED’s are somewhat harder to acquire
• Expense and skill to make IEDs
• Larger chance of being detected
• It does not mean IEDs are not going to be
used
• Bath MI to Columbine to Boston Marathon
Bombings
• Paradigms are rapidly changing
UNDERSTANDING BALLISTIC TRAUMA
 RIFLED AMMUNITION
Lethality increases over 2200 feet per second
 CONSIDER FUTURE ISSUES
TRAUMA FROM
IMPROVISED EXPLOSIVE DEVICES
WHAT CAN WE LEARN FROM
 THE BIBLE OF
TACTICAL COMBAT CASUALTY CARE

Following the SEAL casualties

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

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

Combat Lifesaver is Combat First Aid on steroids

 HOW PEOPLE DIED IN GROUND COMBAT
BELLAMY, RF. CAUSES OF DEATH IN CONVENTIONAL LAND WARFARE, MILITARY MEDICINE. 1984
15% of Ground Combat Deaths are Preventable
TCCC (3) Phases of Care
• CARE UNDER FIRE
• TACTICAL FIELD CARE
• CASUALTY EVACUATION
TCCC TRAINING
 Assessment (Contact and Remote)
 Use of Tourniquet
 Use of Chest Seals
 Use of Nasal Airway
 Wound packing (Hemostatic agents)
 IV administration
 Medications (some)
 Casualty Evacuation
 GENESIS OF MEDICAL SUPPORT IN SWAT

Within a Decade after the formation of Specialized

Tactical Units, the late (1980s) ubiquitously known as
SWAT. Teams started adding in a integrated medical
support.
For 25 years often larger agencies have integrated
prehospital care providers into law enforcement
operations. The SWAT Medic was designed to care for
the team members much like their military cousins.

Many agencies have used integrated medical support in Search

and Rescue operations
 TEMS Post 9/11
TEMS or Tactical Emergency Medical Support is
usually an integrated prehospital care provider
sometimes referred to as Tactical Medical
Providers(TMPs).

TMPs are assigned to a SWAT team. (Models vary

from First Responder to Paramedics)
 COMMITTEE ON TECC ADOPTS
TCCC FOR PUBLIC SAFETY

The TECC website – Sean

Mckay, pictured on the left
Committee Member (Yoda)
 TECC
TACTICAL EMERGENCY CASUALTY CARE 
 TECC (3) PHASES OF CARE

1. Direct Threat Care (Hot

Zone)
2. Indirect Threat care (Warm
Zone)
3. Casualty Evacuation (Cold
Zone)
 LEVELS OF CARE IN TACTICAL OPERATIONS
1. Self Aid/Buddy Aid taught to Police Officer
2. Internal Medical Support integrated into SWAT –
Tactical Medic. Deployed into the Hot Zone
3. External Medical Support and the Continuum Of Care
Edge of Warm/Cold Zone transport to definitive care.
4. Rescue Task Force Support, a new concept. In the
event of MCIs where the event involves violence,
coordinated teams of Police, Fire, EMS enter the warm
zone and evacuate the treatable victims out of the
zone.
 TECC TRAINING (VARIES)
 Assessment Contact and Remote
 Tourniquet Application
 Chest Seals
 Airway Management

 Wound Packing (Hemostatic agents)

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

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

All First responders in the nation should be taught TECC-

Gorham
A NEW HOPE 
RTF is the Rescue Task Force is the 
integration of police, fire, and EMS 
working in concert to treat 
casualties in an active killer mass 
casualty incident or AKMCI. 

However, the principles of a RTF can 
be scaled down to small incidents 
involving 1‐4 victims   
2013 MTOA TEMS Course @ FT McCoy
MY CONTACT INFO

chiefgorham@yahoo.com
563-542-3867
Facebook Michael Francis G
Lafayette County Sheriff’s Office
608-776-4444
PART II THE ABCS OF TEMS
For Justice Clearinghouse
PRESENTED BY MICHAEL GORHAM

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

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

Lafayette County Sheriff’s Office WI

Cuba City Area Rescue Squad
US Coast Guard Auxiliary
 RECOGNITION
This presentation comes from the assistance of many sources:
Midwest Tactical Officer’s Association
Chad Stiles. Chris Cook, Steve Rabinovich, Shane Heilmann Matt Savage
John Hallbrook, State of Iowa Emergency Management
Milwaukee and Oak Creek Fire Departments WI
Arlington County Fire Department VA.

National Tactical Officers’ Association

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

North American Rescue, Brent Bronson

Tactical Medical Solutions
CAVEATS
• I am a student just like you sharing my thoughts, so it if you
disagree with my information, that is your right based on your
experiences and training. I do not like the word expert.
• I have preferences in products however, I am not here to sell
you any product or endorse one over another. (Beware of
Counterfeits)
• My experience is a culmination of 30 plus years working in the
military, private security, police, fire and EMS. My largest
foundation comes from working in rural Southwestern Wisconsin.
My second base was working in the Dane County Metro Area of
Wisconsin ( Madison )
 REVIEW OF PART 1
•Why are we here?

•Active Shooter Events

•What is the Significant MOI (Mechanism of Injury)

•Bullets and IED other penetrating trauma

 REVIEW OF PART 1

TCCC TECC
Military Origin Civilian Adaptation
Victims 18-35 Males Wider Population
Good health Scope of Practice
No restrictions as NREMT, OHSA, other
far as OHSA, NREMT, Medical oversight
Etc
COMMON QUESTIONS

• Training?  What do I need to know 
• TECC can be taught to LEOs and Fire 
• There is no national standards or 
curriculum 
• However, training should follow the  
Committee on TECC guidelines 
COURSES
 National Tactical Officers Association; STORM Specialized
Tactics for Operational Medicine
 Contoms
 National Association of EMTs has TCCC course
selections
 Wisconsin has a variety of courses
 Be careful what you are buying into ask questions to the
vendors
 Medical Background; Instructors; conforms to TECC
 CAUTION WHEN PURCHASING MEDICAL KITS

• Tactical Emergency First Aid Kits are a hot topic now 
• With that comes a desire to address the need 
• We are a capitalist based economy 
CAUTION WHEN PURCHASING MEDICAL KITS
• Think about these issues
• For example  If you buy 14 gauge needles for needle 
decompression; are your people trained to do that.
• Does it fit within their practice  
• How sustainable is it for your agency – medical 
equipment has a shelf life  (Hemostatic agents) 
• Is the supplier reputable and are the products vetted 
either by the military or the 
 RECOOMENDED TOURNIQUETS

SOFT-T Tactical Medical Solutions CAT North American Rescue

PLATINUM 5 MINUTES
AND THE GOLDEN HOUR

What happens in this time frame often dictates the

patients outcome
 TREATMENT PARADIGM

Stabilize injured using ACAB-E assessment and treatment

 Assessment  sometimes referred to as Situation 
 Circulation
 Airway
 Breathing
 Evacuation
 MODALITIES ACRONYMS

Threat Suppression  M assive bleeding 
A  irway
Hemorrhage Control 
R  espirations 
Rapid Evacuation C  irculation 
Assessment 
H ypothermia 
Transport 
and Head out 
 TIME COMPETIVE
Death from Hemorrhage 1 - 3 minutes
Death from Airway compromise 4 - 5 minutes
Death via Tension Pneumothorax 10+ minutes
“Golden Hour” 60 minutes

It is pointless to treat a casualty for a developing tension

pneumothorax while he is dying by strangulation from a
compromised airway or by uncontrolled bleeding.
9% KIA BLEEDING TO DEATH FROM EXTREMITY
WOUNDS

Normal
Death
Blood
probable
Volume
9% KIA BLEEDING TO DEATH FROM EXTREMITY
WOUNDS
5% KIA TENSION PNEUMOTHORAX
1% KIA AIRWAY OBSTRUCTION
 Train for contingencies
What if your people don’t have the equipment for what ever reason?

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

• Primary
• Alternate
• Contingency
• Emergency
 First responsibility stop the threat

GOOD MEDICINE MAY BE BAD TACTICS

 PUBLIC SAFETY RESPONSE

Police agencies have made significant changes in their

response since Columbine. Police are taught to engage the
threat immediately rather than wait.
Fire/EMS agencies still stand outside until the police have
secured the scene.
This may lead to the injured not receiving treatment and
dying from wounds they received
 TEMS is Tactical Emergency Medical Support for
the SWAT Team

The Rescue Task Force is the combined resources of the

public safety team to mitigate a MCI which is a law
enforcement driven incident.

Both use Tactical Emergency Casualty Care,

interventions
 FIRE AND EMS RESPONSE GOALS

1. Provide rapid treatment to the wounded

2. Prevent those who have survivable injuries from
dying
3. Use resources more efficiently and effectively
4. Evacuate the wounded to definitive care sooner
5. Provide the proper gear and security for the
operators
 THE REALITY

Fire/EMS needs to take a more

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

In the active shooter incident the

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

PPI level IIIA Hornet Tactical Vest

PPI level IV Rifle Plates (Chest and Back)
PPI level IIIA Special Ops. Helmet
 RTF EQUIPMENT
MEDICAL - VEST MOUNTED
Tourniquet x 2
H-Bandage pressure dressing x 2
Hemostatic Gauze x 2
Chest seal x 2
NP airways x 2
14ga. 3.5” needles x 2
Tegaderms x10
THE QUESTION OF ARMING MEDICS
1. Varied Responses
2. Based on your Jurisdictional needs and resources
3. Minimally Medics should have weapons
familiarization
4. Why? Disarming Downed Operators with
Altered Mental Status
IF OFFICERS ARE BROUGHT OUT OF THE FIGHT; CHECK
AMS DANGEROUS IF ARMED
RTF OPERATIONS
RTF OPERATIONS
As the contact team moves through the
building searching for the threat, location of
wounded is relayed back to command
After the contact team either neutralizes the
threat or contains it the RTF is deployed
RTF proceeds to the location of the wounded
and begins treatment
RTF OPERATIONS
RTF OPERATIONS A PARADIGM SHIFT
The RTF consists of 2 police officers
and 2 medics
Officers provide front and rear
security and control movement
Medics provide treatment and evac.
of the wounded
RTF operates in the warm zone

Arlington Fire Department VA Initiative

RTF OPERATIONS
RTF OPERATIONS
The objective of the first RTF is to triage then
treat the wounded behind cover not in the line
of fire.
Then they switch objectives and begin evac of
the wounded.
The second and subsequent RTF’s begin evac
of those treated until the team ahead of them
runs out of equipment and then they leap frog
forward to finish treatment.
RTF OPERATIONS
RTF OPERATIONS
OTHER SKILL SETS THAT ARE NEEDED
 BREACHING
 PATIENT EXTRACATION AND EVACUATION
OTHER SKILL SETS THAT ARE NEEDED
Vehicle Platforms Pros and Cons
COMMAND AND CONTROL

• These types of incidents are very dynamic and the number of

threats, victims, etc can change at any time.
• The first Fire/EMS supervisor and the first arriving PD
command officer need to form a Unified Command.
• The number of RTF’s formed is based on the availability of
resources both FD/ EMS and PD.
• In Rural areas consider using VFD personnel to be litter
bearers
• The location of the CCP is based on the building type, number
of victims, threat location, resources, and environmental
conditions.
• Movement is controlled by the police element of the unified
command
THIS IS A LAW ENFORCEMENT EVENT

• Medicine does not drive Law

enforcement tactics

• It is a crime scene and you will need

good documentation
 BE A SCHOLAR AND A WARRIOR

1. What barriers are there going to be?

2. Urban versus Rural ?
3. Paid versus Volunteers?
4. Time and Resources Competitive Goals?
5. Relationships and Networking ?
 LEADERSHIP: PLANNING
•Have a plan focus on strategies not specifics
•Work your plan, training isolation exercises to
scenarios
•Need all stakeholders on board
•Study what works
•Take what works in your jurisdiction; discard what
doesn’t
•Public safety is an Applied Science
Be decisive, improvise, adapt, overcome….Gunny Highway
 MENTAL PREPARATION FOR THIS EVENT

• Most Fire/ EMS are not prepared for entering into the arena of
violence.
• Sometimes Providers hesitate when treating victims of
traumatic violence. ( Train through this; it is an adverse
reaction)
• Lt. Col David Grossman (ret) has done extensive research on
interpersonal violence. There are resources available to
develop body armor for the mind. (ON COMBAT) (THE GIFT
OF FEAR, Gavin De Becker)
• If you find your self excited by the events and overwhelmed
remember to breath. Breathing slow and deep is good for you
to function properly.
 RESOURCE MATERIALS
G AV I N D E
D AV I D G R O S S M A N
R E T I R E D LT C BECKER
RESOURCES
1) COMMITTEE ON TACTICAL EMERGENCY CASUALTY CARE
2) MIDWEST TACTICAL OFFICERS ASSOCITION
3) NATIONAL TACTICAL OFFICERS ASSOCIATION
4) NATIONAL ASSOCIATION OF EMTS
5) NATIONAL REGISRTRY OF EMTS
6) NORTH AMERICAN RESCUE
7) TACTICAL MEDICAL SOLUTIONS
8) QUICK CLOT
9) STATE EMS ASSOCITION (WEMSA)
MY REFERENCE MATERIALS
 THANK YOU FOR DOING WHAT IT IS YOU DO“
THE MEASURE OF A PERSON IS DEFINED BY THE WAY HE MAKES THE WORLD A BETTER PLACE” 
MY CONTACT INFO

chiefgorham@yahoo.com
563-542-3867
Facebook Michael Francis G
Lafayette County Sheriff’s Office
608-776-4444