A talk by Peter Anthony Berlac at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Delivered in collaboration between scanFOAM, SSAI & SFAI.

1. TEMS - Tactical Emergency
Medical Services
A new path we need to implement?
Peter Anthony Berlac
Medical Director
Emergency Medical Services Copenhagen

2. • No potential conflicts of interest
Emergency Medical Services, University of Copenhagen

3. What is a Tactical Emergency Medical Service?
“A non-military medical emergency service modified for the
realities of the tactical environment”
Rinnert KJ, Hall WL. Tactical emergency medical support. Emerg Med Clin North Am.
2002;20:929–52.
”Out-of-hospital care given in hostile situations by specially
trained civilian practitioners, who are trained to provide life-
saving care and transport in situations such as tactical police
operations, active shooters and bombings”
Wikipedia
Emergency Medical Services, University of Copenhagen

4. Conventional EMS at major incidents
• Staging area
• Inner cordon
• ”Scene safe”
• Designated AOR
• Casualties delivered
Emergency Medical Services, University of Copenhagen
Outer cordon
Inner cordon
INCIDENT AREA
INCIDENT SITE
DANGER
ZONE

5. Dilemma: where are the cordons?
Emergency Medical Services, University of Copenhagen

6. Dilemma: time critical injuries
• Massive haemorrhage major cause of death in mass shootings
• Extensive delays in EMS reaching patients due to persisting
threat or police inability to guarantee EMS safety
Emergency Medical Services, University of Copenhagen

7. Why ”tactical” EMS?
From a law enforcement point of view:
• The ability to maintain an aggressive man-hunt and neutralize a
perpetrator without compromizing firepower by providing first-aid
or evacuation of casualties. Focus on stop the killing.
From the casualties point of view:
• For EMS to be able to reach casualties as early as possible in
order to treat & evacuate time-critical injuries (potentially
survivable injuries). Focus on stop the dying.
Emergency Medical Services, University of Copenhagen

8. The profile of wounding in civilian public mass shooting
fatalities. Smith ER, Shapiro G, Sarani B. J Trauma and Acute Care
Surg. 2016 Jul;81(1):86-92.
Emergency Medical Services, University of Copenhagen
• Autopsy reports from 12 incidents (139 dead, 371 gunshot wounds)
• Higher mortality than in combat zones
• No ballistic protection
• Close proximity to targets: higher hit rate
• Fatal shots to head and torso
• No resistance
• Low number ”potentially survivable injuries” (7% vs 24% militært)
• 89% penetrating chest wounds (pneumo-/hemothorax)
• No fatal exsanguinating extremity injuries

9. What needs to be done?
T Threat supression
H Haemorrhage control (massive bleeding)
R Rapid
E Evacuation
A Assessment (triage, life-saving interventions)
T Transport to tertiary care
The Hartford Concensus. Joint Committee to Create a National Policy to
Enhance Survivability from Mass Casualty Shooting Events. 2013.
Emergency Medical Services, University of Copenhagen

10. What needs to be done?
Emergency Medical Services, University of Copenhagen
• ”3 ECHO”. Minneapolis shooting september 2012.
• Enter
• Evaluate
• Evacuate
Autrey AW, Hick JL, Bramer K, Berndt J, Bundt J. 3 Echo: Concept of Operations
for Early Care and Evacuation of Victims of Mass Violence. Prehosp Disaster Med.
2014;29:421–8.

11. Who should do it?
Emergency Medical Services, University of Copenhagen
• ”Hot zone”. Direct threat: Law enforcement special intervention
units with specially trained medical personnel as integral part of
team.

12. Who should do it?
Emergency Medical Services, University of Copenhagen
• ”Green zone”. Safe area: Conventional EMS outside inner
cordon / exclusion zone.

13. Who should do it?
Emergency Medical Services, University of Copenhagen
• Yellow zone. Indirect threat: Need for bridging the gap between
red zone and green zone. Public expectation for duty to act.
• Dynamic threat, dynamic response
• Tactical Emergency Casualty Care training
• Ballistic protection
• Under police firearm protection and command
• Corridors / Evac routes and Casualty Collection Points

14. National joint authorities concept
• Norway
• Finland
• (Sweden)
• France
• UK
• USA
Emergency Medical Services, University of Copenhagen

15. TECC (or equivalent) for EMS and Fire & Rescue
Emergency Medical Services, University of Copenhagen

16. Must read
Emergency Medical Services, University of Copenhagen

17. Take home messages
• Unconventional attacks cannot be managed conventionally
• Casualties die from potentially salvageable time-critical wounds
• EMS can no longer ”sit on the fence” – public demand for risk
willingness
• National joint agency preparedness planning and training.
Emergency Medical Services, University of Copenhagen

18. Den Præhospitale Virksomhed
www.EMSeurope.org
#EMS2018