VOLUME 1
In this issue:
From the Director...
Preparing this column for the first CONTOMS DISPATCH has given me the opportunity to reflect on the trail we've blazed together over the last four years. For the benefit of those who have never heard it before, let me quickly review the history of the Counter Narcotics Tactical Operations Medical Support Program.
In March 1988, Officer Ken Burchell, then assigned to the Special Equipment and Tactics Team (SETT, now called SWAT), Special Forces Branch, United States Park Police, contacted me at the Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences. As a SWAT medic, he was looking for solutions to some medical equipment problems and was aware that the Department of Defense medical school had a particular interest and expertise in special operations medicine. However, we found that our shared interests ran much deeper than expected and a relationship evolved which resulted in a Memorandum of Understanding (MOU) between the two agencies in July, 1989.
At the same time, and in fact for many years preceding, some dedicated individuals had been busy providing medical support to law enforcement operations. Notables among these were Dr David Rasumoff and his colleagues in Medical Company 206, the reserve unit for physicians at the Los Angeles County Sheriff's Department and Dr Richard Carmona with Arizona's Pima County Sheriff's Department. A number of agencies had also developed medical support programs, including the FBl's Hostage Rescue Team and some of the FBI Regional SWAT teams. The National Tactical Officer's Association, under the leadership of John Kolman, marked the beginning of widespread acceptance for tactical emergency medical support (TEMS) when it sponsored the second national TEMS conference at its annual meeting in Tucson, Arizona in 1990. The remarkable accomplishments of these people hinted that the right time might be approaching for the emergence of TEMS as a legitimate medical science.
Recognizing the substantial benefit that had accrued to both agencies as a result of the MOU, members of the US Park Police Special Forces Branch and faculty from the Department of Military and Emergency Medicine met to map out a training curriculum which would allow us to share our experiences with others. We were fortunate to enjoy enthusiastic command support from both agencies, which transformed the CONTOMS proposal into a reality. US Park Police Chief Robert Langston, his predecessor Chief Lynn Herring and Special Forces Branch Major Carl Holmberg (now Deputy Chief) provided expert guidance based on their insightful understanding of the public safety community. Concurrently, USUHS President James Zimble and his predecessor, President Jay Sanford, as well as Dean Nancy Gary repeatedly extolled the virtues of the program and defended its merits in the budget process. Dr Craig Llewellyn, Chairman of the Department of Military and Emergency Medicine, not only serves as the Program's senior statesman on management, fiscal and administrative issues, but continues to teach in every school as a member of the National Faculty. Mr Craig Anderson and others at the Henry M. Jackson Foundation for the Advancement of Military Medicine continue to guide the program's fiscal management.
The initial level of interest in CONTOMS was remarkable and the curriculum committee designed a 40 hour, one-week course. Eventually, the program grew to its present 58 hours. From the beginning, demand has exceeded available space and course content has evolved dramatically during the past four years, based largely on input from students and the sharing of experiences which occurred with each course.
Many of you will recall that two different tracks were originally offered at the provider level: EMT-Tactical (EMT-T) for law enforcement personnel and EMT-Tactical Support and Survival (EMT-S) for fire/rescue and EMS personnel. However, after several test classes, graduates told us that a single, combined provider class was best because it allowed students to share their expertise with others who had different skills and could reciprocate in their own area of specialization. Hence, the CONTOMS Board of Directors elected to offer only one provider level course and all EMT-S certifications were converted to EMT-T. All certifications are still valid for three years and renewal requires attendance at an 8 hour, 1 day recertification program.
At the inception of CONTOMS, the Board of Directors set the goals of (1) establishing a standardized curriculum and certification process that would be consistent across the country, (2) collecting and analyzing the data necessary to support the educational program specifically and TEMS in general, and (3) providing consultation services to public safety agencies for solving both acute operational problems and long term planning needs. It is my pleasure to report to you that all of these goals are being met in full measure. The CONTOMS Program is the most widely accepted SWAT medic training in the country. It has been endorsed by the National Association of EMT's and the National Tactical Officers Association. More than 1500 medics representing more than 260 agencies in 40 states, the District of Columbia and Puerto Rico have been trained to date. Many agencies have established EMT-T as a prerequisite for participation as SWAT medics and, I am pleased to note, an increasing number of jurisdictions are now requiring their tactical teams to have organized medical support for high risk operations. The CONTOMS Data Collection System is the only national database of which we are aware that collects and analyzes medical information specific to tactical team activity. About eight months ago, we embarked on an ambitious project to overhaul the Data Collection System, thereby improving efficiency and reducing analysis errors. The overhaul turned out to be much more difficult than we anticipated and we were not always able to produce an updated quarterly report. However, no data were lost during the interim and under the direction of the Casualty Care Research Center's Assistant Director of Research, Richard K. Pruett, MD, MPH, the system overhaul has been completed and you can look for the delivery of more practical and accurate quarterly reports if you are a system contributor.
Many of you have expressed concern about the future of CONTOMS as a federally-funded program in the current climate of fiscal austerity. You have also asked why we sometimes give such short notice for planned courses. The reason, it turns out, is related to the program's funding cycle. CONTOMS is funded by the Department of Defense under Section 1004 of the National Defense Authorization Act, specifically for providing training to federal, state and local law enforcement agencies with counter-drug responsibilities. The Department of Defense recognizes that the training being offered is unique and that law enforcement operations present one of the best possible casualty care models for low intensity military conflicts of the future. As a result, CONTOMS has historically enjoyed excellent support. However, due to the vagaries of the federal system, we often do not know our funding level until well into the fiscal year and therefore can not make training commitments as far in advance as we all might like. It is the intention of the Board of Directors to maintain the CONTOMS program as a leader in TEMS and continue our contributions to the emerging science of tactical medicine within the fiscal constraints placed upon us. With the open exchange of ideas and experiences which has been the hallmark of our relationship with each of you, I am confident of success.
When you attended the EMT-T school, I told you that your participation made you an ambassador of CONTOMS and the TEMS concept. That remains as true today as it was on the day you graduated. We all benefit greatly by collectively adopting a cohesive, well-presented concept of our operation which has survived repeated scrutiny and validation by a variety of means. Our job is to help you do a better job. Please keep in touch with the CCRC staff and let us know if there are needs we are not meeting. On behalf of the Board of Directors, I want to thank you for your commitment to your fellow officers and continuing support of the CONTOMS Program.
Medical News-Tips for Treating Water Intoxication
Medical Support from the Casualty Care Research Center, Department of Military and Emergency Medicine, was requested for team member selection during a recent recruitment period for a supported law enforcement agency. The selection process included vigorous physical exertion, obstacles, and realistic operational problems, over a 14 day period, with potential for significant injury.
Trained EMT-T's responded to assist in maintaining the health of the participants and treated many minor injuries including rope bums, strains, cutaneous infections, foreign body abscess and stress fractures. One operational exercise involved extended overland movement with full equipment during a period of high humidity. Despite the availability and encouraged use of oral replacement fluids, a number of individuals experienced heat cramps, dehydration and foot injuries. Intra-venous rehydration and aggressive treatment of foot injuries permitted some participants to return to the exercise.
At the conclusion of the exercise, an individual with no prior complaints presented with nausea and lightheadedness. He subsequently collapsed and developed status epilepticus. The individual was treated immediately by several EMT-T personnel and transferred to a local medical facility. Laboratory testing indicated the patient had profound hyponatremia. It was later determined that a combination of profuse diarrhea, not reported tot he medical staff, and water intoxication were the cause of the hyponatremia.
The individual involved in this incident was exceptionally physically fit, allowing him to participate in training activities until he was severely compromised. Sodium and fluid levels were depleted through profuse perspiration and diarrhea over a prolonged period of time. Aware of the need to maintain hydration, he consumed large quantities of water throughout the day, and minimal food or fluids containing sodium. Therefore, his fluid and sodium depletion was replaced only by water.
The individual had repeated seizure activity for greater than two hours, despite Valium 20 mg IV, and did not regain consciousness in the Emergency Department. He was paralyzed, and intubated in the field, with subsequent admission to the Medical Intensive Care Unit. He required both Dilantin and Phenobarbital to control his seizure activity. He remained comatose for three days due to brain edema, a result of seizure activity and hyponatremia. We are pleased to report the officer has recovered completely and is planning to participate in future training and competition.
This incident illustrates the importance of a proactive medical support system in preventing the risks of SWAT training and operations. We monitor all team members to ensure they rehydrate with a diluted electrolyte solution. (Note - A large fluid intake is required when an individual is enduring significant heat stress. Full strength sodium containing fluids, such as Gatorade, cause an osmotic diarrhea when consumed in large quantities. Personnel should be instructed to alternate these fluids with water, or preferably, use half strength solutions).
Oral water hydration is effective when a person has a normal food intake. Any reasonably varied diet provides adequate sodium for the gastrointestinal and renal regulatory systems to maintain a normal electrolyte balance. Individuals with unusual behavior disorders may consume such large quantities of water that the small quantity of unavoidable urinary loss will eventually cause a dilution of the body's sodium, or "water intoxication". Sodium depletion occurs when an individual is unable to consume a normal diet, or loses electrolytes through diarrhea, vomiting or inappropriate urinary excretion caused by a steroid imbalance or drugs. Combine one of these factors with a high loss of fluid and sodium from perspiration, replaced only by water and the result can be either hyponatremia or hypokalemia.
As an aside - we discovered that being in the back of a Suburban tactical ambulance with a wild, seizing SWAT officer, who has exceptional strength and endurance is a significant hazard!
EMT-T Recertification
EMT-T certification is granted in three year increments. All EMT-T's are required to attend a one-day, 8 hour, recertification program to receive an additional three years of certification. The cost of the program is currently $25.00. A schedule of classes will be published each July and mailed to those personnel whose EMT-T expires within that time period.
Most of the recertification classes will be scheduled for USUHS, however, if 20 or more personnel from an agency or region request the training at a specific regional site, we will make every effort to accommodate those personnel.
EMT-T recertification is open to any currently certified EMT-T or any expired EMT-T, whose certification has been expired for no more than 6 months. Seating in recertificationschools is limited, therefore, priority for registration will go to those EMT-T's whose certifications are closest to expiration.
Decertification letters will be mailed to those EMT-T's who do not recertify within the proper time period. Decertification is automatic upon expiration of your original EMT-T certification. Keep in mind that you have 6 months to take a recertification class after the expiration date, however, during that window, you are considered decertified. Personnel whose certification is more than 6 months out of date must reapply and complete the provider school to regain certification.
The schedule of recertification classes is printed on page 6. Questions on this topic should be directed to Mr. Ned Sherburne.
Law Enforcement News-Use of an Armored Personnel Carrier
The United States Park Police, Special Forces Branch Special Weapons and Tactics Team, utilizes an armored personnel carrier (APC) for certain special events,
demonstrations, dignitary protection events and in the service of some high risk warrants. Since an APC was first obtained in 1978, it has been used in approximately 120 missions. One notable mission in which the APC proved valuable was during the terrorist take over of the Washington Monument. During this incident, the suspect attempted to depart the Monument grounds. In light of the highly populated area around the Monument, the decision was made to prevent his departure. Shots were fired to disable the suspects vehicle and the APC was used to approach and arrest the suspect.
During another incident, mutual aid was provided to a neighboring agency when four of their officers were pinned down by a sniper. The APC was used to move SWAT officers close enough to deploy a riot control agent and permit the pinned officers to move to safety. The suspect in this incident fired over three hundred rounds. Eleven rounds struck the APC, however, none penetrated the vehicle. In a second mutual aid event, the APC was called into service to rescue twenty-one individuals who had become pinned down by a sniper in an apartment building across the street.
The APC has been used during a standoff with a suspect who had been evicted from an apartment and barricaded himself inside. The APC was once again used to deploy a riot control agent, following which, the suspect surrendered.
As described above, the use of an APC can be an invaluable asset contributing to mission success.
In the Washington, DC area, the United States Park Police routinely makes its APC available to neighboring jurisdictions upon request.
If you believe your SWAT Team would benefit from the use of an APC, there are several resources to investigate. Through military surplus, an APC may be obtained permanently. In some cases, Memoranda of Understanding with local Active or Reserve military units may be implemented. Certain other vehicles may also serve as protective vehicles, such as armored cars or commercial heavy equipment, modified to your teams specifications.
For additional information regarding the use of an APC in tactical operations, you may contact: Lt Phil Cholak, USPP 202-690-5022.
N. T. O. A. Position Statement of Support for Counter Narcotics Tactical Operations Medical Support Program
(Reprinted with permission from THE TACTICAL EDGE, Fall 1993 issue):
WHEREAS,
The provision of Tactical Emergency Medical Support (TEMS) has emerged as an important element of tactical law enforcement operations and;
The N.T.O.A. has strongly supported the TEMS concept for many years and;
The Counter Narcotics Tactical Operations Medical Support (CONTOMS) Program is a joint federal program supported by the Department of Defense and the Department of Interior, with assistance from the Department of Justice and the Department of Treasury, as well as many state and local law enforcement organizations and;
EMT-Tactical (EMT-T) is a credible, high-quality program of instruction for SWAT medics and; The EMT-T Program has a three year track record of performance in training more than 1,000 SWAT medics from 190 agencies in 38 states and;
EMT-T is co-sponsored by the Uniformed Services University of the Health Sciences, an established medical school with standing to conduct medical education and;
The CONTOMS Program has established a recertification period for EMT-T of three years to ensure proficiency in this rapidly growing field,
THEREFORE: The National Tactical Officers Association recognizes CONTOMS as a valid training program. The EMT-Tactical school is endorsed by the N.T.O.A. as
an outstanding basic training program for SWAT medics.
CCRC Publication Information
Director: Joshua S. Vayer
Medical Director: John H. Hagmann
Editor: Janet Amass
Contributing Staff: Lt Phil Cholak, USPP, Mr Ned Sherburne
CONTOMS DISPATCH is published quarterly in January, April, July and October. Articles and requests for publication should be addressed to:
USUHS/MIM/CCRC
Editor, CONTOMS DISPATCH
4301 Jones Bridge Road
Bethesda, MD 20814-4799
phone: 301-295-6263 FAX: 301-295-6718
This space will be dedicated to the graduates of the EMT-T school in order to facilitate communications with other providers. It is the policy of the CONTOMS Board of Directors NOT to release the names of graduates, therefore we offer this opportunity to contact others. Submit requests for publication to the Editor.
PENNSYLVANIA:
Pennsylvania Paramedics, Health Professionals, EMT'S who have completed the CONTOMS program if interested in attending a round table discussion on PA TEMS
issues and concerns please write to:
Kevin Arthur, EMT-P, EMT-T
Team Leader, Tactical Response Unit York Hospital and Trauma Center
Department of Emergency Medicine 1001 South George Street
York, PA 17405
Anyone with knowledge of incidents of exposure to Oleoresin Capsicum that yielded reactions that are atypical to OC exposures; and how they were medically managed, please write to Kevin Arthur, address above.
Special interest in any/all Registered Nurses who work in the tactical environment. If you are a nurse or know someone who is a nurse assigned to a tactical team, please contact Kevin Arthur, address above.
OHIO:
Joe Hallal is the EMS Coordinator in Shaker Heights, Ohio. As an EMT-T and medic for the SWAT team, he has a special interests in two areas: Innovative ideas related to medical equipment and delivery of care as well as in-service training topics. Submit ideas to CONTOMS DISPATCH for publication to benefit all.
KANSAS:
On behalf of the Johnson County MED-ACT Special Operations Group, we write to enlist your assistance. For the last two years, MED-ACT, a county-wide, third service type EMS agency in suburban Kansas City, has been developing a Tactical Medic Team. The team is operational and provides medical support for Police Tactical Teams for several municipal jurisdictions in Johnson County, Kansas.
Our team has been considering the concept of medics carrying weapons for self-defense. It is in this regard that we request information. Your team may have implemented this policy, or be involved with researching the topic. We would appreciate your assistance in obtaining information that might aid our team in making a decision on this issue.
Below is a short survey that we ask you to complete and return to us. Please include your service name, address, point of contact and telephone number. We are interested in any specific case scenarios that you have encountered that would promote the need for Tactical Medics to carry weapons, or that would discourage such a practice. Also, we would appreciate hearing about any insights that you have gained from your own team's research into this topic. Our goal is to research every angle of this issue. We need your input to be better equipped to present a proposal to our department. Thank you for your assistance
Scott Hendrix, MICT, Tactical Medic
Roger Lippert, MICT, Tactical Medic
Service Name:
Service Address:
Contact Name:
Phone #:
Do your medics carry weapons? yes no
Do your medics make entry? yes no
Have your medics ever used their weapons? yes no
Do your medics perform roles other than medical duties with your team? yes no
If the answer is yes to the previous question, please list those duties:
Please include any other information you feel is important:
Return to: Johnson County MED-ACT, Special Operations Group
111 S. Cherry Street, Suite 300
Olathe, KS 66061
ATTN: Tactical Medic Team