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International School of Tactical Medicine Student Guide Rancho Mirage, California

Tactical Medicine Module A Training Support Package Student Guide

Tactical Medicine Module A - Introduction

We are committed to ensure that you receive the most intense and up to date tactical medical training available. Our instruction technique is based on the building block approach to training with a proven track record of success.

Our tactical instructors have many years of experience as tactical commanders and operators. All physician instructors are reserve law enforcement officers, active on tactical teams, and are residency trained in emergency medicine, trauma surgery and critical care medicine. The instructors are experts in their field with experience and knowledge unlike that found anywhere else. To ensure high quality training, ISTM complies with the California Peace Officer Standards and Training (POST) and the California Emergency Medical Services Authority (EMSA) regulations and guidelines for continuing education for pre-hospital and law enforcement professionals.

Finally, our faculty strictly adheres to current tactical law enforcement accepted standards and emergency medical care guidelines that conform to the civilian EMS system and the practice of emergency medicine.

We promise you an outstanding academic training program that upon completion will enable you to effectively integrate with your tactical team as a tactical medical provider.

We will make every effort to see that you get the most out of your 2 weeks of training and our instructors will work closely with you to help you reach your goals. It is our sincere hope that with this training you will be able to provide state of the art tactical medicine for your team and may perhaps one day save a life during a tactical operation.

Lawrence E. Heiskell, M.D., FACEP, FAAFP Founder and Medical Director ISTM

“It should be borne in mind that there is nothing more difficult to handle, more doubtful of success, and more dangerous to carry through than initiating changes... The innovator makes enemies of all those who prospered under the old order and only lukewarm support is forthcoming from those who would prosper under the new. Their support is lukewarm partly from fear of their adversaries, who have the existing laws on their side, and partly because men are generally incredulous, never really trusting new things unless they have tested them by experience.”

Niccolò Machiavelli, 1514

Disclaimer

The ISTM does not guarantee that participants who attend or successfully complete the Tactical Medicine Course will be able to perform Basic or Advanced adult or pediatric life support in an actual emergency.

Our role is to provide you, the student with the highest quality Tactical Medicine education available anywhere.

Although our courses are designed to teach students how to perform in certain situations, the course does not guarantee that the participants will use this training appropriately in emergency medical or tactical situations outside the classroom.

Law-enforcement tactical operations are an evolving craft and what is best today may or may not be the best tomorrow. Beyond this course, it is incumbent on the student to keep abreast of emergency medical and tactical options and issues.

Finally, your tactical commander, department policies, county EMS protocols and your own skill level will be the ultimate determinant as to what techniques, tactics and treatment you will use in the field.

Copying Course Materials

The student manuals, digital photographic images, PowerPoint presentations, teaching scenarios, training evolutions and other instructional materials are the intellectual property of ISTM and are protected by copyright and other intellectual property laws.

You may not reproduce or copy the materials, in whole or in part, in any manner, without the prior written consent from ISTM.

ISTM P.O. Box 2609 Rancho Mirage, California 92270

Continuing Medical Education

Continuing medical education is an ongoing dynamic process. We make every effort to stay current with the medical literature as well as changes in the standard scope of practice in emergency medicine.

Candidates that successfully complete the Tactical Medicine Module A Course are awarded the following CE and CPT credits:

The Sacramento County EMS Authority designates the Tactical Medicine, Module A Course as a continuing medical education activity for:

20 hours CE

The State of California Commission on Peace Officer Standards and Training (POST) has certified the Tactical Medicine Module A Course for continuing education for law-enforcement for:

20 Hours CPT

Trademarks

The ISTM logo is a trademark and is registered with the United States Patent and Trademark Office. Only International School of Tactical Medicine faculty and its licensees may use these trademarks.

This trademark is the identity of ISTM and when placed on publications, apparel, course materials and other items serve to distinctly identify the materials as having originated from ISTM.

Table of Contents

SECTION 1 – PRINCIPLES AND CONCEPTS OF TACTICAL MEDICINE 1

TRAINING YOU TO SAVE LIVES 2

CRITICAL TO SWAT OPERATIONS 4

SECTION 2 - TACTICAL MEDICAL EQUIPMENT 26

TACTICAL MEDICAL GEAR 27

EQUIPPING THE TACTICAL MEDIC 29

SECTION 3 - TACTICAL GEAR AND EQUIPMENT 45

HAND ARMOR ADVANCEMENTS 48

SECTION 4 - TACTICAL TEAM CONCEPTS AND PLANNING 55

MEDICS ARMED AND READY 67

SECTION 5 - SLOW AND DELIBERATE TEAM MOVEMENT 69

SECTION 6 - INTRODUCTION TO THE TACTICAL PISTOL 87

TACTICAL PISTOL TRAINING SAFETY RULES 88

SECTION 7 - MEDICAL ASPECTS OF DISTRACTION DEVICES 99

USE OF DISTRACTION DEVICES 100

SECTION 8 – DYNAMIC BUILDING CLEARING TECHNIQUES 118

TYPES OF BUILDING CLEARING 119

SECTION 9 – TACTICAL CASUALTY CARE 127

ASSESSMENT AND TREATMENT GUIDELINES 128

BATTLEFIELD OCULAR INJURIES 135

SEAL A SUCKING CHEST WOUND 137

NEEDLE THE CHEST 139

SECTION 10 – MEDICAL ASPECTS OF WOUND BALLISTICS 155

CSI OF WOUND BALLISTICS 156

SECTION 11 – HEMOSTATIC DRESSINGS AND TOURNIQUETS 179

STOP THE BLEEDING 180

SECTION 12 – TEAM HEALTH MANAGEMENT 193

20 TIPS FOR WEIGHT CONTROL AND HEALTHY EATING 194

LIFESAVING PERSONAL MEDICAL INFORMATION 196

SECTION 13 - MEDICAL ASPECTS OF CLANDESTINE DRUG LABS 208

MEDICAL MANAGEMENT OF CLAN LAB EMERGENCIES 209

CLANDESTINE DRUG LABS 213

SECTION 14 – FORENSICS AND EVIDENCE PRESERVATION 236

SECTION 15 - INTRODUCTION TO THE M4 LAW ENFORCEMENT CARBINE 256

M4 CARBINE SAFETY RULES 257

COLT M4 LAW ENFORCEMENT CARBINE 266

DANGEROUS DECIBELS 271

SECTION 16 – CHEMICAL MUNITIONS IN THE TACTICAL ENVIRONMENT 279

SECTION 17 – MEDICAL THREAT ASSESSMENT & BARRICADE MEDICINE 292

SECTION 18 - MODULE A WRITTEN FINAL EXAM 300

APPENDIX A – RESOURCE EQUIPMENT LIST 301

APPENDIX B – REFERENCE MATERIAL 304

Section 1 – Principles and Concepts of Tactical Medicine

Duration 1.5 hours Scope Statement This section provides students with an in depth understanding of the principles and concepts of providing medical support for law-enforcement special operations teams Terminal Learning Objectives (TLO) At the end of this section the students will understand the tactical medicine concept and the roles and responsibilities of the tactical medical provider. Enabling Learning Objectives (ELO) At the end of this section, the students will be able to describe: 1. The historical development of Tactical Medicine 2. Tactical medicine training program goals 3. The roles and responsibilities of the tactical medic 4. Differences in the military and civilian model 5. Team structure and function 6. Problems facing tactical teams 7. Injuries and illnesses common to tactical operations 8. Accessibility and civilian EMS interface 9. Legal considerations 10. Operational standards Resources See Appendix A Instructor to Participant Ratio 2:30 Reference List See Appendix B Assessment Strategy Pre and post testing, end of course critiques, subjective evaluations, and instructor comments.

Training You to Save Lives

Despite the increasing nationwide awareness of the value of having an on-scene specialized medical team, the medical consequences of tactical operations are often overlooked or completely left out of the operational plan. Unfortunately, there are some law enforcement agencies that still deploy S.W.A.T. teams for high-risk warrant service and other operations with no further medical plan other than to call 911 if someone is shot or injured. In today's litigious world this practice is certain to come under close legal scrutiny by the courts.

Civilian EMS Constraints During tactical operations involving a barricaded hostage or active-shooter situations, tactical commanders will often stage civilian EMS personnel remotely for their personal safety.

The traditional EMS crew is reluctant to enter the scene because they are not convinced that the area is absolutely safe to enter, during which time an officer or victims could bleed to death. In addition, critical information necessary for proper care and eventual trauma center management is fragmented and diluted due to confusion and stress on the EMS personnel upon their arrival. A good example was the Virginia Tech massacre in Blacksburg, Virginia.

Not having direct communication channels with the command post removes civilian EMS even further from being able to perform effectively.

A tactical medical team evaluates and treats a victim during a simulated field operation.

What are the Options? Establish a tactical medic support team: Obtain training for the team: Once the Consideration for medical support can be emergency medical team is selected, accomplished through a wide array of training issues must be addressed before options, from civilian EMTs to sworn or the team is deployed. Several options exist designated reserve police officers who are for training the medical team. A two week physicians or paramedics. Each agency dedicated tactical medicine school will must decide on what best suits the needs of provide the essential tactical knowledge and the team, and perform a cost-benefit skill required to operate safely in the tactical analysis of its own program. environment and is the most cost-effective method for training tactical medical Options include deciding whether to train personnel. members from their respective teams to become paramedics or EMTs or borrow Tactical training for medical team members these services from local Fire and EMS. If a is important for a number of reasons. First, higher level of medical care is desired, a no team member, regardless of his position qualified physician should be sought. A or assignment can be an effective qualified physician is one that has component without proper training. experience and training in the recognition and management of medical emergencies Second, tactically training the medical and advanced trauma life support. support personnel allows the medical component to understand all aspects of The source for emergency physicians is tactical operations and the risk-benefit ratio abundant. Most police officers will associated with each tactical decision. personally know several of the local ER physicians having frequently visited local Finally, there is the liability issue. No tactical hospital emergency departments while team commander should allow or feel conducting law enforcement duties. It would comfortable with medical support operating not take long for interested tactical police within this environment without proper officers to identify those physicians with a training. law enforcement mindset and potential team players and who could be viewed as prospective candidates to serve as a team physician.

Critical to SWAT Operations

The scene is a fixture in many war movies: A wounded soldier cries out, “Medic!” then Medically speaking, however, this practice left another soldier, one who carries a medical kit a lot to be desired. The first five minutes are and not a weapon, crawls out from his foxhole critical in the care of a seriously wounded and braves the fury of a firefight or an artillery person. So the time that it took to transport barrage to render aid to his wounded buddy. wounded officers to safe areas for treatment could often lead to tragic results. Medics and corpsmen have been officially assigned to American Army and Marine units Today, more and more police tactical teams since World War I, And with good reason. have added emergency medical personnel. For example, some have trained full-time SWAT Research shows that 90 percent of all battle officers as EMTs or paramedics. Others have deaths occur in the field, prior to any medical trained medical personnel in police tactical intervention. In a landmark review of wounds operations. and death in battle, retired Army colonel Ronald F. Bellamy noted that many combat Injuries from Breaching Charges and deaths were potentially preventable, including Flash-Bangs deaths caused by blood loss from extremity When developing a medical threat wounds, deaths caused by tension assessment for his or her team, a tactical pneumothorax, and deaths caused by airway medic should consider not just the threats obstruction. presented by the bad guys but also injuries that can occur from the use of SWAT tools, The lessons of Bellamy’s research were not including breaching and distraction charges. lost on the U.S. military. They also haven’t been lost on American law enforcement Before each mission, the medic should agencies, as many now have medically consult with the team’s breaching expert trained personnel attached to SWAT teams. regarding the types of explosives he plans to use and the blast forces that may be Seconds Count encountered. Before 1989, there was great diversity in the way in which emergency medical care was Some of the medical problems that can be provided during law enforcement tactical caused by flash bangs and breaching operations. Most law enforcement agencies explosive even when they are used properly relied on regular civilian EMS providers who include: staged at a safe location removed from the area of operation. Some simply called 911 to • Burns, both minor and major. request paramedics when officers or civilians • Smoke-induced bronchospasm. were wounded. • Vestibular dysfunction. • Transient visual disorientation. From an operational standpoint, these • Emotional upset and anxiety. agencies were taking advantage of an • Eardrum rupture has not been established pre-hospital care system; It made reported in general use, but it is sense. possible

Principles of Tactical Medicine entire scene can be secured by law Tactical medical care can be provided by enforcement before moving to the patient. EMTs, paramedics, registered nurses, mid- When a tactical medic is participating in the level providers (such as physician assistants operation, care can generally be rendered to and nurse practitioners), or even physicians the victim in a timelier manner. who serve on police tactical teams. The tactical medic’s level of training will determine what However, it should be understood that both actions he or she can take in the field. For traditional EMS and tactical EMS have their example, mid-level providers and physicians place. Tactical medics cannot carry all the traditionally have training in advanced surgical equipment into the field that a traditional and medical procedures beyond what is paramedic has access to in his or her vehicle. normally allowed for traditional EMS personnel. Access to equipment is just one of the Regardless of the tactical medic’s professional limitations faced by tactical medics. They also standing, he or she will quickly learn that must work under difficult and potentially fluid medical care in a tactical environment can be conditions. For example, a tactical medic may extremely challenging. Traditional EMS have to render aid to a wounded officer or doctrine maintains that rescuer and scene civilian while maintaining light or sound safety are first priorities, and that patient care discipline. is a secondary concern. What sets tactical EMS apart from standard EMS is the ability to Team Health Management render immediate care in the operational area. Although rendering aid under combat conditions is what most officers envision when When a SWAT team relies on traditional EMS they think about the role of tactical medics in personnel to provide medical care and an law enforcement, such actions are really only operator or civilian is acutely injured during the part of the job. mission, the EMS unit must wait until either the victim is brought out to a safe area or until the The primary goal of tactical medicine is to assist a tactical team in accomplishing its mission. This is achieved primarily through team health management, which means keeping the tactical team members healthy before, during, and after operations.

One of the duties of a tactical police medic is to make sure that each member of his or her team maintains the conditioning necessary for effective SWAT deployment. A comprehensive plan of proper nutrition and exercise must be established and maintained.

SWAT conditioning should include a balance of In addition to his or her role as conditioning aerobic exercise, anaerobic exercise, and coach, the team medical officer essentially stretching. Cardiovascular workouts such as becomes the family physician for the tactical running or swimming are excellent for unit and should be prepared for this role. cardiovascular fitness. Circuit weight Regardless of his or her professional resistance training is excellent for strength qualifications, the team medic will likely training, but it must be a total body workout. become the medical advisor for his or her Many tactical operators train some parts of tactical unit. their bodies, but ignore others. This can lead to buff-looking operators who aren’t really as fit The tactical medic should be prepared to act in as they seem, and it can result in injuries. this capacity because it is one of the greatest benefits that he or she can provide to the team. Tactical Medics and Weapons Handling As medical advisor, the tactical medic can Tactical medics have to be more than just foster better team health overall. He or she can emergency medical personnel; they have to persuade officers to maintain their health with be tactically aware and well versed in the regular physical exams and treatment where weaponry used by their teams. appropriate. Smoking cessation, alcohol and

drug counseling, and stress management are Tactical medics can be sworn officers whose also health issues that the team’s medical primary duties are as an operator on the unit officer is in position to address. or they can be medical professionals who work with the team. Either way, tactical In his or her role as team "physician," the medics are going in harm’s way, and they tactical medic is well advised to take a cue should be qualified to carry arms so they can from other medical providers and keep detailed protect themselves. records. Records should be stored for a

minimum of 10 years. This is both for benefit of Even if your medic is a civilian who is not the patient and the protection of the medic. permitted to carry a weapon during your Such records have proven to be indispensable operation, he or she needs weapons as defense documents in several anti-police training. One of the duties of a tactical medic liability lawsuits. Without a medical record, is to take charge of an officer’s weapon there is no proof that appropriate medical care when his condition requires that he be was given to the team members. disarmed. For example, if the officer becomes disoriented, he may become a danger to himself and anyone around him if Medical Threat Assessment One of the most important duties of the tactical he is left in charge of his weapon. In this medic is to create a formal medical threat case, the medic needs to take charge of all assessment (MTA) for each training and of the officer’s weapons and render them operational deployment. A typical MTA safe. includes consideration of issues such as

environmental conditions, fatigue, nutritional A tactical medic should be familiar with issues, plant and animal threats, and a plan for every handgun, shotgun, rifle, submachine extrication and transport of patients. gun, assault rifle, chemical launcher, and less-lethal weapon used by his or her team. Medical intelligence should be gathered prior All tactical team members, whether to or during the mission. This assessment providers or not, should be able to use any includes details such as who is involved, ages weapon a team member carries and render of those involved, medical history, background, it safe. any preexisting medical conditions,

geographical location, and even the weather. team medic’s assessment should be part of this analysis and planning. The MTA is not just essential for the tactical medic’s operations; it is also a critical tool for It is the responsibility of the tactical medic to the team commander as he plans the mission. provide a concise and accurate medical briefing to the commander. Medical threat SWAT commanders consider information from assessment forms should be used on every many sources when they create a tactical plan mission to ensure a systematic approach to the for a mission, including manpower, building assessment process because only a layouts, street layouts, support equipment, systematic approach ensures complete nature of the mission, available weaponry, and assessment of the situation. the reliability of the sources of intelligence. The

Principles and Concepts of Tactical Medicine

Overview

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Section 2 - Tactical Medical Equipment

Duration 1 hour Scope Statement This section provides students with hands on training and familiarization of the medical equipment used in the tactical environment. Terminal Learning Objectives (TLO) At the end of this section the students will become familiar with a wide variety of medical packs, vests, bags and extrication equipment used in the tactical environment Enabling Learning Objectives (ELO) At the end of this section, the students will be able to describe:

1. Design and construction features 2. Load bearing packs 3. Backpack designs 4. Trauma packs 5. Urban carry cases 6. Tactical medical utility vests 7. Self-help kits 8. Flexible litter kits 9. Tactical extraction equipment 10. Belt systems Resources See Appendix A Instructor to Participant Ratio 4:32 Students Reference List See Appendix B Practical Exercise Statement Hands on training Assessment Strategy Pre and post testing, end of course critiques, subjective evaluations, and instructor comments

Tactical Medical Gear

At the International School of Tactical Medicine physical performance. It is unlikely an tactical medical gear is an ever-evolving encumbered team member could fit through discussion. In the tactical medical environment the doorway with any stealth or grace after we are constantly bombarded with more new running 400 yards. equipment that we're expected to carry. This equipment gets very heavy. Everyone wants to A streamlined profile is preferred to a bulky know what the right toolkit to have is and how one, reducing weight at the same time. The to deploy it. I wish it were that simple. best method to accomplish this task is to distribute the weight and bulk among multiple Equipment Lists Vary: We're asked to team members. The same medical equipment provide standard lists of equipment needed for can be distributed among multiple medics on a tactical operation for an agency SOP. If there the same team if a modular approach was was a standard configuration, it would be easy. used. There is no single standard for the makeup of any tactical unit, much less its medical Distributing Weight and Accessibility: At element. ISTM we have all come to agree on one thing: as far as tactical medical equipment, a modular The medical component of a tactical unit can approach to your toolkit. be made up from any mix of first responders, Emergency Medical Technicians (EMT), Every team member should carry a Personal Paramedics (EMT-P), corpsmen, nurses, Supply Module (PSM). This module should physician assistants, or physicians. The gear have basic supplies for each individual team they carry depends on their levels of training, member. The medic should never have to use budget, distance and time to the treatment the supplies he is carrying to treat minor facility and ultimately, agency SOP. One must injuries or initially stabilize a team member. think of what the individual practitioner is actually trained or certified to do in the tactical A PSM typically weighs eight ounces when environment before the equipment can be complete; distributing an eight to 10- pound determined. loads amongst all team members. This reduces bulk and weight for the medic, but any Weight and Bulk Matter: Helmet, goggles, team member may be able to self-administer headset, microphone, balaclava, BDUs, aid prior to the medic’s arrival and intervention. ballistic plates, tactical vest, all the things With multiple casualties or in situations such as attached to the vest, hydration system, belt, the Hollywood shootout, where a medic cannot gun belt, sidearm, long gun, spare magazines, access a downed officer, this may be tactical illumination tools, cuffs, radio, knife, lifesaving. knee pads, elbow pads, boots and gloves are standard for everyone on the tactical team. Every team medical officer with at least an EMT-Basic certification should carry a Basic As medics, we have not even begun to add our Medical Module (BMM). Additional trauma medical toolkit to this already cumbersome supplies, personal protective equipment, load. A fully stocked medical pack for an splinting material and basic airway supplies emergency physician or a trauma surgeon can make up the bulk of the BMM. Oxygen be massive. Load size and weight become a cylinders are too cumbersome to be of use in great factor in a team member’s stamina and the tactical environment, whereas lightweight,

compact tactical litters or other extrication reducing the size of your medical pack and devices are typical additions to the BMM. streamlining your profile. The prepackaging of different items within a modular system aids in Physicians and mid-level providers such as the process of stocking items. The durable, corpsmen, nurses and paramedics will benefit clear-plastic packaging aids in ready from the Intermediate Medical Module (IMM). identification of the module and package This module will contain advanced airway contents. Prepackaged supplies kept in the tools, suturing supplies, IV preparations and support vehicle, Personal, Basic, Intermediate medications. and Advanced Medical Modules all can be restocked immediately as needed during the The Advanced Medical Module (AMM) is mission or after it has been completed. reserved for physicians and will have surgical instruments. In summary, make sure you use a modular approach and distribute medical equipment Durability, Utility and Vacuum Packaging: among team members. Streamline your Tactical units deploy in every kind of equipment list and carry as little unnecessary environment from desert-dry to hurricane-wet. gear as possible. Vacuum packaging small Once wet, most packaging becomes soft and items provides ease of identification, and easy tears open, exposing our costly medical items restocking. to contamination with water, dirt and bacteria. This renders our equipment useless in the tactical pre-hospital environment. If moisture is not your problem, friction and time will do the same damage to your packaging.

The best technique is to vacuum-package it. The evacuation of air from the equipment creates a very compact package that is only a fraction of its prior bulk. The slight addition in weight from the plastic packaging is clearly offset by

Having the appropriate medical equipment with you could mean the difference between life and death for this downed officer.

Equipping the Tactical Medic

The tactical medic must be able to effectively carry equipment and be able to operate in a For example, some medics don surgical gloves tactical situation without hindering the rest of underneath their shooting gloves prior to an the team. So he or she must decide what items operation so they will be ready if the need and tools will be carried into the field and what arises. Although not sterile, the surgical gloves equipment will be left in a vehicle or in a larger do provide protection from body fluid-borne kit. pathogens.

In general, medics carry two sets of medical Personal Supply Module (PSM) equipment. One set is carried for immediate To reduce the equipment carried by the medic care, typically worn in a small backpack or and so that the team members can help load-bearing vest. The second set is carried in themselves, each member of the tactical unit a larger backpack or duffel bag in the support should carry “self-help kit” with medical vehicle. This article is a guide as to which gear, supplies. solutions, and tools should be in each pack.

A tactical medic must be proficient in medical management and patient care under less than ideal circumstances.

Personal Protective Equipment (PPE) A typical personal supply module is vacuum- Universal precautions against infectious sealed and contains supplies for basic trauma diseases must be used by tactical medics. care and for IV access. Vacuum sealing these Masks, eye protection, gloves, and perhaps contents provides protection from the even gowns must be considered. The basics elements. It also cuts down greatly on bulk, but for protection should be carried on the medic’s adds some weight. person in an easily accessible location.

Basic Medical Module (BMM) In addition to a PSM, a Basic Medical Module (BMM) should be carried by team medics. Since every team member on a tactical unit should have at least basic EMT certification, a BMM could be used by any team member to provide initial care to a victim. The BMM should have basic splinting material and dressing material.

Basic airway tools such as nasal airways and a pocket mask should be included. A bag valve mask or more compact alternative is advisable in the tactical environment. A simple bag valve mask alternative device Utilizing a backpack allows the tactical medic to (BVMAD) can be constructed out of carry additional equipment and supplies. respiratory supplies to combine a one-way A cricothyrotomy kit facilitates placement of a valve, flexible tubing, and mouthpiece. This is definitive airway prior to transport. When a the preferred ventilatory device in the tactical definitive airway is combined with the use of a environment, as it allows a rescuer to provide BVMAD, it allows hands-free ventilation of a ventilation without unnecessary bulk. patient, making it possible for one or two team

members to extricate the patient. If a Oxygen rarely is useful in the immediate cricothyrotomy kit is carried, the medic should tactical environment, so leave the O2 cylinders be proficient in its use, as conditions in the in the support vehicle with a regular BVM that tactical environment are difficult at best. can be retrieved when necessary. An automated external defibrillator (AED) should Many intermediate-level medics include also be carried in the support vehicle. A small hemostatic dressings in their trauma kits, but collapsible litter for extrication of a downed the benefits and potential hazards of their use person should be a part of every BMM. are the subject of debate.

Intermediate Medical Module (IMM) Direct pressure with a sterile dressing is the Paramedics and registered nurses can use the best initial approach to hemorrhage control. equipment in an intermediate level module And pressure point compression and (IMM). This kit differs from the BMM, as it tourniquets are useful adjuncts to any bleeding includes equipment and supplies suitable for problem. So these materials should be advanced life support (ALS). included in the major trauma module (MTM): a

set of combine dressings, gauze, petrolatum Under "standing orders" from a team physician, gauze, tourniquets, and Israeli dressings. ALS-qualified medics may provide advanced cardiac life support to a victim. So an IMM is Support Vehicle Module much more extensive than a BMM and Additional supplies and equipment should be contains medications, IV tubing, IV fluids, stored in the support vehicle module (SVM). endotracheal tube, Combi-Tube, For example, ready supplies of consumable Laryngoscope, Light Wand, and, if protocol items should be kept in the SVM so that other allows, Cricothyrotomy Kit. modules can be restocked.

The SVM should contain equipment such as

oxygen cylinders, an AED, airway adjunct The chemical and biological environments are devices, fiber optic scopes, nebulizers, surgical specialized depending on what agent is trays, chest tubes, cervical collars, released. Various civilian and military backboards, peroxide, povidone-iodine, liter protective gear and respirators or supplied air bags of crystalloid IV fluid, replacement filters sources may need to be worn. Operating in for gas masks, and fiberglass splinting CBRN protective gear requires extensive material. training in addition to regular tactical training.

For Advanced Providers Antibiotic prophylaxis with ciprofloxacin, as well Field care is limited only by the equipment that as agent detection equipment, may be carried can be transported and the training of the by the medic in this case. Several biologic and providers. Some of the items carried by chemical diagnostic kits and meters are advanced providers include: available, but costly.

• Central line • Tracheotomy set • Retrograde intubation set • LMA • Chest tube set • Fiber optic intubation set • Blood products or blood substitutes

WMD Specialty Gear Depending on the role of the tactical unit, chemical, biological, radiological, or nuclear (CBRN) threats may be encountered. These incidents require tactical emergency medical care because they are large crime scenes with many casualties.

Tactical medics are much more familiar with evidence collection and preservation, and typically already have necessary security clearance While medics carry a set of equipment for immediate care, a more to enter such an area. Until the extensive bag of supplies that often includes an AED and a collapsible litter is usually kept in the support vehicle. scene is cleared, the tactical medics may be the only medical care available to victims inside.

Radiological incidents would likely involve the dispersal of a radiological agent with conventional explosives, a "dirty bomb."

Learning how to work in a radioactive hot zone produced by a dirty bomb, nuclear detonation, or atomic reactor release requires lots of additional training. But it’s not beyond the realm of tactical emergency medicine.

Finally, while chemical weapon attacks are not (yet) common occurrences for law enforcement, many officers are exposed to chemical hazards from clandestine drug labs. So it’s a good idea for tactical medics to learn how to work in chemical protection suits.

Tactical Medical Equipment

Overview

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Section 3 - Tactical Gear and Equipment

Duration 1 Hour Scope Statement This section provides students an understanding and familiarization with the medical equipment used in the tactical environment. Terminal Learning Objectives (TLO) At the end of this section the students will become familiar with the gear and equipment used in the tactical environment. Enabling Learning Objectives (ELO) At the end of this section, the students will be able to describe:

1. Tactical uniforms 2. Weapons systems 3. Body Armor 4. Communication equipment 5. Illumination tools 6. Entry tools 7. Breaching equipment 8. Night vision equipment 9. Personal gear 10. Special materials and equipment

Resources See Appendix A Instructor to Participant Ratio 4:32 Students Reference List See Appendix B Practical Exercise Statement Hands on training Assessment Strategy Pre and post testing, end of course critiques, subjective evaluations, and instructor comments

Tactical Team Equipment Notes

A. Basic equipment: ______

B. Special equipment ______

C. Weapons ______

D. Ammo ______

E. Body armor ______

F. Communications ______

G. Vision ______

H. Rescue ______

I. Support ______

J. Individual ______

K. Entry tools ______

L. Uniforms ______

Basic Tactical Equipment

Entry Tools Weapons Pry bar Handgun Battering Ram Shotguns Sledge Hammer Sniper rifle with scope Rope with hook M4 Carbine Stop Blocks Submachine gun Ladder Assault rifle Smoke and chemical agent gun Vision Binoculars Ammo Pole mirrors Duty Spotting scopes Shot-locks Spotlights Rubber Night vision Armor piercing Periscope Ferret Rounds Strobe Light Chemical Light Armor Level 4 vests Individual Body bunker/shields Handgun Kevlar helmets Body armor Kevlar blankets Flashlight Pocket mirrors Special Gloves Distraction devices Ear & eye protection Smoke Handcuffs Chemical agents Holster Gas mask Support Knife Duct tape Flexcuffs Spray paint Knee & elbow pads Police tape Pocket knife Vehicles First aid kit Rain gear Extra batteries Uniform Portable Generator Two piece fatigue with x/pockets Lightweight boots Communications Duty belt Portable radios with ear mic (secure channels) Drop leg holster Hostage phones and tape recorders Extra socks Throw phones Ball cap Bullhorn

Hand Armor Advancements

How to protect and repair your best combat and LE tools! Hand injuries account for nearly 10 percent of all emergency department visits in the U.S. A 2008 study at the U.S. Army Institute of Surgical Research, Burn Center at Fort Sam Houston looked at the hand injuries sustained during Operations Enduring Freedom and Iraqi Freedom. They found in a retrospective review of the U.S. Army Institute of Surgical Research Burn Registry that 451 military personnel were admitted during a 34-month period and 239 had sustained hand burns. This clearly demonstrates that hand protection in a combat environment is paramount. Hand injuries are also commonplace in the civilian tactical environment. Breaking and raking windows, breaching doors and clearing rooms all put our hands at risk for injury. Nothing can be more debilitating to an individual than the loss of function of all or part of a hand. Even the loss of a finger can be devastating. Although, with time most individuals can adapt to such a disability, the goal is to prevent such injures by using appropriate gear. Intricate in design and function, the hand is an incredible work of art and anatomy. Form follows function in the hand and any injury to the underlying structures of the hand carries the potential for a serious disability.

Rapid Evaluation The primary goal with injuries to the hand is an accurate and rapid initial medical evaluation. Once an injury occurs, the tactical medic should begin medical treatment rapidly to prevent both short-and long-term effects. The hand consists of 27 bones if you include the eight bones of the wrist. When the other associated structures such as nerves, arteries, veins, muscles, tendons, ligaments, are considered, the potential for a Combat assault gloves should contain a blend of 100% large variety of injuries becomes Kevlar weave with excellent flame and cut resistance greater. without compromising flexibility and tactile function.

Hand injuries can be divided into four general categories: (1) lacerations (2) fractures and dislocations, (3) soft tissue injuries and amputations and (4) burns. The potential for devastating injuries increases tremendously when medical attention is delayed. Even the smallest cut or seemingly innocent hand injury could require advanced treatment to prevent significant loss of function. Even the most insignificant hand injury can have the potential for serious loss of function.

Any laceration that may require sutures warrants a complete medical evaluation. Internal damage to the hand can also occur, and is hidden out of plain view deep within the hand, such

as lacerations of tendons. These can be treated at a later date by a hand surgeon with good results, but you do not want to miss them in your evaluation. Hand Injury Treatment Field care for hand injuries initially involves some smart first aid techniques. The following is a solid checklist of what’s needed depending on the situation.

Lacerations: Fractures and dislocations: • Apply pressure to the wound to stop • Rapid field reduction if possible bleeding • Immobilization by splinting or buddy taping • Wash dirt or debris from the wound if at all • If the bone is exposed, cover with gauze possible • Ice may help decrease the pain, but never • Cover the wound to prevent further apply for more than 20 minutes and never contamination or injury directly to skin • Do not remove large foreign bodies such as nails, hooks, or knives

Soft tissue injuries and amputations: Burns: • Apply pressure to stop bleeding • Thermal (heat) burn: Cool with water • Cover with damp bandage, if possible • Chemical burn: Irrigate with lots of water • Elevate the hand above the heart • Frostbite: Re-warm with warm-water bath • Retrieve amputated body part. If possible, or soak, then cover. cover, keep damp, and place near ice to cool • Do not place body part in direct contact with ice in order to prevent freezing

Additional treatment: • Pain medication • Antibiotics if needed • Tetanus shot if indicated Infections Human or animal bites require thorough cleansing and irrigation to reduce the risk of infection. Puncture wounds such as cat bites and wounds where tissue is crushed such as human and dog bites are particularly likely to become infected. The risk of infection increases when these wounds are sutured. Most bite wounds require antibiotics and close follow up to assure healing.

Preventing an injury is better than treating one. The hand is clearly one of the most critical parts of the body to protect from injury because even with the best treatment, just about any injury leads to some loss of function.

Tactical gloves can protect your hands, specifically the nerves, which can become injured if the palm suffers a direct blow. In addition to protecting your nerves, gloves can protect your skin from direct wounds and cuts. At the International School of Tactical Medicine, we are as concerned about preventive medicine as we are about educating and training good effective tactical medics. The next time you deploy make sure you and your team members have adequate hand armor. Remember you can’t shoot back if your hands are injured.

Tactical Gear and Equipment

Overview

Slide Notes Slide View

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Section 4 - Tactical Team Concepts and Planning

Duration 1 Hour Scope Statement This section provides students with hands on training of tactical team concepts and planning. Terminal Learning Objectives (TLO) At the end of this section, the participants will be able to understand tactical team concepts and planning. Enabling Learning Objectives (ELO) At the end of this section, the students will be able to describe:

1. Team purpose 2. Team objectives 3. Team responsibilities 4. Team member selection process 5. Team procedures 6. Training issues 7. Noise discipline 8. Cover and concealment 9. Team deployment and negotiation procedures 10. Warrant service preparation Resources See Appendix A Instructor to Participant Ratio 4:32 Reference List See Appendix B Practical Exercise Statement None Assessment Strategy Pre and post testing, end of course critiques, subjective evaluations, and instructor comments.

Tactical Team Definitions

1. Purpose - To have specially trained personnel within the organization who are called upon in situations requiring expertise and equipment beyond that normally used by field officers.

2. Objective - The objective of all tactical teams is to save lives, which includes hostages, innocents, officers, and suspects.

3. Responsibilities - To be prepared for any unusual occurrence with trained personnel and equipment.

4. Team Member Selection - The prospective member should be highly motivated, mentally sound, physically fit, experienced, and psychologically tested.

5. Procedures - If you are going to have a tactical team you should have a written policy and procedure manual that includes standard operating procedures to cover all aspects of the unit.

6. Training - Should cover both basic and advanced training with emphasis on training for real life encounters and realism. Surveys in the past have indicated that a minimum of 16 hours training time per month is recommended for part time teams. It also recommended more time for combined teams.

7. 360 Protection – Team Concept - This philosophy should be practiced in both training and activations.

8. Invisible deployment - One of the most important elements for a tactical operation is “surprise”. The suspect(s) can locate you in many ways including sight, sound, smell, and touch.

9. Noise discipline - It is every team member’s responsibility to ensure that their personal equipment, team equipment, and there movement is performed quietly as possible. Noise discipline should be emphasized in training and in activations.

10. Cover and Concealment - Cover is an object that will stop rounds. Concealment will hide your position but will not stop rounds.

11. Communications - Radios should be multi-channeled with a separate frequency for entry team, marksman team, and perimeter team. They should be unable to be compromised by the public or press. Each team should have a list of hand signals that are practiced for emergencies. Cell phones can be a benefit but remember they are not a secured line.

12. Negotiation training - Each team member should be trained in negotiations. All tactical teams should have ongoing training with their negotiation team.

Tactical Team Planning

A. Warning Order - Is a statement of tasks to be accomplished including the who, what, where, when, and why.

B. Building Intelligence - Accurate and thorough information is essential during the planning phase of all operations.

C. Suspect, hostage intelligence - Thorough descriptions of both suspect and hostages to include as much detail as possible.

D. Recon Mission - Or referred to as the scouting mission should be accomplished as soon as possible. You should attempt to have marksmen or personnel in position to cover your movement during the mission. A check off sheet for the scouting mission should be taken with you to guarantee thoroughness. Some of the most important equipment to take with you on the recon is pen and paper, and small binoculars. Take only necessary equipment with you.

E. Operation Order - A brief explanation of the type of operation. It is a statement setting forth the activity of the operation.

F. Debrief - After an operation there should be two debriefs: 1. Just tactical personnel involved in the operation 2. All personnel involved in the operation

Warning Order

A. Situation - Brief statement of suspects, hostages, and Officers involved.

B. Mission - A statement of tasks to be accomplished to include who, what, where, when, and why.

C. Organization - Command structure and Team organization. 1. Commander 2. Team Leader 3. Team Members 4. Recon Team 5. Apprehension Team 6. Perimeter Team 7. Marksman 8. Observer

D. Uniforms - Uniforms must blend into your environment whether its day or night, winter or summer, urban or wooded.

E. Equipment - (see pages on personal and team equipment)

F. Special equipment - Would include such equipment that is shared by other units like K-9, the bomb squad’s robot, fire department emergency equipment, or road department’s large vehicles.

G. Weapons - The incident and your environment will dictate the type of weapons used during certain activation’s. Always plan to have both high and low penetrable weapons available on the entry. Plan to have a weapon capable of breaching, low lethality, and chemical agents with you for the contingencies that can occur.

H. Ammo - The circumstances of the incident and your environment will dictate the type of ammunition to be used during the activation. Just be ready for all contingencies.

I. Chain of Command - There needs to be a clear understanding by all involved who is in charge and who has what responsibilities. It is especially important when there are multiple agencies involved.

Time Schedule

There are many reasons why time schedules are important including tactical planning, team member survival, case preparation, and court documentation. It’s also used as a time line for the command post.

A. Recon out

B. Recon in

C. Detailed planning

D. Detailed brief

E. Equipment

F. Move to staging

G. Final inspection

H. Move from staging

I. Entry

J. End of mission

K. Debriefing

Recon Mission

A. Recon team procedures - Take only needed equipment. Plan for the route to take and ensure that there are persons in positions to cover the team movement. Stay in contact with the command post.

B. Target location and surrounding area - Confirm the target location by address and get a physical description of the location and surrounding buildings and area.

C. Avenues of approach, escape routes, and rally points - Record the avenues of approach from the staging area to the target along with the escape routes in case of being compromised. Find rally points, which are locations to gather at in case of emergencies.

D. Natural and manmade obstacles - Record all possible obstacles including streams, bridges, fences, swimming pools, etc.

E. Cover and concealment - Record all positions that can be used by teams as cover or concealment. Note: Suspects may use this information to their advantage.

F. Fields of fire - Note areas or lanes of fire for team members on the avenues of approach.

G. Vantage points for marksmen - Note the potential locations for marksmen that could provide optimal observation and fields of fire. Know that marksmen will usually find their own hides or use the recon information as a general guide.

H. Environment lighting locations - Whether it is day or night, when recon is completed the lighting conditions should be recorded. The following lighting conditions should be noted: streetlights, outdoor building lights, and motion detecting lights.

I. Open areas - Note yards, fields, roads, and parking lots.

J. Landscape of area - Record any hills, berms, woods, shrubs, streams, stone or gravel areas, and any paved areas.

K. Structural shape of building - Record all doors including screen doors and what they are made of and which way they open. Note the windows, the sizes, security type windows or not, and how many. Note the porch area, which is usually the breach point, how large it is, and how many steps there are. Note if there are fire escapes, railings, type of roof, and upper and lower entry points.

L. Vehicles - List all vehicles in the area along with all their license numbers and descriptions and exact locations.

M. Utilities - Record all locations of connections from the outside of building for possible shut- offs for gas, oil, electric, and water.

N. Persons observed - Descriptions of all people in or around objectives heard or seen and sounds coming from the target location area.

O. Staging area – The best possible location for staging is out of sight and earshot of the target location, while maintaining an optimal avenue of approach.

Building Intelligence

A. Blue prints - Can be acquired from many different sources including the City or County engineers office, building managers, and the Fire Department.

B. Types of communication 1. Phones & locations

C. Building characteristics 1. Lights and water 2. Heating systems 3. Air conditioning unit 4. Gas & electric, locations

D. Doors and windows 1. Types of locks 2. Open in or out 3. Material composition 4. Screen doors

E. Type of roof 1. Skylights 2. Other entry locations

F. Stairs 1. Inside and outside

G. Basements and crawl spaces

Suspect Intelligence

DATE TIME LOCATION OFFENSE

REPORTING PARTY

OVERVIEW

SUSPECT #

NAME

DESCRIPTION:

HT WT AGE

RACE HAIR EYES

COLOR OF CLOTHES

SHIRT PANTS

MEDICAL PROBLEMS

RELATIVES OR FRIENDS

VEHICLE # LICENSE # OWNER DESCRIPTION

INTELLIGENCE SOURCES

LOCAL NAME

STATE NAME

Hostage Intelligence

HOSTAGE #

NAME

DESCRIPTION:

HT WT AGE

RACE HAIR EYES

COLOR OF CLOTHES

SHIRT PANTS

MEDICAL PROBLEMS

RELATIVES OR FRIENDS

VEHICLE # LICENSE # OWNER DESCRIPTION

Operation Order

A. SITUATION

1. Location - Address and description of location. 2. Suspects - Names and alias. 3. Number of suspects - How many suspects involved. 4. Physical description - Thorough description of all suspects involved. 5. Dogs - List all dogs, breeds, and good descriptions.

B. MISSION

1. Warrants - List the type of warrant, arrest or narcotics, etc.. If for narcotics, mention what type of drugs. 2. Barricades

C. EXECUTION

1. Recon report - Use the recon report to formulate the tactical plan.

2. Danger areas - Note the danger areas from the recon report and use to formulate the movement plan.

3. Movement plan - Used to chart a course from staging area to the target location listing contingency plans, rally points, etc.

4. Entry plan - Basic plan to make entry into a location listing team assignments, breaching plans, contingency plans, etc.

5. Alternate entry plan - As part of your contingency planning you should prepare for secondary entry point on all entries.

6. Specific duties - Each person assigned to the operation should have specific duty responsibility. Some may have more than one responsibility.

7. Team leaders - A team leader should remember that his job is to lead the team and not put himself in a position that takes away from his assigned responsibility. Team leaders with the assistance of the recon team will usually formulate the plans for the operation.

8. Team members - Once a team member is assigned to an operation it is his responsibility to make sure he has all needed personal equipment ready, equipment needed for special duties, and a thorough knowledge and understanding of there assignment.

9. Recon team - (see page on recon missions)

10. Apprehension team - The apprehension team is responsible for the securing of prisoners and any other contingencies that may arise such as rescue teams, or rear guard positions.

11. Perimeter team - Responsible for containment and control on the inner and outer perimeters.

12. Marksmen - Responsible for the gathering of intelligence information, long-range security, and precision shooting.

13. Observer - Assigned to a marksman as support and backup.

14. Rescue team - The quick reaction team is ready to respond to any immediate emergency including downed officer rescue.

D. Time schedule - The time schedule is usually developed in reverse order beginning at the proposed entry time and working backwards including leaving the staging area, arriving at staging, perimeter teams in place, recon teams out and in, marksman teams in position, and command post is up and functioning.

E. Control between units - There needs to be direct contact between units involved in the operation usually accomplished through the command post. Those units may include entry team, rescue team, perimeter team, marksmen / observer teams, and support units.

1. Radio - Should have secured frequencies.

2. Channels - Each unit should have the capability of using an individual channel and compatible with all.

F. Inspections - Team leaders should complete inspections before every operation on assigned personnel, equipment, and whether team members understand their assignments.

G. Service support

1. Weapons - Incident will dictate the type of weapons used. Plan for contingencies.

2. Ammo - Incident will dictate the type of ammunition used. Plan for contingencies.

3. Uniforms - The environment will dictate the color of the uniform used.

4. Special equipment - Includes breaching tools, K-9, night vision goggles, robot, listening devices, ballistic shields, maxi beam lights, and distraction devises, etc.

5. Breaks - Team members should be monitored by the command post and or team leaders especially in inclement weather. There are times when some members will stay at assigned positions even though the temperature has made the

member incapable of performing his duties. Some relief may have to be mandatory

6. Food - During an operation as soon as a command post is established the support unit should begin planning for food and water for the units assigned to the location.

Command & Signal

A. Command - Must be a clear line of authority. Who are the on scene Incident Commander, SWAT, Negotiator, and Patrol commanders. This is especially critical with multi-agency incidents.

B. CP location - Located out of sight and sound of the suspect location and somewhere between the inner and outer perimeters in the best tactical location available.

C. Alternate location - We know from experience that tactical operations can be fluid, which may mean that the command post would have to move locations for safety or tactical advantage. During the contingency planning of the operation a secondary location of the CP should be considered.

D. Sub unit - Each sub unit, SWAT, negotiators, patrol, investigation, special operations, and police volunteers should have a commander or leader that has direct contact with the command post at all times.

E. Signals - Communications should be secure as possible and strong enough to communicate at distances.

F. Hot radios - Radios that are assigned to specialty units that are utilized for activations.

G. Type of radios - There are many types of radios utilized during tactical operations. Preferably the radios should be multi-channeled, secured, and adaptable to headsets that include earpiece and microphone.

H. Frequencies - Should be located at bands that do not interfere with other agencies and cannot be tuned into easily by others outside the Law Enforcement community.

I. Call signs - Individual names should be used rather than numbering systems or “handles”. During operations when the adrenaline is pumping trying to remember someone’s moniker or number can be difficult at best and could cause a negative outcome of the operation. Call signs for some specific teams could be used if utilized during training as well as activations. An example would be multiple rescue teams referred to as R-1, R-2 or multiple marksman teams being referred to as M-1, M-2 teams.

J. Channels - There should be channels assigned to each specialty unit with capabilities that include communicating with the command post and each other if necessary.

K. Hand signals - A list of standardized hand signals should be issued to each member. There may be a situation that would call for total silence where hand signals could assist in the communication process. There may be total radio failure at some point where hand signals could help.

L. Telephones - Hard lines are an essential part of the command post operation. Portable or cell phones are extremely useful for both command post staff and team members in the field as long as they remember it is not a secured line.

Tactical Team Debrief

A. All personal accounted for - There should be accountability of personnel throughout the operation including deployment, recon missions, marksman teams, entry teams, and at the conclusion of the incident.

B. All weapons accounted for - All weapons should be accounted for throughout the operation for safety reasons including allowing suspects to obtain additional weapons or leaving weapons behind where civilians could locate them.

C. All equipment accounted for - Most teams work under limited budgets, which would encourage an accountability of all equipment along with the safety issues of leaving distraction devices, chemical agents, and any other piece of equipment that might cause injury or death.

D. Any injuries - All injuries should be reported and documented for possible future issues even though at the time they seem minor.

E. Any shots fired - All shots fired must be accounted for whether they were intentional or not.

F. All ammo accounted for - All ammunition must be accounted for because of safety reasons and accountability.

G. Problems - Any problems should be documented and discussed for training and future activation’s. Learn from those problems so we don’t have the same problem in the future.

Medics Armed and Ready

There is a growing trend in the tactical Team Integration community to utilize qualified medical Once you have selected a suitable candidate, personnel as an integral component of the your efforts turn to the task of fully integrating tactical unit. This trend is receiving various the tactical medic into your team. This means levels of acceptance by tactical teams, training. And the immediate question is just commanders, and agencies. Some hold an how do you train tactical medical personnel? elitist view of tactical operations. They view medics as outsiders and believe that there is Tactical principles can be absorbed through no justification for medical personnel of any the process of observation and mentoring by stripe to enter this exclusive domain. However, experienced team members. Once the key most understand the efficacy of a qualified concepts have been learned, the medic can tactical medic in your then progress to back pocket anytime a engaging in tactical team enters the hot training scenarios. zone. Firearm training is Tactical teams readily another matter and may accept the inherent risks require a different of tactical operations. A approach. The medic team with its own must possess tactical medic not only rudimentary firearms acknowledges this risk skill and safety habits but proactively manages before more it as well. To secure this comprehensive training important asset, teams can take place. Most often have to look new tactical medics will beyond the horizon. Most probably have little or no agencies will not have Tactical medics training for pediatric practical firearms injuries in the tactical environment someone in-house with experience. Keep in an adequate medical background. mind that most LE firearms instructors are oriented to maintain standard firearm skills, not Fire department medics are usually the first develop them. Academy firearms instructors place to look. Depending on your relationship may be more adept at developing skill among with your fire agency as well as the inexperienced shooters but the “boot camp” progressiveness of your governing authority, nature of academy training may not be the best this may be an excellent source. way to train tactical medics.

Consider the local EMS (emergency medical Set The Training Pace services). Emergency department doctors and Tactical medics are typically not from the LE nurses, or ambulance service paramedics and community, so trainers must take care not to EMT’s (emergency medical technicians) may throw them into “the deep end of the pool.” be the right people to augment the tactical Training tactical medics must proceed team. Do not make the mistake of focusing on incrementally and be appropriately paced. men only. It is not unusual to find women Many trainers subscribe to the “crawl-walk-run” serving on tactical units. model of skill development. CRAWL: Initially,

your medic must master the basics of The type of firearms used to train tactical marksmanship and safety. WALK: The next medics raises another set of issues. If the team level of training will introduce elements such as subscribes to the concept of handgun multiple targets, malfunctions and reload drills, uniformity, then your medic will carry the same multiple shooting positions, low light handgun as the rest of the team. The medic techniques, etc. RUN: Skills such as shooting will be obliged to master whatever pistol they and movement techniques will bring your are required to carry. If the medic has a medic to a skill level where they can be handgun choice within a range of options, then incorporated into the team. a more subjective equipment decision can be made. Handgun models with one trigger mode An important part of the firearms training may offer the best type for training and the program is a solid indoctrination in the legal eventual deployment of the tactical medic. and moral aspects involved in the use of deadly force. There are some obvious and not Individualize to Suit Team Needs so obvious reasons for this. The most obvious, The extent to which the medic will use other of course, is that the medic may be required to special weapons is a matter for each team to protect their own life from a deadly threat. decide. Tactical medics should at least be Coupled with this is the moral obligation to familiar with the all of the standard team protect another team member from the same. weaponry in case an injured member’s firearm has to be rendered safe. There is also the A less obvious reason is that the medic will extreme case where the medic may have to most likely be present when the team utilizes utilize a special weapon in an emergency. deadly force as a necessary method of resolution to a tactical incident. The medic will Team commanders and their agencies have probably render medical aid to a suspect choices regarding the deployment of tactical injured by the direct action of the tactical team. medical support. Traditionally, emergency medical support has been staged a set A medic with an ambiguous understanding of distance (and minutes) away, staffed by deadly force issues because of outside competent medical personnel without any influences (such as the entertainment media) knowledge of tactical operations. But consider may not be morally prepared to support the an armed and equipped tactical medic team’s actions. standing at your side, ready to make heroic medical efforts to save the life of their fellow team members. Which would you choose?

Section 5 - Slow and Deliberate Team Movement

Duration 4 hours Scope Statement This section provides students with hands on training in the principles and concepts of slow and deliberate team movement. Terminal Learning Objectives (TLO) At the end of this section, the students will be able to understand the importance concepts of tactical team slow and deliberate movement and stealth entry techniques. Enabling Learning Objectives (ELO) At the end of this section the students will be able to describe:

1. Definition of covert movement 2. Techniques of searching 3. Teamwork concepts 4. Methods for searching hallways 5. Methods for searching stairways 6. Methods for searching open areas 7. Methods for searching multiple rooms 8. Methods for searching warehouses 9. Techniques for the use of ballistic shields 10. Techniques for using video equipment

Covert Team Movement

A. Definition

1. The art of stealth, combined with slow, coordinated and quiet team movement utilized in searching for and /or neutralizing a suspect safely.

B. Movement

1. Used when you do not want your presence or exact location known

a. Entry b. Movement to contact c. Room by room clearing

2. Cat-like movement

C. Searching

1. Detailed and systematic

2. Speed is not important

3. Indoor movement problems

a. Don’t move down the middle of anything (hallways, doorways, and stairways) b. Don’t lean against walls

D. Teamwork

1. Read off each other

2. Anticipate partners’ needs

3. Light discipline

4. Equipment used a. Mirrors b. Shields Extension poles c. K-9

5. Silence personal and team equipment

6. Watch for team member fatigue

COVERT MOVEMENT CONCEPTS

A. Invisible Deployment

1. Light and noise discipline 2. Keep element of surprise as long as possible 3. Don’t automatically change suspect environment a. Don’t turn lights on or off b. Don’t automatically cut power or telephone lines

B. Surprise

1. Deploy or move in unexpected ways 2. Use of diversions

C. Patience

1. Time is on your side 2. Use all available equipment 3. Use timeout technique (all team members stop, listen for several minutes)

D. Cover

1. Move from one cover position to another 2. Don’t move without a person in position to cover you 3. Cover vs. concealment

E. Distance

1. Distance equals safety (the closer you are the less reaction time you have) 2. Angles provide depth

F. Threat rehearsal

1. At every opportunity try to imagine what could possibly happen as the problem progresses and what you could do to react to the problem? 2. Rally points 3. Downed officer rescue

USE OF SHIELDS

Shields offer another level of protection during high-risk operations. Many different opinions exist on how, when, and why they should or should not be employed. Some teams work exclusively with shields on every entry, while others do not use them at all. Certainly, when considering their use, the shield should be relegated to a role of support and benefit to the team without becoming a hindrance.

Often times, a team that does not train extensively with a shield, will opt to discard it as they feel it interferes with team members flowing. Other teams who integrate shields with their training operate more comfortably with them. Whichever opinion one might have, a good general rule is use the shield when it is beneficial to your objectives, and do not become too attached to it during times where it will not support the teams’ objectives.

A. SHIELD TYPES There are many different types of shields and many different manufacturers. Ensure that it is has a ballistic rating for the level of protection desired for each specific entry.

1. ROLLING BUNKER (PERIMETER CONTAINMENT)

These are large bunkers, which have wheels to move the shield around. Deployed often by the by NYPD ESD for officer/subject recovery during active shooter scenarios.

3. 2 MAN (FITS 2 PERSONS)

This is a large man carried type of shield that will easily protect two Officers along side one another.

3. 1 MAN FULL SIZE

This is the most common type of shield. It is carried by one officer and protects a large part of the body. Another officer can be deployed offset and behind the shield man as a cover officer.

4. 1 MAN SMALL OR 2 FULL SIZE

A smaller version of the one-man shield is about half the size that is easier wielded by the operator especially during dynamic movement. Other shields can become too heavy during prolonged operations. They, as well as two full sized 1-man shields, can be used in tandem with another shield, abreast of one another to provide a wide protection area for subject recovery situations.

5. GRIPS - HOW TO HOLD

With the man carried shields, each manufacturer has different designs for holding the shield. Generally the shield is carried with the non-firing hand by grasping underneath the horizontal

bar and resting the elbow on the inside surface of the shield. The shield is raised so that the head of the carrier is below the top edge of the shield and the carrier is looking through the window. The officer should pull the shield into him and be as close to the inside wall of the shield as possible. This helps in protecting as many body parts as possible. The shield man can crouch as low as desired and practical, given the objectives of the operation, to protect the lower portions of the body.

B. USES

As stated earlier, there are many general uses for the shield.

1. APPROACH

The shield is a useful tool to protect the lead element while approaching the entry point. Often times the environment may not provide or allow the use of cover and concealment approach routes. In that event, shields may be wise for additional protection. They are also useful when a team is required to deliver items which were demanded by barricaded subjects and subsequently approved by negotiators and incident commanders. Larger 1 and 2 man shields could work well here.

2. INITIAL ENTRY

1 man full size and/or 1 man small shields can be appropriate during the initial entry phase of a clearing operation. Entry is a critical point in an operation where contact with the subject can occur. Initial entry point doors and windows are locations where team members group until they can enter and begin flowing. Added protection to help with clearing through the entry point and facilitate the flowing can justify a shield. A word of caution; once entry is made, many teams continue grouping behind the shield as they are clearing. If this is done during a dynamic mode; speed, surprise, and shock action can be inhibited.

3. STAIRS - 1& 2 MAN/ 1& 2 SHIELDS

Because of the vertical threat areas present when working in stairwells, shields can provide additional protection either by using one or two shields.

4. WINDOW ENTRY/ GUN PORT

Protecting the breaching team while they are breaking and raking the window is paramount. To cover them effectively, the cover element must be exposed themselves. A shield offers some additional protection for the cover element.

5. USES AFTER ENTRY WHILE CLEARING

A. Search or Slow & Deliberate

Shields can be employed well during S&D type clearing to "Lock Down" uncleared areas while other threat areas are being dealt with. They can also be used by the lead elements as they enter Interior rooms.

B. Dynamic

The large shields can become a hindrance to the team during dynamic operations simply because at the speed at which team members are moving, the large shields slow the officers down. However, the small 1 man shields can be carried down and away while an officer is moving, then rotated in front at critical points.

C. Room entry technique. - cut pie, limited penetration

Using the shield to lead into every room does not lend itself to dynamic clearing. Only in very controlled S&D type operations should this be considered. But, during other S&D operations the shield can be useful to clear corners while cutting the pie or limited penetrations, for example.

D. Blast Shield

The ballistic shield and/or a clear riot shield can be used by teams to stage closer to an explosive charge than they could without the protection of a shield. Normally, the shield would be discarded after the charge detonated.

E. Perimeter - containment

Shields can be deployed at points of containment, which afford good cover. The larger, rolling shields are best suited here.

F. Forced cell extraction

Shields are employed often by corrections teams during forced cell extractions to provide a pinning barrier and protection against shanks or thrown objects to include body fluids.

G. Active countermeasures

The shield man can use the shield to physically control a subject who does not meet the elements of deadly force application but is still non-compliant. This would be done be directing the subject to a wall and pinning the subject.

H. Attics

The nature of attics, specifically entering an attic can expose the first officer to a lot of

threat areas. A small 1-man shield may provide some 6 o'clock protection for the first entry officer.

C. SHIELD MAN SHOOTING

Shooting while carrying or working with the shield requires regular ongoing training. Issues such as making sure the muzzle of the shield man’s hand gun is forward of the shield, the location and muzzle awareness of the cover man and his firearm, reloading, stoppages, and shield team communication must all be addressed.

1. USE SHIELD AS COVER

The shield should be considered similarly as one would consider cover. Keep the shield between the officer and the threat/area. The requirement is to keep as much body behind the shield as possible, given the situation. The nature of holding the shield in close, causes different problems when firing from behind it.

2. WITH HAND GUN

Using hand guns within the shield team offers great mobility to both the shield man and the cover man. The shield man is pretty restricted to using the pistol because of the support hand manipulating the shield. He should use the strong side of the shield and apply one of the below mentioned firing techniques. He must practice one hand reloads and stoppages by using his holster or a holster/secondary firearm attached to the inside of the shield.

The cover man can use a hand gun or a shoulder fired firearm such as a submachine gun. He should, under most circumstances and considering the environment, fire from around the opposite side that the shield man is handling his hand gun. The cover man must keep the muzzle of his firearm forward, past the edge of the shield. If not, he may fire rounds into the back of the shield.

The cover man must be cognizant of the movement of the shield man and must beware not to cross his muzzle with the shield mans’ head and body. He must take measures to prevent the shield man from standing up in front of his muzzle when firing by maintaining physical contact with the shield man.

Slow and Deliberate Team Concepts and Movement

Overview

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Section 6 - Introduction to the Tactical Pistol

Duration 4 hours Scope Statement This section provides students with hands on training in the use of the tactical pistol. Terminal Learning Objectives (TLO) At the end of this section the students will understand the principles and concepts in the use of the tactical pistol. Enabling Learning Objectives (ELO) At the end of this section the students will be able to describe:

1. Pistol nomenclature 2. Ammunition selection 3. Sight picture 4. Proper stance 5. Proper grip 6. Sight picture 7. Loading and unloading 8. Clearing malfunctions 9. Trigger control 10. Cover vs. Concealment Resources See Appendix A Instructor to Participant Ratio 8:32 Students Reference List See Appendix B Practical Exercise Statement Hands on training Assessment Strategy Pre and post testing, end of course critiques, subjective evaluations, and instructor comments.

Tactical Pistol Training Safety Rules

A. FIREARMS SAFETY / MAIN SAFETY RULES 1. Treat Every Firearm as if it Were Loaded 2. Never Point a Firearm at Anything or Anybody that You Do Not Intend to Shoot, or in a Direction Where an Unintentional Discharge May Do Harm. 3. Never Place Your Finger into the Trigger Guard until Ready to Fire 4. Be Sure of Your Target, Backstop, and Beyond

B. RENDERING THE WEAPON SAFE 5. Always Point Weapon in a Safe Direction - MUZZLE AWARENESS – with your trigger finger indexed on the side of the firearm. 6. SAFETY ON (S/white) If Applicable 7. Magazine Removed 8. Bolt, Slide, or Cocking Lever Locked to the Rear 9. Visually and Physically Inspect the Chamber

C. GENERAL TRAINING SAFETY RULES 1. Wrap Around Eye Protection is MANDATORY 2. Ear Protection is MANDATORY 3. Hats (Baseball Style) is MANDATORY 4. Long Sleeve Shirt is recommended 5. We are responsible for each other’s safety - anyone seeing a safety problem must report it immediately to an instructor. Additionally, anyone may stop an exercise if they see a safety problem 6. Report any and all injuries immediately to an instructor – Don’t suffer in silence. 7. It is each participant’s responsibility to cover all open wounds and cuts before class begins. If this type of injury occurs during the training session, the participant will immediately notify an instructor. We will attend to the injury by covering it with first aid materials available. Treat all blood and body fluids with the utmost caution. Gloves will be used if there is any possibility of coming into contact with blood or body fluids. 8. At no time is any participant allowed to leave the training area without notifying an Instructor. 9. Remember to work at your own pace - Don’t over exert yourself. 10. Realistic training is important, however safety comes first! 11. Do not enter any unauthorized areas.

D. SIMULATIONS / SIMUNITIONS

1. No live ammunition will be loaded or carried by anyone during Simulation Training Exercises (Triple Checked by Participants, partners & Instructors). Anyone attempting entry or re-entry to the training area will be triple-checked for live ammunition. 2. When using blank or marking cartridges, or distraction devices, you may only use those that are issued and you must double-check them to insure they are intact. 3. All persons in the training area must wear protective gear (face shields, padding, etc) during Simulation/Simunition training until directed otherwise by the instructor.

4. When using Simunition rounds, NO intentional groin or headshots will be allowed and shots within two feet of a role-player are not allowed. 5. Students will immediately cease activities when a sharp sustained blast of a whistle, and/or an instructor yelling, “stop” is announced. 6. Students will immediately cease actions upon a role-player announcing, “STOP” or “Out of Role”! 7. Mouth guards will be used as needed for Simulation Training.

E. SHOOTING HOUSE SAFETY RULES 1. Authorized firearms instructors must be present during use. 2. BODY ARMOR along with eye and ear protection must be worn. Everyone must wear a hat, gas mask or face shield during the training exercise. 3. Prior to live fire exercises, rooms must be checked to insure that no personnel are present. 4. Targets are placed so that all rounds will hit the impact area. 5. Only use authorized targets. 6. Authorized ammunition will only be used (check the approved list) 7. Instructors will review all targets and angles of deflection before beginning live fire. 8. All damage will be reported without retribution. 9. Shoot house will be cleaned before the end of the training exercises. 10. Cover any additional host agency safety rules.

F. NO PERSONS WILL PARTICAPATE IN TRAINING WITH A BLOOD ALCOHOL CONTENT IN EXCESS OF .00% BY WEIGHT OR UNDER THE INFLUENCE OF DRUGS OR MEDICATION THAT WOULD IMPAIR THEIR MOTOR SKILLS, JUDGEMENT OR BALANCE.

Principles of Shooting

A. Assess threats and discriminate targets

Before you can shoot your target you need to be able to assess the threat. We know through experience that not all threats are targets we can shoot. We must first observe the threat does not have the capability or weapon, ability or distance, and opportunity. We must then discriminate between the targets with two schools of thought, prioritization and spread fire. Prioritization would be deciding which target is the greatest threat and so on. Spread fire would be that all threats are the same and starting at one side and moving to the next target instead of starting in the middle and go one direction and then have to move back across to hit the other targets.

B. Shooting on the move

In tactical operations we know that there is a need to shoot accurately from stationary positions and also shooting on the move. We need to be able to shoot and hit what we are aiming at. There are a variety of incidents that dictate shooting on the move including warrant service, hostage rescue, and pursuit of subjects.

C. Shooting fast

Fast is fine, but accuracy is final. You must learn to be fast in a hurry. Hitting your target is a priority. You should work to increase your speed. Remember to work to perfect the technique and that perfect practice makes perfect technique.

D. Shooting accurate

You must be able to hit your target 100% of the time from both stationary and moving positions.

Fundamentals of Shooting

PRIMARY OBJECTIVES

When considering fundamentals these eight major objectives should be achieved to their fullest extent. The primary objectives, if achieved to a given degree, will increase the shooters ability to hit quickly and accurately with the goal of doing so under the stressful conditions of a firing engagement.

1. CONTROL MOTION

Barring luck, movement in the firearm as the round is fired will adversely affect the strike of the round. Whether the shooter anticipates the shot and allows a pre-ignition push, or simply does not stabilize the gun fully upon presentation, motion will affect the strike of the round. Recoil is motion as well. What must be understood is that motion in the gun must be controlled as much as possible, just long enough to pull the trigger, in order for the round to impact the intended point.

2. CONSISTENCY

When training, shooters must realize the requirement of developing psychomotor skills with the fundamentals, gained through repetitive, correct practice. This allows the shooter to perform them each and every time he/she fires regardless of the conditions one is operating under.

3. STANCE

Keep your feet comfortable a distance apart, knees slightly bent. Hips and shoulders square to the threat. Shoulders rolled forward slightly and a slight forward curvature of the upper body for balance and to dissipate recoil. The head should remain steady. This stance achieves to the fullest degree reduction of motion and in a variety of situations allows the shooter to stay consistent in the platform.

4. GRIP

The webbing between the thumb and forefinger of the firing hand is placed high under the tang of the firearm. Fingers of the shooting hand are wrapped around the grip and the thumb is as high as possible without being placed on the slide. The palm of the support hand is placed touching the exposed portion of the grip on the support side of the gun. The four fingers are wrapped around the fingers of the firing hand firmly under the trigger guard. The thumb of the support hand is stacked underneath the thumb of the firing hand.

5. SIGHTING

The sights must stay aligned throughout the trigger pull and afterwards. The shooter must look through the rear sight, like looking through a window, and focus the eyes fully on the front sight to maintain alignment. While maintaining proper sight alignment, the shooter then places the top edge of the front sight post on the intended point of impact.

6. TRIGGER CONTROL

Trigger control is the firm, constant, even pressure placed on the trigger along the axis of the trigger action. Firm, even, constant pressure is key. It is essential that the proper sight alignment and proper trigger control are performed together.

7. FOLLOW THROUGH

Follow through is simply bringing the gun back on target immediately after recoil. Following through not only aids in reducing the motion of the gun when firing but it also prepares an officer to continuously apply force if needed.

8. SCAN & BREATHE

Once the shooter completes “follow through” and he decides that another shot isn’t necessary, the shooter should then scan and breathe. This is nothing more than lowering the muzzle of the firearm to a cover or ready position, looking left and right across the threat area to look for additional suspects, and breathing to get oxygen flowing back through his system.

Handgun Nomenclature

1. Hammer

2. Control lever / Safety / Decocker

3. Reference line

4. Rear sight

5. Ejection port

6. Caliber designation

7. Front sight

8. Serial number

9. Slide release

10. Trigger

11. Trigger guard

12. Ambidextrous magazine

13. Finger recesses

14. Frame extension

15. Lanyard loop

16. Slide

17. Frame

18. Universal Mounting

19. Grooves

20. Finish

Drawing the Pistol

1. GRIP

Get a firm grip on the firearm while it is the holster. Keep the trigger finger indexed along the frame of the gun and activate the security device.

2. DRAW

Bring the gun up high out of the holster while keeping the elbow in towards the body. As the muzzle clears the front portion of the holster, start rotating the muzzle by dropping the elbow so the gun begins to point towards the threat.

3. READY

The support hand should be coming over to meet the gun as the gun continues straight towards the threat. When the support hand meets the gun, achieve a good two-handed grip on the firearm.

4. SIGHTING

As the arms are extending you can begin to find the front sight with your eyes. As the limit of the arm extension is occurring, the shooter can complete proper sight alignment.

5. FIRE IF NECESSARY

Maintain proper trigger control.

* Remember, the five-point draw process may not always be performed in its entirety. The draw can stop at any point in the process as determined by the shooter to meet a given situation.

Ready Position

Generic Ready Position 1. The point in the draw processes at which both hands grip the firearm. 2. Muzzle is kept towards the threat area. (take into consideration the required manipulation of the gun to maintain laser rule) 3. Elbows bent and pulled in

Threat Ready 1. Always dependent on Threat /Area 2. Always ready to fire immediately 3. Takes into consideration weapon retention

Load / Unload

Load 1. Point pistol in a safe direction. 2. Lock the slide to the rear. 3. Insert a loaded Magazine. 4. Release the slide. a. Activate the slide release. b. Grab the slide over the top and pull slightly to the rear while pushing the grip forward and release the slide. c. Tilt the firearm towards the support side and pinch the slide with the index finger and thumb. Pull the slide towards the rear while pushing the grip forward and release the slide. Unload 5. Point pistol in safe direction 6. Apply safety (if applicable) 7. Remove magazine 8. Lock slide to the rear 9. Visually and physically inspect the chamber

Reloads

A. Speed 1. Pistol is loaded 2. Keep eyes on the threat and/or threat area as much as possible 3. Tilt magazine well towards support side and tuck arm in 4. Find fresh magazine and remove (indexing finger) 5. Depress the magazine release (finger or thumb) fresh magazine is inserted while the used magazine falls.

B. Emergency 1. Slide has locked to the rear 2. Keep eyes on the threat and/or threat area as much as possible 3. Tilt magazine well towards support side and tuck arm in 4. Find fresh magazine and remove (indexing finger) 5. Depress the magazine release; (finger or thumb) fresh magazine is inserted while used magazine falls. 6. Release slide

C. Tactical

1. Pistol is loaded. 2. Keep eyes on the threat and/or threat area as much as possible. 3. Tilt magazine well towards support side and tuck arm in. 4. Find fresh magazine and remove (indexing finger) 5. Depress magazine release (finger or thumb) catching used magazine, fresh magazine is inserted, then place used magazine in pocket (do not place used magazine in pouches) 6. Return to ready

D. One-handed 1. Securing the firearm 2. Activating Slide

Ammo: 30 ROUNDS Target: Paper

1. 3 yard line 2. 7 yard line

Double Taps Hammer A hammer double tap is two rounds fired rapidly with very little set time between shots. The double tap method is generally used when the target is large and/or close and speed is necessary. Controlled Pairs These are fired when the target is more difficult because of size or distance. More accuracy may be required, so set time increases between shots to allow the shooter to stop the firearm and be more precise with sight alignment A. Presenting the Firearm

1. Mounting From the ready position the shooter should simply move the firearm straight to the target. One movement is all that is necessary. The index points must be established prior to firing.

2. Sighting As the pistol is moved to the target the shooters eyes can start finding the front sight.

3. Presentation Time vs. Set Time Presenting the firearm is the process of moving the firearm from the ready position to the firing position. This should be done as fast as possible without causing excess motion and never changes due to target size or distance. What does change based on size and distance is SET time. This is the time required by the shooter to stop the gun out of motion after presentation and in-between successive shots and to insure the alignment of the sights. This varies with the degree of precision and speed required in the firing of the shots. Obviously, a target which is smaller and/or further away will require the application of more SET time. Hammers or Controlled Pairs are differentiated simply by set time.

B. From the Ready

1. 3 yard line 2. 5 yard line 3. 7 yard line 4. 15 yard line

Check and mark targets

5. 25 yard line

Stoppages

1. Failure to fire 2. Stove pipe/failure to extract or eject 3. Double feed

Clearing Stoppages

A. “Tap, Rack, Ready” Method 1. Tap aggressively upward on the bottom of the magazine 2. Rack the slide (Sling shot or over the top) as you turn the slide of the pistol to the side. 3. Ready to fire if necessary.

B. “Magazine Out” Method 1. SEEK COVER, if applicable. 2. Attempt to lock the slide to the rear. 3. Rip magazine out. 4. Rack slide back and forth and lock. 5. Insert fresh magazine. 6. Ready to fire if necessary.

Remember that if the slide will not open then the shooter should attempt to remove the magazine, and then attempt to lock the slide.

C. Transition

Once the stoppage is confirmed the shooter controls the pistol with the support hand and lowers the pistol so that the back of the support hand comes in contact with the support side thigh. As the pistol is lowered to the thigh, the shooter's firing hand releases the pistol grip of the pistol and the back-up firearm is drawn from the holster.

1. Insert a fresh mag on, then bolt forward. Insert a fresh magazine on, and then bolt forward. Inserting a fresh magazine is a good idea as the mag may be the original cause of the malfunction and a number of rounds may have been fired out of the previous magazine so a fresh fully loaded magazine will top the gun off.

2. Do not point firearm up or down, maintain the shooting grip and weapon in shoulder.

Section 7 - Medical Aspects of Distraction Devices

Duration 1 Hour Scope Statement This section provides students with hands on training in the medical aspects and use of distraction devices. Terminal Learning Objectives (TLO) At the end of this section the students will be able to understand the medical aspects and use in the deployment of distraction devices in the tactical environment. Enabling Learning Objectives (ELO) At the end of this section the students will be able to describe:

1. Purpose and definition of distraction devices 2. Correct and incorrect terminology 3. Psychological effects 4. Physiological effects 5. Medical significance 6. Safety concerns 7. Panic and fear responses 8. Team effects and possible injuries 9. Deployment options 10. Immediate action drills Resources See Appendix A Instructor to Participant Ratio 1:32 Reference List See Appendix B Assessment Strategy Pre and post testing, end of course critiques, subjective evaluations, and instructor comments.

Use of Distraction Devices

A. Introduction & history- Distraction Devices were originally designed as a substitute for fragmentation grenades or grenade simulators. They have been referred to as stun grenades or stun bombs, which is the wrong terminology. The distraction devices have been used for many years in tactical operations since the early 1970’s. The Israeli forces, the German GSG9, British SAS and other counter-terrorist organizations were successful using the devices in hostage rescue operations.

B. Types & nomenclature of distraction devices- Refer to the distraction device display box or overheads.

C. Types of diversions - There are two types of diversions including psychological or deceptive as in an illusion or ruse and physiological that works directly on the human senses that creates panic and fear.

D. Hazards and enhancers - Some of the hazards include heat or fire, small children and the elderly, over pressures or loss of hearing, smoke or loss of vision, flying objects, and failure to detonate. Some enhancers include darkness, smaller rooms, and suspect fatigue.

E. Criteria and justifications for use - Generally, whenever a low-level lethality diversion is necessary to enable an entry to be made or an arrest effected. Also distracting a subject to allow apprehension or detention when the suspect is unarmed but violent.

F. Method of deployment- The most common way to deliver a device is hand thrown. There are many other ways, including by 12 gauge shotgun diversion rounds, flash- sticks, or poles.

G. Legal aspects- As Law Enforcement Officers, you must be aware that your actions are subject to the utmost scrutiny regarding every aspect from planning to deployment, to effects. The law makes a presumption that every person is responsible for the logical consequences of his actions.

Rendering Safe In the event that a Distraction Device fails to function, the following steps should be follows if a Bomb Squad or an E.O.D. unit is not available.

1. Allow the device to set for at least 30 minutes before recovering device

2. Approach the device wearing the proper protective clothing (gloves, goggles, hearing protection or helmet with face shield).

3. Using a long handle shovel, pick up the device and remove it to a safe location and place the device in a pail of water for 24 hours, or until the inner cardboard body has unraveled, ant the filler has been diluted in the water.

4. The device can then be removed from the water. The fuse assembly and brass adapter can be removed using the same steps as in reloading the device.

5. Make sure the device is dry, and any cardboard removed from the inside of the device before attempting to reload the device with a new assembly.

DO NOT attempt to puncture the cardboard tube containing the charge with a sharp pointed object, as detonation could take place, resulting in serious injury or death.

Medical Aspects of Distraction Devices

Overview

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Section 8 – Dynamic Building Clearing Techniques

Duration 4 hours Scope Statement This section provides students with hands on training in dynamic building clearing techniques. Terminal Learning Objectives (TLO) At the end of this section the students will be familiar with the fundamentals and equipment used in dynamic building clearing. Enabling Learning Objectives (ELO) At the end of this section the students will be able to describe:

1. Immediate threat concept 2. Speed, Surprise and Shock action 3. Room entry and movement 4. Dealing with multiple threats 5. Clearing open areas 6. Movement in hallways 7. Movement in stairways 8. Tactical use of ladders 9. Clearing multiple rooms 10. Apprehension of unknowns and suspects Resources See Appendix A Instructor to Participant Ratio 4:32 Students Reference List See Appendix B Practical Exercise Statement Hands on training Assessment Strategy

Types of Building Clearing

There are basically two types or rates of clearing a structure; Slow and Deliberate or Covert, and Dynamic clearing. Each method has benefits and downfalls. Each is more applicable than the other in certain situations. The individual operator and the team must be able to effectively maneuver within each type of clearing. Clearing a structure or the methods of clearing is constant regardless of the mission, whether it is a drug raid; warrant service, barricaded gunman, or a hostage situation.

Covert Entry

The goal with Covert Movement is to prevent the team’s exact location from being known to the subject(s) until such a time that the team dictates. Usually if the team is operating in a slow and deliberate fashion, it means that within the situation there is no urgency to control the subject(s) immediately. Time is not critical. The team and the individual team members’ actions will be deliberate, in that, there is time to take things slowly, completely, do one thing at a time.

Because of these characteristics, S&D type clearing often allows for 100% searching of the structure or the area the team is currently operating in. To limit the subjects’ awareness of the team’s presence, the team and individual team members should operate by considering stealth in all things performed.

Noise and light discipline is a must when operating covertly. Because of the lack of urgency, speed is generally not a characteristic. Moving too fast provides opportunity to make noise, miss a threat area or threat indicator, and individuals not mutually supporting one another’s actions can occur. These violate covert clearing principles. Many times the situation presents a lack of intelligence. This fact combined with no urgency should indicate to the team that S&D would be an appropriate method of clearing.

Common situational examples where covert clearing can be appropriate are; barricaded subjects, searches, the need to deny movement or location access to subjects, or the need to move the team closer to the actual crisis point. For example, a hostage is held in room #4 but the team must enter and move/clear past rooms #1,2,3 to get to room #4, they may want to move with stealth and not let their presence known until entry is made into room #4.

Slow & deliberate type clearing should also be considered during situations of extreme danger combined with lack of intelligence. Considerations such as the possibility of booby traps, bombs and explosives, chemical and combustible items, or active shooter scenarios where the subjects’ location are not known or rapidly changing may also be reason to clear slow & deliberately.

Dynamic Clearing

A. Dynamic clearing principle - There are three elements including, surprise, shock action, and speed.

B. Immediate threat concept - Continue movement directly at the threat while attempting to gain all forms of control, visual, verbal, and physical.

C. Hierarchy of threats - Bodies, doors, and hides.

D. Room entry and movement - Don’t stop in doorways, clear doorways quickly, and be decisive in your movement while never entering a room by yourself.

E. Multiple room entries - Number and size of rooms will dictate the amount of personnel needed for the entry. Verbalizations are critical and remember to continually look, evaluate, and react to what you see.

F. Apprehension of suspects and hostages - Segregation vs. consolidation.

G. Control - Not a 50-50 proposition, you either have it or you don’t. Safety is a bi-product of control so once you get it, do not relinquish it.

Dynamic Clearing Situations

A. Use of ladders - There are many uses for ladders during a dynamic entry beginning with movement over fences or walls while moving to the entry and then using them for window entries or second floor entries. They are also useful for porting windows on buses to cover the entry teams and to use as litters to carry the injuries.

B. Open areas - Clearing open areas dynamically can be very dangerous. Utilizing more cover teams while clearing will increase the safety and use all the equipment available. (K-9, body bunkers, and diversions)

C. Multiple rooms - Depending on the number of rooms and there sizes will dictate how many entry teams will be needed. If possible rehearsals will increase the possibility for success. Remember verbalization is essential. Key off the person in front of you evaluate and then react.

D. Hallways and tight places - When moving down hallways remember long cover and don’t move past openings without clearing or verbalizing that the room has not been cleared. In tight places you may have to limit the number of personnel in that area.

E. Stairways - When clearing stairs dynamically remember to have cover personnel in position before moving. Try not to move up or down the middle of the stairs allowing cover personnel to protect your movement. If there are landings on the stairs the point team moving should stop and cover while the next team moves past or leap frogs past the forward cover team.

There is only one reason for a tactical team to operate in a Dynamic mode. The requirement to, based upon the Urgency of the situation, control the subjects immediately. Immediate control is necessary to limit the subjects’ opportunity. This urgency can be in the form of: hostages dying, the threat of imminent injury or death, the likelihood of violent resistive actions, the need to prevent escape, the need to prevent further barricading, or any action which may endanger the public or the officers involved to a greater extent. To a lesser degree, the possibility of evidence destruction or the likelihood of perpetrator response/reaction forces could establish urgency or the need to control immediately.

There are three aspects to dynamic clearing that are critical not only for crisis resolution, but for officer safety as well. They are Speed, Surprise, and Shock action. In an effort to gain control as quickly as possible as well as limit the subjects’ opportunity, Dynamic Clearing is performed at a greater rate of speed. We use Speed to move through a location, dominate it, and control subjects as quickly as possible. The element of Surprise, or to force the subjects’ reaction, is a critical aspect of dynamic clearing.

If the teams’ and the individual officers’ activities include the element of surprise from planning to action, the subject is forced to be reactive rather than proactive. Shock action is used to gain back initiative, keep the violators mentally off balance, and overwhelm their senses. To reiterate; the purpose of shock action is to limit and impede proactive thought and actions of the subject, effectively overloading the subject’s system.

Shock action can be gained and maintained through the use of distractions and diversions, as well as dynamics (aggressiveness) of the team and its individuals. One major consideration with dynamic clearing is that the team should not move so fast as to be out of control and acting individually. The individual team member’s separate actions should support the teams’ activities.

Keep in mind that Warrants and Hostage Rescues can be executed covertly as well, if the mission fits within the characteristics of slow & deliberate objectives. Be careful of combining certain general mission types e.g. warrants, hostage rescues, and barricaded subjects, with a type specific clearing method as any mission type can be conducted either covertly or dynamically. It is the specific elements in each individual situation that should dictate a mode of clearing to the team. This begins first at the need or Urgency to control subjects quickly within a given mission.

Any operation can begin with the team in a covert or dynamic mode, and then based upon the actions occurring inside the location, require the team to change their clearing mode to another. All operations, with the exception of a dynamic entry that has transformed into an emergency situation such as a fire, IED, or a prison riot rescue, will at some point (post assault procedures) become a slow & deliberate activity. Most entries do not eventually require a rapid de-entry once the location is dominated.

Immediate Threat Concept

The reason a dynamic entry is made is to control the subjects. There is no other reason. One cannot control a subject without first finding him, assessing him, and applying the appropriate level of force based on the subject’s actions. The immediate threat concept of room entry is a simple and effective technique that provides for maximum initiative of the team members to decide their actions based upon what is happening in front of them.

It is erroneous to decide from outside a room, where one will go once inside the room without knowing what is exactly transpiring inside. If an officer chooses to move left through the door, before the door is opened and without regard to what is in the room, then the officer is allowing his actions to be decided on best guess. The situation decides the actions of the officers. For example, as an officer is moving though the threshold, he observes a subject in the back right corner of the room. Immediate threat concept dictates that the officer move to the subject to control him. If he were to have made the decision to move left from outside the room, he would not have been able to control the subject as quickly as otherwise.

Room Entry and Movement

So, with the immediate threat concept, team members find a threat and move to control it. If the officer in front of me moves straight into the room, he obviously has something to control there, I should move either right or left to try and find another threat to control. These officers should be moving through the door as close together as possible to mutually support one another. Other officers making entry would also base their actions upon the unfolding situation and other officers’ actions.

Remember the level of force that must be applied does not dictate the movement method of the officer. If I must de-escalate to Active Countermeasures, I must move to the subject to strike him. If I must shoot the subject my movement would still be the same. I wouldn’t change my movement actions because now I must apply deadly force. The force decision (escalation or de-escalation) most often is decided after the officer has committed to his movement, so an officer would not change his movement direction because the force level is different.

Dynamic Clearing Multiple Rooms

Clearing multiple rooms is a very broad subject and there are many options in doing so. Suffice it to say; the situation again, dictates what should be done. If the situation dictates that other rooms must be cleared quickly because of some great urgency, than elements from the team may be designated for responsibility of those rooms. They would deploy immediately to those rooms while other team elements would be dealing with their separate duties. Operating in this manner raises the specter of field of fire issues and must be given great concern. Other ways to operate might include, covering other rooms while one room is being cleared. Once that is accomplished, the next room can be entered. This manner keeps the entire team in a single focus, which maximizes control. Communication between elements is paramount when clearing multiple rooms.

Apprehension of Unknowns and Suspects

There are three types of control; Visual control, verbal control, and physical control. All three must be gained and maintained throughout an encounter. Visual control must happen first, as it will establish the need for verbal control and the level of physical control. Verbal control requests compliance from the subject and provides information to the subject, officers, and others.

Directly, verbal compliance is a choice of the subject, so the only true control is physical control. Regardless of their role, all people inside a location must be controlled. The level of control is flexible. However, remember control is not a 50/50 proposition. They are either controlled or they are not. No middle ground. In most circumstances all subjects must be physically restrained, but in circumstances of immediacy, that may not be possible. In that event, an officer must be designated either by direction or initiative to assume Cover on the subjects.

In the matter of shooting or deadly force, the phrase “you shot him, you bought him, you own him, you stay with him until you give up physical control or authority for the subject to another officer”, is a guiding general rule. That would be true if lesser levels of force were applied. Communication is key to maintaining team control. Once the area of responsibilities are dominated and controlled, physical restraining can begin. Always use the contact/cover principle of handcuffing subjects.

Forced Entry Techniques There are basically 3 types of forced breaching: Mechanical, Explosive, Shotgun. Regardless of the type, good intelligence is required on the breach point to ensure that the team is afforded Positive and Rapid entry into the structure. There are four elements that encompass successful breaching.

1. Good intelligence on the structure and operation of the breach point. 2. Always plan for an alternate breach point as well as possible requirements for interior breaching. 3. Have the necessary tools required to affect the breach; initial, alternate, and interior. 4. Rehearse all aspects of the breach to include entry following the breach.

Mechanical

Mechanical breaching is the use of hand held tools to force the breach point open. A good idea is to talk to firefighters, as they can give great insight into the use of some of the tools. When breaching a door by mechanical means, it is important to know which direction the door opens, as that will determine the procedures employed.

Battering Ram

A battering ram can be handled by an individual or two or more people depending on the size of the ram. Often, the doorknob bolt is the point of attack and the strike should impact just below the doorknob. However, with doors that open out, breachers may find that does not work. In that case, the hinges are the points of attack and the strike should impact low center twisting the door off the hinges.

Another consideration with the ram is the amount of open area surrounding the entrance. For instance, an apartment complex with very narrow halls may restrict the back swing of the ram. In these cases, an individual officer using an overhand strike can be effective. In most cases, after the breach, the breachers should move to the side of the doorframes and allow other members of the entry team to enter first. Most often the breachers should not follow their breach. If two strikes do not open the door, the team should think about moving to an alternate breach point.

Haligan Tool

The Haligan tool is most effective on doors that open out. Haligan tools are equally effective on wood or metal doors because the action of the Haligan tool separates the door from the frame, freeing the doorknob bolt. The Haligan tool is used in conjunction with the sledgehammer or Ram. One officer places the flat, solid portion of the Haligan tool in the crack between the frame and the door. A second officer strikes the Haligan with a sledgehammer seating the Haligan firmly in the crack. The first officer then pulls the handle of the Haligan tool towards the wall of the structure and the door opens. The breachers do not normally follow their own breach, but allow other officers to enter first.

Sledge Hammer

A sledge hammer is most often used in conjunction with another tool such as the Haligan or a Window wand. However, on lighter doors the sledge can be used as a ram to affect a breach. Consider a sledge hammer as a useful part of an entry team’s equipment for use on interior doors that may require breaching.

Window Wand

The window wand is used to breach windows. When breaching wood frame windows, the breacher’s first strike should impact at one of the top corners of the window, breaking the glass. The strike should continue down, across any horizontal supports, and towards the opposite bottom corner. The officer should then "rake" the remaining glass and supports by forcing the wand against the inside edge of the window and circling it 360 degrees. Metal-framed windows create a problem for breachers. Consider two officers to breach windows with metal framing. One officer may deploy a sledgehammer to destroy horizontal supports and a second officer follows with the window wand to breach the glass.

Pry Bar

Pry bars are usually carried into a structure for possible interior breaching. It is not normally used for exterior breaches as they are often not of substantial weight. When used on interior doors it is deployed to simply pry the door away from the frame.

Mule Kick

The mule kick is the preferred method of "kicking” a door open. It is most often employed on interior or light doors. The Hollywood method of standing in front of the door and kicking it leaves the officer vulnerable to injury of the knee or ankle when the door opens. The officer designated to kick the door sets up with his back to the wall and on the side of the doorknob. A second officer provides cover from the opposite side of the door. The officer kicks the door in a backward fashion, directly under the doorknob. The cover officer is then the first to enter.

Bolt Cutter

For obvious reasons bolt cutters are very effective on chain link fences.

Power Saws

“Power saws” refers to tools such as chain saws or the Jaws of Life. These are not recommended when rapid entry is required. They can be used to gain access to reinforced or sealed areas.

Cutting Torches

For heavily reinforced targets, cutting torches should be considered. It is important to note the potential for flame ignition and their lack of breach speed. However, as with power saws, they can be used to gain access to sealed or reinforced areas. Armored cars with the subjects locked inside are a definite application.

Hooks

Hooks are used when security bars are installed over windows or doors. The hooks are attached to the bars and a vehicle of sufficient tow power. The force of the truck’s momentum rips the bars from the structure.

Explosives

A relatively small amount of explosive material can be used to reliably and predictably defeat target materials typically found in urban construction. In the past, typically dynamite was used with varying results, but modern explosive breaching is more of a science and less of an art.

Shotgun

Shotgun breaching is an effective method to breach doors. Shotgun rounds used can be of the 00 buck type, manufactured lock buster rounds, or Shok-lock rounds typically fired from a 12- gauge shotgun. Lock busters rounds can also be home made, however do not attempt a homemade lock buster round without proper training on the correct manufacturing.

When using the shotgun to breach the target can be the hinges, doorknob, or the doorknob bolt. Like explosives, considerable caution must be taken. Often there is some type of object that is projected through the door and carried into the structure. This is primarily true when using the 00 buck rounds. 00 buck contains pellets, and once the round is fired the pellets will either penetrate or ricochet. 00 Buck on the hinges requires the shooter to angle the shotgun up or down so the pellets impact either the floor or the ceiling.

The force of the blast rakes the screws away from the door or frame, allowing the door to be removed. Angle the shotgun down and towards the doorframe when breaching the doorknob bolt. Breaching the doorknob requires a straight horizontal impact, which pushes the doorknob clean through the door. Again, the doorknob and the pellets project inside the structure. Shok- lock or lock buster rounds are very effective and are designed to send fewer projectiles back or into the structure.

The same techniques used to deploy the 00 buck are used with the lock buster rounds. Lock busters simply reduce the projectile factor. Lock buster rounds such as the TKO, Tesar, or Hatten rounds, usually use some type of metal filling or ceramic powder which is compressed to form a solid slug. This slug is applied to the door mechanism. When the filling impacts the door, kinetic energy is transferred through the target, disrupting the mechanism and simultaneously destroying the projectile. Fillings that destroy on impact reduce the potential for secondary fragmentation being projected into the room or back at the breacher.

Some final notes about implementing shotgun breaching:

• Be aware that pieces of the door mechanism may become projectiles. • Copper lock buster rounds seem to be safer, as they tend to resist the potential of the slug compound fusing under extreme heat and temperature changes. If a fusion of the slug compound does occur then the projectile will remain a solid after impact, in effect becoming a rifled slug. • With any shotgun breaching, be prepared to fire more than one round, as the first may not be effective. • A plus to shotgun breaching is that the breacher has an effective firearm in his hands at all times. • Shotgun breaching is a back-up breaching tool, due to the relative high risk.

Section 9 – Tactical Casualty Care

Duration 1 hour Scope Statement This section provides students training in tactical casualty care. Terminal Learning Objectives (TLO) At the end of this section students will understand the techniques of wound recognition and field management. Enabling Learning Objectives (ELO) At the end of this section the students will be able to describe: 1. Basic management plan for tactical field care 2. Care under fire 3. Situational awareness 4. Airway management 5. Hemorrhage control 6. Fluid resuscitation 7. Prevention of hypothermia 8. Monitoring 9. Victim assessment 10. Documentation Resources See Appendix A Instructor to Participant Ratio 1:30 Students Reference List See Appendix B Assessment Strategy Pre and post testing, end of course critiques, subjective evaluations, and instructor comments.

Assessment and Treatment Guidelines

Tactical Casualty Care during law-enforcement special operations is performed in three phases.

The first is: Situational Awareness and Scene Safety; The second is: Assessment, Evaluation and Field Care. The third is: Extraction, Evacuation and Transport.

In the first phase, you are about to enter a tactical environment and a possible crime scene. Your safety is paramount and the possibility still exists that you or other officers at some point may come under hostile fire. The tactical medic must at all time be fully aware of the surroundings and any potential threats. The likelihood of having to draw your weapon and engage a suspect with deadly force is possible but extremely unlikely.

In the second phase, you and your victim/s are considered relatively safe, and you will be able to provide emergency medical care based on your scope of practice, level of training and equipment carried with you. Begin to formulate extraction decisions as you evaluate and treat the victim. Inform your tactical team leader of your clinical findings and when you plan to extract the victim.

In the third and final phase, the victim/s are extracted from the scene and evacuated to the location of the appropriate method of transportation for delivery to a medical treatment facility capable of treating the injury. Transporting the victim to the nearest hospital may or may not be in best interest of emergency care. Trauma is a surgical disease and is treated in the operating room not in the emergency department. Make every attempt to transport the patient with penetrating trauma to an appropriate hospital with trauma services. Try and achieve the platinum half hour.

1. SITUATIONAL AWARENESS and SCENE SAFETY • Determine if your surrounding are free of immediate life threatening concerns. • Do not attempt to provide first aid if your own life is in imminent danger. • If a spine Injury is suspected, do not move the victim unless to preserve life. In law enforcement tactical situations, penetrating trauma is by far the greatest fear. Penetrating trauma is the most likely threat to the victim's life by causing massive hemorrhage. • In a tactical situation, if you find a victim with no signs of life (no pulse, not breathing) Do not attempt to secure or restore the airway. Do not continue first aid measures. • Universal Precautions for body substance isolation and medic safety using personal protective equipment is essential.

A. Situational awareness before providing medical treatment.

B. Determine if the victim has signs of life.

C. Provide necessary emergency medical care.

1. Defend yourself and your patient if necessary.

2. Use appropriate hard cover or concealment if possible.

3. Consider self-aid to stop hemorrhage, if possible. If the victim is unable to move and you are unable to move the victim to hard cover and the victim remains under the threat of direct fire, tell the victim to try not to move and "play dead". This may confuse and misdirect the shooters field of fire.

4. If the victim is unresponsive, move the victim, weapon(s), and mission-essential equipment to hard cover, as the situation allows.

5. Prevent the victim from sustaining additional wounds or injuries.

6. Provide reassurance and encouragement.

7. Apply appropriate hemorrhage control techniques depending on the wound and injury pattern.

8. If the victim has severe hemorrhage from a limb or has suffered amputation of a limb, apply a tourniquet before moving the victim.

2. ASSESSMENT, EVALUATION and FIELD CARE

• Tactical field care is delivered by the medic when immediate threats are suppressed and the scene is relative safe. Tactical field care also applies to those tactical situations in which an injury or illness has occurred during the mission. Available medical equipment may be limited or mission restricted to that carried into the field by the Medic. • In the rare event of nerve agent poisoning or chemical attack, stop the evaluation, and take the necessary protective measures, and begin first aid. • In all situations communicate the medical situation to the team leader and ensure that the tactical situation allows for time to perform any medical procedure.

A. Check for responsiveness.

1. Inquire in a loud, but calm, voice: "Are you OK" Gently shake or tap the victim.

2. Determine the level of consciousness by using AVPU system:

A = Alert V = responds to Voice P = responds to Pain U = Unresponsive.

Check a victim's response to pain by rubbing the breastbone briskly with a knuckle.

3. If the victim is conscious, ask where his/her body feels different than usual, or where it hurts. If the victim is conscious but is choking and cannot talk, stop the evaluation and begin treatment.

4. If the victim is unconscious, continue with treatment.

B. Position the victim and open the airway. C. Assess for breathing and chest injuries.

1. Look, listen, and feel for respiration. If the victim is breathing, insert a nasopharyngeal airway and place the victim in the recovery position. Use suction, if available to maintain airway as needed.

2. Expose the chest and look for symmetrical chest movement and for any other wounds.

A. If the victim has a penetrating chest wound and is breathing or making an effort to breathe, stop the assessment and apply an occlusive dressing or commercial chest seal.

B. Monitor the victim for increasing respiratory distress. If necessary, perform a needle decompression on the same side as the injury.

C. Extricate and transport with the affected side down, if possible.

D. Identify and control bleeding.

1 Examine the victim for bleeding.

2. Remove only the minimum amount of clothing necessary to expose and treat injuries.

3. Check for blood-soaked clothes.

4. Look for entry and exit wounds.

5. If the victim is unable to be moved or rolled on their side for a visual inspection. Place your gloved hands behind the victim's neck and pass them upward toward the top of the head. Check for blood or brain tissue on your hands from wounds.

6. If the victim is unable to be move or rolled on their side for a visual inspection. Place your hands behind the victim's shoulders and pass them downward behind the back, the thighs, and the legs. Check for blood on your hands from wounds.

7. If hemorrhage is present, stop the evaluation and control the bleeding. Apply a tourniquet, trauma dressing, and /or a Hemostatic agent as indicated.

8. Dress all wounds, assess and treat for shock, as indicated.

9. Position the victim with feet elevated. Maintain core body temperature by covering victim with blanket if available.

10. Start intravenous access with IV normal saline or saline lock, If the tactical situation and time permits. Do not delay extraction or evacuation for procedures that will not improve outcome.

E. Examine for spinal injuries, fractures burns, or other injuries.

1. Check for open or closed fractures by looking for swelling, discoloration, deformity, or unusual body position. If a suspected fracture is present, stop the evaluation and apply a splint or immobilize spine.

2. Check for burns and treat as indicated

3. Administer pain medications and antibiotics if indicated.

3. EXTRACTION, EVACUATION and TRANSPORT

1. Use soft litter unless not indicated with suspect spinal injury

2. Confirm egress path is safe and secure.

3. Attempt to interface with civilian EMS with minimal public exposure

4. Contact hospital for pre-hospital report

5. Complete documentation for patient contact 6. Transport patient the most appropriate medical facility that can best care for the patient based on the injuries sustained.

TACTICAL CASUALTY CARE ASSESSMENT AND TREATMENT MODEL

BASIC MANAGEMENT PLAN FOR CARE UNDER FIRE/SITUATIONAL AWARENESS 1. Take hard cover. 2. Determined if patient is Alive or Dead. 3. Direct patient to move to cover and apply self-aid if able and try to keep the patient from sustaining additional wounds. 4. Airway management is generally best deferred until the Tactical Field Care phase. 5. STOP LIFE-THREATENING EXTERNAL HEMORRHAGE, using appropriate PPE, if tactically feasible: - Use Emergency Trauma Dressing - Use a tourniquet for hemorrhage that is anatomically amenable to tourniquet application - For hemorrhage that cannot be controlled with a tourniquet, apply hemostatic Agent 6. Communicate with the patient, if possible in order to encourage and reassure. 7. Extract patient from unsafe area, to include using a soft litter as needed. - Call for Tactical Evacuation (Ground or Air Ambulance)

BASIC MANAGEMENT PLAN FOR TACTICAL FIELD CARE 1. DETERMINE LEVEL OF RESPONSIVENESS - Use AVPU (Alert-Voice-Pain-Unresponsive) - Patients with an altered mental status should be disarmed immediately 2. AIRWAY MANAGEMENT a. Unconscious patient without airway obstruction: - Chin lift or jaw thrust maneuver - Nasopharyngeal airway - Place patient in Recovery position b. Patient with airway obstruction or impending airway obstruction: - Chin lift or jaw thrust maneuver - Nasopharyngeal Airway - Allow patient to assume position that best protects the airway, including sitting - Place unconscious patient in Recovery position - If previous measures unsuccessful: - King Tube or Combitube - Endotracheal Intubation or Blind Nasotracheal Intubation - Cricothyroidotomy, Needle or Surgical 3. BREATHING a. Consider tension pneumothorax and decompress with needle thoracostomy if patient has torso trauma and respiratory distress. b. Sucking chest wounds should be treated by applying a Chest Seal or three-sided occlusive dressing during expiration, then monitoring for development of a tension pneumothorax. 4. BLEEDING a. Assess for unrecognized hemorrhage and control all sources of bleeding. b. Assess for discontinuation of tourniquets once hemorrhage is definitively controlled by other means. Before releasing any tourniquet on a patient who has been resuscitated for hemorrhagic shock, ensure a positive response to resuscitation efforts (i.e., a peripheral pulse normal in character and normal mentation if there is no traumatic brain injury (TBI). 5. INTRAVENOUS (IV) ACCESS - Start an 18-gauge IV (or saline lock) if indicated - If resuscitation is required and IV access is not obtainable, use the intraosseous (IO) route 6. FLUID RESUSCITATION Assess for hemorrhagic shock; altered mental status in the absence of head injury and weak or absent peripheral pulses are the best field indicators of shock. a. If not in shock: - No IV fluids necessary - PO fluids permissible if conscious and can swallow b. If in shock: - Normal Saline, 500-mL IV bolus - Repeat once after 15 minutes if still in shock - Titrate to Systolic BP of 90-100 c. Elevate Lower Extremities d. If a patient with traumatic brain injury (TBI) is unconscious and has no peripheral pulse, resuscitate to restore the radial pulse 7. PREVENTION OF HYPOTHERMIA a. Minimize patient’s exposure to the elements. Keep protective gear on if feasible. b. Replace wet clothing with dry if possible. c. Apply Ready-Heat Blanket to torso. d. Wrap in Blizzard Rescue Blanket.

e. Put Thermo-Lite Hypothermia Prevention System Cap on the patient’s head, under the helmet. f. If mentioned gear is not available, use dry blankets, poncho liners, sleeping bags, or anything that will retain heat and keep the patient dry. 8. MONITORING Consider Pulse oximetry if available as an adjunct to clinical monitoring. 9. SECONDARY EXAM - Check for additional wounds or conditions - Inspect and dress known wounds 10. TREAT OTHER CONDITIONS AS NECESSARY - Spinal Immobilization - Use of Mark I Kit for Nerve Agent Exposure - Use of EpiPen for Anaphylactic Reaction - Treat for Burns 11. PENETRATING EYE TRAUMA If a penetrating eye injury is noted or suspected: 1) perform a rapid field test of visual acuity; 2) cover the eye with a rigid eye shield (NOT a pressure patch). 12. SPLINT FRACTURES AND RECHECK PULSE 13. PROVIDE ANALGESIA AS NECESSARY a. Able to fight: - Tylenol, 650-mg bilayer caplet, 2 caplets b. Unable to fight: - IV or IO access obtained: - Morphine sulfate, 5-10 mg IV/IO - Repeat dose every 10 minutes as necessary to control severe pain - Monitor for respiratory depression. Have Naloxone available. 14. CARDIOPULMONARY RESUSCITATION (CPR) AND AED Resuscitation in the tactical environment for victims of blast or penetrating trauma who have no pulse or respirations should only be treated when resources and conditions allow. 15. COMMUNICATE WITH THE PATIENT IF POSSIBLE - Encourage; Reassure and explain care. 16. DOCUMENTATION Document clinical assessments, treatments rendered, and changes in the patient’s status. Forward this information with the patient to the next level of care. 17. PREPARE PATIENT FOR TACTICAL EVACUATION - Move packaged patient to site where evacuation is anticipated - Monitor airway, breathing, bleeding, and reevaluate the patient for shock.

California EMS Authority

Clinical & Cognitive Performance Evaluation Performance Steps Go No-Go 1. Performed Situational Awareness and Scene Safety a. Established hard cover to prevent the victim from sustaining additional wounds or injury. b. Determine if the victim is alive or dead c. Encouraged responsive casualties to protect themselves and perform self-aid

d. Perform immediate hemorrhage control. Including Tourniquet application if indicated.

2. Performed Victim Assessment, Evaluation and Field Care a. Checked for responsiveness, using AVPU. Alert - Voice - Pain -Unresponsive b. Positioned the victim and established the airway. Inserted NPA, Endotracheal Tube or King Airway and ventilate as necessary. Cricothroidotomy as indicated c. Assessed for breathing and penetrating chest injuries. Applied Occlusive Dressing / Chest Seal for open chest wounds. Needle Decompressed the Chest as indicated for tension pneumothorax. d. Identified and controlled bleeding. Applied Emergency Trauma Dressing Hemostatic Agent, as indicated. e. Assess and Treat for Hypovolemic Shock Elevated lower extremities and prevent hypothermia. Initiated Intravenous access with an IV of Normal Saline f. Checked for spinal injuries, fractures, or other injuries using a rapid head to toe examination. Splint or immobilize as needed. g. Checked for burns. Initiated Burn treatment as needed. h. Performed additional therapeutic measures as indicated for patient condition. Use of Mark I Kit for Nerve Agent Exposure. Use of EpiPen for Anaphylactic reaction. CPR and use of AED, when appropriate. i. Administered analgesic medications and antibiotics, if indicated.

3. Performed Extraction, Evacuation and Transport

a. Extracted the victim to the site where evacuation is anticipated

b. Monitored an unconscious victim's airway, breathing, bleeding, and reevaluate the victim for shock during victim evacuation. 4. Performed all necessary steps in sequence.

5. Identified and treated all wounds and or conditions.

Evaluation Guidance: Score the student GO if all performance measures are passed. Score the student NO GO if any performance measure is failed. If the student scores NO GO on any performance measure, show or tell the student what was done wrong and how to perform it correctly.

Battlefield Ocular Injuries

The war in Iraq has clearly demonstrated that crystal on a watch, it provides us with a clear about 10 percent of all battle-related injuries to window to look through and this portion of eye our troops are penetrating eye injuries from is the most prone to injury. The cornea has no fragments of IEDs (improvised explosive blood vessels and is extremely sensitive. devices), mortars and rockets. The majority of There are more nerve endings in the cornea these battlefield ocular injuries are corneal than anywhere else in the body. The cornea is foreign bodies, abrasions and eyelid approximately 0.5 millimeters thick. The outer lacerations. Other causes of eye injuries layer of corneal epithelium is only about 5 to 6 include chemical conjunctivitis from soldiers cell layers thick and fortunately regenerates handling solvents and fuels. The daily threats quickly when the cornea is injured superficially. include dirt, wind and allergens that are also prolific in the desert environment. Unfortunately, penetration injuries into the cornea may leave a scar resulting in impaired The LE tactical community is not exempt. Eye vision. If the penetrating injury is even deeper, injuries can result from debris in an explosive the object entering the eye can damage the breech, glass from breaking and raking a iris, lens and even enter the center of the eye. window and flying debris from the deployment This is a serious if not a catastrophic eye injury of a flash bang. Tactical teams operating in and may result in blindness or the loss of the Southern California know all too well the effect eye. of the sun, dry wind and blowing sand. The sole purpose of high-tech ballistic eye What Gets Injured protection systems is to protect the eyes from The cornea is the transparent, dome-shaped penetrating trauma and not obstruct your field skin covering the surface of the eye. Like the of vision.

Treatment Superficial injuries caused by dirt or sand can be treated by flushing the eyes with running water. If this is unsuccessful, a closer examination will be necessary. Before this can be accomplished the victim will need a few drops of an ophthalmic topical anesthetic. This will allow the victim to cooperate with a visual exam of the eye. If you can visualize a foreign body and it appears superficial then an attempt to remove it with a cotton tip applicator is worth a try in the field.

If you are unsuccessful and you suspect a metallic foreign body embedded in the cornea you will not be able to remove it without the use of a slit lamp (an adjustable lighted Field treatment of eye injuries brings to mind the admonition to “first, do no harm.” binocular magnifying instrument mounted on a Most eye injuries are best stabilized and table). This will require the patient to be treated in a proper medical facility. transported to a clinic or hospital. At this point

it is best to instill a few more anesthetic eye the next factor, which is compliance. If the drops and prepare for extrication. eyewear does not feel good on your face and Deep-penetrating eye trauma is yet another does not give you excellent peripheral vision story. All of these injuries will need evaluation the user will not wear it. The lack of by an ophthalmologist and it is best to cover compliance obviously increases the risk of a the affected eye with a pair of goggles to serious eye injury. Most S.W.A.T. commanders prevent further injury and transport the patient are now aware of these issues and are to the nearest facility capable of surgically enforcing compliance to reduce workman’s treating ocular injuries. If there is an object comp claims. In the 1990s, the U.S. Army impaled in the eye or surrounding areas, do conducted a study and found that the reason not remove it. Field removal may destroy why compliance was so poor among soldiers is otherwise salvageable tissue. that the goggles issued lacked soldier acceptance because of their appearance. They Eyewear Compliance simply “didn’t look cool”. The bottom line is that Obviously, comfort and field of vision is you want eyewear that is comfortable, looks paramount for the user in selecting eye good and protects well. protection. These two features will determine

THINGS TO LOOK FOR: • Comfortable fit • Shatterproof lenses • Wrap-around coverage • Distortion free • Full UV protection • Fog proof

• Scratch resistant • Retention strap • Clear and dark lenses • Foam spacers to keep particles from slipping under the lenses • Use an optical cleaning cloth to clean lenses

Seal a Sucking Chest Wound

One of the most serious of all penetrating chest injures occurs when a bullet or a piece of shrapnel rips open a hole in the chest wall, entering the lung, causing it to collapse. The victim gasps for air, has extreme difficulty breathing and frothy blood often bubbles from the wound. This is the sucking chest wound, and if not recognized and treated promptly the victim will most certainly die before your eyes.

In this type of injury the chest cavity is no longer a sealed system and unrestricted air is allowed to rush through the wound in the chest A Chest Seal provides a fast and efficient wall and into the chest cavity during inhalation. method for treating a sucking chest This now-positive intrathoracic pressure wound. At least one chest seal should be system causes the lung on the affected side to mandatory in a tactical medic’s kit. collapse. Unless the hole in the chest wall is patched the lung is unable to re-expand. cellophane and Vaseline gauze. In the real world it is probably most likely that when the The untreated collapsed lung results in lack of moment arrives you will not have all your oxygen in the blood and rapidly leads to loss of medical gear with you and a field expedient consciousness and coma. More bad things occlusive dressing will have to be improvised. begin to happen with the shifting of the great vessels to the opposite side of the injury. Your ability to think and act quickly will save Moments later, things get even worse when the victim’s life. One could use a zip lock this pressure kinks off the large blood vessels sandwich bag, a large candy wrapper or a returning all of the body’s blood to the heart, piece of a plastic trash bag. A credit or ID card resulting in decreased blood flow to the heart. would even work once taped into place. After a few minutes the heart no longer pumps Actually, any air-tight material will work quite enough oxygenated blood and the body goes well. Make sure that the dressing extends at into irreversible shock and the victim dies. least 2 inches beyond the wound edges so that the dressing is not sucked back into the wound Forget your stethoscope and x-rays. This is a as negative intrathorasic pressure is restored. do or die situation. A last resort would be the use of the palm of Recognize and Treat your own hand. There remains controversy or The term “sucking chest wound” comes from whether one must leave one side open or a 3 the audible motion of air into but not out of the sided chest seal to allow air to escape, which pleural cavity and causing an eventual tension in theory sounds great, but in reality it may not pneumothorax. be achievable in the field.

Sucking chest wounds require an immediate Even with these interventions it is possible for occlusive dressing. Over the years there have the victim to develop a tension pneumothorax been many suggested field expedient which will need to be released. A needle is dressings such as aluminum foil, duct tape and inserted into the pleural space to relieve the

CHEST SEAL FROM pressure and allow the lung to re-inflate. This is another life threatening emergency. A U.S. NAVY SEAL The ACS (Asherman Chest Seal) is manufactured

by RUSCH, a leader in the development and More advanced occlusive dressing such as manufacture of high quality disposable medical the Asherman Chest Seal have become the devices for anesthesiology and respiratory care. It standard in many tactical medics’ kits as a was invented by a former U.S. Navy SEAL. rapid and effective method.

The ACS is a sterile occlusive dressing for treating Taking Action open pneumothorax and preventing tension Begin by clearly exposing the wound and pneumothroax in chest injuries as a result of a stab, prepare the area for an occlusive dressing. If gunshot wounds and other penetrating chest possible have an assistant with a gloved hand trauma. The unique one-way valve is designed to let cover the wound while you prepare or air and blood escape while preventing re-entry. improvise the dressing. If there is no assistant Battlefield proven, it has become standard issue for and the victim is conscious, place the victim’s the U.S. Army, U.S. Navy and the British Army, and hand over the wound. It sounds silly but every second counts! many U.S. Law Enforcement tactical team medics. Finally, cover the wound with an Asherman or other Chest Sea. You may also have to use USING the ACS an improvised occlusive dressing. Intubation The procedure is simple: may be required at this point, even if the • Don your latex or nitrile gloves patient is conscious, especially if the victim’s • Open the pre-packaged seal condition deteriorates. To more fully re-inflate • Use the 4X4 or other means to wipe away the lung a chest tube will need to be placed at sweat, blood or body fluids the hospital. • Peel off the protective paper liner, exposing the adhesive Remember, trauma is a surgical disease and • Place the chest seal over the wound it is fixed in the operating room. Advanced medical care and immediate extraction and As in any injury, the area surrounding the wound evacuation to a Level One Trauma Center is may be wet from perspiration, blood or body fluids strongly advised. and the adhesive backing may not be sufficient to

hold the dressing in place despite wiping of the area

before application. I recommend reinforcing the

dressing edges with additional adhesive or silk tape

to secure the dressing in place.

• Unique circular design • Pressure-sensitive adhesive, assuring seal • Automatically vents sucking chest wounds • Translucent design allows monitoring of chest wound • Package includes a gauze 4X4 pad to dry the wound before application • Ample 5.5-inch diameter dressing size Easy- open package

Needle the Chest

This article focuses on the life threatening problem of trapped air between the chest wall and the lung, otherwise known as a tension pneumothorax. A tension pneumothrax is believed to cause about one third of combat deaths from penetrating injuries to the chest. These deaths can be reduced or prevented with immediate recognition and treatment. After a victim has suffered a penetrating injury to the chest, a progressive build-up of air can occur. This is usually secondary to an injury such as a gunshot wound or stab wound. The air escapes from the torn or lacerated lung and moves into the area between the chest wall and the lung called the pleural space. A major problem begins when the air cannot return to the lung and with each breath more and more air accumulates in the pleural space.

Essentially what has happened is the creation of a one-way-valve effect. Progressive build-up of air pressure in the pleural space pushes the heart and the major blood vessels exiting and entering the heart to the opposite side of the chest and obstructs venous blood returning to the heart. This leads to circulatory collapse and eventually death if not treated STAT.

Diagnosis When your victim has suffered a penetrating injury to the chest, immediately look for the signs of a tension pneumothorax.

• Deviation of the trachea away from the side of the injury (rare, last to present) • Decreased breath sounds • Distended neck veins

Unfortunately these classic signs are often absent and more commonly the victim has only a fast heart rate and is having trouble breathing. It is extremely difficult if not impossible to appreciate decreased breath and percussion sounds in a loud tactical or combat situation. A chest x-ray is diagnostic but you are out of luck on this one because all you have is your brain and a needle to save this victim’s life.

So what happens if the victim has penetrating injuries to both sides of the chest? The victim may have bilateral tension pneumothorax. The trachea will be found central, while percussion and breath sounds are equal on both sides. These victims are usually found in traumatic arrest. Emergency bilateral chest needle decompression should be done immediately by a trained medical provider.

A simple procedure called needle thoracentesis is used to diagnose and treat a tension pneumothorax. The management of tension pneumothorax is emergent chest decompression with needle thoracostomy. A 14-gauge Angiocath-type (catheter over needle) needle is preferred.

The standard approach is to insert the needle into the second intercostal space at the midclavicular line. Remember the blood vessels and nerves which run under the bottom of the rib. The needle is advanced and immediate rush of air out of the chest indicates the presence of a tension pneumothorax. The maneuver essentially converts the tension pneumothorax into a simple pneumothorax, which is typically not a life-endangering situation.

Many clinicians believe that a tension pneumothorax is a clinical diagnosis and should The ISTM LE Casualty Response Kit be treated with needle thoracostomy. More To save a life in the tactical arena, the recently this dogma has been called into tactical medic needs the right tools and the question. Needle thoracostomy may not be as ability to utilize them quickly. The faculty at benign a procedure as was previously thought, the International School of Tactical Medicine and may be ineffective in relieving a tension meticulously planned and designed the Law pneumothorax. If no rush of air is heard on Enforcement Casualty Response Kit and needle insertion, it may be impossible to know stocked it with high quality components to whether there really was a tension or not, and specifically treat gun-shot wounds, whether the needle actually reached the pleural hemorrhage, tension pneumothorax, sucking cavity. chest wounds, eye injuries, burns, lacerations, as well as other injuries that can This is further complicated with recent studies occur during tactical operations. that in buffed-out males the chest wall thickness at the second intercostals space may be greater The kit can be worn using a tactical drop leg than the general population, requiring a longer configuration, waist belt attachment, or the needle. Some recommend a 3.25-inch (8cm) 14 standard military molle system. The drop leg gauge vs. a standard 2-inch or (5cm) needle to attachments can be removed and replaced ensure reaching the pleural space. in seconds. For more information visit www.tacticalmedicine.com. There are many locations on the chest wall where a needle thoracostomy may be performed. If you have a 14-gauge needle that is less than 3.25 inches and your victim has very large chest muscles simply look for a thin area anywhere on the chest wall especially laterally under the arms and insert the needle here. Do not fixate only on the second intercostal space as your only option for needle insertion.

The Procedure If available, administer oxygen 12 L/min using a non-rebreather mask or positive pressure with bag-valve-mask to pre-oxygenate the victim.

• Locate by palpation the 2nd intercostal space in the midclavicular line on the side of the pneumothorax. • Clean the area with antiseptic. • Re-identify 2nd intercostal space in the midclavicular line. • Insert 14 gauge catheter over the top of the rib into the pleural space.

• Listen for a decompression air rush (hissing sound) from the needle, or aspirate as much air as necessary to relieve the victim’s acute symptoms. If the symptoms are not relieved, reattempt another needle insertion next to the first one. • Leave the catheter in place and apply bandage or small dressing. A field-improvised one-way valve may be attached to the catheter. Do not cap off the catheter; air must be able to escape through the needle in order to relieve the tension pneumothorax. • Transport the victim to the hospital for chest-tube insertion.

Although complications are rare there is a possibility with any procedure. Needle thoracostomies are susceptible to blockage, kinking, and falling out. A relieved tension may re- accumulate undetected. A misdirected long needle can penetrate the heart or blood vessels in the chest. There is the possibility of lung laceration with the needle. Air embolism through such a laceration is also a real concern.

Chest Tube Placement Although some Tactical Medics carry chest tubes in their medical bags for field insertion, at the International School of Tactical Medicine we see little utility or benefit in doing so in the field. Circumstances will dictate who and when a field chest tube should be inserted. Chest tube placement is the definitive treatment of traumatic pneumothorax and requires underwater sealed suction. This invasive surgical procedure should be performed in a controlled setting in an emergency department or hospital by a skilled medical professional.

Remember chest needle decompression can be associated with complications. It should not be used simply because you don’t hear breath sounds on one side. However in clear-cut cases such as shock with distended neck veins, reduced breath sounds, deviated trachea after penetration trauma it could be lifesaving.

Tactical Casualty Care

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Section 10 – Medical Aspects of Wound Ballistics

Duration 1 hour Scope Statement This section provides students with training in fundamentals of wound ballistics. Terminal Learning Objectives (TLO) At the end of this section students will understand the fundamentals of wound ballistics. Enabling Learning Objectives (ELO) At the end of this section the students will be able to describe:

1. Bullet types 2. Temporary and permanent cavity 3. High velocity injuries 4. Low velocity injuries 5. Scatter patterns 6. Shotgun injury patterns 7. Non-fragmenting high velocity injuries 8. Field wound management 9. Gunshot wound myths 10. Entrance vs. exit wounds Resources See Appendix A Instructor to Participant Ratio 1:30 Students Reference List See Appendix B Practical Exercise Statement None Assessment Strategy Pre and post testing, end of course critiques, subjective evaluations, and instructor comments.

CSI of Wound Ballistics

A great deal of time and resources are invested in every tactical officer’s training. How many of them attend a live autopsy of a shooting victim? How many are brought into the operating room with the trauma surgeon, determining actual injuries? The answer is simple: Not enough.

Time in the classroom and on a static or dynamic range is the beginning of the essential education about ballistics. Ballistics is the study of the science of the motion of a projectile in flight, or, understanding the of properties of a bullet’s performance and actions before it hits its target.

Wound ballistics is the study of the projectile’s action in tissue.

Are officers aware of what their duty ammunition can do to the human body? Are they aware that the bullet they are presently carrying and use to protect the public and themselves has no scientifically validated data to support its claim of human tissue performance? The information available for wound ballistics is enormous, confusing, sometimes accurate, other times not. The simple fact is that your duty ammunition has no scientific data on what injuries it will cause for any given area of the body hit or what is the potential for incapacitation. It is time to make up your own mind about stories you have been told, shootings you have witnessed and the failure to incapacitate, of which most of today’s modern ammunition is guilty.

No Silver Bullet There is one way to instantly incapacitate an intended target: This mechanism is to destroy the brainstem, which is the part of the brain just above the spinal cord that is the “master control” center for all body functions. It controls heart rate, breathing, responses, etc. This is the sniper’s domain and would be considered the location of the instant “drop and stop.” This small area is difficult to hit with a handgun for a variety of reasons and beyond the scope of this article. The second way to quickly incapacitate is to have the body lose enough blood so that the brain is no longer capable of normal function due to loss of oxygen to the brain tissue. Destroying the heart, causing A high velocity rifle round creates both a temporary and enough major blood vessels to open and permanent cavity with massive tissue damage. leak the blood out of the arteries and veins are the means to this mechanism of incapacitation. Unfortunately, voluntary actions (a bad guy’s gun shooting at you) can continue for up to 15 seconds after the heart is completely destroyed! This places the tactical officer at tremendous risk for injury if their target still is able to function.

Shot Placement is Crucial There are a few golden rules to follow for incapacitation if you are to trust that your ammunition will serve its intended purpose. First, shot placement so that faster bleeding from more blood vessels can occur. One well placed shot though a major blood vessel will do a lot better job of incapacitating than an entire magazine of bullets hitting nothing but thigh muscle tissue. Second, find autopsy or trauma-surgeon data that lets you know the true bullet performance in living tissue of your duty ammunition. Depth of penetration, expansion, fragmentation are all important, but does your bullet design do that reliably in living tissue compared to the way it was tested in ballistic gelatin? All “usual” commercially marketed bullets were tested in 10% ballistic gelatin, a simulation of thigh muscle. Most people are not shot in the thigh. Most people have skin, fat, muscle, other tissues, bones, nerves, blood vessels and organs that have markedly different properties than ballistic gelatin. Your ammunition was chosen on its ballistic performance in gelatin, not living tissue. Are you willing to trust your life to this type of testing? Just because you hit your target doesn’t mean the bullet performed as advertised; if your threat is still there, your ammunition failed you.

Know Your Ammo’s Capability

Dr. Martin Fackler’s editorial comment to an article on wound ballistics in Journal of the International Wound Ballistics Association makes this point:

“What Gene Wolberg has done here is what every clear thinking LE agency should be doing. Skepticism and meaningful comparison are the essence of common sense and all scientific thought…don’t believe that your tissue simulant is a good predictor just because an Army lab or the FBI uses it and says so— check it out for yourself. (Wolberg, EJ. Wound Ballistics Review, Winter 1991: 10-13.)

The Bottom line is that you must understand what your ammunition can and does do in living tissue in order to perform your tasks as tactical medics and officers of the law.

An injury to a major blood vessel can cause significant hemorrhaging. About 9% of extremity injuries will end in death unless rapid treatment to control bleeding is applied.

Medical Aspects of Wound Ballistics

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Section 11 – Hemostatic Dressings and Tourniquets

Duration 1 hour Scope Statement This section provides students with hands on training in use of hemostatic dressings and tourniquets. Terminal Learning Objectives (TLO) At the end of this section students will understand the concepts and differences in the application of a wide variety of available hemostatic dressings and tourniquets. Enabling Learning Objectives (ELO) At the end of this section the students will be able to describe: 1. Quantification of blood loss 2. Sources of blood loss 3. Signs and symptoms of shock 4. Downed officer assessment 5. Hemorrhage control techniques 6. Hemostatic dressing design and function 7. Tourniquet types 8. Tourniquet application techniques 9. Volume replacement issue 10. Monitoring techniques Resources See Appendix A Instructor to Participant Ratio 3:30 Reference List See Appendix B Practical Exercise Statement Hands on training Assessment Strategy Pre and post testing, end of course critiques, subjective evaluations, and instructor comments.

Stop the Bleeding

Each year, there are more than 70 million total blood volume, which is about 5 liters, an emergency department visits for bleeding. irreversible shock state begins and the victim Bleeding, or acute hemorrhage in medical dies. terms, is a leading cause of death in trauma cases. Under certain tactical situations, Hemostatic Bandages immediate evacuation of gunshot wound There currently are several blood-clotting victims may be an option. Effective and hemostatic bandages on the market. Each has immediate early hemorrhage control is a different mechanism to stop the bleeding. paramount to saving lives. Readers are strongly urged to carefully conduct their own investigation to determine The Clotting Mechanism what is best for their agency, team and level of The coagulation of human blood is a complex training. biological process, and a full description is beyond the scope of this article. When a blood The HemCon Bandage is composed of vessel is severed or damaged, the body reacts Chitosan, which is a biodegradable, nontoxic, to try and stop the bleeding by spasm of the complex carbohydrate of chitin, found in the blood vessel, formation of a platelet plug and exoskeletons of shellfish. subsequent formation of a blood clot. QuikClot is composed of granular zeolite and is If the blood flow is under pressure, such as in a derived from volcanic rocks. When this femoral artery wound, the normal clotting material is placed into a bleeding wound, it mechanism fails to stop the bleeding and the absorbs the water molecules in the blood and victim can bleed to death within a few minutes. creates a high platelet concentration, to Bleeding in the chest, pelvis and abdomen is promote clotting. impossible to detect in the field and can result in a large amount of blood loss. Once the The RDH or Rapid Deployment Hemostat blood loss exceeds about 40 percent of the Bandage is derived from single-cell algae and the mechanism of the material is to act as a catalytic surface that accelerates the normal clotting process. TraumaDEX is a wound- dressing agent material naturally synthesized from potato starch. The particles accelerate natural blood clotting by concentrating blood solids such as platelets and red blood cells.

The Emergency Bandage, Trauma Wound Dressing is an improved version of the time- honored battlefield dressing. This sterile, non- adherent bandage applies pressure to any site, is easily wrapped, secured and can act as a When an officer has incurred a tourniquet in cases of severe bleeding. The significant wound, all team members beauty of this product is that the bandage can should know how to use the tools to be applied to the head, armpit or groin for stop the bleeding. control of hemorrhage in these difficult areas.

Discussion wound or to a pressure point between the All of the hemostatic dressings are supposed heart and the wound. If you then get the to work in seconds, according to claims made bleeding slowed with a pressure point, you by the manufacturers. The questions one must might be able to get the wound dry enough to ask are, do they really work and what should apply the hemostatic dressing into the wound be considered for purchase and distribution to and hopefully it will work. After the dressing is tactical medics? complete, the tourniquet or pressure point may be released. Unfortunately, there are conflicting reports in the medical literature regarding what bandage The one thing we do know is that the time- is the most effective. Unlike drugs that require honored method of direct pressure and a years of testing and approval by the FDA, the tourniquet application for bleeding really works. manufacturers of hemostatic dressings are not It seems prudent that a medic will use the required by law to conduct extensive research simplest and easiest technique in the field for to support their claims. There are very few hemorrhage control. At the International scientific, objective, controlled studies in the School of Tactical Medicine we recommend medical literature to support the claims made that agencies proceed with caution before by some of the companies. It stands to reason, spending valuable resources on the new that if the bleeding is under high pressure or blood-clotting agents until further studies are very brisk, none of these products will work. done, and stick with old-fashioned direct You’ll need to apply direct pressure to the pressure and tourniquets.

Hemostatic Dressings and Tourniquets

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Section 12 – Team Health Management

Duration 1 Hour Scope Statement This section provides students with hands on training in team health management. Terminal Learning Objectives (TLO) At the end of this section students will understand the concepts of tactical team health management. Enabling Learning Objectives (ELO) At the end of this section the students will be able to describe: 1. Tactical officer profile 2. Preventative evaluation and education 3. Mental health issues in law enforcement 4. Incident debriefing and stress management 5. Cardiovascular fitness 6. Proper nutrition 7. Weight loss management 8. Health screening techniques 9. Vitamins and minerals issues 10. Dangers of steroid use Resources See Appendix A Instructor to Participant Ratio 1:30 Reference List See Appendix B Assessment Strategy Pre and post testing, end of course critiques, subjective evaluations, and instructor comments.

20 Tips for Weight Control and Healthy Eating

1. Keep A Food Diary: Write down all the food and beverages you consume for one week. Note the circumstances and time of day such as mealtime, watching TV, at work etc. Choose foods wisely from all of the food groups. Skipping meals often leads to overeating or eating the wrong foods.

2. Set Realistic Goals: remember you put the weight on one day at a time, and that is how it will come off. Two pounds is the maximum you should lose in one week.

3. Drink Plenty Of Water: Try to drink between 6 and 8 glasses every day.

4. Think Nutrition: Choose food that is high in nutritional value and low in fat and calories. It is important to include at least five servings of fruits and vegetables each day. Fruits and Vegetables are high in vitamins, minerals and fiber and low in fat. Some may also play a protective role against certain types of cancer.

5. Cut Down On Portions: Reduce the amount of food you put on your plate. Use a smaller plate. Eat slowly and stop eating when you are full.

6. Eat Balanced Meals: Plan your meals to include food high in complex carbohydrates such as fruits, vegetables, grains and starches. Reduce the fat in your diet to below 30% per day.

7. Increase Your Exercise: This will burn extra calories by increasing your metabolic rate. It will also help to decrease your appetite.

8. Remove Temptations: Do not buy high-calorie snacks. Throw out all candy, ice cream and junk food. Substitute mustard, vinegar and salsas for butter, mayonnaise and salad dressings.

9. Make Smarter Choices: Stay away from fast food. Include plenty of wholesome, nutritious food. The American heart Association recommends limiting your fat intake to no more than 30% of your total calorie intake.

10. Read Labels: Fresh food is a better choice for controlling the fat in your diet. Limit foods that provide more than 3 grams of fat per 100 calories. Be on the look out for foods high in sodium and sugar. Many prepared foods, frozen foods, cured foods and snack foods are high in salt content. Excess salt intake may increase the risk for high blood pressure in some individuals.

11. Change Habits Not Just Your Diet: Use a sensible safe approach to weight control. For long term results concentrate on making gradual changes in your eating habits. A high saturated fat diet and a lack of exercise contribute to obesity.

12. Improve Your Cooking Methods: How you cook is important as what you cook. Broiling, baking, roasting and stewing are the best methods. Trim all visible fat off meat before cooking and limit serving sizes to 3 to 4 ounces. Avoid frying.

13. Cut Down on Alcohol: Eliminate empty calories. A moderate alcohol intake consists of two or fewer servings per day. Substitute water or low-calorie beverages.

14. Avoid Difficult Situations: Eat something before parties and get-togethers. Avoid nibbling.

15. Shopping Wisely: Make a grocery list and stick to it. Stay away from the snack aisles. Concentrated sweets like those found in candy, cookies, sodas provide calories with little or no nutritional value.

16. Determine Your Ideal Weight: Have a body composition test. Learn how much of your weight is fat and how much is lean mass.

17. Know You Health Consequences: A life style that promotes excess weight is a lifestyle with added health risks. The key to successful weight control is replacing unhealthy food with wholesome nutritious food.

18. Choose Foods High In Fiber: A high fiber diet may reduce the risk of certain types of cancer and may help to control blood cholesterol levels. Whole grains, fruits and vegetables are high in fiber.

19. Snack on Healthy Foods: Eat snacks that are low in fat and high in nutrients such as fruits, vegetables, unbuttered popcorn, pretzels, rice cakes and unsweetened cereals.

20. Choose a Diet High in Complex Carbohydrates: Foods high in complex carbohydrates such as breads, cereals, rice, pasta and vegetables are good sources of energy and provide the foundation for a healthy, delicious low-fat meal.

Lifesaving Personal Medical Information

You are in your patrol car and receive a radio call to respond to a robbery in progress. As you reach to activate your lights and siren, your foot pushes on the accelerator and crash! The next thing you know you wake up in the Trauma room with a breathing tube in your windpipe, pain across your chest, abdomen and arms, and you are restrained at your wrists and ankles.

You were in a motor vehicle collision with another that ran a stop sign. Your airbag deployed and the powder/dust from the airbag deployment activated a constricting response in your windpipe and lungs and you could not get air in or out. A passerby tried mouth-to-mouth rescue breathing, thought your heart had stopped and began CPR. They were smart enough to call 911 from their cell phone for EMS to respond. When the medics found you, you had a low oxygen level, your heart rate was slower than it should be and they had no idea why your body was reacting this way based on suspected injuries. The only obvious injury was the abrasion on your face from the airbag. You were unconscious and could not offer the medics any information. Your wallet was quickly checked for a medical information card or the like and none was found.

You got to the hospital where your heart rate was very high due to the medications they gave you to increase it from the dangerously low level you were found with. You now have an arrhythmia (irregular heart beat) that the doctors are trying to figure out if it is due to the accident or was preexisting (you have always had it). We ask your sergeant that responded to the call of officer injured and he did not have any of your medical information with him. All medical information is locked up at the police department in a file cabinet. Your ex-wife refused to speak with us about your medical history after we located her number in your wallet. So the docs are on their own, flying in the dark in terms of knowing what they are dealing with.

Educated Guesses vs. Timely Data We treated what we thought was asthma and we began to treat your arrhythmia and the first medication we administered did not act as we thought it would and made things worse. We ordered a lot of blood work, x-rays, an echo cardiogram and you ended up with a heart catheterization all to try and determine what was going on with your heart… sound farfetched? Welcome to our world in the Trauma Center where your Trauma Surgeon is likely also a Surgical Intensive Care physician and with the Emergency Medicine physician, best able to diagnose and treat your trauma/injury related issues. You also created a sense of frustration in

your trauma team; you don’t carry a medic alert bracelet or necklace, no card in your wallet with any health care information on it or any other type of indication of your general health issues.

Systematic Safety Your safety—and potentially your life— could depend on what medical information is immediately available to doctors caring for you under emergency conditions. Each department and every officer should have a system of maintaining this information in several places. Every S.W.A.T. officer keeps two cards on their person at all times; one in a wallet and one in a designated uniform shirt or vest pocket. Another copy should be in the tactical medic’s vest with all of the other team member’s cards, plus one with the shift commander that is handed off, shift-to-shift. By doing this, a copy is available both in the field to medical personnel (the tactical medic) as well as to the doctors assuming care once you get to the hospital. This information is either in a heat-sealed plastic folded card that has to be cut open and unfolded to see this privileged health information, or on a laminated card that may be seen whenever it is out in the open. There are commercial companies that offer a “dog-tag” like product and ones that have pre-formed cards. Whichever product is used, it has to be tailored to your department’s privacy policy and legal review.

Your team’s tactical medic or physician should be aware of every team member’s allergies and significant medical history. Unfortunately, these providers may not be able to go to the hospital with you, but the information that can assist with your treatment and care can be transmitted directly to the transporting medics or to the hospital’s emergency department doctors.

This information helps guide safe treatment and care. Not having this information means that the treating staff literally guesses and does their best without knowing your medical information that can help guide treatments. It is never a good thing for your body to be exposed to an antibiotic that you are highly allergic to. We may in fact give it to you because it is the one we use for your type of injury, if we do not know that you will have an anaphylactic reaction to it and possibly die from our well-intended treatment.

Do yourself, your family and your department a favor and carry this vital and potentially lifesaving information where your medic, your partner or fellow officers know where to find it. It can make the difference between life and death.

Team Health Management

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Section 13 - Medical Aspects of Clandestine Drug Labs

Duration 1 Hour Scope Statement This section provides students with hands on training in recognition and dangers of clandestine drug labs. Terminal Learning Objectives (TLO) At the end of this section students will understand dangers, health concerns and medical aspects of clandestine drug labs. Enabling Learning Objectives (ELO) At the end of this section the students will be able to describe: 1. Health and safety concerns 2. Hazard identification 3. Activity patterns 4. Methamphetamine manufacturer profile 5. Designer Drugs and fentanyl analogs 6. Exposure risks based on lab conditions 7. Signs and symptoms of chemical exposure 8. Response procedures 9. On-scene medical actions 10. Personal safety protection Resources See Appendix A Instructor to Participant Ratio 1:30 Reference List See Appendix B Assessment Strategy Pre and post testing, end of course critiques, subjective evaluations, and instructor comments.

Medical Management of Clan Lab Emergencies

INTRODUCTION Clandestine drug laboratories are an area of great concern for tactical law enforcement officers due to high risk for personal injury. They are highly dangerous criminal operations. Explosive and toxic chemicals, booby traps and heavily armed criminals can add up to serious trouble for a tactical team. Knowledge of clandestine lab hazards and safety procedures means more than just being a good tactical operator. It could mean the difference between life and death not only the tactical officer but for all team members as well.

THE PROBLEM Extremely large quantities of illegal drugs are manufactured in the United States each year. These kitchens of death produce narcotics, stimulants, hallucinogens and depressants. Clandestine drug laboratories are in violation of the Controlled Substances Act (PL 91-513). Tactical law enforcement officers are at risk for personal injury during the raids on the labs due to the fact that the operators of these laboratories do not follow USEPA (United State Environmental Protection Agency) storage or disposal procedures. In the absence of proper safety procedures and lab cleanup guidelines law enforcement personnel and the general public may be exposed to hazardous materials and experience both acute and chronic adverse health effects as a result of exposure to lab reagents, solvents, drug precursors and by-products improperly used or generated during the manufacture of illegal drugs.

Clandestine drug labs exist in wide range configurations from crude makeshift laboratories sophisticated and technologically advanced facilities. These labs can be found almost anywhere from private homes to apartments, motel rooms, houseboats, RV's, and commercial establishments. Often the laboratories are hidden in nondescript locations such as old houses or barns in remote rural areas.

Isolation is the criminal chemist best friend and urban low income homes and apartments are favorite locations for clandestine labs due to the landlord usually being far away. Trailer type campers, mobile homes and RV's are sometimes converted into a clandestine laboratory because drugs can be cooked and sold for several days and the entire operation then driven or towed to a new area. Self-Storage units and community rental lockers are often used to store laboratory equipment, chemicals and firearms. Lack of proper temperature controls and ventilation at these off-site locations creates a potential for explosion, fire and area contamination.

Of particular concern is the fact that many clandestine drug labs contain sophisticated surveillance equipment and may be booby-trapped to prevent outsiders and law enforcement personnel from entering the laboratory, and to destroy evidence in the facility if discovered. The easy availability of precursor chemicals, low production costs, ease of manufacture and the high profits from drug sales has led to more clandestine drug labs operating in the United States than ever before. This has increased the availability of stimulants and hallucinogens for sale on the streets. According to drug Enforcement Administration (DEA) these laboratories could easily satisfy the current domestic illegal drug demand even if the source and entry of all foreign drugs were halted.

CLANDESTINE DRUG LAB OPERATORS Organized motorcycle and street gangs historically have manufactured and distributed PCP (phencyclidine) and amphetamines. However since 1991 current trends show that the manufacturing and distribution of methamphetamine by Mexican Nationals is overtaking the organized motorcycle gangs. The "cookers" (chemists) of illegal laboratories come from a wide range of backgrounds. They can be an absolute novice with little or no background in chemistry to trained chemists with Ph.D. degrees.

DRUGS, HAZARDS AND WASTES The majority of the drugs produced by clandestine labs are of three types: methamphetamine (82%), amphetamine (10%), and PCP (2.5%). Although the amount of hazardous materials found during a typical clandestine drug laboratory raid are relatively small when compared to say for example an industrial waste site or spill, the real concern is the exposure to toxic chemicals by law enforcement personnel unaware of their presence.

During a tactical operation where officers are engaged in the potential for drug seizures, a lab may be present. If so tactical personnel present could be exposed to toxic chemicals. These include reagents, solvents, drug products and by-products that may be toxic. In addition many of the reagents and solvents present in clandestine drug laboratories are explosive or flammable. For this reason, tactical medical providers should have special training in the clandestine drug laboratory safety procedures and in the proper use of personal protective equipment.

METHAMPHETAMINE "CRANK" The illegal manufacture of methamphetamine is a relatively simple process that does not require a terrific amount of knowledge. The drug is produced in a multi-step process, in either what is called the P-2-P Amalgam Method or the Ephedrine Method. There are over 30 different chemicals that can be used in the manufacture of illicit methamphetamine. To further complicate matters there are over 20 different chemical by-products and contaminants that can be produced during the manufacture of methamphetamine. Also several chemicals used in methamphetamine production can result in a fire or explosion.

The tactical officers' risk for exposure can vary depending on the lab process, and whether or not the lab is actively producing drugs. An active laboratory is one that is fully functional. This lab presents the greatest risk for the chemist and occupants as well as law enforcement personnel involved in the raid. The danger of fire and explosion constitute the greatest risk from chemicals due to solvents that may be present when the lab is entered. In addition large concentrations of corrosives, cyanide and solvents may be present during the lab cooking process resulting in inhalation injuries. Even after the laboratory is shut down and the removal of a clandestine lab material there may persist residual amounts of toxic substances on walls, floors and surfaces of furniture unknown to team members serving a warrant. The skin may also absorb some of the chemicals on direct contact. Inhalation or skin exposure may result in local injury from corrosive substances, with presenting symptoms such as burns to the skin, cough, and shortness of breath and chest pain.

PERSONAL PROTECTIVE EQUIPMENT

Team members entering an active drug lab must utilize air flow respirators that will provide adequate protection against life threatening ambient concentrations of toxic vapors. In addition the skin, face, and eyes must be protected against splashes, chemical spills by using goggles and or face shield. To protect the hands and the exposed areas of the skin impervious gloves and chemical resistant suits and rubber boots should be worn.

SIGNS AND SYMPTOMS OF CHEMICAL EXPOSURE Due to the extensive list of reagents, solvents, precursors, by-products and contaminants found in the manufacture of methamphetamine the discussion of the health effects of each one is far beyond the scope of the article. However it is worth mentioning a few so that you as a tactical operator will be able to recognize the signs and symptoms from each group of chemicals. Keep in mind that a sign is what you can observe in another person and a symptom is what is experienced by the victim but not observable by others. Some signs and symptoms may not be recognized by the victim and therefore the victim becomes dependent on his or her buddy for help.

SOLVENTS Examples include: Acetone, Chloroform, and Ethyl Ether. The breathing of vapors at even low concentrations may result in irritation to the nose, eyes and throat. Loss of coordination and drowsiness or even loss of consciousness can occur with high concentrations.

IRRITANTS AND CORROSIVES Examples include: Acetic Acid, Hydroiodic Acid and Sodium Hydroxide. The health effects from the vapors may cause eye irritation, tearing, burning sensation in the eyes, and the mucous membranes of the throat and nose. The breathing of vapors can cause irritation of the lungs resulting in cough, shortness of breath, and chest pain. In severe case the victims may develop pulmonary edema.

METALS AND SALTS Examples include: Mercury, Lead, and Red Phosphorous Most of the metals and salts are stable in the solid form and present minimal potential for exposure unless it is ingested or if the metal is present in the air as fumes or dust. If inhaled the symptoms may include irritation to the skin and eyes; dizziness, nausea, vomiting, abdominal pain, and loss of consciousness. Chronic exposure to the metals may result in poisoning affecting the central nervous system

EMERGENCY MEDICAL ON-SCENE MEDICAL MANAGEMENT

Whenever possible emergency medical support should be identified and established as per department protocols prior to conducting the raid. The on-scene medical officer should obtain the name, address, route and direct telephone number for the closest medical facility that is capable of handling a hazardous material contamination or accident.

1. Initiate first aid, basic or advanced life support if indicated. 2. Victims exposed to toxic vapors should be removed to fresh air. 3. Direct contamination to the skin with powders or granules should be brushed off and clothing removed. 4. Direct contamination to the skin or eyes by way of a spill or splash should be irrigated with clean running water for at least 15 minutes.

TEAM PHYSICIAN REFERRAL Any team members, lab occupants, and on scene pre-hospital care providers that develop symptoms or suspect they have been exposed to chemicals should be seen by the tactical team physician and transported to an adequate medical facility for evaluation. Also any children or infants removed from a clan-lab during a raid should be seen by the on-scene tactical team physician. In addition any team members that sustained puncture wounds from needles or other drug paraphernalia should be seen promptly by their team physician for a medical evaluation. The likelihood of a chemical or medical emergency occurring during a clandestine drug lab operation is directly related to the knowledge, training, and organization of the tactical team involved.

Clandestine Drug Labs

Basic Profile of a Methamphetamine Manufacturer 1. Age Group: 25 to 35 years old.

2. Usually white males with increasing occurrence of Hispanics

3. They often look like drug users.

4. They seem nervous and paranoid.

5. They may have the smell of chemical odors.

6. May look like “biker-type” individuals with tattoos.

7. Vehicles utilized are usually pick-up trucks, older models and vans.

8. Subjects may rent two or more storage lockers at one time for no apparent reason.

9. Often they will bring other people to the locker to help them move large chemical containers and to act as a “look-out” while chemical containers and contraband is loaded into and out of their vehicles.

10. They usually keep items covered up in their vehicle when coming and going from the storage facility.

11. The items stored in the storage locker will not look like normal household items and persons may close the storage locker door when they are approached by the manager or owner.

12. They make many unusual and seemingly unnecessary trips to and from the storage facility.

13. Look for placards on boxes and drums, i.e. Corrosive, Flammable, and Poison.

14. Chemical odors may be emitting from the storage locker facility.

15. Look for laboratory glassware.

Hazard Identification Overview

Tactical law enforcement personnel and forensic chemists that are working clandestine laboratory cases view clan labs differently from any other form of narcotic related investigation. This is due to the technical complexity of the investigation, associated field hazards and the large amount of evidence usually seized. In addition, clandestine laboratory investigations are an area of law enforcement for which special safety training is required.

Medical Application

The nature of clandestine laboratory investigations intimately involves field personnel in the use, handling, processing, storage and disposal of large quantities of hazardous chemicals in an environment presenting numerous health hazards. In essence, tactical personnel are required to perform continuous enforcement and investigative duties in potentially life threatening and chemically contaminated environments. An understanding and appreciation of the special hazards and unique circumstances of clandestine laboratory raids will yield a better understanding of personnel health and safety issues.

Raid Hazards

A. Laboratory Hazard Priorities

1. Suspects 2. Explosions 3. Fires 4. Weapons 5. Chemical Exposure

B. Raid Trends

1. Booby Traps: Up to 10% of clandestine drug labs have been found to contain booby traps or explosive devices.

2. Hospitalization: In the past up to 4% of all clandestine laboratory raids resulted in the hospitalization of at least one federal investigator.

3. Fires-Explosions: Up to 20% of all clandestine labs resulted in, and or are discovered through fires or explosions.

4. On-the-job-injuries: Clandestine laboratories are considered the largest single source of on-the-job injury incurred by federal narcotic officers.

5. Automatic weapons: Up to 10% of clandestine drug lab suspects and chemists have fully automatic and silenced weapons.

6. Surveillance: Up to 30% of clandestine drug lab cases were found to be using some form of electronic countermeasures.

C. Chemical Hazards

1. Booby traps: a. Hydrogen cyanide gas generators b. Thrown liquids (usually acids). c. Flammable liquid bombs (flammable liquid and incendiary devices or electrical spark generator). d. Shock sensitive bombs.

2. Toxic Atmospheres: a. Phosgene gas from chlorinated solvent decomposition (fire or heat). b. Phospine gas from improperly operated or deactivated red phosphorous reactions. c. Ammonia gas from overheating benzyl cyanide- ethyl acetate intermediates. d. By products of chemical incapability reactions.

3. Fire-Explosions: a. Flammable solvents. b. Electrical hazards. c. Water/air reactive catalysts metals.

4. Hazardous Chemicals: a. Aromatic Hydrocarbons: Benzene, Toluene. b. Aliphiatic Hydrocarbons: Alcohols, Ethers. c. Corrosive liquids and solids: Inorganic acids, Caustics. d. Compressed flammable and corrosive gases: Hydrogen, Hydrogen chloride. e. Reactive and catalytic metals: Nickel, Palladium, Lithium, Soduim. f. Toxic metals: Lead, Nickel, Mercury. g. Suspect carcinogens: Chloroform, Bezene, Lead, Carbon tetrachloride. h. Irritants: Aldehyde, Amine compounds.

5. Dangerous Drugs:

a. PCP b. LSD c. Fentanyl d. MPTP

6. Hazardous Waste:

a. Identified-seized laboratory hazardous waste. b. Accumulated “cook” waste. c. Contaminated glassware. d. Environmental contamination at laboratory site.

Health and Safety Concerns

A. Types of Chemical Exposure

1. Two types of chemical exposure: Passive & Active.

2. Passive exposure is long term to chemical compounds, with or without personal protection or personal knowledge of the exposure.

3. Active exposure is due to spill or immediate contact with chemicals due to an accident or booby-trap.

4. Routes of exposure: Primary is respiratory, second is adsorption trough the skin.

5. Health data is known on some chemicals found in clandestine laboratories. Unknown is what is the long-range effect with combinations of chemicals or by products of designer drug manufacturing.

6. It is of utmost important to document exposure to chemicals in clandestine labs.

B. Types of Chemical Hazards

1. There are three general types of chemicals found at a clandestine laboratory: precursors, reagents and solvents.

2. Many chemicals are respiratory irritants, flammable, acids, and bases and or water-soluble metal poisons.

3. These chemicals can cause skin or tissue burns, respiratory failure, cancer, circulatory system problems and death.

4. Strong bases: sodium hydroxide, methylamine.

5. Strong acids: hydriotic acid, hydrochloric acid, nitric acid, sulfuric acid.

6. Flammable: dimethyl either, petroleum ether, ethanol, isopropanol, acetone.

7. Respiratory irritants: acetic anhydride, hydriotic acid, methylamine, hydrochloric acid.

8. Metal poisons: mercuric chloride, lead acetate.

C. Personal Protection Guidelines

1. Clandestine laboratory sites are literally chemical time bombs.

2. Clandestine chemists are usually not trained chemists; the little knowledge they have about chemistry is learned form other drug chemists.

3. Extremely hazardous situations created from illegal and unsafe disposal of chemical wastes, chemical storage and usage results in both short- range and long-range dangers.

4. It is important to have qualified personnel on-scene to help determine health and safety issues.

5. It is absolutely necessary to have personal safety equipment on hand and to use it as directed by the site safety officer.

6. Allow only qualified personnel into the laboratory site. No media or command staff nosing around.

D. Role of the Forensic Chemist

1. The chemist can advise what type or reaction the suspects are running, what problems the suspect may encounter and what other types of materials the suspect may need to complete the reaction.

2. On reports of large orders of unfamiliar chemicals, the chemist can help determine what might be being synthesized.

3. The chemist can help determine the safest time to seize the laboratory.

4. The chemist can help compile a listing of possible health and safety hazards that may be present at the laboratory site.

5. The chemist can examine the laboratory, disassemble glassware, shut down reactions as necessary and determine if immediate safety hazards can be rendered safe.

6. Assist hazardous waste haulers in sorting and attempting to identify unknown liquids and powders during the destruction phase.

E. Role of the Tactical Medical Officer

1. Along with the forensic chemist can brief personnel involved in the raid as to possible health and safety hazards.

2. Provide instruction on what to do in case of fire and what possible hazards may be encountered.

3. Along with the forensic chemist can brief emergency medical personnel on-scene as to the types of injuries due to chemical exposure that might be encountered.

4. Make the necessary preparation to treat chemical related injuries and pre- plan for on-site decontamination and evacuation to an appropriate medical facility.

5. Along with the chemist provide site safety information during the initial assessment and establish the level of respiratory safety required for personnel entering the laboratory site.

Chemical-Medical Emergencies

Tactical medical personnel supporting SWAT teams involved in clandestine laboratory seizures should have an awareness of the appropriate actions to take in the event of an accident, injury or chemical accident. The underlying principal of emergency actions stipulates that in the event of an emergency, medical personnel must act and make decisions quickly. Such actions and decisions will invariably have far reaching long-term consequences.

Medical Application

Appropriate medical decision making and actions, implemented quickly improve the chances of a safe and effective response to an incident during the course of a clandestine laboratory raid and investigation. Early incident recognition may reduce the severity or even prevent an injury if proper medical action is taken.

Anticipated Events

A. Chemical Emergencies

1. Fire a. Source: Flammable gases, liquids, vapors or solids, or incompatible chemical reactions.

b. Cause: Improper chemical handling or incompatible reactions.

c. Consequence: Fire, explosion, injury, property (structural damage).

2. Explosions a. Source: Flammable gases, vapors or explosive dust, chemical incompatibility reactions, or handling of shock sensitive chemicals.

b. Cause: Improper chemical handling or incompatible reactions.

c. Consequence: Fire, explosion, injury, property (structural damage), and container rupture.

3. Chemical Reaction

a. Source: 2 or more incompatible-exothermic chemical reacting.

b. Cause: Improper chemical handling or incompatible reactions.

c. Consequence: Fire, explosion, container rupture, and chemical spill.

B. Medical Emergencies

1. Chemical Exposure

a. Source: Any chemical material.

b. Cause: Spill, leak, emission or equipment failure, fire, explosion, chemical reaction, improper handling, etc.

c. Consequence: Acute inhalation injury and or external exposure.

2. Serious Bodily Injury

a. Source: Unsafe acts or conditions.

b. Cause: Equipment failure, improper operation, fire, explosion, container handling, fatigue, unsafe conditions, and human error. c. Consequence: Physical trauma.

3. Physiological Disorders

a. Source: Physiological conditions and or environmental stresses.

b. Cause: Variable i.e. Use of protective clothing, tactical vests, hot or cold climate, physical stress, work efforts exceeding personal limits.

c. Consequence: Heat stress, hypothermia, heart attack, and other adverse health effects.

Emergency Medical Care Provisions

Response Actions

1. Planning and Procedures a. Establish medical care support prior to the laboratory raid.

b. Obtain the name, address, route and telephone number for the nearest medical facility capable of handling a contamination injury.

c. Establish procedures for requesting on-site response.

d. Determine the capabilities and limitations of responding aid.

e. Coordinate arrangement with emergency medical facilities,

f. Provide emergency medical resources on-site.

1. First-Aid - Trauma Pack 2. Source of clean water for emergency shower and eye wash. 3. Communications equipment: cell phone, HT. 4. Wind direction indicator. 5. Transportation: ambulance multiple vehicles. 6. Chemical rapid identification capability. 7. Gas and chemical detection devices.

Clandestine Laboratory On-Scene Medical Actions

A clandestine drug laboratory becomes an emergency response at the time it is discovered. The individual who discovers the laboratory is considered the “first on-scene”. The immediate actions taken by this person are mandated to protect the personal safety of others, isolate the area and to initiate a call for assistance.

Medical Application

The first person to discover a clandestine laboratory may be exposed to a large number of hazards. The appropriate initial actions taken at the lab-site can preserve individual safety and protect other team members and the environment. The critical safety actions include calling for assistance, warning others, isolating the area and providing important response information. These safety actions are separate from steps taken to apprehend suspects, securing the area and preserving evidence.

On-Scene Medical Actions

A. Call for Assistance

1. Report incident 2. Exact location 3. Nature of the incident 4. Injuries and actions taken 5. Status of field law enforcement actions 6. Response action needed

B. Personal Safety Protection 1. Avoid unnecessary exposure 2. Avoid contact with liquids, vapors, and gasses 3. Avoid contact with odors 4. Remain up-wind & up-grade at a safe distance 5. Do not enter spill areas if safety is compromised 6. Do not attempt to rescue a victim unless personal safety can be maintained.

C. Public Safety

1. Isolate the area 2. Warn others 3. Evacuate surrounding areas 4. Take only those actions that avoid unnecessary exposure

D. Other Actions

1. Shut off power to building and equipment 2. Eliminate sources of ignition 3. Fight small fires 4. Separate incompatible chemicals 5. Clear debris, which may impede response teams

E. Basic Safety Rules

1. Never enter an unknown environment 2. Observe from a distance 3. Observe with your eyes, not your hands 4. Always request assistance 5. Stay up-wind & downgrade 6. Evacuate at the first sign of potential danger or exposure 7. Prevent unauthorized scene entry

F. Signs and Symptoms of Chemical Exposure

1. Behavioral changes 9. Nausea 2. Breathing difficulties 10. Tearing 3. Coordination difficulties 11. Tightness in chest 4. Coughing 12. Headache 5. Dizziness 13. Diarrhea 6. Diarrhea 14. Respiratory tract irritation 7. Changes in skin color 15. Drooling 8. Fatigue 16. Irritability

G. Chemical Medical Management

Skin Exposure

1. Remove the victim form the area of contamination 2. Remove contaminate clothing immediately 3. Lavage with copious amounts of clean water for 15-30 minutes 4. Treat for shock if present 5. Call for assistance

Inhalation

1. Remove the victim to fresh air 2. Loosen clothing 3. Maintain the airway 4. For particulate exposure, have the victim blow nose, discourage sniffing 5. Treat for shock if present 6. Call of assistance

Ingestion

1. Remove the victim from the contaminated area 2. If conscious rinse mouth with water 3. Loosen clothing 4. Prevent aspiration 5. Treat for shock if present 6. Call for assistance

Medical Aspects of Clandestine Drug Labs

Overview

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Section 14 – Forensics and Evidence Preservation

Duration 1 Hour Scope Statement This section provides students with hands on training in forensics and evidence preservation. Terminal Learning Objectives (TLO) At the end of this section students will understand the necessary issues and concerns of forensics and evidence preservation in the tactical environment. Enabling Learning Objectives (ELO) At the end of this section the students will be able to describe:

1. Tactical medic responsibility 2. Sources of evidence 3. Evidence collection 4. Chain of custody 5. Search & seizure laws 6. Documentation 7. Gunshot wounds forensics 8. Clothing considerations 9. On-scene legal considerations 10. Crime scene examples Resources See Appendix A Instructor to Participant Ratio 1:30 Reference List See Appendix B Practical Exercise Statement None Assessment Strategy Pre and post testing, end of course critiques, subjective evaluations, and instructor comments.

Forensics and Evidence Preservation

Overview

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Section 15 - Introduction to the M4 Law Enforcement Carbine

Duration 1 Hour Scope Statement This section provides students with hands on training with the use of the M4 Law Enforcement Carbine Terminal Learning Objectives (TLO) At the end of this section the students will understand the principles and concepts in the use of the M4 Law Enforcement Carbine Enabling Learning Objectives (ELO) At the end of this section the students will be able to describe: 1. M4 Carbine nomenclature 2. Ammunition selection 3. Sight picture 4. Proper stance 5. Proper grip 6. Sight picture 7. Loading and unloading 8. Clearing malfunctions 9. Trigger control 10. Cover vs. Concealment Resources See Appendix A Instructor to Participant Ratio 8:32 Reference List See Appendix B Practical Exercise Statement Hands on training and range exercises Assessment Strategy Pre and post testing, end of course critiques, subjective evaluations, and instructor comments.

M4 Carbine Safety Rules

A. Introduction 1. Safety 2. Nomenclature/sling 3. Stance, ready position 4. Load, unload and reload

B. Range 1. Semi-Automatic fire 2. Reload 3. Stoppages 4. Firing on the move 5. Backing out

Training Safety Rules A. FIREARMS SAFETY / MAIN SAFETY RULES 10. Treat Every Firearm as if it Were Loaded 11. Never Point a Firearm at Anything or Anybody that You Do Not Intend to Shoot, or in a Direction Where an Unintentional Discharge May Do Harm. 12. Never Place Your Finger into the Trigger Guard until Ready to Fire 13. Be Sure of Your Target, Backstop, and Beyond

B. RENDERING THE WEAPON SAFE 14. Always Point Weapon in a Safe Direction - MUZZLE AWARENESS – with your trigger finger indexed on the side of the firearm. 15. SAFETY ON (S/white) If Applicable 16. Magazine Removed 17. Bolt, Slide, or Cocking Lever Locked to the Rear 18. Visually and Physically Inspect the Chamber

C. GENERAL TRAINING SAFETY RULES 12. Wrap Around Eye Protection is MANDATORY 13. Ear Protection is MANDATORY 14. Hats (Baseball Style) is MANDATORY 15. Long Sleeve Shirt is recommended 16. We are responsible for each other’s safety - anyone seeing a safety problem must report it immediately to an instructor. Additionally, anyone may stop an exercise if they see a safety problem 17. Report any and all injuries immediately to an instructor – Don’t suffer in silence. 18. It is each participant’s responsibility to cover all open wounds and cuts before class begins. If this type of injury occurs during the training session, the participant will immediately notify an instructor. We will attend to the injury by covering it with first aid materials available. Treat all blood and body fluids with the utmost caution. Gloves will be used if there is any possibility of coming into contact with blood or body fluids.

19. At no time is any participant allowed to leave the training area without notifying an Instructor. 20. Remember to work at your own pace - Don’t over exert yourself. 21. Realistic training is important, however safety comes first! 22. Do not enter any unauthorized areas.

D. Force on Force Training

8. No live ammunition will be loaded or carried by anyone during Force on Force Training Exercises (Triple Checked by Participants, partners & Instructors) Anyone attempting entry or re-entry to the training area will be triple-checked for live ammunition. 9. When using blank or marking cartridges, or distraction devices, you may only use those that are issued and you must double-check them to insure they are intact. 10. All persons in the training area must wear protective gear (face shields, padding, etc) during Force on Force training until directed otherwise by the instructor. 11. When using Force on Force rounds, No Intentional groin or headshots will be allowed and shots within two feet of a role-player are not allowed. 12. Students will immediately cease activities when a sharp sustained blast of a whistle, and/or an instructor yelling, “stop” is announced. 13. Students will immediately cease actions upon a role-player announcing, “STOP” or “Out of Role”! 14. Mouth guards will be used as needed for Simulation Training.

E. Force on Force Safety Rules 11. Authorized firearms instructors must be present during use. 12. BODY ARMOR along with eye and ear protection must be worn. Everyone must wear a hat, gas mask or face shield during the training exercise. 13. Prior to live fire exercises, rooms must be checked to insure that no personnel are present. 14. Targets are placed so that all rounds will hit the impact area. 15. Only use authorized targets. 16. Authorized ammunition will only be used (check the approved list) 17. Instructors will review all targets and angles of deflection before beginning live fire. 18. All damage will be reported without retribution. 19. Shoot house will be cleaned before the end of the training exercises. 20. Cover any additional host agency safety rules.

M4 Carbine Nomenclature A. Butt stock with sling attachment and rear take down pin.

B. Rear sight

C. Scope mounts

D. Charging Handle

E. Front sight

F. Barrel and lugs

G. Front sling mount

H. Hand guard

I. Magazine release

J. Magazine well

K. Trigger, trigger guard and pistol grip

L. Safety select lever

Fundamentals of Shooting

PRIMARY OBJECTIVES

1. CONTROL MOTION

Movement in the firearm as the round is fired will adversely affect the strike of the round. Whether the shooter anticipates the shot and allows a pre-ignition push, or simply does not stabilize the gun fully upon presentation, motion will affect the strike of the round. Recoil is motion as well. What must be understood is that motion in the gun must be controlled as much as possible, just long enough to pull the trigger, in order for the round to impact the intended point.

2. CONSISTENCY

3. STANCE

4. GRIP

5. SIGHTING

6. TRIGGER CONTROL

7. FOLLOW THROUGH

8. SCAN & BREATHE

Ready Position The Ready Position begins from the good solid "Fighting Stance". Just as the name implies it is a position from which the shooter is most ready to quickly bring the firearm to engage the threat. This also allows the shooter to maintain observation of the threat and the threat area as the shooter assesses the threat.

A. Weapon in shoulder

The butt stock of the firearm is placed high on the shooter’s body and as close to the cheek of the shooter as possible. The butt stock and the stock weld should be considered the Pivot point or hinge as the shooter goes from the ready position up and into the firing position.

B. Dropped below sight (no tunnel vision) scanning

The muzzle is depressed from firing position to where the shooter can observe the threat or threat area as he is assessing and also enough that the shooter can turn his head left and right without becoming obstructed by the stock.

C. Finger off the trigger and indexed

D. Manipulation of the safety select lever

The safety select lever should be in the desired fire mode (depending on departmental policy).

Load 1. Firearm pointed in a safe direction 2. Safety on 3. Charging Handle to the Rear 4. Magazine on a. Seat and lock b. Two stages 5. Try to pull off magazine to insure it is properly seated

Unload 1. Firearm pointed in a safe direction

2. Safety On

3. Magazine off

4. Charging Handle Lever to the Rear

5. Visually and physically inspect chamber

Reload The reload of the M4 is a planned event, meaning that the shooter should reload when an opportunity exists such as a lull in the firing. The shooter must count their rounds, not necessarily round for round but the shooter must know the configuration of their firearm at all times.

A. Charging handle to the rear

While leaving the stock of the M4 in the shoulder, the shooter locks the cocking lever back with the support hand.

B. Remove the magazine

The shooter then places the support hand over top of the magazine with his thumb on the magazine release lever. Pushing the magazine release lever with the thumb and pulling the magazine out of the magazine well releases the magazine.

C. Insert a fresh magazine

The second magazine is then inserted firmly into the magazine well.

D. Give a tug down on the fresh magazine

A downward tug exerted on the magazine insures that it has been properly seated.

E. Release the bolt assembly forward

The shooter is then ready to fire again if needed.

Stoppages A. Empty magazine

Obviously when there are no rounds in the magazine it is considered a stoppage.

B. Magazine not seated

If the magazine is inserted with the bolt forward the magazine may not be seated. Also if the two clicks or actions that truly seat the magazine in the mag well are not performed the magazine may not be seated. Additionally, the magazine will insert (but not fully seat) upside down in the mag well. A tug downward on the magazine must be initiated to ensure proper seating.

C. Stove pipe

The spent casing is caught between the bolt head and the receiver. This is often caused by light load ammo, poor extraction, and dirty gun.

D. Double feed

Often caused by the shooter "riding the bolt forward" or attempting to perform a "press check” or no extraction, or the shooter not properly clearing the firearm and a round is still in the chamber when a new round is attempted to be chambered.

E. Rounds stuck behind ejector

If this occurs, the only way to clear is to drop the trigger Mech down and "fish" the round out.

F. Rounds behind bolt

Often caused by a "Hot Load" where the gun is forced to "over function" or an empty casing gets caught. The gun must be broken down to clear.

G. Defective ammunition

Not cycling the working parts properly or simply not firing.

Clearing Stoppages in the M4 Carbine

1. Lock back

Lock back the bolt group by pulling the charging handle to the rear. This may eject a live cartridge or spent casing but may not eject a round that may be chambered (depending upon the type of stoppage).

2. Mag off

Remove the magazine. You may see a live round or spent casing fall out of the magazine well but the firearm may still have a round chambered, depending upon the type of stoppage.

3. Shake from 4-8 o'clock.

Shake the firearm from 4-8 o'clock. Simply rotate the firing hand on the pistol grip from the 4-8 o’clock position. This may drop a spent casing that sometimes gets caught on the shelf just below the chamber.

4. Retract the bolt back and lock back.

This should allow the extractor to catch a round that may still be chambered and then extract and eject it.

5. Insert a fresh mag on, then bolt forward.

Insert a fresh magazine on, and then bolt forward. Inserting a fresh magazine is a good idea as the mag may be the original cause of the malfunction and a number of rounds may have been fired out of the previous magazine so a fresh fully loaded magazine will top the gun off.

6. Do not point firearm up or down, maintain the shooting grip and weapon in shoulder position.

Sling Carrying Positions 1. Front 2. Rear (Rappel) 3. Side

Colt M4 Law Enforcement Carbine

The M4 carbine for the US Military and M4LE 6920 carbine for US Law Enforcement was developed and produced by Colt Industries of Hartford, Connecticut. The Colt M4 carbine is actually a family of firearms that traces its lineage back to earlier carbine versions of the M16 rifle. These in turn, are all based on the original AR-15 rifle designed by Eugene Stoner at ArmaLite of Costa Mesa, California. The Colt M4 carbine is a shorter and lighter variant of the M16A2 assault rifle, with 80% parts having commonality.

The Colt M4 carbine is a gas-operated, magazine-fed, shoulder-fired weapon with a telescoping stock. A shortened variant of the M16A2 rifle, the M4 has a 14.5 in (370 mm) barrel, allowing its user to better operate in close quarters combat. The M4 has selective fire options including semi-automatic and three-round burst. The carbine is also capable of mounting an M203 grenade launcher (the M203A1 with a 9-inch barrel as opposed to the standard 12-inch barrel of the M203 used on the M16 series) as well as its successor, the M320 grenade launcher.

The United States Marine Corps has ordered its officers and Staff Non-commissioned officers to carry the M4 carbine instead of the M9 handgun. This is in keeping with the Marine Corps doctrine, "Every Marine a rifleman." The Marines however chose the full- sized M16A4 over the M4 as its standard infantry rifle. United States Navy corpsmen E5 and below will also be issued M4s instead of the M9.

The M4 carbine has largely replaced the submachine gun in military use due to increased use of body armor, as SMGs firing pistol-power cartridges are unable to penetrate modern body armor.

On July 1, 2009, the U.S. Army took over complete ownership of the M4 design. This allowed companies other than Colt Industries to compete with their own M4 designs. On October 30, 2009, Army weapons officials proposed a series of changes to the M4 to Congress. Requested changes include an electronic round counter that records the number of shots fired, a heavier barrel, and possibly replacing the direct impingement

system with a gas piston system. The benefits of this, however, have come under scrutiny from both the military and civilian firearms community.

In September 2010, the Army announced it would buy 12,000 M4A1s from Colt Firearms by the end of 2010, and would order 25,000 more M4A1s by early 2011. The Army announced also to have open competition for the newly designed M4 bolt carrier and gas piston operation system, which would be fitted to the newly bought M4A1 carbines. The service branch planned to buy 12,000 of these conversion kits in early 2011. In late 2011 the Army bought 65,000 more conversion kits. Trijicon TA01 Aimpoint Advanced Combat Optical Gunsights

On 21 April 2012, the US Army announced to begin purchasing over 120,000 M4A1 carbines to start reequipping front line units from the original M4 to the new M4A1 version. The first 24,000 were to be made by Remington Arms Company. Remington was to produce the M4A1s from mid-2013 to mid-2014. After completion of that contract, it was to be between Colt and Remington to produce over 100,000 more M4A1s for the US Army. Because of efforts from Colt to sue the Army to force them not to use Remington to produce M4s, the Army reworked the original solicitation for new M4A1s to avoid legal issues from Colt.

On 16 November 2012, Colt's protest of Remington receiving the M4A1 production contract was dismissed, which was thought to likely result in the Army re-awarding the contract to Remington. Instead, the Army awarded the contract for 120,000 M4A1 carbines worth $77 million to FN Herstal on 22 February 2013. The order is expected to be completed by 2018.

As with many carbines, the M4 is more convenient to carry than a full-length rifle. The ballistic performance is slightly inferior compared to the full- size M16, with its 5.5" (14 cm) longer barrel. This becomes most apparent at ranges of 300 yards and beyond. Statistically, however, most small-arms engagements occur within 100 yards. This means that the M4 is very much an adequate weapon for the majority of troops. The marginal sacrifice in terminal ballistics and range, in exchange for greatly improved handling characteristics, is usually thought Surefire Suppressor to be a worthwhile compromise.

However, there have been some criticisms of the carbine, such as lower muzzle velocities and louder report due to the shorter barrel, additional stress on parts because of the shorter gas system, and a tendency to overheat faster than the M16A2. Like all the variants of the M16, the M4 and the M4A1 can be fitted with many accessories, such as night vision devices, suppressors, laser pointers, telescopic sights, bipods, either the M203 or M320 grenade launchers, the M26 MASS shotgun, forward hand grips, and anything else compatible with a MIL-STD-1913 Picatinny rail on top of the receiver.

Other common accessories include the AN/PEQ-2, Advanced Combat Optical Gunsight (ACOG), EOTech 550 holographic weapon sights ,Trijicon TA01 and TA31, Aimpoint Advanced Combat Optical Gunsights, the M68 Close Combat Optic (M68 CO) being the favorite choice, , Visible and IR (infrared) lights of various manufacturers are also commonly attached using various mounting methods and a detachable rail-mounted carrying handle As with all versions of the M16, the M4 accepts a blank-firing attachment (BFA) for training Aimpoint Comp M68 Red Dot sight purposes.

The M4 carbine has been used for close quarters operations where the M16 would be too long and bulky to use effectively. It has been admired for being a compact, light, customizable, and accurate weapons platform. This has come at the cost of reliability and maintainability. Failure to maintain the M4 causes malfunctions. This became apparent as it saw continued use in the sandy environments of Iraq and Afghanistan. Despite this, soldiers who keep their M4s clean and functioning find it to be an exceptional carbine. In post-combat surveys, 94 percent of soldiers rated the M4 as an effective weapons system.

Trademark Issues

The M4 was developed and produced for the United States government by Colt Firearms, which had an exclusive contract to produce the M4 family of weapons through 2009. However, a number of other manufacturers offer M4-like firearms. Colt previously EOTech 550 holographic sight held a U.S. trademark on the term "M4." Many

manufacturers have production firearms that are essentially identical to a military M4, but with a 16" barrel. Civilian models are sometimes colloquially referred to as "M4gery". Colt had maintained that it retains sole rights to the M4 name and design.

Other manufacturers had long maintained that Colt had been overstating its rights, and that "M4" had now become a generic term for a shortened AR-15. In April 2004, Colt filed a lawsuit against Heckler & Koch and Bushmaster Firearms, claiming acts of trademark infringement, trade dress infringement, trademark dilution, false designation of origin, false advertising, patent infringement, unfair competition, and deceptive trade practices. Heckler & Koch later settled out of court, changing one product's name from "HK M4" to "HK416".

On December 8, 2005, a District court judge in Maine granted a summary judgment in favor of Bushmaster Firearms, dismissing all of Colt's claims except for false advertising. On the latter claim, Colt could not recover monetary damages. The court also ruled that "M4" was now a generic name, and that Colt's trademark should be revoked.

Unique Features of the M4 LE 6920 Carbine

This specially designed law enforcement weapon system features many of the combat proven advantages of the military M4. With the 4-position buttstock fully retracted, the Law Enforcement carbine is less than 30 in (76.2 cm) in length and weighs only 5.65 lbs. (2.56 kg) - ideal for tactical deployment and traditional patrol rifle.

1. Colt's M4 LE 6920 carbine is available with a step-cut barrel that allows it to accept a grenade launcher for non-lethal options. Dual Insulated Handguards

2. The handguard has dual insulated aluminum shielding for more effective heat protection.

3. Unique direct gas operating system eliminates the conventional operating rod and results in fewer and lighter components.

4. The LE6920 LE carbine accommodates the full range of 5.56mm ammunition, including the NATO M855/SS109 and U.S. M193, utilizing a rifling twist of 1 turn in 7" (178mm)

5. Straight-line construction disperses recoil straight back to the shoulder, increasing handling capabilities, especially during repeated fire.

6. Cartridge case deflector allows easy operation in both right and left handed shooting positions for increased tactical applications.

7. Muzzle compensator further reduces muzzle climb and helps eliminate flash and dust signatures.

8. Ejection port cover protects the chamber from dust and mud.

9. Field strips easily without special tools for simple field user maintenance.

10. Flat top receiver allows for removable carrying handle and easy mounting of accessories

11. M203 40mm Grenade Launcher (optional, subject to NFA restrictions) mounts directly to the Carbine without modification.

12. Target style rear sight features dual apertures (0-200m, 300-600m) and adjusts for both windage and elevation.

13. High strength materials add durability to the forearm, buttstock and pistol grip for greater comfort and effectiveness.

14. With the 4-position buttstock fully retracted, the M4LE 6920 Law Enforcement carbine is less than 30 in in length and weighs only 6.95 lbs.

M4 right side view M4 left side view

Dangerous Decibels

Noise Induced Hearing Loss Noise is an enemy of hearing, and it really does not take a lot of noise to damage your hearing. When the ears are exposed to extremely loud noise inner ear structures can be damaged, leading to what is called Noise Induced Hearing Loss or (NIHL). NIHL is actually quite common, affecting about one-third of the nearly 40 million Americans who suffer from hearing loss. Noise, or sound pressure, is measured in decibels (dB). Anything above 120 decibels can damage the ears and result in hearing loss. NIHL is caused by exposure to either a sudden, loud noise or exposure to loud noises. A dangerous sound is anything that is 85 dB (sound pressure level SPL) or higher. Gunfire ranges from 140 to 190 decibels depending on the weapon and caliber fired. Pitch is another measurement of noise, pitch, is the frequency of sound vibrations per second. The lower the pitch the fewer vibrations per second. Pitch is measured in Hertz (Hz), which means cycles per second. When hearing loss begins, a person will, generally, first have trouble hearing high-pitched noises.

How the Hearing Loss Occurs Loud noise causes damage to the hair cells in the inner ear and to the 8th cranial nerve resulting in sensorineural hearing loss or nerve deafness. Permanent damage can occur from even a brief, intense noise such as an explosion or gunfire especially in a closed environment. Hearing loss from loud noise may be immediate or occur slowly over years of continuous exposure. Immediate hearing loss is often accompanied by tinnitus, or ringing in the ears. Immediate hearing loss can occur in one or both ears and often involves severe damage to the inner ear structure. Because loud noise does not cause pain until the sound reaches very high decibels, people generally do not recognize noise as damaging until after the damage is done. It does not take much to start a gradual damaging effect that can lead to partial or total hearing loss. According to the U.S. Environmental Protection Agency, individuals regularly exposed to sound levels above 70 decibels can begin to damage hearing.

Anatomy and Physiology of Hearing Sounds are collected by the external ear (auricle) and transmitted down the external ear canal to set the eardrum in motion. The eardrum separates the canal from the middle ear with its 3 ossicles the malleus (hammer), incus (anvil), and stapes (stirrup). The eardrum's vibrations are picked up and amplified by the ossicles and conducted to the cochlea (the organ of hearing). The whole system, from the auricle to the stapes, is the conducting apparatus of the ear. There is a clear tendency for the ear to be more tolerant of noise at the low frequencies, as opposed to the middle and higher frequencies.

The ear appears to be particularly vulnerable to frequencies in the range of 2000 to 4000 Hz, or even 6000 Hz. These frequencies are likely to be generated by gunfire, explosions, and some types of aircraft noise. The loudness level or intensity of noise, measured in decibels, and the length of exposure are critical. Continued exposure to noise above 85 db over time will cause hearing loss. According to the National Institute for Occupational Safety and Health, the maximum exposure time on a single episode at 85 db is 8 hours, and at 110 db it is one minute and 30 seconds. Noise levels above 140 db can cause immediate irreversible hearing damage.

Frequency, measured in cycles per second or Hertz (hz), is also important as high frequency noise can cause more damage than low frequency noise.

At higher intensity, noise becomes explosive and causes a blast type injury to the ear. It may rupture the eardrum, causing a conductive hearing loss. If no further damage has been done, the hearing loss may be temporary. If the eardrum heals, complete restoration to normal is possible. The noise pressure may damage or dislocate the ossicles of the middle ear, causing a conductive hearing loss that may be permanent unless the ear is successfully operated upon. The blast may also tear the sensitive part of the cochlea (the organ of Corti) from its moorings, causing a sensorineural hearing loss that is permanent and irreparable. Any combination of these injuries may occur, so that the hearing loss may be conductive, sensorineural, or mixed

Most people lose their hearing slowly over a 15 to 20 year period because regular and repeated noise exposure damages the complicated and intricate hair cells of the inner ear that interpret sound vibrations as words, music or other sounds. Unlike the hairs on top of your head, which can be sheared off and grown back, hearing hair cells can't grow back because they are such highly developed, end stage cells.

Prolonged exposure to noise can actually change the structure of the hair cells in the inner ear, resulting in hearing loss. Tinnitus, which is the sound of ringing, roaring, buzzing, or clicking inside the head, often occurs with prolonged noise exposure damage, as well. Hearing loss from noise can be permanent or temporary. If the hearing loss is temporary, hearing usually recovers within 16 hours of loud noise exposure.

A tactical team prepares for an aircraft assault using suppressed weapons.

Decibel Exposure Time Guidelines

Accepted standards for recommended permissible exposure time for continuous time weighted average noise, according to NIOSH and CDC, 2002. For every 3 dBs over 85dB, the permissible exposure time before possible damage can occur is cut in half.

Continuous dB Permissible Exposure Time

85 db 8 hours

88 dB 4 hours

91 db 2 hours

94 db 1 hour

97 db 30 minutes

100 db 15 minutes

103 db 7.5 minutes

106 dB 3.75 min (< 4min)

109 dB 1.875 min (< 2min)

112 dB .9375 min (~1 min)

115 dB .46875 min (~30 sec)

Because NIHL is not immediately apparent, many law enforcement professionals leaving or retiring from their agencies are unaware of the full extent of their hearing damage. Some agencies are now just beginning understanding the link between law enforcement service and NIHL. It may take some time and unfortunately lawsuits before law enforcement agencies and city and county governments recognized the need to suppress all weapons used on entry teams.

Enter the U.S. Department of Labor Occupational Safety & Health Administration (OSHA). These are the Federal standards and regulations for Occupational Noise Exposure.

1910.95: Protection against the effects of noise exposure shall be provided when the sound levels exceed those shown in Table 1 when measured on the A scale of a standard sound level meter at slow response.

1910.95 (b) (1): When employees are subjected to sound exceeding those listed in Table 1, feasible administrative or engineering controls shall be utilized. If such controls fail to reduce

sound levels within the levels of Table 1, personal protective equipment shall be provided and used to reduce sound levels within the levels of the table.

1910.95(b) (2) If the variations in noise level involve maxima at intervals of 1 second or less, it is to be considered continuous.

Table 1 - PERMISSIBLE NOISE EXPOSURES

Duration per day, hours Sound level dBA slow response 8...... 90 6...... 92 4...... 95 3...... 97 2...... 100 1 1/2 ...... 102 1...... 105 1/2 ...... 110 1/4 or less...... 115

Table 2 SHOTGUNS (DECIBEL AVERAGES) .410 Bore 28" barrel 150 dB 26" barrel 150 dB 18 " barrel 156 dB 20 Gauge 28" barrel 152 dB 22" barrel 154 dB 12 Gauge 28" barrel 151 dB 26" barrel 156 dB 18 " barrel 161 dB

Table 3 CENTERFIRE RIFLE (DECIBEL AVERAGES)

.223, 55GR. Commercial load 18 " barrel 155 dB .243 in 22" barrel 155 dB .30-30 in 20" barrel 156 dB 7mm Magnum in 20" barrel 157 dB .308 in 24" barrel 156 dB .30-06 in 24" barrel 158 dB .30-06 in 18 " barrel 163 dB .375 18" barrel with muzzle brake 170 dB

Table 4 Pistol (DECIBEL AVERAGES)

.44 cal 170 dB .45 ACP 165 dB .357 magnum 160 bB 9mm 165 bB .38 Special 150 dB .22 cal 145 dB .40 cal 165 dB

The Source of the Problem Current law enforcement tactics require that tactical team members be in very close proximity to one another as the building or home is searched and cleared for suspects. Weapons are held essentially a few inches away from the ears of team members as each threat area is search and cleared. The room or immediate threat area is often flooded with multiple team members. Pistols, submachine guns and assault weapons ready to fire and are held in extremely close proximity to each officer during entry.

A discharge of the firearm to engage or neutralize a threat would be more than sufficient to produce an amplified devastating irreversible noise injury to the hearing of the officer(s) especially the individual whose ears are inches away from the weapon. Repeated shots fired will further damage the hearing of the officer(s). This devastating sound will disorient, distract and impair the ability of the tactical operator to make split second decisions. What has happened is essentially the team has been reverse “flash banged” giving their opponent the now the tactical advantage. While the officer is focused on recovering from the noise injury he is at a disadvantage and has lost his ability to focus on the threat. When multiple shots are fired in a close environment there is always the risk of contagious fire and the sympathetic response from other startled officers to pull the trigger and inadvertently discharge their weapons.

Although one ear will typically have an ear piece attached to the radio it will not provide sufficient protection for this high level of noise. The other ear is often unprotected because the tactical operator needs his sense of hearing to perform tactically. In this situation all officers are essentially unprotected and vulnerable to NIHL. Some agencies require that tactical officers wear some form of hearing protection in the ear opposite the earpiece. It is the opinion of the author that this practice is highly variable as well as the quality of the hearing protection used by tactical teams and or provided by their agency.

Suppressor Science The standard unit of measure is 1 dB which is the amount of sound that is barely audible to the average human. Most efficient modern suppressors will drop the sound by at least 30 dB. To appreciate how significant a reduction 30 dB represents, one should understand how sound is measured. The decibel scale is logarithmic, meaning that each unit is 10 times that of the preceding one. For example, a noise source measuring 80 dB is 10 times as loud as a source measuring 70 dB and 100 times as loud as a source reading of 60 dB. A small difference in

value actually means a tremendous difference in intensity. Reducing a gunshot by even 30 dB makes it 1,000 times quieter and it is this tremendous drop in the amount of sound that the suppressor preserves your hearing form damage.

Suppressors should be viewed as hearing protection safety equipment A suppressor or sound moderator is a device that when attached to a firearm reduces the amount of noise and eliminates the flash generated by firing the weapon. It generally takes the form of a cylindrically shaped metal tube that is fitted onto the barrel of the firearm, with various internal mechanisms to reduce the sound of firing by slowing the escaping propellant gas. Suppressors are unfortunately known as “silencers”. This is a gross misconception that has permeated throughout our society since Hiram P. Maxim invented the “Maxim Silencer” and patented it in 1909 as well as a silencer or muffler for gasoline engines.

The portrayal of silenced firearms on television and in movies over the years has erroneously created the concept that silencers completely eliminate the sound of firing, or reduces it to a quiet puff sound. I am sure almost everyone has seen on television or in the movies a “silencer” attached to a revolver which made little or no sound when fired. It is this type of Hollywood nonsense that has ruined the reputation of suppressors. It is unfortunate that in this country suppressors are viewed as sinister and as assassination tools. In France for example, suppressors are sold openly in stores without restriction or registration. In fact in France and Switzerland you can be fined by law enforcement for discharging a firearm without a sound suppressor in certain locations.

How quiet is quiet? No suppressor completely eliminates the noise of a discharging firearm. In fact, the decreased noise can still be heard and very noticeable for some distance, depending on the surroundings and environmental conditions. However, to be 100 percent truthful I have personally seen and fired a Remington 512 Score Master .22 cal rifle modified with custom full barrel integral suppressor using .22 cal CB minicaps. The report from the weapon was essentially mechanical noise only of the firing pin striking the rim of the cartridge. I am not sure what the purpose would be for this type of weapon with such an extremely low powered .22 cartridge would be except for demonstration purposes or to shoot a fox in a hen house as to not disturb the chickens. Believe it or not this was Hiram P. Maxims’ original intent for inventing the “silencer”. For those of you who have never lived on a farm, disturbed chickens will quit laying eggs, sometimes for several days.

Benefits of Suppression A suppressor is meant to reduce the report to a more comfortable level for the shooter. When a round is fired and the very hot gases exit the barrel quickly it makes the distinctive gunshot. When the suppressor is attached it gives the gases more time to expand and cool. Even subsonic bullets make distinct sounds by their passage through the air and striking targets, and supersonic bullets produce a sonic boom, resulting in "ballistic crack." Semi- automatic firearms also make a distinct noise as their action cycles, ejecting the fired cartridge case and loading a new round. Thus, the ideal suppressed weapon would be either a single- shot or a manually-operated repeating firearm such as a bolt-action rifle When mounted on pistols and submachine guns with subsonic (slower than the speed of sound) ammunition, a good suppressor can reduce the sound to roughly comparable to a staple gun. Often the sound of the gun's bolt cycling is louder than the actual report.

A good example of this is the Hecker & Koch MP5SD. This integrally suppressed submachine gun used by many law enforcement agencies drops the speed of the bullet to approx 850 feet per second and eliminating the supersonic crack, or the bullet would to exceed the speed of sound at approx 1150 feet per second. Suppressors have other benefits besides just reducing noise. Most suppressors are effective recoil reducers. A suppressor also cools the hot gases coming out of the barrel enough that most of the lead vapor that leaves the barrel condenses inside the suppressor, reducing the occupational lead exposure to the shooter and others around them. Suppressors are particularly useful in enclosed spaces where the sound, flash and pressure effects of a weapon being fired are amplified such as close quarter battle (CQB) in a mobile home, or in tubular assaults (buses, trains and planes). Such effects will disorient the shooter, affecting concentration and accuracy, and can permanently damage hearing very quickly.

Both side arms as well as long guns should be suppressed during tubular assaults to avoid officer hearing injury

There are many benefits with suppressors on law enforcement rifles as well. The suppressor can reduce the recoil significantly as it traps the escaping gas. This gas mass is a little less than one-half the projectile mass (approximately 1.6 grams vs. 4 grams), with the gas exiting the muzzle at about twice the projectile's velocity, thus giving a reduction in the felt recoil of approximately 15%.

Some of the newer suppressors on the market can actually improve minute of angle accuracy and increase the bullet velocity by 30 to 50 feet per second. There is also a further benefit which is often neglected. A sound suppressor nearly eliminates the muzzle flash, depending on the specific ammunition fired. This could be very important during tactical operations at night, since some well trained criminals know to identify and shoot at muzzle flashes. Another concern of muzzle flash is warrant service in a location that is suspected being a clandestine drug lab. A muzzle flash in this environment if there were high levels of a volatile gas would be catastrophic for everyone in the room or building.

Retrofitting the weapons systems Technology has made tremendous progress in the past five years in the design, construction and manufacturing of suppressors for the military and law enforcement. Suppressors are smaller, lighter and one company is producing suppressors that have a projected life span of over 30,000 rounds. Heckler & Koch and SIG SAUER produce handguns with factory threaded barrels ready for suppressor attachment. Also there are several manufactures that produce threaded barrels so that almost any handgun can be fitted with a suppressor. Many law enforcement agencies today are switching to the Colt M4 as their primary tactical team weapon. Several companies are producing suppressors for the M4. Long gone are the days of screwing on suppressors to these guns after removing the Colt bird cage flash hider.

Today’s suppressors have quick attach/ detach designs that allow the operator to attach and remove the suppressor from the weapon in a matter of seconds and there are nylon Velcro pouches to store the suppressor on the tactical vest or belt for immediate use if necessary.

With the current climate of prolific litigation and liability for workplace injuries it makes perfect sense that law enforcement agencies should become proactive and take steps to mitigate the losses of personnel in the form of increased disability payments and early retirement from hearing loss. The amount of money saved by city and county governments could easily be a $15,000 $30,000 per year per officer out on early retirement or disability from hearing loss. The few dollars invested to retrofit the teams’ weapons would pay huge dividends in the long term. Law enforcement agencies, city, county and the federal government need to wake up and an recognize that suppressors are not assassination tools but are hearing protection safety equipment and should be a required necessity for the health and safety of all law enforcement professionals who go into harms way.

Section 16 – Chemical Munitions in the Tactical Environment

Duration 1 Hour Scope Statement This section provides students with hands on training in the use of chemical munitions in the tactical environment. Terminal Learning Objectives (TLO) At the end of this section students will understand the use of chemical munitions in the tactical environment. Enabling Learning Objectives (ELO) At the end of this section the students will be able to describe: 1. Indications for use 2. Chemical munitions preparation 3. Delivery systems 4. Effects of exposure 5. Lethal concentration computation 6. CN, CS& CR exposure field management 7. MACE exposure field management 8. Principles of field decontamination 9. Airway management 10. Site control and containment Resources See Appendix A Instructor to Participant Ratio 1:30 Reference List See Appendix B Assessment Strategy Pre and post testing, end of course critiques, subjective evaluations, and instructor comments.

Chemical Munitions in the Tactical Environment

Overview

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Section 17 – Medical Threat Assessment & Barricade Medicine

Duration 1 Hour Scope Statement This section provides students with training in medical threat assessment and barricade medicine in the tactical environment. Terminal Learning Objectives (TLO) At the end of this section students will become familiar with and understand the dangers of suspect with disguised weapons in the tactical environment. Enabling Learning Objectives (ELO) At the end of this section the students will be able to describe: 1. Planning advantages 2. Operations requiring medical threat assessment 3. Mission operational security 4. Hazardous material threats 5. Biological threats 6. Environmental threats 7. Information prioritizations 8. Information transfer 9. Data customization 10. Medical threat assessment resources Resources See Appendix A Instructor to Participant Ratio 1:30 Reference List See Appendix B Assessment Strategy Pre and post testing, end of course critiques, subjective evaluations, and instructor comments.

Medical Threat Assessment and Barricade Medicine

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Section 18 - Module A Written Final Exam

Duration 1 Hour Scope Statement The final written exam for Module A Terminal Learning Objectives (TLO) At the end of this section students will have completed a 50 question multiple-choice exam covering the material learned and practiced in the first 40 hours of the 2-week school and the Module A course. Enabling Learning Objectives (ELO) At the end of this section the students will be able to describe:

The answers to the 50 multiple choice question in the final exam for Module A course. Resources See Appendix A Instructor to Participant Ratio 2:32 Reference List See Appendix B Practical Exercise Statement Written exam Assessment Strategy Pre and post testing, end of course critiques, subjective evaluations, and instructor comments.

Appendix A – Resource Equipment List

Classroom Equipment

• Classroom facilities for 50 participants • High quality projector screen • Comfortable chairs and tables for 50 participants • Wireless remote control for computers • 50 student course manuals • 2 high definition video monitors • 12 Instructor manuals • DVD and VHS tape player • Tower computer and back up laptop computer • Podium with wireless microphone system • Monitor for tower computer • High quality audio sound system and speakers for • High definition digital projector classroom • High quality projector screen • Extension cords • Wireless remote control for computers • 2 Power Strips • High definition digital projector • Flip charts with easel and markers • PowerPoint presentations on CD-Rom or hard drive

Medical Equipment

• 6 Tactical Medical vests • 30 Cook retrograde intubation sets • 6 adjustable size cervical collars • 6 McGill Forceps • 4 Backboards • 6 Gum Elastic Bougies • 12 laryngoscope handles • 12 sets of adult Ambu Bags • 24 Miller laryngoscope blades • 12 sets of pediatric Ambu Bags • 24 McIntosh laryngoscope blades • 1 Full Brozelow Pediatric Advanced Life Support Kit • 8 sets of spare AA batteries for laryngoscope handles with Brozelow Tape • 4 Laerdal Intubation Training Mannequins heads • 6 Boxes of 4 x 4 dressings • LMA Intubation Training Mannequin head • 6 Boxes of 2 x 2 dressings • 10 - 15 LMA Tubes various sizes • 8 Chemical Ice Packs • 1 Combitube Intubation Training Mannequin head • Band Aids Standard Size (50 minimum per week) • 10 Combitubes various sizes • Band Aid Large (20 minimum per week) • 40 Surgical Airway sets with scalpels, # 11 and # 15 • Peroxide 2 bottles per week blades with scissors, curved hemostats and pickups • Betadine 2 bottle per week with teeth. • 4 Cook Wadwahs • 80 Chux pads • 6 Blackhawk Special Operations Medical Backpacks • 4 boxes of latex and nitrile exam gloves S, M, L, XL fully stocked each with: • 80 Hog tracheas for surgical airway workshop o IV tubing • 1 cooler with dry ice for storage of fresh hog tracheas o Crystalloid Solution • 25 -30 Israeli Bandages (Emergency Bandage) o Tourniquets • 5 C.A.T tourniquets o Combine Dressings • 10 -15 MAT Tourniquets o 4x4 dressings o • 25 - 30 Small Ace bandages IV Catheters o • 25 - 30 Large Ace bandages Airway section o Trauma section • 6 Adult View Max laryngoscope handles o Basic Medical Section • 6 Pediatric View Max laryngoscope handles o Advanced Medical Section • 6 Adult View Max laryngoscope handles o Specialty Section • 6 Pediatric View max laryngoscope handles o Splinting equipment • Vacuum Sealer for equipment with sufficient supply of vacuum packaging

Tactical Medical Scenario Equipment • Safety equipment: Comprehensive First Aid Kit for • 6 Scenario Props Set which includes the following: each active Station o Booby traps • 1 Fire Extinguisher for each active station o IED’s sawed off shotgun • 6 sets handcuffs / flexi-cuffs o Old handguns • Wand style metal detector for each scenario for safety o Training knives check o Rubber snakes handcuffs • Suitable realistic location for tactical-medical o Flex cuffs scenarios (old hotels, apartment complexes, buildings, o Flashlights warehouses etc) o Used detcord • 6 Blackhawk Special Operations Medical Backpacks o Claymore mine fully stocked each with: o Large infant dolls o IV tubing o Timers, wire o Crystalloid Solution o Old circuit boards o Tourniquets o Duct tape o Combine Dressings • 6 Simulaids Moulage Kits complete with large o 4x4 dressings assortment of trauma and gunshot wound overlays, o IV Catheters makeup and artificial blood o Airway section • 1 Clandestine Drug Lab complete set up for o Trauma section methamphetamine manufacture including all o Basic Medical Section glassware, heating mantels, flasks, beakers, o Advanced Medical Section condenser, separatory funnel, graduated cylinders, o Specialty Section ether cans, acetone cans and chemicals o Splinting equipment • Note: Restricted items, possession of this material • 12 Laerdal Full Body Trauma Mannequins is a felony by non-law enforcement personnel • 12 Laerdal Full body Trauma Mannequins carry bags • 2 Laerdal Pediatric Trauma Mannequins • 60 sets of Motorola 800 UHF Radios • 8 Portable flexible tactical litter kits • 12 Motorola Talk - About radios chargers with spare • 50 Gas Masks with carry bags batteries • 4 pelican 5150 cases for Gas Masks • 6 Large Orange Cones to marks scenario stations • 1 Gas Mask cleaning and repair kit • 6 First Aid Kits for scenarios stations • 6 Blank pistols .22 cal • 6 Coolers for ice water at scenario stations • 300 Rounds .22 cal blanks • 10 DEF Tec 25 Flash Bangs (NOTE: This is a BATF • 6 Blank pistols 8mm regulated item and requires a BATF destructive • 300 rounds 8 mm blanks device permit as well as a California Department of Justice permit (DOJ) and is a felony for possession by • 40 LYT’s in 9mm, 40 cal, 45 cal, and 223 non-law enforcement personnel) • 6 sets of police officer uniforms for trauma manikins • 2 Canine intubation manikins • 6 sets of SWAT officer uniforms for trauma manikins • 1 High Definition Digital Camcorder with tapes complete with tactical vest, body armor, duty weapon • 2 Digital SLR Cameras • 12 sets of civilian clothing for trauma manikins • 2 High Definition Flat Panel Monitors

Tactical Equipment

• 1 Armored Vehicle BEARCAT • 1 Portable Electric Honda Generator • 1 Hydraulic breeching tool • 2 100 Foot heavy duty extension cords • 1 Super Halligan tool • 1 gas can for generator fuel • 1 Mobile home Breacher • 1 set out door portable halogen light system • 1 Thor’s Hammer • 1 Class 4 Body Armor for demonstration with ceramic • 1 Break - N -Take Tool plates • 1 Breachers Tactical Backpack Kit • 1 Ballistic Helmet • 1 Heavy door battering ram • 1 Nomex Balaclava • 1 Steel Wedge • 1 pair Nomex Gloves • 1 Pry bar • 1 pair tactical goggles • 1 Sledge Hammer • 1 pair knee pads • 8 -10 Shape charges • 1 pair elbow pads • 4 Water Charges • 1 remote camera system • 20 feet of DETCORD • 1 flash bang pole • Note: Restricted item requires BATF, and • 1 tactical service knife California Department of Justice permits • 1 drop holster with duty belt • 1 Benelli M1 Super 90 shotgun for breeching • 20-25 shot lock 12 gauge rounds • 1 Remington 870 shotgun for breeching

Range & Firearms Training Equipment

• 12 Sets of Hearing protection for instructors • 40 Viking M4 Carbine VTAC slings • 12 sets of eye protection for instructors • 4 Simunition Kits in 38 caliber • Hearing protection: 100 sets of foam ear plugs • 6 Simmunition Kits in 9 mm • 60 pairs of ballistic eye protection • 60 Force on Force Helmets • Range facilities with a minimum of 4 separate Sub • 60 Sets of Force on Force neck protection Ranges. • 60 Sets of Force on Force Male groin protectors • 25 Glock 17 Pistols • 15 Sets of Force on Force Female groin protectors • 45 Gock 17-T Force on Force Pistols • 60 Large Heavy duty bags for Force on Force Pro • 15 SIG 9 mm 229 Pistols Gear • 12 Sets of Flashlights Lights for instructors and Range • 1 Sniper Rifle and Sling in 308 or 300 Winchester Master Magnum / WSM • 80 sets of spare batteries lithium batteries for the • Ammunition for Sniper Rifle flashlights • Ultrasonic Parts cleaner for weapons systems • 10 sets of spare bulbs for the flashlights • 50 cleaning rods and .556 mm brushes • 50 Dropleg holsters for Pistols • 500 100% cotton 9 mm, 40 cal, 45 ACP and .556 • 50 tactical holster duty belts cleaning patches • 50 dual magazine pouches • 6 bottles of Breakfree • 2 Tactical pistols with threaded barrels and • 6 bottles of Hoppes # 9 suppressors • 2 large cases for firearms cleaning supplies • 40 Colt 6920 Law Enforcement Carbines • 1 armorer’s kit and tool box for Glock 17 pistols • 80 Lancer 30 Round Translucent Magazines • 1 armorer’s kit and tool box for Colt M4 • Note: Above items are restricted and require • 2 armorer’s manuals for each weapons system used California Department of Justice permits o Pistol • 500 SEB style paper targets o SMG • 6 heavy duty staple guns o Shotgun • 8 rolls duct tape o Carbine • 40 sets of Ballistic Body level IIIA Armor for o Precision Rifle participants • 1 M4 Spare parts box with extractors, ejectors, firing • 8 sets of Ballistic Body Armor level III A for Instructors pins, firing pin springs, bolt heads, bolt carriers and • 45,000 rounds 9mm 40 cal and 45 ACP ammunition take down pins. • 1000 Force on Force Rounds • 6 pelican 5150 cases with locks for pistols • 20,000 Rounds .556 ammunition • 4 pelican cases with locks for transporting M4 • Water and ice chest cooler for each sub range Carbines • Safety equipment: Comprehensive First Aid Kit for • 40 Steel target systems each active Range / Sub Range • 8 cans assorted color spray paint • Safety equipment: Fire Extinguisher for each active • 40 Target stands Range / Sub Range • 250 cardboard backing for paper targets • Wireless Dual Channel PA System with boom Microphones

Appendix B – Reference Material

Campbell J, Heiskell L, Smith J, Wipfler J: Tactical Medicine Essentials, Second Edition textbook 388 pages, Jones and Bartlett Learning publisher, September 2020

Heiskell L: The Tension Pneumothorax, Tactics and Preparedness, pp 14,15, February, 2020

Heiskell L, How to Prevent Positional Asphyxia, Police September 2019 Heiskell L, How to Start a Tactical Medicine Program, Police, March 2019 Heiskell L, Use an Emergency Bandage to Control Bleeding, Police p 28, March 2018 Heiskell L, Olesnicky B, Tactical Medicine, Wilderness Medicine Chapter 23, 7th Edition 2017 Tang D. MD, Olesnicky B.MD, Eby M. MD, Heiskell L. MD: Auto-Transfusion Tourniquets: The Next Evolution of Tourniquets. Open Access Emergency Medicine, pp 29 – 32, January 2014 Heiskell L. Why Officers Need Advanced Medical Training, Police pp 68-74, June 2016 Campbell J. MD, Heiskell L. MD, Smith J. EMTP, Wipfler J. MD: Tactical Medicine Essentials. Jones and Bartlett Learning, Textbook 387 pages, 2012 Heiskell L, Olesnicky B, Tactical Medicine, Wilderness Medicine Chapter 25, 6th Edition 2011 Heiskell L: Needle the Chest: Tactical Weapons, pp 94 - 95, September 2010 Vail S: Field Trauma Care for LEOs, POLICE, Vol 34, No 8, pp 38 - 39, August 2010 Pi J: Bilateral Vascular Restraint: Facts and myths of the carotid restraint, The Tactical Edge, pp 44 - 50, Summer 2010 Sztajnkrycer M: Learning From Tragedy: Preventing officer deaths with medical interventions, The Tactical Edge, pp 54 - 58, Fall 2009 Bailey J: Deputy Gets Schooled in Tactical Medicine, Maryland Sheriff. Vol 25, No 4, pp 29 - 31 Winter 2009 Gerold K,Gibbons M, McKay S: The relevance of Tactical Combat Casualty Care (TCC) guidelines to civilian law enforcement operations, The Tactical Edge, pp 52-60, Fall 2009 Heiskell L: Seal a Sucking Chest Wound: Tactical Weapons, p74, September 2009 Vail S: Life or Death Medical Alerts: Tactical Weapons, p 84, May 2009 Soto R: Tactical Rescue Operations: The Tactical Edge, pp 60-62, Spring 2009 Heiskell L: Extreme Cold Ops Survival: Tactical Weapons, p 88, March 2009 Levy M, Gerold D: Preventing Ring Associated Injuries: Think twice about wearing that ring, The Tactical Edge, pp64-66, Winter 2009 Heiskell L: Get'Um Breathing Stat: Tactical Weapons, p 70, January 2009 Micheli A: Tactical Medic: Kommando, p 50-56, November 2008 Heiskell L: Hand Armor Advancements: Tactical Weapons p 78 November 2008 Krebs, D: Venomous Snakes and Arthropods: A threat to mission success, The Tactical Edge, pp 62-72, Fall 2008 Menley, C: Medics Armed and Ready: Tactical Weapons, p 14 September 2008 Heiskell L: Dangerous Decibels, Does SWAT Need Suppressors: Police, pp 58-62, August 2008 Croushorn J, Westmoreland T: Tactical Medical Equipment: Part 2, The Tactical Edge, pp 58-63, Summer 2008 Heiskell L: Stop the Bleeding: Tactical Weapons, pp 64-65 July 2008 Johnson M., Brownlee C: Tactical Medicine: An investment you can live with. SWAT, pp 62-64, 88, May 2008

Heiskell L: Battlefield Ocular Injures: Treating and protecting eyes for those on the beat and in the sand box. Tactical Weapons pp 60-61 May 2008 Micheli A: International School of Tactical Medicine: RAIDS Italia, pp19-23, April 2008 Bryant N: Into the Hot Zone: Training to become a tactical medic, National Fire and Rescue, pp18-23, March - April, 2008 Croushorn J, Westmoreland T: Tactical Medical Equipment: Part 1, The Tactical Edge, pp 60-64, Spring 2008 Olesnicky D: Blast Injury Treatments: Multi-Major Responses: Projectile Signs Primary Wounds, Trauma and more. Tactical Weapons pp 28-29, March 2008. Gerold KB: Tourniquet use for extremity wounds sustained during law enforcement operations: The Tactical Edge, pp 56 - 63, Winter 2008 Vail S: CSI of Wound Ballistics: Know what you ammo is capable of before pulling the trigger, Tactical Weapons pp 34-35, January 2008 Olesnicky, BT: Combat Medical Gear: Essential tools could mean life or death, Tactical Weapons pp 92-09, November 2007 Lawner B, Alves D, Gerold K: A microscopic offender: armed, dangerous and contagious: The Tactical Edge, PP 56-61, Fall 2007 Heiskell L: Medical Alert: Training You to Save Lives, Tactical Weapons, pp 91-92, July 2007 Heiskell L: Tactical Medicine for Law Enforcement, PORAC Law Enforcement News: First Responders Master On-Scene Advanced Life Support, pp 8-9, Vol 39 No 7 July 2007 Weiss J, Davis M: Tactical Medic Scenario Training, The Tactical Edge, pp 50-52, Summer 2007 Heiskell L: Olesnicky BT, Welling L, Tactical Medicine and Combat Casualty Care: Chapter 23. Wilderness Medicine Textbook 5th Edition, 2007 McKay s, Hoyne C: High Threat Immediate Extraction: The Immediate Reaction Team (IRT) Model, The Tactical Edge, pp 50-54, Spring 2007 Hansen D: International School of Tactical Medicine: The Best Medicine in the Worst Places, SWAT, pp 48-53, May 2007 Bertolli E, Forkiotis C, Pannone D, Dawkins H: Tactical Vision Care, The Tactical Edge, pp 62-65, Winter 2007 Greenberg M, Wipfler J: Medical Ballistics: The Tactical Edge, pp 68-78, Fall 2006 Heiskell LE, Olesnicky BT: Equipping the Tactical Medic, POLICE, pp 36-40, Volume 30 No 3, March 2006 Floyd K, Justice W: Teaching New Dogs Old Tricks: Advances in adult I/O vascular access, The Tactical Edge, pp 64-66, Summer 2006 Heiskell LE: First Aid: Tactically Trained Medical Personnel Are a Critical Element in SWAT Operations, POLICE, Volume 30, No 3, pp 28-34, March 2006 Gibbons ME, Gerold K: A Team Approach to TEMS: MarylandState Police Tactical Medical Unit, The Tactical Edge, Vol.24 No 2 Spring 2006 Madsen M: Tactical Casualty Care Innovations, The Tactical Edge, pp 60-66, Volume 24 No 1 Winter 2006 Ciccone TJ et.al.: Successful Development and Implementation of a Tactical Emergency Medical Technician Training Program for United States Federal Agents, Prehospital and Disaster Medicine, pp 36-39, Vol 20 No 1, 2005 Chiasson A, Weisinger Y: Medical Force Protection, The Tactical Edge, Vol. 23, No. 1, Winter 2005 Zotti R, Gibbons M: Tactical Long Rifleman Care: Tactical Medicine From Afar, The Tactical Edge, Vol. 23, No. 4, p78-79, Fall 2005 Bjerke H, True D: Trauma Center Integration Into TEMS, The Tactical Edge, Vol. 23, No. 3, pp 75-75, Summer 2005

McCarthy P: TEMS and Specialty Impact Munitions, The Tactical Edge, Vol. 23 No. 2, pp 52-54, Spring 2005 Wilkerson W, Lutes M: Simulator Training for TEMS Providers, The Tactical Edge, Vol. 22, No.4, pp 60-62, Fall 2004 Heiskell L,Olesnicky D, Vail S: Blood Clotters: SWAT Medics Report Their Findings on High-Tech Hemostatic Dressings Used To Stop Bleeding When Seconds Count.,Vol 28, No.8, pp 52-59, August 2004 Heck J: Electrical Impluse Devices: The Medical Implications, The Tactical Edge, Vol.22, No. 3, pp 74-75, Summer 2004 Baez A, Sztanjnkrycer M: Basic Principles of Protective Medical Support, The Tactical Edge, Vol. 22, No. 2, pp 63-67. Spring 2004 Heiskell L: Heckler & Koch's Advanced Tactics & Medicine Course: On The Cutting Edge, POLICE, pp 56-59, January 2004 Rathbun D: The Tactical Operator's Role on The TEMS Team, The Tactical Edge, Vol. 21, No. 1, pp 56-57, Winter 2003 Floyd K, Justice B: Field Management of The Complicated Airway, The Tactical Edge, Vol. 21, No.1, pp 48-50, Winter 2003 Zelt K: SWAT Response to WMD Incidents, The Tactical Edge, Vol. 21, No. 1, Winter 2003 Rathbun D, Johannes D: Dental Emergencies in the Tactical Setting, The Tactical Edge, Vol. 21 No. 4, pp 66-68, Fall 2003 DePatto J: York Hospital Medic 97 TRU: A Retrospective Look, The Tactical Edge Vol. 21 No. 4 pp25-31, Fall 2003 Brooks J, Curtis D, Sweetland J: SWAT Response to a WMD Attack. The Tactical Edge. Vol. 21 No. 3, pp 32-38, Summer 2003 Heck J: Kinetic Impact Weapons: The Potential for Injury, The Tactical Edge, Vol. 21 No. 3, pp 62-64, Summer 2003 Rathbun D: TEMS-Specific Training and Continuing Education, The Tactical Edge, Vol. 21 no. 2, pp 52-54, Spring 2003 Boseman W: Medical Threat Assessment: The Taser M26 Less Lethal Weapon, The Tactical Edge, Vol.21, No.2 pp 32-34, Spring 2003 Burke T: Every Team Needs Tactical Medical, Tactical Response, pp 28-31 Spring 2003 Rinnert K, Hall W: Tactical Emergency Medical Support, Emergency Medicine Clinic of North America, Vol. 20, No.4, November 2002 Carmona R: TEMS Transitioning Into the New Millennium, The Tactical Edge, Vol 20, No 3, pp 64-65, Fall 2002 Bozeman WP, Eastman ER: Tactical EMS: An Emerging Opportunity in Graduate Medical Education. Prehospital Emergency Care Vol 6 No 3, 322-324, 2002 Carmona R: Public Health Aspects of Tactical Emergency Medical Support, The Tactical Edge, Vol 20, No 3, p 58, Summer 2002 Carmona R: TEMS Best Practices and Evidenced Based Medicine, The Tactical Edge, Vol 20, No 2, p 58, Spring 2002 Williams G: TEMS and The Cypress Creek Advanced Tactical Team, Vol.20, No 2, pp18-21, Spring 2002 Greenberg M, Wipfler E: Explosions and Blast Injuries: Dealing with The Terrorist Threat, The Tactical Edge, Vol 20, No 2, pp 29-34, Spring 2002 Carmona R: TEMS Bibliography II, The Tactical Edge, Vol 20, No 1, pp 53-54 Greenstone J: The Role of Tactical Emergency Medical Support in Hostage and CrisisNegotiations, Vol 20, No 1, pp 33-35, Winter 2002

Sullivan P, Richards L: Force Protection: Law Enforcement Support to Mass Casualty / Mass Decon Operations, The Tactical Edge, Vol 19, No 4, pp 27-30, Fall 2001 Krebs D: Preventing Lyme Disease in Tactical Operators, The Tactical Edge, Vol 19, No 4, pp 68-69, Fall 2001 Carmona R: Practical Aspects of TEMS Equipment Selection, The Tactical Edge, Vol 19, No 4, pp 62-63, Fall 2001 Hodgkinson J: Documentation for the Tactical Medic, The Tactical Edge, Vol 19, No 4, pp 58-59, Fall 2001 Sharma N: Tactical EMS Case Review, The Tactical Edge, Vol 19, No 3, p 64, Summer 2001 Barren J: Treatment and Avoidance of Chemical Poisoning, The Tactical Edge, Vol 19, No 3, pp 42-44, Summer 2001 Carmona R: Evolving TEMS and Tactical Concepts in Response to the Active Shooter, The Tactical Edge, Vol 19, No 3, pp 52-54, Summer 2001 Carmona R: Controversies in TEMS, The Tactical Edge, Vol 19, No 2, pp 61-63, Spring 2001 Kregs D: Medical Response to the Joseph Palczynski Incident, The Tactical Edge, Vol 19, No 1, pp 99-101 Winter 2001 Carmona R, Kester, D: The Tactical Emergency Medical Support (TEMS) Plan, The Tactical Edge, Vol 19, Vol 1, pp 61-62, Winter 2001 Heck J, Byars D: Chemical and Biological Agents: Implications for The TEMS Provider, The Tactical Edge, Vol 19, No 1, pp 52-55, Winter 2001 McCarthy P: Medevac Operations: A Tactical Consideration, The Tactical Edge, Vol 19, No 1, pp20-22, Winter 2001 Carmona R: TEMS and Emerging WMD Threats, The Tactical Edge, Vol 18, No 4, pp 70-72, Fall 2000 Greenberg M, Wipfler E: Administrative Considerations for Tactical Emergency Medcine Support, The Tactical Edge, Vol18, No 4, pp 64-68, Fall 2000 Carmona R, Kester D: Integration of Medical an Immediate Action Drills (IADS), The Tactical Edge, Vol 18, No 3, pp 75-76, Summer 2000 Heck J :Terrorist Bombings: Ballistics, Patterns of Blast Injury and Tactical Emergency Care, The Tactical Edge, Vol 18, No 3, pp 53-55, Summer 2000 Wipfler E, Kaufman T, Greenberg M: Weapons of Mass Destruction: Dealing With The Threat, The Tactical Edge, Vol 18, No 3, pp 44-51, Summer 2000 NTOA Correction Committee: TEMS and the Corrections Tactical Unit, The Tactical Edge. Vol 18, No 2, pp 70-71, Spring 2000 Heck J, Kepp J: Medical Equipment Selection for Protective Operations, The Tactical Edge, Vol 18, No 2, PP 68- 69, Spring 2000 Carmona R: A Brief History of TEMS and a Farwell Tribute to CMDR Rasumoff, The Tactical Edge, Vol 18, No 2, p 67, Spring 2000 Sharma N: Vancouver Police Deploy SWAT-Tactical EMS, The Tactical Edge, Vol 18, No 2, pp 35-38, Spring 2000 Heiskell L: Hepatitis B: What Are The On-Duty Risks?, Police, Vol 24,No 2, p 10, February 2000 McCarthy P: Rapid Medical Assessment, The Tactical Edge, Vol 18, No 1, pp 52-55, Winter 2000 Carmona R, Rasumoff D: Psychological and Physical Changes Following an Officer Involved Shooting. The Tactical Edge, Vol 18, No.1, pp70-71, Winter 2000 Heiskell L:HIV Disease: What Are The On Duty Risks ?, Police, Vol 24, No 1, p 14, January 2000 Rasumoff D, Carmona R: The Pregnant Trauma Victim, The Tactical Edge, Vol. 17, No.1, pp 67-70, Winter 1999 Mazzocco W: Tactical Emergency Medical Support: Now More Than Ever. Police , Vol. 23 ,No. 9, pp 24-26 September 1999

Heiskell L, Tang D: Tactical Emergency Medical Support TEMS: Playing a Vital Role in SWAT Operations. Police, Vol. 23, No. 9, pp 36-37, September 1999 Rasumoff D, Carmona R: TEMS Planning For Extraordinary Deployment at a Public School, The Tactical Edge, Vol.17, No. 4, pp 71-75, Fall 1999 Carmona R, Rasumoff D: Suggested Guidelines for TEMS Policy and SOP, The Tactical Edge, Vol. 17, No. 3, pp 95-96, Summer 1999 Elliott T: Firefight. Fire Chief Magazine, pp 44-50, August 1999 Carmona R, Rasumoff D: TEMS for VIP / Dignitary Protection Details, The Tactical Edge, Vol. 17, No.2, pp 60-61, Spring 1999 Smile B: Tactical Medics: Front-Line Medicine Evolves as a Specialty, JEMS, Vol.25, No.5, pp 50-64, May 1999 Carmona R, Rasumoff D: Guidelines for the Development of TEMS Programs, The Tactical Edge, Vol.16, No.1, pp75-77, Winter 1998 Madsen M: Use of an Emergency Medical Information Card by a Tactical Team, The Tactical Edge, Vol.16, No. 4, pp 45-49, Fall 1998 Kowalski B, Frazier J, Grande C: TACMED vs. MEDTAC: The Basis of Medical Support for Tactical Operations, The Tactical Edge, Vol.16, No. 4, pp 39-44, Fall 1998 Rooker, N:Special Operations Medical Association, The Tactical Edge, Vol. 16, No.3, p 97, Summer 1998 Baker A: Down and Dirty DOR: A Five -Officer / Two Shield Rescue Tactic, The Tactical Edge, Vol. 16, No.3, pp 14-20, Summer 1998 Carmona R, Rasumoff D: Officer Assisted Suicide - A Different Form of Euthanasia, The Tactical Edge, Vol. 16, No. 3, pp 75-76, Summer 1998 Pierluisi G: Operation Support: The Role of the Tactical Medic. Rescue Technology, pp 32-36, July / August 1998 Rasumoff D, Carmona R: Mortality and Less Lethal Technology, The Tactical Edge, Vol.16, No.2, pp 78-82, Spring 1998 Greenstone J: Tactical Emergency Medical Support for Hostage and Crisis Negotiations. The Police Chief. pp 38-41, March 1998 Heiskell L, Tang D: AIDS & Hepatitis: What Are the Risks to Police Officers Police Vol.22, No 1, pp 34-36, January 1998 Carmona R, Rasumoff D: TEMS Literature: A Bibliography, The Tactical Edge,Vol. 15, No.1, pp 65-66, Winter 1997 McCue W: Officer Down: An Immediate Action Drill For Wounded Officers, SWAT Magazine, Vol. 17, No.6, November 1997 Rasumoff D, Carmona R: Advanced Life Support In TEMS: The Effect of New Trauma Studies, The Tactical Edge, Vol.15, No. 4, pp 78-80, Fall 1997 Gorham J: Epidemiology of SWAT Injuries: Implications for TEMS Provider. Prehospital Emergency Care, July / September 1997 Heiskell L, Carrison D: Doctoring Up Your Team, Vol.29, No.7, p 19, Emergency, July 1997 McConnell M, Van Stralen D: Emergency Medical Decision - Making in The Tactical Environment. The Tactical Edge, Vol 15, No.3, pp 32- 39, Summer 1997 Heiskell L, Tang D, Carlo P: Tactical EMS Training For The 21st Century. The Tactical Edge, Vol. 15, No.3, pp 76- 79, Summer 1997 Carmona R, Rasumoff D: Evolving Roles of the TEMS Provider. The Tactical Edge, Vol. 15, No.3, pp 57-59, Summer 1997 Myers C: In The Line Of Fire: Tactical Medics Become a Vital Component of SWAT, Vol. 29. No.7, pp 16-19 & 46, Emergency, July 1997

Rasumoff D, Carmona R: Standard Prehospital Care: The Next Major Issue in TEMS. The Tactical Edge, Vol. 15, No. 2, pp 59-64, Spring 1997 Heiskell L: Medical Management: K-9 Emergencies. Police, Vol. 21, No. 2, pp 52-57, February 1997 Heiskell L, Carrison D: H&K's New Tactical Emergency Medicine Course is Challenging, Demanding and on the Leading Edge. SWAT, pp 26-29, October 1996 Jones J, Reese K, Kenepp G, Krohmer J, Into the Fray: Integration of Emergency Medical Services and Special Weapons and Tactics (SWAT) Teams. Prehospital and Disaster Medicine. Vol. No.3 pp 202-206, July-September 1996 Rasumoff D, Carmona R: TEMS Tips for the Medical Officer. The Tactical Edge, Vol. 14, No. 4, Fall 1996 Carey G: TEMS Support for Small Law Enforcement Agencies. The Tactical Edge, Vol. 14, No. 4, pp 36-39, Summer 1996 Heiskell L, Carlo P: Scoop and Run vs Stay and Treat: Some Tactical Considerations.TheTactical Edge, Vol. 14 No. 3, pp 61-63 Summer 1996 Carmona R, Rasumoff D: Trends in Tactical Emergency Medical Support. The Tactical Edge, Vol. 14, No. 2, p 52, Spring 1996 Heiskell L: The Road to Wellness, Police, Vol 20, No 11, 71-75 November 1996 Heiskell L: Danger: Clandestine Drug Labs, Police, Vol 20, No 9, pp32-35,73-75, September 1996 Heiskell L, Tang D: Medical Management of K-9 Emergencies Part 2. The Tactical Edge, Vol 14. No.1, pp 44-52, Winter 1996 Heiskell L: Management of Tactical Medical Teams: Police SWAT Medical Personnel Are Agency Assets. Law & Order, April, 1996 Heiskell L, Tang D: Tactical Emergency Medial Support for Law Enforcement SpecialOperations Teams. SWAT, pp 69-73, February 1996 Leibovich M, Speer C: Physician Involvement in Police Tactical Teams. The Tactical Edge, Vol.13, No. 4, pp 48- 50, Fall 1995 Rasumoff D, Carmona R: An Evaluation Period for TEMS Personnel: Do We Need One? The Tactical Edge, Vol. 13, No. 4, pp 83-86, Fall 1995 Miller C: Blast Injuries. The Tactical Edge, Vol. 13, No. 4, pp 45-47. Fall 1995 Heiskell L, Tang D: Medical Management of K-9 Emergencies: Part 1. The Tactical Edge, Vol. 13, No. 4, pp 51-56, Fall 1995 Carmona R, Rasumoff D: Use of TEMS on SWAT Operations. The Tactical Edge, Vol. 13, No. 3, p 69, Summer 1995 Arthur K: Bag-Valve Alternative. The Tactical Edge. Vol. 13, No. 3, pp 19-20, Summer 1995 Carmona R, Rasumoff D: The Integration of Tactics and Emergency Medical Support. The Tactical Edge, Vol. 13, No. 1, pp 69-70, Winter 1995 Heiskell L, Tang D: HIV and Hepatitis B: Tactical Silent Enemies. The Tactical Edge, Vol. 13, No. 1, pp 55-58, Winter 1995 Wolff, E: The SWAT DOC. Florida SWAT Association New Letter, Fall 1994 Rasumoff D, Carmona R: The Africanized Honey Bee. The Tactical Edge. The Tactical Edge. Vol. 12, No. 4, pp 84- 87, Fall 1994 Carmona R, Rasumoff D: Diet and Performance in the Tactical Environment. The Tactical Edge, Vol. 12, No. 3, pp 82-83, Summer 1994 Carmona R: Cost Effectiveness Alternatives for thee Provision of Live-Fire Training, The Portable Live-Fire Training House. The Tactical Edge, Vol. 12, No. 3, pp 21-23, Summer 1994

Heiskell L, Tang D: Medical Aspects of Clandestine Drug Labs. The Tactical Edge, Vol. 12, No. 3, pp 51-54, Summer 1994 Vayer J, Hagmann J, Llewellyn C: Refining Prehospital Physical Assessment Skills: A New Teaching Technique. Annals of Emergency Medicine, Vol. 23, No. 4, pp 786-790, April 1994 Heiskell L, Carmona R: Tactical Emergency Medical Services: An Emerging Subspecialty of Emergency Medicine. Annals of Emergency Medicine Vol. 23, No. 4, pp 778-785, April 1994 Rasumoff D, Carmona R: Position Paper: Use of Physicians in the Tactical Environment. The Tactical Edge, Vol. 12, No. 2, pp 77-86, Spring 1994 Carmona R, Rasumoff D: Selection and Retention of Special Operations Team Members. The Tactical Edge, Vol. 12, No. 1, pp 72-75, Winter 1994 Heiskell L, Tang DH: Case Study: The Moreno Valley Hostage Incident. The Tactical Edge Vol. 12. No. 3, pp 36- 38, Winter 1994 Carmona R, Rasumoff D: Inclusion of Physicians in Civilian Tactical Law Enforcement Operations. The Tactical Edge, Vol. 11, No. 4, pp 70-71, Fall 1993 Carmona R, Rasumoff D: Echeloned Field Medical Care: Definition and Justification. The Tactical Edge, Vol. 11, No. 4, pp 72-76, Fall 1993 Carmona R, Rasumoff R: Medical Aspects of the Force Continuum. The Tactical Edge, Vol.11, No. 1, pp 69-71, Summer 1993 Heiskell L: Triage and Transport: The Golden Hour Begins. The Tactical Edge, Vol. 11, No. 1, pp 50-52, Summer 1993 Watch M: The Tactical Paramedic, Law Enforcement Technology, 40-41,53, March 1993 Rasumoff D, Carmona R: How Are We Doing with TEMS? The Tactical Edge, Vol.11, No. 2, pp 71-74, Spring 1993 Heiskell L: Profiling and Predicting the Suicidal Suspect. The Tactical Edge, Vol. 11, No. 2, pp 43-45, Spring 1993 Carmona R, Rasumoff D: Understanding the Risks and Benefits in Selection of Mission-Specific Personnel Protective Equipment. The Tactical Edge, Vol.11, No. 1, pp 68-70, Winter 1993 Heiskell L: Basics of Field Wound Management. The Tactical Edge Vol. 11, No. 1, pp 60-62, Winter 1993 Sanders N: Should Physical Fitness Qualifications Be Required for SWAT? The Tactical Edge, Vol. 10, No. 4, p 30, Fall 1992 Rasumoff D, Carmona R: A Basic Strategy for Neurological Assessment. The Tactical Edge, Vol.10, No.4, pp 62- 67, Fall 1992 Heiskell L: Profiling and Predicting The Violent Suspect. The Tactical Edge, Vol. 10, No. 4, pp 39-40, Fall 1992 Carmona R, Rasumoff D: Forensic Aspects of Tactical Emergency Medical Support. The Tactical Edge, Vol. 10, No. 3, pp 54-55, Summer 1992 Heiskell L: Hyperthermia and Heat Illness: Considerations in Hot Weather Special Operations. The Tactical Edge, Vol. 10, No. 3, pp 20-22, Summer 1992 McArdle D: Integration of Emergency Medical Services and Special Weapons and Tactics (SWAT) Teams: The Emergence of the Tactically Trained Medic. Prehospital and Disaster Medicine, July-September 1992 Rasumoff D, Carmona R: Caring for Children in the Tactical Environment: It's No Small Thing. The Tactical Edge, Vol. 10, No. 2, pp 48-53. Spring 1992 Heiskell L: Aeromedical Evacuation in the Tactical Environment. The Tactical Edge, Vol. 10, No. 2, pp 41-43, Spring 1992 Carmona R, Rasumoff D: Preliminary Review of Tactical EMS Survey. The Tactical Edge, Vol. 9, No. 1, p 62, Winter 1991 Heiskell L: Hypothermia and Frostbite: Considerations in Cold Weather Special Operations. The Tactical Edge, Vol. 10, No. 1, pp 26-29, Winter 1992

Burg M: Tactical EMS. Emergency Medical Services, Vol. 21, pp 76-77, 1992 Maunder M: Paramedics and Tactical Operations: The Integration of Medical Personnel in Law Enforcement. The Tactical Edge, Vol. 10, No. 1, pp 33-34, Winter 1992 Sanders N: Priorities for Forward Casualty Care: Lessons From the Battalion Medical Officer. The Tactical Edge, Vol. 10, No.1, pp 28-29, Fall 1991 Heiskell L: Fundamentals of Wound Ballistics. The Tactical Edge, Vol. 9, No. 4, pp 22-24, Fall 1991 Carmona R, Rasumoff D: Evaluation of Risk Factors Causing Performance Decrement During Special Operations. The Tactical Edge, Vol. 9, No. 4, pp 53-55, Fall 1991 Carmona R, Rasumoff D:Tactical Emergency Medical Support (TEMS) An Emerging Specialized Area of Prehospital Care. Prehospital and Disaster Medicine, p 394, 1991 Rasumoff D, Carmona R: Combined EMT Class For SWAT Personnel. The Tactical Edge, Vol. 9, No. 3, pp 58-62, Summer 1991 Rasumoff D, Carmona R: Burns in the Tactical Environment. The Tactical Edge, Vol. 8, No. 9, p 54, Spring 1991 Carmona R, Rasumoff D: Tactical Emergency Medical Support. The Tactical Edge, Vol. 8, No. 1, pp 54-56, Winter 1990 Carmona R, Rasumoff D: Regionalization of SWAT Operations: Administrative and Tactical Considerations. The Tactical Edge, Vol. 8, No. 4, pp 35-36, Fall 1990 Carmona R, Rasumoff D: Early Recognition of Impending Airway Difficulty in the Tactical Environment. The Tactical Edge, Vol. 8, No. 4, pp 54-58, Fall 1990 Carmona R, Rasumoff D: Essentials of Tactical Emergency Medical Support. The Tactical Edge, Vol. 8 No. 3, pp 54-56, Summer 1990 Carmona R, Brennan K: Review of the National Conference on Tactical Emergency Medical Support. The Tactical Edge, Vol. 8, No. 3, pp 7-11 Summer 1990. Carmona R: Officer Safety In Special Operations: Assessing the Risk / Benefit Ratio. The Tactical Edge, Vol. 8, No. 2, Spring 1990 Rasumoff D, Carmona R: Aggressiveness, Positive Attitude, and the Fight or Flight Reactions. The Tactical Edge, Vol. 8 No. 2, pp 44-47, Spring 1990 Murphy M: FBI SWAT Paramedics. The Tactical Edge, Vol 7, pp 22-24, 1989 Quinn M: Into the Fray: The Search and Rescue Role with Special Weapons Teams. Response, Vol. 6 pp 18-20, 1987