Ready for the Heat: Training Inside the Hot Zone

On a sweltering July afternoon, a small team of experienced paramedics along with some curious medical residents and fellows marched single-file toward a narrow hallway inside a small police training structure.

Fully briefed earlier in the day on what they were going to experience, they began to proceed inside. A rare look of anxiety could be read on most of their unprotected faces.

And that was the point of this unusual training: to see how this team of highly trained individuals would perform outside of their comfort zone.

As the team slowly walked into the training structure, loud blasts could be heard, followed quickly by thick clouds of oil-based tear gas. The New Mexico State Police Special Operations team members conducting this scenario were the only ones wearing gas masks.

It did not take long for the choking to start. For some the panic that followed took even less.

The hallway they had to traverse wasn’t long, maybe 20 feet. However, the second the conditions changed, sight diminished, breathing impaired, the single-file line became a clogged artery of humanity. Those in the back were forced to wait as those in front of them struggled to make their way out.

Somebody said it felt like an eternity.

But in less than 15 seconds it was over. Team members bolted out of the rear exit, gasping. As they escaped, each member staggered around in the fresh air, rapidly blinking their eyes, trying to alleviate the irritation. Thick rivers of mucus clogged their nasal passages, making efforts to breathe even more difficult.

“It’s amazing how quickly your fight-or-flight response kicks in,” says veteran medic and team member Rachel Wennekamp. “The moment you’re no longer able to breathe, you really have to focus. The lectures we sat through today helped prepare me for that, but nothing compares to actually going through it. That feeling of not being able to breathe is something I’ll remember forever. But now that I have, I’ll know how to focus if I’m in that situation for real.”

Another team member, Mike LaVigne, a 25-year EMS veteran, described the experience as the most intense training he’s ever been through.

“You start out smelling what you think is fireworks,” LaVigne says. “You think, Oh, this isn’t so bad, but then you can’t catch your breath, almost like a laryngospasm occurs, and when that happened…”

LaVigne’s words stopped, and he shook his head, reaching for a description not readily available. Then a knowing smile brightened his face. “I’m just glad I didn’t piss myself.”

Extreme Training in Unrelenting Conditions

The medical residents and fellows who volunteered to join their paramedic counterparts seemed to have similar reviews for their experience: Glad they did it. Wouldn’t want to do it again.

Both the paramedics and medical residents and fellows are part of a special medical activation program instituted by the University of New Mexico Hospital to help medical staff better understand the prehospital situations faced by EMS and police.

The trainings are coordinated and executed by the University of New Mexico Tactical Emergency Medical Service (TEMS) team, a cadre of highly experienced paramedics specially selected to respond with law enforcement to high-risk situations in case officers need immediate medical attention.

Started as an extension of the University of New Mexico Hospital’s EMS consortium—a select group of emergency room physicians specially trained to respond to 9-1-1 calls in fly cars to provide EMS immediate on-scene medical control—several of the trainings TEMS develops mimic scenarios law enforcement must go through.

“Exposure to tear gas is something law enforcement officers go through during their academy,” says TEMS team leader Elliott Guinn. “It’s just one of the dangerous and unpredictable hazardous conditions they may face on a call.”

By working so closely with law enforcement on these types of high-risk calls, TEMS members may similarly be exposed to these hazards.

“Of course on a call like this, where tear gas is going to be used, we would respond with our gas masks on,” says Guinn. “But just having a mask is not something you can always count on. You might get it knocked off, or the seal may not hold. So by going through this training, the team becomes prepared for what to expect if that happens and to not panic if they’re caught in that situation. Because if an officer goes down and tear gas has been deployed, we’re still going in to get them.”

And it’s this understanding—that every call they respond to may require them to respond into the hot zone to treat a fallen officer—that drives this team to withstand extreme training in unrelenting conditions.

Speed and Trained Efficiency

Established in 2013, the team has responded to numerous SWAT standoffs, accompanied law enforcement serving warrants to potentially armed suspects, and stood with police through near-riot situations. Each member of the team is equipped with a police radio, Kevlar helmet, bulletproof vest, gas mask and the goals and objectives of each scene they respond to. TEMS members don’t carry weapons.

According to the team’s medical director, Joy Crook, MD, when a law enforcement agency requests the team, the team’s on-call member of the day is quickly notified. They get a brief rundown of location and nature of the event as they respond to the team’s base on the campus of the University of New Mexico Hospital. UNMH, where Crook serves as an ER physician, is centrally located in Albuquerque and the only Level 1 trauma center in New Mexico.

Each mission starts out with a sole provider and a very austere EMS setup. Almost every item brought to the scene can be carried by the TEMS provider once there. This includes IV supplies, a few narcotics, some first-line ACLS meds and a vial of tranexamic acid (TXA). Recently approved for the TEMS team, TXA prevents enzymes in the body from breaking down blood clots. This makes it a highly effective tool, since every call has the potential for a life-threatening hemorrhage. That’s pretty much it—no supplemental oxygen, no cardiac monitor, no stretcher.

Fast and light is how Guinn describes it.

If the law enforcement request could have the potential for a high casualty rate, more TEMS members can be activated to respond. “But for the most part, you’re on your own out there,” says Guinn.

Crook defines the TEMS role on the scene this way: “For the most part we are there to watch solely over the law enforcement personnel we respond with. That’s not to say we won’t look at or treat a civilian or a suspect if they happened to be injured. But we respond with a limited amount of resources and supplies. So our main focus is to handle any potential injuries our law enforcement officers may incur. All other injuries are usually handled by local EMS providers.”

Prior to leaving the hospital, the team and medical director discuss the need to check blood out of the UNMH blood bank to carry with them.

“It’s pretty unique for our team to be allowed to carry blood,” says Crook. “I think only one other flight service in the state may carry blood, but I definitely think we are the only ground transport that does.”

On a recent SWAT standoff where two suspects were barricaded in a house and things seemed unlikely to resolve peacefully, a TEMS member checked out 4 units of O-negative blood, the universal donor, prior to leaving for the scene.

Once the mission is accepted, TEMS does not respond in an ambulance, but rather a large sedan equipped with lights and sirens that’s on loan from the New Mexico Department of Public Safety. The vehicle has been customized to carry all of TEMS’ gear, radios for contact with law enforcement agencies and fire departments, and a satellite phone.

What it isn’t equipped for is patient transport. Thus the logistics of getting a patient off scene have to be worked out quickly, should the need arise.

“In most remote areas, we would anticipate using a helicopter for transport,” says Crook. “Our medics would go with the patient and maintain care until they are delivered to the hospital.” In less remote areas a local ground EMS ambulance with the TEMS medic riding along would be utilized.

On every scene, the TEMS member links up with a law enforcement contact so they can be debriefed on what’s happened and its likely outcomes. It’s here the TEMS member is able to voice ideas about safety and any medical concerns.

Solid Core Foundation

That unified teamwork is what has kept TEMS so stable in membership. Since its inception, the team has had little turnover in its ranks. With 18 medics operating on a rotating on-call schedule, it could be difficult to maintain that enthusiasm, but Crook says it hasn’t been.

“We’ve been real lucky to keep our core group,” she says. “With the type of training our team goes through, along with the protocols we have, it would be hard if we had a high turnover.”

Guinn says when the team was initially put together, the founding members only wanted seasoned medics who could demonstrate a solid foundation in both clinical thinking and skills. The team’s initial spots were quickly filled by medics intrigued by the protocols and challenges it presented.

This core foundation has been so solid that recently, cofounder Colby stepped down from his position as one of the team leads to accept a job with Golder Ranch Fire District near Tucson, AZ. However, he continues to make regular trips back to Albuquerque to participate in trainings and help in QI reviews.

Better to Have a Medic and Not Need Him…

According to Crook, despite the team’s numerous callouts, they’ve been fortunate to not yet have been needed. Most SWAT standoffs usually end in one of two ways: The suspect is taken into custody without incident or engages the police and dies. Confirming the death of a suspect is something TEMS has done more than once.

One recent request for a TEMS response shows the team’s growing stature. On May 24 prospective Republican presidential nominee Donald Trump visited Albuquerque on a campaign stop. Tensions were high, as Trump had made several controversial statements regarding immigration and border control. And while city law enforcement was prepared for protesters, the situation quickly began to spin out of control. Large crowds of protesters began lighting fires, smashing windows and throwing rocks at both police and their horses. The rioters threatened to break barricades that prevented them from entering the Albuquerque Convention Center where Trump was speaking.

TEMS was activated and stood with police as medical support. The incident made national news. Luckily no serious injuries were reported from the scene.

Currently TEMS is contracted to respond with the New Mexico State Police tactical teams, the New Mexico State Police bomb team and the Rio Rancho SWAT team. They are looking for more law enforcement agencies to contract with. In addition, the team is looking to expand its bases so members do not have to respond to the UNMH campus to pick up equipment and meds.

“With a state as large as New Mexico, I’d like to see a base established somewhere in the southern half of the state, and maybe one a bit farther north,” says Crook.

Canine Program

Another aspect that TEMS members Guinn and J.R. Colby, another founding TEMS member and seasoned firefighter/paramedic, recognized was that on a great number of calls, SWAT utilizes K9s to help resolve standoffs safely.

“Dogs have underdeveloped lacrimal glands,” explains Guinn, “so the gas doesn’t really bother them. Also, the dog’s thick fur keeps the oil-based gas from penetrating down into their skin.”

Guinn, Colby and Crook developed protocols and training specifically for treating an injured K9. Each member has an opportunity to place IVs and learn CPR landmarks and medical dosages appropriate for the average-size police dog.

The risks involved with treating a fallen K9 officer are not something to be overlooked.

“Unlike a human, you can’t explain to a dog what you’re doing and why they’re hurting,” says Guinn. “Also, most police dogs are conditioned to be handled only by their handler. So the risk of being bitten by an injured police dog is one each TEMS member understands and has agreed to accept. “

For more information on the University of New Mexico Tactical Emergency Medical Services team, contact Guinn at pca003@gmail.com or Crook at jcrook@salud.unm.edu.

Paul Serino, NRP, CCT-P, BS, is a 14-year paramedic and frequent contributor to EMS World Magazine.