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| By Elliot D. Carhart, MHS, RRT, EMT-P, EMT-T Medical protocols for the tactical medic must be geared toward keeping the tactical operator in a condition capable of continuing toward their mission objectives. How to Develop Tactical EMS Protocols Paramedics operating in this unique prehospital specialty face many challenges that cannot be resolved through the application of standard prehospital protocols In civilian law enforcement situations such as active shooters, barricaded subjects and hostage takers, specially trained teams of offi cers (i.e., SWAT) carry out the mission so as to ensure success.1 These missions are some of the most dangerous responsibilities of civilian law enforcement agencies, with injuries occurring in as many as one- third of tactical operations and related training.2 However, law enforcement tactical teams, trained to respond to these events, are typically not prepared to treat the casualties of these poten- tially violent encounters. Recent years have seen a surge in violent crimes across the world. Notable events, such as Columbine, Beslan, 26 FEBRUARY 2012 | EMSWORLD.com Virginia Tech and many others, have influenced the development of a concept known as tactical emergency medical support (TEMS). This concept has been formally evolving since 1989 and is steadily gaining acceptance.3,4 Evidence now shows that integration of tactically trained paramedics can improve the outcome of tactical operations.5 As a result, the tactical medic has become an "integral team member in specialized law enforcement operations."6 there is a potential liability faced by any tactical team that conducts operations without the ability to provide immediate medical intervention.7 Paramedics operating in this unique prehospital specialty face many chal- Further, lenges that cannot be resolved through the application of standard prehospital protocols. Paramedics functioning in the tactical environment must be prepared to deal with limited resources, delayed transport and a higher occurrence of penetrating injuries.8 Further, the tactical paramedic must overcome these chal- lenges while dealing with the complexi- ties of a potentially hostile environment. While there are strong guidelines in place for care in today's combat tactical environment, care in the civilian tactical environment is sometimes lacking direc- tion. This area of medical care falls in a gray area between combat medicine and standard prehospital care, where neither is fully appropriate.