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Tactical Medicine
ESSENTIALS
SECOND EDITION
John E. Campbell, MD, FACEP

Lawrence E. Heiskell, MD, FACEP, FAAFP
Jim Smith, MSS, NRP, FABCHS, CPC, CLEE
E. John Wipfler III, MD, FACEP
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assumes no responsibility for, the correctness, sufficiency, or completeness of such information or recommendations. Other or additional safety measures may be required under particular
circumstances.
This textbook is intended solely as a guide to the appropriate procedures to be employed when rendering emergency care to the sick and injured. It is not intended as a statement of the
standards of care required in any particular situation, because circumstances and the patient’s physical condition can vary widely from one emergency to another. Nor is it intended that this
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23 22 21 20 19 10 9 8 7 6 5 4 3 2 1
BRIEF CONTENTS
Section 1 Elements of Tactical Medicine

Chapter 1 History and Role of the Tactical Medical Provider
Chapter 2 Safety and Wellness of the Tactical Medical Provider
Chapter 3 Tactical Team Fundamentals
Chapter 4 Equipment of the Tactical Medical Provider
Chapter 5 Weapons Handling and Firearms Safety
Chapter 6 Unconventional Weapons and Criminal Tactics
Chapter 7 Medical Intelligence
Chapter 8 Medical Response to Active Assailant Mass Casualty Incidents
Chapter 9 Operational Tactics
Chapter 10 Tactical Team Activations
Section 2 Assessment and Management of Injuries

Chapter 11 Patient Assessment in the Tactical Environment
Chapter 12 Controlling Bleeding
Chapter 13 Basic Airway Management
Chapter 14 Advanced Airway Management
Chapter 15 Shock Management
Chapter 16 Extraction and Evacuation
Chapter 17 Ballistic, Blast, and Less-Lethal Weapons Injuries
Chapter 18 Torso Injuries
Chapter 19 Head, Neck, and Spine Injuries
Chapter 20 Extremity Injuries
Chapter 21 Soft-Tissue Injuries
Chapter 22 Environmental Emergencies
Chapter 23 Medications in the Tactical Environment
Chapter 24 Weapons of Mass Destruction
Chapter 25 Hazardous Materials and Clandestine Drug Labs
Chapter 26 Challenges in Tactical Medicine
Appendix A K-9 Management
Appendix B TEMS Forms
Appendix C Defensive Tactics
Appendix D Law Enforcement Education for Tactical Medical Providers (TMPs)
Glossary
Index
CONTENTS
Section 1 Elements of Tactical Medicine

Chapter 1 History and Role of the Tactical Medical Provider
Introduction
The History of Tactical Emergency Medical Support
Civilian Emergency Medical Services
Law Enforcement Overview
The History of SWAT Units
The Beginnings of TEMS Units
Roles Within the SWAT Unit
Roles and Responsibilities of the Tactical Medical Provider
Bilateral Command
Command Systems: LIMS and NIMS
Tactical Medical Provider Training
Tactical Medicine Curriculum
Law Enforcement Training for Tactical Medical Providers
Unit Training
Hazardous Materials Training
Bloodborne Pathogens Training
Continuing Medical Education
Chapter 2 Safety and Wellness of the Tactical Medical Provider

Introduction
Health and Wellness
Preventive Medicine Principles
Wellness for the SWAT Unit and TEMS Unit
Diet and Nutrition
Exercise
Personal Hygiene Considerations
Sleeping Habits
Stress Management
Downtime
Spirituality
Hobbies and Interests
Maintenance of Lasting Personal Relationships
After Critical Incidents
CISM Controversies
Patient Confidentiality
Radio Reporting
Chapter 3 Tactical Team Fundamentals

Introduction
Mission Goals
Types of Incidents Requiring Activation
Weapons and Tools
Forcible Entry Tools
SWAT Explosive Breaching Considerations
Less-Lethal Weapons
Close-Range Impact Weapons
Electronic Control Devices (ECDs): The TASER® ECD
Compressed-Air Technology
Extended-Range Impact Projectiles
Noise-Flash Distraction Devices
Less-Lethal Chemical Agents
Chapter 4 Equipment of the Tactical Medical Provider

Introduction
The Tactical Medical Provider Uniform
Additional Insignia
Extreme Weather Garments
Cold Weather Gear
Warm Weather Gear
Tactical Personal Protective Equipment
The Ballistic Vest
The Ballistic Helmet
The Balaclava
Eye Protection
Hearing and Ear Protection
Gloves
Medical Protective Gear
Kneepads
Hydration Systems
Gas Mask or Air-Purifying Respirator
Flashlights and Illumination Tools
Essential Emergency Medical Gear: A Four-Level System
Level 1
Level 2: Medical Vest with Utility Pouches, Belt, and Thigh Packs
Level 3: Tactical Medical Backpack
Level 4: Tactical Medical Advanced Life Support Kit
Additional BLS Trauma Management Kit
Tactical Medical Supplies
Tactical Compression Bandages
Tactical Tourniquets
Improvised Tourniquets
Clotting Agents, Hemostatic Bandages, and Hemorrhage Control
Chest Seals for Penetrating Chest Trauma
Chest Decompression Devices
Airway Devices
Automated External Defibrillator
Oxygen Tanks
Stretchers and Extraction Gear
Field-Expedient Decontamination Equipment
Personal Dosimeters
Additional Equipment to Consider
Chapter 5 Weapons Handling and Firearms Safety

Introduction
Firearms Overview
Handguns
Long Guns
Firearm Caliber
Ammunition
Firearms Training
Handgun Safety
Choose the Right Weapon
Practice
Securing a Firearm
Downed SWAT Officer Firearm Security
Suspect Firearm Security
Chapter 6 Unconventional Weapons and Criminal Tactics

Introduction
The Human Body and Mind
Criminal Tactics
Criminal Suspect Weapons Issues
Edged Weapons
Firearms
Types of Conventional Explosives
Secondary Explosive Device Threats
Booby Traps
Chapter 7 Medical Intelligence

Introduction
Medical Planning for Safe Training
Law Enforcement Training Injuries and Deaths
Hot Weather Considerations
Cold Weather Considerations
Additional Environmental Threats and Prevention
Cross-Agency Training
Medical Planning for Incident Sites
Special Event Planning
Planning for Medical Support During a Mission or Training
Nutrition, Hydration, and Sleep Factors
Preventive Care and Support
Rehabilitation Stations
Medical Records
Medical Plan
Medical Intelligence
Medical Threat Assessment
Postmission Medical Planning
Chapter 8 Medical Response to Active Assailant Mass Casualty Incidents

Introduction
High-Threat MCIs
Active Assailant Incidents
Five Tiers of Medical Response
The Threats
Rapid Response and Extraction Times
Body Count per Minute
Law Enforcement Response
Rapid Reaction Teams
EMS and Fire Medical Response to AAMCIs
Rescue Task Forces
Primary Objectives of Medical Responders
Firefighters and EMS Personnel Integration with LEOs
Concepts and Goals for RTF Medical Personnel
The Hartford Consensus
Chapter 9 Operational Tactics
Introduction
Activation
SWAT Unit Activation
TEMS Unit Activation
Callout Formation
SWAT Officer Data Cards
Medical Threat Assessment
Personnel Tracking
Tactical Plan Development
Immediate Action Drills
TEMS Unit Staging
Perimeters and Zones at Callouts
Staging of the TEMS Unit in the Tactical Environment
Positioning of EMS Transportation
Entry for the Tactical Team
Indications for Dynamic or Stealth Entry
Entry Team Operations
The Stack Formation
Stairs Tactics
The Pie Tactic
Clearing Rooms: Entry and Egress
Victim Restraint
TEMS Operational Procedures
Recognition of High-Threats and Threats
Cover and Concealment
Quick Peeks
Light Tactics
Sound and Light Discipline
Using Other Senses to Maintain Situational Awareness
Covert Communications
Radio Communications
Mission Completion
Post-Mission Debriefings
Chapter 10 Tactical Team Activations

Introduction
Variety of SWAT Missions
Tactics
Emotionally Disturbed Persons
Tactics
Active Shooter Scenarios
Tactics
Escaped Fugitive or Suspect
Tactics
Mass Gathering Events
Tactics
Riots
Tactics
Downed SWAT Officer or Bystander in an Exposed Position
Tactics
Executive Protection
The Role of the TMP
Tactics
High-Risk Prisoner Transport Medicine
Tactics
Section 2 Assessment and Management of Injuries

Chapter 11 Patient Assessment in the Tactical Environment
Introduction
Scene Safety
360-Degree Situational Awareness
Partners-in-Safety
Safety When Treating Suspects
Tactical Patient Assessment: Call-A-CAB ’N Go Hot
Call
A: Address Threats
CAB: Circulation, Airway, and Breathing
‘N: Neurologic Status Check
Go
Hot
Patient Assessment During Evacuation
SAMPLE History
Secondary Assessment
Remote Assessment Medicine
Barricade Medicine
Triage
Mass-Casualty Incident
SWAT Assessment Triage
Chapter 12 Controlling Bleeding

Introduction
Identify Hemorrhage
Sources of Bleeding and Characteristics
Hemorrhage
Hemorrhage Treatment
Principles of Tourniquet Use
Junctional Tourniquets
Chapter 13 Basic Airway Management

Introduction
Causes of Airway Obstruction
Manual Maneuvers
Head Tilt–Chin Lift Maneuver
Jaw-Thrust Maneuver
Basic Airway Adjuncts
Nasopharyngeal Airway
Oropharyngeal Airway
Ventilations
Mouth-to-Mouth Ventilation
Mouth-to-Mask Ventilation
The Bag-Mask Device
Suctioning the Airway
Chapter 14 Advanced Airway Management

Introduction
Airway Obstruction
Orotracheal Intubation
The Sellick Maneuver
The Intubation Procedure: Visualized (Oral) Intubation
Patient Intolerant of the Endotracheal Tube
Single Lumen Airway
King LT Airway
Laryngeal Mask Airway
i-gel Supraglottic Airway
Digital Intubation
Nasotracheal Intubation
Surgical and Nonsurgical Airways
Open Cricothyrotomy
Needle Cricothyrotomy
Rapid-Sequence Intubation
Chapter 15 Shock Management

Introduction
Hypovolemic Shock
Treatment for Hypovolemic Shock
Treatment Goals
Treatment Steps
IV Therapy and Hypovolemic Shock
IV Administration
IV Troubleshooting
Intraosseous Infusion Administration
Chapter 16 Extraction and Evacuation

Introduction
Extraction
Self-Extraction
Overview of Manual Extraction Techniques
Patient Handling
General Rules for Rescuers
Dragging
Manual Carries
Evacuation
TEMS and EMS Interface
CASEVAC Versus MEDEVAC
Communicating with Civilian EMS and Hospitals
Air Medical Evacuation
Preparing a Landing Zone
Chapter 17 Ballistic, Blast, and Less-Lethal Weapons Injuries

Introduction
Ballistics
Types of Ballistic Wounds
Assessment and Management of Ballistic Injuries
Ballistic Vest Removal
Blast Injuries
Tissues at Risk
Assessment and Management of Blast Injuries
Law Enforcement Bomb Technician
Less-Lethal Weapons Injuries
Close-Range Impact Weapons
Extended-Range Impact Projectiles
Noise-Flash Distraction Devices
Less-Lethal Chemical Agents
Compressed-Air Technology
Chapter 18 Torso Injuries

Introduction
Load-and-Go Injuries to the Chest
Penetrating Wounds and Major Blunt Trauma to the Chest
Complications of Penetrating Wounds and Major Blunt Trauma to the Chest
Load-and-Go Injuries to the Abdomen
Blunt Trauma
Penetrating Trauma
Pelvic Fracture
Chapter 19 Head, Neck, and Spine Injuries

Introduction
Load-and-Go Injuries to the Head, Neck, and Spine
Head
Neck
Spine
Treat-Then-Transport Injuries
Eye
Ear
Nose
Oral Injuries
Chapter 20 Extremity Injuries

Introduction
Load-and-Go Injuries to the Extremities
Amputation
Femur Fractures
Open Fractures
Complications of Extremity Injuries
Closed Fractures
Sprain
Strain
Dislocations
Chapter 21 Soft-Tissue Injuries

Introduction
Load-and-Go Injuries
Thermal Burns
Electrical Burns
Closed Wounds
Open Wounds
Bite Wounds
Subungual Hematoma
Fungal Skin Diseases
Contact Dermatitis
Friction Blisters
Chapter 22 Environmental Emergencies

Introduction
Cold Exposure
Hypothermia
Local Cold Injuries
Heat Exposure
Heat Cramps
Heat Exhaustion
Heatstroke
Lightning
Stabilizing Care
Bites and Envenomations
Spider Bites
Hymenoptera Stings
Snake Bites
Scorpion Stings
Tick Bites
Poisonous Plants
Chapter 23 Medications in the Tactical Environment

Introduction
Medication Considerations
The Five Rights of Medication Administration
Medication Administration in the Tactical Environment
Over-the-Counter Medications
Prescription Medications
Reporting the Use of Medications to Command Staff
Pain Medications
Antibiotics
Pain Medications in the Tactical Environment
Meloxicam, Acetaminophen, and Ibuprofen
Morphine
Fentanyl
Nausea Medications in the Tactical Environment
Ondansetron
Ketamine
Medication Storage
Chapter 24 Weapons of Mass Destruction

Introduction
Chemical, Biologic, Radiologic, and Nuclear Threats
Chemical Terrorism/Warfare
Biologic Terrorism/Warfare
Nuclear/Radiologic Terrorism
Scene Safety for the TMP
Secondary Device or Event (Reassessing Scene Safety)
Chemical Weapons
Blister Agents
Pulmonary Agents (Choking Agents)
Nerve Agents
Metabolic Agents (Cyanides)
Biologic Agents
Viruses
Bacteria
Neurotoxins
Other Biologic Toxins
Nuclear Weapons
What Is Radiation?
Sources of Radiologic Material
Nuclear Energy
Nuclear Weapons
Radiologic Dispersion Device
How Radiation Affects the Body
Response
Suicide Bombings
Response
Chapter 25 Hazardous Materials and Clandestine Drug Labs

Introduction
Hazardous Materials
Classifications of Hazardous Materials
Protective Equipment for Hazardous Materials Incidents
SCBA and the Tactical Environment
Clandestine Drug Labs
Clandestine Drug Lab Considerations
Rapid Decontamination
Chapter 26 Challenges in Tactical Medicine

Introduction
Challenges of Treating the Restrained Patient
Excited Delirium
On-Site Screening Examination for Suspects
Crime Scene Considerations
Preserving Evidence
Physical Signs of Death
Special Considerations
Appendix A K-9 Management

Police Dog Emergency Medical Gear
Preparing for Police Dog Emergencies
Canine Tactical Assessment
Call-A-CAB ’N Go Hot
Circulation
Airway and Breathing
Load–and–Go
Pain Management
Fractures
Heat Emergencies
Poisoning
Appendix B TEMS Forms
Appendix C Defensive Tactics

Introduction
Principles of Self-Defense
Winning a Confrontation
Fight or Flee
Self-Defense Moves
Combat Physiology
Hormones and Nerves
Blood Vessels
The Brain
The Heart
The Eyes
The Ears
The Gastrointestinal and Genitourinary Tracts
The Skin
Restraint Devices and Techniques
Weapons and the TEMS Unit
Firearms
Batons
OC Spray
Illumination Tools
Knives
TASER and Other Conducted Electrical Weapons
Appendix D Law Enforcement Education for Tactical Medical Providers (TMPs)
Introduction
The Role of TMPs
Training Limitations
TMPs and Law Enforcement
Tactical Medical Curriculums and Training
LEO Competency Requirements
TMP Self-Defense at the Tactical Scene
Armed TMP Elements
Suggested Competency Requirements
Weapons Safety and Skills
Knowledge of Laws and Liabilities
Police and SWAT Topics
Emergency Medical Service (EMS) Scope of Practices
Summary
Glossary
Index
AUTHOR BIOGRAPHIES
John Emory Campbell, MD, FACEP Dr. Campbell passed away in 2018. Dr. Campbell was an excellent physician, innovator, pioneer, and
teacher with many outstanding achievements.
Dr. Campbell was known worldwide for his innovative and groundbreaking work in developing prehospital trauma education. In 1982, Dr.
Campbell founded the Basic Trauma Life Support (BTLS) program. It was the first course and curriculum dedicated to prehospital trauma
assessment and trauma care worldwide. He taught, alongside Colonel Jim Smith (his future co-author), and conducted the first BTLS course
in August of 1982. He wanted to teach paramedics the principles of advanced trauma life support (ATLS) to improve the care provided to
trauma patients. He partnered with the Alabama Chapter of ACEP to publish the first BTLS textbook in 1982. Basic Trauma Life Support has
since been renamed to International Trauma Life Support (ITLS) to better reflect its scope and mission, and it is now a global organization
offering 15 types of trauma courses and teaching over 30,000 students annually in over 40 countries.
“John did not set out to be an EMS leader,” said ITLS Editor-in-Chief Roy Alson, PhD, MD, FACEP, who has served on the editorial board
alongside Dr. Campbell for many years. “Thirty years ago, he developed a new trauma course and said, ‘Why aren’t we teaching this to
EMS?’ Along the way, he convinced countless doctors, nurses, and EMS, fire, and police personnel to share his vision. The legacy John
leaves is measured in the lives saved by those who have been ITLS trained. He will be missed.”
Dr. Campbell had a lifelong interest in the military and supported law enforcement throughout his life. Dr. Campbell, Chief Jim Smith, Dr.
Lawrence Heiskell, and Dr. John Wipfler worked together with over 120 contributors and reviewers to generate the first comprehensive
textbook on tactical medicine, Tactical Medicine Essentials, which was copyrighted and published in 2012. Endorsed by the American
College of Emergency Physicians, Dr. Campbell was able to contribute his extensive experience in the public safety prehospital arena to this
textbook. The first edition has sold over 6000 copies and is used in tactical medicine education worldwide. Dr. Campbell’s legacy lives on not
only in the form of ITLS, but also in the form of Tactical Medicine Essentials, Second Edition, written by his three co-authors.
Lawrence E. Heiskell, MD, FACEP, FAAFP Dr. Heiskell is the founder and medical director for the International School of Tactical
Medicine, the first and only state and federally approved tactical medicine school approved by the California Commission on Peace Officers
Standards and Training (POST) and the United States Department of Homeland Security (DHS). Dr. Heiskell is residency trained and board
certified in emergency medicine and family practice and has been a practicing emergency physician for more than 32 years.
Prior to attending medical school, Dr. Heiskell spent 5 years with the United States Antarctic Research Program and served on three
expeditions to Antarctica and the South Pole. He was awarded the Congressional Antarctic Service Medal in 1979. He has 29 years of
experience as a SWAT team physician beginning as a reserve deputy with the Kern County Sheriff’s Department in Bakersfield, California.
He is currently a reserve police officer and tactical physician with the Palm Springs Police Department in Palm Springs, California.
Dr. Heiskell served on an 18-agency member tactical medicine coalition under the auspices of the California Commission on Police
Officer Standards and Training and California Emergency Medical Authority (EMSA) to create the State of California Tactical Medicine
Operational Programs and Standardized Training Recommendations.
He is a graduate of Riverside Sheriff’s Office (RSO) SWAT School, National Tactical Officers Association (NTOA) School, Heckler & Koch
SWAT School, and the Federal Bureau of Investigation (FBI) SWAT School. Dr. Heiskell has lectured extensively in the United States and
abroad on tactical emergency medicine and has published over 70 articles and other publications on tactical medicine topics.
Dr. Heiskell has provided special operations emergency medical support for the FBI, Drug Enforcement Administration (DEA), and the
Bureau of Alcohol, Tobacco, and Firearms (ATF).
Colonel Jim Smith, MSS, NRP, FABCHS, CPC, CLEE Colonel Smith currently serves as the public safety director for a rural community in
the United States. He has more than 45 years’ experience in public safety as a certified police chief and has served as a bureau commander
in a metropolitan police agency supervising an FBI certified bomb squad and a clandestine laboratory entry-assessment team, 911 center
serving more than 30 agencies, responded more than 300 bomb/incendiary incidents, and more than 100 clandestine laboratories. Smith has
served as the public safety coordinator for a university with multiple campuses. Smith has developed several classes for the university
environment addressing clandestine laboratories, emergency management, WMD, and crisis management. He has been a practicing
paramedic for more than 45 years and is a certified fire instructor. Smith has a master’s degree in science in safety from the University of
Southern California and a bachelor’s degree from Troy University. He has served as a paramedic in the tactical setting for many years and
teaches classes in this arena. Smith served as a task force officer on a federal joint terrorism task force and as a senior health physics
technician and radiochemist at an operating nuclear power facility for several years. He has written several textbooks including subject matter
on bombs and bombings, response to WMD events, EMS operations in the WMD setting, and crisis management. He also serves as a peer
reviewer for several textbook publishers and professional journals, and he has more than 100 peer-reviewed articles published. Smith has
conducted research on explosion and fragment suppression leading to the production of specialized equipment and a patent issued for the
process. Smith teaches criminal justice, homeland security, and terrorism classes for the University of Phoenix and Troy University.
E. John Wipfler III, MD, FACEP Dr. John Wipfler is a board certified attending emergency physician and a Clinical Professor of Emergency
Medicine at the University of Illinois College of Medicine. In medical school, he joined the armed forces starting in 1985 and retired at the
rank of Major, U.S. Army Medical Corps (Res) after 14 years of service. In 1994 as an academic emergency physician, he obtained training
and additional military experience (Panama, multiple military bases) and started volunteering as a tactical physician for several SWAT teams
in the Midwest. Gaining valuable experience over the past 25 plus years, he continues to serve as tactical physician and TEMS medical
director for three SWAT teams and multiple law enforcement agencies in central Illinois.
Since completing his internship in surgery and residency in emergency medicine, he teaches and practices medicine with the Department
of Emergency Medicine at OSF Healthcare Saint Francis Medical Center, a Level I Trauma Center in Peoria, Illinois. Dr. Wipfler co-founded
the first tactical EMS unit in the state of Illinois, the Special Tactical Assistance Trauma Team (STATT) in 1998. He is a sworn LEO, a
Sheriff’s Physician who has been involved in tactical operations for more than 220 SWAT callouts. The STATT Tactical EMS unit (five
physicians, one nurse, two paramedics) supports three law enforcement tactical teams: Central Illinois Emergency Response Team (CIERT),
Illinois Law Enforcement Alarm Services team (ILEAS region 6/7), and the Peoria City Police Department Special Response Team (SRT). He
also supports callouts and/or training with the United States Secret Service for regional presidential motorcade escorts, United States
Marshals Service (SOG), and the Drug Enforcement Agency (DEA). He has flown SOG helicopter missions with the United States Marshals
Service Special Operations Group during high-risk prisoner transport.
As a certified firearms instructor who is also qualified expert in pistol, small-bore rifle, and high-power rifle marksmanship, Dr. Wipfler
routinely teaches firearms safety classes integrated with tactical medicine principles. He is certified by the Illinois State Police, and along with
his wife they have taught over 10 concealed carry courses. He has completed multiple military and civilian tactical/medical courses, including
the Chapman Academy (Basic and Advanced Pistol, Tactical Rifle), Combat Casualty Care Course, Counter Narcotics & Terrorism
Operational Medical Support (CONTOMS), Radiation Emergency Assistance Center/Training Site (REAC/TS) radioactive injury management
course, Heckler & Koch Basic and Advanced Tactical EMS courses, United States Army Medical Research Institute for Infectious Disease
(USAMRIID) Chemical and Biological Warfare School, Insights Training, and Strike Tactical Solutions close quarters combat courses.
Dr. Wipfler was instrumental in starting and served as medical director of the Region 2 RMERT disaster response team in central Illinois,
and has deployed on multiple real-world disasters including several large tornado strikes with mass casualties. Dr. Wipfler served with 12
others on the founding executive council for the sole state-wide disaster response agency in Illinois, the Illinois Medical Emergency
Response Team (IMERT). He served for 5 years as medical director of Life Flight, and has served as a flight physician for hundreds of air
medical rescues and transfers.
He has coauthored textbooks on emergency medicine and firearms safety, written chapters for textbooks—including the tactical medicine
chapter in the International Trauma Life Support (ITLS) text—as well as multiple tactical medicine and research papers. Dr. Wipfler lectures
internationally (Japan, Taiwan, Hong Kong, others) and teaches tactical medicine, disaster preparedness, bioterrorism/WMD response, and
advanced emergency ultrasound at the University of Illinois College of Medicine.
In 1999, Dr. Wipfler developed one of the first emergency medicine residency program tactical medicine elective rotations in the world.
This is a 2-week training session that over 90% of the EM residents at UICOMP/OSF St. Francis Residency Program complete during their 3-
year training program. Many have graduated and moved on to new communities where they now serve as tactical physicians throughout the
United States.
As the co-chair of the Illinois Tactical Officers Association (ITOA) tactical EMS committee, he has been involved in expanding TEMS in
the Midwest and instructing Tactical EMS with the Chief Jeff Chudwin and the ITOA and other law agencies, and he has co-chaired the
annual ITOA Tactical Medicine Conference for 6 years. He gained valuable experience by teaching with Dr. Heiskell at the International
School of Tactical Medicine in California for many years.
In 2005, Dr. Wipfler was asked by officials with the Department of Homeland Security to serve with an 18-agency member tactical
medicine coalition in California, representing the Illinois Department of Public Health Tactical Medicine Committee. This California committee
worked with the California Commission on Police Officer Standards and Training and California EMS Authority (EMSA) to create the State of
California Tactical Medicine Operational Program and Standardized Training Recommendations, approved in March 2010.
He continues to engage in firearm competition, 3-gun matches, advanced pistol courses, and other training, which help keep his skills
sharp. Dr. Wipfler recently competed in the 2018 U.S. National Patrol Rifle Competition in Novi, Michigan (LE only), where he scored in the
top 9 shooters of over 100 law enforcement officers. For hobbies, he enjoys scuba diving, fishing, and continues to engage in mountaineering
with friends and family, having summited the Matterhorn, Mount Rainier, Mount Shasta, Mount Baker, Long’s Peak, Hallet’s Peak, and
others. He and his wife are blessed and very proud of their six children and many travels and family adventures they have shared together.
When he initiated one of the first tactical medicine teams in the Midwest, he began teaching EM residents about tactical medicine. At that
time, in 1999, there was no formal textbook of tactical medicine, and so he was honored to serve as the lead author and join with three
trusted friends (Chief Jim Smith, Dr. Heiskell, and Dr. Campbell) to assemble a textbook that gathered the input and expertise of over 120
seasoned professionals in prehospital and tactical medicine, fire, law enforcement, disaster response, military operations, and other talented
individuals. Many members of the ACEP Section of Tactical Medicine were able to provide valuable expert input. The resulting textbook,
published by Jones & Bartlett Learning, was endorsed by ACEP, and is now used to help educate students internationally. This new second
edition was enhanced even further by additional expert reviewers and with updated information. Dr. Wipfler considers it a true honor and a
privilege to medically support the brave men and women in blue and camo uniforms.
ACKNOWLEDGMENTS
Special Thanks
The authors would like to extend a very special thanks to the following individuals who generously gave their talents, time, and extensive
knowledge to the formation and enhancement of this book:
Glenn A. Bollard, MD, FACEP

Past-Chair and Past Section Development Coordinator, Tactical Emergency Medicine Section
American College of Emergency Physicians
Special Certification, Forensic Medicine and Ballistics
Meadville, Pennsylvania
Martin Greenberg, MD, FACS

Chief, Section of Hand Surgery, Illinois Masonic Medical Center
Clinical Assistant Professor of Orthopedic Surgery, University of Illinois
Chair, EMS Advisory Council TEMS Committee
Tactical Physician, South Suburban Emergency Response Team (SSERT)
Reserve Police Officer, Village of Tinley Park, Illinois
Chicago, Illinois
Michael R. Meoli, Firefighter, EMT-P, Tactical Paramedic, SOC (SEAL)

Tactical Paramedic Firefighter, Special Trauma and Rescue (STAR) Team
Mobile Medical Strike Team, Paramedic Field Training Officer/Preceptor
San Diego Fire and Rescue Department
Special Warfare Operator Chief (SEAL)
Special Operations Command (SOCOM) Advanced Tactical Practitioner (ATP)
Casualty Assistance Calls Officer (CACO)
Tactical Combat Casualty Care (TCCC) Instructor/Trainer
Command Fitness Leader (CFL), US Navy Reserve SEAL Team 17
Coronado, California
Reviewers
Paul Abdey, Dip IMC RCS (Ed), Paramedic
Tactical Medicine Unit Manager
Kent Police
Maidstone, Kent, United Kingdom
Jeff W. Adams
Lieutenant (ret), Special Response Team Commander
Peoria Police Department
Peoria, Illinois
Amado Alejandro Baez, MD, MSc, MPH, FACEP, FCCM

Professor and Vice-Chair for Operational Medicine
Director, Center for Operational Medicine
Department of Emergency Medicine
Medical College of Georgia, Augusta University
Augusta, Georgia
James Bender, BS, EMT-P, HEM

Tactical Paramedic
Healthcare Emergency Manager
Medical Horizons Consulting
Washington, Illinois
Sean Benson
Firearms Tactical Advisor, Bronze Commander, and Trainer
Firearms Training and Development Unit
Rotherham Police Station
Rotherham, South Yorkshire, United Kingdom
Neil P. Blackington, EMT—Tactical

Deputy Superintendent, Commander, Support Services Division
Boston EMS
Boston, Massachusetts
Brandon Bleess, MD, FACEP

Medical Director, Life Flight
Attending Emergency Physician, Department of Emergency Medicine
Clinical Assistant Professor of Emergency Medicine
University of Illinois College of Medicine
Tactical Physician, Special Tactical Assistance Trauma Team (STATT)
Deputy Sheriff, Woodford County Sheriff’s Office
Peoria, Illinois
William P. Bozeman, MD, FACEP, FAAEM

Associate Professor, Director of Prehospital Research
Wake Forest University, Department of Emergency Medicine
Winston-Salem, North Carolina
Walter J. Bradley, MD, MBA, FACEP

Physician Advisor, Trinity Medical Center
Medical Director, Illinois State Police Tactical Response Team
Medical Director, Tactical Medicine Team, Moline Police Department
Moline, Illinois
David W. Callaway, MD, FACEP, MPA

Professor, Emergency Medicine
Chief, Division of Operational and Disaster Medicine
Department of Emergency Medicine, Carolinas Medical Center
Chair, Section of Tactical Medicine, American College of Emergency Physicians
Charlotte, North Carolina
Dale Carrison, DO
Professor of Emergency Medicine
Chair, Department of Emergency Medicine
University of Nevada School of Medicine
Las Vegas, Nevada
Matthew Clark
State Registered Paramedic
Police Specialist Firearms Officer
United Kingdom
Keith F. Collins, NREMT-P, CIC

Tactical Medic
Rotterdam Police Department
Rotterdam, New York
Jeff Chudwin, JD
President, Illinois Tactical Officers Association
Chief of Police (ret), Olympia Fields Police Department
Olympia Fields, Illinois
Michael Colvard, DDS, MS, M O Med RCSEd

Associate Professor of Oral Medicine and Diagnostic Sciences
Director, Disaster/Emergency Medicine Readiness Training Center
University of Illinois at Chicago
Chicago, Illinois
John H. Cottey II, MD

Emergency Physician
University Medical Center Brackenridge
Austin, Texas
John Croushorn, MD, FACEP

Chair, Department of Emergency Medicine, Trinity Medical Center
Tactical Physician, Federal Bureau of Investigation
Major, United States Army Medical Corp (vet)
Birmingham, Alabama
W. Scott Crowley, BA, EMT-P

EMT Program Director
Phoenix College
Phoenix, Arizona
Fabrice Czarnecki, MD, MA, MPH

Director of Medical-Legal Research, The Gables Group, Inc.
Attending Physician, Emergency Department, St. Joseph Medical Center
Towson, Maryland
Tony Damiano
Tactical Medic
Polk County Sheriff Department
Bartow, Florida
Andrew Dennis, DO, FACOS, DME

Trauma Surgery/Burn Surgery/Critical Care
The Cook County Trauma Unit, Cook County Hospital
Cook County Sheriff’s Police Hostage and Barricade Team
Chairman, Department of Surgery, Chicago College of Osteopathic Medicine of Midwestern University
Medical Director/Team Surgeon/Police Officer
Cook County Sheriff’s Police Department, Emergency Services Bureau
Northern Illinois Police Alarm System Emergency Services Team, Des Plaines, Illinois Police Department
Chicago, Illinois
Raffaele DiGiorgio, NREMT-P, UK HPC Registered Paramedic

Owner
Global Options & Solutions
Knoxville, Tennessee
Chris Dinsdale
Senior Lecturer, Prehospital Medicine
Tactical Medicine Specialist
Sheffield Hallam University
Sheffield, South Yorkshire, United Kingdom
Franco Dillena
Training Officer
Miramar Police Department
Miramar, Florida
Steve Erwin, BS, NREMT-I, Tactical EMT-I, EMSI

Program Manager, Emergency Medical Service
Louisiana Department of Health and Hospitals
Baton Rouge, Louisiana
Alexander L. Eastman, MD, MPH

Deputy Medical Director, Police Officer, Tactical Physician
Dallas Police Department
Assistant Professor of Surgery, Division of Burns, Trauma, and Critical Care
University of Texas Southwestern Medical Center
Dallas, Texas
Michael Eby, MD, FACOG

Chief, Surgical Critical Care, Jerry L. Pettis Memorial Veterans Affairs Medical Center
Loma Linda, California
Tactical Physician/Reserve Officer, San Bernardino Police Department
San Bernardino, California
Richard C. Frederick, MD, FACEP

Vice Chair, Department of Emergency Medicine, OSF Saint Francis Medical Center
Clinical Associate Professor of Surgery, University of Illinois College of Medicine
Auxiliary Deputy Sheriff, Peoria County Sheriff’s Office
Peoria, Illinois
Mark Griffeth, EMT-P

Manager, Facilities Division, Medical Programs
Illinois Law Enforcement Alarm System (ILEAS)
Urbana, Illinois
Russell J. Graham, BA, AAS, EMT-P

Staff Sergeant
Stephen Grasso, BA, EMT-P

Battalion Chief/SWAT Medical Team Leader
Lauderhill Fire-Rescue
Lauderhill, Florida
Joseph R. Haake, MD, FACEP

Tactical Physician, Carbondale Police Department
Emergency Physician, Southern Illinois Healthcare
EMS Medical Director, Southern Illinois Regional EMS
Captain, U.S. Army Reserve, 303rd Field Hospital
Carbondale, Illinois
David Halliwell, MSc Paramedic, FIFL, MIFPA

Head of Education
South Western Ambulance NHS Trust
Bournemouth, Dorset, United Kingdom
Brendan E. Hartford, EMT-Tactical

SWAT Team Training Coordinator, Chicago SWAT
Chicago Police Department
Chicago, Illinois
George Z. Hevesy, MD
Chair, Department of Emergency Medicine
Attending Emergency Physician, OSF Healthcare Saint Francis Medical Center
Clinical Associate Professor of Emergency Medicine, University of Illinois College of Medicine
Tactical Physician (ret), Special Tactical Assistance Trauma Team (STATT)
Auxiliary Deputy Sheriff (ret), Peoria County Sheriff’s Office
Peoria, Illinois
John Holschen, EMT-P, Tactical Paramedic

United States Army Special Forces Medical Sergeant (ret)
Heiho Consulting Group, LLC
Bothell, Washington
Matthew N. Jackson, MD, FACEP, FAAEM

Medical Director for Pre-Hospital and EMS, OSF HealthCare System
EMS Medical Director, Region II, PAEMS
Clinical Assistant Professor of Emergency Medicine, University of Illinois College of Medicine
Peoria, Illinois
Joshua Jeffries, EMT-P, Tactical Paramedic

Firefighter and Paramedic, Morton Fire Department
Private Security Specialist
Prehospital Educator – PAEMS
Tactical Paramedic, STATT TacMed Team
Police Officer, Washington Police Department
Instructor, TacMed Essentials LLC
Morton, Illinois
Neil Jones
Firearms Instructor
Tactical Firearms Unit
Sussex Police
Lewes, Sussex, United Kingdom
Sean Johnston, EMT-P, Tactical Paramedic

SRT - Special Response Team Tactical Officer
Peoria Police Department
Peoria, Illinois
Thomas M. Kamplain, Jr, MS, NREMT-P, Tactical Paramedic

Director, EMS/Fire Science
DeKalb Technical College
Covington, Georgia
Shane Knox, MSc, HDip-EMT

Advanced Paramedic
Training and Development Officer
HSE-National Ambulance Service College
Ballinasloe, County Galway, Ireland
Terry G. Kaufman
Tactical Medic, Lafayette Police Department
Manager, Flight Safety, Petroleum Helicopters, Inc.
Lafayette, Louisiana
Jacqueline E. Krajecki, RN, BSN, MSNA, EMT-LP, CEN, CCRN, CFRN, CRNA
Certified Registered Nurse Anesthetist
The Anesthesia Group of Sarasota
Sarasota, Florida
Austin Lamb, MD, FACEP

Peoria, Illinois
Gordon L. Larsen, MD, FACEP

Medical Advisor, Technical Rescue/Zion National Park Search and Rescue Team
Attending Emergency Physician, Southwest Emergency Physicians, Dixie Regional Medical Center
St. George, Utah
Justin M Lemieux, MD
Clinical Assistant Professor, Stanford Emergency Medicine
EMS/Disaster and Tactical Medicine
Medical Director/Field Physician San Mateo Regional Tactical EMS
Instructor, International School of Tactical Medicine
Medical Team Manager FEMA US&R CA-TF 3
Mountain View, California
Christopher J. Loscar, NREMT-P

St. Clare’s Hospital MICU
Dover, New Jersey
Mark A. Lorenz, MD, AAOS

Orthopedic Surgeon, Hinsdale Orthopaedics
Clinical Associate Professor, Loyola University Medical Center
Hinsdale, Illinois
David Q. McArdle, MD
Attending Emergency Physician, Georgia Emergency Associates, South East Georgia Medical Center, Brunswick, Georgia
Occupational Medicine Physician, Defense Support Systems LLC, Greenville, South Carolina
Federal Law Enforcement Training Center, Glynco, Georgia
Reserve Officer/Tactical Physician, University of Colorado Police at Boulder, Colorado
Affiliate Faculty Department of Criminology & Homeland Security, Regis University, Denver, Colorado
President, TacMedMD LLC
Medical Director, ColoradoSTAR
Centennial, Colorado
Kevin J. McCollin, MBA/HCM, NREMT-P

Director of Emergency Medical Services
Dugway Emergency Medical Services
Dugway, Utah
Lt. Craig McElhaney, NREMT-P

SWAT Medic
Miramar Fire-Rescue
Miramar, Florida
Tom McGarey, MA Ed, BSc

Paramedic Tutor
Regional Ambulance Education Centre
Northern Ireland Ambulance Service
Belfast, County Antrim, Northern Ireland
Sean D. McKay, EMT-P, Tactical Paramedic

Instructor, Tactical Medicine
Operational Rescue
Associate, Asymmetric Combat Institute
Taylors, South Carolina
Rick F. Miller, MD, FACEP

Director (ret), Pediatric Emergency Medical Services, OSF Saint Francis Medical Center
Clinical Associate Professor of Emergency Medicine, University of Illinois College of Medicine
Tactical Physician (ret), Special Tactical Assistance Trauma Team (STATT)
Deputy Sheriff (ret), Peoria County Sheriff’s Office
Peoria, Illinois
Alan Moore
Paramedic and Registered Nurse
London, England, United Kingdom
Jesse Munk, EMT-P, Tactical Paramedic, IDPH-LI

STATT Tactical Paramedic
Woodford County Sheriff’s Deputy
Instructor, TacMed Essentials Basic/Advanced
FLETC Tactical Medicine Instructor
EMS Shift Supervisor
HazMat, Rope operations, Vehicle Machinery Tech
Bloomington Firefighter
Bloomington, Illinois
Keith Murray MD, FAWM, FACEP

Emergency Medicine Physician
Medical Director Pittsburgh SWAT
Medical Director University of Pittsburgh SERT
Pittsburgh, PA
Wren Nealy, Jr, EMT-P, Tactical Paramedic

Director of Special Operations, Cypress Creek Emergency Medical Services
Lead Instructor, Tactical Medical Operational Support Course
Houston, Texas
Deputy Sheriff and SWAT Assistant Team Leader, Waller County Sheriff’s Office
Hempstead, Texas
Bohdan (Dan) T. Olesnicky, MD, ABEM, ABIM

Director of EMS, Eisenhower Medical Center Instructor, International School of Tactical Medicine
SWAT Physician, Palm Springs Police Department SWAT Palm Springs, California
Kevin Olver
Police Tactical Firearms Trainer
Cleveland and Durham Police Tactical Training Centre
Stockton-on-Tees, Cleveland, United Kingdom
Brian P. Pasquale, MPH, NREMT-P

SSG (ret), 68W_W1, USSOCOM-SOF-Paramedic
Co-founder
Tac-Med LLC
Collegeville, Pennsylvania
William F. Pfeifer, MD, FACS

Clinical Professor of Surgery, Rocky Vista University College of Osteopathic Medicine
Associate Clinical Professor of Surgery, University of Colorado Health Sciences
Mile High Surgical Specialists
Denver, Colorado
Jason R. Pickett, MD, EMT-P/T

Assistant Professor, Division of Tactical Emergency Medicine
Department of Emergency Medicine, Boonshoft School of Medicine
Wright State University
Major, USAR Medical Corp
Kettering, Ohio
Scott Plantz, MD, FAAEM

Associate Clinical Professor
Mount Sinai Hospital
Chicago, Illinois
James P. Phillips, MD FACEP

Assistant Professor of Emergency Medicine
Fellowship Director and Chief, Disaster and Operational Medicine
George Washington University Hospital
Senior Fellow, Center for Cyber and Homeland Security
Elliot School of International Affairs
Washington, District of Columbia
Guadalupe (Wally) Quintanilla, EMT-P, AAS

TEMS Team Leader, South Suburban Emergency Response Team
Corporal, Posen Illinois Police Department
Posen, Illinois
Engineer/Paramedic, Orland, Illinois Fire Protection District
Orland Park, Illinois
Colleen S. Ragon, RN, MSN, CEN, CFRN

Tactical Nurse, Special Tactical Assistance Trauma Team (STATT)
Central Illinois Emergency Response Team (CIERT)
Peoria Police Special Response Team (SRT)
Illinois Law Enforcement Alarm System (ILEAS) Region 6 Team
Auxiliary Deputy Sheriff, Peoria County Sheriff’s Office
Flight Nurse Specialist, Life Flight, OSF Saint Francis Medical Center
Peoria, Illinois
David Rathbun, EMT-P

Los Angeles County Sheriff, Special Enforcement Bureau (ret)
Tactical EMS Chair, National Tactical Officers Association
La Canada, California
Lee Raube, DO
Peoria, Illinois
Nicholas R. Reinhart, DO, FACEP

Medical Director/EMS Medical Director
OSF Healthcare Saint Elizabeth Medical Center
Ottawa, Illinois
Attending Emergency Physician
OSF Healthcare Saint Francis Medical Center
Peoria, Illinois
John Rigione, EMT-P

President
Emergency Medical Solutions, Inc.
Bangor, Pennsylvania
Hector Roman, AS, EMT-P, Tactical Paramedic

Hospital Corpsman 1st class (FMF)
Advanced Tactical Training, Inc.
Coral Springs, Florida
Malcolm Q. Russell, MBChB, DCH, DRCOG, MRCGP, FIMC RCS(Ed)

Managing Director
Prometheus Medical Ltd.
Hope-under-Dinmore, Herefordshire, United Kingdom
Navin Sharma, RN, BSN, CEN, EMT-P, Tactical Paramedic

Police Officer (ret)/Tactical Paramedic-RN
Instructor, Tactical Emergency Medicine
Vancouver, Washington
Daniel Smiley, EMT-P

Chief Deputy Director
State of California Emergency Medical Services Authority
Sacramento, California
Andrew Smith
Medical Emergency Response Team Paramedic
Royal Air Force
Chippenham, Wiltshire, United Kingdom
William Smock, MS, MD, FACEP, FAAEM

Professor, Department of Emergency Medicine
University of Louisville School of Medicine
Police Surgeon, Louisville Metro Police Department
Tactical Physician, Floyd County, Indiana Sheriff Department
Tactical Physician, United States Marshals Service, Western District, Kentucky
Medical Advisor, Louisville, Kentucky Division of the Federal Bureau of Investigation
Louisville, Kentucky
Chuck Soltys
Special Agent/EMT-B
Drug Enforcement Administration (DEA)
Chicago, Illinois
Brian L. Springer, MD, FACEP

Assistant Professor and Director, Division of Tactical Emergency Medicine
Department of Emergency Medicine, Boonshoft School of Medicine
Dayton, Ohio
Kent Spitler, RN, NREMT-P, BS, MSEd, CPP

Director, Department for EMS Education
Gaston College
Dallas, North Carolina
Clint Steerman, NREMT-P, Tactical Paramedic

Chief Executive Officer
Metro One Ambulance
Martinez, Georgia
Hugh E. Stephenson, Jr, MD, FACS

University of Missouri System Curator Emeritus
John Growdon Distinguished Professor of Surgery Emeritus
Missouri University School of Medicine
Columbia, Missouri
Richard B. Schwartz, MD, FACEP

Chairman and Professor
Medical College of Georgia at Augusta University
Augusta, Georgia
Matthew D. Sztajnkrycer, MD, PhD

Medical Director, Rochester Police Department
Medical Director and Tactical Physician, Rochester Police Department/Olmsted County Sheriff’s Office Emergency Response Unit
Associate Professor and Chair, Division of Emergency Medicine Research
Mayo Clinic
Rochester, Minnesota
David H. Tang, MD, FAAEM

SWAT Team Physician and Reserve Police Officer, Palm Springs Police Department, Palm Springs, California
Attending Physician, Eisenhower Medical Center
Forensic Medical Director, Barbara Sinatra Children’s Center
Rancho Mirage, California
Nelson Tang, MD, FACEP

Chief Medical Officer, Center for Law Enforcement Medicine
The Johns Hopkins University Director of Special Operations, Department of Emergency Medicine
The Johns Hopkins Medical Institutions
Baltimore, Maryland
Nicholas R. Taylor, EMT-Tactical

Special Agent, United States Army Criminal Investigation Division
EMT-Tactical, Patrol Officer, Pontiac Police Department
Pontiac, Illinois
Dan Toomey
Training Program Services
Commission on Peace Officer Standards and Training
West Sacramento, California
Richard Tovar, MD, FACEP, FACMT

Attending Emergency Physician, Medical College of Wisconsin
Tactical Physician, New Berlin Police Department
New Berlin, Wisconsin
Mark Tutila, NREMT-P, Tactical Paramedic

Instructor, Tactical Paramedic
Clinical Supervisor, Regions Hospital EMS
St. Paul Fire Department
St. Paul, Minnesota
Sydney Vail, MD, FACS

Medical Director, Trauma Surgery Program, Department of Surgery
Division of Burns, Trauma, and Surgical Critical Care
The Trauma Center at Maricopa Medical Center
Medical Director of Tactical Medicine Programs and Tactical Physician, Arizona Department of Public Safety, State Police SWAT
Medical Director of Tactical Medicine Programs and Tactical Physician Tactical, Maricopa County Sheriff’s Office SWAT Team
Phoenix, Arizona
Instructor, International School of Tactical Medicine
Palm Springs, California
Joshua S. Vayer, CSA

Division Director, Uniformed Operations
Federal Protective Service
US Department of Homeland Security
Washington, District of Columbia
Michael D. Volling, EMT-P

Chief of Police, Village of Glencoe
Tactical Commander, Northern Illinois Police Alarm System (NIPAS) Emergency Services Team
Village of Glencoe, Illinois
Rease E. Watson, EMT-P, Tactical Paramedic

Captain, Special Operations Division
Hazardous Materials/Weapons of Mass Destruction/Technical Rescue
City of Peoria Fire Department
Auxiliary Deputy Sheriff (ret), Peoria County Sheriff’s Office
Peoria, Illinois
Kenneth Whitman
Senior Law Enforcement Consultant, California Commission on Police Officer Standards and Training
Project Manager, POST Tactical Medicine Core Competencies Program, Sacramento, California
Lieutenant, Rocklin Fire Department
Rocklin, California
John M. Wightman, EMT-P, Tactical Paramedic, MD, MA

Professor and Director for Academics
Division of Tactical Emergency Medicine
Boonshoft School of Medicine
Dayton, Ohio
Diane Kruger Wipfler, OTR, EMT

Instructor, TacMed Essentials LLC
Director of Logistics, TacMed Essentials Basic and Advanced
Illinois State Police Certified Concealed Carry License Instructor
NRA Certified Handgun Instructor
Metamora, Illinois
Mark T. Wold, EMT-P, Tactical Paramedic

Public Safety Officer, Tactical Paramedic, Evidence Technician, Juvenile Officer
Glencoe Police Department
Village of Glencoe, Illinois
Erik Wright, MD
Chief Resident, Emergency Medicine Residency Program
OSF Healthcare Saint Francis Medical Center
Peoria, Illinois
Matt Zukosky, MA, NREMT-P, CIC

Emergency Medical Care Program Coordinator, Suffolk County Community College
Selden, New York
Tactical Paramedic, Southampton Village Police Department
Southampton, New York
The authors would also like to thank:
Sheriff Michael McCoy, Chief Steve Settingsgaard, Captain Michael Scally, Captain Doug Theobald, Chief Deputy Joseph Needham,
Lieutenant Jim Pearson, Deputy Michael Ealey, Lieutenant Mike White, Lieutenant R. Scott Cook, Lieutenant Mike Mushinsky, Lieutenant
Mike Clark, Lieutenant James Middlemas, Lieutenant Joe Hartwig, Sergeant Jake Faw, Sheriff Matt Smith, Chief Deputy Dennis Tipsword,
Captain Rodney Waters, Sheriff Brian Asbell, Chief Loren Marion, Dan Smiley, Dan Toomey, Fire Chief Edward Olehy Jr, Assistant Fire
Chief Tony Ardis, Chuck Fugitt, Tom Stimeling, Lance Koss, Brian Kroll, Ben Gareau, Rick Waldron, Ben Wallick, Jesse Munk, Tony
Salvator, Nate Lunt, Doctor Gina Piazza, Denise Louthain, Lieutenant Doug Gaa, Lieutenant Joe Hartwig, Lieutenant John Ghidina,
Lieutenant Ed Meister, Lieutenant David Rogers, Officer Jeff Stolz, Officer Chad Hazelwood, Officer Rory Poynter, Deputy United States
Marshall Greg Sims, Bob and Carol Heinz, Pete Fandel, Andrew Rand, Rex Comerford, Doctor Tom Trent, Doctor Wade Richey, Doctor
Justin Johnson, Doctor Nathan Jones, Doctor Greg Tudor, Doctor Jim Ellis, Doctor Bob Tillotson, Doctor Tim Wheeler, Claire Merrick, Tim
Murray, Doctor Todd Nelson, John Gilman, Doug Wipfler, Jim Etzin, Shannon Benko, Wes Smith, Mike Adams, Patrick Merfeld, J.T. Thomas,
Steve Slawinski, Rick Brown, Mike Marquis, Tony Centimano, Ross Johnson, Alexis Ferraro, Jack Wipfler, Shirley Wipfler, Doctor Corey
Massey, Henk Iverson, Doctor Jeff Juhala, Doctor Moses Lee, Diane Wipfler, Rebecca Wipfler, Maria Wipfler, Matt Wipfler, Kate Wipfler,
Laura Wipfler, Libby Wipfler, Seth Barker, Sean Johnston, Kevin Mowery, Jim Mulay, Terry Kaufman, Ricky Wolfe, Garry Grugan, Ryan
Beck, Chuck Fugitt, James Bender, Doctor Jane Billeter, Doctor Bernard Heiliczer, Doctor Bruce Sands, Doctor Mark Sloan, Leslie Stein-
Spencer, Sharon White, Rob Chiapano, Steve Slawinski, Randolph Christianson, Andrew Hamilton, Steve Knickrehm, David Lis, Doctor Josh
Vayer Robert Raica, John Stoeber, John R. Allen II, Doctor Jonathan Allen, Joseph Collins, Doctor Winn Curran, Christian Davis, Don
Dougherty, Steve Drewniany, Doctor Anthony R. DuBose, Ken Elmore, Don Fallon, Kelly Fieux, Nathan Gunkel, Steve Harris, Rick Leska,
Chuck Menley, Andrea Michell, Doctor James Munis, Doctor Robert L. Norris, Doctor Keith Rose, Dr. Alejandro Baez, Gary Sommers, Kyle
Stjerne, Doctor Lynn Welling, Matt Willette, Gerald Smith, Steve Simpson, Rick Smith, Command Sergeant Major Alex Cabassa, Steve
Simpson, Denise Louthain, Doctor Wade Richey, Major James Ayer, and Claire Merrick.
Special thanks to the excellent men and women, and administrative support of: Palm Springs Police Department, California EMSA, California
Police Officer and Standards Advanced Medical Transport of Central Illinois, Peoria Police Department, Peoria County Sheriff’s Office,
Central Illinois Police Alarm System Region 6 team, Palm Springs Police Department, U.S. Marshals Service, U.S. Secret Service, Illinois
State Police Tactical Response Team, Sisters of the 3rd Order of Saint Francis in Peoria, Illinois, OSF Saint Francis Medical Center, Life
Flight/OSF Saint Francis Medical Center, Department of Emergency Medicine, Sister Judith Ann Duvall, Keith Steffen (CEO) and
administrative officers, OSF Saint Francis Medical Center.
FOREWORD
As we approach the 30th anniversary of Tactical Emergency Medical Support (TEMS), we see this essential specialty area in continued
evolution based on changing complex threats, which we collectively call “all hazards.” We also note that what started out as an aspiration 30
years ago is now a national standard for law enforcement teams involved in high-risk operations. We are grateful that since the inception of
the TEMS concept, many other tactical medicine programs have come forward to further our profession. These include but are not limited to
Counter Narcotics Tactical Operations Medical Support (CONTOMS), International School of Tactical Medicine (ITMS), International Tactical
EMS (ITEMS), Committee for Tactical Emergency Casualty Care (C-TECC), Committees of the National Association of EMS Physicians, the
American College of Emergency Physicians, and the American College of Surgeons.
TEMS, like our EMS systems, is largely a product of the rapid evolution of military medicine in combat, which then transfers the newly
acquired intellectual property, technology, and equipment to the civilian sector. From the earliest times of civilization, we see historical
artifacts demonstrating how Greek and Roman armies attempted to triage, transport, and care for injured soldiers. During the Napoleonic
wars of the very early 19th century, we also see how Baron Larrey implemented rapid transport of the combat injured via the first ambulances
who took the injured to definitive care. And, during our Korean and Vietnam wars, we began to see trauma registries, true field care through
well-trained medics, rapid transport, and the first trauma centers.
All of the aforementioned experiences have allowed us to develop the most sophisticated emergency medical and trauma care systems in
the world. Now a new iterative transformation is upon us due to complex evolving threats that inspire us to be innovative and disruptive as
these new threats required adjustments to our training, equipment, policies and procedures.
When we began TEMS in the late 1980s, we incorporated a military special operations model of medics being part of the operational
team since it made no sense that most SWAT teams then had little or no medical input for prevention, health, and safety, and, in fact, when
confronted with an injured suspect or officer in a tactical situation, they often had to call 911! The idea then, as it is now, is that the medic
provides scientifically sound advice to commanders on nutrition, exercise, selection of appropriate safety equipment, training and scope of
practices for TEMS incorporation, medical intelligence during operations, and when needed, scene medical care and coordination with local
EMS.
In the early TEMS days, most of our focus was on the most common missions at that time, warrant service, barricaded subjects, and an
occasional hostage rescue. Over the past three decades, we have once again witnessed the evolution of a set of new threats that include but
are not limited to domestic terrorism, mass casualty incidents, active shooters, the threats of global terrorism, and a propensity to see more
combat type casualties in a domestic urban environment. Hence, the “all hazards” domain continues to increase necessitating TEMS to
improve, modify, and adapt to these ever increasing and more complex threats.
From the ongoing Iraq and Afghanistan combat threats, we have learned the importance of “buddy care;” relearned the necessity for
tourniquet use; moved damage control surgery closer to the front; and advanced the science of fluid resuscitation, hemorrhage control, and
early management of head injuries.
Due to the Department of Defense Tactical Combat Casualty Care (TCCC) group chaired for over a decade by Dr. Frank Butler, we have
a global trauma registry that weekly captures all emerging data needed to guide us in our TEMS related practices. So unlike Vietnam, where
lessons learned took decades to translate to civilian EMS and emergency/trauma care practices, the TCCC has accelerated this translation
in real time in an unprecedented fashion. In addition, we have continued to see an increase in civilian TEMS-related academic and tactical
publications.
Our TEMS nomenclature, training, policies, and practices will continue to evolve as we incorporate TCCC data and mine our own data in
order to improve the health of our operators as well as decrease morbidity and mortality. Once again, we owe a debt of gratitude to our
authors who saw the need to revise the first edition due to the new threats and opportunities and to incorporate evolving contemporary
TCCC, national EMS and emerging new science data to generate cutting edge best practices.
VADM (Ret.) Richard Carmona, MD, MPH, FACS

17th Surgeon General of the United States
Deputy Sheriff, Pima County Sheriff’s Department
PREFACE
For this second edition of Tactical Medicine Essentials, it is important to remember the brave men and women in our armed forces who
forged many of the medical lessons learned in military environments and also those who wore and continue help keep law and order. The
“thin blue line” of law enforcement is what separates and prevents anarchy and chaos from ruining our modern civilization.
This book is dedicated to the pioneers in uniforms of camo and blue and brown, and upon their shoulders we continue to engage in and
improve the concepts of tactical emergency medicine.
During the 1980s, the world saw the development of a trauma medical care education program that has since been adopted worldwide.
This program was developed by Dr. John E. Campbell and was originally known as Basic Trauma Life Support (BTLS). Today it is known as
International Trauma Life Support (ITLS). Dr. Campbell sadly passed away in August 2018 at age 75, and yet many of his colleagues
continue to proudly carry the torch of enhancing prehospital trauma care.
Years ago, Dr. Campbell identified the need for additional education in several areas of EMS. He was particularly concerned about the
global lack of knowledge and skill sets within EMS as they pertained to weapons of mass destruction (WMD) and tactical medicine. At that
time, the majority of EMS professionals were not fully prepared or trained to respond to these critical incidents.
In 2000, Chief Jim Smith, a veteran police officer, educator, paramedic, and colleague of Dr. Campbell, developed a course outline and
curriculum for these two areas. After first working together with colleagues on a WMD program, the need for tactical medicine program was
further identified. As friends, Dr. Campbell and Dr. John Wipfler worked together and discussed collaborating on a tactical medicine project.
With over 17 years as an emergency physician and associate professor teaching emergency medicine at a Level I trauma center, as a
tactical, flight, and disaster physician, and as a Major (ret) in the United States Army Medical Corps, Dr. Wipfler had developed a unique
knowledge base and skill set.
Rounding out the team of authors was Dr. Lawrence Heiskell, founder and director of the International School of Tactical Medicine, an
emergency physician and reserve police officer who has pioneered, directed, and taught tactical medicine to thousands of students over the
past 25 years. In 2018, Dr. Heiskell was awarded the American College of Emergency Physicians (ACEP) Tactical Medicine Section 2018
Tactical Emergency Medicine Visionary Leader Award.
With special editing contributions by Dr. Marty Greenberg, Dr. Glenn Bollard, and Navy SEAL Chief Mike Meoli, along with over 120
contributors and reviewers, this team labored for over 5 years to create one of the world’s first educational textbooks for the providers of
tactical medicine.
During the development process, Kenneth Whitman of the California Commission on Peace Officer Standards and Training (POST) and
Dan Smiley of the California Emergency Medical Authority (EMSA) requested that Dr. Heiskell and Dr. Wipfler participate on an 18-agency
member committee to develop the first state-wide Tactical Medicine Core Competencies and Standardized Training Recommendations for
the state of California. The result was a first-of-its-kind milestone in statewide-standardized tactical medicine training. This textbook
incorporates these recommendations and guidelines, which were finalized in March of 2010. These co-authors would eventually participate in
a national effort with Dr. Richard Schwartz and others with the National TEMS Initiative and Council (NTIC).
The first edition of this textbook was published in 2012, and since then, further advances in tactical medical have evolved. The world has
seen increased active shooter attacks, terrorist tactics have changed, and the need is even greater than before.
The California TCC, the U.S. Armed Forces TCCC, and TECC have further evolved and expanded, and these are described in this
second edition. In 2016, the NTIC Core Competency Domain was modified and improved, and consolidation and cooperative development
with the Committee for TECC is creating opportunities for national standardization of TEMS training programs and a future accreditation
process. With continued dedication to excellence by key leaders, the specialty of Tactical Medicine should progress from a set of individual
experts to a national standard of care.
The authors extend their sincere gratitude to the many excellent editors, reviewers, colleagues, and friends who have all contributed to
this textbook. The authors thank the excellent editorial and production staff at Jones & Bartlett Learning, especially Christine Emerton.
For the second edition, we would like to especially thank Ashley Procum and Alex Belloli. We also wish to thank our spouses and families
for their patience and support as the hours slowly passed as we produced this text. The goal was, and still is, to better enable tactical medical
providers to safely, skillfully, competently, and confidently provide tactical medicine support for special weapons and tactics (SWAT) and
special operations teams throughout the world.
Excellent Medicine at Lightning Speed is the motto of the tactical medicine team led by one of the co-authors. We hope that many will
benefit from the educational material in this textbook, and may each reader and student be blessed with the knowledge and skills learned so
that others in need will benefit and continue to serve their fellow mankind.
INTRODUCTION
The concept of emergency medical support has evolved into the dynamic field of what is now known as tactical medicine. The absolute
necessity of medical support is apparent and important now more than ever in the history of SWAT and law enforcement special operations.
This textbook will be a great resource for you, the tactical medicine provider, in improving your knowledge and skill sets. The authors have
provided you with decades of real-world experience.
All aspects of tactical medicine are explained in detail. The book has information on how to handle everything from routine medical
problems to more complex and serious injuries and illnesses that can occur in the tactical environment.
Saving lives and reducing liability are goals of every law enforcement agency. This book teaches and shows you how to accomplish this.
It will be a valuable tool for any tactical medicine provider who works with law enforcement agencies, their special operations teams/SWAT,
mobile field teams, bomb squads, K-9 units, and other elements with unique deployment circumstances that can benefit from close-up
medical support.
Ron McCarthy
Los Angeles, California Police Department
Special Operations Team (LAPD SWAT) (ret.)
Los Angeles, California
Courtesy of Dr. John Wipfler and Dr. Lawrence Heiskell.
SECTION
1
Elements of Tactical Medicine
CHAPTERS
1 History and Role of the Tactical Medical Provider
2 Safety and Wellness of the Tactical Medical Provider
3 Tactical Team Fundamentals
4 Equipment of the Tactical Medical Provider
5 Weapons Handling and Firearms Safety
6 Unconventional Weapons and Criminal Tactics
7 Medical Intelligence
8 Medical Response to Active Assailant Mass Casualty Incidents
9 Operational Tactics
10 Tactical Team Activations
Image credit FPO.
CHAPTER
1
History and Role of the Tactical Medical Provider
OBJECTIVES
Define tactical medicine.
Define tactical emergency medical support (TEMS).
Discuss the history and evolution of TEMS.
Describe the civilian emergency medical system.
Describe the organization of and roles in law enforcement.
Discuss the history of Special Weapons and Tactics (SWAT) units.
Discuss the roles within the SWAT units.
List the roles and responsibilities of the tactical medical provider (TMP) before, during, and after a deployment.
Define bilateral command.
Describe the elements of TMP training.
Introduction
units are specialized law enforcement units that deal with a variety of critical (or high-risk) incidents including
Special Weapons and Tactics (SWAT)
barricaded felony suspects, hostage rescue scenarios, perpetrators armed with military-style weapons, orga-nized crime, methamphetamine
laboratories with chemical and explosive threats, terrorist acts, bomb threats, dignitary protection, riots, and other hazards Figure 1-1 .
Figure 1-1 A SWAT unit in training.

Courtesy of John Wipfler.
Tactical medicine is the services and emergency medical support needed to preserve the safety, health, and overall well-being of SWAT unit
personnel.
Tactical emergency medical support (TEMS) is the prehospital emergency care provided during SWAT unit training and deployment (critical
incidents and deployment). During training and deployment, SWAT unit personnel are accompanied by personnel trained in TEMS—known
as tactical medical providers (TMPs).
The mission of the TMP is to support the wellness of the SWAT unit and perform emergency medical care in the tactical environment for
any person in need, from SWAT unit personnel to suspect.
Training to become a TMP is challenging. The TMP often acts as the bridge between law enforcement and emergency medical services.
You will be challenged, both physically and mentally, during this course. You must keep your body in excellent condition so you can master
the skills needed to survive and provide medical care in a tactical environment. You must also remain mentally alert to cope with the various
conditions and stresses you will encounter.
This chapter discusses the history of tactical emergency medical support, the modern emergency care system, the roles in a SWAT unit,
the roles and responsibilities of a TMP, and the concept of bilateral command.
At the Scene
SWAT units are sometimes called by other names. Depending upon the local mission and other factors, SWAT units are sometimes assigned more general names such as special
response team (SRT) or emergency response team (ERT). SWAT unit personnel are referred to as SWAT officers or tactical officers.
The History of Tactical Emergency Medical Support
Napoleon Bonaparte and his surgeon, Dominique Jean Larrey, are recognized as having the first modern field medical evacuation system
integrated into combat units. Those wounded in Napoleon’s army were treated and evacuated by dedicated horse-drawn wagons and
medical personnel during battle. The availability and provision of battlefield medical care undoubtedly contributed to his army’s initial
success.
Later, during the American Civil War, Clara Barton helped show the benefits of providing medical stabilization of wounded soldiers before
and during transport from the battlefield. Her philosophy of treating soldiers as soon as possible was another step in the evolution of the
present day military and civilian prehospital emergency care systems.
World Wars I and II saw the development of ambulance corps to rapidly care for and remove injured persons from the battlefield to take
them to hospitals far from the front. But, during the 1950s and the Korean War, military medical researchers recognized that bringing the
hospital closer to the field would give patients a better chance of surviving Figure 1-2 . Helicopters, another new technology, brought patients
to Mobile Army Surgical Hospitals (M*A*S*H units) that helped thousands survive.
Figure 1-2 Temporary hospitals, such as this one in use during the Korean War, were set up to provide more rapid care for the injured.
Courtesy of the National Library of Medicine.
Over the years, US Special Forces teams such as Delta Force or SEAL, as well as international military and police special operations
teams such as the German GSG9 or the Russian Spetsnaz, have integrated personnel who were specifically trained and equipped for
special medical support during missions. Medical support has often contributed to the success of these missions. Over time, the evolution of
other special operations military teams occurred, and a majority of these included their own medical assets. A key principle was found to be
true: If a team cannot take care of injuries and illness, it is not a truly mobile, self-sufficient unit.
Unfortunately, emergency care of the injured and ill for civilians did not progress to a similar level. As late as the early 1960s, emergency
ambulance service and care across the United States varied widely. In some places, it was provided by well-trained advanced first aid
personnel who had well-equipped, modern ambulances. In a few urban areas, it was provided by hospital-based ambulance services that
were staffed with interns and early forms of prehospital care providers. In many areas, the only emergency care and ambulance service was
provided by the local funeral home using a hearse that could be converted to carry a cot. In other places, the police or fire department used a
station wagon that carried a cot and a first aid kit. In most cases, these vehicles were staffed by a driver and an attendant who had some
basic first aid training. In the few areas where a commercial ambulance was available to transport the ill, it was usually similarly staffed and
served primarily as a means to transport the patient to the hospital.
Many communities had no formal provision for prehospital emergency care or transportation. Injured persons were given basic first aid by
police or fire personnel at the scene and were transported to the hospital in a police or fire officer’s car. Sick patients were transported to the
hospital by a relative or neighbor and were met by their family physician or an on-call hospital physician who assessed them and then
summoned any specialists and operating room staff that were needed. Except in large urban centers, most hospitals did not have the same
emergency department staff available today.
The emergency medical services (EMS) system as we know it today had its origin in 1966 with the publication of Accidental Death and
Disability: The Neglected Disease of Modern Society, known more commonly as “The White Paper.” This report, prepared jointly by the
Committees on Trauma and Shock of the National Academy of Sciences/National Research Council, revealed to the public and Congress the
serious inadequacy of prehospital emergency care and transportation in many areas. As a result, Congress mandated that two federal
agencies address these issues. Funding sources and programs were created to develop improved systems of prehospital emergency care.
In 1969, Dr Eugene Nagel began training fire fighters from the Miami Fire Department with advanced emergency skills such as cardiac
monitoring and IV therapy. Dr Nagel also developed a telemetry system that enabled fire fighters to transmit a patient’s electrocardiogram to
physicians at Jackson Memorial Hospital and to receive radio instructions from the physicians regarding what measures to take.
In 1973, the Emergency Medical Services System Act defined the required components of an EMS system, with emphasis on regional
development and trauma care. The act provided a structure and uniformity to the EMS system that came out of pioneering programs in
Miami, Seattle, and Pittsburgh, and the Illinois Trauma System.
Many cities set up individual advanced EMS training, and regions added their own spin to what they thought was the essential standard of
care. In 1977, the first National Standard Curriculum for paramedics was developed by the US Department of Transportation, based on the
work of Dr Nancy Caroline.
Through the 1980s and 1990s, EMS continued to evolve and the number of trained personnel grew. Federal funding and staff were
reduced, and the responsibility for funding EMS was transferred to the states. The National Highway Traffic Safety Administration (NHTSA)
developed “10 System Elements” in an effort to sustain EMS systems. The rapid advancement slowed greatly after this change in
responsibility, primarily because of funding issues. Although it was made clear that the federal funding being provided was just “seed money”
and that long-term local funding strategies needed to be developed, many states believed that the federal dollars would not go away.
Unfortunately, federal funding of EMS did become obsolete.
Civilian Emergency Medical Services
The emergency medical services (EMS) system of today consists of a team of health care professionals who, in each area or jurisdiction, are
responsible for and provide emergency care and transportation to the sick and injured. Each emergency medical service is part of a local or
regional EMS system that provides the many prehospital and hospital components required for the delivery of proper emergency medical
care. The standards for prehospital emergency care and the individuals who provide it are governed by the laws in each state and are
typically regulated by a state office of EMS.
In most states, individuals who work on an ambulance are categorized into four training and licensure levels: emergency medical responder
(EMR), emergency medical technician (EMT), advanced EMT (AEMT), and paramedic. An EMR has very basic training and provides care before the
ambulance arrives. EMRs may also perform in an assistant role within the ambulance. An EMT has training in basic life support, including
automated external defibrillation, use of airway adjuncts, and assisting patients with certain medications. An AEMT has training in specific
aspects of advanced life support (ALS), such as intravenous (IV) therapy and the administration of certain emergency medications. A paramedic has
extensive training in ALS, including endotracheal intubation, emergency pharmacology, cardiac monitoring, and other advanced assessment
and treatment skills.
Each EMS system has a physician medical director who authorizes the emergency medical provider in the service to provide medical care in
the field. The appropriate care for each injury, condition, or illness that the emergency medical provider encounters in the field is determined
by the medical director and is described in a set of written standing orders and scope of practice. Scope of practice is a comprehensive guide
delineating the emergency medical provider’s scope of practice. Standing orders are part of scope of practice and designate what the EMT is
required to do for a specific complaint or condition.
The medical director provides the ongoing working liaison between the medical community, hospitals, and the emergency medical
providers in the service. If treatment problems arise or different procedures should be considered, these are referred to the medical director
for his or her decision and action. To ensure the proper training standards are met, the medical director determines and approves the
continuing education and training that are required of each emergency medical provider in the service.
Law Enforcement Overview
Law enforcement officers—frompolice officers to SWAT officers—are empowered to enforce the law and preserve order. Law enforcement
officers are armed and authorized to use negotiation and physical force under certain conditions when carrying out their duties to prevent,
protect against, detect, investigate, and prosecute criminal behavior. Law enforcement organizations consist of many levels (ranks) and
positions. The names of these positions may vary throughout the United States, but the basic job description still applies. Positions in law
enforcement include:
Patrol officers. Patrol officers are the “eyes and ears” of law enforcement and are the largest component of a department. Patrol officers
usually patrol within assigned areas while in uniform as they tend to the immediate needs of the community. They are usually the first
responders on the scene.
Detectives (investigators). These officers have been promoted from patrol and conduct detailed follow-up investigations of assigned
cases (such as arson, rape, child abuse, homicide) with the goal of developing a case suitable for prosecution by the legal system of the
criminal offender.
Supervisors (sergeant, lieutenant). These officers coordinate and manage a group of personnel, such as patrol officers or detectives.
Chief executive officer (sheriff, chief of police, commissioner, marshal). This officer leads, coordinates, guides, and manages all
units and all personnel within the agency on a daily basis.
Specialized units. These law enforcement units are made up of officers with specialized training, including SWAT, internal affairs,
training, and detention.
The History of SWAT Units
Before 1966, few law enforcement agencies utilized SWAT units for calls involving high-risk conditions, such as barricaded suspects carrying
weapons. Regular patrol officers, who were often inadequately prepared, trained, and equipped, usually responded to these high-threat
assignments and resolved them with what they had on hand.
A series of significant historic events led to an increased interest in specially trained units for law enforcement agencies in the United
States. In 1965, the Los Angeles Watts Riots left over 1,000 wounded and 34 dead. The University of Texas clock tower shooting occurred
when an ex-soldier used several guns to kill 14 people and wound 32 others on August 1, 1966. Civil unrest and multiple riots in the mid-
1960s shook law enforcement agencies nationwide and forced them to consider how they would react to these violent acts in their own
jurisdictions.
In 1967, the Los Angeles Police Department (LAPD) was among the first to organize full-time SWAT units specifically trained to handle
high-risk incidents and has deployed paramedics with the SWAT unit since its inception. Over the past few decades, an increasing number of
SWAT units have incorporated the TEMS philosophy. In addition, the Federal Bureau of Investigation (FBI) Hostage Rescue Team (HRT)
and other government special operations teams routinely deploy with a TEMS component.
The Beginnings of TEMS Units
Law enforcement agencies in the United States have become increasingly aware of the value and benefits of a TEMS program. On a
national level, there were meetings in 1989 and 1990 that further explored ideas and concepts of providing emergency medical support to
SWAT units. In 1991, the first abstract and presentation speaking to this issue was delivered at the National Association of Emergency
Medical Services Physicians meeting. In January 1993, a Subcommittee on Tactical Emergency Medicine was formed within the California
Chapter of the American College of Emergency Medicine. The first National SWAT Physicians Conference took place in March of 1993.
Several tactical medicine training programs also began in the early 1990s.
Today, training courses and tactical medicine conferences occur with increasing frequency. TEMS is an evolving specialty that is
increasingly utilized by law enforcement agencies to save lives and ensure that SWAT units have the ability to resolve critical incidents as
safely as possible.
Roles Within the SWAT Unit
SWAT units around the world have a similar organization of duties. Each SWAT unit member has a special area of expertise, such as
assault, arrest, rescue, negotiations, and/or TEMS. Many SWAT officers are cross-trained and are able to fill in for several positions outside
their specialties if needed. During deployment (or a mission), each SWAT officer is assigned a specific role or position Figure 1-3 .
Figure 1-3 During a deployment (or mission), each SWAT officer is assigned a specific role or position.
The following SWAT unit positions are usually deployed during a deployment:
Incident commander. Typically an upper-level law enforcement administrator who supervises the entire operation from the incident command
center.
Tactical operations leader.
Usually assumed by a mid-level law enforcement lieutenant who has extensive tactical experience. The tactical
operations leader directs the details of the deployment from either the incident command center or from a separate but nearby tactical
operations center (TOC).
Team leader. Directs the SWAT unit personally when entering buildings and is often located in the middle of the entry team line.
Immediate reaction team. A group of five to seven SWAT officers and at least two TMPs who stand ready to immediately respond while
detailed tactical plans involving the entire SWAT unit are being created.
Marksmen (snipers). Located in a hidden position close to the criminal suspects, usually two or more marksmen observe and provide
information, security, and precision long-range threat neutralization Figure 1-4 .
Figure 1-4 Marksmen are positioned in a hidden location that allows them to observe suspects and provide immediate neutralization of
threats.
Courtesy of Lawrence Heiskell.
Observer. Deploys with the marksmen to assist and provide area security.
Point man. Guides the entry team to the deployment area and enters the building or other structure first, equivalent to the point of a spear.
Breacher. Carries a heavy metal battering ram and other tools (eg, crowbars, explosive entry devices, and hydraulic rams) to force open
doors or walls Figure 1-5 .
Figure 1-5 Explosive devices may be used by the breacher to gain entry into the structure.
Entry team. Usually four to eight SWAT officers are part of an entry team. The entry team is responsible for finding and arresting criminal
suspects and clearing the building. Depending upon the deployment, the entry team may be responsible for rescuing hostages or clearing
and securing specific rooms.
Gasman. If the situation calls for it, the gasman may shoot or throw chemical agents into a building with the goal of forcing the criminal
suspect(s) to leave the building.
Rear guard. Provides rear security for the entry team.
Tactical medical providers. TMPs provide medical support before, during, and after SWAT deployment. They may be organized as a
subunit within a SWAT unit in order to provide comprehensive coverage. Tactical emergency medical care can also be provided by
designated SWAT officers with ALS training.
In addition to the previously mentioned positions, there are several additional personnel who may play a significant role in a SWAT
callout, depending upon the callout. The following positions are deployed on a case-by-case basis, and are not common among all SWAT
units:
Negotiations team. A group of law enforcement officers with special training in crisis negotiations and psychology. The negotiations teams
help resolve a large percentage of SWAT incidents and are an integral part of SWAT units.
K-9 officer. A law enforcement officer who trains and deploys dogs used to search a building, apprehend a fleeing subject, and sniff for
drugs and explosives.
Rescue team. A backup team of SWAT officers that is designated to stand by, ready to come to the aid of or supplement the primary entry
team. It will ideally contain TMPs.
Perimeter security team. Composed of additional, uniformed patrol officers and undercover patrol officers who are usually needed to provide
an outer-perimeter security ring, to help ensure that no criminal suspects leave the callout site, and to prevent bystanders from entering
the high-threat inner perimeter.
Bomb squad. Composed of specially trained law enforcement officers and specialists who have unique equipment and protective gear to
assist in recognition and inactivation or neutralization of explosive threats.
Roles and Responsibilities of the Tactical Medical Provider
The specific responsibilities of the TMP vary depending upon the type of deployment and the level of care that the TMP is authorized to
provide, from BLS (EMR and EMT levels) to ALS (AEMT and paramedic levels) Figure 1-6 . The primary responsibility of the TMP is to
provide emergency care inside or near the inner perimeter. The secondary responsibility is to optimize the health and safety of the SWAT
unit.
Figure 1-6 The TMP has key roles before, during, and after deployment. Here, the SWAT unit and TEMS unit are participating in a
premission briefing.
Before deployment, the TEMS unit is responsible for:

Attending SWAT unit training sessions
Providing preventive medicine, health maintenance, and injury control measures
Providing medical care to SWAT officers who become injured or ill at training
Preparing to deal with pertinent medical threats and hazards expected at a SWAT unit training event and during deployment
Providing education in first aid and combat casualty care to SWAT officers, including:
– Instruction in CPR, combat first aid, ballistics, field medicine, and other medically related topics that pertain to the tactical environment
– Practicing “officer down” immediate action drills, extractions, and other scenarios Figure 1-7
Figure 1-7 A TEMS unit conducting officer down drills during training.
Identifying and preparing for any preexisting medical conditions of SWAT officers
Making recommendations to optimize internal policies related to TEMS and general law enforcement health issues
Serving as a resource for any medical concerns that affect the law enforcement agency
During deployment, the TEMS unit is responsible for:
Remaining available to provide emergency medical care for those in need (ideally remaining close enough to respond within a 30-second
response time for all injured SWAT officers)
Participating in mission planning, preparing an assessment of medical threats, and providing appropriate advice while keeping the
mission appropriately confidential to avoid any information leaks that would jeopardize the SWAT unit
Preplanning and arranging emergency medical evacuation and transportation pertinent to the mission, including methods of transport,
appropriate selection and notification of hospitals, and route planning
Providing appropriate preventive and immediate medical care to SWAT officers, other law enforcement officers, and public safety
personnel
Providing secondary emergency care and triage for those in need, including bystanders, suspects, or others on site at the discretion of
the SWAT unit leaders
Providing “assessment and clearing” of suspects prior to incarceration as directed by the SWAT unit leader or commander
Advising the command staff of developing medical concerns, and remaining available for medical consultation to the SWAT unit
leadership
Performing remote assessment of any downed victims in exposed areas and then advising the incident commander about the likely
viability of the victims (their chances for survival)
Improving SWAT unit performance and morale by the presence of immediate medical support, which has positive psychological benefits
Functioning as a liaison with the local EMS system, hospitals, and officials from other public safety and law enforcement agencies
After a mission, the TEMS unit is responsible for:
Participating in postincident debriefing and review, assisting command staff with analysis of the operation/training event and any medical
care delivered, and making improvements to the TEMS unit, policies, and procedures as needed
Reviewing and documenting all medical treatment and records relevant to operational or training missions
Appropriately optimizing treatment, rehabilitation, and mental health for injured SWAT officers through involvement with hospitals,
physicians, family, and police department officials, while maintaining HIPAA/patient confidentiality regulations
Incorporating “lessons learned” into future unit training and preparedness, thus assisting with preventive medicine efforts and the
improvement of care
Bilateral Command
Typically, TMPs operate under the daily direction of the EMS medical director. During a tactical operation, however, the involved law
enforcement agency is usually in charge of the overall scene. In situations where the TEMS unit is made up of emergency medical care
providers from both law enforcement and civilian public safety agencies, a bilateral command exists. It is important to determine who is
actually in control of the TEMS unit before training and callout missions.
In most circumstances, TMPs report directly to the law enforcement tactical operations leader (usually the lieutenant of the SWAT unit)
during a mission. However, the scope of practice and procedures surrounding medical care and medical decision making are ultimately left to
the EMS medical director. Therefore, this bilateral command structure, where law enforcement assumes command in the field while medical
direction is given remotely, exists in most tactical environments. If a TMP is employed by the fire department and is essentially on loan to the
police department, then the leadership structure and chain of command will be worked out by the involved agencies, but in most cases the
mission priorities of the law enforcement leadership involved will have priority.
At the Scene
In most agencies, the EMS medical director has ultimate control and authority over the TEMS unit. In some agencies, an additional physician may assume the medical direction for the
TEMS unit, providing off-line direction via procedures and scope of practice and providing online direction in person or over the radio. This additional physician may also assist with
maintaining the health of the TEMS and SWAT units.
At the Scene
If a group of medical providers (such as TMPs in a TEMS unit) enters into a mutual aid agreement or contract to provide medical support for another public safety entity or
government organization in a certain state, then that medical unit must function under the rules and regulations of the state EMS regulatory system.
TMPs rarely encounter discrepancies between on-scene command and medical direction because they should be trained in specific
tactical medical scope of practice taking into consideration each approach to the patient in the tactical environment. Furthermore, direct
online communication with medical control is often not possible or practical in the tactical environment. Thorough medical care is sometimes
tactically inadvisable; therefore, in the chaotic tactical environment, the effective leadership by SWAT incident commanders should be
followed to maximize unit safety. Medical procedures and patient assessment will be done only after the tactical environment has been
appropriately stabilized. Therefore, the bilateral command issue is more theoretical in practical application.
Online medical direction, communicated face-to-face, by radio, by cell phone, or by another device, should be sought whenever there is a
question about the most appropriate medical treatment option for a patient, or to receive advice in uncertain situations. For TMPs who
function as part of a regional, statewide, or nationwide SWAT unit, and whose callout territory may take them outside of their own EMS
region, the command structure differs. In this case, the medical direction should be arranged and provided to the TEMS unit by an EMS
physician with wider jurisdiction. Ideally, the provision of medical direction consists of pre-established scope of practice and policies modified
specifically for the tactical environment. Follow the scope of practice and policies of your agency.
At the Scene
In nearly all circumstances, TMPs are required to comply with the state-mandated EMS rules and regulations, which may be diverse and complex. In addition, unique medical tactics,
techniques, and procedures (TTP) may be specially permitted for the TEMS unit after appropriate EMS application and approval is given on an individual unit basis by the state EMS
agency.
Command Systems: LIMS and NIMS
The Law Enforcement Incident Management System (LIMS) is based upon the National Incident Management System (NIMS). NIMS is the
standardized incident management scope of practice used throughout the United States, which is now required in all law enforcement
operations. Under the LIMS system, there is a law enforcement incident commander (IC) who serves as command in most callouts Figure 1-
8 .
Figure 1-8 The Law Enforcement Incident Management System.
As in NIMS, under LIMS each law enforcement agency uses a similar scaleable incident management system but may elect to add or
remove various components, such as the operations or planning sections. If the incident is large and involves multiple agencies, this
framework may be included within a unified command with representatives from various agencies such as law enforcement, EMS, fire
service, public works, and elected officials serving as the commanders in a unified command structure. However, only law enforcement
managers command and direct law enforcement agency assets and operations.
Under LIMS, the safety officer and/or the TEMS unit can observe and report directly to the law enforcement IC any safety concerns, and
can halt operations if a substantial hazard is discovered that will endanger personnel and the success of the mission. The planning section
reports to the law enforcement IC and assists in providing viable plans to resolve the incident and intelligence on the suspects involved. The
logistics and finance/administration sections secure the needed personnel and material items to support the operation. Logistics is also
responsible for the staging of law enforcement, EMS, and other assets. The operations manager directly supervises tactical operations.
Usually the entry team, tactical marksmen, and the TEMS unit report to the operations manager, and it is usually necessary for the TMP to
interface through the external EMS system.
Tactical Medical Provider Training
Tactical Medicine Curriculum

There is currently no national standard TMP curriculum. There is a consensus among SWAT unit leaders, however, about the major areas
that should be learned and practiced by TMPs. These include specific SWAT unit tactics, weapons training, and immediate action drills, as
well as training in hazardous materials and bloodborne pathogen management.
In addition to completing a training program covering the essential knowledge and skills of tactical emergency medicine, you must also
gain experience through routine training with the SWAT unit. Through ongoing SWAT unit trainings, you will learn about your specific unit’s
abilities, weapons, and tactics. Mastery of the specific SWAT unit tactics, weapons, immediate action drills, and many other important topics
will come after multiple cooperative training exercises and real-world callouts. These experiences will enable you to gain the remainder of the
knowledge and skills that will enable you to provide rapid, safe, and effective medical care in the tactical environment Figure 1-9 .
Figure 1-9 Cooperative training exercises enable TMPs to provide effective medical care in the tactical environment.
Law Enforcement Training for Tactical Medical Providers

The law enforcement status and training required for tactical medical personnel is a joint decision of the leadership of each law enforcement
agency, local EMS organization, and municipality associated with a TEMS unit. The options may vary between using fully trained and sworn
law enforcement officers to provide medical support, as contrasted with using civilian medical personnel who have received baseline law
enforcement and tactical training by working with the SWAT unit on an informal basis. In between these two options may be reserve police
officer training, auxiliary deputy status, and other law enforcement positions.
There are several ways for TEMS unit personnel to acquire law enforcement training and possible certification, and the involved agencies
should come to an agreement upon what will work best given the regional policies and political situations. A common approach is to have
TMPs attend a reasonable amount of law enforcement training that they and their designated law enforcement agency mutually agree upon,
within their time constraints, funding, and local policies. Law enforcement training will highlight the unique hazards and life threats faced by
anyone entering the tactical environment Figure 1-10 .
Figure 1-10 Law enforcement training highlights the unique hazards and life threats TMPs will face in the tactical enviroment.
The bottom line is that you must have a baseline understanding of law enforcement and the operational aspects of the SWAT unit. In
every unit, the primary role of the TMP is medical support, but, as in any uncontrolled environment, the unexpected sometimes occurs. You
must be prepared to make a split-second decision when faced with an armed and high-threat criminal suspect. There will be times when a
SWAT officer may not be immediately present to assist in resolving the situation. You should learn and know use of force, self-defense laws,
arrest and control techniques, and combat skills. Additional skills necessary in the tactical environment might include crowd control, weapon
retention, and use of less-lethal weapons Figure 1-11 .
Figure 1-11 TMPs engaged in weapons familiarization and target practice.

If the TEMS unit is authorized to carry self-defense weapons, you must complete initial training and qualification, and ongoing
requalification weapons requirements. Most armed units require completion of training held to the same standard as a law enforcement
officer in basic police academy Figure 1-12 .
Figure 1-12 Armed TEMS units must complete all required weapons training.
Regardless of whether or not the medical personnel are armed, at a minimum all TMPs should learn and maintain skills in safe weapons
handling and unloading, as well as techniques for rendering weapons safe. Participation in routine marksmanship training is desirable, and
medical personnel should be familiar with all types of weapons used by the SWAT unit.
Unit Training
You will receive perhaps your most valuable education as you routinely participate with your own SWAT unit on a monthly basis. Most SWAT
units are part-time and practice once or twice a month for about 8 to 16 hours per month. Larger US cities may have a full-time SWAT unit
(eg, Los Angeles, New York City) who train and participate in high-risk warrant service and tactical deployment essentially every day. Tactical
training sessions offer a good opportunity to learn about and practice the unit’s tactics and tools. More importantly, training offers
opportunities to practice downed officer immediate action drills and other skills in order to perfect and maintain your own tactical medical
knowledge and skills.
Safety
Weapons training for TMPs must stress that, in the tactical environment, weapons should not be “fired and forgotten.” TMPs should maintain weapons-handling skills and always seek
to improve on their education.
Two components are necessary for effective routine TEMS training: TEMS unit and SWAT unit involvement. TEMS training should be
well-coordinated with routine SWAT training in order to ensure that all personnel (medical and nonmedical) are familiarized with each other’s
tools, techniques, and skills Figure 1-13 . Routine training for SWAT and TEMS personnel should include tactical law enforcement training for
TMPs, combat first aid training for SWAT officers, and training specific to unique hazards of the tactical environment (eg, hazardous
materials, bloodborne pathogens). Cross-training within the SWAT unit as well as with other agencies involved in responses is an important
consideration.
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climate, upon an equal soil, freely pasture his herds and flocks where
he pleases, and love his neighbor better than himself.
OUR FARMERS.
The test of profitable farming is the state of the account at the end
of the year. Under free trade the evidence multiplies that the English
farmer comes to the end of the year with no surplus, often in debt,
bare and discontented. Their laborers rarely know the luxury of
meat, not over sixteen ounces per week,[87] and never expect to own a
rood of the soil.
But under the protective policy the American farmer holds and
cultivates his own land, has a surplus at the end of the year for
permanent investments or improvements, and educates and brings
up his sons and daughters with the advantages and comforts of good
society. There are more American houses with carpets than in any
other country of the world. I believe it will not be disputed that the
down-trodden tillers of the soil in Great Britain are not well fed; that
they are coarsely underclad, and that for lack of common-school
culture they would hardly be regarded as fit associates here for
Americans who drive their teams afield, or for the young men who
start in life as laborers upon farms. The claim that free trade is the
true policy of the American farmer would seem to be, therefore, a
very courageous falsehood.
It is an unfortunate tendency of the age that nearly one-half of the
population of the globe is concentrated in cities, often badly
governed, and sharply exposed to extravagance, pauperism,
immorality, and all the crimes and vices which overtake mankind
reared in hot-beds. I would neither undervalue the men of brilliant
parts, nor blot out the material splendor of cities, but regret to see
the rural districts depopulated for their unhealthy aggrandizement.
Free trade builds up a few of these custom-house cities, where gain
from foreign trade is the chief object sought, where mechanics,
greater in numbers than any other class, often hang their heads,
though Crœsus rolls in Pactolian wealth, and Shylock wins his pound
of flesh; but protection assembles artisans and skilled workmen in
tidy villages and towns, details many squadrons of industry to other
and distant localities, puts idle and playful waterfalls at work, opens,
builds up, and illumines, as with an electric light, the whole interior
of the country; and the farmer of Texas or of New England, of Iowa
or of Wisconsin, is benefited by such reinforcements of consumers,
whether they are by his side or across the river, at Atlanta or South
Bend, at Paterson or at Providence. The farmers own and occupy
more than nineteen-twentieths of our whole territory, and their
interest is in harmony with the even-handed growth and prosperity
of the whole country.
There is not a State whose interests would not be jeopardized by
free trade, and I should like to dwell upon the salient facts as to
Missouri, Kansas, Indiana, Alabama, Illinois, and many other States,
but I shall only refer to one. The State of Texas, surpassing empires
in its vast domains, doubling its population within a decade, and
expending over twenty million dollars within a year in the
construction of additional railroads, with a promised expenditure
within the next fifteen months of over twenty-seven millions more,
has sent to market as raw material the past year 12,262,052 pounds
of hides, 20,671,639 pounds of wool, and 1,260,247 bales of cotton.
Her mineral resources, though known to be immense, are as yet
untouched. Her bullocks, in countless herds on their way to market,
annually crowd and crop the prairies from Denver to Chicago. But
now possessed of a liberal system of railroads, how long will the
dashing spirit of the Lone Star State—where precious memories still
survive of Austin, of Houston, of Rusk, and of Schleicher—be content
to send off unmanufactured her immense bulk of precious raw
materials, which should be doubled in value at home, and by the
same process largely multiply her population? With half as many in
number now as had the original thirteen, and soon to pass our
largest States, wanting indefinite quantities of future manufactures
at home, Texas should also prepare to supply the opening trade with
Mexico, in all of its magnitude and variety, and far more worthy of
ambition than in the golden days of Montezuma.
No State can run and maintain railroads unless the way-stations,
active and growing settlements and towns, are numerous enough to
offer a large, constant, and increasing support. The through business
of long lines of railroads is of great importance to the termini, and
gives the roads some prestige, but the prosperity and dividends
mainly accrue from the local business of thrifty towns on the line of
the roads. It is these, especially manufacturing towns, which make
freight both ways, to and from, that free trade must ever fail to do,
and while through freights, owing to inevitable competition, pay little
or no profit, the local freights sustain the roads, and are and must be
the basis of their chief future value. Without this efficient local
support, cheap and rapid long transportation would be wholly
impracticable.
The Southern States, in the production of cotton, have possibly
already reached the maximum quantity that can be cultivated with
greatest profit, unless the demand of the world expands. A short crop
now often brings producers a larger sum than a full crop. The
amount of the surplus sent abroad determines the price of the whole
crop. Production appears likely soon to outrun the demand. Texas
alone has latent power to overstock the world. Is it not time,
therefore, to curtail the crop, or to stop any large increase of it, while
sure to obtain as much or more for it, and to turn unfruitful capital
and labor into other and more profitable channels of industry? The
untrodden fields, where capital and labor wait to be organized for the
development of Southern manufactures and mining, offer unrivaled
temptations to leaders among men in search of legitimate wealth.
The same facts are almost equally applicable to general
agriculture, but more particularly to the great grain-growing regions
of the West. A great harvest frequently tends to render the labor of
the whole year almost profitless, whenever foreign countries are
blessed with comparatively an equal abundance. The export of corn
last year in October was 8,535,067 bushels, valued at $4,604,840,
but the export of only 4,974,661 bushels this year brings $3,605,813.
An equal difference appears in the increased value of exports of flour.
A much larger share of crops must be consumed nearer home, if any
sure and regular market is to be permanently secured. The foreign
demand, fitful and uncertain as it is, rarely exceeds one-twentieth of
even the present home requirements, and the losses from long
transportation, incident to products of great bulk, can never be
successfully avoided except by an adequate home demand.
Farmers do not look for a market for grain among farmers, but
solely among non-producing consumers, and these it is greatly to
their interest to multiply rather than to diminish by forcing them to
join in producing or doubling crops for which there may be an
insufficient demand. Every ship-load of wheat sent abroad tends to
bring down foreign prices; and such far-off markets should be sought
only when the surplus at home is excessive or when foreign prices
are extraordinarily remunerative.
The wheat regions of the West, superb as they undoubtedly are, it
is to be feared, have too little staying character to be prodigally
squandered, and their natural fertility noticeably vanishes in the rear
unless retained by costly fertilizers almost as rapidly as new fields
open in front. Some of the Middle States as well as the New England,
though seeking fertilizers far and near, already look to the West for
much of their corn and bread; and there is written all over Eastern
fields, as Western visitors may read, the old epitaph, “As we are now
so you may be.” It will take time for this threatened decadence, but
not long in the life of nations. The wheat crop runs away from the
Atlantic coast to the Pacific, and sinks in other localities as it looms
up in Minnesota, Nebraska, and Dakota. Six years of cropping in
California, it is said, reduces the yield per acre nearly one-half.
There was in 1880 devoted to wheat culture over thirty-five million
acres, or nearly double the acreage of 1875. In twenty-five years a
hundred million people will more than overtake any present or
prospective surplus, and we may yet need all of our present
magnificent wheat fields to give bread to our own people. Certainly
we need not be in haste to slaughter and utterly exhaust the native
fertility of our fields on the cheap terms now presented.
England, with all her faults, is great, but unfortunately has not
room to support her greatness, and must have cheap food and be
able to offer better wages or part with great numbers of her people. I
most sincerely hope her statesmen—and she is never without those
of eminence—will prove equal to their great trust and to any crisis;
but we cannot surrender the welfare of our Republic to any foreign
empire. Free trade may or may not be England’s necessity. Certainly
it is not our necessity; and it has not reached, and never will reach,
the altitude of a science. An impost on corn there, it is clear, would
now produce an exodus of her laboring population that would soon
leave the banner of Victoria waving over a second-rate power.
Among the nations of the world the high position of the United
States was never more universally and cordially admitted. Our rights
are everywhere promptly conceded, and we ask nothing more. It is
an age of industry, and we can only succeed by doing our best. Our
citizens under a protective tariff are exceptionally prosperous and
happy, and not strangers to noble deeds nor to private virtues. A
popular government based on universal suffrage will be best and
most certainly perpetuated by the elevation of laboring men through
the more liberal rewards of diversified employments, which give
scope to all grades of genius and intelligence and tend to secure to
posterity the blessings of universal education and the better hope of
personal independence.
Speech of Hon. J. D. Cameron, of Penna.
On the Reduction of Revenue as Affecting the Tariff. Delivered in the

United States Senate January 16, 1882.
Mr. Cameron, of Pennsylvania. I move to take up the resolution
submitted by me in relation to internal-revenue taxes.
The motion was agreed to; and the Senate proceeded to consider
the following resolution submitted by Mr. Cameron, of
Pennsylvania, December 6, 1881:
Resolved, That in the opinion of the Senate it is expedient to
reduce the revenue of the Government by abolishing all existing
internal revenue taxes except those imposed upon high wines and
distilled spirits.
Mr. Cameron, of Pennsylvania. Mr. President, the surplus revenue
of this Government applicable to the payment of the public debt for
the year ending June 30, 1881, was $100,069,404.98.
The inference from these figures must be that if such surplus
receipts are applied to the reduction of the debt it will be paid within
ten or twelve years. The question then is: Should the people continue
to be taxed as heavily as they now are to pay it off within so short a
period? Is it wise or prudent?
No one will deny the wisdom of the legislators who inaugurated
the system of reducing the debt, or the patriotism of the people who
have endured a heavy load of taxation to pay the interest and reduce
the principal of such indebtedness. Both have been causes of wonder
to the world, and have shown the strength, honesty, and prudence
attainable under a republican form of government in matters where
it was thought to be weak. It is acknowledged that the course thus
pursued by Congress, and supported by the people, has had several
good results. The exercise of the power of the Government and the
cheerful submission to the enacting nature of the laws by the people
has had an undoubted tendency to elevate and strengthen the moral
tone of the nation, giving the people more confidence in each other,
and compelling the approval of the world. It has reduced the
principal sum of our national indebtedness until it is entirely within
the ready control of the financial ability of the people either to pay off
or to pay the interest thereon. It has established the credit of the
country, and brought it up from a position where the 6 per cent. gold
bonds of the United States before the war would not command par to
a present premium of 17 per cent, on a 4 per cent. bond, and to the
ready exchange of called 6 per cent. bonds into new ones bearing 3½
per cent. interest. It has demonstrated the ability of the country not
only to carry on a most expensive internal war, but to pay off its cost
in a time unknown to any other people; and further, that the ability
of the country to furnish men and material of war and to meet
increased financial demands is cumulative. The burden carried by
this country from 1861 to the present day has been much greater
than it would be if laid upon this nation and people from 1881 to
1900.
The burden, therefore, of the present debt would fall but lightly on
the country if the payment thereof should be for a time delayed, or
the rate at which it has been paid be decreased. It thus becomes a
question of prudence with the Government whether they will
continue the burden upon the people, or relieve them of part of it.
The burdens of general taxation borne by the people are very
onerous. They have not only the General Government to sustain, on
which devolves the expenses of legislation, of the Federal judiciary,
of the representatives of our country in all the principal governments
and cities of the world, of the management of such of our internal
affairs and conveniences as belong to Congress, the keeping up of our
Army and Navy, the erection of public buildings, the improvement of
the rivers and harbors, and many other items that require large
annual expenditures. With the increase of population and the filling
up of our unoccupied lands almost all these annual outlays and
expenses will tend to increase in place of decreasing, and all such
expenditures must be in some way met by the people of the country.
They have also to sustain their State governments with the expenses
and outlays incident to them, their legislatures, judiciaries,
penitentiaries, places of reform, hospitals, and all means of aiding
the afflicted, to sustain the common schools, to pay the cost of such
improvements of rivers, of canals, of railways, or of roads as the
States may undertake. They have also the heavy cost to meet of city
governments, of county, town and borough governments; they must
pay the inferior Legislatures, erect buildings, provide water, police,
jails, poor-houses, and build roads and take care of them.
On the liberality of the people the country depends for the building
of charitable institutions, universities, colleges, private schools of
high grade, and every variety of relief to the poor and the afflicted. In
addition to these burdens almost all the States, most of the large
cities, and many of the counties and towns in the States still labor
under the burdens of indebtedness incurred during the war to
sustain the General Government, which indebtedness, incurred on
the then value of paper currency, has now to be paid in gold. They
have not had the means at command to pay off much of such
indebtedness like the General Government, nor to refund it at a
lower rate of interest. The superior credit of the General Government
has been made partially at the expense of the local governments. I
have stated these facts that Senators might keep in mind that the
question should not be considered as merely one of our ability to
reduce our indebtedness by paying off annually one hundred
millions of dollars and by continuing our present laws for raising
revenues, as if it were but a small matter for the people to do, but it
should be considered in connection with the total burden of taxation
imposed by the revenue laws of the General Government, as well as
by those of the State and the subordinate governments within their
bounds.
There is, therefore, a strong argument to be found in these facts of
the other burdens of taxation borne by the people in favor of
reducing the amount of revenue applicable to the payment of the
public debt when it can be done without injury to the credit of the
Government and without risking in the least the ability of the
Government either to pay such indebtedness as it matures or to
interfere with the ability of the Government to fully provide for the
wants of the country as they may be developed. A complete
statement of the percentage of taxation borne by each male citizen of
the United States over twenty-one years of age in the various ways
stated would astound the Senate and the country. There is probably
no country in the world where the taxation direct and indirect is so
heavy, and only a people situated and circumstanced as the
American people are could prosper under such a burden. If no other
reason could be advanced in favor of a reduction of the amount of
moneys derived from our internal-revenue laws than this one of
reducing the burdens of the people, it would be amply sufficient, in
my judgment, to warrant the proposed reduction. Yet I will say
frankly that I have another object in wishing to have the internal
revenue reduced, and I hope before long that every vestige of that
system will cease to exist. That object is to prevent any material
change being made in the tariff upon imports as it now exists, for
upon its existence depends the prosperity, the happiness, the
improvement, the education of the laboring people of the country,
although I do not object to a careful revision of it by a competent
commission.
I want to say a word here about the arrears of pension act. This act
never should be repealed, and in my judgment it never will or can be.
It has lately been held up to contempt by that class of people who
twenty years ago were engaged in exhorting these same pensioners to
go to the front, and who now object to rewarding them; but their
opinion is not shared by the people at large; in fact, no more
essentially just law was ever placed upon the statute book. Its effect
is simply and solely to prevent the Government from pleading the
statute of limitation against its former defenders. It did not increase
the rate of pensions in any way whatever, but merely said that a man
entitled to a pension for physical injury received in Government
service should not be debarred from receiving it because he was late
in making his application. To the payment of these pensions every
sentiment of honesty and gratitude should hold us firmly committed.
My friend the Senator from Kentucky [Mr. Beck] is very honest, is
generally very astute, and has great capacity as a leader. My personal
friendship makes me desire his success, and as an individual I want
him to be the recipient of all the honors his party can bestow upon
him, but I am very sure that he is now opposing a measure that is
intended to promote the welfare of and is in accord with the wishes
of the people of the country. He is leading his party astray, he is
holding it back, he is tying it to the carcass of free trade.
Politically I am glad that he is; on his own account I regret it. He is
opposing the principle of protection, and, in my judgment, no man
can do that and retain the support of the people. No party can to-day
proclaim the doctrine of “a tariff for revenue only” and survive.
Opposition to an earnest prosecution of the war for the suppression
of the rebellion failed to destroy the Democratic party because of the
recruits it received from the South, but opposition to the doctrine of
protection to American productions, hostility to the elevation of
American labor, no party in this enlightened day can advocate and
live. I am astonished that the Democratic party does not learn by
experience. The “tariff-for-a-revenue-only” plank in the Cincinnati
platform lost it Indiana, lost it New York, and in 1884 it will lose it
one-half of the Southern States.
The President pro tempore. The morning hour has expired. Is it
the pleasure of the Senate that unanimous consent be given to the
Senator from Pennsylvania to proceed with his remarks?
Mr. Beck. I move that unanimous consent be granted.
The President pro tempore. The Chair hears no objection, and
the morning hour will be continued until the Senator from
Pennsylvania closes his remarks.
Mr. Cameron, of Pennsylvania. The great question of protection to
American labor will be the question which will obliterate old
dissensions and unite the States in one common brotherhood. The
Democratic party has made its last great fight. It will struggle hard,
and in its death throes will, with the aid of a few unsuccessful and
disappointed Republicans, possibly have temporary local successes,
but death has marked it for its victim, die it will, and on its tomb will
be inscribed, “Died because of opposition to the education, the
elevation, the advancement of the people.”
The historic policy of this country has been to raise its revenues
mainly from duties on imports and from the sale of the public lands.
There are many reasons in favor of this policy. It is more just and
equal in its burdens on the States and on the people; it is less
inquisitorial, less expensive, less liable to corruption; it is free from
many vexed questions which our experience of twenty years in
collecting internal revenue has developed. The internal revenue
brings the General Government in contact with the people in almost
every thing they eat, wear, or use. The collection of revenue by duties
on imports is so indirect as to remove much of the harshness felt
when the citizen comes in direct contact with the iron grip of the law
compelling him to affix a stamp to what he makes or uses. No one
will question the fact that the collection of internal duties
unfavorably affected the general morals of the nation.
The internal revenue laws were adopted by the Government as a
war measure, as an extraordinary and unusual means of raising
money for an emergency, and it is proper and in accordance with
public opinion that with the end of the emergency such policy should
cease. I cannot but think that every Senator will agree with me that
the end of the emergency has been reached. The emergency
embraced not only the time of the expenditures, but their
continuation until the debt incurred during the emergency was so
reduced as to be readily managed, if not exclusively by the ordinary
revenues of the Government, yet with a greatly reduced system of
internal revenues and for a limited time. But in determining wherein
such reduction shall be made, two great interests of the country are
to be considered:
First, the system of duties on foreign goods, wares, &c.
Second, our national banking system.
It has been proposed to meet this question of reduction by
lowering the rates of duty, and thus to continue in this country
indefinitely the use of direct and indirect taxation, supposing that
such reduction would require the prolonged continuation of internal
taxation.
The first effect of this would be to increase the revenues, as lower
duties would lead for awhile to increased importations; but
ultimately these increased importations would destroy our
manufactures and impoverish the people to the point of inability to
buy largely abroad, and when that point would be reached, we should
have no other source of revenue than internal taxes upon an
impoverished people. At first we should have more revenue than we
need, but in the end much less.
This statement of the effect of lower duties may at first seem
anomalous and questionable, but that such would be the result is
proven by the effect on the revenues of the country of the reduction
in duties in the tariff of 1846 below that of 1842. This will be evident
from the Treasury statistics of the years 1844, 1845, 1846, 1847, &c.,
which will show for the latter years a large increase of revenues. A
reduction of duties which would affect the ability of our
manufacturers to compete with foreign makers would cause a large
importation of goods, with two objects: first, to find a market, the
effect of which would be to keep the mills of England and other
countries fully employed; and, second, a repetition of the custom of
English manufacturers to put goods on our markets at low and losing
prices for the purpose of crippling and breaking down our operators.
And the increase of out national revenues would continue until our
fires were stopped, our mills and mines closed, our laborers starved,
and our capital and skill, the work of many years, lost. This time
would be marked, by a renewal of our vassalage to England. Then the
tables would be turned, our revenues would fall off with our inability
to purchase, our taxation would continue and become very onerous,
and in place of a strong, reliant, and self-supporting people,
exercising a healthful influence over the nations of the world, we
would be owned and be the servants of Europe, tilling the ground for
the benefit of its people; our laborers would be brought down to a
level with the pauper labor of Europe.
Our form of government will not permit the employment of
ignorant pauper labor. It is a government of the people, and to have
it continue to grow and prosper the people must be paid such wages
as will enable them to be educated sufficiently to realize and
appreciate the benefits of its free institutions; and knowing these
benefits, they will maintain them. If, on the other hand, it is
desirable that the revenues from duties should be decreased, and
thereby retain both kinds of taxation, the direct and the indirect, the
best possible way to do this would be to largely increase the duties on
imported goods, which would for a time decrease the imports,
thereby decreasing the amount of duties received. This tendency
would last until, through this policy, the wealth and purchasing
power of the country would so largely increase that the revenues
would again increase, both by reason of decreased cost in foreign
countries and because of the purchase by us of articles of special
beauty, skill, and luxury. It may be said (and however paradoxical it
may appear, the assertion is proven by the history of the tariff) that
while the immediate tendency with free-trade duties is to increase
imports and revenues, the ultimate result of such low duties is to
decrease the imports and revenues, due to the decreasing ability of
the country to purchase. The immediate tendency of protective tariffs
is to decrease imports and revenues, but the final result is to increase
the imports and duties, arising from the greater ability of the country
to purchase. But my intention is not to discuss at this time the
question of a tariff, but to show the effect of a change in the duties on
imports upon the revenues of the country.
I clearly recognize that while the public mind is decidedly in favor
of encouraging home manufacturers by levying what are called
protective duties, yet the people are opposed to placing those duties
so high that they become prohibitory and making thereby an
exclusive market for our manufacturers at home. It seems very clear
to my mind, in view of these statements as to the result of decreasing
or increasing the duties on our imports, that no reduction of revenue
is practicable by changes in our tariff.
The second great interest of the people, which will very shortly be
directly affected by the large and increasing surplus revenues of the
country, is the system of national banks, and this through the
decrease of the public indebtedness by the application of the annual
surplus to its payment. The large annual reduction of the public debt
will very shortly begin to affect the confidence of the public in the
continuation of the system. It will increase public anxieties and
excite their fears as to a substitution of any other system for this that
has proven so acceptable and so valuable to the country. If the
national banking system is to be worked out of existence, it will
inevitably cause serious financial trouble.
Financial difficulties among a people like those of this country,
however ill-based or slight, are always attended by disastrous
consequences, because in times of prosperity the energies and
hopefulness of the people are stretched to the utmost limits, and the
shock of financial trouble has the effect of an almost total paralysis
on the business of the country. It is certainly the part of
statesmanship to avoid such a calamity whenever it is possible.
I unhesitatingly declare and believe that the value of our system of
national banks is so great in the benefits the country derives
therefrom and the dangers and losses its continuance will avoid that
it were better to continue in existence an indebtedness equal to the
wants of the banks which the country may from time to time require
until some equally conservative plan may be offered that will enable
us to dispense with the system.
It is also important in this connection for Senators to bear in mind
that the increasing business of the country will annually require
increased banking facilities, and consequently increased bonds as the
basis on which they can be organized; and it should not be
overlooked that a possible determination by Congress to pay off by
retiring or by funding the greenbacks will create a great hiatus in the
circulating medium of the country, which can only be replaced by
additional national-bank notes based upon an equivalent amount of
public indebtedness.
In view of the statements I have made, I cannot but conclude that
the wisest and most prudent course for Congress is to leave the
question of changes in the tariff laws to be adjusted as they may from
time to time require, and to make whatever reduction of the income
of the Government that may be found desirable by reducing the
changes in the internal-revenue laws.
The national revenue laws as they now are may be greatly and
profitably changed. They are very burdensome to a heavily-taxed
people, and such burdens should be relieved wherever it is possible.
This can now be done with safety by providing that so much of the
public debt may be paid off from time to time as may not be required
to sustain the system of national banks.
I move that the resolution be referred to the Committee on
Finance.
The motion was agreed to.
Extracts from Speech of Hon. Thomas H.
Benton,
On Proposed Amendments of the Constitution in relation to the

election of President and Vice-President, Delivered in the U. S.
Senate Chamber, A. D. 1824.
He said:—The evil of a want of uniformity in the choice of
Presidential electors, is not limited to its disfiguring effect upon the
face of our government, but goes to endanger the rights of the
people, by permitting sudden alterations on the eve of an election,
and to annihilate the rights of the small States, by enabling the large
ones to combine, and to throw all their votes into the scale of a
particular candidate. These obvious evils make it certain that any
uniform rule would be preferable to the present state of things. But,
in fixing on one, it is the duty of statesmen to select that which is
calculated to give to every portion of the Union its due share in the
choice of a chief magistrate, and to every individual citizen a fair
opportunity of voting according to his will. This would be effected by
adopting the District System. It would divide every State into
districts equal to the whole number of votes to be given, and the
people of each district would be governed by its own majority, and
not by a majority existing in some remote part of the State. This
would be agreeable to the rights of individuals: for in entering into
society, and submitting to be bound by the decision of the majority,
each individual retained the right of voting for himself wherever it
was practicable, and of being governed by a majority of the vicinage,
and not by majorities brought from remote sections to overwhelm
him with their accumulated numbers. It would be agreeable to the
interests of all parts of the States; for each State may have different
interests in different parts; one part may be agricultural, another
manufacturing, another commercial; and it would be unjust that the
strongest should govern, or that two should combine and sacrifice
the third. The district system would be agreeable to the intention of
our present constitution, which, in giving to each elector a separate
vote, instead of giving to each State a consolidated vote, composed of
all its electoral suffrages, clearly intended that each mass of persons
entitled to one elector, should have the right of giving one vote,
according to their own sense of their own interest.
The general ticket system now existing in ten States, was the
offspring of policy, and not of any disposition to give fair play to the
will of the people. It was adopted by the leading men of those States,
to enable them to consolidate the vote of the State. It would be easy
to prove this by referring to facts of historical notoriety. It
contributes to give power and consequence to the leaders who
manage the elections, but it is a departure from the intention of the
constitution; violates the rights of the minorities, and is attended
with many other evils.
The intention of the constitution is violated because it was the
intention of that instrument to give to each mass of persons, entitled
to one elector, the power of giving an electoral vote to any candidate
they preferred. The rights of minorities are violated, because a
majority of one will carry the vote of the whole State. The principle is
the same, whether the elector is chosen by general ticket, or by
legislative ballot; a majority of one, in either case, carries the vote of
the whole State. In New York, thirty-six electors are chosen; nineteen
is a majority, and the candidate receiving this majority is fairly
entitled to receive nineteen votes; but he counts in reality thirty-six:
because the minority of seventeen are added to the majority. These
seventeen votes belong to seventeen masses of people, of 40,000
souls each, in all 680,000 people, whose votes are seized upon, taken
away, and presented to whom the majority pleases. Extend the
calculation to the seventeen States now choosing electors by general
ticket or legislative ballot, and it will show that three millions of
souls, a population equal to that which carried us through the
Revolution, may have their votes taken from them in the same way.
To lose their votes is the fate of all minorities, and it is theirs only to
submit; but this is not a case of votes lost, but of votes taken away,
added to those of the majority, and given to a person to whom the
minority was opposed.
He said, this objection (to the direct vote of the people) had a
weight in the year 1787, to which it is not entitled in the year 1824.
Our government was then young, schools and colleges were scarce,
political science was then confined to few, and the means of diffusing
intelligence were both inadequate and uncertain. The experiment of
a popular government was just beginning; the people had been just
released from subjection to an hereditary king, and were not yet
practiced in the art of choosing a temporary chief for themselves. But
thirty-six years have reversed this picture; thirty-six years, which
have produced so many wonderful changes in America, have
accomplished the work of many centuries upon the intelligence of its
inhabitants. Within that period, schools, colleges, and universities
have multiplied to an amazing extent. The means of diffusing
intelligence have been wonderfully augmented by the establishment
of six hundred newspapers, and upwards of five thousand post-
offices. The whole course of an American’s life, civil, social, and
religious, has become one continued scene of intellectual and of
moral improvement. Once in every week, more than eleven thousand
men, eminent for learning and for piety, perform the double duty of
amending the hearts, and enlightening the understandings, of more
than eleven thousand congregations of people. Under the benign
influence of a free government, both our public institutions and
private pursuits, our juries, elections, courts of justice, the liberal
professions, and the mechanical arts, have each become a school of
political science and of mental improvement. The federal legislature,
in the annual message of the President, in reports of heads of
departments, and committees of Congress, and speeches of
members, pours forth a flood of intelligence which carries its waves
to the remotest confines of the republic. In the different States,
twenty-four State executives and State legislatures, are annually
repeating the same process within a more limited sphere. The habit
of universal travelling, and the practice of universal interchange of
thought, are continually circulating the intelligence of the country,
and augmenting its mass. The face of our country itself, its vast
extent, its grand and varied features, contribute to expand the
human intellect and magnify its power. Less than half a century of
the enjoyment of liberty has given practical evidence of the great
moral truth, that under a free government, the power of the intellect
is the only power which rules the affairs of men; and virtue and
intelligence the only durable passports to honor and preferment. The
conviction of this great truth has created an universal taste for
learning and for reading, and has convinced every parent that the
endowments of the mind and the virtues of the heart, are the only
imperishable, the only inestimable riches which he can leave to his
posterity.
This objection (the danger of tumults and violence at the elections)
is taken from the history of the ancient republics; and the tumultuary
elections of Rome and Greece. But the justness of the example is
denied. There is nothing in the laws of physiology which admits a
parallel between the sanguinary Roman, the volatile Greek, and the
phlegmatic American. There is nothing in the state of the respective
countries, or in the manner of voting, which makes one an example
for the other. The Romans voted in a mass, at a single voting place,
even when the qualified voters amounted to millions of persons.
They came to the polls armed, and divided into classes, and voted,
not by heads, but by centuries.
In the Grecian republics all the voters were brought together in a
great city, and decided the contest in one great struggle.
In such assemblages, both the inducement to violence, and the
means of committing it, were prepared by the government itself. In
the United States all this is different. The voters are assembled in
small bodies, at innumerable voting places, distributed over a vast
extent of country. They come to the polls without arms, without
odious instructions, without any temptation to violence, and with
every inducement to harmony.
If heated during the day of election, they cool off upon returning to
their homes, and resuming their ordinary occupations.
But let us admit the truth of the objection. Let us admit that the
American people would be as tumultuary at this presidential election
as were the citizens of the ancient republics at the election of their
chief magistrates. What then? Are we thence to infer the inferiority
of the officers thus elected, and the consequent degradation of the
countries over which they presided? I answer no. So far from it, that
I assert the superiority of these officers over all others ever obtained
for the same countries, either by hereditary succession, or the most
select mode of election. I affirm those periods of history to be the
most glorious in arms, the most renowned in arts, the most
celebrated in letters, the most useful in practice, and the most happy
in the condition of the people, in which the whole body of the citizens
voted direct for the chief officer of their country. Take the history of
that commonwealth which yet shines as the leading star in the
firmament of nations. Of the twenty-five centuries that the Roman
state has existed, to what period do we look for the generals and
statesmen, the poets and orators, the philosophers and historians,
the sculptors, painters and architects, whose immortal works have
fixed upon their country the admiring eyes of all succeeding ages? Is
it to the reign of the seven first kings?—to the reigns of the emperors,
proclaimed by the prætorian bands?—to the reigns of the Sovereign
Pontiffs, chosen by a select body of electors in a conclave of most
holy cardinals? No.—We look to none of these, but to that short
interval of four centuries and a half which lies between the expulsion
of the Tarquins, and the re-establishment of monarchy in the person
of Octavius Cæsar. It is to this short period, during which the
consuls, tribunes, and prætors, were annually elected by a direct vote
of the people, to which we look ourselves, and to which we direct the
infant minds of our children, for all the works and monuments of
Roman greatness; for roads, bridges, and aqueducts, constructed; for
victories gained, nations vanquished, commerce extended, treasure
imported, libraries founded, learning encouraged, the arts
flourishing, the city embellished, and the kings of the earth humbly
suing to be admitted into the friendship, and taken under the
protection of the Roman people. It was of this magnificent period
that Cicero spoke, when he proclaimed the people of Rome to be the
masters of kings, and the conquerors and commanders of all the
nations of the earth. And, what is wonderful, during this whole
period, in a succession of four hundred and fifty annual elections, the
people never once prepared a citizen to the consulship who did not
carry the prosperity and glory of the Republic to a point beyond that
at which he had found it.
It is the same with the Grecian Republics. Thirty centuries have
elapsed since they were founded; yet it is to an ephemeral period of
one hundred and fifty years only the period of popular elections
which intervened between the dispersing of a cloud of petty tyrants,
and the coming of a great one in the person of Philip, King of
Macedon, that we are to look for that galaxy of names which shed so
much lustre upon their country, and in which we are to find the first
cause of that intense sympathy which now burns in our bosoms at
the name of Greece.
These short and brilliant periods exhibit the great triumph of
popular elections; often tumultuary, often stained with blood, but
always ending gloriously for the country.
Then the right of suffrage was enjoyed; the sovereignty of the
people was no fiction. Then a sublime spectacle was seen, when the
Roman citizen advanced to the polls and proclaimed: “I vote for Cato
to be consul;” the Athenian, “I vote for Aristides to be Archon;” the
Hebran, “I vote for Pelopidas to be Bœotrach;” the Lacedemonian, “I
vote for Leonidas to be first of the Ephori,” and why not an
American citizen the same? Why may he not go up to the poll and
proclaim, “I vote for Thomas Jefferson to be President of the United
States?” Why is he compelled to put his vote in the hands of another,
and to incur all the hazards of an irresponsible agency, when he
himself could immediately give his own vote for his own chosen
candidate, without the slightest assistance from agents or managers?
But I have other objections to these intermediate electors. They are
the peculiar and favorite institution of aristocratic republics, and
elective monarchies. I refer the Senate to the late republics of Venice
and Genoa; of France, and her litter; to the Kingdom of Poland; the
empire of Germany, and the Pontificate of Rome. On the contrary, a
direct vote by the people is the peculiar and favorite institution of
democratic republics; as we have just seen in the governments of
Rome, Athens, Thebes, and Sparta; to which may be added the
principal cities of the Amphyctionic and Achaian leagues, and the
renowned republic of Carthage when the rival of Rome.
I have now answered the objections which were brought forward
in the year ’78. I ask for no judgment upon their validity of that day,
but I affirm them to be without force or reason in the year 1824.
Time and EXPERIENCE have so decided. Yes, time and experience,
the only infallible tests of good or bad institutions, have now shown
that the continuance of the electoral system will be both useless and
dangerous to the liberties of the people, and that the only effectual
mode of preserving our government from the corruptions which have
undermined the liberties of so many nations, is, to confide the
election of our chief magistrates to those who are farthest removed

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Tactical Medicine Essentials 2nd

Edition John E. Campbell

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Cecil Essentials of Medicine (Cecil Medicine) 10th

John E. Campbell, MD, FACEP

Jim Smith, MSS, NRP, FABCHS, CPC, CLEE

E. John Wipfler III, MD, FACEP

JONES & BARTLETT

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Printed in the United States of America

Section 1 Elements of Tactical Medicine

Section 2 Assessment and Management of Injuries

Section 1 Elements of Tactical Medicine

Chapter 2 Safety and Wellness of the Tactical Medical Provider

Chapter 3 Tactical Team Fundamentals

Chapter 4 Equipment of the Tactical Medical Provider

Chapter 5 Weapons Handling and Firearms Safety

Chapter 6 Unconventional Weapons and Criminal Tactics

Chapter 7 Medical Intelligence

Chapter 8 Medical Response to Active Assailant Mass Casualty Incidents

Chapter 10 Tactical Team Activations

Section 2 Assessment and Management of Injuries

Chapter 12 Controlling Bleeding

Chapter 13 Basic Airway Management

Chapter 14 Advanced Airway Management

Chapter 15 Shock Management

Chapter 16 Extraction and Evacuation

Chapter 17 Ballistic, Blast, and Less-Lethal Weapons Injuries

Chapter 18 Torso Injuries

Chapter 19 Head, Neck, and Spine Injuries

Chapter 20 Extremity Injuries

Chapter 21 Soft-Tissue Injuries

Chapter 22 Environmental Emergencies

Chapter 23 Medications in the Tactical Environment

Chapter 24 Weapons of Mass Destruction

Chapter 25 Hazardous Materials and Clandestine Drug Labs

Chapter 26 Challenges in Tactical Medicine

Appendix A K-9 Management

Appendix B TEMS Forms

Appendix C Defensive Tactics

Glenn A. Bollard, MD, FACEP

Martin Greenberg, MD, FACS

Michael R. Meoli, Firefighter, EMT-P, Tactical Paramedic, SOC (SEAL)

Amado Alejandro Baez, MD, MSc, MPH, FACEP, FCCM

James Bender, BS, EMT-P, HEM

Neil P. Blackington, EMT—Tactical

Brandon Bleess, MD, FACEP

William P. Bozeman, MD, FACEP, FAAEM

Walter J. Bradley, MD, MBA, FACEP

David W. Callaway, MD, FACEP, MPA

Keith F. Collins, NREMT-P, CIC

Michael Colvard, DDS, MS, M O Med RCSEd