Portland’s Rapid Response Team, a Novel Approach to TEMS in Civil Disturbance

In early 2017, the Portland, Ore. Bureau of Fire & Rescue (PF&R) established a unique tactical emergency medical support (TEMS) team to work with the Portland Police Bureau (PPB) during civil disturbances. PPB has a long-established all-hazards unit, the Rapid Response Team (RRT), whose operational portfolio includes crowd management and control tactics and techniques. Violent protests in Portland following the 2016 election, along with the 2016 Dallas Police assassinations, demonstrated the urgent need for an embedded TEMS capability in RRT. Promptly after the formation of the team, the newly selected Firefighter-EMTs determined that the spectrum of medical threats they faced greatly exceeded traditional SWAT medicine.  In the years since integrating into RRT, the Firefighters on the team have built a unique TEMS capability while simultaneously maintaining a busy operational tempo. The operational and medical lessons learned by the team are potentially valuable for medical directors; for physicians treating persons injured in civil disorder events; and for operational pre-hospital personnel who may be called on to conduct TEMS in mass gatherings, civil disorder, and riots.

Mission of PF&R TEMS

The primary mission of RRT Firefighters is to provide medical assistance to law enforcement.  Additionally, when the tactical situation allows, RRT Firefighters provide medical assistance to people involved in protests when ambulances are unable to access the scene. This unique, dynamic operational model is a sub-specialty of TEMS that focuses on rendering care during unstable mass gatherings. Specifically, the medical-operational aspects of providing care under direct threat during mass gatherings pose challenges not well documented in the medical or tactical literature. RRT Firefighters have broadened their focus from traditional TEMS to include the possibility of active shooters and other hostile events spanning from explosive devices; terrorism, chemical, biological, and other hazardous substances; fire as a weapon; and other threats not fully realized.   

Team Establishment and Training

The RRT TEMS program was established in early January, 2017. All of the Firefighters on the team are full-time, sworn employees and certified EMTs. Many are assigned to specialty programs in PF&R, namely, the Technical Rescue and Hazardous Materials teams. The training and experience of these specialists has been an important force multiplier for RRT. Since all the Firefighters were already experienced EMTs, the initial training for the new team members was focused primarily on effective medical operations in the law enforcement environment. Initial training for the team included a brief overview of the principles of Tactical Emergency Casualty Care (TECC), then a three-day shadowing of PPBs Rapid Response Team Basic course. Just days after completing these hasty courses, the newly trained Firefighters were called to work during protests on Inauguration Day, and mass gatherings the following morning. The operational tempo increased in the weeks that followed. In their first year, RRT Firefighters were conducting TEMS operations at large protests approximately every two weeks.

Future training plans for team members involves a more formalized pipeline. PF&R Firefighters are selected for duty on RRT following an application and interview process. The notional future training pipeline will include pre-course work on the TECC guidelines and skills, followed by the RRT Basic Course, then the NAEMT TECC course or an equivalent. Team members are expected to maintain their skills through simulation and physical skills practice during their regular duty days at the fire station.

Learning From Others

Portland has a history of civic engagement and protest, and this holds true today. Recent mass gatherings in the city have taken a somewhat violent turn, and the RRT Firefighters have actively sought to consider holistic medical threats, not simply the medical threats faced by police. A true all-hazards approach is, however, extraordinarily complex. In an effort to focus their medical practice, RRT Firefighters settled on the 10 competency domains described by Pennardt, et al.¹ (derived from Schwartz, et al.²) as the training baseline for all members. For years, PF&R has provided TEMS support to PPBs SWAT unit, the Special Emergency Reaction Team (SERT). SERTs experienced Firefighter-Paramedics provided invaluable assistance advising the RRT TEMS Firefighters on equipment selection and ways to effectively integrate with police. And while TEMS has been robustly described in the literature, there is a dearth of writing about TEMS in the civil disturbance environment. Vayer’s chapter³ provided an important starting point. Even more valuable was the experience of the Vancouver, BC Fire Rescue Service’s supporting their police department’s Public Order Group. PF&R members traveled to Canada to learn firsthand how this team had provided medical aid in mass gatherings as well as their experience during the 2011 Stanley Cup riots, where numerous critically injured patients were rescued from deep within rioting crowds. This information provided RRT with a solid foundation to build upon.

The Expanding Spectrum of Threats Becomes Clear

RRT Firefighters quickly recognized that the spectrum of threats in a dynamic mass gathering exceeded the normal medical paradigm for TEMS. Traditional civilian TEMS is implicitly focused on treating a single patient suffering from a high velocity penetrating trauma. From day one, RRT Firefighters understood that treating a wounded police officer was the pinnacle of their practice, but other complex threat scenarios quickly became clear. Well before the vehicle-ramming murder in Charlottesville, RRT Firefighters observed firsthand when panicked motorists tried to weave their way out of a raucous protest. After operations concluded, the Firefighters discussed what they had seen and attempted to formulate a response plan. PF&R personnel scoured media reporting and video of the scourge of vehicle-ramming attacks in Europe, and began training on potential vehicle attack vectors. Because of the uptick in violence at protests RRT Firefighters widened their focus to a true all-hazards approach. The scenario of a shooter within a crowd was particularly troubling. Even before Las Vegas, team members considered the possibility of a shooter attacking from an elevated position. The routes and times of protests are often well publicized, and a bombing similar to the Boston Marathon attack was yet another scenario that required exploring. Traditional TEMS may consider these contingencies, but RRT Firefighters had to plan and operationalize potential responses to them on a scale not typically seen before in the United States.

In a protest, the relatively straightforward interventions described in the TECC Guidelines for ALS/BLS Medical Providers are complicated by an environment that may not permit patient access. Remotely assessing a patient in a hostile crowd, at night, through the facepiece of a gas mask, is more complicated still. Any military medic knows that they may have to treat a wounded enemy, but protesters–even riotous protesters–on the streets of an American city are not enemies. In Portland, the injuries suffered by protesters were often inflicted by other, opposing protesters. This protest dynamic has been seen in other cities, but it dominates the civil disturbance environment in Portland and turns protests into three-way confrontations that are tactically complex.

Injuries and Treatments

The treatments rendered to date by RRT Firefighters have been varied but expected. Numerous patients have presented with facial trauma following fistfights. In late Spring, 2019, a particularly violent protest resulted in multiple head-injured patients. Video of these injuries revealed the likely mechanism as batons, and possibly a crowbar. In the same way, RRT Firefighters have evaluated patients suffering from acute anxiety, sprains and strains, dehydration, heat exhaustion, and overdose. These patients all required physician evaluation; however, few were critical or met trauma system entry criteria.

While most injuries encountered thus far have been fairly routine, protests and riots present unique medical threats. Chief among these was a police concern regarding the directed use of hazardous materials, namely hydrofluoric acid. PPB officers advised RRT Firefighters that hydrofluoric acid had been used to commit vandalism during the 2011 Occupy protests, and officers were concerned about its use as a weapon during future disturbances. Given the unique pathophysiology of HF exposure, described neatly by Schwerin & Hatcher⁴, RRT Firefighters engaged PF&Rs Medical Director, Dr. Jon Jui, to assist with educating local emergency departments on the treatment and management of this low-probability, high-consequence injury. In the same way, law enforcement was concerned with the use of fire as a weapon during protests. RRT Firefighters engaged the leadership of the Legacy Oregon Burn Center to select portable extinguishers that could be used to extinguish a burning victim without causing further harm. Following these discussions, and a period of testing and evaluation, all RRT Firefighters were equipped with small portable Halotron extinguishers. Hydrofluoric acid exposure or thermal burns are certainly not encountered in every civil disturbance, but addressing the medical management of these injuries was reassuring for law enforcement.

Medical-Legal Issues

Civil disturbances in Portland are often kinetic. The evaluation and treatment of low acuity patients represented a potential tactical challenge. While RRT Firefighters recognized that it would be inconsistent with the TECC guidelines to fully evaluate and treat every civilian patient presenting with vague or non-critical symptoms, members of the team were also concerned about fundamental medical-legal issues of patient abandonment. The hypothetical scenario of an RRT Firefighter being compelled by the tactical situation to leave a civilian patient’s side during initial evaluation was particularly troublesome. In response to these concerns, PF&Rs advice attorney drafted legal guidance indicating his opinion that a medic who made a legitimate attempt to evaluate a patient and arrange for continued care was on solid legal ground in the event of a civil action. Dr. Jui concurred with this guidance, which was an important step in protecting RRT Firefighters from civil liability. Soon after this guidance was distributed to the team, the hypothetical situation was realized. RRT Firefighters were able to successfully order resources and/or direct patients out of hazard areas, even when the Firefighters themselves had to suspend treatment in order to continue to move with their embedded police squads.

Conclusion

The spectrum of medical threats in the civil disturbance environment is broad, but the Portland Firefighters engaging these threats continue to work diligently to mitigate them. TEMS is a mature professional discipline, and a key component of RRTs success thus far has been the willingness of team members to stand on the shoulders of giants by scouring both military and civilian TEMS experiences for clinical and operational pearls. By embracing the best lessons of TEMS, the team has been able to spend time exploring and mitigating tactical medicine “zebras;” minimally described, high-consequence, low-probability events like fire as a weapon, acid attacks, and intentional MCIs. Tactical Medicine is a profession, and RRT Firefighters are moving it forward in a considered manner while maintaining an exacting operational tempo. 

References

1. Pennardt, A., Callaway, D. W., Kamin, R., Llewellyn, C., Shapiro, G., Carmona, P. A., & Schwartz, R. B. (2016). Integration of tactical emergency casualty care into the national tactical emergency medical support competency domains. J Spec Oper Med, 16(2), 62-66.
2. Schwartz, R. B., McManus, J. G., Croushorn, J., Piazza, G., Coule, P. L., Gibbons, M., ... & Lerner, E. B. (2011). Tactical medicine—competency-based guidelines. Prehospital Emergency Care, 15(1), 67-82.
3. Vayer, J. S. (2009). Medical Support of Civil Disorder Operations. In Emergency Medical Services: Clinical Practice and Systems Oversight (1st ed., Vol. 4, pp. 39-45). Dubuque, IA: Kendall Hunt Pub.
4. Schwerin, D. L., & Hatcher, J. D. (2019, June 14). Hydrofluoric Acid Burns. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK441829/.

Morgan West, TP-C