Updated February 2015
In his novel, Medic Up: Where Criminals, Swat Teams & Medicine Intersect, Dennis Krebs tells the fictional tale of a SWAT team tactical medic responding to a hostage standoff with an armed murderer.
In writing the book, Krebs drew from personal experience: He spent seven years as a tactical medic for several agencies, including as a mission support specialist for the U.S. Department of Homeland Security’s Federal Protective Service and a senior mission specialist for the Johns Hopkins Division of Special Operations, which contracts with federal agencies to provide tactical medical support and medical direction in austere and complex environments. Krebs has also taught tactical medicine for Johns Hopkins and the Department of Defense’s Counternarcotics Tactical Operations Medical Support.
Krebs got his start as a volunteer firefighter-EMT in 1972 for the Baltimore County Fire Department. He later joined the Baltimore City Fire Department and then returned to the county to serve as a cardiac rescue technician and later a paramedic. He retired as captain in 2005. He currently teaches Tactical Combat Casualty Care to U.S. military personnel and volunteers with the Pikesville Volunteer Fire Company near his home in Cockeysville, Md.
An expert in violence and injury prevention for firefighters and EMS providers, Krebs is also the author of When Violence Erupts: A Survival Guide for Emergency Responders, first published in 1990 and updated in 2003, and the Special Operations Mission Planning Field Guide, a field operations manual for SWAT teams and tactical medics. He spoke with Best Practices about the role of tactical medics and how EMS can prepare for violence on the job—whether it’s an active shooter or aggression directed at EMS providers.
How did you become interested in violence avoidance for EMS?
In 1982, I was working as a firefighter-paramedic for Baltimore County Fire Department. We responded to a 7 a.m. call for a man slumped over the steering wheel of a car. The window was down, and there was a strong odor of alcohol coming from the vehicle. I reached in and shook the man, and he brought up a .357 magnum handgun to my face. Luckily there was a state trooper coming up the other side of the car. He dove through the window and grabbed the guy’s arm.
At the time, police survival training was very new. One of my friends was a Maryland state police officer, and I got permission to go through the state police survival training. Afterward, state trooper Mark Gabriele and I adapted survival training to meet the needs of firefighters and paramedics. We started teaching courses around the country.
In one of the first classes we taught, a female EMT was sitting in the front row, shaking her head. She said, ‘My job is to try to help people, whether bullets are being fired or knives are being thrown.’ We had to do a lot of work at that time to teach people that the job isn’t to go into unsecured areas and get yourself hurt.
Scenes of shootings and stabbings are very dangerous. When Violence Erupts: A Survival Guide for Emergency Responders grew out of that. That work also made me realize there’s a need for medics with specialized training for responding to some of those incidents.
What is a tactical medic?
A tactical medic can be an EMT or a higher-level medical provider who operates with a limited amount of equipment, in an austere and hostile environment, in conjunction with law enforcement.
There are all sorts of models in tactical medicine. A number of federal law enforcement agencies, such as the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF), the U.S. Drug Enforcement Agency (DEA) and U.S. Immigration and Customs Enforcement (ICE) have agents cross-trained as EMTs. At some law enforcement agencies, such as the Los Angeles County Sheriff’s Department, their tactical medics were sheriff’s deputies prior to going to school to be an EMT.
Here in Maryland, in a lot of jurisdictions, tactical medics are drawn from the local agency that provides EMS, such as fire departments. The Baltimore City Fire Department and the Police Department have tactical medics who go out with their quick response team, another term for a SWAT team. The tactical medic is paid by the fire department. On a normal day, that medic is riding an ambulance with the fire department. If it’s a call for the SWAT team, he’d go out with them.
The training for tactical medics can also vary. Some agencies will put them through a three-week SWAT school, just like Danny Weaver, the fictional character in my book. Other times they will put them through a one- to two-week SWAT primer. Since tactical medics may not be carrying a firearm or might not be responsible for taking a suspect down, they may not need an entire SWAT school. They just need a condensed version to allow them to operate with the SWAT team.
At federal law enforcement agencies, the tactical medic is often an EMT with an expanded scope of practice. They carry additional drugs and are taught how to do things that the normal EMT would not do, such as needle decompressions in the case of a collapsed lung due to a bullet wound. Paramedics who operate with law enforcement teams are also usually given additional capabilities, such as suturing.
What makes a good tactical medic?
Experience in emergency medicine—and you want to have a fair amount under your belt. Law enforcement isn’t going to take somebody who is six months out the door of an EMT school and say, Come be a tactical medic. You need to have seen a lot. You need experience in seeing shooting victims, something you don’t see a lot of in suburban and rural areas.
When you roll up on the scene and you have all these guys wearing black and helmets and carrying big guns and there’s smoke from the discharge of weapons still in the air, that’s not natural for most EMS providers. There is going to be a period of time for them to grasp what they’re involved in. So you need someone with a good bit of maturity so they know how to conduct themselves. Another important quality is to be able to take direction well. Not doing it can quickly get you killed.
You also have to be physically fit and have endurance. As a tactical medic, you can be involved with long-term operations or hostage standoffs, where you will have little food and no sleep. I was involved with the Joseph Palczynski standoff, which included several days searching for him, and then a four-day standoff. [In March 2000, Palczynski killed four people and took a family of three hostage. It ended with two hostages escaping—a man and woman who crawled out a window and left the third hostage, their 12-year-old son, inside. Baltimore County Police rescued the boy and shot and killed Palczynski.]
We staged in a house two doors up from him. We got there on a Friday evening and did not leave until Sunday morning. When I got relieved and got home, I laid down on the couch for an hour and I was called back and stayed there through Monday night.
Are there tactical medics working for the Baltimore County Fire Department?
Not yet. In 2013, a SWAT officer was shot and killed—they were going after a guy they were interested in for some shootings. While searching for him, they went into a house; a number of folks were in there. The suspect they were looking for bolted, but some others had weapons and the officer was shot in the back. The bullet went underneath his body armor and killed him.
Baltimore County Police Department did not have tactical medics, and the fire department had refused to have tactical medics assigned to work with the team. After the officer was killed, the police looked around their own ranks. One of the police officers was a volunteer firefighter/paramedic, so they made him their tactical medic.
Tactical medics provide emergency care to injured law enforcement officers, bystanders and even suspects. Are they there only for injuries?
Tactical medics also provide mission planning and medical intelligence, which gets compiled into a medical threat assessment, a report that includes potential risks; information about nearby hospitals, including location and capabilities; medical transport options; and how you are going to react to various situations that might occur on scene.
Medical intelligence takes into account the time of year. If it’s summer, you can have issues with dehydration; if it’s winter, hypothermia. You look at what diseases are endemic in the area. Those can include plague, Lyme disease, Tularemia. We determine if we will encounter rodents or fleas, which can carry disease, and make sure we have respirators if we may need them.
What was your most interesting mission as a tactical medic?
When I was working with the Johns Hopkins special operations division, they had contracts with a number of federal law enforcement agencies. Our role was to train the medics who worked for the federal agencies, go on missions with them and provide medical direction. On one mission, myself, a physician and law enforcement officers flew into a remote wilderness area near the Canadian border to apprehend a suspect. The closest hospital had 25 beds and was 75 miles away; the closest trauma center was two states away. If somebody got hurt, it would be a very long time before they’d get advanced medical care, so that’s why they needed a medical team with them.
All of our gear had to be shipped in to the closest airport. We also had to provide our own medical transport—in this case, we rented a minivan and configured it like an ambulance. We had to determine where we could land a helicopter. Because of distance, the closest helicopter could only make it to a neighboring state, so we would have had to meet it there. We agreed that the doctor would take care of everything from the chest down. I would take care of the airway.
We did all of this preparation, yet when you go to grab somebody, everything happens very fast. It was over in a matter of minutes. But it’s gone the other way, too, where things didn’t go so well. So you have to be prepared for it.
What are your thoughts on active shooter protocols, in which EMS responders enter warm zones to treat victims?
I was involved in the U.S. Fire Administration’s paper [Fire/EMS Department Operational Considerations and Guide for Active Shooter and Mass Casualty Incidents], and it is a good idea to get EMS into secured areas with the police.
But there are caveats. You have to be able to get into the building safely, and there are logistical considerations in making this happen. When you look at the overhead views of schools, they usually have playing fields around them, which gives the shooter a large field of vision. The shooter can see any activity going on outside, including a group of EMS providers coming up with their gear and their bags. You can become a target.
Most active shooters act alone. In only 2% of cases have they set IEDs, but you don’t want to be part of that 2%. At Columbine, if they had wanted to, the shooters could have looked out the window and begun shooting large scale at anybody. They had multiple IEDs set.
Equipment is another consideration. It’s a good idea to have body armor and Kevlar helmets. The problem is, where are you going to get it? Generally, the police don’t have stashes of body armor and helmets, unless you’re an agency like the Los Angeles Fire Department, which has body armor assigned to every fire truck, battalion chief’s car and ambulance.
Years ago, I was vehement about trying to establish tactical EMS in Baltimore County, and a chief officer said to me, The cops have the guns. It’s their problem. They can deal with it. But it’s not a mindset we can have. These situations are happening. We have a responsibility to deal with them collectively as emergency providers. Yet when violence erupts, the point when you arrive on scene at a mass shooting is not the time to try something new. You need to train with local law enforcement before the hour of need.
You also have to keep in mind that not every incident is going to fall within the parameters that we like to throw around. With active shooter incidents, the timeline is usually short—they’re over in an average of about 12 minutes. But there can be other types. When you look at terrorist incidents, such as the Belsan school siege in Russia in 2004 which killed over 380 people; the Taj Mahal Palace Hotel attacks in Mumbai, India in 2008 [167 dead]; and the Westgate shopping mall attack in Kenya in 2013 [72 killed], those blow our statistics out of the water. Those incidents lasted for days and involved larger groups of people. Should a terrorist organization elect to hit the U.S. in that type of manner, we’d be looking at a much different scale incident.
Should EMS prepare for those kinds of incidents?
Yes. You can start by having a drill, such as at a mall, and running through some of these scenarios. You can start small—maybe three or four people shot, and then the next time, you plan something a bit bigger, such as some type of a group has initiated it, they have shot 50 people, and they have IEDs planted or maybe a chemical agent that’s released. A larger scale drill would need to involve everyone from local law enforcement, the local FBI office, the local Joint Terrorism Task Force, and state and local emergency management.
What prompted you to write a novel about tactical medics?
I thought it would be an interesting read; most of the general population doesn’t even know there are medics assigned to SWAT teams. But I found it’s a lot more difficult to write fiction than it is to write a manual like When Violence Erupts.
With fiction, you have to paint a picture. You need a plot line that hasn’t been done and isn’t predictable. My first draft was 25 pages, because I was writing as if I was writing a training manual. So I went back and took some college classes on fiction writing and kept working on it.
Medic Up was a close take-off on what I’ve been through. I’m having greater difficulty in coming up with the plot line for a second novel. I’m trying to work on another one, but there is always something better to do, like wash the dishes.
