TACTICAL MEDICINEWHY PUTTING SOLID BOUNDARIES ON SCOPE OF PRACTICE MATTERS.Krisztian ZerkowitzDon’t get me wrong, if you ask me, everyone in the protective industry should be a paramedic, or hell, a doctor, when it comes to being able to treat potential casualties.On the team side or the client. So, this article, even if it hurts me to write it, might make sense. The thought came up to me on my last deployment last month, to Libya. Where I was teaching a Law Enforcement agencies working check points in remote areas, about medicine.To make a long story short, the terms of reference asked for basic first aid, but the ground operations required keeping people alive for over 3 hours of transport time. In Libya… under Libyan conditions. Well, for me, basic first aid was not going to work and I had to come up with an idea on what to teach these officers that would make sense, fit in the given time frame and in the end, save lives.When you look at many different first aid courses that are available out there, they all adhere to some level of accordance, to some scope of practice and to some skillsets. As I look at some of these, these are either not enough, going too far or not long enough for the skills provided. Let me explain.First things first, fortunately, both in hostile environment as well as in executive protection, the number of medical emergencies dealt with by team members are minimal. There are not so many issues to be reported and I guess this is why, as a medic, I am sometimes “shocked” by the medical readiness of some of the teams we work with. Back to training and the skills.“ It seems that some people disagree about the need of having a paramedic on board. There is cost to consider of course, having a paramedic is going to cost you (or the client).  Most, if not all, operatives are trained in the skills of first aid, CPR, bobo-treatments and the use of an AED. Great, they should be. If you are reading this, YES, this is a minimum. Not just for a CP operator, but, for life, like you know, to help people…Besides this, some take it up a notch and will do a TCCC-like training, to get some of the tacticool things under the belt and have that vital skill for when everything else goes wrong. Also, GREAT. You should, because, well, things might go bad and you might need this at one point or another.Some operators will even go further than this, do an ACLS class, ITLS, PHTLS, FREC, FPOS, whatever you want to call it. And I personally, can only applaud this! Keep it up, go for it! But, what about this cope of practice, which is so important and where does it come into play. Well, it comes into play with the program providers, the training schools. All of whom are genuinely trying to provide the best possible training out there, giving people the best possible skills in the least possible of time. So, for them as well, GREAT! Please, don’t get me wrong.So where comes the issue? Well, it goes to the following. Medicine is a very complicated science and it actually is not a half-time job, it is sort of full time and it takes a lot of skill. Everything is connected in medicine and for this, learning a little, will take you to learning a little more, to practicing more to, well… never stop learning. And this is the issue. Let me give you a small example:You are attending a TCCC class for all providers. You are not in the medical field, but want to be able to save patients from avoidable deaths. Ok, great. And in your class, they tell you at one point, check his pulse. Ok, so they teach you to do so. You check the pulse. So now, have they taught you what that pulse means? Have they taught you about the heart rate, pressure, the absence of a radial pulse, but the presence of a central pulse? This is just an example, to go here:You have been taught a skill, on which you will act, check, but actually not know what it means, how to go about it. So your course, which I am sure was a great course, has taken your scope of practice further than the courses content itself and has left you doing things without understanding it, or being able to act upon it.Another example, you take, the same TCCC class and they take out some raw meat, a trachea of some animal. They show you the landmarks to cut and the entire kit to perform your first Cricothyroidotomy. Yes, you now know how to cut, insert a tube and get air in the patients lungs. GREAT! How much air, how much pressure on the BVM, what’s next, what if it doesn’t work? Again, so many questions, unanswered, but skills given.Ok, ok, last one… Learning to IV the patient. Great, love it! Good skills. So, why? When? How much? What? Why not? When not? What if it goes south? Signs? Symptoms?Sure, I will stop. And yes, all of these are teachable skills and can be taught in a very long, course. And are these things truly necessary, for YOU? In your role, in YOUR SCOPE OF PRACTICE? Because, yes, they might be and if they are, you should go out there and spend a lot of time learning about them. If they are not, or if your role doesn’t really require you to do so, or even better, your local legislation doesn’t ALLOW you to do so, you should not learn about them. In this case, you should become VERY good at the basics, VERY proficient at YOUR scope of practice.Do you have a medical director in the State, country, region you work in? Are you as the “team medic” getting licensed to practice in the region you are operating in? Think about these as your client might need to understand the “scope of practice” you are able to provide him.Having a CRIC kit, O2 bottles and a full IV kit in your extensive med bag, with someone who can do the “procedure” is not that hard. As the “skills” themselves are easy to teach and many providers will teach them. The hard thing is the when do I use it, may I use it, what happens if I use it and the outcome is different then what it was on the mannequin, or, ok, done, now what?I would have never thought I would say this, but sometimes, less is more. Sometimes, it is not your thing and you should not venture out in the field you are not ready to walk through completely. Being real good at the basics is FINE, also in a high speed profession like EP. Think about it;You don’t call yourself EOD because you did a Level 3 IED course of which half was online. So why would you call yourself a medic, if you did a 5 day course? You are not and shouldn’t want to be, you are a good first responder, which is fine!If you want to do more, be able to do more and be a medic, a team medic, than strap in and know that you are going to be a team specialist. You are going to focus more time on this and you will probably be the one distributing band aids to the entire team, but also the one attaching a 6-lead to a client who suffered an arrest in the sticks, get him back to life with your meds and instruct the team on how to help, what to organize and what steps 4, 5 and 6 will be.Because lets face it, if you need those sexy advanced skills in your job, your job is somewhere where it is UP TO YOU, NOBODY ELSE IS COMING. And in that case, 5 days of training, just won’t cut it!Scope of practice, what changes the outcome for the patient, the provider and the team!Krisztian was raised as a Diplomatic Close Protection Officer, working mainly for diplomatic missions, including assignments to the Middle East and Africa. Recently certified as a Tactical Paramedic, Krisztian spent the last 10 years of his protective career specialising in tactical medicine in high-risk environments and close protection. Two passions combined where enough remains to learn and experience.