Issues of Concern
Approach to Medical Threat Assessment
The MTA may be conducted for military personnel during deployments to foreign countries or training in the home nation, as well as for other operational teams facing potential medical threats, such as law enforcement tactical units, emergency response teams, and humanitarian organizations. Medical casualties can result from infectious agents and environmental factors, including extreme temperatures, regardless of location. While disease and injury rates cannot be precisely predicted before deployment, the assessment informs operational planning and risk mitigation. Evaluating medical threats involves defining the at-risk population, analyzing potential hazards, determining priority countermeasures, considering mission timing and duration, and specifying the precise operational location. (Source: Petruccelli and Smoak, 2003)
Defining the at-risk population
Identifying the at-risk population is the first step in an MTA, typically conducted at the operational level for the entire deployed force. However, different subgroups face varying risks based on their roles, such as soldiers in close contact with local populations being more vulnerable to certain diseases. In some cases, medical officers may need to assess risks for the indigenous population as well, highlighting the importance of clearly specifying who needs protection.
For team members, premission health measures should provide access to a physician for routine screenings, preventive care, and treatment of common medical issues. Team members may consult tactical physicians for personal health concerns. However, while team physicians may offer occasional advice or treatment for minor ailments, they should avoid becoming de facto personal physicians. This role extends beyond the tactical physician’s scope, and general advice or informal referrals should be the standard.
Each team member should maintain a medical card documenting medical conditions, medications, immunizations, and allergies. This information should be securely stored yet readily accessible to the TEMS provider and should accompany a team casualty to the hospital. Immunizations should be up to date, particularly for tetanus and hepatitis, with additional vaccinations recommended based on anticipated exposure to uncommon pathogens in the operational jurisdiction.[1] Physical fitness standards should be encouraged to ensure team members can meet any reasonably anticipated physical demands.
Analyzing potential hazards and prioritizing countermeasures
Potential health threats during a mission include battle and nonbattle injuries, environmental hazards, psychological stress, and infectious diseases. Among these risks, disease and nonbattle injuries are the primary causes of morbidity in deployed personnel and can lead to mass casualties, especially during prolonged missions.[2][3][4]
Combat injuries are increasingly responsible for total mortality in warfare due to advancements in weapon lethality, though their prevention falls under military tactics rather than medical planning. For the TEMS team, proper personal protective equipment (PPE) is essential for mitigating combat and noncombat threats. Each team member, including medical personnel, should wear ballistic protective gear, typically consisting of a ballistic vest and helmet. The level of protection must correspond to the expected weapon threats for a given mission. Vision and hearing protection should be mandatory. During mission preparation, TEMS providers should ensure team members wear appropriate protective gear and emphasize the importance of goggles and hearing protection.
Recent military operations have demonstrated a lower mortality rate when all personnel are trained in Tactical Combat Casualty Care (TCCC) principles.[5][6] Lessons from military settings suggest that equipping civilian teams with similar life-saving skills for self-aid and buddy-aid can provide significant benefits. Each team member must be capable of administering critical medical care and should carry essential life-saving equipment as part of their kit. In hostile fire situations, a TEMS provider may be unable to reach a casualty, making it essential to collaborate with team commanders to ensure appropriate medical equipment is distributed to all personnel.
In combat, hemorrhagic shock remains the leading cause of preventable death in casualties with survivable injuries. Tourniquets are highly effective in controlling extremity hemorrhage, and every team member must be proficient in self-application and assisting others. Prehospital administration of blood products has become more common in civilian emergency medical services (EMS), with low-titer O whole blood (LTOWB) shown to reduce mortality.[7][8] The TCCC Committee has updated fluid resuscitation guidelines, designating cold-stored low-titer O whole blood (CS-LTOWB) as the preferred option and fresh low-titer O whole blood as the primary alternative.
Crystalloids and Hextend are no longer recommended for hemorrhagic shock resuscitation.[9] To optimize casualty care, the TEMS team leader should explore methods to ensure LTOWB availability for all tactical missions.
Nonbattle injuries result from accidents involving vehicles, heavy equipment, fires, and physical exertion during activities like construction, which may be mitigated by adequate training and PPE use. Human risk factors such as alcohol use, medication effects, inadequate sleep, and time zone shifts further contribute to nonbattle injury rates. To address these human risk factors, TEMS teams should implement strict rest and hydration protocols, enforce policies on alcohol and medication use before deployment, and incorporate acclimatization periods for time zone adjustments. Fatigue management strategies can help maintain cognitive and physical performance during missions.
Environmental hazards in any operational setting include living threats such as venomous animals and ectoparasites, as well as nonliving dangers like extreme temperatures, pollution, and industrial waste. Exposure to these hazards can result in a myriad of adverse manifestations, ranging from chronic, subclinical conditions to acute, life-threatening intoxications. Some environmental threats, such as severe air pollution, can immediately impair operational effectiveness, while others, like exposure to mutagens, may have long-term health consequences.
Significant adjustments to the operational plan are unnecessary on days with moderate temperatures and minimal chance of rain. However, the team must be prepared to function in all environmental extremes. Extreme heat presents challenges because team members cannot wear less than the required protective gear, which restricts heat dissipation and raises the risk of heat-related injuries. In high temperatures, minimizing equipment weight and wearing clothing that facilitates effective sweat evaporation can help manage heat stress.
Cold conditions may require modifications in equipment and planning, as additional clothing layers may be essential to reduce heat loss, particularly for prolonged missions. Team members should layer efficiently to regulate body temperature while maintaining tactical mobility and quick access to gear. Each individual must ensure their layering system is comfortable and effective before the mission begins. Once operations are underway, safely adding or removing layers is unlikely to be feasible.
Rain gear should be issued and worn when the chance of rain is significant, particularly in cold environments where moisture increases the risk of hypothermia. For prolonged operations, plans should allow personnel to rotate out of harsh conditions and remove excess gear as needed.
Access to food and both hot and cold drinks should be ensured. Ideally, the designated gear-down area should be an environmentally controlled space, such as a building or a temperature-regulated vehicle like a bus, to help prevent hyperthermia and hypothermia.
Operating in a tactical environment increases the risk of musculoskeletal injuries due to unfamiliar terrain and limited visibility, making complete prevention impossible.[10] However, wearing protective gear, including long-sleeved shirts, pants, knee and elbow pads, abrasion-resistant gloves, and sturdy footwear, can reduce the likelihood and severity of these injuries.
Environment-specific protective measures must also target biological and chemical threats. Training in species identification and avoidance, along with carrying antivenom when applicable, reduces the risk of envenomation. Ectoparasite exposure may be minimized through insect repellents, permethrin-treated clothing, and routine hygiene.
Respiratory protection, including respirators and masks, helps prevent the immediate effects of severe air pollution while minimizing exposure duration. (Source: US Fire Administration, 2022) Selecting safer operational zones further reduces risk. Industrial waste hazards necessitate thorough premission assessments, appropriate PPE, and access to decontamination facilities. To counter toxic exposures, including mutagens and hazardous chemicals, monitoring air and water quality, utilizing PPE, and implementing medical surveillance programs are essential for both immediate and long-term health preservation.[11][12]
The psychological challenges of deployments are often underestimated, yet prolonged separation from loved ones, personal safety concerns, and unfamiliar responsibilities can lead to significant mental strain. Without proper support, these stressors increase the risk of anxiety, depression, suicidal ideation, and other serious behavioral health issues. In high-risk environments, such as conflict zones, the psychological burden is further intensified by combat stress, loss of comrades, and friendly fire incidents.
Addressing the psychological challenges of deployments requires a comprehensive approach spanning predeployment, in-deployment, and post-deployment phases. Mental resilience training before deployment equips personnel with stress management techniques, while regular psychological assessments and peer support programs during deployment help identify and mitigate mental health concerns.[13][14] High-risk environments necessitate immediate psychological support and structured debriefing sessions following traumatic events.[15] After deployment, access to counseling and therapy, along with family support initiatives, aids in long-term recovery.[16] Ongoing monitoring and evaluation of these interventions ensure they remain effective in safeguarding mental well-being.
Infectious diseases have historically caused the most nonbattle casualties, making an understanding of their epidemiology essential for accurate MTAs. Arthropod-borne diseases, fecal-oral infections, and respiratory illnesses pose significant risks, with some capable of incapacitating large numbers of personnel. Vaccination has greatly reduced the threat of severe respiratory infections, though outbreaks still occur, particularly in confined living conditions.
Sexually transmitted, bloodborne, and environmentally acquired infections are less likely to cause widespread epidemics. However, these conditions can still impact mission effectiveness, especially among high-risk groups, including Special Forces units and personnel in confined living conditions or exposed to contaminated environments.
Prevention of sexually transmitted infections in deployed groups aligns with broader public health strategies. Recommended measures include comprehensive sexual health education, condom use, vaccinations, preexposure prophylaxis for high-risk individuals, regular screening, prompt treatment, partner notification, and ensuring access to prevention and care resources.
Wearing gloves, eye protection, a long-sleeved shirt, and pants can help protect team members from bloodborne pathogen exposure. Each team member should also include a set of medical gloves in their kit if they need to provide care to a casualty. The TEMS provider must assist the command staff in ensuring each team member wears the required items.
Environmentally acquired infections include conditions such as leptospirosis and helminthic infestation, which are transmitted by contact with soil, water, and animals in the area. Protective measures from these infections include vaccination, chemoprophylaxis, proper PPE use, environment monitoring, and safe food and water handling practices.
Bioterrorism involves the deliberate release of biological weapons, including bacteria, viruses, toxins, and fungi, to spread disease and cause death in humans, animals, or plants. Past use by nation-states and terrorist groups has led to large-scale epidemics. Despite international prohibitions like the Geneva Protocol, terrorist organizations favor biological weapons due to their ease of deployment, devastating effects, and low cost, though their unpredictable nature poses risks to both intended targets and unintended populations.[17]
Healthcare professionals, including TEMS personnel, must be trained in recognizing, evaluating, and treating bioterrorism-related threats, with an interprofessional team playing a crucial role in managing potential attacks and mitigating their catastrophic consequences. Enhancing training, education, and scenario-based simulations can strengthen preparedness, while comprehensive response plans should be developed to include workplaces, communities, and healthcare institutions.[18]
Chemical hazards pose a significant concern for tactical teams. Team members must be trained to recognize and counter a range of chemical threats. Many of these dangers can be anticipated, allowing mitigation strategies to be integrated into the operational plan. However, teams must also be prepared for unexpected chemical exposures. Contingency plans should include rapid deployment of a hazardous materials (HazMat) team. Each team member should have sufficient HazMat training to recognize when activation of specialized support is necessary.
If the team deploys chemical agents such as oleoresin capsicum (OC) or tear gas (CS), all members must receive thorough training in their use, storage, and potential physiologic effects. Gas masks should be readily accessible, with cartridges capable of filtering riot control agents and other unknown chemicals. Given the widespread presence of opioids, teams should carry naloxone for potential exposures. While the risk of toxicity from incidental external contact is often overstated, preparation remains essential. If the premission assessment indicates a high risk of exposure to a specific agent, operators or the TEMS provider should carry suitable PPE and antidotes. The suspected presence of highly toxic agents may warrant delaying or significantly modifying the tactical plan.
Radiological threats should also be evaluated, considering both external and internal exposure risks from accidents, malicious use, or environmental contamination. Preparation involves training personnel in radiation safety, maintaining appropriate PPE, and establishing decontamination and treatment procedures. Effective response requires protocols for detection, mitigation, and medical management of exposure. Operational planning should identify high-risk areas, implement safety measures, and ensure access to medical resources for radiation injuries.
Prioritizing medical threats during deployment requires focusing on the most critical risks rather than compiling exhaustive lists, as excessive detail can hinder decision-making. A risk categorization system that considers both the likelihood of occurrence and the potential for widespread impact can help commanders allocate resources effectively. Rapid-onset conditions, such as diarrheal diseases, typically pose a greater operational threat than slower-developing illnesses, such as schistosomiasis, emphasizing the need for targeted prevention and intervention strategies. Quantitative models for predicting disease and nonbattle injury rates remain imprecise, but historical data, expert consensus, and technological advancements, such as artificial intelligence, guide medical planning by accounting for combat intensity, environmental conditions, and preventive measures.[19]
Considering mission timing and duration
Assessing threats based on the mission timeline helps ensure personnel are fit for duty and protected against endemic diseases. Seasonal variations influence disease prevalence and environmental risks, as vector-borne illnesses like malaria peak during rainy seasons. Certain mission phases pose heightened risks, particularly initial deployment, when personnel adapt to new environments, or during intense operations, which often coincide with increased stress and injury rates. Factoring in disease incubation periods allows for predicting symptom onset after exposure, enabling timely surveillance and early intervention. The planned activities of the group, along with the expected time and duration of the operation, determine exposure risks and guide resource allocation for sustained medical readiness.
Specifying the precise operational location
Evaluating geographic risks is essential for MTA, as mission location influences health threats and medical response planning. Endemic diseases, environmental hazards such as extreme temperatures or altitude, and the availability of local healthcare resources must be evaluated. Surveillance for occupational and environmental exposures, including industrial waste, air pollution, and contaminated water sources, helps identify potential hazards. Urban settings may present increased risks of chemical exposure and communicable diseases due to population density, while rural areas may pose challenges related to zoonotic diseases and limited medical infrastructure. Evaluating medical facilities, evacuation routes, and logistical support ensures timely access to care if needed.
Due to the high risk of injury during an operation, tactical teams should establish contingencies for the rapid extrication of casualties. EMS units involved in the operation should have a predetermined staging area. Staging locations must be positioned far enough from the operational site to protect EMS personnel from stray gunfire. The EMS unit should also remain out of the visual range of the target location to preserve operational security.
The EMS unit's staging location must balance safety considerations with the need for rapid deployment to the scene if required. The TEMS provider should be familiar with the capabilities of local hospitals to coordinate the transport of casualties to the nearest appropriate facility. The location of the designated receiving trauma center and the transport route to the hospital should be determined during the planning phase and included in predeployment briefings for the entire team. A final check using a readily available trip planning app powered by the Global Positioning System (GPS) should be conducted to identify any traffic delays or road closures that could impact the planned route.
Reporting the Threat
The TEMS provider is typically the designated team member who serves as the link and liaison to the civilian EMS system. Maintaining reliable communication is a high priority. EMS providers should receive the information necessary to facilitate a prompt response. Disclosing additional details, such as full addresses or the names of target individuals, is generally unnecessary and could compromise tactical team safety.
Threat information should be communicated to commanders, medical personnel, and servicemembers to ensure appropriate planning and response. Commanders need concise briefings that highlight the highest-priority threats to guide operational decisions, such as acclimatization periods and preventive measures. Medical personnel require technical literature and logistical preparation to address expected health risks, including those uncommon in their home country. Servicemembers benefit from clear, accessible educational materials that dispel myths and reinforce protective behaviors. The information should be strategically placed within the operational plan, ensuring visibility where it is most impactful.
Advancements in Conducting Medical Threat Assessments
Recent MTA advancements have significantly improved tactical medical operations. These advancements include the integration of modern technologies, enhanced training, expanded roles for medical providers, and strengthened collaboration efforts.
The use of decision support systems has enhanced the responsiveness of medical care while mitigating risks associated with medical evacuation. Emerging technologies, including automation and artificial intelligence, further streamline treatment processes, enabling medics to concentrate on patient care rather than administrative burdens. (Source: Biswas, et al, 2023)
Tactical medicine has evolved substantially over the past 2 decades, with training programs increasingly tailored to high-threat environments. Continuous updates to TCCC guidelines ensure that prehospital trauma care remains evidence-based and aligned with battlefield conditions.
Tactical medical providers now fulfill expanded roles beyond caregiving, serving as advisors and administrators involved in MTAs and risk reduction strategies. Additionally, psychological support and team health maintenance are increasingly recognized as essential components of comprehensive MTAs. (Source: American College of Emergency Physicians, 2025)
Effective interagency coordination has become a critical aspect of tactical medical operations. Tactical medical providers collaborate closely with local EMS and other agencies to ensure seamless integration of medical resources and rapid response capabilities during high-risk deployments. (Source: National Tactical Officers Association, 2025)
EMS Tactical Medical Threat Assessment and Protection