“All for One – All for the Same Goal“

Interagency Exchange at the Combat Medical Care Conference 2025 – Summary of the TEMS Symposium

Sebastian Weber^a, Florent Josse^a,b

^a Department AINS, Bundeswehr Hospital Ulm

^b Tactical Medicine Working Group of the German Society for Military Medicine and Military Pharmacy, Bonn

On the second day of the Combat Medical Care Conference 2025, alongside the main event and the SOF Medic Meeting, the TEMS (Tactical Emergency Medical Services) Symposium once again took place. As one of the three pillars of the Combat Medical Care Conference, the exclusive and closed symposium, professionally led by the TREMA (Tactical Rescue and Emergency Medicine Association), serves as a meeting point and as an exchange platform for all non-military governmental, particularly police, users of tactical medicine. In 16 presentations, divided into four thematic blocks, international emergency personnel, experts, and medical professionals shared their experiences, concepts, and research results. Following the presentations, there was a lively exchange among the 240 participants.

The following summaries provide a concentrated overview of the individual contributions of the TEMS Symposium 2025. Further information on the entire 2025 program can be found on the homepage of the Combat Medical Care Conference (www.cmc-conference.de).

1. Session of the TEMS Symposium

Open Thorax, Yes or No?
Case Report of a Thoracic Gunshot Wound

Einsatzkommando COBRA and Dr. Mario Krammel (AUT)

The first thematic block was opened by a representative of the Austrian Einsatzkommando COBRA and Dr. Mario Krammel from the Vienna Emergency Medical Service with a case study of a prehospital resuscitative emergency thoracotomy (PERT) on a thoracic gunshot wound. The presentation provided insights into tactical medical decision-making. It underscored the importance of the so-called “4 E“ as prerequisites for such an invasive emergency procedure: Expertise, Equipment, Environment, and Elapsed Time. Besides the professional content, this joint presentation was a prime example of interagency collaboration under extreme operational conditions.

Key Messages

• Clamshell thoracotomy is not an operation but an emergency measure as part of cardiopulmonary resuscitation (CPR) in cases of (traumatic) cardiac arrest.
• Goal: Relief of pericardial tamponade and/or proximal aortic occlusion for bleeding control.
• The decision to perform must be made in the shortest possible time under enormous pressure.
• “4 E“ as prerequisites for execution: Expertise, Equipment, Environment, Elapsed Time.
• Realistic training (“Train as you work“) for such emergencies is particularly relevant as preparation.

Clever Instead of Combative, Strategically Placing Medical Work

Michael MacLean (DEU)

Michael MacLean from the University of Police Baden-Württemberg emphasizes the importance of target-group-oriented training with his analysis of a knife attack. His statement “Do good and talk about it“ also highlighted the necessity of collecting, analyzing, and ultimately publishing data. This way, strategic-level training for casualty care can be improved sustainably and in the long term.

Key Messages

• Training: “Know and accept your target group.“
• Didactic Reduction: Sometimes less is more.
• Police medical actions are already a relevant factor for saving lives today (→ “Police First Aid“).
• Generate and utilize data: “Do good and talk about it.“

Methoxyflurane – Take a Deep Breath and Blow the Pain Away

Sebastian Weber (DEU)

Major (MC) Dr. Sebastian Weber from the Bundeswehr Hospital Ulm presented the use of Methoxyflurane (Penthrox^®) as a fast-acting, inhalative emergency analgesic that allows patient-controlled, practical, and pragmatic pain relief, particularly in acute trauma (NRS ≥ 4) – without vascular access and with minimal logistical effort. Methoxyflurane, developed initially as an inhalation anesthetic in the 1960s, is now used exclusively for analgesia in low doses. It shows a good safety profile, has a low dependency and abuse potential, a rapid onset, and quick elimination. The application is uncomplicated, possibly even by non-medical personnel, and requires no special equipment or documentation. It has been successfully tested in numerous international studies and operational areas – e.g., in Australia, the UK, France, NATO, as well as in mountain rescue and police operations (Figure 1).

Key Messages

• Analgesia is a fundamental human right and is often neglected.
• Methoxyflurane is a SAFE, FAST, and EFFECTIVE analgesic for patient-controlled analgesia in acute trauma-associated moderate to severe pain.
• Methoxyflurane has the potential to complement/improve pain management in tactical medicine usefully.

Fig. 1: The application of Methoxyflurane for analgesia is safe and simple. (Image: A. Weber)

FAST, TALON, or EASY: Which Intraosseous Access is Optimal for Police Medical Personnel?

Dr. Christoph Eisner (DEU)

Lieutenant Colonel (MC) Dr. Christoph Eisner from the Bundeswehr Central Hospital in Koblenz discussed in his presentation the various devices available on the market for intraosseous access.

Are We Applying MARCH Correctly? Hip Trauma in a Tactical Situation

Simon Franz (DEU)

Colonel (MC) Dr. Simon Franz from the Bundeswehr Hospital Ulm provided a compact overview of prehospital treatment strategies for pelvic trauma. He highlighted the role of the pelvic binder with its correct application as a potentially life-saving measure (Figure 2).

Key Messages

• Pelvic injuries are a strong indicator of severe trauma.
• Hemodynamic instability as a decision aid for applying a pelvic binder as a life-saving measure.
• Important points for applying the pelvic binder are:
• Internal rotation of the legs and fixation in this position,
• Correct positioning of the binder over the greater trochanters,
• Preferably, the two-helper technique for the application,
• Re-evaluation after application.
• The technique for applying pelvic binders should be practiced regularly.

Fig. 2: The correct application of the pelvic binder is potentially life-saving in severe pelvic trauma. (Image: S. Franz)

2. Session TEMS Symposium

The second thematic block focused on the definition and significance of the zoning concept for interagency collaboration during special operational situations.

February 13, 2025, Munich – Why Zones Are Not an Either-Or

Michael Storz (DEU)

Michael Storz from the Munich Fire Department demonstrated, using the example of the Amok driving incident in Munich on February 13, 2025, how flexible zoning, close coordination with the police, and deliberately pragmatic resource deployment enabled rapid casualty care even without structured patient staging.

Case Report: Brazil – MASCAL under Care Under Fire Conditions

Eder Prestes (BRA)

Eder Prestes, a Medic from the BOPE special unit of the Rio de Janeiro Military Police (BRA), presented the challenges during the “Care Under Fire“ phase (Figure 3) of an extensive gun attack with 13 victims. At the same time, he advocated for the expansion of the availability and use of blood products, for comprehensive uniform training in “Tactical Combat/Emergency Casualty Care,“ and for optimizing communication between agencies.

Fig. 3: Positions of the injured and the shooter‘s field of fire during an extensive gun attack in Rio de Janeiro (Image: E. Prestes)

From Three to Four: How Much of a Difference Does It Make, How Many Zones Are Defined?

TREMA e. V. (DEU)

At the end of this thematic block, a representative from the “Operational Tactics Department“ of the Tactical Rescue & Emergency Medicine Association (TREMA e. V.) presented the 4-Zone Model, an extended tactical zoning concept for interagency collaboration during special operational situations. It aims for easy comprehensibility, clear responsibilities, and universal applicability, minimizing interface problems between police, rescue services, and fire departments (Figure 4).

Fig. 4: The TREMA Four-Zone Model (Adapted from TREMA.ev)

3. Session TEMS Symposium

The third thematic block delved into the zoning concept with a focus on triage, followed by a panel discussion.

Are We There Yet? Quality Indicators and Key Insights from Rescue Operations in Terrorist Attacks

Professor Dr. Thomas Wurmb (DEU)

Professor Dr. Thomas Wurmb from the University Hospital Würzburg opened this thematic block by demonstrating that many insights from past terror and amok situations have been identified and documented (“lessons identified“), but not systematically and consistently implemented (“lessons learned“). The theoretical knowledge is present, but implementation, practice, and interdisciplinary collaboration are lagging. It was also evident here that zoning concepts need to be reconsidered and triage kept simple.

Key Messages

• Triage must be simple and must not hinder the directed transport chain.
• Patient flow is more critical than individual treatment.
• “Saving as many as possible succeeds when killing is stopped, dying is prevented, and patient flow is prioritized over individual treatment.“

Triage Systems: What Works When Tactics Play a Role?

Dr. Andreas Bayer (DEU)

Dr. Andreas Bayer from the Institute for Emergency Medicine and Medical Management in Munich analyzed the influencing factors on the triage process in life-threatening operational situations (LbEL). Through various real case examples, it became clear that classical triage algorithms, such as STaRT (Simple Triage and Rapid Treatment) or SALT (sort, assess, life-saving interventions, treatment, and/or transport), are rarely applied in civilian emergency services and military areas — intuitive decision-making dominates. He introduced the “Ten Second Triage (TST) Tool,“ a novel pre-triage algorithm already established and validated in the UK, which embraces this intuitive applicability, aligns with the MARCH structure, and integrates life-saving immediate measures.

Key Messages

• Intuitive decision-making dominates in triage — especially when (police) tactics play a role (→ LbEL).
• Pre-triage algorithms must be “situation-elastic,“ i.e., scalable depending on the situation and resources.
• Life-saving immediate measures must be part of pre-triage algorithms.
• The “Ten Second Triage (TST) Tool“ could be this pre-triage algorithm.

Zones and Triage: Key to MASCAL Management Regardless of Tactics

Dr. Claire Park (UK)

Dr. Claire Park, working for London’s Air Ambulance Charity and King’s College Hospital in London, seamlessly continued from the previous presentation, as she and her research team developed the Ten Second Triage (TST) tool.. Therefore, she was able to answer several questions about it and provide further details. In her presentation, she analyzed why the term “hot zone“ delays life-saving measures (“therapeutic vacuum“) using real attacks in London and Manchester. She presented pragmatic improvement suggestions, including the TST as a pre-triage algorithm. Furthermore, she demonstrated how patient flow in so-called “hot zones“ during life-threatening operational situations can be accelerated to further increase survival rates (“no preventable deaths“) in the future.

Key Messages

• The term “Hot Zone“ delays medical action.
• Time is life: “The Death Clock“ must be stopped, especially with “survivable“ injuries (these include particularly hemorrhage and airway obstruction).
• Life-saving immediate measures as soon as possible by police and/or civilian participants.
• Integrated teams of police forces and medical personnel as a possible concept.
• Cross-agency shared mental models must be created, e.g., through joint exercises and training.
• The Ten Second Triage (TST) tool allows for quick triage and evacuation decisions.
• Data and research gaps: more collaborative (forensic, medical, and police) data analysis is necessary (“multi-agency data“).

4. Session – TEMS Symposium

The fourth thematic block was significantly characterized by presentations on handling chemical (C), biological (B), radiological (R), and nuclear (N) threat situations (CBRN).

“Over the Counter“ – Realistic Threat Analysis of Chemical Danger

Helen Schwan (DEU)

Helen Schwan, a firefighter and NBC specialist advisor, warned of real dangers from freely available (“over the counter“) chemicals in drug and/or terror labs and provided practical advice for emergency personnel, especially on recognition, securing, and decontamination.

Key Messages

• Everyday substances, laboratory chemicals, and even household products can become chemical threats.
• GAMS rule for operations involving (chemical) hazardous substances:
• Recognize danger,
• Secure and cordon off,
• Save people,
• Alert special forces.

Preparation and Management of Bioterrorist Situations by the Public Health Service

Daniel Lauer (DEU)

Daniel Lauer from the Robert Koch Institute (RKI) presented the role of the RKI as a public health institution in bioterrorist threat situations using the example of the ricin attack attempt in Cologne 2018. He emphasized the relevance of coordinated cross-agency operational structures and the importance of early risk assessments. Bioterrorist operational situations can only be managed in close cooperation.

Key Messages

• Bioterrorist attacks are realistic threat situations.
• Effective “Multi-Agency Coordination“ (first responders, security forces, and public health) is essential at all (tactical, strategic, and operational) levels for management.
• Public health authorities must be involved early and are responsible in bioterrorist attacks.

CBRN Capabilities and Skills: What Medical Training Level Makes Sense for Police Units? – A Discussion Proposal

Police Baden-Württemberg (DEU)

A representative of the Police Baden-Württemberg discussed the necessity of a holistic approach to CBRN protection within police structures (CBRN is the abbreviation for chemical, biological, radiological, and nuclear threats). Technical and medical CBRN protection should not be viewed separately and must be integrated into the police‘s overall tactical concept. Particularly relevant areas highlighted for CBRN protection were: personal protective equipment, detection and decontamination of hazardous substances, as well as diagnostics, therapy, and initiating the rescue chain in case of contamination. This presentation also demonstrated the importance of interagency collaboration, as adequate and consistent CBRN protection cannot be achieved without the civilian health system.

Exertional Heat Stroke – Too Hot to Handle?

Dr. Andrea Schirner (DEU)

Dr. Andrea Schirner examined the so-called “exertional heat stroke,“ an acute heat-related emergency that can occur under high physical exertion, such as in sports or official duties. It is defined by a core body temperature (CBT) over 40.5°C and neurological dysfunction (e.g., confusion, seizures, unconsciousness) due to heat stress with or without physical exertion. This is a life-threatening emergency associated with an 80 % mortality rate without treatment. It primarily affects young, healthy, and physically active individuals, such as athletes, military personnel, and police officers. Dr. Schirner recommends “cool first, transport second“ (cold water immersion with a cooling rate of -0.15°C/min) as the guiding principle for treatment. She presented practical cooling methods, such as the “TACO“ (tarp-assisted cooling) or Body-Bag method, and debunked common misconceptions in dealing with “exertional heat stroke.“

Key Messages

• Exertional heat stroke is not a trivial event but a life-threatening emergency.
• Gold standard of therapy: “Cool first, transport second.“
• Cold water immersion (CWI) is the most effective cooling method; goal: CBT 38.6°C or when a cooling time of 10 minutes is reached.

When the Longest Seconds Never End – Excited Delirium and TASER

Dr. Boris Singler (DEU)

Dr. Boris Singler, Medical Director of the Nuremberg Emergency Medical Service, examined the complexity of the so-called “Excited Delirium Syndrome (EDS)“ using a real case example. This is a (still) unofficially recognized but described state of excitement/exception in forensic and emergency medical literature. These emergencies, often in combination with drug use and/or psychiatric preconditions in patients, frequently involve police participation. Close coordination and cooperation between emergency medical services and police can be the decisive “life-saving“ prerequisite to enable rapid and safe medical sedation of patients. In these emergencies, the use of electroshock weapons is also common. However, there is no evidence that these trigger EDS; rather, it is a coincidence.

Key Messages

• Excited Delirium Syndrome (EDS) is a life-threatening emergency that often occurs with sudden death during law enforcement (police involvement).
• EDS is associated with drug use and/or psychiatric preconditions in patients.
• The use of electroshock weapons is not confirmed as a cause of death in these cases.
• There are no validated therapy recommendations. Symptomatic treatment, exceptionally rapid and safe sedation, is a priority.

Final Remarks

The presented contributions share a standard message: Tactical medicine is more than just a rigid algorithm. It requires adaptive strategies, interdisciplinary collaboration, and courageous on-site decisions. The presented analyses, concepts, and case reports provided valuable impulses for training, equipment, and further development. They impressively demonstrated that life-saving medicine can be administered under extreme conditions in danger zones when approached tactically.

The TEMS Symposium 2025 has once again sustainably proven: The goal of the Combat Medical Care Conference, to continuously advance casualty care through knowledge exchange, network building, and strengthening partnerships in tactical medicine, knows no boundaries between agencies and organizations.

This interagency exchange will also be featured at the next Combat Medical Care Conference, “Across Borders – Beyond Limits,“ on July 7/8, 2027.

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For the Authors

Lieutenant Colonel (MC) Dr. Sebastian Weber
Department of Anesthesia, Intensive Care, Emergency Medicine, and Pain Management (AINS)
Bundeswehr Hospital Ulm
Oberer Eselsberg 40, 89081 Ulm
E-Mail: sebastian1weber@icloud.com