The day begins calmly. Workers settle at their desks, turn on computers, busy themselves with the day's projects and exchange greetings as they grab cups of coffee.
So far, the most pressing concerns in most minds are deadlines, lunch plans and getting to their child's school play after work.
Suddenly, chaos erupts. A shooter has entered the building. Or perhaps someone has set off a car bomb. Panicked workers rush toward whatever they perceive to be safe places -- exits, locked rooms, stairwells -- and fear the worst.
Law Enforcement Officers (LEOs) are mobilized and sent to the scene with multiple responsibilities: apprehending the perpetrators, tending to wounded workers and leading as many to safety as possible.
Specially trained Tactical Emergency Medical Providers may accompany those LEOs to start rendering care to the victims even before the situation has been stabilized.
Are they prepared? Dr. Scott Goldstein, chief of tactical medicine at the Albert Einstein Healthcare Network and president of the Philadelphia Tactical Medical Association, naturally wants the answer to be, "Yes."
The goal of a symposium he held recently at Einstein on "Advanced Tactical Medicine: The Israeli Experience" was to aid in preparing key personnel for such emergencies.
Goldstein's interest in tactical medicine was sparked by an opportunity to serve as tactical medical director for the Dauphin County Crisis Response Team and Penn State Hershey. This experience, coupled with enhanced training in the field, further attracted him to the specialty, "a perfect match of excitement and basic medicine," he noted.
"There are parts of the job that pertain to basic medical care and medical record keeping along with the excitement of going out on a warrant search at 4 in the morning.
"I also enjoyed the camaraderie between the team members, which, after a while, included myself. After I relocated to the Philadelphia area, I wanted to continue educating, learning and participating in the field of tactical medicine."
Circumstances happily answered his wish when he met members of the Institute of Terrorism Research and Response -- self-described as "an American and Israeli nonprofit corporation created to help organizations succeed and prosper in a world threatened by terrorism" -- "and we decided to put a combined course on."
In his symposium, Goldstein said he "wanted to provide a quality course in the field of tactical medicine in the Philadelphia area as there seemed to be a paucity of opportunities" locally.
He invited experts from the Israeli Defense Forces as well as from the United States -- the FBI, state police and the Philadelphia medical examiner's office. The purpose was not only to give lectures on crucial skills needed in emergencies, but also to engage participants in hands-on practice of the skills they learned.
The two-day conference earlier this year, attended by some 50 people, provided a history and overview of current developments in the field and a lecture on tactical medicine in Israel.
The conference culminated in a simulation held in Einstein's Korman Building, partly deserted, with areas under construction.
It included the role playing of wounded patients, hostages and terrorists, while other participants were taken through the building, working together to defuse the "crisis" -- a rehearsal of real-life emergency conditions that merit "care under fire."
This term, said Dr. Stephen Pulley, a member of Einstein's Department of Emergency Medicine, was one he first learned at the symposium. "In the course," he explained, "they highlighted simple steps to take in the care of someone injured in an active situation to decrease mortality and stabilize the situation until they can be safely evacuated."
These techniques, he said, were "honed over the past eight to nine years in the Middle East and Southwestern Asia. It was these interventions that have allowed catastrophically injured soldiers to be returned home alive at impressively" high numbers.
The challenge of the symposium, according to Dr. Glenn Bollard, section development coordinator of the Section of Tactical Emergency Medicine within the American College of Emergency Physicians, was that participants came in with different levels of skill and experience.
Yet, despite this, he was impressed by the cooperation and teamwork among the participants. And he considered the simulation to be a success. "To add realism, their roles were different than what their typical responsibilities would have been in real life. In the practice scenarios, they carried simulated weapons and moved forward in an assertive tactical response to an active threat situation," which included an active shooter and hostages being held.