Tactical Medicine
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Tactical Medicine

Author

Sriram Venkatesan, FAWM
Medical Student
Sri Ramachandra Medical College, India
Vice Chair, EMRA Prehospital & Disaster Medicine Committee
EMRA Rep to the ACEP Tactical & Law Enforcement Medicine Section

Faculty Editor

Yevgeniy Maksimenko, MD, MA, MPH, NRP, FAWM, DiMM
Maj., USAF, MC
Assistant Professor
Department of Military and Emergency Medicine
Uniformed Services University

Faculty Reviewer

Russell Baker, DO, FACEP, FAEMS
Assistant Professor
Fellowship Program Director, Tactical Medicine
Texas Tech University Health Sciences Center El Paso 

Special thank to our 2nd edition writing team

Mohammad Kassem, MD
Catherine Steger, DO

 

INTRODUCTION

Description of the specialty
Tactical medicine is the practice of prehospital emergency care specifically designed for the support of high-risk law enforcement operations. Police tactical teams are responsible for an ever-widening scope of responses to critical law enforcement situations, national security threats, antiterrorism activity, mass gatherings, and disaster response missions. Casualties in such situations are increasingly likely, and advanced medical knowledge is required to meet an expanding scope of the situations faced. Accordingly, tactical emergency medical support (TEMS) has gained recognition as an essential element of the modern law enforcement mission.

Tactical medicine augments law enforcement operations by performing medical threat assessments, delivering on-scene emergency medical care, and promoting the safety and health of law enforcement personnel. Tactically-trained medical personnel achieve their objectives through mission pre-planning, implementation of clinical practices developed specifically for tactical applications, and provision of a critical interface between law enforcement personnel, conventional EMS, and the existing health-care system infrastructure.

The broad goals of tactical medicine are to facilitate the overall success and safety of law enforcement missions during all phases of a tactical operation through the delivery of preventative, as well as timely, emergent medical care. The basic approaches utilized by tactical medicine providers were initially developed by the military, with the main premise being that integrated medical personnel reduces time from injury to treatment and improves survival. This concept has been adapted to the civilian law enforcement environment. The primary function of tactical medicine during a mission is to provide broad medical support including injury prevention, resource identification and allocation, and rapid access to emergency medical care within the operation.

History of the specialty/fellowship pathway
In the late 1980s, leadership within law enforcement, emergency medicine, and emergency medical services (EMS) began to develop consensus on the provision of dedicated medical support for tactical teams. In 1993, the National Tactical Officers Association (NTOA) issued a position statement in support of tactical emergency medical support, emphasizing that “the provision of TEMS has emerged as an important element of tactical law enforcement operations.” The National Association of EMS Physicians (NAEMSP) further described medical support of law enforcement special operations in 2001. In 2004, ACEP issued a position paper endorsing TEMS as an essential component of law enforcement teams that “helps maintain a healthy and safer environment for both law enforcement and the public.”

Qualified physician involvement and medical oversight is an essential element of prehospital medicine, with tactical medicine being no exception. The professional practice of tactical medicine continues to evolve and aims to attain formal recognition. Recent progress was made when basic competency in TEMS was added as a sub-requirement of ABEM subspecialty certification in EMS. Future development of this medical practice will include dedicated fellowship training in tactical medicine. Several fellowships already are active across the country.

Why residents choose to follow this career path
Physicians working in tactical medicine have a strong interest in out-of-hospital emergency care and a special interest in working with law enforcement agencies. Tactical physicians can actively deploy in the field with their teams or provide medical support in the form of training and medical direction. An essential component is integrated training with the tactical team, which can greatly enhance mission readiness. Tactical medicine often provides additional niche training opportunities in executive protection, mass gatherings, and care in austere environments. Physicians seeking to train in tactical medicine often have backgrounds in law enforcement and/or military service, and this practice environment is seen as an opportunity to merge those prior experiences with clinical medicine. This may also serve as a means for residents and physicians to engage in other activities outside the traditional realm of medicine and give back to their communities.

How do I know if this path is right for me?
Tactical physicians have a strong sense of community service and expect to be on-call for emergency responses on a near-continuous basis. Working with law enforcement carries some inherent risks, and physicians practicing tactical medicine expect regular exposure to high-threat incidents. Tactical physicians must have an excellent understanding of their local and regional emergency health-care infrastructure and possess the interpersonal and communication skills to work effectively within their systems. Occupational health is an essential component of tactical medicine, and physicians must be prepared to spend considerable effort on officer health and safety issues. Finally, law enforcement requires a strict adherence to chain-of-command protocols, so tactical physicians must be adept at such procedures and enjoy working within this framework.

While not required, previous experience in EMS, law enforcement, or military medicine is helpful in gaining an appreciation for the unique challenges of emergency care in the prehospital and out-of-hospital setting. Elective rotations in EMS, wilderness medicine, or international disaster response can provide residents with exposure to working in limited-resource settings, though not replace essential experience of working with tactical teams. Some local law enforcement groups allow medical students and residents to shadow and learn from tactical scenarios. One such example is the National Center for Medical Readiness (NCMR), also known as Calamityville in Fairborn, OH. Several tactical medical support courses are available for those interested in an introduction, such as the 1-Day tactical medicine course for emergency personnel offered by Federal Law Enforcement Training Centers (FLETC), a division of the U.S. Department of Homeland Security and the Counter Narcotics and Terrorism Operational Medical Support (CONTOMS), a program run by the U.S. Park Police and the U.S. Department of Health and Human Services. Finally, the Tactical Combat Casualty Care (TCCC) courses offered by NAEMT and developed by the U.S. Department of Defense (DOD) Joint Trauma System provide a perspective adapted to the military combat environment.

Career options after fellowship
After fellowship, most physicians continue their careers as tactical physicians with law enforcement agencies, typically working in these capacities at least part-time. Depending upon geography, such opportunities may already exist, or physicians may work to develop positions within local departments. Military physicians often end up supporting combat units as medical directors or flight/battalion/division surgeons. Many concepts are similar, focusing on the need to apply preventative and emergency medicine principles to a combat/tactical environment. Less commonly, fellowship-trained physicians may elect to work with search and rescue teams, in disaster and international medicine, or conventional EMS systems.

Academic vs. community positions
Well-established positions in law enforcement tactical medicine are typically based at academic institutions. These centers will often have longstanding programs in place with larger agencies, especially at the state or federal levels. Tactical physicians at academic centers will maintain these positions as part of their academic profiles and administrative roles. Well-qualified physicians employed by a community hospital or in private practice may actively work in the field as tactical physicians with a local department. These responsibilities are more commonly individually negotiated, either with or without compensation, separate from primary employment.

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
Dedicated tactical medicine fellowships are currently offered at Johns Hopkins University through its Center for Law Enforcement Medicine, Texas Tech University Health Sciences Center El Paso (TTUHSC), and Wake Forest University. All three programs maintain their tactical medicine fellowship programs separate from, and in addition to, their EMS fellowship programs.

With the advent of ACGME accreditation for EMS fellowships, some exposure to special operations or tactical medicine is required within all accredited EMS programs. The degree can be quite variable, though, and is highly dependent on availability of local resources and institutional expertise.

EMS fellowship programs that offer significant tactical medicine exposure or experiences include:

Length of time required to complete fellowship
The tactical medicine fellowship program at Johns Hopkins is two years long, while the programs at Texas Tech University Health Sciences Center and Wake Forest University are one year. EMS fellowship programs accredited by the ACGME offer some degree of exposure to tactical medicine under the core curriculum heading of special operations. ACGME-accredited EMS fellowships are one year in duration.

Skills acquired during fellowship
The goal of tactical medicine fellowship training is to prepare academic emergency physicians for leadership, field support, and medical direction of law enforcement special operations and tactical medicine programs. A fellowship in tactical medicine has a significant operational component, providing trainees with key skills needed to safely operate and provide care during high-risk tactical operations, large-scale mass gatherings, and dignitary protection missions.

Typical curriculum
The main components of a tactical medicine fellowship include mentorship in the medical direction of special operations while applying the fundamental tenets of prehospital emergency care; direct experience with local, state, and federal law enforcement; exposure to tactical, protective, special event, international, and remote consultation programs; and escalating medical control responsibilities. Additional areas of focus include the education and training of law enforcement medical providers, continuous quality improvement of care, involvement in the administrative and developmental aspects of tactical and operational medicine programs, and academic research in the field of law enforcement medicine.

The fellowship program at Johns Hopkins specifically includes both training and field deployment with multiple federal law enforcement and homeland security teams.

At Texas Tech, fellows are provided the opportunity to attend courses such as: CONTOMS EMT-Tactical, EMT-T Advanced, and Tactical Medical Director; Basic SWAT; Advanced Hazmat Life Support; Advanced SWAT; Breaching; Close Quarter Battle (CQB); and Incident Command. Courses can be selected as available and according to the fellow's interests. As part of the program, fellows also attend a Basic Peace Officer course to obtain full law enforcement credentials.

Fellows at the Wake Forest University program are provided the opportunity to undergo North Carolina’s Basic Law Enforcement Training (BLET) so they can be directly sworn in with their future agency, if they end up staying in North Carolina.

Fellows at all three programs will have a core clinical commitment of a certain number of required hours per month at their emergency department.

Board certification afterwards?
No.

Average salary during fellowship
Salaries during fellowship vary widely by institution. Applicants should refer to the fellowship program’s website or contact the program directly for specific information. Fellows generally earn a PGY-4 salary and are provided opportunities for moonlighting during fellowship.

PREPARING TO APPLY

How competitive is the application process?
Because the field is small and training opportunities specific to tactical medicine are extremely limited, it is difficult to quantify competitiveness. All three programs accept one fellow annually.

Requirements to apply

  • Board-certified or board-eligible in emergency medicine
  • Ability to pass a criminal background check and obtain security clearance(s)
  • Have the psychomotor skills and physical fitness to function in austere and dynamic treatment environments
  • Demonstrated interest in prehospital emergency care and/or tactical medicine strongly preferred
  • Willingness to directly participate in potentially dangerous law enforcement operations

Previous experience in EMS, military, or law enforcement is not required.

Research requirements
Research is not absolutely required; however, fellows are expected to publish during their fellowship, and previous meaningful research experience is preferred.

Suggested elective rotations in residency
Robust in-program EMS rotation/elective or an immersive away elective, preferably at a program with substantive experience and faculty participation in tactical medicine.

Suggestions on how to excel during elective rotations
Evaluators in prehospital, including tactical, medicine typically want to see a balance between active interest, capabilities, and receptiveness to learning. Because operating in the law enforcement environment has risks, supervisors must ensure that trainees listen well and follow directions precisely. Adhere to chain-of-command protocols, and understand the importance of teamwork. Comply with all uniform attire (if provided) requirements, and communicate any changes in personal schedule or availability. Ensure your equipment is mission-ready at all times. Always arrive early to any assignment, whether training or operations. Staying late to finish group assignments or tasks will be noteworthy.

Should I complete an away rotation?
If an emergency medicine residency does not provide internal exposure to tactical medicine, away rotation(s) would be helpful to potential applicants, both in demonstrating interest and gaining exposure to determine if tactical medicine is a good fit. Commercial, off-the-shelf tactical medicine courses are generally less preferable than rotations at academic centers.

What can I do to stand out from the crowd?
Quality longitudinal experience in tactical medicine is a welcome attribute in any applicant. Despite this, meaningful opportunities vary across residency programs. Field experience in any area of prehospital medicine, including EMS and disaster medicine, can be helpful in gauging a candidate’s aptitude for practicing medicine outside of a hospital and his/her understanding of the challenges such work entails. Early rotations and involvement with local law enforcement training scenarios show significant interest over other candidates. Most residency programs are willing to set up rotations with local law enforcement and first responders to give the resident adequate exposure. Consider completing field tactical medicine certification courses like TCCC or TECC.

Should I join a hospital committee?
Hospital committees related to tactical medicine are rare, but serving on them (if possible) would be a beneficial experience.

Publications other than research
Any publication that you can include in your CV relating to tactical medicine will likely bolster your application.

How many recommendation letters do I need? Who should write them?
Obtain three letters of recommendation at minimum. At least one should be from the residency director, and ideally one from a supervisory faculty member with expertise in tactical or law enforcement medicine. Supplemental letter(s) from non-physician supervisors with detailed knowledge of the applicant’s capabilities in the field are welcome.

What if I want to work as an attending before applying?
Work experience as an attending emergency physician is potentially quite helpful to the tactical medicine fellow because clinical excellence is a hallmark of successful tactical physicians. Law enforcement agencies look for maturity, leadership, and experience in the physicians they choose to support operational teams.

What if I’m a DO applicant?
DO applicants are welcome.

What if I am an international applicant?
Unfortunately, due to medical licensure requirements and the need to obtain security clearance(s), international applicants are generally ineligible. Eligibility should be discussed with each program directly.

APPLICATION PROCESS

How many applications should I submit?
There are three dedicated tactical medicine fellowship programs currently offered. Applicants with a strong desire to pursue tactical medicine training at the fellowship level should consider applying to all three programs beforeconsidering EMS fellowship programs that offer significant tactical medicine exposure as well.

Common mistakes during the application process

  • Application/CV does not display a clear interest in tactical medicine
  • Choosing letter writers who do not know you well
  • Grammatical errors in your application
  • Weak personal statement

Application deadlines
The fellowship program start date is July 1 at Johns Hopkins. Applicants are encouraged to apply early, though mid-year candidates may be considered.

Interested candidates for the Texas Tech program should contact the program directly for application details. Application deadlines are typically flexible.

Candidates interested in the Wake Forest fellowship should contact program organizers1 for more information and application details. There is no specific application deadline, although decisions are typically made late winter/early spring.

Tips for writing your personal statement
Personal statements for fellowships will be similar to those written for the residency application process or other graduate medical education programs. Applicants should focus on factors that motivated them to pursue a career in tactical medicine and highlight relevant past experiences, including any special qualifications. Statements should clearly identify any potential barriers to working with law enforcement agencies or that might preclude obtaining security clearances.

Is there a match?
No.

What happens if I don’t obtain a fellowship position?
Applicants with a strong desire to pursue tactical medicine training at the fellowship level can either wait a year or consider EMS fellowship training at a program with significant tactical medicine exposure.

INTERVIEW PROCESS

How do I stand out from the crowd?
The culture of law enforcement emphasizes uniformity, rank, and adherence to chain-of-command. Along these lines, interviewees should dress neatly, professionally, and be well-groomed. Interviewees should address all individuals by title and/or rank. Punctuality and preparedness are essential.

What types of questions are typically asked?
Personal motivation, meaningful experiences, and well-documented involvement in tactical medicine are highly desirable and should be anticipated discussion points. Functional experiences in other prehospital settings such as disaster and EMS are also noteworthy.

Tactical physicians must be able to demonstrate strong leadership, clear decision-making, and clinical excellence under challenging and stressful conditions. Some interview questions may seek to determine an applicant’s aptitude and suitability for medical operations in complex and austere field environments.

How many interviews should I go on?
If you are invited to interview at any of the three programs in existence, you should go.

PREPARING FOR FELLOWSHIP

Textbooks and other recommended reading

  • Stair RG, Polk W, Shapiro G, Tang N. Law Enforcement Responder: Principles of Emergency Medicine, Rescue, and Force Protection. Burlington, MA: Jones & Bartlett; 2012.
  • Campbell JE, Heiskell LE, Smith J, Wipfler EJ. Tactical Medicine Essentials. Burlington, MA: Jones & Bartlett; 2011.
  • Schwartz RB, Swienton RE, McManus JG. Tactical Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.
  • Jadick R, Hayden T. On Call in Hell: A Doctor’s Iraq War Story. New American Library; 2007.
  • McDevitt I. Tactical Medicine: An Introduction to Law Enforcement Emergency Care. Paladin Press; 2001.

Important skills to focus on in residency
Proficiency with core-content emergency medicine and procedural skills acquired during residency are crucial and form the competency base for the practicing tactical physician. Rotations in EMS, trauma, urgent care, occupational health, and critical care are particularly germane.

As a tactical medicine provider, you will be required to learn how to care for yourself or others in a bad situation. Being able to perform the necessary measures to save lives and, if needed, the know-how to utilize a pistol to protect life is essential. A Close Quarters Pistol course or, at the minimum, a gun safety course and practice at a gun range for accurate marksmanship is recommended if you plan to apply for the fellowship.

Experience with operational skills in the field environment — including proper PPE donning and doffing (especially in the setting of tear gas and pepper spray), radio communications, emergency vehicle operations, and understanding of prehospital provider scopes of practice — can be particularly helpful to potential fellows.

Tips on how to succeed as a fellow
Consistent demonstration of enthusiasm, professionalism, strong interpersonal skills, willingness to work hard (both physically and mentally), and adherence to command infrastructure is essential for success as a fellow in tactical medicine.

CONCLUSION

Additional resources

Journals

National organizations

Conferences

  • ACEP Tactical & Law Enforcement Medicine Section Meeting (held during the annual ACEP’s Scientific Assembly)
  • Special Operations Medical Association Scientific Assembly
  • NAEMSP Annual Meeting
  • World Association of Emergency and Disaster Medicine (WADEM) World Congress

How to find a mentor
Seek opportunities with residency faculty actively involved in tactical medicine or other practicing tactical physician(s) in your area.

Contact the EMS or disaster faculty at your institution to get involved with prehospital medicine.

Contact fellowship programs with content of interest to seek potential rotations or electives in tactical medicine or EMS.

Reach out to the ACEP Tactical & Law Enforcement Medicine Section and the EMRA Prehospital & Disaster Medicine Committee. You also could sign up as a mentee in the EMRA Mentorship Program for guidance.

Reference

  1. Dr. William Bozeman, Wake Forest University, wbozeman@wakehealth.edu.
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