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Tactical Medicine

Authors

Mohammad Kassem, MD
Clinical Research/Ultrasound Fellow
Department of Anatomical Sciences
St. George’s University School of Medicine

Catherine Steger, DO
Emergency Medicine Resident
Nassau University Medical Center

Special thanks to our 1st edition writing team

Nathan Woltman, MD
Krystle Shafer, MD
Nelson Tang, MD, FACEP

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, anti-terrorism activity, mass gatherings, and disaster response missions. 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, urgent, and emergency medical care. The basic approaches utilized by tactical medicine providers were initially developed by the military, and have 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, 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, the American College of Emergency Physicians 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 tactical medicine. Professional practice in tactical medicine continues to attain formal recognition and, as an example, basic competency is a newly established sub-requirement of ACGME subspecialty certification in EMS. Dedicated fellowship training in tactical medicine is an emerging concept.

Why residents choose to follow this career path
Physicians working in tactical medicine have a strong interest in prehospital and out-of-hospital emergency care and a special interest in working with law enforcement agencies. Tactical physicians actively deploy in the field with their teams, and formal training greatly enhances mission readiness. Tactical medicine often provides additional niche training opportunities such as 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 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 abroad, in EMS, or in wilderness medicine can provide residents with exposure to these elements, though few will specifically involve 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, Ohio.

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 a local department. Military physicians who have completed tactical medicine fellowship training add this qualification when they return to active duty service. 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 their primary employment.

IN-DEPTH FELLOWSHIP INFORMATION

Number of 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 upon availability of local resources and institutional expertise. EMS fellowship programs that offer significant tactical medicine exposure or experiences include Washington University, University of New Mexico, Boston University, Wright State University, University of Illinois Peoria, Carolinas Medical Center, UT Southwestern, and Medical College of Georgia.

The only dedicated tactical medicine fellowship at this time exists at Johns Hopkins University through its Center for Law Enforcement Medicine. Johns Hopkins maintains this fellowship program separate from, and in addition to, its EMS fellowship program.

Length of time required to complete fellowship
The tactical medicine fellowship program at Johns Hopkins is 2 years in length.

EMS fellowship programs accredited by the ACGME offer some degree of exposure to tactical medicine under the core curriculum heading of special operations. ACGME EMS fellowships are 1 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. Fellowship in tactical medicine at Johns Hopkins 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 rotations/curriculum
The main components of the Johns Hopkins 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.

Board certification afterwards?
No.

Average salary during fellowship
Salaries during fellowship, whether EMS or tactical medicine, vary widely by institution. Applicants should contact potential fellowship programs directly for specific information. Fellows generally have some limited opportunities for moonlighting during fellowship.

PREPARING TO APPLY

How competitive is the fellowship application process?
Because the field is small and the training opportunities specific to tactical medicine are extremely limited, it is difficult to quantify competitiveness. There is currently 1 fellowship position available per year (up to 2 concurrent fellows per year) at a single program. 

Requirements to apply

  • Board certified or board-eligible in emergency medicine
  • Ability to pass a criminal background check and obtain security clearance(s)
  • Ability to function in austere environments
  • Demonstrated interest in prehospital emergency care and/or tactical medicine strongly preferred

Previous employment in EMS 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 to take during 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 these 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. Remember to 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?
A quality longitudinal experience in tactical medicine is a welcome attribute in any potential 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 shows 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.

Should I join a hospital committee?
Hospital committees related to tactical medicine are rare, but are a beneficial experience if possible.

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

How many recommendations should I get? Who should write these recommendations?
Obtain 3 letters of recommendation at minimum. At least 1 should be from the residency director, and 1 ideally from a supervisory faculty member with expertise in prehospital or tactical medicine. Supplemental letter(s) from non-physician supervisors with detailed knowledge of the applicant’s capabilities in the field are welcome. 

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
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?
Currently there is only a single dedicated tactical medicine fellowship program.

Applicants with a strong desire to pursue tactical medicine training at the fellowship level should also consider EMS fellowship programs that offer significant tactical medicine content. 

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 common fellowship program start date is July 1 at Johns Hopkins. Applicants are encouraged to apply early, because there is only one position offered each year. 

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 this a match process?
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 should also 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 pre-hospital 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 the single program in existence, you should go.

PREPARING FOR FELLOWSHIP

Textbooks to consider 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.

Important skills to practice while in residency to prepare for fellowship
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.

Experience with operational skills in the field environment – including PPE, 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

  • Tactical Emergency Medicine Section, American College of Emergency Physicians
  • Special Operations Medical Association
  • National Association of EMS Physicians

Conferences

  • Special Operations Medical Association Scientific Assembly
  • NAEMSP Annual Meeting
  • ACEP Tactical Medicine Section Meeting (held during ACEP’s Scientific Assembly)

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 EMS or tactical medicine.