RAMS Tactical Emergency Medicine Roadmap

Tactical EMERGENCY MEDICINE Tactical Emergency Medicine is the provision of medical support, threat assessment, and medical care of tactical operations and law enforcement personnel.

MED STUDENT (MS3/4)

JUNIOR RESIDENT

background

Senior RESIDENT

Resources

AUTHOR: Aaron R. Kuzel, D.O., M.B.A. Welcome to the Tactical Emergency Medicine Roadmap, your definitive step-by-step guide on how to succeed in Tactical EM at every training level. Don’t know where to start? Click on “Background” or select your training level above. A full list of fellowships, conferences, and podcasts can be found in “Resources.”

For pearls of wisdom from faculty and residents in the trenches, click on “Insider Advice.”

FELLOW

insider Advice

1 - SENIOR MEDICAL STUDENT (MS3 and MS4) As a Medical Student, you should focus on learning the role of TEMS (Tactical Emergency Medical Services) within the field of Emergency Medicine. There may be opportunities to express one’s interest in tactical emergency medicine through participation in Tactical Casualty Combat Care (TCCC) courses, Tactical Emergency Medical Support Courses, or tactical medicine drills or exercises if offered by your institution. As you prepare your application on VSLO and ERAS, read the list of residencies that offer a tactical emergency medicine component as published in the ACEP Tactical Emergency Medicine Section.

FAQ Will academic or community programs offer more opportunities for participation in tactical emergency medicine?

Academic emergency medicine programs likely have established relationships with law enforcement agencies. In addition, some academic programs have established relationships with state and federal law enforcement agencies such as the FBI, DEA, U.S. Marshall Service, U.S. Border Patrol and other federal agencies. In comparison, community programs may also employ tactical emergency physicians within their own EMS agencies or local law enforcement. Community physicians can hold tactical responsibilities and duties that may be negotiated outside the tactical physician’s place of employment.

Should I choose a three year or four year emergency medicine residency program?

There are no definitive answers or determined benefits on whether to choose a three or four year emergency medicine residency in regards to a career in tactical emergency medicine. A four year program does allow for more elective rotations in residency to further explore tactical emergency medicine opportunities.

Additionally, there are a number of emergency medicine residency programs that provide components of tactical emergency medicine training. These programs either offer emergency medicine electives or have devoted faculty who serve in law enforcement positions or lead tactical emergency medicine related research. This list is maintained by the ACEP Tactical Emergency Medicine Section.

2 - JUNIOR RESIDENT PGY-1

As an EM Intern, you should review the your residency’s educational program to identify opportunities in tactical medicine. Learn whether the department has tactical physicians within the EMS Division, or if particular physicians in your program have tactical responsibilities; such individuals can serve as mentors. In addition, ACEP has Tactical Emergency Medicine Section that can provide opportunities for involvement .

PGY-2

As a Junior Resident, you should have identified a mentor and be seek out additional opportunities to pursue your interest in tactical medicine.

Identify a Mentor • I dentify a mentor in your program who may have a working relationship with:

– L aw enforcement

– S erves as a medical director for local, state, or federal law

– W ork with these faculty members to obtain certifications in

enforcement

tactical medicine or research projects.

• I f your program doesn’t have faculty involved in tactical

medicine, you can join the ACEP Tactical Emergency Medicine Section and seek mentors from experts in tactical emergency medicine for guidance.

Courses and Certifications: • S everal courses are offered for certification in tactical medicine, including: – T actical Casualty Combat Care (TCCC) This course is offered by the National Association of Emergency Medical Technician (NAEMT). It was created by the U.S. Department of Defense Committee of TCCC to teach medical and traumatic care under fire. There are two types of courses offered, a one day course for individuals who will be exposed to a combat zone and a two day course offered to military medical personnel. https://www.naemt.org/education/naemt-tccc – T actical Emergency Casualty Care (TECC) This course is designed similarly to the TCCC course, but developed for civilians.

– T actical Emergency Medicine Support (TEMS)

– R escue Task Force

– F EMA Courses

This course is intended for practicing physicians, as well as leaders in medical support for tactical operations. It provides lectures and scenario-based training that prepares attendants to develop medical models and policies related to medical support of tactical operations, as well as skills for supporting high-risk law enforcement operations.

This course provides training at the point of injury during an active shooter scenario, and is designed for law enforcement and EMS.

3 - SENIOR RESIDENT As a Senior Resident, continue to work with a mentor in developing a plan for your career in tactical medicine or develop/complete a research or education project related to tactical medicine.

Become more involved in your local EMS, Police and Fire community response to learn the relationship regarding the political interplay between the various city and state components.

As a senior resident, there are many ways that you can be involved in tactical medicine. In addition to the courses mentioned in the Junior Resident section, there are numerous opportunities to develop and your skills as an interested tactical emergency medicine physician.

• A ttend policy meetings that discuss tactical medicine or operation medicine • W ork with your EMS physicians or tactical physicians to develop policy related to tactical or mass casualty incidents.

• A ttend EMS and/or local law enforcement trainings, if permissible.

• P erform research in tactical emergency medicine projects • A ttend conferences to network with tactical physicians and officer leadership:

– National Association of EMS Physicians Annual Meeting

– National Tactical officers Association Conferece

– Special Operations Medical Association Scientific Assembly

– American College of Emergency Physicians (ACEP) Section Meetings during the Annual Meeting.

4 - FELLOWSHIP There is currently only one fellowship offered in Tactical Emergency Medicine, at Johns Hopkins University. The main components of this fellowship are mentorship in medical direction of special operations and their medical programs; direct field experience with local, state, and federal law enforcement; and engagement in medical control responsibilities for these law enforcement activities.

Emergency Medicine Department Tactical Medicine Fellowship

• J ohns Hopkins University: Start date is July 1st with one position offered. The application process does not have a match process, but according to the website, mid-year candidates can be considered.

– h ttps://www.hopkinsmedicine.org/emergencymedicine/ fellowship_programs/tactical_medicine.html As there exists only one fellowship for tactical emergency medicine, applicants who desire a career in tactical medicine may also pursue an EMS fellowship program with a tactical medicine department or offer emphasis on tactical emergency medicine. Information on these fellowships can be found on the ACEP Tactical Emergency Medicine Section website. Pursuing EMS positions and fellowship is how most physicians interest in tactical emergency medicine become involved with tactical teams and departments. Additionally, some physicians may pursue further tactical training or basic law enforcement training.

Military Emergency Medicine Tactical Fellowship The Special Operations Medical Association offers a Military EMS and Disaster Medicine Fellowship Program that is a two year fellowship that including an MPH degree. There are three spots offered to the branches of the Armed Forces and the application deadline is October 1st.

• http://www.specialoperationsmedicine.org/Pages/ fellowshipprograms.aspx

Networking

• S enior residents should: – Network with the ACEP Tactical Emergency Medicine Section – A ttend the annual ACEP Tactical Emergency Medicine Section meeting at ACEP – Consider networking events at SAEM’s or SAEM’s regional meetings to meet physicians and programs that have established tactical medicine departments or programs – Consider attending meetings with a tactical focus such as the Special Operations Medical Association or SOMA Scientific Assembly or the National Association of EMS Physician or NAEMSP Annual Meeting

FAQ

Is the Fellowship in Tactical Medicine at Johns Hopkins competitive?

It is difficult to quantify competitiveness as there is only one fellowship program with one position, however, with one position, the openings are very limited.

Where Can I Find Information on EMS Fellowships that have Tactical Medicine Components?

Applicants should use the published residency information on the ACEP Tactical Emergency Medicine Section’s website.

From an academic perspective, tactical medicine is really going to be achieved through EMS fellowships. There are not really well defined ways of getting involved or alternative routes other than checking your local agency.

5 - BACKGROUND What is Tactical Emergency Medicine?

Tactical emergency medicine, as it pertains to civilian emergency physicians, supports law enforcement operations relating to or constituting actions requiring an immediate, upgraded level of law enforcement response. Local, State, and Federal law enforcement tactical teams are experiencing an unprecedented increase in scope of response situations including: hostage situations, mass shootings, anti-terrorism activity, clandestine operations, mass gathering event security, national security activities, and disaster response activity.

As the need for tactical operations increases, the need for trained tactical emergency physicians and EMS providers is becoming more relevant and required.

According to the National Tactical Officers Association, physicians trained in Tactical Emergency Medical Support (TEMS) “conduct medical threat assessments, render immediate medical care in austere environments, and provide logistical support to further the health and safety of law enforcement personnel and reduce the incidences of injury, illness, disability and death associated with training and tactical operations.” Tactical emergency physicians are responsible for the development of medical policies, and providing medical training for tactical teams and tactical medical support teams.

The History of the Field

On August 1, 1966, a shooting conducted by a student occurred at the University of Texas at Austin resulted in the deaths of 14 individuals and wounding of another 31 people. This event, now referred to as the “Texas Tower Shooting,” resulted in a large, unorganized response from civilian and law enforcement individuals. The incident demonstrated to law enforcement agencies the need for the formation of specialized “tactical” response teams that could respond to situations that required expertise above those of a normal police officer.

The result of the Texas Tower Incident was the construction of specialized teams now referred to as Special Weapons and Tactics or SWAT teams. Today, SWAT teams respond to a host of law enforcement operations and tactical missions such as hostage situations, security missions, explosive ordnance disposal, mass gathering security, anti-terrorism activities, and high-risk warrant service. The development of tactical emergency medical services quickly followed and in 1993, the National Tactical Officers Association (NTOA) issued a policy statement in support of tactical medical support as, “an important element of tactical law enforcement operations.” These position statements have been revised twice; in 2007 and 2013. In 2018, the NTOA created a section devoted solely to TEMS guidelines. These 2018 guidelines established the importance of the medical operations in the field of tactical operations.

In conjunction with the NTOA’s position policy, the National Association of EMS Physicians (NAEMSP) in 2001 provided a position paper further describing the role of physicians and emergency medical services in law enforcement activities. Further, the American College of Emergency Physicians (ACEP) issued a position statement affirming the position of the NAEMSP in 2004 stating the TEMS, “helps maintain a healthy and safer environment for both law enforcement and the public.”

Although there has been incredible strides in adoption of tactical medicine components to law enforcement, EMS agencies, and Emergency Departments, tactical emergency medical services are not standardized or implemented throughout the United States. The ACEP Tactical Emergency Medicine Section continues to advocate for formal recognition of tactical emergency medicine as a subspecialty. Most recently, for an EMS Fellowship to maintain ACGME subspecialty certification, the fellowship must offer certain requirements in tactical training or education. There is currently one two year fellowship offered by Johns Hopkins University in tactical emergency medicine, but board certification is currently unavailable.

6 - RESOURCES Professional Societies

Publications

•N ational Association of EMS Physicians

•H eiskell LE, Carmona RH: Tactical emergency medical services: An emerging subspecialty of emergency medicine.

Ann Emerg Med April 1994;23:778-785.

•N ational Tactical Officers Association • S ociety of Academic Emergency Medicine • S pecial Operations Medical Association •T actical Emergency Medicine Section, American College of Emergency Physicians

Journals • J ournal of Emergency Medical Services • J ournal of Special Operations Medicine •P rehospital Emergency Care

Recommended Conferences •A CEP Tactical Emergency Medicine Section at ACEP Annual Meeting •N ational Association of EMS Physician Annual Meeting • S ociety for Academic Emergency Medicine Annual Meeting • S pecial Operations Medical Association Scientific Assembly

• Montgomery HR, Butler FK, Kerr W, Coklin CC, et al.

TCCC guidelines comprehensive review and update. JSOM. 2017;17(2):21-38.

•N ational Tactical Officers Association. NTOA position statement: Inclusion of tactical emergency medical support (TEMS) in tactical law enforcement operations.” Tactical Edge.

2007;25(3):10.

•R amirez ML, Slovis CM, (2010) Resident involvement in civilian tactical emergency medicine. J Emerg Med. 2010;39(1);49-56.

•T ang, N, Kelen GD, (2007). Role of Tactical EMS in Support of Public Safety and the Public Health Response to a Hostile Mass Casualty Incident. Disaster Medicine and Public Health Preparedness. 2007; vol.1/suppl 1: S55-S56.

• Wipfler E.J. Tactical Medicine Essentials. (2012). American College of Emergency Physicians.

•Y oung JB, Sena MJ, Galante JM. Physician roles in tactical emergency medical support: The first 20 years. J Emerg Med. 2014;46(1):38-45.

7 - INSIDER ADVICE Dr. John Wipfler III, MD, FACEP, Emergency Physician at OSF Saint Francis Medical Center and Chair-Elect of the ACEP Tactical Emergency Medicine Section, Excerpt from Life as a Tactical Medicine Doc: An Interview With John Wipfler III, MD, FACEP on EMRA “You really have a lot of options as far as being a tactical medicine provider goes, depending on the level of involvement you would like to have and the level of participation your local agencies are willing to grant you. You can be the medical director of a tactical emergency medical service unit, where you mainly function as the primary physician for the team, as well as writing medical protocols, and leading trainings for your team. Or you can choose to be more hands-on, embedding within the team and participating in the same training as the tactical operators as well as being in charge of the medical aspects of your unit. EMS medical directors also help support their local tactical medics and rescue task forces and can choose to be more or less involved.�