"Shots fired! Officer down! Officer down!” Those words send shivers down the spine of every first responder and medical professional.
Active shooter. Inside: A man has barricaded himself after shooting family members and calling 911. The initial responding police units walked into a trap, and now 2 officers face life-threatening injuries. The shooter is still an active threat somewhere in the building. SWAT is activated, but they are bringing an important asset with them, an emergency physician. Not a typical day in the ED.
Lives are at stake. Waiting for the scene to be secured effectively so that prehospital professionals can treat the officers will decrease the chance of their survival. Tactical EMS has been rapidly growing around the country for specifically these types of situations, but in a few select places, the practice of physicians performing emergency medicine in tactical environments has also taken hold. In fact, tactical EM has emerged as an evolving subspecialty, allowing physicians to potentially render medical care in high-threat environments, where most civilian EMS and fire crews cannot safely respond. Taking shape as a civilian equivalent to the military’s battlefield medicine and special operations medicine, the slogan that captures tactical EM is “doing the best medicine in the worst places.” Tactical emergency physicians are able to support a wide variety of teams with no one single standard. Some examples include working with Special Weapons And Tactics (SWAT), federal law enforcement teams, wilderness and waterborne extraction teams, HAZMAT, and Search and Rescue (SAR) squads. The need for medical personnel in these high-risk situations is also clear, as most officers and federal agents are not usually required to undergo medical training and tactical EMS specialists are few and far between. Furthermore, the combination of volume (with > 50,000 yearly SWAT deployments in the U.S. alone) and tactical environments that are not optimized for medical care, the need for well-trained physician-led tactical medical teams is clear. To hear from the experts in this field, we bring you Drs. Jeremy Ackerman and Ross Berkeley, who discuss their experiences as tactical emergency physicians..
Jeremy D. Ackerman, MD, PhD, FACEP
Department of Emergency Medicine
Emory University School of Medicine
Wallace H. Coulter, Department of Biomedical Engineering
Co-Director Medical Innovation Residency Track, Emory University School of Medicine
Ross P. Berkeley, MD, FACEP, FAAEM
Program Director & Interim Chair
Department of Emergency Medicine
University of Nevada, Las Vegas School of Medicine
How would you define tactical emergency medicine and what is your current role in it?
Dr. Ackerman: “So I gravitate to the definition that the National Tactical Officers Association uses which says tactical medicine covers medical care in the planning and execution of tactical missions, including extended operations and extreme environments, as well as shorter operations. So something which may be a little different from my EMS-
trained colleagues is that I’m more interested in care in the field or care under fire, unlike those who prefer to not usually put on body armor and sit in an armored vehicle, but to supervise operations as medical director.”
Dr. Berkeley: “I have served as a tactical physician for the Las Vegas Metropolitan Police Department (LVMPD) SWAT team since 2005, which typically involves on-scene medical support during team deployments to high-risk warrants and barricades. In non-military settings, tactical medicine is a specialized field involving the provision of pre-hospital medical oversight and support for law enforcement personnel, as well as bystanders, in scenarios in which civilian EMS personnel cannot respond, often due to scene safety concerns. The LVMPD tactical physicians are involved in the initial mission briefing with the SWAT team, which includes a review of the schematic layout of the target location and the tactical plan. During each scene response, the physician and a tactical medic, who is also an officer with LVMPD’s Search & Rescue, are deployed in a tactical rescue vehicle. The physicians wear body armor and are on-scene as the SWAT team clears the building, either dynamically (rapid breach entry) or tactically (slow and methodical). The tactical physicians are tasked to stabilize individuals on-scene with an injury or acute medical condition, utilizing the principles of Tactical Combat Casualty Care (TCCC), with prioritization depending on the level of injury and the tactical situation.”
Could you describe your path and inspiration in getting involved in tactical EM?
Dr. Ackerman: “In addition to my role as an emergency physician, I am a biomedical engineer. I also teach at Georgia Tech how to design medical devices, and, more broadly, innovation and problem-solving in medical and healthcare spaces. I literally did not know that tactical medicine was what I wanted to do until I accidentally stumbled upon it. And as I was getting pulled into tactical medicine, with not much prior knowledge in it, I started to realize I would need to develop a similar skill set as my officers. Meaning if I am going to sign off on a set of orders, I need to understand the environment you’re going to use it in, which is what led me to realize my knowledge limitations and ultimately pursue police academy training. When I realized my team wanted me to deploy with them, it became kind of essential for a medical doctor like me to almost have the same level of training going into the field. One of the moments which made me go to the police academy, was when we had our active shooter drills in preparation for Super Bowl events, where we basically would run towards the threat. It is a little bit of oversimplification, but when we are there as a SWAT team we are there to figure out what the threat is, where it is and stop ‘em. Often the fastest way to do that is run towards the sounds of the gunshots. To do that you have to be able to function as a tactical officer as well as a healthcare provider.”
Dr. Berkeley: “My residency training at the University of Pittsburgh included participation in a unique program involving on-scene response via a resident EMS response vehicle, in order to provide medical direction and hands-on stabilizing prehospital care for patients with critical illness, such as cardiac arrests and major traumas. The experience highlighted the unique nature of the provision of medical care by physicians in the prehospital setting, and I was seeking similar opportunities when I moved to Las Vegas. Fortunately, my mentor was actively involved with the LVMPD Tactical Medical Program, and I applied for a position as a tactical physician once a spot opened up on the team.”
What is an average working week/month in your life as a tactical EM physician? How many hours dedicated to tactical work, including training, going on calls, maintaining skills, etc, do you have per week/month?
Dr. Ackerman: “The short answer is no, so we don’t have a standardized schedule for every week. Other than our training days once every 2 weeks, our schedule is given a couple of days in advance based on upcoming operations by our tactical unit. Some operations come together with no advanced warning.
Dr. Berkeley: “In addition to 7 LVMPD Search & Rescue officers with EMS training (2 paramedics and 5 AEMTs), our team consists of 10 physician volunteers and 4 civilian paramedic volunteers. We take calls each month to cover 12- and 24-hour shifts, and coordinate based on our primary work schedules. Typically, I cover 48-60 hours of call each month, in addition to 4 hours of monthly training, which may involve simulated downed-officer and multiple casualty scenarios, procedural skills labs, and a variety of other training exercises.”
How do you balance your work life between being an academic or community EM physician and tactical work? Do you get dedicated time off to pursue other stuff such as these?
Dr. Ackerman: “So it does take a bit of creativity and being a glutton for punishment to move your schedule around to fit your field training days and adjust your schedule ahead of time-based on operations announced by your tactical unit. Academic EM helps in that as money from contracts can reduce clinical time.”
Dr. Berkeley: “This is a volunteer role which is incredibly fulfilling and enjoyable, and never feels like ‘work’ to me. To the contrary, I feel that my role as a tactical physician is an opportunity to serve the community, and helps provide me with an increased sense of balance in life.”
As a board-certified/residency-trained physician, what are the job prospects for those interested in tactical EM? What types of roles can a physician possibly perform or be hired for in this field?
Dr. Berkeley: “It may not be realistic to view working as a tactical physician as a ‘job prospect’ – generally, most of these positions are voluntary without any compensation. A physician serving in an administrative role as a medical director for a tactical medical program may potentially receive some compensation, but the stipend would not likely suffice as a primary job. A role like this is not about money, it’s about the opportunity to serve and help make a positive impact.”
Are there other additional unique aspects of tactical EM that EM physicians do not normally have to worry about?
Dr. Ackerman: “Anytime I tell people that I go out with SWAT teams, that I went through the police academy, and I’m in an environment where I feel it is most appropriate for me to be armed, I get asked frequently, “You’re armed, how can you shoot people?” It comes back to “do no harm”. The biggest threat to my patient, my officer or the civilian who is injured, is the person who already shot them once. In my view, the Hippocratic Oath is problematic in modern healthcare but is sort of the biggest single barrier to the role I have taken up in tactical medicine. Our whole job as physicians is to navigate the issue of how to provide the most benefit with the least risk of harm and balance that with the patient’s wants, needs and wishes. When we were on station at events related to the Super Bowl, the reality was that the possibility of a large-scale attack, active shooter or bomb was extremely rare and unlikely. But if you’re going to be in that environment and poised to be able to provide help, you also need to do the first thing that mitigates that threat to other people including the officers, which is to eliminate the threat. It’s an approach developed in the military that is highly applicable in the law enforcement tactical environment too.”
Dr. Berkeley: “Any time medical care is being provided outside of the controlled environment of the hospital, particularly during SWAT team operations, scene safety is a key element that needs to be considered. One example I previously would not have considered is that the use of a laryngoscope to intubate during nighttime operations creates a visible light source that could potentially make the tactical clinician a target for an armed suspect. A phrase that some may have heard is that ‘good medicine can sometimes be bad tactics….’ There is an initial learning curve to adjusting hospital-based skills to the tactical environment. Equipment and medication limitations also create unique challenges in the provision of care under potentially austere conditions.”
Do you have any advice for medical students and residents interested in pursuing a career in tactical EM?
Dr. Ackerman: “So I think for medical students and residents, the most straightforward way would be to pursue an EMS fellowship and look for a place, like Hopkins or UT San Antonio where there is a focus on tactical medicine, in their EMS fellowship. Make sure wherever you’re going there are opportunities to actually work with tactical teams. Agencies who need a physician often will go to the training programs they know about when they have a need. I think the path I have taken to essentially find a connection with an agency first, without prior training or experience, is still possible, but there are a lot of things that can make it a bit challenging. It requires a bit of luck to find the right agency, with officers in leadership that see the value in working with clinicians and that have the resources and the patience to provide some of the training. I think for folks coming out of the military, it becomes easier to get buy-in from tactical units.”
Dr. Berkeley: “First, I would encourage anyone with an interest in tactical medicine to pursue their passions. Since medical students and residents are still in training, I suspect that opportunities to serve as a tactical clinician involved in unsupervised patient care may be rather limited — that will likely vary depending on the design and nature of the particular tactical medical program, state licensing laws, and school/residency policies and procedures. One great way to get involved may be to consider volunteering with the local tactical medical team to serve as a ‘victim’ for training scenarios — that may lead to additional opportunities along with the chance to network with others who have a shared interest. I have had some emergency medicine residents, and even a medical student, attend our monthly tactical medical training, and some have accompanied me on scene responses. Those with a significant passion could also consider attending a tactical medicine course, such as the one offered by the International School of Tactical Medicine.”
For the residents and medical students, in particular for those without prior tactical exposure, how would you recommend getting involved/get started?
Dr. Ackerman: “Like a lot of things in life, you have to be prepared and show up. My opening came from another project which led me to start talking to police officers. That led to introductions to SWAT members, then invitations to observe training, then invitations to participate in training, and finally invitations to assist with operations. I did some reading and training on my own so that I would be ready to learn and perform. Many departments offer short “Citizen’s Academy” which may be a way to meet some officers and department leadership while simultaneously learning about police operations. Talk to tactical physicians to make sure you understand what you can offer to a team and find out if they can help make introductions.”
Dr. Berkeley: “In addition to the above suggestions, I would recommend seeking out a mentor early for personalized guidance. Tactical medical programs vary widely based on the particular agency, city, and state – the specific role of the physician on the team (including whether or not they are armed) and even potential expectations for physician training as a law enforcement officer, are unique to each program.”
The field of EMS as a subspecialty of EM is well established, however, tactical EM seems to exist as quite a specific niche. In order to get the best professional exposure/ training possible, would you recommend that the interested residents pursue a specific Tactical Medicine fellowship (such as the one offered by Johns Hopkins/San Antonio), seek an EMS fellowship, or choose an entirely different path?
Dr. Ackerman: “I think fellowships with a tactical component are a good start and even an EMS fellowship without a specific tactical experience probably helps. Some of the people I know who are in tactical EMS have never put on body armor, have never handled or fired a gun! Most tactical medicine is identical to EMS — it is the supervision of emergency medical providers in the field. If you are interested in tactical EM, I would highly recommend pursuing an EMS fellowship. Would it be better to do one with a tactical focus – probably, but I don’t think it’s essential. Not doing an EMS fellowship is possible but you have to remember that there is a lot you will have to learn on your own.”
Dr. Berkeley: “The pursuit of fellowship training is a very personal decision. For someone with a significant passion for tactical medicine and aspirations to serve in a leadership/ administrative role, the additional training may align with their personal and professional goals and be valuable to their development. However, completion of a fellowship is not necessary for the vast majority of emergency physicians (myself included) who choose to serve as tactical physicians. I felt well-prepared for many aspects of the role when I first started and rapidly learned the finer points of tactical medicine via the monthly training, in addition to completing SWAT school with the LVMPD. My fellow volunteers on the LVMPD Tactical Medical Team include physicians from multiple other specialties, including trauma surgery, anesthesiology, and neurosurgery.”
Given the current social and political climate regarding law enforcement, what are your thoughts on the future of tactical medicine in general and specifically for physicians?
Dr. Ackerman: “I think in healthcare, there is a pretty big need to have us understand policing and how it works. I also think in healthcare, we have a big opportunity to help guide and possibly lead some of these discussions on policing. I think we (in healthcare) have a good platform to try to get society to address what I would argue as the ‘bigger picture’ problems. But it is a bit of a problem when in healthcare we don’t understand how policing works or many of the current laws. I think there is a developing role for tactical physicians to address this. I think the opportunities for physicians to work with law enforcement will continue to be out there. I do worry a little bit that as physicians, we have a risk of getting stuck in the cross-hairs of investigations into law enforcement. There are a few cases where physicians have used firearms which has led them to lose their medical license. That is something I genuinely worry about, amplified by the recent events. Unfortunately, with increased numbers of mass casualty events resulting from violence, there appears to be an increasing need for tactical medicine. Tactical physicians are needed to support teams and potentially aid in the medical response to these events.
Dr. Berkeley: “Emergency medicine physicians are accustomed to working collaboratively with many other specialties, as well as with EMS and law enforcement personnel, as key elements in the mission to serve as the safety net for the community. Embedding a tactical physician into a law enforcement team creates a unique opportunity to provide advanced medical care to both suspects and bystanders in situations in which it may not be possible for EMS personnel to respond. Since law enforcement personnel may also be the first to arrive on-scene and encounter patients with significant medical issues and/or traumatic injuries, tactical physicians also have an opportunity to further serve the community as a whole by educating our police colleagues on basic lifesaving and the Stop the Bleed campaign. I think there will continue to be a need for tactical physicians in the years to come.”
Acknowledgment: We would like to use this opportunity to thank Drs. Ackerman and Berkeley for their time and effort in making this article possible.