Tactical Emergency Medical Support units are necessary assets to the community. There are many personnel involved in the team with varying role. The addition of a physician to the team has many advantages and disadvantages. If a tactical physician is utilized, proper training, continuing education, and liability coverage must be established prior to the tactical mission. The Tactical physician should be involved in the planning and execution of the mission with complete understanding of the available resources on site. It is important to disclose all of the benefits and disadvantages to the tactical physician position in order to provide the best care to the patients and while protecting the law enforcement agencies. However, many still believe adding physicians to the tactile field expose personnel to greater danger and may disrupt the law enforcement’s mission.¹

Keywords: tactical emergency medical, tactical physician, law enforcement, physician, danger, investigation, federal, bureau, enforcement, education, assets, liability, coverage, benefits, disadvantages, utilized, available, disclose, mission

TEMS, tactical emergency medical support; FBI, federal bureau of investigation; SWAT, special weapons and tactics; TCCC, tactical combat casualty care; TP, tactical physician; EP, emergency physician

The Federal Bureau of Investigation (FBI) reported in 2014, 51 law enforcement officers died from injuries in the line of duty during felonious incidents as well as 48,315 officers were assaulted while performing their duties in 2014.² Special weapons and tactics (SWAT) teams sustain injuries due to the high-risk environments at a rate of approximately 33 per 1,000 officer missions.³ The military and law enforcement agencies have realized it is important to have rapid medical care on- scene in addition the Special Forces also are accompanied with specialized medics with enhanced scope of practices for emergency medical care. Tactical Emergency Medical Support (TEMS) began as the medical support to SWAT teams in order to provide preventative, urgent, and emergent medical care during their high-risk mission.³

Tactical physician: potential and pitfalls

Tactical Emergency Medical Support units are a growing necessity for law enforcement agencies to provide injury prevention, immediate care of injuries, and medical augmentation to the success of the law enforcement operations, which are dangerous.⁴ The TEMS personnel are usually comprised of medical personnel ranging from paramedic, emergency medicine technicians, medic trained officers, and now the growing presence of physicians. The TEMS personnel are key components to the law enforcement special operations. TEMS have been utilized in hostage situations, siege, bomb threats, and in other tactical situations after police request.⁵ The tactical physicians are very important team member to initiate crucial medical care that potentially life- saving intervention in the field by skilled practitioners. This vital time is delineated, as a “Golden hour” a concept that accentuates the urgency of care required by major trauma patients to prevent unnecessary deaths or disabilities.⁶

Physician presences within the TEMS are more popular and the need is increasing, which is exceeding the current number of physician on staff with current law enforcement agencies. The role of a tactical physician (TP) has actually morphed into becoming an active member of law enforcement and vital part of the tactical emergency support. The physicians are in positions with the special weapons and tactics unit. Instead of being at a close location, informed, equipped, and ready to receive more than one casualty like in a hospital or mobile unit; the practitioner is actually suited, armed, and expected to enter directly into a hostile situation with the same combat-ready experience and mind set of the companion officers.⁷ “SWAT Doctors are health care providers who have taken the initiative, time, and training to practice Tactical Emergency Medicine. These clinicians serve as active members on Tactical units around the country, delivering emergency medical care. They are trained in evidence preservation, ballistics, hostage negotiation, explosives, firearms, combat, tactics, Nuclear, chemical and biological hazards, and battlefield medicine.⁸ The Las Vegas Metropolitan Police Department SWAT team utilizes TPs in the initial mission, briefing with the SWAT team including the schematic layout, review of the target location, and the tactical plan.⁹ During the response, the medic and physician are deployed in the tactical rescue vehicle and are required to wear body armor and await the SWAT team to clear the scene. The physician’s role is to stabilize any individual on-scene injuries or acute medical conditions, while utilizing the principles of the tactical combat casualty care (TCCC) as well as prioritizing victims depending of the level of injuries and the tactical situation. TCCC is a course, which introduces evidence, based, life saving techniques, and strategies for providing the best traumas care on the battlefield.¹⁰

The presence of a TP as part of a SWAT unit provides several benefits. As a member of a law enforcement group, this physician would be the first medical professional on the scene. The physician’s proximity to the incident gives any victims a marked advantage. By virtue of their training, this TP will be in a place that traditional emergency medical services cannot go because of the risk of harm. Another advantage the Tactical Physician brings to the SWAT unit is their unique combination of their skills and training, which is more advanced than the basic medic. These physicians are trained in the use of weapons and how to handle the situations, which a law enforcement unit would encounter.¹ Compared to SWAT officers, a typical Emergency Physician (EP) would be in grave danger if he was placed in a dangerous police situation without further training. However, the tactical officer has been equipped with training that would allow them to respond as law enforcement for the protection of themselves, suspects, victims and other officers.

In addition to skilled law enforcement training these individuals are highly qualified physicians. Their training in emergency medicine is a benefit to everyone involved. SWAT operations can result in injury to officers, suspects, or other victims. Military data suggests that 80% of those who succumb to a penetrating injury do so within 30 minutes of sustaining the wound.¹¹ As both an officer and a physician, the TP brings a unique blend of two different skill-sets which can save the lives of others. In 2008, Gildea & Janseen¹² reported approximately 48% of United States civilian tactical teams utilized physician, with 81% of the percentage of physicians responding to callouts.¹² Most physicians were utilized in non-breach entry teams and usually in a non-combat role. All of the cases reviewed 94% of the cases reported benefit due to the physician involvement.

The TP find them bound by two oaths. At first glance these oaths appear contradictory. As a law enforcement officer, they have taken the pledge to “protect and serve”. This protection and service extends to everyone involved. In a hostile situation the TP would be obligated to protect and serve other officers, the public, any victims involved and even the suspects themselves. The other oath taken is the Hippocratic Oath. This oath binds physicians to the maxim, “Primum non nocere”, first do no harm. This phrase is not actually in the oath and scholars have stated that is was not penned by Hippocrates himself.¹³ While not explicitly contained in the oath, physicians consider this maxim to embody the spirit of the Hippocratic Oath. Nonetheless, the oath of the officer and the oath of the physician can be seen as complimentary instead of contradictory. Over the years the Hippocratic Oath has been changed to meet the values, the customs of modern society, and practices. Originally the Hippocratic Oath contained bans on abortion, euthanasia and surgery all of which are now part of medicine throughout the world. It contained an introduction, swearing by pagan gods as well as a pledge to provide medical education for free. These practices are outdated and do not fit into our understanding or practice of modern medicine.¹⁴

When considering these two oaths, a reinterpretation could dissolve the contradictions between the two roles of a TP. The Hippocratic Oath has been changed to meet the values of medicine in the past and it can be changed today. If the greater good of society is served by the presence of the TP on a law enforcement team then physicians can collectively choose not to let the oath shackle them in opposition to the needs of society. The question can be raised, does the oath belong to physicians or do physicians belong to the oath? TPs minimize the harm to everyone involved thus remaining true to the spirit of both oaths.

An additional perspective on these two oaths is that they are actually a wearing of the same hat. The officer and the physician share the duties of protecting and serving those in their care. Officers may be seen as another professional holding true to the intent of “Primum non nocere”. It is unthinkable that the intention of an officer is to do harm in a tactical situation. But rather, it is understood that they are looking to mitigate any harm by using the least amount of force necessary to bring a resolution to the conflict. Equate this to the idea that many medical interventions, be they pharmaceuticals or surgery, can cause a necessary harm to the patient in order to protect the patient from greater harm in the future.

In contrast, there are several concerns regarding the role and usage of a TP. At first glance, this may seem to be an ideal situation for providing top-notch, “hands on,” highest level of medical training to our valuable members in service. Physicians have provided immeasurable service to our police officers while serving in other critical roles such as consultant, psychiatrist, counselor and advisor. The vast amounts of these physicians volunteer their time and receive no monetary compensation. A few have elected to become formally certified and sworn as police officers. However, the role of the TP is much more in depth and demanding. It requires devotion to not only the practice of medicine but increasing one’s knowledge, furthering education, and skills as military personnel; however, does acting in a civilian environment compete with physician’s medical legal pitfalls.¹⁵

Additional time to learn and master mental, emotional, and physical strengths is imperative. While a trauma surgeon or emergency department physician operates seemingly flawless in his or her surroundings of the actual operating or established emergency room, their function outside this realm is a huge inquest. This valuable person can easily move from the position of asset to distraction or liability. Duties of the TP have been fairly well defined and the significance of understanding on the part of the physician is not negotiable. They must know and understand the logistics as well as physical and psychological limitations of the team in multiple dynamic environments. This realization is critical when it actually comes to advising recommendations to command, and administering medical care in real-time, hostile situations in which the physician is physically involved. There is a need to ask the question as to why the provider is seeking the role.

Is it because he or she believes their lone talent is an invaluable, lifesaving service that cannot be provided by any other trained medical professional given the same setting and circumstances? Is it for the excitement and honor of wearing a badge, carrying a weapon- what experience past medical training, motivation and goals drive someone to seek the position? A thorough mental health assessment is mandatory. One’s personal desire or want for becoming a TP can’t overshadow the safety and interrupt organization of the thousands of those already well trained law enforcement individuals. “A medical degree does not automatically make an individual an ideal candidate to participate in law enforcement operations”.¹⁶ Members of SWAT are in impeccable physical condition, highly trained individuals with either past or current military experience. Their expectations and service have been described as beyond that of a member of conventional police officers including expert marksmen with a breadth of knowledge in combat training. Those that serve as members of the team devote countless hours finishing and honing their skills.

While either an EP or trauma surgeon have undergone rigorous years of training and practice in either acute or sub acute settings, most will admit that their fields are actively evolving and ever changing. New techniques, treatment modalities, changes in standard of care not to mention pharmacotherapies are being generated on a daily basis. Many hours are spent studying, learning and practicing skills in order to be proficient in their area of expertise. One would question whether to excel in one area, such as learning about tactical techniques, firearms, ammunition, marksmanship, policy and procedures, legal ramification, etc., would lead to a decline in either staying current or advancing in the other lifestyle or scope of practice in medicine.

The question of money or funding is an important factor as well. Given the nature of the profession, a majority of physicians may feel the need to serve in the capacity of an operational police physician out of an altruistic manner. However the task or position is not one that a single individual can assume. There must be an agreement or access and established support through the commanding staff, other professionals on the medical team, which must extend regional medical facilities and providers. This brings the question of financial burden to the table for discussion. While the physician’s monetary compensation may be little to none, the spectrum of malpractice, disability, workman’s compensation, and potential legal costs are a responsibility that must fall on someone’s shoulders. The doctor, the affiliated medical practice or the branch of law enforcement must be willing to absorb any associated liabilities.

Another area of concern regarding a TP is the liability coverage during the tactical situations. For example, who decides who is treated first the victim or the offender? If the physician makes to decision who to treat first, does he assume medical liability to the medical outcome of that patient? These questions vary from team to team and dependent on the state laws.¹⁷ The physician may be able to obtain medical liability coverage for tactile missions through his primary carrier, but he may also be covered by governmental agency that he is supporting. A TP must obtain some form of liability coverage and not assume he will be covered under the Good Samaritan Law. While Good Samaritan law can be efficacious to a certain degree, this has the legal potential to change if a physician is directly called, linked to or involved in a criminal medical emergency.¹⁸ These are just a few concerns that should be further explored. Even before the debate of TPs and their role as well as relationship with firearms, another battle has ensued. Providers have been and are currently being examined as well as scrutinized for their role in curbing gun violence. The American Academy of Pediatrics, American College of Physician, and American Medical Association are members of the Handgun Epidemic Lowering Plan.¹⁹ Indeed, if one had any reservations regarding the volatility of the topic, they need only to Google “Docs vs. Glocks.” A number of articles, opinions and information pertaining to a lawsuit can be found. A current medical legal battle is being fought, in Florida, regarding personal physicians’ place in posing questions as to whether or not a patient has a gun. One such ongoing example can be found such as that outlined in Miami Harald’s, “Stage set for major appeal in Florida’s ‘Docs vs. Glocks’ case.” An appeal has been filed and law reviewed that restricts physicians from gun ownership discussion.²⁰ This debates the act of discussion of firearms, not the personal use by the doctor. It has been seen as a means of division by involving politics with the sacred patient-physician relationship. Therefore, it should be concerning, in regards to public back lash, when a physician’s role is to be armed as he willfully enters a situation where he is expected to take a life should the opportunity present.

In Conclusion, the world has several new challenges for emergency medical response teams especially after the September 11, 2001 incident. Bombings and mass shooting are common among the headlines of world’s newspapers. Within the military, medical personnel and the Red Cross have protected people under international humanitarian law.²¹ TPs and local EMS do not share the protected person designation with their military counterparts. Therefore, most emergency medical responders cannot gain access and proximity to these embattled areas without risking injury or violence. This brings the TP, with their particular skill and training, to the forefront of this challenge during the medical response in order to provide further advanced support to the front lines to save more lives.

There are many benefits and disadvantages with regards to the inclusion of a TP into law enforcement situations. Tactical Emergency Medicine is an evolving area of emergency medicine with several fellowship programs emerging providing specialized training to Emergency medicine physicians.²² It is important to realize the differences in the basic emergency medicine training in the hospital versus tactical emergency medicine. If a TP is utilized, proper training, continuing education, and liability coverage must be established prior to the tactical mission. The TP should be involved in the planning and execution of the mission with complete understanding of the available resources on site. It is important to investigate all of the benefits and disadvantages to the TP position in order to provide the best care to the patients and while protecting law enforcement agencies. However, many still believe adding physicians to the tactile field expose personnel to greater danger and may disrupt the law enforcement’s mission.¹ Most physicians on TEMS operational team are volunteers and their time availability limit their commitments to TEMS as well4. The overall reality and safety of this role remains to be determined.²³

None.

The author declares no conflict of interest.

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