Resident Involvement in Civilian Tactical Emergency Medicine

Mario Luis Ramirez, MD, MPP; Corey M. Slovis, MD, FACEP, FAAEM


J Emerg Med. 2010;39(1):49-56. 

In This Article

Abstract and Introduction


Background: Tactical emergency medicine services (TEMS) has emerged as a specialized niche within the field of emergency medicine. With increasing demand for physician participation in civilian tactical teams, there will be efforts by residents to become involved at earlier points in their clinical training. Objectives: This article discusses resident involvement with a civilian TEMS unit and provides five maxims for emergency physicians to better understand the difference between working in the emergency department or with emergency medical services vs. in a TEMS environment. Discussion: Differences between TEMS and other trauma life support models, institutional and political barriers likely to be encountered by the resident, the value of preventive medicine and the role of the physician in long-term tactical operations, opportunities for subspecialty growth, and the role of operational security are all discussed in detail. Conclusion: Tactical emergency medicine is a specialty that utilizes the full array of the emergency physician's skill set. It is also a field that is ripe for continued expansion, but the resident looking to become involved with a team should be aware of the requirements necessary to do so and the obstacles likely to be encountered along the way.


Interest in prehospital care research continues to grow within emergency medicine (EM), and the operational boundaries of its providers are continually being pushed further outward. Indeed, for many of us in the field, potential involvement in this earliest phase of care—with television images of lifesaving in-field cardiac defibrillations, racing ambulances, and medical helicopter evacuations in our minds—was one of the most alluring calls to join the ranks of emergency physicians, with the goal that we too would practice the best medicine "anywhere, anytime."

As the number of training programs in emergency medicine has grown, so too has the number of subspecialty areas within the field. One such niche is tactical emergency medicine services (TEMS), herein defined as the provision of emergency medical support to civilian law Special Weapons and Tactics (SWAT) and military special operations units. Importantly, this care encompasses not only that provided while under active fire, but also includes the preventive and primary care that takes place before combat ever begins. One study showed that among SWAT teams specifically, there were approximately 1.8 officer casualties, 18.9 injured perpetrators, and 3.2 injured bystanders per 1000 officer missions.[1] These statistics indicate a need for close medical support when these types of inherently dangerous operations are taking place.

Traditionally, the involvement of physicians in this area of medicine, and especially in the training for such participation, has come at the fellow or attending level. Currently, some emergency medical services (EMS) and occupational medicine fellowships include involvement with a TEMS team as an option for those interested. But, as former tactical medic and Surgeon General Richard Carmona pointed out, tactical medicine is a field that is likely to grow over the next few decades, and as that expansion occurs, it is likely that residents will try to become increasingly involved at earlier points in their postgraduate training.[2] A recent study by Bozeman et al. illustrates this point by showing that approximately 18% of U.S. emergency medicine residency programs now include some exposure to tactical medicine as part of their curriculum.[3] As such, this expert opinion article describes five maxims derived from one emergency medicine resident's experience with civilian tactical medical care. It is neither a clinical study nor a structured literature review, but rather an opinion piece intended to help emergency medicine residents and emergency physicians better understand the difference between conventional prehospital and inpatient emergency medicine and that of tactical emergency medicine.


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