The Journal of Emergency Medicine, Vol. 46, No. 1, pp.

3845, 2014
Copyright 2014 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2013.08.022

Selected Topics:
Prehospital Care
PHYSICIAN ROLES IN TACTICAL EMERGENCY MEDICAL SUPPORT: THE FIRST
20 YEARS
Jason B. Young, MD, PHARMD,* Matthew J. Sena, MD, FACS, and Joseph M. Galante, MD, FACS*
*Department of Surgery, University of California, Davis Medical Center, Sacramento, California, and Department of Surgery, David Grant
Medical Center, Travis Air Force Base, California
Reprint Address: Joseph M. Galante, MD, FACS, Department of Surgery, Division of Trauma and Emergency Surgery, University of California,
Davis Medical Center, 2315 Stockton Boulevard, Room 3012, Sacramento, CA 95817

, KeywordsTEMS; tactical emergency medical support;

SWAT; law enforcement; tactical medics

, AbstractBackground: The benefits of Tactical Emergency Medical Support (TEMS) elements are providing
injury prevention, immediate care of injuries, and medical
augmentation of the success of dangerous law enforcement
operations. TEMS is recognized by civilian Special
Weapons and Tactics (SWAT) and various other law enforcement agencies around the country as a vital addition
to such SWAT teams. The integration of specially trained
TEMS personnel has become a key component of law enforcement special operations. Objective: Our aim was to
review the published literature to identify if there is
a role for physicians within TEMS elements with regard
to its establishment and progression, and to characterize
the level of physician-specific support provided in the tactical environment for civilian tactical law enforcement
teams. Discussion: Physician presence as part of TEMS
elements is increasing in number and popularity as the realization of the benefits provided by such physicians has become more apparent. The inclusion of physicians as active
and participating members of TEMS elements is a critical
measure to be taken for tactical law enforcement units.
Physicians provide an added level of medical expertise to
TEMS elements in rural and urban settings compared
with law enforcement personnel with medic training.
Conclusions: Physician involvement is an essential element
of a successful TEMS program. There is a need for more
physicians to become involved as TEMS personnel for specialized tactical teams to spread the time commitment and
increase their availability to tactical units on a daily
basis. 2014 Elsevier Inc.

INTRODUCTION
Law enforcement officers perform their duties with the
daily risk of serious injury or death. In 1999, forty-two
law enforcement officers were feloniously killed, and
16,285 of the 50,026 on-duty assaults of officers resulted
in personal injury, including death (1,2). Members of
Special Weapons and Tactics (SWAT) teams are at
increased risk for injury. Law enforcement activities,
such as serving high-risk warrants, hostage rescue, and
dignitary protection, are unsafe, thereby increasing the
morbidity and mortality of law enforcement officers, perpetrators, and innocent bystanders. SWAT team members
sustain an injury rate of 33 per 1000 officer missions (1).
Perpetrators are injured at a rate of 18.9 per 1000 officer
missions, and bystanders are injured at a rate of 3.2 per
1000 officer missions (3).
It is unsafe for tactically untrained emergency medical providers to issue medical care in hostile environments (1). The traditional approach of emergency
medical services (EMS) in the tactical setting, in most
circumstances, is not practical and increases the danger
to the providers (3).

RECEIVED: 30 March 2012; FINAL SUBMISSION RECEIVED: 28 February 2013;

ACCEPTED: 14 August 2013
38

Physicians as TEMS

39

Recent military medical success has highlighted the

importance of shifting conventional practices and principles, such as the ABCs of trauma, to tactical-specific
medical care, which emphasize hemorrhage control
over airway establishment. The concept of Tactical Emergency Medical Support (TEMS) has been developing for
the past 20 years. Tactical medicine is the delivery of care
to specialized military or law enforcement units under
battlefield conditions (4). TEMS is designed to fit the
distinct needs of high-risk law enforcement personnel
in the tactical setting (5). The primary goal of TEMS is
to minimize the potential for injury and illness and to provide care from the tactical field to a definitive care facility
(1). SWAT teams and various other law enforcement
teams have recognized the benefits of providing a medical
support element, which is capable of providing injury
prevention and immediate real-time care when injuries
occur, and can potentially augment the success of law enforcement operations, such as medical consultation during hostage situations (5).
One area not clearly defined is who is best suited to
provide this care. In the military model, medics or corpsmen provide the majority of care under fire. These individuals have a specific skill set to successfully treat the
injured warrior. This is not always true with civilian
EMS providers who might occasionally be required to
treat a penetrating wound or intubate a patient, but might
spend the majority of time dealing with unrelated medical
emergencies. Perhaps on the civilian side, a physician
with a more specific skill set and experience is the more
appropriate provider in a tactical environment.
Our aim was to review the published literature to identify if there is a role of physicians within TEMS elements
with regard to its establishment and progression and to
characterize the level of physician-specific support provided in the tactical environment for civilian tactical
law enforcement teams.
METHODS
We conducted a comprehensive search of the literature
with the assistance of a medical librarian using the
PubMed database for published articles during the last
20 years (January 1, 1991 to October 1, 2011). Limits included human subjects and English language. We conducted our literature search using the following key
words: Tactical Emergency Medical Support; TEMS;
SWAT; Law Enforcement; Tactical Medics; and Organic
Medical Elements. To be eligible for inclusion, articles
had to discuss TEMS in civilian law enforcement settings. We excluded advertisements and position statements. Two reviewers independently performed both
study selection and data extraction. Inter-rater reliability
was not measured. We did not assess the scientific quality

of the articles included, as all article types, except for advertisements or position statements, were used for the review if they met inclusion criteria. After analyzing each
article selected for inclusion in the review, they were classified based on physician use. The following categories
were used: physicians used as tactical medics; the suggestion of using physicians as tactical medics; or not using or
suggesting the use of physicians as tactical medics. Additionally, TEMS physician type, use of operator support
for TEMS physicians, TEMS physicians with law enforcement training, arming of TEMS physicians, and additional TEMS physician duties were collected.
RESULTS
Twenty unique citations in the PubMed database potentially relevant to the topic were identified. Of those, 18 articles met inclusion and no exclusion criteria based on the
titles and abstracts. Of the two articles that were excluded, one was a position statement and the second
was an advertisement. Of the 18 articles that met inclusion criteria, 14 were able to be retrieved in fulltext form and were reviewed for the study outcome
(Table 1). The four articles meeting inclusion criteria
that were not reviewed were unavailable from our institutions library or any available online resource. No
prospective trials were identified comparing the effectiveness of physicians vs. other providers. Twelve authors
were responsible for authoring the 14 articles. Of the 12
authors, 10 are physicians. Three of the articles discussed
physicians used as TEMS (3,6,7). Five of the articles
suggested the use of physicians as TEMS as well as
used physicians as TEMS (1,4,5,8,9). The remaining six
articles did not discuss the use of, or suggest the use of,
physicians as TEMS (1015).
Physicians of various specialties were used as TEMS
personnel, including cardiothoracic surgery, emergency
medicine, family practice, obstetrics, pediatrics, and
trauma surgery (Table 2) (1,35,8,9). SWAT operator
armed cover was provided for TEMS physicians in all
of the articles (Table 2) (1,39). Four articles noted
TEMS physicians also trained as law enforcement
officers (Table 2) (1,3,8,9). Three articles noted the use
of armed TEMS physicians (Table 2) (1,3,9). Various
additional TEMS physician duties were also discussed
in each of the eight articles, such as participation in
team training exercises, administrative duties, team
negotiator collaboration, weapons familiarization, team
health maintenance, preventive medicine, and toxicology
training (Table 2) (1,39).
The 1994 article by Heiskell and Carmona noted that
there were benefits to having knowledge and expertise
provided on scene by tactically trained physicians, especially when the nearest trauma center might be hours

40

J. B. Young et al.

Table 1. TEMS Articles Published During the Last 20 Years

First Author

Year of Publication

Type of Article

Classification*

Sztajnkrycer (13)
Metzger (7)
Gildea (8)

2010
2009
2008

Retrospective review
Case report
Descriptive study (survey)

Tang (15)
Sztajnkrycer (14)
Bozeman (6)
Ciccone (10)
Rinnert (1)

2007
2007
2005
2005
2002

Review
Descriptive study (survey)
Case report
Descriptive study
Review

Bozeman (5)

2002

Descriptive study (survey)

Lavery (4)

2000

Retrospective review

Smith (12)
Greenstone (11)
Jones (3)
Heiskell (9)

1999
1998
1996
1994

Review
Review
Descriptive study (survey)
Review

Use of physicians as TEMS not suggested

Physicians used as TEMS
Physicians used as TEMS
Suggests use of physicians as TEMS
Use of physicians as TEMS not suggested
Use of physicians as TEMS not suggested
Physicians used as TEMS
Use of physicians as TEMS not suggested
Physicians used as TEMS
Suggests use of physicians as TEMS
Physicians used as TEMS
Suggests use of physicians as TEMS
Physicians used as TEMS
Suggests use of physicians as TEMS
Use of physicians as TEMS not suggested
Use of physicians as TEMS not suggested
Physicians used as TEMS
Physicians used as TEMS
Suggests use of physicians as TEMS

TEMS = Tactical Emergency Medical Support.

* Classification: Articles classified on basis of: 1. Physicians used as TEMS; 2. Suggests use of physicians as TEMS; 3. Use of physicians
as TEMS not suggested.

away (9). The advanced medical training and skills that

these TEMS physicians possess might prove to be beneficial when the level of injuries sustained and subsequent
treatment requirements exceed paramedic protocols (9).
TEMS physicians can increase the capability, reduce liability factors, and improve public opinion of tactical
teams, as well as provide medical education, preventive
medicine, and team health management on a routine basis
(9). On-scene TEMS physicians are able to provide an expert level of medical knowledge, can provide guidance
for paramedics assigned to the team and, in the event
that injury management exceeds paramedic protocols,
the TEMS physician is readily available on scene to deliver such care rather than potentially risk mission security or delay medical care by having to call the base
station hospital (9).
Jones et al. conducted a two-page survey consisting of
20 questions focusing on the availability and training of
emergency medical support personnel by SWAT unit
commanders from the 200 largest metropolitan areas in
North America in 1995, to which 150 responded (3). Surveys received were from inner-city and suburban areas,
however, 68 SWAT teams (36%) had tactical operations
in rural or remote locations (3).
Seventy percent of those surveyed had TEMS personnel as members of their SWAT team (3). Twenty-three
percent of those surveyed did not have any type of
EMS preplan or protocol from injuries likely to occur
during tactical operations, 78% did not have medical directors (3). Of those that had medical directors, 39% were
physicians (trauma surgeon or emergency medicine physician) (3). The majority of injuries (64%) reported were

minor injuries, and 42% of the injuries reported were

deemed major injuries consisting of gunshot wounds,
chemical exposures, fractures or dislocations, explosive
injuries, and dog bites (3).
The type of medical support for SWAT operations,
from most to least common, were civilian standby ambulance at a predesignated location (tactical 911), SWAT
officer with medical training, EMS called by radio dispatch, civilian emergency medical technician (EMT)/
paramedic on tactical team, fire department medic on tactical team, physician on tactical team, and air ambulance
(3,4). The majority of the standby ambulance personnel
had received no prior specialized tactical medical
training and were not allowed to enter an area until
tactically secured (3). This type of medical support was
recognized as a potential for jeopardizing security (3).
Many of the police officers are trained at the level of
American Red Cross First Aid and cardiopulmonary resuscitation (3). Problems that can occur with this model
of tactical medical care is the personnels time away
from their law enforcement duties in order to train and
maintain emergency medical skills, and the reduction of
law enforcement capabilities should one member of the
tactical team need to treat an injured officer (4).
A few of the recommendations from the SWAT unit
commanders who completed the survey regarding ways
to improve the EMS response during tactical operations
consisted of physicians assisting teams on high-risk
incidents and local physicians to assist with medical
training (3).
The Newark Model was touted by Lavery et al. in
2000, with tactical medical personnel operating under

First Author

Type of TEMS Physician

Operator Support
for TEMS Physician

TEMS Physician Law

Enforcement Trained

TEMS Physician
Armed/Unarmed

Metzger, 2009 (7)

Not available

Yes

No

Unarmed

Gildea, 2008 (8)

Yes

Yes and no

Not available

Bozeman, 2005 (6)

Cardiothoracic surgery; emergency

medicine; family practice; obstetrics;
pediatrics; trauma surgery
Not available

Yes

No

Unarmed

Rinnert, 2002 (1)

Various specialties NOS

Yes

Yes and no

Armed and Unarmed

Bozeman, 2002 (5)

Various specialties NOS

Yes

No

Unarmed

Lavery, 2000 (4)

Trauma surgery

Yes

No

Unarmed

Jones, 1996 (3)

Emergency medicine; trauma Surgery

Yes

Yes and no

Armed and unarmed

Heiskell, 1994 (9)

Various specialties NOS

Yes

Yes and no

Armed and unarmed

Additional TEMS Physician Duties

Physicians as TEMS

Table 2. Discussed Role of Physician as TEMS Personnel (Articles Published During the Last 20 Years)

Participation in team training exercises;

provide care for team, suspects,
hostages, and bystanders; team
health maintenance; disease
prevention
Participation in team training exercises;
team health maintenance
General health maintenance; sports
medicine; preventive medicine;
occupational medicine
Team health maintenance; pre-emptive
reconnaissance of environmental and
situational aspects of tactical mission;
coordination of operation with local
EMS agencies and medical facilities;
evaluation and care of officers, civilian
bystanders, and perpetrators;
weapons familiarization
Team health maintenance; preventive
medicine; sports medicine; toxicology
Team health maintenance; administrative
duties such as acting coordinators
between hospital, law enforcement,
and state department of health
bureaucracies; collaborate with team
negotiators; mediation of medical
jurisdiction disputes; participation in
team training exercises; weapons
familiarization
Participation in team training exercises;
weapons familiarization; evaluation
and care of officers, hostages, victims,
and bystanders; tactical medical
preplanning; toxicology training
Tactical medical preplanning; toxicology
training; team health maintenance;
preventive medicine; participation in
team training exercises

EMS = emergency medical services; NOS = not otherwise specified; TEMS = tactical emergency medical support.

41

42

the support of a Memorandum of Understanding implemented between the Federal Bureau of Investigation
and the University Hospital of the University of Medicine
& Dentistry of New Jersey (4). The TEMS team is composed of paramedics, nurses, and physicians with EMS/
field experience (4). Lavery et al. identified physicianspecific tasks as assessment of special medical needs in
the field; expertise in coordinating efforts with multiple
institutions such as hospitals, law enforcement agencies,
and state department of health bureaucracies; expertise in
dealing with the potential for mass casualties; ability to
advise team negotiators who might be dealing with sick
or injured hostages; expertise in mediating medical territorial disputes; and the ability to provide daily medical
supervision of law enforcement personnel during extended field operations (4,16).
Bozeman and Eastman conducted a survey in which
physician participants were asked to measure their
baseline knowledge (SWAT team tactics, equipment,
operations, special medical needs, forensic examination, evidence protection, and medical threat assessments) and comfort levels (directing paramedics and
providing patient care in the tactical setting) in six areas
related to TEMS before the start of the 8-h course, and
again were retested at the completion of the course and
at 4 months from the time the course was taken (5). Providers had significant increases in their knowledge of
tactical medicine during and up to 4 months after the
course.
Gildea and Janssen developed a survey in which
SWAT team leaders, operators, and medical support personnel were asked to address the inclusion and utilization
of physicians on tactical teams, as well as comment on the
pattern of injuries sustained by members of tactical teams
both during call outs and training (8).
Of the 209 completed surveys accumulated, 199 were
analyzed, of which 63 responses were from team leaders,
26 from operators, and 110 from medical support personnel (8). According to Gildea and Janssen, there has been
a noticeable increase with regard to utilization of physicians in tactical teams based on previous survey responses (8,17). Nine percent of tactical teams surveyed
had a physician on their team in the mid-1990s vs. 48%
in 2005 (8,17). In each of these surveys, physician
involvement with tactical teams was seen as beneficial
(8,17).
Based on survey responses by tactical team leaders,
operators, and medical support personnel, physician
TEMS providers are regarded as members who add
a higher level of care, know the team members medical
history, bring a different situational awareness, provide
a psychological benefit, increase peace of mind for officers and their spouses, and impact the overall health
and fitness of the team (8).

J. B. Young et al.

DISCUSSION
Law enforcement officers and special operations teams
(SWAT) are placed in dangerous situations on a routine
basis. Such unsafe scenarios increase the morbidity and
mortality of law enforcement officers, perpetrators, and
innocent bystanders (1). These environments are especially unsafe for untrained emergency medical providers
to deliver tactical medical care.
Tactical medicine is a new skill set with nationwide
application in prehospital care (3). This has emerged
from the militarys Tactical Combat Casualty Care
(TCCC or T-Triple C) model. The United States (US)
Navy SEAL teams led the way for the development of
TEMS by training medics for the unique and extremely
dangerous environment of special operations (8).
TCCC is a set of guidelines developed by the US Special
Operations Command, which seeks to customize the
principles of sound trauma care for successful use on
the battlefield. Butler et al. published the original article
describing TCCC in special operations in Military Medicine in 1996 (18). This work was the product of extensive research conducted by the authors that was, in
part, prompted by the events that occurred in Mogadishu,
Somalia in October of 1993. The TCCC guidelines
describe three phases of combat mission care: 1) care
under fire; 2) tactical field care; and 3) combat casualty
evacuation care. The TCCC guidelines have strived to
emphasize airway management, breathing, bleeding,
intravenous access, fluid resuscitation, wound inspection
and dressing, analgesia, splinting, vitals assessment, antibiotic therapy, and CPR. The TCCC guidelines are endorsed by the American College of Surgeons and the
National Association of Emergency Medical Technicians. TCCC guidelines are structured to accomplish
three primary goals: 1) treat the casualty/save preventable deaths; 2) prevent additional casualties; and 3) complete the mission. The three most common preventable
combat death scenarios, taken and extrapolated from
Vietnam War data, are extremity hemorrhage (60%), tension pneumothorax (33%), and airway obstruction (6%).
These tenets are practiced by individuals who are focused on tactical medicine full time. The scope of practice of the military medic, especially in combat, is very
different from the civilian paramedic.
SWAT teams injuries, from low to high acuity, happen
during call outs as well as training, which indicates the
need for specially trained TEMS to attend to the needs
of tactical personnel, not only in the hostile environment
of call outs, but also during training conditions (8). In the
Gildea and Janssen article, survey responses from tactical
team leaders, operators, and medical support personnel
regarded physician TEMS providers as being able to
add a higher level of care to the tactical team as well as

Physicians as TEMS

positively impact the overall health and fitness of the

team (8).
Tactically trained physicians as specialized TEMS
personnel are reported to be used more frequently in
law enforcement special operations (7). With specialized
TEMS physicians integrated into the SWAT team being
positioned a short distance away from the site of entry,
critical, time-dependent interventions can be performed
rapidly and in close position to the casualty location,
far within the outer perimeter established by law enforcement (7). Such close proximity entries would not occur
with traditional EMS responses if the scene remained unsecured (7). Rapid, on scene interventions might be required in high-risk situations, as certain injuries are
immediately life threatening if not identified and treated
within the first few minutes after the injury has occurred
(7). In the Jones et al. article, SWAT commanders recommended deploying trained physicians as TEMS personnel
to assist teams on high-risk situations (3). Under the Newark Model, physicians operating as TEMS personnel are
regarded as highly essential members of the tactical
team, as they provide expertise in many areas, such as
providing medical care in the tactical field and being adequately positioned to assist with crucial administrative
requirements of successful tactical operations, such as
mission preplanning, coordinating with multiple institutions, and consulting with and advising other team members from safe areas (4).
Physicians act as team members, but they cannot act as
sole providers. The optimal TEMS set up would involve
TCCC-trained SWAT operators with one EMT or paramedic operator as part of the stack. This medic would
be supported by a TEMS-trained physician who was located at a safe area.
One limitation of this review is that 10 of the 12 authors who wrote the articles discussed here are physicians. This might introduce an element of bias, as
physicians authoring these articles might be more inclined to suggest using tactically trained physician personnel rather than nonphysician personnel as TEMS
providers, arguing that they might be more experienced,
beneficial, and appropriate in tactical situations that require medical support. There were no articles identified
that compared patient outcomes between physician vs.
nonphysician providers.
CONCLUSIONS
Although tactical medical support is not a novel concept,
physicians as part of TEMS programs are increasing in
number as well as popularity as the realization of the benefits provided have become more apparent (8).
Trauma and emergency physicians are in the position
to offer great expertise to the tactical unit when trained in

43

tactical medicine. For example, the scoop and run theory will not suffice when a tactical operation involves
a clandestine drug laboratory in a rural or remote location, such as desert or mountainous terrain, with the nearest trauma center hours away (9). Advanced life support
might be required on scene despite the availability of
aeromedical evacuation capabilities (9). The on scene
specialized TEMS physician has a clear understanding
of the risks and benefits of the overall tactical operation,
is readily available in the event that complications of injuries exceed paramedic protocols, and can foresee risks
incurred with prolonged operations or those occurring
during severe weather conditions, which can ultimately
place the team members and the entire operation as
a whole at risk (9). The TEMS physician is in a unique
position to advise unit commanders and team leaders of
such risks (9).
Physicians have a well-honed skill set that allows them
to deliver a high level of care, even in the tactical environment. This added skill set can augment operator and
EMT-driven TCCC and will take law enforcement tactical medicine to the next level.
AcknowledgmentsThe authors would like to acknowledge all
federal and local law enforcement officers who, without hesitation, place their lives on the line on a daily basis in order to ensure the safety and peace of societys citizens.

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Physicians as TEMS

45

ARTICLE SUMMARY
1. Why is this topic important?
The topic of physicians as tactical emergency medical
support (TEMS) personnel is important because, although
TEMS is not a novel concept, the presence of physicians
as part of TEMS programs is increasing in numbers as
well as popularity as the realization of the benefits provided have become more apparent. The benefits of
TEMS elements, which are capable of providing injury
prevention, immediate real-time care when injuries occur,
and augmenting the success of highly dangerous law enforcement operations, has become increasingly recognized by civilian Special Weapons and Tactics (SWAT)
and various other law enforcement agencies around the
country as vital additions to such tactical teams.
2. What does this review attempt to show?
This review attempts to show that physician involvement is an essential element of any successful TEMS program. We describe the roles of physicians within TEMS
elements with regard to its establishment and progression,
and identify the level of medical support provided in the
tactical environment for civilian tactical law enforcement
teams.
3. What are the key findings?
The key findings of this review are that trauma and
emergency physicians are in the position to offer great expertise to the tactical unit when trained as specialized
TEMS personnel. The on-scene specialized TEMS physician has a clear understanding of the risks and benefits of
the overall tactical operation, is readily available in the
event that complications of injuries exceed paramedic
protocols, and can foresee risks incurred with prolonged
operations or those occurring during severe weather conditions, which can ultimately place the team members and
the entire operation as a whole at risk. The optimal TEMS
set up would involve Tactical Combat Casualty Care
(TCCC) trained SWAT operators with one emergency
medical technician or paramedic operator as part of the
team. This medic would be supported by a TEMStrained physician who was located at a safe area.
4. How is patient care impacted?
Patient care is impacted by this review because tactically trained physicians can provide a significant benefit
to TEMS elements in rural and regional settings compared
with TEMS personnel with basic medic training. Physicians have a well-honed skill set that allows them to
deliver a high level of care even in the tactical environment. This added skill set can augment operator- and
EMT-driven TCCC and will bring civilian law enforcement tactical medicine to the next level.