Advancing the Field of Tactical Medicine

[Moderator] All right. Well, good evening. We'd like to welcome everybody from our capital medicine section to a very special presentation. We're gonna have a webinar, educational. We're very blessed to have two outstanding emergency physicians who are basically been doing a whole lot of work in the field of tact medicine. We're gonna look really learn a lot from them tonight. Very blessed to have them with us tonight. We're gonna have Dr. Nelson Tang and Dr. Bill Bozeman, and we're gonna do is have them pretty much introduce themselves. We'll talk briefly about 'em in a second, and we're gonna talk about in a little over an hour. We have a chance for questions. If anybody has any particular topics, you'd like to, for sure, bring up for discussion later on, be sure and type it in, Dr. Brian Springer, the chair-elect is going to keep track of those and we'll look forward discussing things at the end there, too. So a couple of business keeping items here, I'd like to do is, is just go through a couple things need to know about the presentation. It could be good for one hour of CME. So the way that works, you need to check in your chat box, that there is a CME required form, that this is the written verbal notice we have to present everyone. It's a disclosure to learners that would listen to interest conflicts, any possible corporate sponsors with their newer corporate sponsors for this presentation. Some housekeeping rules, otherwise too, if you're not speaking, please keep your microphone on mute that way we keep the background noise to a minimum. If you have a question, you can raise your hand by clicking the button down there on your screen there. Throughout the Zoom options or you can actually type in your question in the chat box and Dr. Springer will monitor that and talk about later. So the other thing is if you wish to claim CME hours, make sure that Deanna knows by email from the chat box that you've attended. She'll keep track of most of you. And if she has a question, some people may show up just with their phone number, then she'll need to know exactly who you are to give credit for that. So, anyway, Deanna's email is on her website. It's also, I give it to you here, it's dharper@acep.org, so, dharper@acep.org. Need your complete name, email, and ACEP number. Now we keep track of that and get proper credit for the presentation. So if there's no further questions right now, we'll go ahead and get started. I'd like to introduce Dr. Nelson Tang, who is basically a very involved physician with many of the federal agencies, and he has done his training at Johns Hopkins. He's actually worked extensively getting a lot of the training programs going there, including the tactical medicine fellowship and multiple other programs there, too. And Dr. Tang will be talking more extensively about that and how he got into it. One of the advantages of having Dr. Bozeman and Dr. Tang talk about how they got into what they developed is in this chat group, as well as the future physicians who watch this video recording, it's gonna be important for the newer doc to figure out, "Hey, how'd they get into it?" What are some ways I can get into it in my region and my particular niche of the world. And is this a good lessons learned from these two gentlemen. So Dr. Bill Bozeman is a professor and he's director of pre-hospital research there at Wake Forest University. That's in Winston-Salem, North Carolina, and he's been doing that 20 plus years there. And he actually was down in Jacksonville, Florida before that. And he's been instrumental in getting a lot of the training programs going there. And he'll tell you about the programs. Some other things he's been involved with. So that's about it for now. The gentlemen's got a lot to talk about. I'm gonna pass it to them. Dr. Tang, Dr. Bozeman. Thank you again for being here tonight and we're looking forward to your presentation. Thank you.

[Tang] All right. Well, thank you, John. And thank you to everyone in the section for just spending a little time with us. When John first reached out and invited myself to participate in this session you know, those who know John is he's very gregarious and super complimentary and said, "You know, just get on for an hour with Bill and share everything you know about tactical medicine and how you got where you are." So I'll do my best to stumble along and share little pearls along the way. This is also a pretty special night for me. I've been waiting to share this with the group . Bill, Dr. Bozeman, was actually my chief resident at Hopkins when I showed up on day one as an intern. And so, Bill for my three years of tormenting you, I'll owe you forever, but it's really special to me that you and I have both wound up in this space. And I think doing important things and contributing to a bigger cause, I think. So, John, I think as far as disclosures, I have nothing proprietary to report to the group. I think the part of the request was just to share how each of Bill and I got to where we are today. And I will tell you, there was really no roadmap, kind of things happened along the way. And certainly some opportunities presented themselves and some through a lot of hard work and grinding away, we made for ourselves, I think. By way of background, we can go to the next slide, John, by way of background, I am emergency medicine trained. I did my residency at John Hopkins and I still practice clinically at the main hospital in Baltimore, Johns Hopkins Hospital. Currently I'm the vice chair for operational medicine. And that broadly oversees really just a tremendous amount. Bill, if you think back when we were at Hopkins, just how much pre-hospital involvement we had. and I say that tongue in cheek, we as a program, we had very little exposure, very little connectivity to the local and regional EMS system. And now we have a huge footprint in the area. We have medical oversight for a number of EMS jurisdictions in the state. We have one of, if not the largest critical care transport program, air and ground, in Maryland, and certainly quite a number of tactical medicine programs, the EMS and tactical medicine fellowships fall under my broad oversight. A very talented faculty. We have wonderful trainees. Dr. Caitlin Hack is on the call tonight. She's our current EMS fellow, so Kate, thanks for joining us.

[Bozeman] If I can go ahead and interrupt and get this thing started off right. All of those things that Nelson just shared are largely due to Nelson Tang, just so everyone knows, he won't mention that, but it is largely due to his vision and his leadership that whole program has grown. And it's so nice to see that it did.

[Tang] Well, thank you, Bill, I've had a lot of help along the way, and been fortunate to just keep company with talented and smart people. So thank you though. I grew up in New York and New York City, and really there were very, very few opportunities to volunteer or become involved in any sort of prehospital medicine, operational medicine. And so, as my residency was completing, I sort of grabbed every opportunity to get involved and get hands on and just really learn about everything prehospital. I became the disaster control physician for the hospital. I took on the role. Thankfully there was an opening, but I took on the role of medical director for our hospital based transport program. And then I really think it was pretty close to my first year as an attending, I went to a meeting of the international tactical EMS association. ITEMS, which was run, is run by Jim Edson. I forget where it was, somewhere out West, meeting might have been a little bit of an overstatement, a relatively small gathering in a hotel ballroom, met some wonderful people, doing great stuff that I had no idea was even potentially an area of practice and met Rich Carmona, who to this day, I still count as a role model, just an overwhelmingly talented and impressive person. And I came back to Baltimore from that meeting and, Bill, I presented this to Jim Schulman and said, we really need to build a tactical medicine program. And Jim is a very, is our chief administrative officer and was very and said, well, that's very interesting to definitely look into that, then promptly shooed me out of the office.

[Bozeman] But come back when you have some grants.

[Tang] Well, if only that, I think it was more, we have no idea what you're talking about. No idea how, how our institution would fit into this and not to prolong the story any bit, but the Secret Service has its its training center in Maryland and came to us in 1999 and said, we need some help. We wanna build an EMS jurisdiction here in Maryland, and we need an EMS medical director. And Jim said, well, have I got the guy for you. And really that's where I sort of cut my teeth in terms of law enforcement and so, and building a medical support program. And then we just, slowly added on to that. DHS came to us in 2004 and then 2007, ATF, the Marshall service and Maryland State Police all knocked on our door and said, hey, we want a part of what you're building. And so today we have a center for law enforcement medicine. It's very intentionally not named tactical medicine because at least at the level of services that we provide, it really is beyond the warrant service work., that's critically important, but it is really building a comprehensive medical program, operation medicine program to support all aspects and all phases of law enforcement operations. And it keeps us very busy. We've had the opportunity to work with just really wonderful people. I'm one of those people who I'm not very techy, but I really like to see and learn how things work behind the scenes. So having had the opportunity to travel the world with fairly elite groups behind the scenes at national special security events, really is the kind of thing that just makes me smile at the end of a long day and my colleagues and I, we joke 'cause even at this, to this day, you drag yourself home at four o'clock in the morning, you're sweaty, you're dehydrated, your truck is at disarray and you just kind of chuckle at it, say, boy, that was a cool day. That was really neat. Hadn't done that before. And I think probably hopefully that resonates with just about everybody, if not everybody on this call tonight. This is the stuff that makes us happy, helping others in this way is just our little contribution, I think, to the world. And so I've been very privileged. I'm thankful to be able to spend this evening with you all and I'll end there and hopefully will we'll have better conversation along the way. Bill, it's all you.

[Bozeman] All right. Well, that's gonna be hard to follow up on. That was a beautifully articulated story, seriously. And what you said at the end definitely resonates with me and I know it does with all the people on the call. It's really an honor to do this. It's not, it's maybe a calling, it's maybe a personal thing, but it's really my honor to be involved in this sort of thing. Alright, but to get back to the slides. So I didn't grow up in New York City, I grew up in Pensacola, Florida, and I did my emergency medicine residency up in Baltimore at Johns Hopkins, as Nelson mentioned, I was a chief there when he first got there. And he's got a funny story about an intubation. I've got a funny story about, do you remember Chaz Shoenfeld, the attending out at Bayview? Well, Chaz smoked like a smoke stack and he was out on the deck smoking a cigarette and his buddy, a friend of his was in as a patient and we cut off an endotracheal tube and put it in his mouth. And when Chaz walked back in, I was pretending to bag the guy, but anyway, shenanigans. I did my emergency medicine at Hopkins and I do have a little bit of a push the envelope flavor to my career, which has opened up some doors. I had a fantastic time at shock trauma, which is for those who don't know, that is a freestanding trauma only hospital also in Baltimore affiliated with the University of Maryland. And it was founded by the famous R Adams Cowley, who was instrumental in coining the phrase "the golden hour" and all this. That's a rich surgical history, but the intergalactic shock trauma center is a well known place, so I had a fantastic time there. I decided at the end of my residency that I wanted to do a trauma fellowship and such a thing did not exist. But one of the things that we are somehow gets ingrained into us at Hopkins is, well, if it doesn't, but it should, go make it happen. And so I approached the people at Shock Trauma and at University of Maryland and designed this fellowship, which to my great pleasure is still going to this day. They take two or four emergency medicine trauma fellows a year, I think. I think generally it's just one or two, but I did. I was the first of the trauma fellows in the modern iteration. They did have emergency medicine intensivist fellowships, but this was the first one to focus on trauma resuscitation as well as critical care. As part of that, I went over to a little place called Bosnia, while they were having a bit of a spat over there, got a little bit of a taste of some military medicine, some heavy duty trauma things, a mass casually event was a, it was a nightly event over there, not every night, but good many so that I somehow folded, I still dunno how I did it. I think Dr. David Brachs was involved, as Nelson will remember one of our other famous colleagues, but having done a trauma and critical care fellowship, as well as my emergency medicine. One of the things that really I thought was cool were the Maryland State Police helicopters. They flew these great Dauphins around, but the Maryland EMS or helicopter EMS system has a dual mission. And any given mission for that aircraft and crew may be a law enforcement mission, or it may be a medical mission. So all of the paramedics bringing us patients into shock trauma in their cool little Maryland state police jumpsuits in their cool helicopters, they all had a shoulder holster with a firearm in it. And they were all dual-role medics, as well as law enforcement. And I thought that was pretty cool. So all of this is kind of percolating around and I wasn't aware of any tactical medicine opportunities. I guess I was maybe somewhat aware of its existence, but I went from Maryland down to Jacksonville, Florida and took a faculty position there. And that was I suppose, '96 or so, so mid to late nineties. And one of the things that I started getting involved with there was the Jacksonville Sheriff's Office. It's actually a large police department that encompasses the police for the city and the sheriff for the county. And I started kind of hanging out with their SWAT team a little bit, and I knew that the CONTOMS program, the counter narcotics and terrorist operations medical support, which is a federal thing, and it's still going and it's still an outstanding program. I got some great people with it. They had a one day medical director course, and I thought that would be a fun thing to do. And I got a grant from the American Body Armor people who had a factory in Jacksonville to pay for the CONTOMS folks to come down and give it to us as a one day training course. And of course I had to involve the local SWAT team, 'cause we needed all the gear and their toys and all. So that's really kind of cemented the relationship with that SWAT team and our tactical medicine program grew from there in Jacksonville. After about five or six years there, the other fun thing I did there was the NASA space shuttle program. So I got to run around SWAT teams as well as NASA would come and pick us up in a NASA airplane for every shuttle launch and landing, they would stop by Gainesville and pick up a few, stop by Jacksonville, pick up a few docs. And so we'd have four docs for every launch and every landing of the space shuttle. And that was a fun program to be involved in, too. So a common theme with my career has been, wow, I can't believe they pay me to do this stuff. This is great. But kinda like Nelson said, it's the ability to interact with and support and play some small role in these operators and what they're doing and what they're doing, you know, the good in the world is a big deal. From Jacksonville, I moved up to Winston-Salem to Wake Forest, which is a wonderful place to be and to have an academic career. Along with me, I brought some funding, which I think was key in my personal story and development, because I had gotten some funding from the National Institute of Justice to do some taser related studies. That was during the time where there was a big thing about taking tasers away, they're killing people. And I somehow talked the NIJ into the idea of funding me to do some medical research because I had an inside track with these police departments using tasers. And that was a neat sort of mesh between the research part of me and the tactical part of me. But the key thing was that they actually gave me a grant that went with me up to Wake Forest and kind of like Jim Schulman kind of didn't know what to do with that idea when you first went to him, Nelson. When I came up to Wake Forest, they had no idea. They kind of knew there were some doctors who liked to run around with ambulances, but I was able to tell the chairman at the time that this is an important part of what I do. And if you want me to come up with this research money, I'm gonna have to be able to do the research and to do that I need to have a tactical medicine sort of program going on. So somehow the stars aligned and they let me do that. Since then, our tactical medicine program has grown. We support three SWAT teams and a bomb squad locally, as well as some other things. But that's kind of the story of my pathway into it rather than Nelson had people come knocking on his door and was able to turn those into this wonderful program that he's got going. I kind of went at it from a different pathway and was able to make an argument for having some tactical medicine program because I had a grant because I need to do this research. And that's kind of how I got my foot in the door and started doing things. Let's see my academic appointments are, I'm a professor of emergency medicine. I'm the director of pre-hospital research. And like all of us, I've got a whole bunch of other hats that I wear. I just told you about some of the key professional experiences, kind of the pathway. So currently our tactical medicine roles and positions, we do have our tactical medic program. I'm the medical director for that program. We have a tactical medicine elective for residents and the occasional medical student. We have a tactical medicine fellowship. We're currently having our second fellow who I believe is on the line. Hey Chris, let's see.

[Man] Hold on.

[Bozeman] So Chris Rider is our current tactical medicine fellow. He's about to finish up and get sworn and join his home agency. We're also, we've recently gotten a new little gig and we'll be providing the tactical medic courses for the DEA. So a little bit of nudging into the federal space to play in the same box as Nelson. So that's kind of the background story on me. I know we've got other things to talk about, so maybe we should keep it going. I think we're about on time, aren't we?

[Wipflier] Yeah, we're right on time. This is excellent information. And thank you very much for summarizing some brilliant careers there. I tell you there's a lot of the things we do. We do a complete detail on both of you take about two or three hours, we'll move on to some exciting stuff, too, in addition. So thank you for the intros. Excellent.

[Tang] Bill, kudos, by the way, I know you're being humble, but that DEA program is huge. And I know they are very happy to have your support, so good job on that.

[Bozeman] Well, thank you. We're excited to do it. It's really shaping up to be a good program.

[Tang] Yep. So I'll take the helm for the next section. There's a lot of tabs there and I don't know that I have discreet, bulletized, take home points for all this, but we'll work through some of this together and certainly if there are questions, John, you, or Deanna, or Brian, maybe are tracking questions. So hopefully, we won't miss anything. One of the things that continues to occur to me is that even though, obviously we're all in this group and other organizations, where we're very like-minded, I think, in our interest, in the craft of tactical medicine, I think TEMS as a whole is still somewhat of a, it's two things, I still think it's very much a grassroots type initiative. I think it's sustained at this moment in time nationally by hardworking, talented, and very motivated individuals. Having said that, I still think it's a heterogeneous line of work. I think what Bill described his career experience and what he does currently in the field is probably very different or reasonably different than what I do and what our, my colleagues here do. It doesn't make any of it less worthy. It just means that I don't think there's one cookie cutter, like this is the way you build a tactical medicine program. If you listen to sort of my background and Bill's background, there there's a fair amount of opportunism that has occurred and not in a negative way. It just means being vigilant for potential opportunities. And when we've, I think, identified one, just both feet in, jumped in and tried to make the most of it. The first thing I have says MOU versus contract. And historically those are the two big categories of written agreements, I think, between a law enforcement organization, agency department and at least the physician level engagement. I am also aware that there's probably another fairly sizable group of folks that are working with departments and agencies without a written agreement. I actually just, we just came back in a large group from the Soma meeting and I met up with one of our former tactical medicine fellows, who has started working with a municipal police department in a tactical physician capacity. Doesn't yet have any written agreement yet, delineating his responsibilities and the agency's responsibilities to him. And so perhaps the big umbrella comments here fall in the category of it really, I think we're probably beyond the point as a group of just these informal relationships. Not that they're not valuable, not that sometimes we have the opportunity to provide mutual aid support for other entities, but I think if involvement is going to be meaningful, organized and sustained, at the end of the day, this still is still a high risk engagement, both in terms of the physical threats to us as a group, but also just workplace injuries, someone throws a back out, someone breaks an ankle, supporting an agency, who is responsible for us when that happens? And it's not always clear, like we, there is a lot of feel good energy when I think we work with agencies that like having us out and we like working with them. But when something unexpected happens with potentially some liability and some risk, all of a sudden, there's lots of hands in pockets and shoulder shrugging and "I don't know." So I think probably the most important thing here is that, you know, I think it's on us. I think we have some responsibility here to build the collective awareness and understanding of how to craft MOUs and I throw myself in as guilty. I didn't have a lot of advice for our former grad in terms of, "Well, here's a template MOU for you to use and bring to your department." And so I think there's still some work to be done. Contracts are great. I have no doubt that our program would not have progressed as quickly as it did without the availability of contractual funding. My chair, my direct report does not manage our program. It's a high five in the hallway, "Everything good?" "Everything's good, sir." And we move on and that independence in an academic center and very much it'll surprise you. It hasn't changed much. We're still very much an ivory tower medical institution. The fact that we can do what we do is because we are self-funded, the department incurs no expense in us training our trainees, in hiring our providers and our faculty level work. So I guess that's sort of our other category. I am also aware that if one's individual practice setting is a smaller community, a local department, or even a state level agency, the limitations are what they are. I don't think, I'm not suggesting that the first conversation is introducing oneself and saying, "I need to be paid to help you out." Having said that, I think many on this call probably have been doing strong work and supporting meaningfully their respective departments and agencies for some time. I would suggest keep moving that bar or that line forward. I think it's probably great that individuals are willing to volunteer their time and resources to support the teams that they work with, but I'm not sure and this isn't like me all knowing, this is just, I'm not sure we're doing like the, our colleagues and the practice of tactical medicine a favor by continuing to volunteer our services. I think that once relationships are established, communications are strong, I think there are ways for departments and us physicians to collaborate, let's work together. Let's look to identify some funding that can offset some professional time so that you guys who are doing this are not working a full complement of shifts and doing all your hospital related work, and then working with their teams on the evenings and weekends and holidays and so forth. So I'm not sure I've articulated that particularly well, but I think continuing to advocate for appropriately funded physician support of agencies and departments and teams is something we should maintain a priority. I've spent probably the better part of my academic career in the federal acquisition arena. I'm fairly well versed in navigating government procurement. The dent on my head is from spending as much time as I do dealing with procurement officers who are really, really, really a special breed of individual. They are the actual gatekeepers for the operations of the government. And so much as a medical program and us can come to an agreement as to costs and funding and statements of work, we mutually, we have to get past the procurement officers who operate sort of above the law, who have speak their own language, establish their own requirements. And it is a perpetual challenge to navigate the procurement process. Every one of our contracts has a very, very discreet statement of work that delineates our responsibilities to the agency, as well as their responsibilities to us. These are over time, we've had the ability to contribute and hone these and make them fairly appropriate documents. But in the early days, when presented with contracts and statements of work, incredibly obtuse documents, no real idea of what they were talking about or what our responsibilities were. We didn't walk away though. The right thing to do was to say, sure, we'll do all of that, whatever that is. And over time helped the agency understand the actual best way for us to help them. Deliverables, you know, there are longitudinal ones, right? So our center, we maintain a 24/7 call center, which is also the dispatch center for our critical care transport team. So it was already in existence. We just kinda tailored it to our needs, but we maintain a call center. We deliver protocol, written protocols to all our agencies about once a year. Sometimes I can stretch that a little bit for most of the groups that we work with, the agencies we work with, we do all of our national registry EMT and paramedic refresher training in house. And this has been a key way for us to remain very closely tethered to the agencies we work with. So we are, this is, our programs are very different than a local or a geographically centered department. This is not your volunteer fire squad. I don't see these providers on a day in and day out basis. We don't have cookouts together. I don't have that opportunity, would love it, but I don't have it. And so the only way to one, I think, ensure that their continuing education is, I won't say appropriate, but I think, directed towards the work that they're actually being asked to do, to make clear the medical direction, expectations for their performance in the field, their reporting back in terms of patient care reports, the QA processes, I can only do that if once a year core refresher training happens in house, and so we, in many cases, we bring them back to Baltimore to Hopkins, to do the training. And in some, with some groups, we have an agreement, then we do them in alternating years. So we'll pick another, just a third party city of interest to everybody and we'll travel there and we'll do the training together for a week. This is all predicated on appropriate funding. We are the stewards of our own program here at Hopkins. And so contracted funding that comes in, I manage principally and largely exclusively. And so I direct how much of that funding goes to faculty support, salary support, and staff support, and that is the majority of it. I think those who work at academic centers realize the fixed overhead in an academic medical institution. I don't think I'm talking outta school, but about 25% of all the contracted funds that come into our department go directly to the Dean of the school of medicine and to the chair's office of the department of emergency medicine. So we operate as competitive as I think we try to be when we acquire these contracts, we start out 25% in the hole. And so having gotten on that soapbox and talking about volunteerism, there is still a large spirit of we do a lot of work core work that may not be specifically indirectly funded because these are the right things to do. These are the ways we maintain very close ties to the programs that we're affiliated with, but we could not do this at the level we do this without appropriate contractual funding. I'll leave it at that.

- Actually, just a quick comment. The last time I was doing a federal grant for research, the indirect costs were above 40%. So however much money you need, you had to add it, add on another 40, 45% 'cause that's what went to the Dean and the school of medicine.

- I've been successful thus far in keeping our contracted work more on the clinical services side versus the sponsored project side, which is really where all the grants fall. But there is increasing and mounting pressure for us to move our agreements over to the sponsored project. So I'm fighting it on a daily basis and.

[Bozeman] Ouch.

[Tang] You know, I sleep with one eye open. All right, John, I think we can hit the next tab and then I'll turn it over to Bill.

[Bozeman] So this is gonna be the bounce back and forth between me and Nelson section. And then I think we're both gonna talk shortly about some fellowship things. So the next section to talk about is scholarly activity and research. And trust me, I don't come at this from the I'm a big researcher guy. I have had some success in doing some research, and I'm very grateful for that, but I really appreciate the fact that an important part of what we do, and if we're looking at advancing tactical medicine as a specialty, or maybe a better word is what Nelson was saying is law enforcement medicine, because there's more to it than running around, kicking in doors, of course, but scholarly activity and research and development of this specialty at a larger level has to involve some publications because otherwise no one knows about it. The Arlington Fire Department Program comes to mind and Reed Smith is a genius. And he came up with a rescue task force idea, I'm sure among others, but he was able to implement that. And the world never heard about it until some sort of publicity and publication was started. And often it's in, they begin in trade journals or specialty journals or something and they become more and more awareness grows. And now who doesn't do some version of a rescue task force for an active shooter? Which is something we keep seeing in the news. Brilliant ideas like that, or brilliant programs or wonderful things that can be going on locally. No one's ever gonna know if it doesn't make it into some sort of publication. The previous literature on tactical medicine, on the one hand, yes, it's a small niche. And compared to all of medicine, there's not much there, but speaking of Rich Carmona, when he started doing things in Pima county in the 1980s, he started publishing little articles about it in "The Tactical Edge." We actually have a reading list for our tactical medicine elective. And the very first item on the reading list is Rich Carmona's article covering 20 years of evolution of tactical EMS. And so it's really does become one of those standing on the shoulders of giants, any little additional thing that any of us are able to contribute, it really builds on this larger body of medical literature and not just medical, but trade literature and awareness of these things. Some of the things that came to my mind, Rich Carmona, of course, the NCG folks, publishing, defining the core skillset. What do tactical medics and SWAT operators, what do they need to even know? What is the skillset? And of course, developing interesting and amazing devices like the abdominal aortic junctional tourniquet and things. The group out of DC doing analysis on mass shootings, of course, Reed Smith and Dave Calloway and the TCC group that took the TC three guidelines and have translated them into a civilian appropriate version of tactical emergency casualty care. That was a great idea. And no one ever knew about it until they started publishing it. So there were lots and lots of things, all the position papers are important. All the military medicine and the trauma medicine and the EMS studies that we've all seen that contribute. There's a huge base that we're all standing on. We've had some success outta Wake Forest with simple things like just doing surveys. Hey residents who gets some exposure to tactical medicine, and we've published those things. We've done statewide surveys of how many counties have a tactical medic group supporting their law enforcement. And we published that, you don't have to be a super fancy researcher person to publish some straightforward things, just establishing that this is a part of medicine, and this is a niche with some very special things to it. Coming up soon, we'll be reporting some fellowship curricula, which we'll talk about next. In my own personal case, as I mentioned in the first part, it was that combination of doing some tactical things and being involved with law enforcement that allowed me to go to the NIJ, the National Institute of Justice and get funding to do studies of less lethal weapons like tasers. And it was really just leveraging those opportunities that led to a whole series of research things, which is for me, expanded to police use of force, excited delirium syndrome, and an upcoming study that I can't tell you any details about, but it's gonna be good, on vascular neck restraints. And rather whether we're really killing people left and right with vascular neck restraints, like we were with the tasers. Oh, but we weren't. So we have had some success in doing that. I think that's a small part. The larger part of advancing our field of tactical medicine or law enforcement medicine, is really continuing to expand on things to get not just good ideas or good techniques, but to establish who we are and what we do. And my big question for the group, 'cause Nelson and I have been talking for way too long, is what do people think we should do next? What are the important areas that our scholarly activity needs to focus on? The types of programs? Interesting pieces of equipment? Interesting setups? How Hopkins has a whole center for operational medicine? Did I get the name right, Nelson? I was close.

[Tang] Close enough, Bill.

[Bozeman] Close enough.

[Tang] You're good.

[Bozeman] All right. Anyway, that's my little spiel on the scholarly activity is very important. And I think we can all contribute to that. You don't have to be an academic. You don't have to be a fancy, fancy researcher. You don't have to remember chi-squared analysis or anything stupid like that. That's what software is for. And I would encourage everyone either right here, right now in the comments or just in general, help us decide where to go next with the scholarly side of things.

[Tang] I think that's very, it's a very nice description of where we stand right now. I wanna just mention something regarding surveys. There is a growing, disdain may be the right word or certainly lack of appreciation for survey methodology. Even amongst our EMS colleagues, there really is lack of interest in just survey data. And I understand where some of that comes from, but I think that for TEMS and for tactical medicine, there's so many of us doing different things in different settings at this moment in time and achieving small victories, small successes, whether it's training methodology, approaches to protocol design, even provider perceptions regarding modes, method of education, I spend a tremendous amount of time teaching operational medics. And once in a while I have these moments where like, do they even, are they learning? Do they enjoy this way of learning? Should we be looking at novel approaches? We just publish something in JSOM, regarding using standardized patients in tactical medicine education. You know, we're all very, very, I'm virtually certain that everyone on this call is very familiar with running TEMS scenarios, a moulage casualties, GSW scenario, hyper realistic setting. And so I think as a group, we're really good at that. I think we're really good at that. We understand the value of that, but a lot of our expectations for our medics is to provide sick call level care on operations and while deployed. So these are the sore throats, runny nose, chest pains, back pains and it's, these aren't sexy scenario driven type medical complaints. And so we've looked into the medical school which uses standardized patients, God forbid we call them role players, there's memo writing, there's complaints, there's phone calls, if you call 'em role role players, there's standardized patients and I'm not, I mean they truly are professionals at what they do, but using those individuals to portray individuals that have serious medical, not necessarily TEMS related complaints to develop that acumen amongst our provider cohort, to how to handle that, how to make good medical decision making and treatment strategies. Because a lot of our scenarios are, hey, let's get an operator to portray an injured person. Well, that's probably okay if it's a fracture or a GSW or something, but for someone having chest pain, you really need someone who's very, very good at portraying somebody having chest pain and allowing our medics to work through it. So again, it's a big resource, it's expensive to do. And I just bring that up as an example of if we roll something like that out, I'd really like to know amongst the trainees, whether it's well received, whether the comfort level with dealing with medical complaints is any better after a pretty significant investment in a training platform. And so I think surveys are still important. I wouldn't abandon surveys. I think it's helpful for us to hear about what you all are doing in the field, what the experiences are and this is us helping each other. And so I'm just sort of shout out for don't throw away the survey of methodology. It can be genuinely helpful to the rest of us.

[Bozeman] Or, to just amplify what you just said, going ahead and publishing innovations and training with well-articulated reasons behind them, like Nelson just did, that's a publication right there. And apparently just came out in Soma, yay.

[Tang] Yep.

[Bozeman] So why don't we go ahead and move on to the next section.

[Tang] Ah, fellowship.

[Tang] So the remaining section that Bill and I agreed to talk that we should talk about is really they're bundled together. It's training and transferring the knowledge that we've accumulated, all of us, everyone on this call and those who couldn't even make this call, we've all made inroads, we've built programs, we've developed relationships. How do we translate that to the next generation of tactical physicians and leaders of tactical medicine? Bill, you mentioned Reed Smith. So recently he and I were on a call with an international delegation and Reed introduced me as the grandfather of tactical medicine in this and.

[Bozeman] Love it.

[Tang] I don't know how I feel about that. It was well received, but I have increasingly thought about the likelihood that I don't know how much longer I will be doing exactly what I'm doing now. And so the challenge I think is for, not all of this, it would've been a complete failure on my part if this program folds collapses, the contracts go away if, and when I hang up my cape. And so for me, our fellowship program is one piece of this. We've had wonderful people come through the fellowship over the years, and I really value it as a formal platform to transfer some of what we do. Now I also do recognize that a lot of fellows or potential fellows really wanna do the sexy stuff at the end of the day, put on body armor, every other conversation is multicam or ranger green, like, right. It's, just, I'm gonna put that.

º[Bozeman] Nine millimeter or 40? 40 or 45?

[Tang] Exactly. And there's nothing wrong with that. I mean, I have to like, let's full transparency. That's pardon my language, that's the cool shit that we all enjoy doing, right? So let's, that's an integral part of it. And certainly practicing effectively and safely in that environment is a huge responsibility. It is a huge responsibility, but I think, increasingly, I've come to the realization that what I really hope to do is train future leaders and managers of programs. So to be administratively facile, to be fiscal ninjas and manage budgets and decide on where resources should be appropriately deployed. I think that's huge. We've had a, so we've been training tactical medicine at the fellowship level for quite some time. I don't know, 15ish years, but not always branded as the tactical medicine fellowship. So one of the huge like, oh, crap moments that we've had is so when the ACGME allowed EMS fellowships to apply and to be approved as ACGME programs, our program, at that point, we had one fellowship. It was the EMS fellowship. It was heavily obviously heavily geared towards operational and tactical medicine, but it was still branded as EMS fellowship. The day we became an ACGME accredited EMS fellowship, all that internal flexibility went away. We literally had like this much of a sliver of elective time to do tactical medicine work with our fellows. And so we had a kind of a revelation moment, said we really need to, for folks that really want to come and be immersed in the tactical medicine part of what we do, we really need to break out the tactical medicine part and make it its own fellowship. So our TM fellowship is not in and of itself that longstanding, but the spirit of it, the heritage of it, goes pretty far back. Our fellowship is a two year fellowship. It's a pretty significant commitment for those that want to come. And that really comes from a very pragmatic reason. The operational entities that we work with, one the background clearance portion to get people in a position where they can work, function with these teams. There's a fair amount of lead time. The sort of interpersonal familiarity and comfort level amongst our operational groups with a new doc, it takes some time to build that credibility. And so what we were finding is before we went to a two year format, by the time a trainee reached that moment of truth, where they were cleared hot, could deploy operationally with these teams, it was like January, February, and then a month later, they were starting to look for, apply for their next job and potentially relocating. So we, from a very selfish point of view, we got literally like two to three months of productivity out of a trainee. And so we really just weren't getting the yield for the investment in our trainees. And I say that sounds very, it's not very altruistic, but that's not the sole part of it. It's really like for folks to get to a management level and sort of glean that from the faculty. It just took longer than a year. And so our fellowship is a two year program and there is the ability within that to get an MPH at Hopkins during that two year program. But you know, that's sort of where we stand now. There's still very strong interest in this. And I wanna mention that a mind blowing thing is happening in the last three to four months, maybe six months, I have been overwhelmed with the number of cold calls, emails, contacts from medical students and undergraduate students who, I'm not kidding, I think I have a list of about 14 or 15 that I have yet to get back to who wanna know how we got, how I got into this space, how they can develop their interests and make themselves good candidates for fellowship, or to work in this space. I don't know what to do with this. They're seeking mentors and they, and it's very much a responsibility I feel like I owe, but that's hours and hours and hours of mentor time per person. And I don't know how to do this. So the message is, I guess on the flip side, the message is getting out. I think the good work we as a group are doing, the positive sort of glow or afterglow of successful operations that we support, I think it's getting out. I think there's a lot of interest in it. I think the challenge for us is how to appropriately mentor these folks, whether they come to our fellowship or whether someone comes to me, Bill, or to you, or winds up doing an EMS fellowship, but still very, very interested in TEMS. That's our future, we have to find a way, personally, I need to find a way, I don't know that answer yet. And as a faculty, our challenge is to find a way, but how do we nurture that interest? How do we direct those people to make good choices in their professional careers so that someday, when I really am a grandfather, I turn around and these folks are here. They're doing the good work. Now they're carrying on our mission. It's tough, I don't know the answer here.

[Bozeman] Yeah, so just a question for you, just for clarity, your two year program is the first year your traditional ACGME accredited EMS followed by a looser year of tactical, or have you spread things out and intermingled?

[Tang] Yeah, they are functionally two completely different fellowships. So not that they don't cross pollinate and co-mingle, so our EMS fellows certainly do have some availability to get involved in our tactical stuff. The ACGME just doesn't give them a lot of time to do that in their core curriculum. And our TEMS fellows are invited and strongly encouraged to attend the EMS programs, didactic curriculum, because you know, I think Bill, you and I both came with strong EMS roots and interests. And I'm still a firm believer that a lot of what we do, I think in tact, and in TEMS, we do, right? Because we've learned from the EMS side of the house, like we've taken lessons, learned good sound principles, protocols, QA, medical oversight, online, medical control, all that I stole from our EMS colleagues.

[Bozeman] Oh yeah, me too.

[Tang] We just rebranded it. But so there is a lot of co-mingling, but they're two functionally separate programs. So those two years, unfortunately for the moment they don't get any ACGME certificate. There there's no board certification eligibility for tactical medicine. I know John is chomping at the bit to get into that space. But yeah, right now, two separate different entities. They spend a lot of time together, but they wind up with different deliverables at the end.

[Bozeman] Got it. So I think Nelson just said something really insightful. And that is that from a historical perspective, there are a number of programs across the country that I'm aware of, I don't know a lot of details about some of them, that have had a very similar sort of EMS fellowship with a heavy tactical or operational sort of twist to it. But I think you nailed it with, now that all the EMS fellowships are ACGME accredited. There's very little wiggle room there and you can't really cover the core curriculum for EMS and do a bunch of tactical. There's just not enough hours of the day to do that or months in the year for a fellow. So the operational medicine type fellowships, I know that NCG has been big in this. I think Dallas has had one for many years. Minneapolis has got one. I think had one up there for quite a while, but I think that at this point, we're at the phase of development of kind of a wild west out there. And the fellowship that we developed is very similar to Nelson's, it's a freestanding, one year tactical medicine fellowship. We're only into fellow number two this year, and he's doing great. The first fellow that we had had just completed our EMS fellowship and transitioned into our tactical fellowship, just like up at Hopkins. The current fellow just wanted to do tactical. And as a board eligible EM-trained person, we decided that might be a okay thing. And he has proven himself to be a tremendous asset. The basic structure that we've done and I don't think we're unique, but we're unusual anyway, is that the first section, the first several months of the tactical fellowship is heavy on didactics. The whole thing is very loosely structured, lots of free time, 'cause we want them out doing operational things, but there's some structured didactics. We encourage them to participate with the EMS fellowship as well, if they haven't just completed it. But functionally, we are unusual in our relatively small town of Winston-Salem, North Carolina. It's not, it's not a tiny town. It's a big enough town to have a very active SWAT team and actually three of them. But our police department SWAT team has a full time element. And those officers spend all day, every day on SWAT, which is very unusual. Even big cities generally have a part-time SWAT team. You have your primary assignment and then you go to your SWAT training or operational things on an as needed basis. We actually have a full-time SWAT element that operates all day, every day. And the current fellows spent quite a great deal of time running around with them doing their every day, which is catching bad guys and doing vehicle assaults and all sorts of things. So he got a lot of face time and quickly traversed that credibility gap, the kind of a, who is this guy? He's the new doc, we're not sure about him. That allowed him to quickly traverse that gap and be recognized and accepted and really well liked. After the first few months of that kind of come the cold months. You go to basic law enforcement training and you complete a five or six month program of BLET is what it's called in North Carolina, in other states it's called post or something similar. But at the end of that, he will be a sworn law enforcement officer. The plan for each of the fellows is to place them with a home agency to hold their certification. And we are not as far down the road, I think because we're doing it differently than Nelson. He makes great points about contracts versus MOUs and having some funding come in. We're really still working at the single agency level, not a federal agency with lots and lots of people across the country. And I think we need to mature that area a little bit, but that's how the Wake Forest tactical medicine fellowship is set up. One year program free standing, either with or without an EMS fellowship, but you have to be board eligible in emergency medicine. And the first section is didactics and supporting a local kind of a very busy SWAT team full-time element. And then the second part is doing your basic law enforcement training and becoming a sworn officer. The thought behind that, by the way, is a number of us are sworn and a number of us are unsworn. And I think one of there's an important barrier there, and I'd love to hear from some of the comments and some of our colleagues on the line of there's an important difference there. You're the doc, we love you. We want you on everything, but you're not quite one of us. And even if you're an Army doc, if you're not sworn and not truly part of the agency, that's an important barrier when you're working at this local level. So I'd love to hear some thoughts and comments from our colleagues who are listening in. And I think Nelson and I have probably talked about enough.

[Wipflier] Yeah.

[Springer] Hey gentlemen, actually a question from somebody in the audience that I think relates a lot to what you're talking about here, as far as for the fellowships, the question is for those who have been in practice and cannot logistically go back to fellowship, what do you suggest is a good way to develop the skills to do this job?

[Bozeman] That's a great question.

[Tang] So, I think I'd seek a little clarification in practice, meaning doing tactical medicine stuff, working in the field, partnered with a team already, because if that's the context of the question, I would say, don't do a fellowship. You are already doing the work. I mean, I think there is no. Oh, okay. I see the answer now in regular EM practice. I think that's a challenge. I think part of what we are describing here really is a niche area of practice that's in evolution. The fellowships are a formalized way to transfer some of the knowledge, but it's not all of the knowledge. I mean, I think what Bill and Bill's teaching in his fellowship and what Alex is teaching in Dallas, I think like in our program, it's probably very similar, but not exactly the same. I think we are just hoping to share some core set of experiences and then realizing too, that even our fellows, when they're done, there's not a tactical medical director position waiting for that person. They've got to go out and actually seek out that opportunity and build relationships and find a practice setting. So unfortunately, I don't really have a great example, answer if you're already well established in EM practice, going back to do a fellowship is likely to be not ideal if downright unfeasible, but I think networking, I think this section, I think going to meetings, going to Soma, go the C-Tech meeting happens twice a year. The mid-year meeting is, or the annual, I forget the nomenclature, but the mid-year meeting is always at Soma. The winter meeting is usually for last year, was at NAMSP and is always in collaboration with another large meeting. It's the, if there is nothing more heartwarming, it's the fact that us, you, us, this group of people is so willing to help each other, so willing to share ideas, so willing to offer resources. So take advantage of that. Best practices are out there. They're just not necessarily, I don't know that you necessarily have to do a fellowship to get those best practices. I think these forums, a exchange of ideas, this is a great way to learn from each other. I'm so thankful that Bill and I could just talk at you for the last hour, but really, really, I hope the group knows that I only know those things that I know, and that I've been doing for a while. There's so many of you that are doing hero stuff out there, really sort of putting in practice these things that we talk about in these meetings and conferences that what I do here in our program is, it's clearly not the only way. And you guys are doing tremendous things out in your, with your teams, with your respective departments and so kudos to you all, I'm just grateful to spend the time with you kind of share a little bit about how we do what we do. It's not the only way. And ours is not necessarily the best way, we've had some opportunities along the way, built some relationships and I'm here to just tell you how we do it.

[Bozeman] I would echo that. But also back to that question, one of the things that comes to my mind, if you're out in EM practice, and you'd like to start doing this, of course, it depends on what level, if you wanna go directly to Nelson's level and work with federal agencies and get contracts, that's gonna be tough, but what is not tough is the well worn pathway that so many of us on this call have traveled of introduce yourself to the local SWAT team, or get a buddy who knows the SWAT team commander and say, Hey, would it be okay if I came out to your training? You know, would you like to have a doc involved sometimes? And I'd like to just kind of see what you guys do and approach it from a sort of a humility in what you do or don't know about tactical things, but offering to be a doctor who can be supportive of them. And I have never seen that met with anything but appreciation, and of course, come on out, doc, we're happy to have you come talk to us or come hang out with us at training. And that's how you start the process of becoming a tactical doc with the local team. And you don't have to have a credential other than being an emergency medicine doctor who's got enough interest and you care enough about them to show up. So that's a well worn pathway.

[Tang] So John and Brian, we have one question that I see, but also can you advance the next slide because there is one thing that we should probably talk about and that's the graphic Bill put up there, but. Oh, Dave McCardle had great, great message here. ISEP conference in Dallas. Another great platform. Yes, another great association. Great networking. So thank you, Dave. Go to that, too. Brian, can we take the question up on the screen?

[Springer] Oh yeah, yeah, yeah. Go ahead, yeah, Bob. Yeah, we gotcha. Unmute yourself there.

[Margulies] Thank you. For those of you who don't know me, I'm probably one of the elders. I turn 80 this month, next week, actually. And I've been doing emergency medicine for 53 years. My background is very different. Though I've been a police officer twice and I retired just about a year ago for the second time. My concern is not for what you're doing in academics. I absolutely agree that we have to have the training. I did it the hard way. I started as a police officer, went to medical school, went into the military for the second time, made a career out of it the second time. I chaired operational emergency medicine at the Uniform Services University, played with all the teams in several different places. When I got out, I did exactly what you were saying, Bill, I went to every police department, wherever I was, and I volunteered. What I don't see is enough emergency physicians in places other than academic medical centers, getting out and helping all of the police departments. It's not just big cities. I was last working in a small town with a six man department and we had drug busts, warrants, DUIs, all the same stuff. And we had to go through it all without a SWAT team. Every individual was SWAT, whether they wanted to be or not, but it was the medical training that they lacked. And so now even retired, I'm still teaching field medicine, trauma medicine, first aid, medical care, because lots of times police officers are the first ones on the scene for that chest pain, that stroke, that whatever it turns out to be. And so they need some of that. My prayer is that we get our people outside of big cities and academic medical centers and to where, if you'll pardon the expression, the rubber really meets the road on a daily basis. I've done the big city thing. I was Hartford, Connecticut police surgeon, fire surgeon, state police, special team surgeon. I understand it. It's all good, but there's more to it. And am I the only one who is not in an academic medical center question mark. And thank you. And by the way, that was a beautiful presentation and both of your backgrounds, extraordinarily impressive. I applaud you for what you've done and what you're doing. I'm just asking for a little more.

[Bozeman] Well, thank you for those wonderful comments. We appreciate them.

[Wipflier] Definitely to add to Bob's comments there, too. One thing we're going to be doing this next month, gonna come up with several task forces, one of which is gonna be to actually create for those physicians who want to be listed to create a list of two or three docs who actually been doing tactical med for a while to serve as mentors for other people. And getting back to the question earlier about, well, how does a doctor what comes after, to answer the question of, well, how does a doctor who can't really do a fellowship, how do you get educated? Really two things that, like the gentleman had said before, key thing I found out is, number one, your law enforcement unit will teach you, just be there, be humble, and just the desire to learn. And number two is, go hang out with other docs who've been doing it a while, go over their training, hang out with them in all day. You know, don't be a pest, but go there for a couple days of training, look at their gear, see what they carry, ask 'em questions. And then a couple of weeks or months down the road, when you're actually accumulating gear yourself, you have a nice baseline to start off and go with. But I think I'd like to do is get a list of as many docs in each state as possible who want to be listed. And that will be a good reference point for some of the newer people out there to get oriented and get up and running on there, so good. What other questions? Brian, anything else you need to talk about?

[Tang] John, if I may, I wanna thank Dr. Margoles, if I pronounce your name right. Thank you for your service, your lifelong service at so many levels. Thank you for your comment. I think when we, when we focus on tactical medicine, I think, as you alluded to, we're losing sight a little bit on the impact of like patrol officer training, patrol officer preparedness. If it helps at all, because I share space with so many EMS experts on my faculty in our program. The, I think that is happening. I think the lessons learned, bleeding control TCCC lessons, TECCC, hemorrhage control, tourniquets, that stuff is happening. Your point is extraordinarily well taken. More needs to happen at the local level, smaller department level. And so, whatever I think the way to make that happen is as you've done is to continue to make that, let us not forget that, make it a priority, let it be part of our core mission to translate the life saving things beyond the specialized teams and the cool guy stuff and make sure that the patrol officer has the same access to training and equipment and so forth. So I thank you for that. I also would like to say thank you for really being the real grandfather of tactical medicine. So that, and I mean that with the utmost respect and admiration, sir, thank you for everything you've done in your career.

[Margulies] Thank you. Yeah, I was a patrol officer, my car, my route, my town, one cop at a time on the street, gets really interesting, but we do need the training programs. My route was tortuous, it was fun. Roping outta helicopters, falling outta planes, all that good stuff. It was great. But teaching the street cops right now really, really gets it to me. I've got some of our local cops now carrying their guns and their tourniquets when they're off duty.

[Bozeman] Good for them.

[Margulies] I've even got some of them carrying chest seals, but the point is thank you. Great presentation, really well organized.

[Wipflier] I definitely agree with you totally on that, Bob. Thank you very much. So Dr. Tang and Dr. Bozeman, what what'd like to do is wrap things up here. We're doing excellent session. We don't have too long. People are about an hour or 24 minutes here. What other things would you like to talk about before we call it a tonight here? Anything else for wrap?

[Bozeman] I just like to say thank you to you, John, for instigating all of this and to Nelson for putting together the slides and to Deanna, but mostly for people like Bob and all the other people who have joined us tonight to listen to me and Nelson kind of babble on about things. I hope it's been helpful to in some way, and I have all the respect in the world for all the other people who can and should, and maybe even already have, Brian, done one of these, and I'll be sitting back with a bourbon next time instead of an iced tea, listening instead of talking.

[Tang] I beat you to it, Bill.

[Bozeman] I know you did.

[Springer] Who says I wasn't drinking back when I was doing my presentation? Hey, there just not so much questions, but just for those who, just noticing here among the comments, just a common theme about the importance of reaching out beyond just SWAT and how critically important it is to be working with patrol there's comment here. Oh, current tactical fellow at Wake and talking about the ability to get out there and get better integrated with law enforcement and law enforcement education, from Dave McCardle of course, with ICEP and so much other stuff talking about area of leverage in would be by helping prevent the psychological stress trauma through stress inoculation in patrol. So again, just a really potentially expansive role that we could play as far as for helping out medicine. Well, my apologies by bringing medicine out there to law enforcement, and then also a comment here, which I see Dr. Tang actually saw and commented on coming from Tom Meyer, who said great program. One of the keys in turning to turn application into vocation, getting funded by hospital or government board says research is critical, but even more important is local press. And being able to tell the story of the patient regarding what good things happened which wouldn't have happened without tactical medics. And of course, Dr. Tang very truly responded, great point of course, also media being a double edged sword. So approach all that carefully.

[Wipflier] Well said. Thank you for summarizing that. Appreciate it, Brian. Thank you, also, too, there's a very excellent physician who's got a lot of military special ops training and also does tactical medicine in south, Missouri, Dr. Matt Brent. He has offered to if anybody knows anybody in Missouri area, the Arkansas area he's available as a reference in that area. And that's exactly the type of comment I think we can really use from everybody on this call, those people who've got even a moderate. It's a lot of experience. You guys are, ladies and guys, are very willing to share their time in teaching whoever wants to be on a list will be sending that around, we'll keep that very discreet. And it's not gonna be going out to shareware, it's gonna be section members only, but would you wanna be a resource to help another doc or another tact unit get up and run it? So that's a good thing to do also to wrap things up. As far as the situation up in Minneapolis, we've working with the directly with the ACEP leaders, the top leaders on down to get permission to release that letter out the general public, specifically aiming for the law enforcement community mainly, and sometimes this next week, our director, Rick Murray is expected to get feedback on what degree we're allowed to release that. So we're gonna do is make that available document. We're gonna probably add to it. And the ASAP, as you know, is a very wonderful organization. They're also gonna be very careful about what gets released, perception from the public and so on. You guys understand that. So as soon as that's available, we're gonna get that out. So keep track of emails. We're gonna have the survey coming out. We're also gonna have several task forces and I'd love to get everybody's participation on that. Pick out, everybody's got a full plate, pick out one little niche. These are not gonna be a year or two, maybe this as like a task force meet on and off via Zoom for about one or two months and achieve your goal. And we're done, check the box and we move on from there. So some other exciting projects coming up to will be bringing that up to date on. So anyway, so Dr. Springer, any other comments and then Dr. Tang, Dr. Bozeman, last, any final comments or anything?

[Tang] Just thank you everyone for your time. It's nice to spend evening with you and please be safe. Keep up the good work.

[Bozeman] Yes, thanks to everyone. We appreciate it and stay safe.

[Springer] And gentlemen, thank you so much for your time and the effort that you put into this and really sharing a wealth of knowledge with us. And it is deeply appreciated. Thank you.

[Wipflier] The Zoom calls, it's hard to have a big round of applause, but I know everybody's applauding. I'll applaud myself and thank you very much, Bill and Nelson. We appreciate your time and efforts and we'll look forward to continue to work on things together. Thank you very much, everybody have a great evening.

[Bozeman] Sounds great. Take care.

[Tang] Thank you all

[Wipflier] Thank you. Good night.