Tactical and Law Enforcement Medicine Past Lessons and Future Directions

- Welcome everybody to the latest of our ongoing tactical section webinars. We look forward to sharing information from our meeting in San Francisco. We had a great meeting, great attendance, those of you who were present, and we discussed some very important topics, which will be discussed later on in the webinar. Just some basic housekeeping information if you would, make sure that your microphones are muted. That helps greatly to limit the background noise and interference during the presentation. If you have a question, there's a couple of ways you can do that. You can at the end, we open up for Q and A. You can ask questions there or during the presentation if you want to use the raise your hand option or in the chat box, which we will monitor and pass on to the speakers if you have a question you wanna post that way. With that, I think, Brian, it's back to you.

- Very good, Rick, thank you very much and welcome everybody. Really glad to have you all here. This is our first webinar now since the Scientific Assembly and first webinar since we've elected our new section officers for the section for tactical medicine, which is now at least per our vote, the section four tactical and law enforcement medicine. And hopefully within the next couple of months, we will have ACEP's blessing to make that our section's official names. I just wanna start by introducing myself and our section officers, just for me, most of you out there are probably fairly familiar with me from previous webinars as well. And being the chair-elect for these past two years and working really closely with our immediate past chair, Dr. John Wipfler. I'm at Wright State University in Dayton, Ohio. I'm full-time faculty with the residency training program there. I've actually been full-time faculty there now for over 20 years. I've been a tactical medical provider or now as the Ohio revised code calls it, a tactical medical professional, for the last 17 plus years, working with a number of agencies in our region here. I'm a sworn peace officer and also a federal deputy as well. I help to create and currently run Wright State's tactical medical division. And again, it's through that division that we do work with a host of agencies throughout the southwest Ohio, at the local state as well as the federal level. I am absolutely honored to take the reins as the section chair. Honestly, when John asked me a couple of years back if I was interested in being his right hand man, as the chair elect when he was taking over his chair, my first thought was, wow, who is his first choice and what happened? You know, did they die or get into some sort of horrible trouble? So now he's scraping the bottom of the barrel here. But we've really, we've had a really good run, made some great strides over these last couple of years, and my goal is to really go ahead and continue to push and make some strides. Our chair elect is Dr. Keegan Bradley, Keegan, would you like to introduce yourself please?

- [Keegan] Thanks Brian, yeah, everyone. I'm Dr. Bradley. I dunno if some of y'all may know me, some of y'all may not. I'm based outta Dallas, also a tactical EMS provider. I just actually got sworn in recently with the Collin County Sheriff's Department, so I'll be running with them. And then kind of the whole north Texas area. And we're actually hopefully looking to set up a team for the kinda state regional area. So one of many hats that I wear, I work with FEMA. I also worked as an EMS medical director, but I got the opportunity to start pretty early in my academic career with this group. And it's been really great. I will say sometimes I feel a little like the black sheep, being with these great docs, they already got 10 times the resume accomplishments I do. So it's a great opportunity and great honor to get to keep moving up and keep working for y'all as the vice chair.

- Awesome, thank you Keegan. And for anybody who's wondering, Keegan is actually at a holiday party right now. Again, chiming in from inside of a closet, trying to get away from all of the music and dancing and debauchery that's going on. So hence the background noise. Our secretary is Dr. Dominique Wong. Dominique, would you like to introduce yourself please?

- Yeah, I'm Dominique Wong. I am clearly the underachiever of the group. I was a tactical physician for five years before it all just sort of collapsed and went out the door. But I continue to work with law enforcement on a lot of their medical issues, do a lot of training, a lot of consulting, most of it informal. I've done some event medicine, was the EMS director for the World National Spartan Races, GNCC Races, EMS Medical director. I'm based out of West Virginia. Like I said, I am the underachiever of the group. So anyway, I was the newsletter editor for the past two years and so, yeah, that's it.

- Well, I'd say you're a pretty high functioning underachiever having really done great work with the newsletter these past couple of years. And also just your ability to really kind of come up and address some of these key issues in law enforcement medicine is impressive. So don't worry, we'll squeeze a lot outta you, I promise Dominique. Our new newsletter editor is Dr. Jeremy Ackerman. Jeremy, introduce yourself please.

- Hi, I'm Jeremy Ackerman. I am on the faculty of the Emory University School of Medicine, the Department of Emergency Medicine. I accidentally ended up on a SWAT team about six years ago and now I'm sworn as an officer and work with a variety of agencies in the Atlanta area. This is sort of a secondary academic pursuit for me. I'm actually a biomedical engineer and work on developing medical devices and things like that, whenever I get a chance. And I guess in terms of this section, I'm also the ACEP rep to the Committee for Tactical Emergency Casualty care as well.

- Outstanding, thank you sir. And yeah, sincerely appreciate that and having that connection with TECC is critical. And we'll actually give you the chance to talk about some of the updates coming up here in just a little bit. I also, of course, had planned on having our immediate past chair talk for a few minutes, and that would be the illustrious Dr. John Wipfler who is currently somewhere out and I'm still not quite sure exactly where he is, whether he's actually back in Illinois or if he's still in Colorado or if he's like stuck out in the middle of a snowstorm or something.

- I think he's in the witness protection program.

- Is that, so yeah, we may never actually see him again. We're hoping that he may actually chime in on this webinar at some point tonight. But I think part of that is at least if he can kind of break away from his security detail. Dr. Bradley, if you would be so kind, I'd like to just kind of start here just to help catch everybody up, with an overview of some of the key items that were discussed this past October at the Scientific Assembly in San Francisco. And Dr. Bradley, if you would be so kind as to give us a brief overview. Let me rephrase that, Dr. Bradley, finish your drink and get back in the broom closet and give us a brief overview.

- [Keegan] There we go, sorry, I was getting out loud music. So yeah, to give everyone an overview, just kind of what went on and it was a great session. We got a lot done. We had some great lectures. One was on San Francisco fire by their EMS medical director and just kind of talking about how their system set up, that included their response with law enforcement, operations. We had another talk on coach less lethal tactics and weapons, which was really good, that's always good to hear about. And he was kinda good about emphasizing some of the injuries to be aware of and how those can be actually still lethal weapons. So always remember that, we had another great lecture by Dr. Wong's, medical students, I believe, not residents, medical students, they give a great talk. I'll actually let Dr. Wong probably touch on that a little more if she wants. That was a great talk. I actually asked them for their slides to use later down the road. It was just kinda touching on law enforcement and tactical EMS and kinda the difference it makes. Then we had some voting, we brought in the new officers for this round, Dr. Springer alluded to, and then we actually received some awards from ACEP itself, for both the newsletter and then I think it was our website that we've been doing. So our section's been doing very well and it's getting recognition, which is very good to hear about. So both the officers and the members clearly made this group what it is and made it very successful. And then finally, kind of the last highlight I'll touch on is we had a vote to change the name if y'all have not heard about that. We've transitioned from the tactical EMS section to now tactical law enforcement's medical section and there's some kinda new developments with that, but that's for the future.

- Excellent, thank you sir. And yeah, I mean obviously a lot of important stuff. Again, I really, I wish that Dr. Wipfler was here right now to kind of toot his horn here. As far as for the section awards. I mean we obviously, we all as section leaders as well as section members, worked really hard with him to help move our section ahead. But to get that recognition from ACEP was, I think really, really important. And I think it really reflects well on his leadership. Of course, also, speaking of ACEP, I would be remiss, I know I've talked about our officers here, our representatives from ACEP Rick Murray and Deanna Harper. Would you both please just say a quick hello to everybody and introduce yourselves as well?

- Sure, be glad to. I don't know you, my name is Rick Murray. I've been with ACEP 26 years. I'm the director of the EMS department. Been involved in EMS as a paramedic beginning in the mid seventies. And I did have a couple year stint in law enforcement, but trying to do fire EMS and law enforcement then go to college was a big challenge. So I couldn't keep all three going, but I really enjoyed working with this section and continued to watch it grow and there's some very exciting projects in the future.

- And I'm Deanna Harper and I've been at ACEP for about almost 14 years. I've been in EMS since, actually 1999 is when I started. And I've done anything from director of operations, out in the street, you name it. So I've worked with Rick for about 30, probably 34 years. So we've been closely together for many years. So this team has a lot of meaning to us. It means a lot to us to watch it become so successful. And I appreciate all the hard work. I can't tell you how much I enjoy this section and being able to participate with it. So thank you for making me a part of this team as well.

- Cool, thank you both so much. And yeah, Dr. Wong just posted here too, I mean, Deanna and Rick have done tremendous work to help this section and that is absolutely 100% true. And the awards that this section received, again, we could not have done that without you guys. So again, most sincere thanks and looking forward to continuing to work with you for my next two years and certainly beyond that as well. So tactical and law enforcement medicine. So that term has already gone and popped up here several times over just this last 20 minutes. And as noted, we as this section now have voted to change our name from the section for tactical emergency medicine to the section for tactical and law enforcement medicine. And like to talk a little bit about sort of the background of that, what the concept is in terms of particular to law enforcement medicine. And I'd like to let Dr. Wong just kind of take the lead on that and then I'll give some updates on where we are exploring sort of the bigger picture with law enforcement medicine.

- All right, great. I am going to share screens. So can everyone see that? Okay, great.

- [Speaker] That looks good.

- Great. So, I really feel strongly this isn't just a name change, that it has a whole lot of punch behind it. This is an abbreviated version from a talk, a conversation we had, gosh, was it about a year ago now, on one of these meetings. And it's also an abbreviated version of the talk that Dr. McCartel had asked me to give for IACP. So very condensed, it doesn't have a lot of the background behind it, but more of a skeleton outlook of the framework we were talking about when we came up with the concept for TALEM or Tactical Law Enforcement Medicine. If you want any of the background research or data references, just get ahold of me, I'll be happy to give that to you. So this is kind of, have you guys seen these memes? Just speaking to everybody, I think they're hilarious. But anyway, so surfers, right, what my friends think I do, what my mom thinks I do, what my girlfriend thinks I do verses what I think I do and what I really do, which is really a matter of perception versus reality. And like I said, I'm the one who had the failed career at tactical medicine. I did it for about five years, but let's see, but had a lot of struggles with it. And then as again, like I said, I ended up doing quite a bit more work, even more than when I was doing spot call outs with law enforcement and then talking to friends, they were sort of seeing a lot of the same things. And then looking at the data, it seemed to back it up. So I kind of made my own, what my mom thinks I do versus what I do. So a tactical physicians, so what tech meds think they do versus what we really do. And these are just some pictures from some of my experiences. So I get calls for like forensic things, could you come help us? Does this look human to you? We put out a bulletin, a law enforcement medicine, medical bulletin. If somebody, if an officer gets injured, I'll get a call really often to sort of liaison with the hospitals, do a lot of training, like I'm sure a lot of you do, ask to review records for law enforcement or for like a lifesaver awards. And then a lot of calls, a lot of texts about family members. So really there's just a lot going on besides the SWAT callouts, at least in my experience. And then as we got looking at some of the data, we realized that really there is a lot more that we could be doing, ultimately to prevent law enforcement officer deaths. So in comparison, this is the TEMS definitions, and I don't expect anyone to read all the words on this slide, and the highlights in red are my changes. But the upshot is, no matter whether the definitions from ACEP TE section, whether it's from Wikipedia, whether it's from California Post or any of the other definitions, it really TEMS is by definition for SWAT or cert special operations. And that's where they've defined themselves. I absolutely appreciate everything TEMS does and that's what drew me into it in the first place. But we kind of were have gone through the process of realizing that there is a lot more that can be added to that TEMS response. So this is a quick summary. The vast majority of law enforcement medical incidents are not in a tactical setting. So where we currently are in the tactical setting, or were as far as TEMS physicians hands down, the vast majority of incidents are patrol or non tactical. A lot of the preventable deaths are going to happen in situations where no tactical physician would be available. So that sudden cardiac death, infectious diseases, suicide, what we call routine law enforcement encounters, sort of like ER, right? Nothing's routine. You never know when something bad's gonna hit the door. And so all these other situations where no tactical physician would be available. A lot of of unique scenarios that are unique to law enforcement that have special medical considerations. So mass casualty incidents, civil unrest, again, routine law enforcement encounters, the altered dangerous or the mentally ill law enforcement interaction, situations like that, we considered all the potential victims. So it's not just law enforcement officers, it's also the public they serve. Anytime there's a law enforcement in a call for law enforcement or a law enforcement response, it's because something potentially dangerous is going on. And by dangerous, we mean the potential for injury or illness, medical. So in response, adding onto the law enforcement or I mean the TEMS response part of the puzzle, we also really have to be available to advanced research, to advise on all different levels, from local to state, to federal levels. We absolutely have to be ready to train law enforcement officers themselves because again, unless you have a physician in every patrol car, they will have to be able to respond in a medical way also. So just I will go through this quickly. The vast majority of law enforcement medical incidents are not in the tactical setting. Like I said, and I'll just show you real quick, in the center in the orange, it's the tactical law enforcement line of duty deaths for the past decade from felonious assault. And on the left is patrol, again showing tactical or where there may be a tactical physician is a very small minority of the line of duty deaths from felonious assault. Just put another way, here's all that 95% are non tactical. That means only 5% have the chance of having a tactical physician present. So we're impacting this small segment. I, I believe in a really positive way, but I'm also seeing all these other opportunities for us, many preventable deaths from multiple causes when there's no tactical physician available, like sudden cardiac death, infectious disease, like I mentioned before, law enforcement officers die earlier than the general public. They have higher suicide rates, have earlier cardiac disease, and a lot of that is preventable. Interestingly, with COVID, there are more COVID deaths and all other line of duty deaths combined for the last two years. So, again, that's a perfect example of where physicians should have been involved more closely with law enforcement. I'm not gonna get into the weeds, but this is just showing that for every five years of life, the average life expectancy of a typical police officer in Buffalo was much lower than the general public. This was another student that Dr. McCartel had involved with IACP, aside from his data, showing the line of duty deaths and in red for the last two years, and that is almost entirely because of COVID. sudden cardiac death is really significant in this line of work, probably related to the sudden stop and start, going from zero to 60 sort of work that it is. So again, a lot of places where expert medical advisement would be helpful and training also. So other scenarios with special considerations for medical care. So this is every time the law that law enforcement officers interface with the general public. And then a lot of examples of this, from civil unrest to high threat events like mass casualty incidents, which are on the rise to drugs of abuse, altered and dangerous persons and routine encounters. And each of these, again has a law, it's a law enforcement encounter, but it has such a strong medical side to it where I really, I think we all think we really could be helpful. So sorry about that, so this is just an example, but Reed Smith, I'm sure a lot of you all know him or have heard the name, his analysis of the injuries in civilian mass shootings, when a lot of our data comes from military events, civilian mass shootings, one of the most common causes of potentially preventable death is nonvascular lung injuries. And yet I see it really often, that we have a lot of law enforcement that are continuing the emphasis on tourniquets and don't carry vented chest seals or aren't trained in them. So again, just another example where I believe as tactical and law enforcement medicine physicians, not just TEMS physicians, we can have a big impact on preventable death. A really quick review, this is what Dr. Bradley touched on, the medical students looked at some active shooter events. And what we found out was that, for instance, an Aurora Colorado theater shooting, as well as the Marjorie Stoneman Douglas High School shooting, that law enforcement represented here in the blue, saw the majority of victims. They saw the majority in the first 30 minutes when you to scoop your most critical patients. And indeed they saw the most critical victims over traditional EMS or fire systems. So whether they want to do a lot medically or not as law enforcement officers, there is clearly a role for us as law enforcement physicians to train law enforcement on response, MCI response. In a nutshell, what we think the role of tactical and law enforcement medicine physicians, the way it differs is that not only are we still focusing on responding, there's a lot of room for research. There's so many unknowns right now. There's a significant need for physicians to be able to advise, to give the medical side of it to law enforcement leadership. And again, training is a component we can't get away from because, again, the majority of the incidents happened with the patrol officer and there is not gonna be a physician there. So it can't simply be a matter of us being there to respond. We absolutely have a responsibility to train officers. So that is in a nutshell, the rationale behind expanding Thames. This is a lot of words that said basically the same thing, but in a more formal way, just a loose definition of what tactical and law enforcement medicine would be. I'm not gonna keep you focused on a lot of wordy slides here, we definitely wanna do this in partnership with law enforcement medicine. We want it to be useful to law enforcement medicine. We want to be sensitive to law enforcement context. We really want this to be evidence-based and ethically driven. And ultimately, we hope to provide a network of expertise. I know we will save more lives if we expand the work that we're doing. Again, this is an example, this is actually a slide from my local police department. This was after I was no longer doing, being a tactical provider, which was in another county. I had trained these guys and then their chief asked me to review the records. And I know just in that one year, that more lives were saved by the trainings we had, than any event in those five years that I was on a SWAT call out. So, how did we go through this pathway as a 10 section? Well there was a CME presentation, we had an open discussion, there was virtual conversation during the CME presentation. There were email invitations and then there was the ACEP discussion forum. We also had an open discussion and a lot of opportunity for people to weigh in on the name change. We had some really good comments about that, especially from some of the military partners. And then there was the vote at scientific assembly. And so that is the path that we ended up taking. And here's another one again, just because I think they're really funny and if anyone has any questions, let me know. And if you want, again, that was a really superficial view, but if you want any more of the data or references, let me know.

- Excellent, thank you. Any questions for Dr. Wong? Good, I have a few things to say about this concept of law enforcement medicine and just sort of expanding on what Dr. Wong has said. If we look sort of at, if we think of the definition of TEMS as Tactical Emergency Medical Services, that certainly is incomplete. Back in the day as far as with their definition of TEMS, refer to it and still refers to it as tactical emergency medical support in an effort to sort of address what we're talking about here, which is that this is much broader than just going in caring for officers or bystanders or subjects during a SWAT call out. But that this involves all the different medical aspects in terms of preventative medicine, medical pre-planning, infectious disease, vaccinations, on and on and on. And despite that as their working definition and many of us being sort of a aware of that concept, we still really just have not had much in the way of cohesion in terms of all the other relevant players outside of just the tactical side. And of course, I mean, patrol being a big part of this, but again, looking also from the occupational medicine side of things, psychiatry and psychology, cardiology, I mean, these things are so, so important and we are discussing these things that are absolutely critical to the health and wellness of our officers, but we're discussing amongst ourselves and we're not connecting with the other relevant players. And this is a way to go ahead and bring that together. Now also, looking beyond in terms of really big picture, this goes beyond just SWAT and patrol and law enforcement. This really is key in terms of with the public and benefit to the public. And if we talk about the social determinants of health, if we talk about things such as poverty, substance abuse, lack of access to resources, and I mean all sorts of resources in terms of medical, social services, psychiatric, gang violence, crime, criminal activity. I mean, the majority of people who live in poverty are not criminals, but they are disproportionately by far and away the victims of crime. And of course, who are the ones who are gonna be the first ones in contact with the public dealing with these and frontline, as far as for social determinants of health, it's gonna be law enforcement. I mean, in some cases it's us, emergency physicians, it's somebody's coming into the ED, there oftentimes is going to be some law enforcement aspect of this and we need to be working with law enforcement, law enforcement absolutely needs medical directors to go ahead and to help guide them and to work with them to better go ahead and serve the public. And I'm just gonna go and I'm gonna say that the social justice warriors, I mean they certainly addressing some important problems, but I think they have the solution backwards. The answer is not to defund the police, it's to engage even more with the police to go ahead and to help them help the public. And I think we're gonna be a key part of that and we need to be a key part of that. Now, name change of the section I think was a critical first step because that's still perception is reality. We're not gonna be just the tactical medical section, we're not gonna be just, you know, docs with glocks. People are gonna actually be looking at us and they say, ah, okay, tactical and law enforcement medicine. And many will probably ask, what is law enforcement medicine? Many may initially be turned off by that concept because tactical medicine, they're just like, oh yeah, tactical, whatever that's all about. But now we're specifically pulling the name and term law enforcement in and I think that's gonna wake some people up and I think that's gonna be a good thing. We had, the section leadership and along with Rick and Deanna we met with leadership from ABEM on November 30th. And among those at ABEM was their executive director, as well as their director of medical affairs. And we laid out to them the concept of law enforcement medicine and our feeling that this needs to be an area, that this is a key subspecialty of emergency medicine and there needs to be some means of additional training and certification and recognition of that. And I will tell you, they absolutely, they bit, they had no issues with any of these concepts whatsoever. They think, they're with us and that this is something that is really important. It's interesting they did go ahead and sort of give us a little bit of background and said, you know what, there's a lot of people within emergency medicine who are going, me, me, me, what I do is important and we need to go ahead and have our own little sort of niche within the specialty. But this one I think was kinda a clearer eyeopener for them in terms of how important it is to medicine, to law enforcement and to the public. The question now is whether or not this is going to move in the direction of sub-specialty certification, IE, actually going and requiring a additional fellowship training, as opposed to the moving in the direction of focus practice designation. Now we're still discussing that right now in terms of amongst the leadership, this is certainly something where, as far as for section membership, we certainly welcome everybody's input. Of course there's clear advantages and disadvantages, whichever direction we head in. Of course there's always the option to pursue subspecialty certification. But away from ABEM and again, something that again, we've discussed, but that also certainly creates its own sort of of problems. I really, really, again wishing that Dr. Wipfler was here because this really has been his baby. But just so that you all know, again, this is something where we've talked about it, we've got the section name change and we are now actively engaging with ABEM as far as for determining how to go ahead and to get this locked in. You certainly can all be expecting that no matter which direction we go in, whether it's subspecialty certification or focus practice designation, that we'll be reaching out to section members to help pull you in as far as for doing, working parties for us basically to help actually create law enforcement medicine and help us devise curriculum, study guides, foam podcasts, et cetera. This is going to be a lot of work, but of course it's not something that's gonna be done overnight. This is going to be a project that is going to emerge over the course of years and will hopefully be carrying on for decades beyond and have its influence. Are there any questions or comments or concerns specific to law enforcement medicine at this time? I see hands and I see here, wait, so all right, to keep it formal here. So, all right, we'll start at the top here, so Larry Goldhahn.

- [Larry] Yes, hi, Larry Goldhahn here. A little bit about me. I've been sort of lurking on the sidelines at these webinars and I like this idea of moving forward, a little bit about my background. I've been working with a, we call it a QRT, a quick response team, but that's our county SWAT. I've been working with them for the last two years and Jermaine to this discussion, for seven years at my prior job, I was also a medical director for forensic nurse examiner team. So this is something near and dear to my heart with the interface, with the law enforcement side of things. I had a question it for clarification. When you're talking about moving towards subspecialty certification, are you talking about subspecialty certification underneath emergency medicine or is a sub subspecialty of EMS subspecialty? Is it gonna be one under that one or which way is it going?

- Yeah, and that's actually certainly one of the things that we are actively discussing. Yeah, if it would be, if it's subspecialty certification, then that really does make it a different animal than EMS. And we, by the way, clearly, part of our mission in terms of with whichever direction we go, whether it's subspecialty certification or focus practice designation, is we need to be able to lay out to ABEM, what makes law enforcement medicine different than EMS. I mean, rather than emphasizing the areas where there's crossover, we have to emphasize the area where there is differences. If we were to do focus practice designation, then we could potentially create something that could also be folded into a one year EMS fellowship, which would give EMS fellowships that additional certification when they complete their fellowship, which is certainly one of the pluses for doing a focus practice designation. So the answer to your question is, we haven't decided yet.

- [Larry] Fair enough, thanks.

- You're welcome, who else? I see other hands up. Oh yeah, all right. I'm sorry Dr. McCartel Yes.

- Yeah, I have to do it the old fashioned way. I couldn't find the button to put a cute little hand up on my screen. I think a couple issues need to be addressed. I think we had discussed a lot in the past few months, especially from the IACP'S perspective, we really need to broaden it more than just emergency medicine physicians. We've got a variety of different physicians doing various levels of support of law enforcement, be it cardiology, be it orthopedics, be it trauma surgeons. And I think we need to keep it a big tent as far as the medical community, certainly going forward. As far as, I think you'll remember, we had that discussion a few months ago where some of the leaders of TEMS residencies were talking about the fact that they had to wait till the year after somebody had done an EMS fellowship if they were gonna get any law enforcement training. So I think that's certainly something important to consider. But I recently did some training in Western Kansas and I realized they don't really have emergency medicine physicians out there because in many parts of middle America, call is handled by family practice people, nurse practitioners, because in some of these critical, many of these critical access hospitals, thoroughly seeing maybe 25 to 50 patients a day. And that frankly just doesn't justify having a board certified emergency physician there, let alone somebody specially trade. And the other thing I think we need to keep in mind is whatever track we need to do, I think we should have ongoing discussions with, which is the group of people that do post certifications around the country because it's actually harder to move as a police officer from one state to another, especially people that are reserve officer status than it is to move as a physician. So certainly we wanna have those people in the loop as far as what's going on with this project as well. That's it for me.

- Excellent, thank you, sir. Dr. I see you've gotta hand up there too.

- Thank you, Dr. Springer. I'd like to riff on Dr. Wong's presentation if I may. I don't know how many, I don't recognize some of the names from previous meetings, so may I take a moment and just tell them where I'm coming from?

- Oh, please sir.

- I've been practicing emergency medicine for 53 years. I am a retired, commissioned and sworn law enforcement officer and combat Vietnam era. But the point is, in police work, as Dr. Wong so clearly pointed out, it is not the SWAT team that is taking most of the hits. It is our officers doing traffic stops, domestic violence calls, mentally ill, just the drugged, drunk, deranged, before they get to the emergency department, it's the patrol officer who has to deal with them. I believe that where we go in training police officers has to be, as you said, Dr. Springer, a lot past tourniquets. What a lot of people know but don't appreciate is that the reason the military emphasizes extremity injuries is because they're wearing body armor. Now most of our officers are supposed to be wearing body armor, but very few of them are wearing rifle plates. And that is a concern. So it's not just extremity injuries, as you very clearly stated, I though retired, I still get phone calls from the officers that I worked with, social calls, medical questions, assistance. If you are on the street, you actually become part of the brotherhood, sisterhood. You are not somebody who drops in for the occasional lecture or the exciting event. I think that teaching really has to go beyond the departments that we are affiliated with. I teach a lot of police officers, not from a department that I was affiliated with, just because they all need this information and training. I'll step off the soapbox. Thank you, sir.

- Excellent, thank you sir. Yeah, we really, again, I don't think we're gonna find much in the way of argument among our section members about the importance of this concept and moving just beyond SWAT and certainly just good having Dr. McCartel also chipping in here too, because obviously among the other organizations that we will need to be reaching out to are IACP. Again, it's been mentioned here in the conversation too, EMSP and their TAC Med group. There's so many out there and even though of course now, meeting with ABEM. Yeah, it's a big deal. But I still tell everybody, this is our baby steps and expect to be hearing a lot more about this in the future. And also, please, please, again, thoughts, issues, concerns about this, ideas about this concept, funnel it and my direction, funnel it in the direction our section leadership, push it out there to all the section members and in our forum so that we can discuss it because this requires the input of everybody.

- Can I add something there, Brian?

- [Dominique] Yes.

- I just wanna say, you know, none of us that I know of are getting really rich off of this, it may be naive, but our goal is simple. We really want to save as many lives as we can, as as physicians understanding law enforcement perspective, any omissions are purely unintentional at this point. And so keep the comments coming and the suggestions coming. Dr. McCartel, working with your group was really interesting to see how many law enforcement leaders were there and how many different specialties were involved that were interested. Something that I personally hadn't considered before. The goal of this isn't to make it exclusive, another exclusive certification or title or something that's impossible for people to get. It's rather to get this core body of knowledge across so that more law enforcement lives can be saved and it's to be as inclusive as possible, while still maintaining that level of expertise. So I think, I mean I've been doing this a long time, but I think I'm still naive on that level. I want to keep it that way if possible. I don't need another political thing in my life. I don't need another grab for anything in my life, you know, at this point. So again, keep the suggestions coming. They've been great so far.

- Cool, I appreciate that Dr. Wong. And you know, the only thing that I can certainly promise you is that at some point, this will become political, so just get ready for it and it's bound to happen anyhow, so, so speaking of involving others, let me just move on now to our next topic. I had pushed out an email to the section and I had mentioned in there that we, again, the leadership have discussed the concept of associate membership. And I think I probably put it at the bottom of the email, so you probably all read the first couple lines like, yeah, Springers is rambling here, so, and missed that. So associate membership, we talked about whether it would be beneficial to the section since we're engaging in this larger concept of law enforcement medicine, to allow non ACEP physicians to join the section. So they would be able to participate in webinars, they would enjoy those section benefits. They would be paying dues in order to have this associate membership, but they would not be voting members really at this point. We're still kind of tossing the idea around. Again, potential advantages would be to create a more inclusive forum and bring in some of those other partners, kind of help bring them in under our roof. Questions that come up though are still, so, you know, who really would we be allowing, how are we going to potentially vet them? I mean, again, Dr. Wipfler and I, again, discussing like, well, whether or not they're gonna need a signed form from like some SWAT team leader saying that they're involved out there in TEMS. And I'll just say since again, this is right now just open forum. I am, I'm still a little iffy on the concept, of course, certainly my, my, my job will be to do ultimately, the bidding of the section. I kind of wonder though, I think that this, while it is critically important to go ahead and to do that outreach and to bring others into our discussion, whether or not I want them there for every discussion, I'm still a little bit iffy on that as opposed to at certain times for certain meetings, maybe bringing in select invitees to join in. But again, I'm still willing to discuss this concept. Does anybody have strong feelings one way or the other? Dr. McCartel

- [McCartel] I'm just gonna ask, do we have some kind of a mechanism for students? Because Dr. Wong certainly has a farm club out there in West Virginia. She has the two people that Keegan referred to and I don't know what specialty they're going into, but she also had a guy who looks like he's gonna go to general surgery, gave a great talk on the COVID deaths and I certainly think it'd be good for us to have some kind of a student section as well.

- Agree, actually, you know what, Rick and Deanna, I mean actually back when I was like a student member of ACEP, I was not a section member and of course I know we have, EMRA and sections. Is that something that will students, could students join the section?

- Yes, so currently there is a med student category to join ACEP. So as long as they're an ACEP member, they could join the section. So there's currently three categories. If they're an a full ACEP member, an EMRA member or a med student who's joined ACEP, they could join. So what happened several years ago, 15 years or so ago, the sections voted to let others join the section. So that would include, that included non ACEP physicians or nonphysician members, like EMS or whatever. And at that point the section decided to limit it just to ACEP members, except for the section to decide who they want to allow. But it would require a vote of the section membership. And then as Brian mentioned, they could not be an officer, they could not vote and then you could limit their access to like the listserv and being invited to the webinars and so forth. You can spell out what you want them to be involved or have access to.

- Very good, excellent. Thank you. I'm afraid to again drop the dreaded S word, but I think what we may end up doing to discuss specifically as far as for associate membership and also maybe ideas to expand our student outreach, will be to send out a survey and get section feedback that way. So I'll be working on putting something together here, get it out your way and then you'll get annoying, incessant emails from me saying please fill out your survey. Please fill out your survey, some upcoming discussion about things coming coming our way for the calendar year of 2023. I'm gonna turn it over to Dr. Ackerman to talk a little bit about the newsletter and also to give us some updates on TECC, Dr. Ackerman.

- Thanks, so I guess the other thing, jumping off of the medical student, since we've got a few different names online than I've seen before, over at SAM, we are also trying to put together a tactical and law enforcement medicine group with the hope that there would be a lot of overlap and collaboration and recruitment for medical students and residents who might not be familiar with the concept, which seems to be an awful lot of them at the SAM meetings. So if you are an SAM member or have contact with some, that very long link I just put in the chat, and it's been posted to the section message board, please get people to sign up. I think we need to get up to 75 people signed up to get a interest group over at SAM. So in terms of the newsletter, I think in thinking about tactical and law enforcement medicine as its own distinct thing within medicine and specifically within emergency medicine, we need to be working on creating our literature. And so our newsletter, while there are things about the section that we will continue to put out, information about our officers, I think this is an opportunity for folks who want to start thinking about contributing to the body of literature that we truly need. I would love to have people step up and say, look, I wanna write an article about, even if it's something that isn't very developed, we can probably work with you and get something where at least we can start some conversations and hopefully across the larger group, start laying out some of the groundwork for things that maybe would turn into formal publications in other settings. So I would love to have volunteers to step up if there's something that a team that you work with does particularly well. A way that you approach training that you think is different, unique, that should be shared. It may be as little as just a few paragraphs but this is a great opportunity to share it with the larger group. I'm hoping to put together a little bit of a journal watch, kind of plucking out of the wide range of journals out there that are relevant to what we do. Some interesting little summaries of things. I actually have a few medical students and residents who've expressed some interest in working on that. So if any of you see articles that you think would be appropriate, please go ahead and send them my way. I think that that, again, we can't all be reading all the journals that might be relevant. So you know, I stumbled across an article that had to do with training, medical training needs for officers in Scandinavia. I doubt that anybody else found that one. It's one of my random literature searches, but again, it's something that contributes to what we all really should be developing a broader base of knowledge about and understanding because it's the heart of what we do. I'll pause for just a second just in case there are any questions about the newsletter or ideas, things that anybody would like to see, that we can start putting in. I will put my email address in the chat as well and I think on the section area for ACEP, that you also can click on people there and message them. So that's another option as well. All right, so I will jump forward to the Committee for Tactical Emergency Casualty Care, which I am the ACEP rep for on the guidelines committee. We actually had a meeting last week, two days, and I guess there's sort of three major things that came up that you can expect to be hearing more about over the next little bit. One of the items is, the next version of the guidelines is going to include a preamble. It will be including some items about the history and rationale and things like that, that have kind of historically been missing from the TECC guidelines, that probably will be useful for many of us as educators and as medical directors, to sort of help the folks that we are leading in training to understand those guidelines. Part of that is a bit of discussion that was interesting at the meeting about in the context of TECC, what the word tactical means. And the short answer is, it doesn't mean what most of us think it means, that the initial idea was it was tactical as in tactics, that is the set of rules and other things that you use to rapidly make decisions in a high stress environment. That happens to work very well in the tactical environment where we've got lots of Velcro and holsters and firearms and things like that, but is also equally applicable to other settings. And the CTECC has actually had contact from other disciplines, including those out fighting wildfires, to look at how do you use some of the ideas and concepts within TECC, in those settings where the threat is not a bad guy shooting or blowing things up, but it's a force in nature, a building that is actively collapsing or other sorts of things. So that's something that I think for many of us, who've always thought of it as the civilian version of TCCC, is going to be a little bit of a growing distinction. The other part that comes out of that discussion is the TCCC guidelines are largely written around the assumption that those who are injured are relatively young, relatively healthy soldiers as opposed to our officers that are a pretty wide range of ages and range of medical conditions, our civilians, which are all over the age range. And so a big chunk of what we were doing was actually discussing line by line in some of the guidelines, where terminology needed to be changed to move the guidelines away from sort of a combat facing mindset. So the term we were throwing out was de-Velcroizing. And so there are a lot of things where the discussion, at what point does a casualty become a victim or a patient, as opposed to sort of the generic, more combat oriented terminology. So that's something that will be a change. I don't think it changes what we teach or what we do, but it does change what the words of the guidelines, if we're going to quote them, actually say, there will be one new guideline that will be forthcoming, which we spent a good bit of time on, which is around specifically pediatric care. There is not a whole lot in there that for most of us as emergency physicians is a surprise, obviously with kids, we need to think about some of the anatomical differences, physiologic differences, size differences. There was a longer discussion about how we define pediatrics and the primary author was tasked with coming up with a good set of words that basically was, if they look like a kid, they're a kid. That way we avoid having to figure out in the field whether somebody is 15 or 14 or 16 and what body parts they may or may not have hair on and various other things that in other sets of guidelines would slow us down in determining who to apply this to. I think the one surprising recommendation across the room for many of us was that the pediatricians felt very strongly that in pediatric trauma, we needed to be checking blood sugars, which was sort of a bit of a shock and led to a little bit of a discussion about how necessary that was. And it seems like our pediatric colleagues were digging in on that one. So if it's not in your pediatric response bag, get some glucose tabs and a glucometer in there. So I think those are the major issues from the CTECC. The next meeting coming up is going to be at the NAEMSP meeting. So as part of that meeting, and specifically it will be on the 24th and they're gonna do a shorter meeting than what they generally have done at NAMSP and that's gonna be from five to 7:00 PM and I think that's a Tuesday. As we get closer, I will post something out to the section. Just as a reminder, all CTECC meetings are open meetings, so if you happen to be at that meeting, definitely you should come. The next meeting after that will be at the SOMA, Special Operations Medical Association, Scientific Assembly. They do not yet have a date for that one.

- Excellent, thank you very much Dr. Ackerman, and sincerely appreciate your input and stuff that obviously is critical to us and we like having our man on the inside to help sort through this. It's kind of fascinating as far as for pediatric trauma, both the glucose part and they're sort of Supreme Court-like description is like, yeah, I know it's a kid when I see it. So really, really neat and please keep us posted. One thing as far as for also marking your calendars. Our first CME webinar is going to be coming up on January 10th. Again, that's a Tuesday. We're gonna be scheduled for our usual time, which is going to be 7:00 PM central, 8:00 PM Eastern standard time. And the illustrious forensics guru, Dr. Bill Smock, will be talking about forensics, what the tactical medic needs to know. And he's a pretty engaging speaker and he always has cool pretty gory slides. So definitely mark down that date and that time. And again, CME will be provided. We're working on locking all that down now as well. So I hope to see you all there, for the last 15 minutes, I mean really here, what I'd like to do would be just to open this up in terms of open form as far as for questions, on any of the material that we have covered this evening. Again, whether TECC, law enforcement, medicine associate membership, anything, I'll kind of turn it over to the audience, if anybody has any questions, come. I saw a hand, we're gonna have to, you have to have a kid or a grandkid, right? Or who can show you how to actually do.

- I've been looking for this button but I couldn't find it. But anyway, I'm old fashioned I'll just, but no, since you brought up Bill Smock talking about forensic medicine, especially on the living, as opposed to pathologists doing this group, he's affiliated with the Alliance for Hope out of San Diego. And that's something you may wanna check. They do a lot of work on strangulation training and I'm sure, not on how to do it, but how to treat it and how to document it. But they're going to be having a conference in Fort Worth, Texas from like February 28th to the end of that week. And a couple days of, it's gonna be people that have already had their training. They're going to be giving a workshop on courtroom presentation. But they're also gonna have a pediatric non-fatal strangulation conference there too. And I'm not sure if they're having one on adults as well or not, but take a look at the Alliance for Hope website. I know they're doing the pediatric strangulation assessment at that conference, and that might be a good follow up to Bill's talk.

- Excellent, thank you, sir. Any other questions, comments, concerns? Death threats for me.

- If anybody on is gonna happen to be in San Antonio on January 25th. The ASTM, which writes a lot of standards for a variety of things, is holding a meeting where standards for a wide variety of public safety equipment is going to be discussed. There's a working group that is working on creating a standardized testing system for tourniquets, which I will be at that meeting specifically. But looking at the schedule for the day and the day before, there's standards for body armor and a variety of other pieces of equipment that folks might be interested in. And again, this is another group that is essentially if you show up, you can join in. And so an another one to be aware of. On the note of the forensics, a few weeks ago I was asked with a nurse that is working with my SWAT team to do a webinar for the Association of Forensic Nurses, which happened after they asked her to write a book chapter that we did. And their group has expressed some interest in sort of being our partner in nursing that's getting into this space. And as far as I know, there isn't really any other place that the nurses in the space have gotten together. And certainly there are multiple nurses out there, working with law enforcement, a variety of capacities.

- Awesome, that's really exciting, especially, well as far as for bringing nursing in, but then also just going back to standardized tourniquet testing. I mean, maybe the rats tourniquet will finally just go away forever. And the thought of which makes me very happy. Other input questions, concerns from anyone out there? Well, if not, then we will wrap this up 10 minutes early. Again, I really want to give my sincere thanks to everybody for tuning in here tonight for everybody's input. And please again, spread the word to your colleagues, to other section members about the work that we're engaging in here. And I encourage you to encourage them to participate. I encourage you all to participate. My virtual door is always open, so please email me, let me know what questions you have and if you have questions for any of the other section leadership, please reach out to us. Again, thank you so much to Rick and Deanna for once again, making all this happen and helping us keep our section members engaged. When John Wipfler initially was talking about how we really wanted to have some sort of online engagement on a almost monthly basis, I thought, oh man, that's gonna be super labor intensive. And as my tenure for being the section chair approached, I thought, well, maybe we'll go ahead and reduce this. And then of course, at the Scientific Assembly, we get all these section awards and I think, shit, well, I guess we're sticking with this and it's a great way to go ahead and to engage with everybody. And I am really looking forward to when we do this again in January, though I certainly will say, I hope to hear from you all before that, if not to you and to your families. Wishing you all very, very happy holidays here. And please be in touch and if not, then plan on talking to you again in 2023. So thank you all and good night.