"Do Know Harm" read the morale patch on the man's battle-dress uniform.
Even though he, like me, was a primary care doctor taking a tactical medicine course that teaches the skills needed to be part of a SWAT team, the sentiment stopped me cold. I had no designs on trading my white coat for a ballistic vest, but I'd been intrigued to learn that a colleague was a SWAT doctor. So during my vacation in Palm Springs last February, I signed up to join him.
It was more than curiosity. I found it troubling and wanted to find out for myself what it means to be part of a paradigm that imagines communities as battle zones, where choosing sides is expected and a willingness to use deadly force is taught. I wanted to know, as a doctor, what would happen in that context to my professional empathy, that essential capacity that makes doctors people who heal—or at least, people who treat the sick or injured and who try to "do no harm."
Tactical medicine began with the war on drugs and a commitment to "take care of the good guys." This battlefield medicine is now part of law enforcement doctrine and is practiced by physicians throughout the United States. SWAT team doctors are often deputized, and armed, and they serve at the will of local police. They help develop strategies by analyzing evacuation routes and planning for exposure to chemicals or animals. They even make sure that snipers who have an allergy to poison ivy know how to avoid it. Sometimes SWAT docs stay behind in armored vehicles, but often, especially on smaller teams, they enter with the rest of the team.
The class I took had SWAT officers, EMTs, firefighters, and physicians from a range of specialties. Some had found their way to SWAT duties through their local gun clubs, some as a form of community service, and others out of a desire for adventure and boredom with routine medicine. They all shared what our course materials described as a "law enforcement mentality."
Part of the allure of this hyper-masculinized medicine is, I believe, related to healthcare's new realities. Gone are the days of the solo practitioner, where all you needed was a shingle, a stethoscope, and a willingness to work long hours. Now medicine is all about multi-specialty groups, hospital systems, an emphasis on shared decision-making and models of caregiving that rely on teams of doctors, nurses, and other "physician extenders." This is a sharp contrast with the authoritarian traditionalism that many physicians expected to be their privilege.
The two weeks of training were divided into class and field work. Class focused on clandestine labs, bombs, WMDs, clearing buildings of threats, and a survey of the less lethal weapons used for crowd control. There were lectures on the treatment of hemorrhage, penetrating chest wounds, and a talk on team health that focused on diet, exercise, and attention to stress management. We learned how to survive being shot from a video featuring officers who had done so. The film included a cameo by Sylvester Stallone. We also learned the protocols that govern what to do if we shot someone ourselves.
We were always geared up for our field work. We were instructed to "train as you fight," so we did—with helmets, ballistic vests, elbow pads, knee pads, and water reservoirs on our backs. We shot on the move and from the ground, and we were taught the skills to keep fighting even if one of our weapons failed.
Every lesson was framed as good guys vs. bad guys. I thought I was resistant to that kind of siege mentality, but it left a mark. There was a moment as I was firing my M-4 rifle at the silhouetted man-shaped target in front of me when I heard my instructor shout "let it out," and all I thought was Kill, kill, kill.
The Force on Force scenarios—think live-action _Call of Dut_y—stressed active shooter simulations, including one at a day-care center. By the end of the course, we had been flash-banged and shot at, and we ourselves had shot someone, placed tourniquets, sealed simulated chest wounds, and intubated patients, all under extreme conditions. The refrain was: "Good medicine can mean bad tactics—and bad tactics gets people killed."
We were much more than what former LAPD chief Daryl Gates imagined when he created the acronym SWAT in 1967. We were a special weapons attack team with full medical autonomy. There is no historical precedent for this: Even military doctors are not expected to be "warriors in the sense of taking up arms, unless their own lives, or those of their patients, are threatened."
After our final exams, the police officers received peace officer standards and training credits, the doctors, continuing medical education credits, and everyone a challenge coin—a commemorative medallion, modeled on what members of the military receive, to recognize our achievement.
I have great respect for the SWAT officers I met. They are highly trained and highly skilled; the best of them have the power and grace of a Heisman winner or a Bolshoi Ballet dancer. For hostage situations, barricaded suspects, and active shooters, I have no doubt that they're the guys for the job.
But for my medical colleagues, I worry. Volunteering for a militarized police unit, choosing tactics over medicine, and being in environments where someone who should be presumed innocent may be killed are disturbing mutations in our centuries-old ethic of care. "Injuring occurs," wrote Harvard professor Elaine Scarry, "because we have trouble believing in the reality of other persons."
So to any doctor who wants to volunteer, I would say: Care for the police in your town, teach them techniques that can save their lives and help them save others, but don't forget to teach them empathy. Empathy is not only good medicine, but as Captain Ron Johnson of the Missouri State Highway Patrol knows, good tactics, too.
Stuart Lewis is a General Practioner whose writing about medicine has appeared in the Guardian_, Columbia: A Journal of Arts and Literature, and several medical publications. _