The protective mission exists whenever it is deemed appropriate or necessary to dedicate personnel and resources to the safety and physical well-being of an individual or group of individuals. Protection enshrouds these individuals, commonly referred to as “very important persons” (VIPs), in a conceptual envelope consisting of and supported by physical security enforcement, threat countermeasures, dynamic intelligence acquisition, and operational contingency preplanning. In the past decade, increasing emphasis has been placed on developing specialized emergency medical capabilities in support of protective operations.

Historically, protective methodologies were developed and utilized by law enforcement for the physical security of political leaders and high-ranking government officials, generically referred to as protectees or principals. Perhaps the most widely recognized example is that of the U.S. Secret Service and its protective mission serving the President and Vice President and their immediate families. Increasingly, the private sector has been similarly challenged to deploy protective measures for leaders of industry and commerce and popular sports and entertainment figures, as well as individuals of significant wealth and personal influence.

Within the protective arena, the enhancement of readiness for medical contingencies has gained recognition as an essential priority. Having immediate access to qualified and dedicated emergency medical resources for both the VIP protectee and, to a lesser extent, the personnel engaged in protection, or the protective detail, is consistent with the overall protective mission. The intrinsic medical assets dedicated to protection may be broadly deemed protective medicine. Protective medicine assets ideally serve dual functions, as both an evaluative adjunct for threat assessments and an immediate intervention mechanism in the event of medical contingencies.

The overriding principle that governs protective methodology is the single-minded focus on the security of the VIP or protectee. In fact, personnel involved in protection may be very simply separated into two distinct categories: those directly engaged in physical protection and those providing operational support. This basic concept may challenge conventional paradigms of the medical provider. Regardless of how experienced, advanced, or technically proficient the medical providers assigned to protection may be, they are nonetheless considered support personnel.

It is important to recognize that it is ultimately the VIPs or protectees that determine the level of protection, and similarly protective medical support, that is acceptable or desired. It may be generally true that protectees are often accepting of as much protection as may be offered to them, however, there exists the possibility that a particular VIP may elect to refuse some or all protection. Broad decision making and planning for protection must be in the context of protectee agreement and cooperation. It is further conceivable that protectees may specifically elect to minimize or dismiss entirely their medical support, potentially out of concerns for the public appearance of frailty or infirmity.
It is a generally advisable principle that medical personnel assigned to protection deploy and operate discretely, so as not to widely identify the nature or extent of their intended mission (Fig. 33.1).

Fundamentally, the actual medical care rendered to VIPs should not be expected to be intrinsically different from that afforded to the population at large, although certainly the scope and scale of available resources in some instances might be greater for such individuals. From generalized experience, it may appear that accessibility to both primary and specialist care is superior for the VIP, due to either their individual influence or the effectiveness of others acting on behalf of the VIP. Nevertheless, in the United States, access to appropriate and timely emergency care is considered universal and remains undifferentiated based on an individual’s wealth, stature, or influence. Regardless of whether the clinical care sought is routine, urgent, or emergent, enhancing intrinsic medical capabilities may reduce the challenges posed to protective operations of getting care for a VIP.

There exists a broad spectrum of emergency medical services (EMS) that may be deployed in support of protective operations. The manner in which these may be enlisted can be broadly categorized into three models of protective support. Each of these approaches has its intrinsic advantages and potential drawbacks. The selection of one versus another is a command decision of the highest order and must be commensurate with threat assessments and the overall level of protective support deemed necessary.

The most basic and easily configured level of support involves incorporating preexisting medical services and providers, on an ad hoc basis, into the protective environment (1). Examples are adding a local private or jurisdictional EMS to a traveling motorcade and arranging for medical providers to be either on-site or on-call at the location of an event attended by a protectee. This approach minimizes costs and requires little or no long-term intrinsic program maintenance. Potential disadvantages to be expected include medical providers lacking familiarity with law enforcement and protective operations, limited ability to conduct thorough background clearances of providers, and inconsistency of medical capabilities from venue to venue. The concerns for operational security (OPSEC) are elevated with these types of arrangements.

An intermediate model is one that incorporates some fixed medical capabilities into the protective operation itself in a longitudinal fashion. As an example, the agency or department responsible for protection may choose to employ or contract medical personnel and acquire EMS transport vehicles as intrinsic assets. This approach increases the degree of standing medical readiness and some capability, depending on levels of providers, for initial treatment, triage, and transport in the event of emergency medical contingencies. There are increased direct costs for this approach and it does relatively little to enhance the capability for primary care, preventive medicine, and advanced interventions and therapeutics.