[Editorial Forward: Officer Tyler Campbell, Winimac Police Department, recently completed the requirements for Senior Instructor. His current article presents a thought-provoking question: can police do more to save lives? This article is worth consideration by both law enforcement agencies and individual officers.]
Emergency Medical Training Increases Survivability of Victims
By Officer Tyler Campbell
The preservation of life falls to every police officer in the United States. Police officers must protect themselves, other officers, and the public as a whole, yet felonious acts still occur on a daily basis. The 2019 Department of Justice study on criminal victimization indicates 1,019,940 people victimized by aggravated assault in the United States.[1] The ability of police officers to provide emergency medical services upon their initial arrival saves lives that may otherwise be lost.
Police Response Requiring Medical Intervention
Numerous law enforcement situations necessitate medical intervention, including aggravated battery, active shooter situations, neglect of children, and many others. According to the International Association of Chiefs of Police, “…more than 80 percent of law enforcement agencies responded to medical emergencies, and approximately 50 percent of agencies provided some form of on-scene patient care.”[2] With 45.9% of police officers in the United States operating at the first responder medical level or above,[3] there is still a need for further education to police agencies about the benefit of these courses.
Active Shooter
Active shooter situations demonstrate tragic circumstances necessitating medical training for law enforcement officers. The Federal Bureau of Investigation has defined an active shooter situation as “one or more individuals actively engaged in killing or attempting to kill people in a populated area.”[4] In 2019 alone there were 28 active shooter events as defined by the Federal Bureau of Investigation.[5] This does not take into account other shootings in private venues that do not meet the definition of active shooter.
The police response to an active shooter may appear contradictory to normal police priorities. The duty of the initial arriving police officer in an active shooter situation is to neutralize the threat. This may involve bypassing critically injured victims to ensure the most expeditious neutralization of a shooter.[6] The duties of law enforcement following initial incident stabilization are widespread and concurrent, and include searching for additional shooters, securing the crime scene, and stabilizing victims.[7]
Emergency medical services and fire departments that commonly assist in these situations usually stage in a secure area to await a safe scene. The period of time required to secure a protected corridor for medical personnel to triage, treat, and evacuate victims could be significant. If police officers could provide stabilization care before dedicated emergency personnel can arrive, the survivability of victims increases significantly.
The Golden Hour Paradigm
Faster treatment of victims of trauma will increase survivability. “The first hour after injury will largely determine a critically-injured person’s chances for survival.”[8] The ability for police officers to provide care within that first hour directly contributes to survival. The comparisons between traumatic injury in the law enforcement setting and combat injuries in the military are telling. The United States Naval Institute concludes that, since they have implemented a Golden Hour policy, the survival rate of injured service members has increased.[9]
Some disagree regarding the golden hour thought process. According to Lerner, the Golden Hour thought process is an outdated and there isn’t necessarily a direct correlation between time and trauma. Lerner criticizes Cowley’s theory as based on a Vietnam war era study and deserves more current analysis. Lerner further cites Cowley’s research and states that Cowley’s research involved studies at rural Maryland hospitals. Lerner posits that with the limitations of hospitals in the rural setting, transfer of care to the next levels could be extended. The case study showed patients that were seen at six hours had double the mortality rate as patients seen within the Golden Hour.[10] There was a lack of research showing mortality rates between the two time frames. Regardless, the Golden Hour paradigm is still a common practice among pre-hospital care providers and the United States military.
Law Enforcement Training
The initial training for law enforcement officers in the United States traditionally consists of some type of basic training course. This training is critical for the success of police officers, however, there is often little to no instruction in the emergency medical field. For example, the Indiana Law Enforcement Academy Tier 1 course provides nine hours of instruction in emergency medical services awareness out of a 600-hour course.[11] The Indiana Law Enforcement Training Board also requires certification in CPR that is done at the police officer’s parent agency.
Police officers across the nation frequently receive cross-training in the EMS field, often spending personal money for the training. The United States Department of Defense (DoD) created a curriculum to train its members in pre-hospital care. The Tactical Combat Casualty Care course that was developed by the DoD was adapted to medical personnel and law enforcement by the National Association of Emergency Medical Technicians.[12] This training in initial trauma care and evacuations has proven invaluable in extending the Golden Hour and increasing survivability rates.
Crossover Training with Emergency Medical Services
The National Registry of Emergency Medical Technicians (NREMT) acts as a certification agency within the United States that is not government affiliated. The NREMT sets standards for several states for requirements for pre-hospital healthcare providers. The available levels of certification are Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Advanced Emergency Medical Technician (AEMT), and Paramedic.[13]
The basic life support level consists of the EMR and EMT levels. At this level students are taught skills that would be most applicable for police officers engaging in their duties, including tourniquet application, wound packing, trauma assessment, shock management, and other critical skills.[14] Police officers that are trained to one of these levels have the ability to assist victims to a higher degree. Police agencies within the United States would do their communities a significant service if each officer under their purview were trained to the Emergency Medical Responder level.
Application and Training of Tourniquets
The use of tourniquets in the combat setting began as a life saving measure in the last several centuries. Ancient examples abound of doctors tying strips of cloth around an extremity before amputation for a wound that would be easily treatable today. Those old strips of cloth evolved into a modern lifesaving tourniquet. This has not always been the case.
As recently as 2012, the EMS thought process was that the application of a combat tourniquet equated to a lost limb. Even so, the tourniquet was still used because the alternative was loss of life. The United States wars in Iraq and Afghanistan from 2001 to present have provided drastic improvements in design and application of this critical tool. The United States military has been training in the use of tourniquets in combat situations during this period and have found that application of tourniquets for up to two hours can preserve the viability of limbs.
Police officers and departments in the United States have adapted military data and have begun to use these tools. As of 2015, approximately 30.6% of police departments issue tourniquets to their officers with a total of 85.2% of officers authorized to purchase tourniquets.[15] A police officer should be able to readily access two tourniquets while responding to unknown or high-risk situations. The ideal situation would allow for four or more tourniquets to be available. In practice, officers that are in possession of at least one combat style tourniquet will provide the public, fellow officers, and themselves an advantage.
Suggested Equipment for Trauma Care
There are several other tools available for police officers to provide aid to victims of trauma: hemostatic agents, pressure dressings, and chest seals are some examples that can be carried and utilized with basic training. Hemostatic agents promote rapid blood coagulation in arterial bleeds, where there is sufficient blood loss to activate the chemicals involved. Pressure dressings are applicable in extremity wounds similar to those indicating tourniquets. The effectiveness of pressure dressings at hemorrhage control, especially due to amputation, is less effective than tourniquets. Chest seals are an effective tool, however the use is specifically designed for sucking chest wounds. Field expedient chest seals can be just as effective without the need for purchasing proprietary equipment. These tools can be applied effectively given proper training; however, they lack the wide application and ease of use of tourniquets. As with any new tools, police officers must comply with federal, state, and local laws as well as department standard operating procedures.
Conclusion
Ensuring preservation of life, safety, and the protection of property falls to the dedicated men and woman who earn the title of police officer in the United States. Throughout the years, people have invented new equipment, developed new techniques, and examined case studies on war and conflict to assist in these processes. Emergency medical services and other emergency services personnel put their lives at risk every day, however there are unsafe situations that demand solely a police presence. There will always be victims of violent crime; and the ability for law enforcement, the true ‘first responders’, to assist these victims is critical.
[1] Morgan, R., and Truman, J. (2020) Criminal Victimization 2019, U.S. Department of Justice, Bureau of Justice Statistics, NCJ 255113. https://www.bjs.gov/content/pub/pdf/cv19.pdf.
[2] Bollard G., Czarnecki, F., McArdle, D., Meade, J., Pappas, P., Springer, B., Sztajnkrycer, M.D. IACP Police Physicians Section Emergency Trauma Care. Accessed September 21st, 2020. International Association of Chiefs of Police. https://www.theiacp.org/sites/default/files/2018-08/Emergency%20Trauma%20Care.pdf.
[3] Aberle, S.J., Dennis, A.J., Landry, J.M., Sztajnkrycer, M.D., (2015) Emergency Medical Response in Active-Threat Situations: Training Standards for Law Enforcement. Federal Bureau of Investigation Law Enforcement Bulletin. https://leb.fbi.gov/articles/featured-articles/emergency-medical-response-in-active-threat-situations-training-standards-for-law-enforcement.
[4] Federal Bureau of Investigation (2020). Active Shooter Incidents in the United States in 2019. https://www.fbi.gov/file-repository/active-shooter-incidents-in-the-us-2019- 042820.pdf/view.
[5] FBI (2020).
[6] Payne, A. (September 21st, 2020) Federal Law Enforcement Training Center Active Shooter Instructor. Personal Interview.
[7] Payne (2020).
[8] Cowley, R.A. (1975). A Total Emergency Medical System for the State of Maryland. Maryland State Medical Journal, Volume 24, Pages 37-45.
[9] Richmond, L. C. (2019). PROLONG THE 'GOLDEN HOUR': When rapid evacuation of casualties to higher-level treatment is unavailable, Fleet Marine Force corpsmen must be trained in prolonged field care. U.S. Naval Institute Proceedings. https://www.usni.org/magazines/proceedings/2019/december/prolong-golden-hour.
[10] Lerner, B. E. (2020) The Golden Hour: Scientiļ¬c Fact or Medical ‘‘Urban Legend’’? Golden Hour. https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1553-2712.2001.tb00201.x.
[11] Indiana Law Enforcement Training Board (2020). Basic Course Schedule 221 Final. https://www.in.gov/ilea/files/Basic%20Course%20Schedule%20221%20Final.pdf.
[12] Tactical Combat Casualty Care. National Association of Emergency Medical Technicians. Accessed September 21st, 2020. https://www.naemt.org/education/naemt-tccc.
[13] NAEMT (2020).
[14] National EMS Scope of Practice Model (2019). National Highway Traffic Safety Administration. https://www.ems.gov/pdf/National_EMS_Scope_of_Practice_Model_2019.pdf
[15] Aberle, S.J., Dennis, A.J., Landry J.M., Sztajnkrycer M.D., (2015) Hemorrhage Control by Law Enforcement Personnel: A Survey of Knowledge Translation from the Military Combat Experience. https://academic.oup.com/milmed/article/180/6/615/4160528.
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