Force Science News

Force Science News #158: Could more wounded cops be saved with police-specific combat care?

Training note: By popular demand, we’ve added a handful of additional seats to the previously sold out Force Science Certification Course scheduled for Nov. 8-12, 2010 in San Jose, CA. To inquire about registering or for additional details, e-mail training@forcescience.org.

In this issue:

I. Could more wounded cops be saved with police-specific combat care?

II. Letters from FS News readers

I. Could more wounded cops be saved with police-specific combat care?

A study of “preventable” deaths among LEOs wounded in felonious attacks suggests that a new protocol for emergency “combat care” designed specifically for law enforcement may be necessary to augment the military model currently emphasized in police circles.

“Potentially fatal wounds suffered by cops tend to be different from those suffered by soldiers,” says Dr. Matthew Sztajnkrycer, a Force Science advisor who conducted a recent analysis of how officers are killed in the U.S. “Identifying just what those differences are is an important first step toward making changes in training that may save lives now being lost unnecessarily.

“The long-range implications in terms of immediate response in the field could be huge.”

Sztajnkrycer’s study is part of an ongoing personal campaign to improve police medicine, motivated by his active roles as chairman of emergency medicine research at the Mayo Clinic, a “SWAT doc” for law enforcement agencies in Minnesota, a faculty member for the Force Science Analysis certification course, and a member of FSI’s technical advisory board.

RESEARCH GOAL. Currently, Sztajnkrycer explains, most police training for immediate emergency care of wounded officers in the field derives from the military-based Tactical Combat Casualty Care (TCCC) model, which “prioritizes the use of tourniquets for control of life-threatening extremity bleeding.”

This approach has been credited with saving “countless lives in forward operating environments” in Iraq and Afghanistan. However, “no studies have examined its appropriateness” in typical domestic law enforcement situations, he says.

That was a gap he sought to close.

RESOURCE POOL. Drawing on FBI summaries of LEOs feloniously killed during a recent 10-year period, he isolated 341 “immediate deaths.” That is, “those occurring within an hour after wounding” and most likely to prove fatal “without immediate lifesaving interventions.”

He eliminated cases of “multi-system blunt trauma,” typically caused by vehicular attacks and considered too complex for a TCCC-type intervention, and those of fatal head trauma, which he categorized as “non-preventable deaths.”

In the end, he narrowed his database down to 123 officers whose deaths from wounds were “potentially preventable;” i.e., the victim might reasonably have been saved timely and appropriate medical intervention. Overwhelmingly, the preventable fatalities resulted from gunfire.

WOUND DIFFERENCES. According to earlier studies by other researchers, more than 60% of all preventable military combat deaths occur because the victims bleed out from wounds to their arms or legs, Sztajnkrycer notes. That’s why TCCC emphasizes rapid “extremity hemorrhage control” (tourniquet application) above all other medical procedures, especially if emergency lifesaving is attempted under conditions of a continuing active threat.

In contrast to the military experience, however, Sztajnkrycer found that only 1.6% of the potentially preventable LEO deaths involved extremity hemorrhaging. In actual numbers, that’s just 2 officers during the study period. Both of them died more than a decade ago in the same incident at the hands of an offender who shot each in the femoral artery with an assault rifle.

“No law enforcement death due to isolated extremity trauma has been reported since 1998,” Sztajnkrycer says. In part, at least, that could well be because wounding patterns incurred in police incidents are much different than those encountered in military combat, where IED blasts have become typical causes of injury.

The next most common cause of preventable death in combat, according to military data, is “tension pneumothorax,” accounting for one-third of mortalities, Sztajnkrycer reports. This occurs “when a collapsed lung causes pressure to build up in the chest cavity, compressing the heart and great blood vessels,” leading to shock and ultimately fatal consequences.

Among LEOs, Sztajnkrycer found, more than 70% of potentially preventable deaths resulted from chest wounds, likely attributable to the close-quarters nature of most attacks on police. That’s over twice the military incidence.

The specific nature of these injuries was hard to determine, he says, “because of the limited medical data provided” by the FBI summaries. But while most deaths probably involved bleeding from the heart and major vessels, at least some likely evolved from “undiagnosed and untreated tension pneumothorax.”

Indeed, he estimates, from 5 to 14 times more wounded officers may have succumbed from that kind of injury than from extremity hemorrhaging.

The second greatest cause of preventable LEO deaths, according to Sztajnkrycer’s analysis, was wounding of the neck and throat. Again, specifics were elusive but he concluded that some of these deaths likely “occurred due to spinal cord injury or injury to the carotid artery and/or jugular vein.”

Others may have involved airway compromise, another concern addressed in the TCCC modality. In that case, TCCC calls for the placement of a nasopharyngeal airway. “Unfortunately,” Sztajnkrycer points out, “in the context of penetrating neck wounds”—as from a gun or edged weapon—“it is unlikely that this simple approach would have any effect on the outcome.”

UNREALISTIC PRIORITIES? In light of his findings, Sztajnkrycer suggests that the TCCC model’s focus on tourniquet application, which has been vigorously promoted in police publications and training conferences, “may be over-emphasized in the law enforcement setting.”

By the same token, he believes that tactical medical training for cops might save more lives by placing “heavy emphasis on the recognition and management” of tension pneumothorax.

That might seem like a tall order. Treatment of that condition “involves inserting a sharp, large-gauge needle into the chest cavity to vent the trapped air,” a procedure that is considered “an advanced, paramedic-level skill beyond the capabilities of most police officers,” he says.

Yet, the military considers this skill “so critical that it is taught to non-medical combat lifesavers,” who have proven that they can “safely and rapidly perform it in a limited setting.”

As part of his police-related medical responsibilities, Sztajnkrycer taught the procedure to a test group of nearly 2 dozen Minnesota LEOs and found that they could learn it in about 90 minutes and maintain their skill in applying it “without significant deterioration” for months afterward. He continues to teach it as a gross motor skill in scenario-based training, in which officers must recognize the condition and perform emergency treatment “while operating tactically and maintaining situational awareness.” A report on this experiment appears in the journal Prehospital and Disaster Medicine[Click here to read it]

Such treatment, of course, supposes the presence of functional backup to aid the downed officer—another telling difference in many instances between the military and much of law enforcement. Unlike soldiers, who usually operate in groups of 3 or more, “many officers patrol individually,” Sztajnkrycer says.

Of the 123 officers with potentially treatable wounds who “might have benefited from live-saving interventions, 44 “had no assistance present at the time of their injury.” Aside from the use of a 1-handed tourniquet, all skills in the TCCC model “are buddy-care procedures.” This “decreases the ability” of TCCC skill sets to “impact preventable law enforcement deaths,” Sztajnkrycer says.

THE FUTURE. Ultimately, Sztajnkrycer wants to see created an evidence-based, widely accepted protocol of emergency medical procedures tailored expressly to law enforcement realities and the life-threats officers face on the street. Toward that end, he is currently involved in 2 major moves forward:

• He is collecting autopsy reports on officers who have died of chest trauma to determine the exact nature of their injuries, the means by which these wounds might have been treated to prevent death, and the extent to which non-medical personnel might be trained to tend to these casualties in the field. He anticipates some firm conclusions by the end of this year and plans to present preliminary findings at the IACP conference in October in Orlando.

• He expects soon to launch a dedicated website to collect important specifics that are missing from the FBI’s data base on officers killed and assaulted. This will allow officers and agencies to anonymously report details of both fatal and non-fatal woundings. Among a variety of new information, he hopes to compile details on “near-misses”—wounds that proved survivable and how they were treated. Force Science News will report particulars of this site and how you can interact with it in the near future, then follow up periodically with the findings it yields.

“I have 2 fundamental goals in my research,” Sztajnkrycer told FSN recently. “One is to empower officers with the knowledge and confidence necessary to save their life or their buddy’s life in a medical emergency. The other is to provide law enforcement decision-makers and funding bodies with up-to-date scientific information so they know where to get the best bang for the bucks they spend for equipment and training.”

Meanwhile, is it appropriate for law enforcement to abandon the TCCC model for medical response just yet?

“Unequivocally no,” Sztajnkrycer stresses. “At the moment, TCCC is the best formalized approach to treating combat casualties that we have. Tourniquets can save lives in certain circumstances, and they may have saved many near-misses that we have not currently documented. Using a tourniquet is a skill every officer should have. The need for that skill may arise rarely, Sztajnkrycer says, “but rare does not mean unnecessary.”

“Also TCCC teaches a certain disciplined mind-set in approaching medical problems in threat situations that is important for officers to integrate. TCCC is a work in progress, just as medicine in general is a work in progress. In the future, both will be different from what they are now.

“The point is not to train cops to be paramedics but to teach them some down-and-dirty techniques to keep themselves and others alive in a medical crisis. The challenge is to find out which easily learned skills are most useful to law enforcement compared to other at-risk professions.

“I think in 1 to 2 years, we’ll have figured out what those skills are and know how best to teach them.”

[A report by Dr. Sztajnkrycer describing his study appears in The Tactical Edge magazine, published by the National Tactical Officers Assn. Click here to access “Learning from Tragedy: Preventing Officer Deaths with Medical Interventions.”]

II. Our readers write….

Active killer surprise
Regarding our report on single-officer response to active killer emergencies [Transmission #155, 7/30/10]: In our summer training on active-shooter response, we tried something with amazing results.

In a scenario where a suspect moved and shot inside a building, as a real offender would when hunting for victims, we had a 2-officer team enter and about 15 seconds later, a second team go in. Each team would split up, so 4 officers total were moving independently rather than maintaining any kind of team cohesion.

Several times the first officers would get the suspect cornered from different angles and killed before the other 2 could even get in. We then had the suspect start running from the officers when he saw them. With 4 officers coming from different directions, the suspect didn’t have a chance and the incident was over in seconds compared to minutes when the teams stayed together.

Having multiple officers splitting in different directions was by far the most effective way to stop the active shooter. The officer playing the suspect role usually would engage the first officer he came in contact with. This effectively stopped the suspect from seeking out victims because he was engaged with the officer. Usually within seconds a second officer would arrive and the suspect would be taken out. The suspect was so focused on the first officer, he wouldn’t see the second and was completely surprised.

One question that’s asked when we have officers go in different directions is what about cross-ire between officers if they come in contact with the suspect. From what I’ve seen, when you have a contact team or even just 2 officers moving together, one will almost always get out in front of the other. They when they make contact with the suspect and start to engage him, almost always the officer in the rear shoots at the suspect even though his partner is a few feet in front of him—easily shooting the partner in the back. During our scenarios where officers split we never ran into a crossfire situation. Not saying it isn’t possible but it seems the risk is much greater when staying together.

Inv. Robert Duncan, active-shooter instructor
Waterloo (IA) PD

K-9 simulator scenarios
Reference our article on K-9 training simulator scenarios [Transmission #156, 8/14/10]: We’ve designed our own and have had them in place for several years as part of the Advanced K-9 Handler class we host each year. We have scenarios for K-9 handlers as well as ones for patrol officers as a backup to the K-9.

We saw the importance of using the simulator when they were first introduced. It became apparent when we went through on our own, then went through with the dogs. We found that when handlers had their dogs, part of their attention was always occupied with what the dog was doing, slowing their response from what it was while alone. It started us on the road to integrating a lot of scenario training into our weekly training.

Sgt. Kevin King
Spokane (WA) PD

Written by Force Science Institute

September 10th, 2010 at 10:20 am

Posted in Force Science News