Officer Down!

As you and your partner climb into your rig, you hear over the county law enforcement channel, “Officer down, officer down!” You respond and are cleared to approach the scene, and as you pull up near the two-story house, four colleagues are carrying the injured officer across the lawn to your ambulance. As they lay him down, one says, “He was hit in the upper leg. As soon as we could, we put a tourniquet on it, and then poured in the clotting agent you showed us how to use.” As your partner begins her initial rapid trauma assessment, you check the leg and find the wound has stopped bleeding. An officer places the injured officer on oxygen via a non-rebreather mask, and you quickly wrap the wound with a sterile trauma dressing and gauze. As your partner finishes her assessment and critical interventions, you place a cervical collar and move the injured officer o­nto a long backboard. You depart for the trauma center with a total on-scene time of six minutes.

Introduction

In 2010, the year of the most current data available at the time of this article, 128 law enforcement officers were killed in the line of duty in the United States. Of these, 56 were killed feloniously (i.e., intentionally) by a suspect. Another 72 were killed accidentally (i.e., unintentionally) in the course of their duties. Another 53,469 were assaulted in the line of duty.¹ Seventy-five percent of those killed were assigned to patrol activities, and 57% were killed with at least one other officer present. Fifteen officers were killed in ambushes and another 14 during arrests. Only three were killed during tactical operations such as high-risk warrants. Fifty-five of the 56 officers killed intentionally were killed by handguns. Thirty-six of these officers were wearing body armor.¹ Of those, 46% were shot in the head, 12% in the front upper torso, 5% in the back, and the rest were shot in areas their body armor did not cover. Whereas firearms were responsible for the majority of officers feloniously killed in the line of duty, motor vehicles (see photo 1)  were responsible for 78% of those killed accidentally. These include deaths in pursuits, roadblocks and from being struck during traffic stops. These have remained consistent over the last five years.¹

Of the more than 53,000 officers assaulted in 2010, more than 13,000 (26%) of those sustained some form of injury. The leading cause of injury was fists, hands and feet, which were twice as likely to occur as the second cause, edged weapons. Firearms were the third cause, coming in slightly behind edged weapons.¹

Responding and Scene Issues

Not all officer-down calls involve violence and an aggressor. Some may involve an officer falling down a flight of stairs, slipping on ice, drowning while attempting a water rescue or suffering a cardiac arrest. Regardless of the cause, you should expect that emotions on scene from officers and other responders will vary dramatically.^2–6 This may also take the form of aggression, possibly directed at EMS by friends and relatives if a suspect was also injured or killed at the scene.⁷ Typically EMS will stage at a location a few blocks from the incident, although tactical paramedics and dual-role police/paramedics may not stage, instead responding directly to the scene due to their advanced tactical training and operational capabilities.⁸

Once cleared to respond to the scene, EMS providers need to remember that it is a crime scene and anything and everything may be evidence. Unfortunately, once EMS providers finish their training, there is often little to no ongoing education in the area of crime scene operations.⁹ That being said, there is also scant education for law enforcement on the needs or operational priorities of EMS providers at crime scenes.⁹ Although an EMS provider’s focus is on the patient, which in this case is an injured officer, preservation of the crime scene—including the officer and his or her uniform—must be considered.^10,11

Preservation of the crime scene can be accomplished by remembering a few simple steps as you enter. First, if law enforcement advises that the patient is obviously deceased (see sidebar),¹² enter with a minimum number of EMS providers and ask if there is a route through the scene to the patient. Those entering should enter and exit via the same route. This will cause the least disturbance of the crime scene, but allow an adequate number of providers to enter. Do not touch, move or disturb anything unless it is necessary for patient care. When assessing the patient, remove the minimum clothing necessary and do not cut through bullet, knife or projectile holes. As you open and use supplies, try to place your garbage in one place. Lastly, advise law enforcement of anything that you may have touched, moved or disturbed, and document in as much detail as possible your assessment and all of your actions.^13,14

Though the scene may be “secure” or “safe” according to law enforcement, EMS providers still need to maintain 360-degree situational awareness.⁸ Threats may emerge from pets, distraught family or friends, bystanders or crowds if the scene is outdoors or at a large venue, and even the patient, especially if the officer is hypoxic or has suffered head trauma.

Initial Assessment and Interventions

Ideally, initial treatment following an officer being injured is provided by the officer him- or herself, if able, or by a partner once the threat is neutralized.⁸ The primary concern for EMS providers is assessing and correcting problems associated with compromises to the airway, breathing and circulation. Due to research from combat medicine and the tactical training of many law enforcement officers, you may find an officer rendering care using a CAB approach, which is stopping any life-threatening bleeding by direct pressure and then assessing and intervening in compromises of the airway and breathing.^8,15 Many law enforcement officers are issued or purchase Israeli 16 or Combat Application Tourniquets (CATs),¹⁷ both of which have demonstrated effectiveness in controlling extremity arterial bleeding.^17,18 They may also carry one of a number of hemostatic agents (Table 1) which have been demonstrated to successfully slow or stop arterial bleeding,^19,20 especially in areas where a tourniquet cannot be used.

If in the scenario above a tourniquet had not been applied and you observed arterial bleeding as you approached the officer, you would have directed another officer to apply direct pressure while your partner placed a tourniquet two inches above the injury site (see photo 2) and tightened it until the bleeding stopped. If one tourniquet does not stop the bleeding, it is recommended that a second be applied above the first¹⁸ or a hemostatic agent be used once forward arterial flow has been slowed.¹⁹

As your partner worked on controlling the bleeding with an officer, you’d move to the head and begin your rapid trauma assessment by asking the injured officer what happened and where he hurts.^8,18 This not only yields pertinent information as to what happened, but also allows you to assess his neurological status, the patency of his airway and how well he’s oxygenating. C-spine control may also be initiated at this time based on mechanism of injury. Say the officer is able to answer questions appropriately, though somewhat anxiously. Your partner advises there appears to be an entrance and exit wound in the leg. You assess his respiratory status at 28 and non-labored. You palpate a rapid, strong carotid pulse, but the radial pulse is rapid and weak, and the skin is cool, pale and slightly clammy to the touch. A firefighter slips a non-rebreather oxygen mask on the officer, delivering 15 liters per minute. Based on your assessment at this point of major, uncontrolled extremity hemorrhage and signs of hypovolemic shock, you have determined the officer to be a load-and-go patient.⁸

As other firefighters bring a long backboard, you perform a rapid trauma assessment of the neck, chest, abdomen, pelvis, and upper and lower extremities. As the team places a cervical collar on the officer and log-rolls him onto the board, you rapidly assess his back. During your assessment you unclip his duty belt by undoing his keepers and cutting his uniform belt. As you hand the duty belt to an officer, the team rapidly secures the injured officer to the board and moves him to the ambulance for transport.

Assessment Considerations

Assessing an injured officer is no different than any other trauma patient. What differs are the components of their uniform you may need to remove to adequately assess and manage them. The first component is the officer’s duty weapon (see photo 3), backup weapon(s), Taser and other devices which may be present and could pose a threat to EMS if the officer becomes combative from hypoxia, shock or a head injury. Ask for assistance from the officer’s partner. They will be able to secure any weapons or take appropriate steps if they are evidence. If the officer is wearing body armor, you need to remove it to assess the chest. To do this, simply pull the Velcro apart at multiple locations (see photo 4). Once you remove the armor, check the inside of it. Often the officer has their blood type labeled on the inside of the body armor (see photo 5). Body armor is designed to stop certain types of rounds. If the officer is struck by a higher-powered round than the vest is designed to stop, there is a high probability the round will penetrate the vest.²¹ Body armor is also not designed to stop pointed or edged weapons. In either type of attack, damage to the uniform and vest gives the provider one of the first assessment clues as to whether the officer has sustained injuries, where they may be and their severity. Even if the vest stops a round, the officer can still suffer life-threatening blunt force trauma.²²

Communication With Other Officers and Family

With HIPAA there is a fairly clear line of what we can and cannot say to others, as well as to family members. Many officers have already expressed to their partner(s) whom they want contacted if they are injured in the line of duty and what they want those people told. Some law enforcement agencies have HIPAA documents on file expressly for that purpose.

There are three questions all officers want answered (Table 2). These are not just for the officers on scene, but help guide their departmental critical incident protocol that is initiated when an officer is injured or killed in the line of duty.^23,24 The goal of this is to notify family and other officers in the department before they find out through other channels; contact clergy and associated resources; and, depending on the size of the department, begin working with other law enforcement agencies to help cover their area.

When leaving the scene, the officer’s partner may request to ride in the ambulance so that someone from their department is with the injured officer and able to relay information to the officer’s family. This is especially critical if the officer is not expected to survive and may want to relay last wishes or messages to loved ones. If the officer’s partner or another officer cannot go with them due to the unfolding event, often their partner will make sure they have a cell phone to call family while en route to the hospital. It is also not beyond the realm of possibility that family of the injured officer may show up on scene or, in rare circumstances, be brought to the scene by another officer (for example, for an officer involved in a motor vehicle crash requiring extensive extrication who is not expected to live).

Special Considerations

There are four special considerations an EMS system should plan for in caring for injured officers. First, officers and suspects should always be transported in different ambulances. This is done out of respect for the officer, who may be critically injured and dying, and safety issues. If the suspect’s arm needs to be unsecured for an IV and there is an armed officer in the patient compartment of the ambulance, there is a possibility, albeit slim, that the suspect could get possession of the officer’s sidearm. Second, law enforcement officers will generally want to escort the ambulance to the hospital, especially if the injuries are life-threatening. Third, if the officer becomes combative and needs to be restrained due to hypoxia, shock, head injury or other conditions, use soft restraints, not handcuffs. Finally, the officer may refuse pain medications. This may seem strange or counterintuitive. From the officer’s perspective, they are concerned with remembering and recounting the event as clearly as possible. This is not only for the post-incident investigation; if the incident goes to trial, any medications that may have altered the officer’s perception, interpretation or recall of events may be used discredit their testimony.

Psychological/Emotional Response of EMS Providers

There is ample literature on post-event psychological and emotional response to traumatic incidents,^25,26 but in talking with EMS providers who have responded to officers who have been mortally injured, it is clear the psychological and emotional responses can begin even before they arrive on scene (and even before they are dispatched). Receiving a call like “officer down” may result in the EMS crew wanting to get to the injured officer quickly and may precipitate risky driving behavior.²⁷ EMS personnel should recognize their own responses to such situations and attempt to keep their emotions and behavior from influencing their reactions.

EMS providers have described their initial responses on these scenes as surprised or shocked. Some described a moment of hesitation as they processed what they were seeing, especially if it was an officer they knew. Following this was a period of refocusing. Some EMS providers believed they refocused faster because they knew the officer involved.²⁸ Once refocused, EMS providers described falling back on their training,²⁷ which they felt overrode their emotions²⁹ and allowed them to perform the required tasks no differently than for other patients. Some even thought they perhaps performed at a higher level.

Termination of resuscitation is a difficult decision to make for any patient. It is even more difficult when that decision involves an officer. One EMS provider said, “It wasn’t an easy decision, but it was the right decision.” EMS providers have also described wanting to maintain the dignity of the officer during and following resuscitation when it was terminated on scene. Following termination, EMS providers described being angry and trying to control emotions as they informed partners and wrote their reports.

The days following an officer-involved call, especially a line-of-duty death, will be very challenging for the EMS provider. Feelings of sadness alternating with feelings of anger at the attacker are common.³⁰ It is common for EMS providers to feel helpless or that they didn’t do enough.³¹ Manifestations of post-traumatic stress, such as flashbacks or sudden feelings of sadness or loss,³⁰ are common and may be experienced for some time following the incident.

Preparing

Nothing can truly prepare an EMS provider for what they will see and feel during and after responding to an “officer down” call. EMS providers who have responded to downed officers and terminated resuscitation believe the following four areas will assist other providers faced with such a situation. First, be prepared for horrific injuries—especially to head—since officers are often shot at close range. Airways with significant problems that are difficult to control should also be anticipated due to the close ranges involved. Second, emotions may be overwhelming. EMS providers should rely on their training. Training and repetition of tasks were described by EMS providers as being key components to being able to refocus and treat the officer. Third, realize that the officer may have suffered mortal injuries and that there may be nothing you can do to change the outcome. This recognition may help reduce, though not completely remove, the feeling of guilt in a provider that more could not be done to help the officer. Finally, treat the officer with dignity. The way you conduct yourself and treat the officer during and following resuscitation will help the other officers present. Remember, they will be emotional victims of the incident just as EMS providers are.

Conclusion

Violence directed toward law enforcement officers is an unfortunate reality that will continue resulting in many officers being injured—and in some cases dying—in the line of duty. EMS will continue to respond to and care for injured officers. Beyond this, EMS needs to be an aggressive advocate for working with law enforcement agencies in their area to develop and deliver short courses on self-treatment and treating your partner until EMS arrives, and by developing pocket trauma kits that contain a tourniquet and hemolytic agent. EMS must pursue preparing the officers with whom they work for the unthinkable no less aggressively than law enforcement pursues wanted criminals.

References

1. FBI. About Law Enforcement Officers Killed and Assaulted, 2010, www.fbi.gov/about-us/cjis/ucr/leoka/2010.

2. Reiser M, Geiger S. Police officer as victim. Prof Pysch: Research & Practice 15(3): 315–323, 1984.

3. Miller L. Tough guys: Psychotherapeutic strategies with law enforcement and emergency services personnel. Psychotherapy: Theory, Research, Practice, Training 32(4): 592–600, 1995.

4. McCaslin S, et al. The impact of personal threat on police officers: Responses to critical incident stressors. J Nervous & Mental Disease 194(8): 591–597, 2006.

5. Renck B, Weisaeth L, Skarbs S. Stress reactions in police officers after a disaster rescue operation. Nordic Jour Psychiatry 56(1): 7–14, 2002.

6. Aaron J. Stress and coping in police officers. Police Quarterly 3(4): 438–450, 2000.

7. Ellis C, Lord J. Homicide. National Victim Assistance Academy, www.ncjrs.gov/ovc_archives/nvaa99/welcome.html.

8. Campbell J, Heiskell L, Smith J, Wipfler III E. Tactical Medicine Essentials. Sudbury, NY: Jones & Bartlett, 2012.

9. Casay J, Burke T. Police and EMS: Can’t we all get along? Law & Order 5(6): 97–101, 2003.

10. Fisher B. Techniques of Crime Scene Investigation, 6^th ed. Boca Raton, FL: CRC Press, 2000.

11. Bledsoe B, Porter R, Cherry R. Paramedic Care: Principles & Practice, 3^rd ed. Upper Saddle River, NJ: Pearson, 2009.

12. Sunnybrook Centre for Prehospital Medicine. Deceased Patient Protocol, www.socpc.ca/newfiles/TorontoDeceasedPatientProtocolFinal.pdf.

13. New York Department of Health, www.health.ny.gov/nysdoh/ems/original/operatio/8-5.pdf.

14. U.S. Department of Justice, Office of Justice Programs. Crime Scene Investigation: A Guide for Law Enforcement, www.fbi.gov/about-us/lab/forensic-science-communications/fsc/april2000/twgcsi.pdf.

15. Tactical Combat Casualty Care Curriculum, www.naemt.org/education/PHTLS/TCCC.aspx.

16. Shipman N, Lessard C. Pressure applied by emergency/Israeli bandage. Military Med 174(1): 86–92, 2009.

17. Walters T, et al. Effectiveness of self-applied tourniquets on human volunteers. Prehosp Emerg Care 9(4): 416–422, 2005.

18. Middleton T. Lessons from the battlefield. EMS World, www.emsworld.com/article/10320031/lessons-from-the-battlefield.

19. Burgert J, et al. Effects of arterial blood pressure on rebleeding using celox and traumadex in porcine model of a lethal femoral artery. Amer Assoc Nurs Anesth 78(2): 115–120, 2010.

20. Alam H, Boris D, Dacarta J, Rhee P. Hemorrhage control in the battlefield: Role of new hemostatic agents. Mil Med 170(1): 63–69, 2005.

21. Second Chance Body Armor. Monarch Series, www.secondchance.com/default.aspx.

22. McMullen MJ, Williams CJ. Injuries to law enforcement officers shot wearing personal body armor: A 30-year review, www.policechiefmagazine.org/magazine/index.cfm?fuseaction=display&article_id=1571&issue_id=82008.

23. Wade D. Line-of-duty-death police verification notifications. FBI Law Enforcement Bulletin, April 2001.

24. Wilson B. Standardized law enforcement funeral protocol. Police Chief 73(5), 2012.

25. Gersons B. Patterns of PTSD among police officers following shooting incidents: A two-dimensional model and treatment implications. Jour Traumatic Stress 2(3): 247–257, 1989.

26. Loo R. Post shooting stress reactions among police officers. Jour Human Stress 12(1): 27–31, 1986.

27. Jansen A, et al. Central command neurons of the sympathetic nervous system: Basis of the fight-or-flight response. Science 270(5,236): 644–646, 1995.

28. Rivard J, Dietz P, Martell D, Wrawski M. Acute dissociative responses in law enforcement officers involved in critical shooting incidents: The clinical and forensic implications. J Forens 47(5): 1–8, 2002.

29. Shipley P, Baranski J. Police officer performance under stress: A pilot study on the effects of visuo-motor behavior rehearsal. Int Jour Stress Management 9(2): 71–80, 2002.

30. He N, Zhao J, Archbold C. Gender and police stress: The convergent and divergent impact of work environment, work-family conflict, and stress on coping mechanisms of female and male police officers. Policing 25(4): 687–708, 2002.

31. Honig A, Roland, J. Shots fired; officer involved. Police Chief, Oct. 1998.

The article is dedicated to officer Richard Crittenden, Sr., North St. Paul PD (LODD 9/7/09), Sgt. Joseph Bergeron, paramedic, Maplewood PD (LODD 5/2/10), and all law enforcement officers who have made the ultimate sacrifice.