Less Lethal Injury Management

The modern law enforcement officer often has a wide array of less lethal weapons at his disposal, including chemical and inflammatory agents, directed energy devices (e.g., TASER), impact weapons (e.g., handheld batons and impact munitions) and trained police dogs (K-9s). These weapons have proven to be very useful in obtaining compliance and/or taking uncooperative or combative suspects into custody. In addition, many private citizens carry some type of similar less lethal weapon for protection.

EMS personnel are sometimes requested to assess and treat people who have had less lethal weapons used against them. This is dependent on a variety of issues, including the policies of the involved jurisdictions, type of weapon used, and potential injuries or illnesses resulting from its use. Many myths and misconceptions exist regarding the effects of less lethal weapons, so it is important for EMS personnel to have a basic understanding of less lethal weapons in common use. That understanding must include knowledge of the mechanisms of injury or other conditions that may occur during or after the use of less lethal weapons, and basic patient assessment and treatment that may be necessary.

These tools are referred to as “less lethal” instead of “less than lethal” or “non-lethal.” While the semantics may seem insignificant at first glance, the difference in terms is actually very dramatic. “Less than lethal” and “non-lethal” both imply that death cannot possibly result from the use of such a weapon. The term “less lethal” properly takes into account the remote possibility that death may result from virtually any given tactic or tool under the right set of circumstances. The use of these tools is accepted because the odds of death or serious injury resulting from their use are extremely low and in some cases, statistically insignificant. Less lethal weapons are very effective at bringing control to chaotic situations.

EMS responsibilities regarding these situations actually begin long before the EMS dispatch. You should communicate ahead of time with local law enforcement agencies to determine what types of less lethal weapons they may use and to identify the injuries and illnesses that may be possible as a result of such use. Taking the time to talk now and ask questions will be more effective than trying to sort out concerns at 0300 hours with an uncooperative suspect in custody who is complaining of injury. Don’t let your personal opinions of the subjects involved or the use of force affect your response to the patient. Your job is to assess, treat and possibly transport a patient irrespective of your feelings about the patient and whether you feel the force used was justified.

Ensure law enforcement has the suspect under control before you try to begin assessment and treatment. Even if the suspect appears to be cooperative, be extremely cautious in requesting that handcuffs be removed. They were put on the suspect for a reason, and they are helping to maintain scene safety for you and your crew. Most assessment techniques and treatments can be performed without removing a suspect’s handcuffs. Keep in mind that a suspect’s complaints of illness or injury may be legitimate, they may be a feeble attempt to delay a trip to jail or they may even be planning to escape custody from the less secure environment of an ambulance or hospital. If in doubt, consult with medical control and local law enforcement, and avoid removing handcuffs unless absolutely necessary. If a suspect must be transported for further treatment, consider whether transport by ambulance is actually necessary or if the suspect can be transported by patrol car.

Oleoresin Capsicum (Pepper Spray)

Chemical and irritant weapons come in different compositions and deployment methods but all are designed to cause so much discomfort that a suspect will be persuaded to cooperate. While effective on most people, they are often less effective on subjects who are intoxicated, drugged, mentally ill, highly agitated or highly focused. Oleoresin capsicum (OC), better known as pepper spray, is currently the preferred agent for use by both law enforcement and civilian defense sprays. Unlike chemical agents such as CS and CN, OC is an inflammatory food product made from natural plant oils. It is not a chemical and therefore has no chemical code. The primary component of OC that makes it hot is capsaicin, extracted from the capsicum in peppers and commonly used in over-the-counter topical analgesics.

The effects of OC vary from person to person based on many factors, including, but not limited to, complexion, amount of exposure, delivery method, motivation level, psychiatric conditions, and drug or alcohol impairment. OC has no known lasting effects. The respiratory tract becomes inflamed and swells, and the subject may cough, gag and gasp for breath as they experience significant nasal drainage. The subject’s skin may temporarily change color to red, yellow or orange and they may complain their skin feels hot. The eyes may open and close rapidly or shut completely. The subject may temporarily experience body shakes, weak legs, poor balance, hearing impairment or rigid muscles. Psychological effects on the subject may include panic, confusion, disorientation and intense fear of blindness and/or suffocation.

The use of OC has been thoroughly studied by numerous organizations including the National Institute of Justice. An increase in blood pressure and heart rate is possible and anticipated due to the discomfort caused by the use of OC, and the likelihood that someone sprayed with OC has been involved in an altercation with police or others. There has been no evidence of abnormally low O₂ levels or complications for suspects with a history of lung disease, asthma, smoking or respiratory inhaler use. There has never been a substantiated death attributed solely to the use of OC and only two in which its use was cited as a contributing factor making them statistically insignificant compared to the millions of OC exposures since its use began.

Treatment for a subject exposed to OC is usually as simple as flushing with cool water and facing the subject into the wind. Encourage the patient to force his/her eyes open to allow the fresh air and water to remove the resin. Water sources in the field may include sinks, garden hoses, fire trucks, or sterile water bottles or normal saline bags from your ambulance. Either have the patient remove his/her own contact lenses or use a contact lenses remover. Soft contacts will have to be discarded. Continue to calm and verbally reassure the patient that he/she is safe and that the effects will wear off. Discourage the patient from rubbing his/her eyes and/or affected skin. Monitor the subject for respiratory or cardiac distress due to exertion, stress or positional restraint. Recovery time may vary from as little as 10 minutes to 2 hours.

Electronic Control Devices (ECD)

Both private citizens and law enforcement have used a variety of electronic control weapons (ECDs) over the years. Some sources refer to the newest generation of these weapons by a variety of other terms including conducted energy weapons (CEWs) and electro-motor dysfunction weapons. Handheld stun guns are considered old technology but are still occasionally encountered in the field. Shock belts and shock shields are sometimes used in correctional or courtroom environments to control prisoners. Stun guns, shock belts and shock shields all work through pain compliance. The most popular electric weapons currently in use by both law enforcement and civilian populations are manufactured by TASER© International. Unlike electric weapons based on pain compliance, the TASER’s effectiveness is based on electro-motor dysfunction. The wave of electrical pulse from the TASER overwhelms the body’s natural electrical signals to the muscles. The most common TASER products used by law enforcement are the TASER model X26 and model X2.

TASER products are used in one of two primary ways—probe deployments and drive stuns. Probe deployments are the preferred method due to increased standoff distance and greater effectiveness. When the trigger of the TASER is pulled, compressed nitrogen fires two barbed probes out to a maximum distance of 35 feet depending on the type of probe cartridge that is being used. The barb allows the probes to easily attach to a person’s skin or clothing. The pulses of energy from the TASER are then sent along two thin wires that connect the probes to the TASER. If good contact is made between the probes and the subject, temporary electro-motor dysfunction results. The second method of TASER use is the “drive stun.” A drive stun is conducted by pressing the TASER against the body of the resistant person while activating the electrical pulses. This method depends primarily on pain compliance as the contact is not sufficient to cause electro-motor dysfunction.

News reports about TASER usage like to focus on the fact that the X26 delivers 50,000 volts when discharged. That number is probably used because it scares people who don’t understand the significance of amps and volts. Amps are a much better indicator of danger than volts. Amperage levels are generally considered lethal at levels from 0.1–0.2 amps. The average current of a TASER X26 is well below dangerous levels at 0.0021 amps. For comparison, a 100 volt wall outlet delivers 16.0 amps and a Christmas tree light bulb delivers 1.0 amps. In terms of joules, the X26 delivers 0.07 joules per pulse compared to an external cardiac defibrillator that delivers 150–400 joules per pulse. According to a study commissioned by the National Institute of Justice and released in 2011, “current research does not support a substantially increased risk of cardiac arrhythmia in field situations” involving use of devices such as the TASER. It is estimated that well over one million TASER shocks have been delivered during both volunteer training applications and field applications. Testing on animals has shown insignificant effects on heart rhythms or blood pressure. Pacemakers and implanted defibrillators are designed to withstand external electrical forces 800 times stronger than the TASER. Pacemakers and implanted defibrillators may experience a momentary effect if placed in direct contact with a TASER, though no health danger has been identified from this.

The injuries that are most likely to be sustained from TASER use include muscle strains from strong contractions, and cuts, bruises and abrasions from falls. Small burn marks may be present if drive stuns have been delivered from the TASER. Multiple burns may be present due to repeated drive stuns in a dynamic encounter and they are easily treated with antiseptic and adhesive bandage. The probes that are discharged from the TASER X26 are identical to a #9 fish hook. In order to safely remove a probe from human tissue, touch the probe and see if it moves easily. If so it is simply in the soft tissue and can be removed by pulling the skin taut and firmly pulling the probe out. Be sure to keep your fingers far enough away from the probe that you won’t be cut by the barb as you pull the probe out. Disinfect the site and cover with an adhesive bandage. If the probe does not move easily it may be stuck in bone or cartilage and will require removal at the hospital. Likewise, probes should not be removed in the field if they are stuck in sensitive areas such as the eyes, groin or nipples. Consider removal by hospital staff if the probe is stuck in an area where noticeable scarring could possibly result, such as the face. While officers are trained to remove probes from soft tissue, some agencies prefer that EMS or hospital staff remove probes and evaluate any subject who has been shocked with a TASER.

Impact Weapons

Law enforcement officers have been carrying impact weapons longer than they have been carrying firearms. Today’s common impact weapons come in multiple forms, including various styles of handheld batons (collapsible and non-collapsible) made of polycarbonate, wood or metal. Though flashlights are not intended as impact weapons, they have become weapons of opportunity in rapidly evolving situations, delivering similar injuries as traditional batons. Impact weapons also include munitions that are fired at a suspect. These munitions may be made of rubber, foam, wood or cloth bags filled with lead shot (beanbags). Some impact munitions contain OC or irritant chemicals for additional effect.

Impact weapons work by delivering fluid shock to the bones and muscles. Because their effectiveness is based on pain compliance, there is a good possibility that multiple impacts may be delivered and there may be multiple impact injury sites due to the movement of both suspect and officer. The typical injury locations with handheld impact weapons include extremity muscle groups, bones and joints, but impact munitions may also be directed at the torso depending on the type of munition used. Impacts to the head and spine are traditionally avoided but may have been intentional based on a deadly force threat or unintentional due to movement by the suspect and officers. Depending on the circumstances, impact weapons may cause pain, bruising, swelling, fractures and difficulty with movement. Treatment is fairly routine—assess the patient for DCAP-BTLS. Control bleeding (rare), apply ice packs to the impacted area and splint any suspected fractures.

Police Dogs (K-9s)

Law enforcement agencies have used dogs trained to apprehend suspects longer than they have used any other less lethal weapon besides impact weapons. A bite from a trained K-9 is typically different than a bite from a regular dog or “attack” dog. Regular dogs will bite multiple times, sometimes known as “typewriter” biting. These bites may also be found in multiple locations and will include puncture marks and indications of chewing and tearing of the flesh. A police K-9 is trained to “bite and hold,” which limits the number of punctures. Tearing of the skin may still occur somewhat as the suspect may try to fight the K-9 or pull the extremity out of the K-9’s mouth. Though the bite is different, treatment for K-9 bites is still similar to that for any other dog bite—control bleeding, irrigate the wound, if possible, with normal saline or sterile water, and apply dressings and bandages.

Conclusion

Regardless of the type of less lethal weapon used, the following priorities need to be followed by EMS personnel. Ensure the scene is safe and the suspect/patient is under control before approaching and making contact. Adhere to basic body substance isolation precautions. Consider whether or not handcuffs actually need to be removed in order to assess and treat the patient. The single most accurate predictor of violence is a history of violence. If the patient was previously combative with others, including officers, there is a high probability the patient could become combative again and potentially target you and your crew. Otherwise, follow your local protocols based on the basic complaint of your patient where practical. Monitor the patient for respiratory and/or cardiac compromise based on the likelihood the patient is very agitated and may be under the influence of drugs or alcohol.

Any such incident will be much easier to resolve if you have taken the time to talk with your local law enforcement agencies and determine what types of less lethal weapons they use, the types of calls involving less lethal weapon use in which they expect an EMS response, and under what conditions they expect EMS to assess, treat and transport a suspect/patient. Ask to attend and observe in-service training in less lethal weapons by local law enforcement agencies so you can see first-hand how they work and what to expect.

The next decade will see the continuing development of the current array of less lethal weapons and the increased use of new technologies, including laser dazzlers, which cause temporary blindness and disorientation when directed toward a person’s eyes; active denial systems or microwave emitters that excite water molecules in the outer surface of the skin and cause the targeted person to experience a burning sensation; and long range acoustic devices (LRAD) that direct highly focused audio toward a target causing pain. Regardless of the type of weapon used, the intent of less lethal weapons will still be to stop hostile action and/or take suspects into custody with the least chance of injury to everyone involved. EMS personnel will continue to find themselves being dispatched to assess and treat those who have been affected by less lethal weapons.

Bilbiography

U.S. Department of Justice, Office of Justice Programs, National Institute of Justice. Study of Deaths Following Electro-Muscular Disruption, May 2011, www.ncjrs.gov/pdffiles1/nij/233432.pdf.

Eric Dickinson is a lieutenant with the Vinton (IA) Police Department and a NRAEMT. He is an adjunct EMS instructor at Kirkwood Community College (Cedar Rapids, IA), has been a frequent guest instructor for the Iowa Law Enforcement Academy and the Federal Law Enforcement Training Center (FLETC), and is the author of the book The Street Officer’s Guide to Emergency Medical Tactics. Contact him at edickinson49@hotmail.com.