Risk Reduction in Officer Rescue: A Scenario-Based Observational Analysis of. Medical Director, Rochester/Olmsted County Emergency Response Unit

Transcription

1 Risk Reduction in Officer Rescue: A Scenario-Based Observational Analysis of Medical Care Matthew D. Sztajnkrycer, MD, PhD Medical Director, Rochester Police Department Medical Director, Rochester/Olmsted County Emergency Response Unit Associate Professor of Emergency Medicine Mayo Clinic Rochester MN P: F: Sztajnkrycer.matthew@mayo.edu The views presented in this publication are those of the author, and do not necessarily reflect those of the Rochester Police Department, Rochester/Olmsted County Emergency Response Unit, or Mayo Clinic. 1

2 Then I heard the voice of the Lord saying, Whom shall I send? And who will go for us? And I said, Here I am. Send me! Isaiah 6:8 Disclaimer: While I have the privilege to work alongside the men and women of law enforcement, I am not a sworn officer. As such, I will always defer to my colleagues regarding sound tactical decision-making. The following article discusses tactics in terms of medical decision-making. While data-driven, it is observational, and should not replace sound tactical decision-making and common sense. Introduction At its most basic level, the downed officer rescue reflects the fundamental conflict between a need to do what is perceived as right for the downed officer versus the risk such action creates, both to the rescuers and to the downed officer. In its coldest analytical form, it is a classic risk-benefit analysis. Logic would state that risks and benefits should be weighed in order to come to a reasonable decision as to whether or not to effect a rescue. The reality is that this calculated analysis frequently does not occur. Even when not under stress, the decision-making process of our brain is frequently illogical, emphasizing wants over needs [1]. In the setting of a critical incident, mental 2

3 processes are further altered. Adrenaline levels are high, there is a desire (if not always a need) to help, and time keeps ticking away, increasing the level of stress and the perceived need to do something. Feeding into the risk benefit analysis is the fact that law enforcement is by definition a high-risk occupation. In 2007, there were 57 line-of-duty deaths (LODDs) resulting from felonious assault; 55 resulted from gunfire [2]. Officers have already accounted for this risk in simply accepting their career, and as such are frequently willing to accept a higher level of risk than would otherwise logically be considered acceptable. When dealing with injuries under conditions of active threat, such as during a downed officer rescue, it is important to understand that medical needs are simply another tactical consideration. This is highlighted in the statement Good medicine can be bad tactics, and bad tactics can get everyone killed or cause the mission to fail [3]. It is important to understand this concept in order to successfully do what is best for both the downed officer and the rescuers. The most appropriate tactical medical care may actually be threat neutralization. As an example, consider the conflict between medical care and threat neutralization in an active shooter scenario. No law enforcement operation is without risk. The goal of any successful tactical plan is not to completely eliminate risk (which is impossible, and will lead to inaction), but rather to manage it in such a way that it is reduced to acceptable 3

4 levels. The purpose of this article is to examine the nature of risk specific to downed officer rescue, and discuss some potential ways to minimize risk. Phases of Risk in Officer Rescue Every rescue situation, regardless of the nature of the threat, can be defined in terms of three phases of risk (Figure 1). The Approach Risk Phase occurs during the transition from the relative safety of the point of last cover and concealment (LCC) into the hot zone, where a potential active threat exists. The Approach Risk Phase consists of the distance that must be covered in order to reach the downed officer. It is during this period of time that the team first exposes itself to the potential threat. The Aid Risk Phase consists of the period of time the officers spend in the hot zone, under threat of effective fire, assessing the downed officer, and performing preliminary care (Figure 2). This phase is high risk because any suspect is likely now aware of the rescue attempt, the team is relatively static, and situational awareness is easily lost while focusing upon the injured officer. The final Extraction Risk Phase consists of the distance that must be covered to return the downed officer to a position of relative safety, where further medical aid and definitive evacuation can be performed. 4

5 Basic Principles: Recovery or Rescue? Consider the following training scenario: An officer responding to the scene of a domestic violence call is shot upon exiting his car calls from the scene report an officer down behind his car. The responding tactical team observes the officer in a seated position behind his car, not moving. The distance from team to downed officer is approximately 25 meters, all open ground. What should they do? Conceptually, a downed officer rescue may be viewed as a barricade situation, with the open ground between rescuers and downed officer serving as a barrier to effectively reaching the officer (Figure 3). The most fundamental question the team must answer is whether this situation represents a downed officer rescue or a body recovery. A striking example from the Vietnam era demonstrates the risk of attempting a rescue when the situation is actually a recovery [4]. During a patrol, a squad member is shot in the head, and lies motionless in the kill zone, with minimal bleeding from the wound. A squad member responded to his side, and attempted to apply a field dressing to the lethal head wound. He was shot in the hand and wrist. A second responder was shot in the forearm, a third in the shoulder, a fourth in the chest and wrist, a fifth in the back, and a sixth in the thigh. 5

6 Many times it is difficult to tell whether the situation is a rescue or a recovery. Due to the nature of the incident, an initial hands-on assessment is often impossible. As such, the assessment is based upon the presence of absence of indirect signs of life. These may include spontaneous movement, spontaneous chest rise, or exhaled breath plume on a cold day. Gunshot wounds to the head with exposed brain matter may be another indicator, although there are numerous cases of survival despite these wounds. Tactical medics may be extremely useful in these circumstances, providing the on-scene commander with medical intelligence concerning the nature of the injuries, and whether they are incompatible with life. Thinking outside the box, a frequently under-utilized medical asset in remotely assessing a downed officer is the sniper. A sniper is trained to provide real time information in much greater detail than the typical operator. If it remains impossible to distinguish between rescue and recovery, the most appropriate response is often to assume a rescue situation (ie. that a potential benefit exists) and act accordingly. However, in simply taking a few seconds to make these quick assessments rather than immediately rushing forward into the hot zone, rescuers have already made a significant risk assessment modification. The tunnel vision surrounding the downed officer is removed, and possible threats and safe areas identified. 6

7 The above-described training scenario was run with approximately 150 participants representing more than 6 agencies, on 3 separate occasions, and in two different countries. Every group of participating tactical operators approached the downed officer, despite the fact that the officer showed no signs of life, and had a simulated head injury with exposed brain (Figure 4). The scenario was actually designed to force operators to distinguish between rescue and recovery operations. As in the Vietnam example, teams exposed themselves to risk for no possible benefit. One of the arguments put forth by the officers for their actions in this scenario was that they could not tell if the victim was alive or dead without examining him, and therefore they were required to go forward. This requirement to go forth is beyond the scope of this article. However, other than one team calling out to the downed officer, no team attempted remote assessment in a rapid yet organized fashion. If the situation is determined to be a recovery, no further time pressure exists. There is no longer a patient with the potential to deteriorate. This is not a foreign battlefield, where the deceased may find their bodies desecrated, and so must be rapidly recovered. The situation can hopefully be resolved in a safer manner, and allow for dignified recovery of the body. Interestingly, once committed to going forward, teams frequently continued with body recovery rather than simply determining absence of life and retreating. By locking into a rescue mindset, and therefore extracting the body, the average time in the hot zone during these recovery scenarios increased by 26.8 seconds (Figure 5). While these times may 7

8 not appear very long, consider that a semi-automatic AK-47 clone can fire 30 rounds in approximately 5 seconds [5,6]. Approach Risk Phase: Look Before You Leap Once the decision is made to initiate a rescue, the first critical medical decision to be made from a tactical standpoint is determining whether the downed officer is sick or not sick. Sick implies that the officer will die in the next minutes without medical intervention. Not sick means that, while injured and in need of medical treatment, the officer can survive for at least this long. This decision is critical from a tactical standpoint, because a sick patient requires immediate attention, and therefore adds an element of time pressure absent from a non-sick patient. The sick patient may require a hasty rescue team from responding patrol officers, while from the medical stand-point the not sick patient can await the arrival of a specialized tactical team. Time pressure increases stress, which alters physical abilities and mental processing, and therefore increases operational risk. By determining not sick, the operational risk to both downed officer and rescuers is decreased. Prior to leaving LCC and entering the hot zone, rescuers should take a few moments to survey the scene one last time. This includes: Scanning the area for potential cover, concealment, and for threats (debris, secondary devices, suspects). 8

9 Determining the best approach to the casualty. Planning the best route of return with the downed officer, given the fact that several guns will now be off-line and extra weight will be present. Remotely reassessing the downed officer to determine self-extrication capability. In training scenarios involving an approximately 25-meter distance, the average time to reach the downed officer during the Approach Risk Phase was 20.9 seconds (range seconds). Even accounting for a reactionary gap in the suspect s response to the rescue, this is still sufficient time to significantly injure or kill several members of the rescue team. If the officer is awake and able to move, order the officer to an area of relative cover. This simple action may actually remove the need for an immediate rescue attempt. Consider the following case, again from Vietnam [4]. During another patrol, a squad member is shot in the left elbow, and calls for a medic. The medic responds, and while evaluating the casualty, is shot in the head and killed. A second responder responds to both victims, and is shot in the chest and killed. The wounded soldier then crawls 50 yards out of the kill zone, and is eventually evacuated to medical care. If the officer is awake and able to move, order the officer to initiate self-aid as appropriate, while awaiting rescue. Unfortunately, many people equate being 9

10 shot with being helpless or dead, something frequently reinforced in training. Nothing could be further from the truth; it is important to remember that this applies to suspects as well as officers. Once injured, some officers may simply shut down. Forcefully remind them that they need to fight, that they are not to give up. If the injury has easy emergency treatment, such as applying pressure to a wound to decrease bleeding, officers should be ordered to perform these actions if safe to do so. Depending upon their injury, they may be able to provide cover for the rescue team. They certainly should be asked to provide intelligence on the situation, thereby keeping them engaged and actively involved in their own survival. Aid Risk Phase: Remote Medical Assessment Before leaving the LCC, take a few seconds to assess the medical needs of the downed officer (Figure 6). Remember, you may be the first medical responder in this rescue. The burden is then placed upon you to know what should and should not be done, and how to do it [7]. What are the officer s injuries? What medical care is needed? More importantly, what medical care can be safely performed? Is there cover nearby where the officer can be moved to have this care provided, prior to definitive extraction? How long are you willing to spend in the hot zone? By answering these questions ahead of time, exposure time in the hot zone will be minimized, therefore reducing risk. When the decision is made to move, be decisive and quick. And always try to maintain tactical awareness. 10

11 Aid Risk Phase: Care Under Fire As a consequence of the events in Mogadishu, Somalia, in 1993, the United States military reevaluated the way in which it approached medical care in the combat setting. The result of this re-evaluation was the development of Tactical Combat Casualty Care (TCCC), arguably the most important tactical medical development since Vietnam [3, 8, 9, 10]. TCCC recognizes that medicine is simply another tactical variable in combat. It designates 3 phases of care, based upon threat potential: Care Under Fire (CUF), Tactical Field Care (TFC) and Casualty Evacuation Care (CASEVAC). Care Under Fire (CUF) is the care rendered upon reaching the downed officer when the potential for active threat still exists. Due to the high threat level, medical care in the hot zone is extremely limited. The current TCCC guidelines explicitly establish procedures for hot zone care (Table 1). Most recently, the prevailing wisdom is to avoid any medical treatment in the hot zone, and to focus solely on extrication [11]. Minimizing care in the hot zone minimizes exposure time and therefore risk. In these scenario-based training exercises, the average time spent in the hot zone assessing the patient and performing CUF was 49.4 seconds (range seconds). Recovery assessments took less time (average 30.0 seconds; range seconds) than rescue assessments (average 62.0; range seconds). 11

12 The only medical care provided in the hot zone is control of life-threatening hemorrhage [8,9,10]. Due to the nature of the hot zone, the need for continued situational awareness, and the inability to provide sustained pressure on a bleeding wound in the hot zone and during rapid extraction, this is achieved through the rapid use of a tourniquet (Figure 2, 7). A general rule of thumb is that tourniquet placement in the hot zone should take no more than 7 10 seconds. Remember that during this time, the officer applying the tourniquet will lose situational awareness. In training scenarios, the average time to apply a tourniquet upon reaching the downed officer was 56.3 seconds (range seconds). Again, consider that it takes approximately 5 seconds to fire 30 rounds from an assault rifle [5,6]. This delay in tourniquet application time reflects the perceived need to perform a cursory assessment of the downed officer, as well as the time required to remove the tourniquet from a pocket or pouch, open it up for use, and deploy it. Remote assessment and preplanning will remove delays in assessment and decisionmaking. Every officer should be instructed in the rapid use of a tourniquet; the hot zone is not the place to use any equipment for the first time (Figure 2). Pre-designation of a rescue aid officer provides multiple advantages. First, that officer will have personal protective equipment (eg gloves) appropriate for body substance isolation. While the victim may be a fellow officer, this does not 12

13 preclude the risk of blood-borne diseases. Second, the rescue aid officer will know that he/she can focus on the downed officer in relative safety, as the other officers will maintain situational awareness. Most importantly, the rescue aid officer can expedite medical care and extraction by having a medical preplan, including having the tourniquet out and readily available for use as appropriate. Extraction Risk Phase The extraction phase poses its own unique problems, not the least of which is being encumbered by a fellow officer who may be unable to assist in movement. In training scenarios, the average time to extract the team approximately 40 meters was 30.0 seconds (range seconds), compared with an average 20.9 seconds for approach. In order to minimize risk, an appropriate extraction route, with suitable points of cover, should be determined prior to leaving the LCC. The goal of this phase may not be to remove the officer to a point of definitive safety. It may be easier to move the officer to a position of relative safety, provided by the availability of cover. Once in this position of relative safety, additional care can be rendered, and emphasis placed upon neutralizing the threat. 13

14 One common failure of the extraction phase is package separation (Figure 8). This has been noted in a previous article [12]. The extraction package consists of 2 groups of officers, those physically performing the extraction by carrying or supporting the downed officer (extraction group), and those providing protection and situational awareness for the extraction group (cover group). Due to a combination of factors, the extraction group tends to outpace the cover group. The larger the distance to be covered, the larger the gap becomes, such that eventually the extraction group is left exposed and with limited defensive and offensive options. Another common failure is simply reversing back out to safety. This poses a problem for several reasons. The first is that there may be safer, alternate routes, including those that provide better cover. Additionally, teams tend to simply turn around and face in the direction they are extracting. In so doing, the team faces weapons and protective equipment (eg ballistic shields) forwards towards relative safety, while leaving flanks and rear exposed. Recently, attention has focused upon the extraction risk phase as a priority phase in rescue [11]. The focus of care under fire is slowly shifting from limited medical care (stopping life threatening hemorrhage using tourniquets) to rapid extraction to a position of relative safety. Although research remains limited, this fundamental change in the concept of care under fire has already resulted in the 14

15 development of several exciting new high-risk extraction tools, including handsfree tools which permit the use of weapons during the extraction phase. Immediate Rescue Drills The rescue of a downed officer is a high threat procedure. The risk exists, during all phases, that the rescuers come under direct fire, and that one or more rescuers are injured. This did occur during several of the training drills (Figure 9). It is important that the team have an immediate action drill should this occur. At a minimum, this drill should include: Suppressing in-coming fire from the threat if feasible. Identifying the presence and location of downed rescuers. Rapidly identifying who amongst the team will respond to the new downed officers and who will continue with the primary rescue. Immediately extracting the downed rescuer, rather than retreating and reapproaching. Due to this potential for rescuer injuries, if team size permits, back-up rescue aid officers should be identified, not only to respond to any rescuer casualties, but also to replace the primary rescue aid officer should he/she be injured during the approach. Conclusions 15

16 The rescue of a downed officer is a mission critical element in law enforcement. While these rescues remain high-risk, there are ways to at least favorably modify the level of risk involved. The key to any successful operation remains appropriate, realistic, and on-going training. While training time and budgets become increasingly tenuous, every officer must understand not simply that they may one day find themselves injured in the line of duty, but that they may one day find themselves as the first medical responder in these events. In one study, 32% of officers reported a line of duty injury serious enough to require transport to an ER. Importantly, 41% of officers in the same study reported that they had responded to the scene of a seriously injured officer; 70% of these officers reported that they were on scene prior to the arrival of definitive medical care [12]. As such, every officer should be familiar with the basic concepts of TCCC and CUF, and the use of a tourniquet. Knowledge is power, after all. 16

17 Acknowledgements I would like to thank all the men and women of law enforcement who took the time to participate in these training sessions, and who place their lives on the line every day. This work is dedicated to them and their families. 17

18 References 1. Gardner D. Risk. Virgin Books, Limited. London. 1 st Edition US Federal Bureau of Investigation, Uniform Crime Reporting Program. Law Enforcement Officers Killed and Assaulted Federal Bureau of Investigation. US Department of Justice. October Butler FK Jr. Tactical Medicine Training for SEAL Mission Commanders. Mil Med 2001; 166: Burchell K, Bohn K, Cholak P, FitzGerald D, Heck J, Holmberg K, Hunt R, Kepp JJ, King K, Pierce J, Wightman J, and Vayer J. Emergency Medicine Technician Tactical Provider Program Student Manual, US Immigration and Customs Enforcement, Federal Protective Services Anonymous. Semiautomatic AK47 30 Rounds Extremely Fast Rate of Fire. last accessed 10/14/ Anonymous. Fast AK Shoot. last accessed 10/14/ Sztajnkrycer MD, Callaway DW, and Baez AA. Police Officer response to the Injured Officer: A Survey-Based Analysis of Medical Care Decisions. Prehospital Disast Med 2007; 22: Butler FK Jr, Hagman J, and Butler EG. Tactical Combat Casualty Care in Special Operations. Mil Med 1996; 161 (Suppl 1): Butler FK and Hagman JH. Tactical management of Urban Warfare Casualties in Special Operations. Mil Med 2000; 165 (Suppl 1):

19 10. Committee on Tactical Combat Casualty Care: Military Medicine. In: Prehospital Trauma Life Support, Military Edition, Revised 5 th Ed. McSwain NE, Frame S, Salome JP (eds). Mosby. St Louis Pp Croushorn J and Westmoreland T. Tactical Medical Equipment. The Tactical Edge 2008; 26 (2): 60,62, Sztajnkrycer MD, Meoli M, Baez AA, and Etzin JM. Victim rescue Drill: Lessons Learned. Emerg Med Serv 2006; 35; 32,34,36. 19

20 Table 1: Care Under Fire Procedure 1. Keep casualty engaged as a combatant if possible. 2. Return fire as directed or required. 3. Prevent further injuries to responders or casualty. 4. Stop life-threatening external hemorrhage. 5. Defer airway management until the Tactical Field Care stage. 6. Extract the casualty to safety as soon as possible. 20

21 Figure 1: Phases of Risk Downed officer rescue can be defined in terms of 3 phases of risk. See text for details. 21

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23 Figure 2: Aid Risk Phase Medical care in the hot zone predominantly involves rapid, safe patient extraction. Life-saving interventions are limited to tourniquet application for massive hemorrhage. The hot zone is not the place to learn tourniquet application. In this image, the officer has unthreaded a pre-threaded tourniquet, and is now trying to re-thread it. 23

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25 Figure 3: Approaching Rescuers Take Fire The open ground serves as a barrier to safely reaching the downed officer. 25

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27 Figure 4: Recovery Scenario After calling out to the downed officer, the team moves forward (A) and assesses the downed officer (B), thereby exposing themselves to a potential threat. Note the simulated brain matter on the facemask of the downed officer. 27

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29 Figure 5: Effects of Recovery on Extraction Time The decision to recover the body (B) or simply extract (A) resulted in a 26.8 second increase in time of the Extraction Risk Phase. 29

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31 Figure 6: Aid Risk Phase Little care can be performed in the hot zone for an eviscerating injury, in this case caused by an explosive device. By planning prior to movement from LCC, time in the hot zone is minimized. In this scenario, a secondary device was present. 31

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33 Figure 7: Care Under Fire Tourniquet Placement Continued realistic training is important to develop proficiency under stress conditions. While two operators are off-line, the remainder of the team provide cover and situational awareness. 33

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35 Figure 8: Package Separation As time progresses (A through D), note the increasing exposure of the extraction group to a possible threat. 35

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37 Figure 9: Rescuer Down Rescue operations are not without risk. A responding officer is struck by the suspect and falls (A). While his partner backs away to safety, officers treating the original downed officer are unaware of the new casualty. 37

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