Law Enforcement Medicine: A Specialty Whose Time Has Come

Does law enforcement need its own medical specialty? Mass shootings, terrorist attacks and unprecedented shootings of police officers in 2016  strongly support the answer...yes

In the early 1990s, specific training and certifications were being finalized for a new medical specialty called emergency medicine. Prior to the development of this new specialty, most emergency room doctors — for the previous 30 years — lacked specific education and training in emergency care. Today board-certified emergency medicine physicians are experts in trauma, prehospital care and all forms of medical pathology. The mass shooting in San Bernardino in 2015, as well as several other incidents in the United States, have highlighted physicians’ involvement in law enforcement and the discussions for the development of a new medical specialty: a discipline structured to operate in an austere and often violent environment that includes tactical operations, teamwork, mission planning and expertise in prehospital care related to the dynamics of explosive, high-energy wounds and other critical injuries. These discussions refer to a new specialty termed “law enforcement medicine.”

The events in San Bernardino introduced the world to Dr. Michael Neeki and the bravery, professionalism and expertise of law enforcement medical providers. Dr. Neeki is a civilian volunteer for the Inland Empire SWAT team, a special operations group that serves multiple cities in the county of San Bernardino. He has been integrated into the operations of this team and serves as the team physician. Dr. Neeki was one of the earliest first responders to arrive on scene at the San Bernardino shooting. Because of his tactical capabilities, he was able to operate at ground zero and provide needed medical care within minutes. Dr. Neeki has been interviewed by dozens of news sources, including CNN, the Los Angeles Times and People magazine. He has become the face of law enforcement medicine.

Unknown to most of the general public, physicians have been involved in law enforcement tactical operations for decades. There are a handful of physicians in the United States who are actual police officers or sheriff’s deputies and fully trained SWAT officers, and they can operate in every capacity of a SWAT team. In addition to these physicians, many agencies have incorporated paramedics into their special response teams. The Los Angeles County Sheriff’s Department Special Enforcement Bureau (SEB) and Huntington Beach Police Department have done this for years. Captain Jack Ewell, Deputy Steve Doucette and Firefighter/Paramedic Ray Casillas are some of the most recognized and respected names in the tactical medicine community. This close-knit community also includes many physicians. Dr. Lawrence Heiskell is considered one of the grandfathers of tactical emergency medical support (TEMS). He has been rallying for TEMS for almost 30 years and was the founder of the first tactical medicine school in California. Currently, Dr. Heiskell, along with a group of TEMS experts and members of the California TEMS Initiative Council (CALTIC) are refining the education curriculum and training of tactical medicine for the California Commission on Peace Officer Standards and Training (POST). The final product will be mandatory law enforcement medicine training for all California law enforcement officers.

It will never be known if law enforcement physicians could have altered the final death toll in the terrorist attacks in Nice, Brussels, Istanbul and other cities in 2016,  but these world events have clearly shown a need for physicians on scene in the increasingly dangerous world of law enforcement. Is there an organized precedence for physicians being trained to work in violent and austere environments? The answer is yes. The world of military special operations medicine has existed for years. The Green Berets, Delta Force and SEALs all deploy with combat-trained, battle-ready physicians. 

The development of a new civilian medical specialty is never an easy or timely task. The creation of law enforcement medicine would necessitate an unprecedented partnership. If the specialty medical boards are to develop law enforcement medicine, they will be bound to partner outside of organized medicine to facilitate the education, training and expertise involved in tactical medicine. A collaborative effort between medicine and law enforcement would result in a physician prepared to function in a dynamic mass casualties incident. Only a new breed of physician would be interested in the physical challenges and rigors of law enforcement medicine, and law enforcement would have to realign their methods and traditions to accommodate physicians into the required education and training of tactical operations. While this group would not fit easily into the current field training of police cadets, the creation of law enforcement medicine is a must, and collaboration needs to drive this partnership. The result will be tactical operations with better medical care for today’s chaotic and brutally violent environment. 

Several current medical specialties already provide the skill set to function in a tactical environment. Anesthesiology, emergency medicine and general surgery are disciplines that incorporate the knowledge, training and skills that law enforcement medicine would require. Physicians in these specialties are experts in acute traumatic evaluation and diagnosis, resuscitation and life-saving procedures. They routinely function as team leaders, directing health care team members in the management of a critically injured patient. Law enforcement medicine physicians would lead the paramedics and emergency medical technicians (EMTs) currently involved in the medical side of law enforcement and further build upon the team model. Conceivably, these medical teams would train together clinically in hospital settings, as well as in tactical special operations to assure their abilities to work at ground zero with enforcement teams seamlessly operating around them. The presence of the direct supervision of a law enforcement physician could allow the tactical paramedics and EMT to function at an unprecedented level, similar to a military special operations medic, all while safely functioning side by side with special operations law enforcement officers. The continuing work of the Physicians Section of the International Chiefs of Police (IACP) and the support of medical providers like the Hartford Group give further credibility to the creation of law enforcement medicine.

Developing the momentum to create a new medical specialty designed for law enforcement seems like a minimal effort when considering the volume of civilians killed and injured by groups like ISIS and the increase in ambush attacks on officers. Physicians do not typically seek to mix medicine and law enforcement, but the current involvement of physicians in tactical medicine leads to the belief that interest in the new medical specialty would grow quickly on the news of its development. The Department of Homeland Security and the State of California are often considered leaders in the advancement of law enforcement. Both are currently pursuing tactical medicine as an integral part of law enforcement training and operations. It makes sense that the Accreditation Council for Graduate Medical Education (ACGME) be invited to join in the advancement of tactical medicine to a new specialty. The existence of three current medical specialties with the needed skill sets makes this task seem inevitable. 

In December 2015, a terrorist attack in Paris resulted in 130 people killed and over 300 injured. The tally in the March 2016 attack in Brussels was 34 killed and over 250 injured. Bastille Day, Nice: 86 people killed and 434 injured. June 2016: 49 people killed and 53 injured in the Orlando Pulse Nightclub shooting. And as of mid-December 2016, 64 U.S. law enforcement officers had been shot and killed in the line of duty. Would the outcomes of these events be different with the existence of a law enforcement physician and tactical medical team? The need for law enforcement medicine seems apparent.

The First Responders of the Millennial Generation......Are they prepared?

In recent years, terrorist type acts seem to be at a new high. Attacks are more violent and frequently supported by access to global technology and advanced weaponry. We want to discuss why millennial first responders should have outcome-based training to effectively make important decisions in evaluating hazards and risks in today’s terroristic environment. It reasons how the military have statistically proven that training geared towards the millennial can minimize battle field deaths through customized medical training using informatics technology.  A systematic approach to modernized learning of appropriate tactical medical techniques, coordinated planning, and readily available up-to-date informatics technology will prepare first responders for today’s globally driven violent environment. 

Though widely appreciated within the military organizations of our allies and partners in the war on global terror, civilian EMS had been slow to embrace the military standards and changes to training methodology and the cost-benefit of incorporating them into civilian pre hospital care within the continental United States until recently. Our current EMS programs are lagging behind the criminal elements that are more technologically advanced. Of those EMS systems surveyed, the majority said their respective organizations had not made specific plans to accommodate the learning differences of the millennial team members, nor has the tactical medical training been updated to include advanced digital technology.

With availability of persuasive social networks coupled with the rapid advancement of mass communication, the risks and responsibility of EMS and other first responders will continue to grow exponentially here in the continental United States. Though widely appreciated within the military organizations of our allies and partners in the war on global terror, civilian EMS has not been advancing with technology and developing trends globally. The old philosophy of no-change-needed, compounded by the current significant budgetary constraints, has kept our antiquated emergency response system slow to react to modern times.  

As difficult as it was for the military to collect casualty data despite uniform standard operating procedures and relatively low casualty numbers in comparison to the civilian environment, its success far out reaches that of the civilian world in providing data analysis. Such information ultimately drives evidence based decision making and best practice development. Additionally, the Army has seen a cost savings through use of smart phones, tablets and applications to make information field available.

Is it time to make a change in our civilian system to offer these young first responders the best chance to save others and save themselves?

----Dr. Mark Cannon, Dr. Donna Wanser-----

Law Enforcement Lives Matter.

The year 2014 has come to a close with one hundred and eighteen United States law enforcement officers losing their lives while on duty.  Fifty-seven officers were murdered with forty-seven being shot and killed.  While it was not the deadliest year for law enforcement in the last decade, death by gunfire rose over fifty percent compared to 2013.  

Recent tragic events involving U.S. law enforcement has led to unparalleled community protests and anti police demonstrations which on several occasions have led to further violence against law enforcement officers. The recent murders of New York police officers has invoked its own social movement that proclaims law enforcement lives matter too. The men and women who protect and serve us are husbands, wives, parents, children, brothers and sisters like every other family in our society. They have taken on a very difficult career which requires split second decision making that can lead to life changing results. In 2013, 49,851 law enforcement officers were assaulted on duty. If our civilized society is to continue it must fully embrace that law enforcement lives matter.

Notably, the government is now proclaiming that the terrorist cells are moving forward with soft terrorist attacks worldwide, including the United States.  This further increases the risks of our U.S. law enforcement. The recent execution style murder of two police officers in Paris, France is just another example of how influential these terrorist are becoming. Our law enforcement teams are now faced with soft terrorist attacks and deadly domestic attacks.  How do we best prepare our local law enforcement teams for today’s environment?

Being shot and killed remains the number one cause of death for law enforcement officers and the numbers are growing. It is almost double that of car accidents. In addition to human deaths, seven law enforcement service dogs have been killed in 2014. Five being shot to death and two stabbed. Despite what appears to be a growing public perception that law enforcement officers can make "superman" like decisions in split seconds, and have adequate training to prepare them for all types of situations, the numbers are asserting otherwise. There is no acceptable rate of injury or death for those who protect and serve us making continuous learning necessary to keep up with today’s violence.

An important part of officer safety is training both the law enforcement officer and the first responders in civilian tactical medicine. The medical community is actively working on evidenced based pre hospital care that is designed and proven to be effective for civilian first responders. Currently, the military's Tactical Combat Casualty Care doctrine (“TCCC”) is the only proven type of training that has been shown with great success to be effective on the battlefield. Unfortunately, the mechanism of battlefield injury does not parallel the injuries seen predominately in civilian life. The tactical situations of the battlefield, though occasionally compared, have few similarities with majority of the situations encountered by law enforcement. Evacuation and transportation to tertiary care centers is typically fairly constant throughout the metropolitan areas of the United States, thus unlike the military, does not play a significant role in injury survival.

Catastrophic bleeding, similar to military findings, is the number one cause of civilian trauma death with survivable injuries. It is recognized that an arterial injury can lead to death in as little as three minutes with loss of consciousness occurring as fast as 90 seconds. The importance of bleeding control has made a significant push into first responder training in various regions of the country. There are, now, numerous case reports in the civilian literature regarding immediate blood loss control by first responders, including law enforcement officers, where the victim survived due to the care they received at the site of injury.

The introduction of the modern battle tourniquet has been the most significant contributor to civilian tactical medicine training and pre hospital bleeding control since the US Civil War. In 2006 after uniform distribution of tourniquets to all US combat forces, the US Army Institute of Research reported an 85% reduction in extremity bleeding deaths in Afghanistan and Iraq. On the civilian side, the aftermath of the Boston Marathon Bombing saw the largest use of tourniquets for bleeding control than in any other previous critical incident in the United States.

As specifics of civilian trauma death are further defined, more research is being performed to develop a TCCC like tactical medicine doctrine for civilian first responders. Definitions regarding the immediate tactical situation are being adapted from TCCC to give first responders guidelines on when medical care is appropriate and expected versus making the tactical circumstances the top priority.

 The creation of tactical zone language has helped define the priorities in high risk critical incidents where tactics and injury management are combined. The high risk zone or "Hot Zone” is defined as an area where an immediate threat is imminent and the top priority is threat management. Active shooters, structurally unstable buildings, bombings and natural disasters may all be considered hot zone situations where medical aid stands behind tactical considerations in regards to priority decisions. The "Warm Zone" is defined as the area close to an imminent threat that has some form of security and protection. In this location, tactical considerations remain top priority, but with adequate security, medical aid can be initiated following the medical BABC's (Bleeding, Airway, Breathing and Circulation). The warm zone may at any time convert back to a hot zone where the top priority converts back to threat management with the emphasis on tactics. The warm zone is mostly where the services of law enforcement, Fire and EMS will merge and work in union, each bringing their unique expertise. The "Cold Zone" is defined as where advanced medical aid is performed and transportation and evacuation are planned and executed.

The usage of the tactical zones is an example of how civilian tactical medical response can be performed in an effective and safe tactically forward manner. Additionally, continued civilian based research driving improvement to pre hospital care training, will provide first responders the knowledge, mindset and skill set to operate and survive in the increasingly violent environment that today’s millennial society is becoming. The one hundred eighteen US law enforcement officers who have died while on duty in 2014 are only a fraction of the first responders on duty deaths this year worldwide.

The violence of 2014

The year 2014 is shaping up to be one of the most violent years for law enforcement in recent times. Thirty-three officers have been shot and killed between January 2014 and September 9, 2014. By comparison, there is a 72% increase in gun related deaths in 2014 over the same period in 2013. Seventy three law enforcement officers in total have lost their lives on duty so far in 2014. (www.odmp.org)

 

Being shot and killed remains the number one cause of death for law enforcement officers and the numbers are growing. It is almost double that of car accidents. In addition to human deaths, seven law enforcement service dogs have been killed in 2014. Five being shot to death and two stabbed. Despite what appears to be a growing public perception that law enforcement officers can make "superman" like decisions in split seconds, and have adequate training to prepare them for all types of situations, the numbers are asserting otherwise. There is no acceptable rate of injury or death for those who protect and serve us making continuous learning necessary to keep up with today’s violence.

 

An important part of officer safety is training both the law enforcement officer and the first responders in civilian tactical medicine. The medical community is actively working on evidenced based pre hospital care that is designed and proven to be effective for civilian first responders. Currently, the military's Tactical Combat Casualty Care doctrine (“TCCC”) is the only proven type of training that has been shown with great success to be effective on the battlefield. Unfortunately, the mechanism of battlefield injury does not parallel the injuries seen predominately in civilian life. The tactical situations of the battlefield, though occasionally compared, have few similarities with majority of the situations encountered by law enforcement. Evacuation and transportation to tertiary care centers is typically fairly constant throughout the metropolitan areas of the United States, thus unlike the military, does not play a significant role in injury survival.

 

Catastrophic bleeding, similar to military findings, is the number one cause of civilian trauma death with survivable injuries. It is recognized that an arterial injury can lead to death in as little as three minutes with loss of consciousness occurring as fast as 90 seconds. The importance of bleeding control has trickled into first responder training in various regions of the country. There are, now, numerous case reports in the civilian literature regarding immediate blood loss control by first responders, including law enforcement officers, where the victim survived due to the care they received at the site of injury.

 

The introduction of the modern battle tourniquet has been the most significant contributor to civilian tactical medicine training and pre hospital bleeding control since the US Civil War. In 2006 after uniform distribution of tourniquets to all US combat forces, the US Army Institute of Research reported an 85% reduction in extremity bleeding deaths in Afghanistan and Iraq. On the civilian side, the aftermath of the Boston Marathon Bombing saw the largest use of tourniquets for bleeding control than in any other previous critical incident in the United States. The quick action of the numerous Massachusetts National Guardsmen who were present, all previously trained in TCCC, saved the lives of many of the victims by using their issued battle tourniquets. Their actions were mimicked by multiple Good Samaritans who used anything they could find to create a tourniquets and saving even more lives.

 

As specifics of civilian trauma death are further defined, more research is being performed to develop a TCCC like tactical medicine doctrine for civilian first responders. Definitions regarding the immediate tactical situation are being adapted from TCCC to give first responders guidelines on when medical care is appropriate and expected versus the volatile situation where rendering medical aid is too tactically risky.

 

It is recognized that poor tactics or omitting high risk zones are not acceptable protocol  in first responder doctrine or training. The creation of tactical zone language has helped define the priorities in high risk critical incidents where tactics and injury management are combined. The high risk zone or "Hot Zone” is defined as an area where an immediate threat is imminent and the top priority is threat management. Active shooters, structurally unstable buildings, bombings and natural disasters may all be considered hot zone situations where medical aid stands behind tactical considerations in regards to priority decisions. The "Warm Zone" is defined as the area close to an imminent threat that has some form of security and protection. In this location, tactical considerations remain top priority, but with adequate security, medical aid can be initiated following the medical BABC's (Bleeding, Airway, Breathing and Circulation). The warm zone may at any time convert back to a hot zone where the top priority converts back to threat management with the emphasis on tactics. The warm zone is mostly where the services of law enforcement, Fire and EMS will merge and work in union, each bringing their unique expertise. The "Cold Zone" is defined as where advanced medical aid is performed and transportation and evacuation are planned and executed. This area is either a significant distance from the ongoing imminent danger or the threat has been neutralized whereas the location has been declared safe.

 

The definitions of the tactical zones are an example of how civilian tactical medical response can be performed in an effective and safe manner. Additionally, continued civilian based research driving improvement to pre hospital care training, will provide first responders the knowledge, mindset and skillset to operate and survive in the increasingly violent environment that today’s millennial society is becoming. The seventy-three law enforcement officers who have died while on duty in 2014 are only a fraction of the first responders on duty deaths this year. Firefighters and EMS personal also face high risk situations. September 11, 2001 is a somber reminder of this fact. Uniform process, updated training procedures and continued research are paramount in keeping our law enforcement and first responders safe.

 

As an aside, though very graphic, the video of the 2011 Sindh Ranger shooting in Karachi, Pakistan displays how quickly human mental status changes with severe blood loss followed by death and stresses the need for civilian tactical medical training for first responders.

Is Tactical Combat Casualty Care (TCCC) worth the investment?

Are the practices of Tactical Combat Casualty Care (“TCCC”) training a good investment for civilian emergency medical services (“EMS”)? The year 2014 brings a continuation in declining training budgets for first responders. Currently, civilian EMS systems lack the comprehensive death and injury data base that have been developed by the military and little to no national research has been done on the results of Tactical Emergency Medicine Support (“TEMS”) teams in the United States.  In a budget conscious environment, is it a lack of conclusive data to support the cost or lack of unified standards to make TCCC an integral part of Emergency Medical Services training?

 

The 20th anniversary of the introduction of TCCC will occur in 2016 marking its first adoption by the US Navy SEALS and US Army 75th Rangers. By 2014, all US forces and the US Coast Guard have incorporated TCCC into their standard combat training. Multiple combat allies have also accepted the validity of TCCC and integrated it into its own training standards. Despite this, the question arises if TCCC is meaningful training in the civilian EMS environment. 

 

The US Army and Canadian military forces have recently published its death and injury data from 2001-2011 combining both Iraq and Afghanistan theaters. Unsurprisingly, traumatic hemorrhage remains the leading cause of preventable death on the battlefield. The predominate mechanism of injury for both military forces was explosive. Tension pneumothorax and loss of airway continue to follow hemorrhage as the leading causes of preventable death but only a distant second and third respectively. 

 

The US military command and its allies have committed millions of dollars to train their troops in TCCC. Evidence based review demonstrates this was money well directed. The armed forces trauma information system is used to track injury, patho-physiology of death, battlefield circumstances, pre-hospital treatment and hospital management. The military tracking system also includes detailed autopsy reports. Currently, the US civilian emergency medical system has yet to achieve a comprehensive data base capturing the continuum data from point of injury to hospital based care. Despite the lack of a broad based civilian trauma tracking system, the increasing incidents of public mass shootings and bombings, similar to the Boston Marathon, have brought awareness to some important deficits in civilian EMS capabilities. Education and training for mass traumatic hemorrhage is paramount and its recognition has unequivocally saved thousands of lives in terrorist type situations worldwide.

 

Yet still it is said that combat casualties and civilian injuries are not mirror images of one another. The development of Tactical Emergency Casualty Care (“TECC”) has been an attempt to create a "civilian" version of TCCC that better addresses the civilian needs given the uptick in traumatic attacks on the public. Critics of TECC argue that it too closely resembles TCCC training and does not address the top causes of death in the civilian world. This argument exists because the top causes of traumatic civilian death have not been well demonstrated. TECC, like TCCC, is centered on teaching the “MARCHE” algorithm. Massive bleeding, Airway, Respirations, Circulation, Hypothermia and Evacuation make up the MARCHE methodology. The core skills taught are tourniquet placement, chest needle decompression and recovery airway position in both TCCC and TECC.

 

Detractors of TECC suggest that management of mass bleeding is the only addition needed to the traditional "ABC"s of standard U.S. EMS training. However,  tension pneumothorax leading to death in the civilian population is extremely rare making the chest decompression skill a nice addition, but far from necessary. The Canadian military data from Afghanistan support this argument against teaching chest decompression. The Canadian findings indicate the majority of soldiers who attempted a needle decompression on the battlefield performed it incorrectly. Teaching the recovery airway position may also be a poor utilization of resources. Following "ABC" training, U.S. EMS's goal is a definitive airway. The recovery airway position taught in TCCC and TECC is not an acceptable management of an unconscious person in the U.S. system. It is not difficult to appreciate the argument against acceptance of an entirely new training system when the current nationwide U.S. EMS protocols can be modified to meet the evolving needs.

 

The need for tactical training is strongly supported across the United States by local, state and federal law enforcement, fire and EMS. Multiple national organizations and government agencies representing these entities have publicly supported and are actively developing programs to prepare EMS and firefighters to work in more austere or violent environments. Unfortunately, unlike the military, there is no nationally unified tactical emergency medical training. Laws, policies, and organizational development vary extensively from state to state. California is one of a few states that has a centralized governing body for all law enforcement standards and education which includes tactical training. This allows for the development of a statewide tactical training program that fit the needs of the state’s centralized EMS system. The other 49 states may have institutional differences and their tactical programs vary by each state’s or region’s standards of training. This creates the need for a national standardized training program, but the implementation, is understandably, difficult due the wide ranging variation in institutional structure, training and working environment.

 

A recent national study on the strategic planning and training for American law enforcement indicates that 2-year plans are being created to be more flexible with the dynamics of the external traumatic environment. Currently data regarding crime rates is available in the U.S.  Partnering with the National Board of Critical Care Transport Paramedic Certification and further analysis of crime data may pinpoint training in regions with and above a certain crime rate index  to begin nationalizing mandates and require a TEMS program with locally tailored TECC training or newly modified “ABC-H” training

Training supervisors are expected to carefully scrutinize training expenditures. Hemorrhage control and tactics training for a violent environment are two components of TCCC that have repeatedly proven valuable training in the more recent civilian terrorist events. To accomplish the incorporation of this new training into the current standards and protocols, it may require an unprecedented partnership between federal, regional, state and municipal law enforcement, fire, and EMS to make meaningful progress. Basic unified standards that are adaptable for localized training programs and additional funding will  prepare present emergency medical services in times of crises derived from our increasingly global and violent society.

LAX shooting: TSA officer Hernandez bled for 33 minutes at scene - report

Hernandez family via AP

Slain TSA worker Gerardo Hernandez, seen in this June 2013 photo released by him family.

By Tami Abdollah, The Associated Press

LOS ANGELES - An airport security officer lay helplessly bleeding after a gunman opened fire at Los Angeles International Airport as paramedics waited 150 yards away because police had not declared the terminal safe to enter, according to two law enforcement officials.
It would be 33 minutes before Transportation Security Administration Officer Gerardo Hernandez, who was about 20 feet from an exit, would be wheeled out by police to an ambulance, said the officials, who were briefed on the investigation and spoke on condition of anonymity because the probe was still ongoing into the Nov. 1 shooting.
For all but five of those minutes, there was no threat from the suspected gunman — he had been shot and was in custody, they said.

 

 

While it's not known when Hernandez died or if immediate medical attention could have saved his life, officials are examining what conversations took place between police and fire commanders to determine when it was safe enough to enter and whether paramedics could have gone into the terminal earlier, one of the officials said.
Formal conclusions may take months to reach, but what's known raises the possibility that a lack of coordination between police and fire officials prevented speedy treatment for Hernandez and other victims.
TSA workers at LAX have been wondering the same thing, said Victor Payes, who works at the airport and is president of the local union.
"I basically think there's a lack of coordination between entities at this airport. That lack of coordination may have led to something that shouldn't have happened," Payes said. "We may be talking about Officer Hernandez as a survivor."
Representatives for the Los Angeles Police Department, Los Angeles Fire Department and Los Angeles Airport Police said they couldn't comment on the ongoing investigation until extensive reports are finished.
Authorities say that Paul Ciancia entered Terminal 3 with a duffel bag, pulled out an assault rifle and started shooting. They said he had a note in his bag that said he wanted to "kill TSA" and that he wanted to stir fear in them, criticizing their searches as unconstitutional.
He was shot by airport police officers four times, in the mouth and leg, before being taken into custody. He remains in fair condition at a hospital and his doctors will determine when he's fit to appear in court.
In the chaotic moments after the gunfire began, as travelers dove to the ground or scrambled for cover in restaurants and stores, officials worried there could be bombs in the terminal and tried to determine Whether the gunman had any accomplices. In the first 30 minutes, there was also an unfounded report of two suspicious people on an adjacent parking garage roof, one of the officials said.
Officers from multiple agencies bent down to check on Hernandez before moving on, officials said.
Police broadcast over their radios that Ciancia was in custody at 9:25 a.m., five minutes after Hernandez was shot in the chest. That's when a nearly 26-year veteran Los Angeles police officer checked on Hernandez several times, repeatedly telling officers who came by from various agencies "he's dead," according to one of the law enforcement officials.
It's unclear whether the officer was qualified to determine Hernandez was dead. No officers rendered first aid on scene, according to surveillance video reviewed by the officials. Finally, airport police put Hernandez in a wheelchair and ran him to an ambulance.
Trauma surgeon David Plurad said Hernandez had no signs of life when he arrived at Harbor-UCLA Medical Center. Doctors worked for about an hour to revive him despite significant blood loss.

First Responders and the Silent Killers

In the dangerous world of law enforcement, a peace officer's exposure to human bodily fluids and fluid-related infections is not typically discussed as a topic of officer safety. Unlike the obvious danger of being assaulted, the risks of blood-borne infections are silent with virtually no recognizable warning signs. As potentially life-threatening as any violent encounter, certain contagious infections have significant adverse consequences, which can extend to an individual’s family health, as well as the fitness to continue a career in law enforcement. Peace officers dedicate the majority of their time preparing for an immediate violent threat. Firearms training, defensive tactics and the wearing of body armor all play major roles in crisis preparation. In the presence of these modern silent killers, it’s important to recognize the risks associated with body-fluid exposure and to pursue the education, planning and prevention of exposure and transmission of these diseases.

 

The Centers for Disease Control and Prevention (CDC) estimates that more than one million people are infected with the Human Immunodeficiency Virus (HIV) in the United States.¹ It is estimated that 1.2 million individuals are infected with the Hepatitis B virus and 3.2 million are infected with the Hepatitis C virus.^2,3 All three of these viral infections will lead to death. The majority of infected individuals do not show outward signs of their disease and may be unaware of their contagious risk. Regardless of the situation, age or sex of an individual, the universal precaution protocol should be followed with any contact in the field.⁴ The route of work-related transmission of HIV, Hepatitis B and Hepatitis C to a peace officer is identical to any other first responder or health care provider.^5,6 Exposure to bodily fluids, especially blood through an open wound, eye contact, needle sticks or a human bite, are the most common pathways for infectious transmission.^5,6 Research about the relative risk of law enforcement officers being infected after an exposure is not well defined and minimal in comparison to the amount of research directed toward health care workers and their related risk.

 

The backbone of all law enforcement operations entails planning and prevention on a daily basis. As with U.S. health care protocol, the use of universal precautions should be standard operating procedure within law enforcement.⁴ Although federal safety mandate requires every law enforcement agency to supply gloves and eye protection in every patrol car, comprehensive officer safety does not stop at federal law or OHSA requirements.^7,8 Peace officers should make every effort to follow a daily routine of precaution and proactiveness. This should include covering all wounds or scratches with a waterproof dressing prior to dressing in uniform. Beginning each shift wiping down shared equipment with an antiseptic wipe, as well as after every use, is also good practice. Another one is making every attempt to wash both hands with an anti-bacterial soap after removing protective gloves each time. All of these are good simple practices that will help lower the risk of infectious transmission after an exposure.

 

Despite the best precautions, bodily fluid exposure will occur at some point during a career in law enforcement. Not all bodily fluids have the same risk of infectious transmission.^5,6 The types of bodily fluid vary in risk of infectious transmission. Blood, semen and vaginal fluid exposure carry the highest risk of infection.^5,6 For HIV and Hepatitis B, there are currently no documented cases of transmission through urine, feces, sputum or vomitus.^5,6 In the dynamic world of law enforcement, determining what specific bodily fluid was included in an exposure is almost impossible. For a peace officer, all bodily fluid contacts should be treated the same. Post exposure, wash the affected area with an antiseptic soap as soon as time allows and scrub it vigorously. Contact a supervisor and inform them of the exposure. OSHA regulations require every department to have a formal bodily fluid exposure policy and plan.^7,8 Federal law requires that an employee be seen by a licensed physician within one hour of exposure.^7,8 Department supervisors should be able to provide guidance in regard to departmental policy and adherence to OSHA guidelines. Do not be embarrassed or reluctant to seek medical attention immediately. Federal law requires that all law enforcement agencies keep this information strictly confidential.^7,8 Do not deny the significance of a scratch or needle stick. Receiving care in hours — not days — can make the difference in life or death. Not all medical providers will be up to date on current CDC recommendations. Demand current CDC protocols be reviewed by your medical provider and presented to you with the facts of your case in mind. 

 

It is important to consider both the bodily fluid and the type of exposure. Not all exposures carry the same risk of infectious transmission. The CDC classifies exposure into three categories: Category I include all dirty needle sticks and contact of bodily fluids in the area of an open cut or wound.^5,6 For example, a human bite falls into Category I.^5,6 Category II includes exposure in the eyes, nose and mouth.^5,6 Category III includes contact with a bodily fluid on skin that has no open wounds or scratches.^5,6 The chance of infection after a category III exposure is virtually zero.^4,5

 

HIV is responsible for the AIDS syndrome. Though current treatment has made dramatic changes in how HIV is viewed, it has no cure or vaccine, and without treatment it will lead to death. Current data shows a transmission rate after an infected needle stick to be 0.3% and exposure with infected fluid with a wound or scrape on your skin to be 0.1%.^5,6 There are no current documented cases of transmission of HIV after exposure to infected fluid with intact skin, i.e., blood on hands, skin or uniform with no scrapes or cuts. The virus is considered to be very weak. It is typically killed with hand soap, clothing detergent or any of the commercial antiseptic lotions available.⁹ The virus dies very quickly when outside the body.⁹ If a category I or II exposure does occur, seek immediate medical attention. Do not wait to complete an assignment or shift.

 

In 2008, with never-reported details, previously sealed New York state court documents disclosed the medical retirements of four New York City police officers who were infected with HIV on the job. Court documents indicated one officer was cut with a contaminated razor blade, another one was bitten in the hand by a HIV positive criminal and the third sustained a cut to the hand while searching a prisoner.¹⁰ The route of infection for the fourth officer is not known. None of the infected officers completed exposure reports at the time of the incidents, making it impossible to prove their exposures were work related.⁹ At the time of the court hearings, one HIV infected female officer was also claiming duty-related exposure from her sexual relationship with one of the four infected male officers.^10,11,12 Brooklyn federal court records indicate that the NYPD Pension Board reviewed the claims of a total of 12 HIV infected officers from November 1999 and August 2007.¹⁰

 

The present antiviral drugs have been shown to be very successful in preventing viral transmission but must be started immediately if the exposure was high risk. Because not all people will tell you they are either HIV or Hepatitis positive or even know their status, knowing state law in regard to forced testing is important. The Fourth Amendment has jurisdiction over forced testing. Voluntary consent to test an individual’s blood is the best method to achieve results. While still in the field, try to get as much information about the person’s medical past. A history of IV drug use, incarcerations, sexual orientation and previous blood transfusions are important pieces of information in determining relative risk. While on scene, don’t be concerned about saving the needle or fluid-contaminated object involved in the exposure. Testing the fluid on the needle has shown to be very inaccurate and not worthwhile.⁶ Further, trying to transport the needle only increases the risk of being injured again. The information gathered from a suspect or victim will be very helpful to physicians when it is not clear cut if antiviral drugs will be recommended. The drugs have very serious side effects that need to be discussed prior to initiation of treatment. Because of this risk of these drugs, it is recommended that only certain exposures be treated.^5,6 If your exposure is not category I or II, no treatment is recommended.^5,6 If your exposure is a category I or II and the HIV status is not immediately known, your physician will discuss with you the options and risks. This is where finding out information on the subject or victim is so important. Female officers who could possibly be pregnant should have an immediate pregnancy test prior to starting any treatment.

 

Hepatitis B is one of the scariest of the “silent killers” out there. It can remain alive and infectious seven days outside the body.⁶ Like with HIV, there appears to be no known risk of transmission when Hepatitis B-infected blood makes contact with clothes or skin that has no wounds or scrapes.^5,6 Unlike HIV, the risk of transmission of Hepatitis B after a human bite is real.² Depending on the viral count in the infected blood, the chance of becoming infected can reach as high as 30% after a bite.² On July 24, 1991, Front Royal Police Lieutenant William Farrell died from complications of Hepatitis B. He contracted the virus during an on-duty fight where he was scratched and bitten.¹³ The Hepatitis B vaccine, a three-shot series, is very effective in prevention of this virus, but must be received prior to exposure. Becoming Hepatitis B positive will eventually lead to liver failure and death. After infection, there is no treatment at this time. By law, the Hepatitis B vaccine must be provided free of charge by your agency.^7,8 To be effective, the vaccination series should occur at the start of a career. Every 5-7 years, the effectiveness of the vaccine should be checked with a simple blood test. If you have had the vaccine and testing shows that it’s effective, there is no recommended treatment for a Hepatitis B exposure, regardless if the status of the subject is positive or not.⁶

 

Hepatitis C, like Hepatitis B infections, will ultimately lead to liver failure and death if a liver transplant is not available. The risk of infection after a dirty needle exposure is 1.8%.³ Risk after fluid exposure to your eyes or mouth is 0.9%.³ Though the risk of acquiring Hepatitis C from a human bite is much lower than Hepatitis B, the risk is estimated to be approximately 2% depending on the viral count of the infected person.¹⁴ There is no treatment currently for exposure to Hepatitis C infected fluid.⁵ During the ensuing fight and arrest of a drunk man 24 years ago, a Blue Mound Police Officer was bitten in the arm. After two years of unexplained fatigue, the officer was diagnosed with Hepatitis C. In 2010, the retired 57-year-old man was fighting liver cancer and cirrhosis and desperately waiting for a liver transplant to save his life.¹⁵ Unlike Hepatitis B, there is no vaccine to prevent the infection.⁵ It too can live outside the body for a long period of time, living up to four days at room temperature.^4,5 It is a very strong virus that is hard to kill and washing your hands may not be enough. Some recommend washing your exposed skin with diluted bleach, but this may not be practical. Because both forms of Hepatitis can survive outside the body for so long, cleaning all shared and restraint equipment is important.

 

How long these silent killers can live outside the body is important information to know and consider when thinking about possible treatments.

 

 

HIV    

Considered a very weak virus.

Usually killed with hand soap.

Dies very quickly outside the body.

 

HEPATITIS B           

One of the scariest of the silent killers.

Washing hands helps decrease risk of infection.

Can remain alive up to seven days outside the body.

 

HEPATITIS C           

Very strong virus that is hard to kill.

Washing hands may not be enough.

Can live up to four days outside the body.

 

Like all aspects in law enforcement, planning ahead and developing a routine is key to decreasing the risk of infectious fluid exposure. Wearing of gloves and eye protection should be part of every pre-shift checklist. Checking for any skin wounds and covering them with a waterproof barrier should occur before a uniform goes on. Spending a few moments cleaning the shared equipment should occur daily. Washing the area vigorously with anti-bacterial soap or the equivalent as soon as possible after exposure could be a life saving practice. Remembering to interview your subject or victim in regard to high-risk behavior will greatly help in defining the risk of an exposure and in evaluating treatment options. Their cooperation and voluntary consent will go a long way in expediting your need for immediate care and treatment. Don’t deny the danger of a silent killer.