On the morning of the Boston Marathon, I would have never imagined that the tragic events of that day would result in the best argument to date for the advancement of the Tactical Emergency Casualty Care (“TECC”) doctrine. Born from the military Combat Casualty Care (“CCC”) philosophy, TECC is the civilian modification of CCC. The emphasis of both is based on the recognition and treatment of the top causes of death after a survivable injury before evacuation to an acute care medical facility. Combined with the importance of maintaining the highest level of tactics and operational security, TECC provides first responders with the training and equipment needed to fulfill any mission as well as successfully treat many injuries that can result in death in as quickly at three minutes. CCC was first introduced in 1996 after a retrospective review of military combat deaths. Bleeding, inability to breathe, and chest trauma that occurred before a soldier could be transported to a medical facility were identified as the top causes of battlefield death. These causes of death were associated with a 14% mortality rate during the Vietnam War. The battlefield mortality rate decreased to approximately 9% during the first Gulf War and was attributed to the roll-out of CCC training for all combat soldiers. These statistics further improved with the later conflicts in Iraq and Afghanistan. By 2006, all combat soldiers in the US military were being issued combat tourniquets as part of standard first aid equipment. The training dictated that operational tactics and safety were always top priority. Regardless of the injured, CCC, however, emphasizes that when under an attack the priority is to fight and overwhelm the enemy with superior firepower. If a rescue was possible during the fight an attempt would be made, but a suicide rescue was never an option. Once the injured and rescue team were in a place of protection, only then would treatment to manage bleeding, loss of airway and chest injury commence.

The two bombs that exploded in Boston were each built inside a self securing metal pressure cooker and were detonated minutes apart among the spectators. Each device had explosives, nails and bbs packed inside the containers. The three people who died most likely died from the effect of the blast pressure of the explosion. This type of injury is classified as a primary blast injury. The 300 surviving victims had a combination of the 4 classes of blast injuries (Primary, Secondary, Tertiary, and Quaternary). Secondary injuries are caused by shrapnel or fragmentation of the bomb container. Tertiary injuries result when the victim is thrown against an object or off their feet. Quaternary is any injury not associated with the other 3 classes. The most common non-lethal primary injury is the loss of hearing due to the pressure disruption of the ear drum. Severe injury or death is due from the effect the pressure wave has on the internal organs. Almost every Boston victim had some loss of hearing along with multiple other injuries. The predominant injury encountered was the secondary class. Shrapnel and fragmentation resulted in penetrating trauma with all forms of amputation, life threatening bleeding, loss of breathing, and chest injuries. The fact that so few died after two explosions initially was thought to be a miracle. The fact, however, is that training provided by CCC and TECC to soldiers and emergency first responders is what made the difference. Present as support staff for the Boston marathon were 400 Massachusetts National Guardsmen who all had received CCC training and had battle tourniquets as part of their personal equipment. The quick recognition of the injuries and critical bleeding led to battle tourniquets being placed on many of the victims. This also provided the example for many of the Good Samaritans helping other victims to model. Belts, torn clothing and shoe laces were all used as tourniquets to slow life threatening bleeding. According to one Boston physician, they had never seen so many tourniquets. The number of deaths that could have occurred had it not been for the heroic actions of the first responders could have been in the hundreds.

Interest in Tactical Emergency Casualty Care is growing, but it is not standard or part of mainstream first responder training. Despite this, there are hundreds of examples where TECC training was used to save a civilian or first responder's life. With the significant increase of deaths of law enforcements officers caused by gunfire in the last decade, it is difficult to understand why TECC training has not been incorporated into the training of every law enforcement officer in the United States. Progress is being made in educating our government officials on the benefits of TECC training. The recent formation of the Committee for Tactical Emergency Casualty Care has brought physicians, law enforcement, rescue and emergency medical service together to lead the future of TECC programs. The Los Angeles County Sheriff SWAT team and the US Border Patrol Borstar division fully recognized the benefits of TECC training and have implemented it in their respective departments. Orange County, California has become the gold standard for TECC training for all its law enforcement officers. Through a Homeland Security Urban Area Security Initiative Grant, the Santa Ana and Anaheim Police Departments have combined to train over 800 officers in TECC with courses occurring monthly open to all county law enforcement. Local and national awareness of TECC is on the rise. It has become the passion of Huntington Beach, CA Firefighter Ray Casillas. A highly decorated firefighter/paramedic, Casillas has drawn from his long career as a SWAT medic and firefighter to seek the assistance from two of the biggest names in the development of the military CCC doctrine, Drs. Frank Butler and U.S. Surgeon General Frank Carmona to support TECC training.

No miracle occurred in saving the lives of many of the Boston bombing victims. The fast action and training of the first responders is what made the difference. Those in the terrorist intelligence community are probably a little surprised it took as long as it did to have a successful bombing on U.S. soil. When we look at our own landscape just in California, the list of potential terrorist sites is probably too long to count. Our success thus far in preventing terrorist attacks has been good and perhaps occasionally lucky. Boston clearly indicates that our post attack response can still use improvement furthering the need for mandatory advanced training. Sadly, it has taken 300 hundred injured and three dead to really draw attention to our violent society and the critical responsibilities of our first responders. In the last 12 months, eight mass shootings have occurred in the United States. We probably cannot determine exactly, but now know for sure there were large numbers of lives saved because of TECC training at each of these incidents.  Hopefully in the future, Orange County, the Los Angeles County Sheriff and the U.S. Border Patrol current training procedures will be considered standard mainstream training and not cutting edge training and deployment programs.

The beginning of year 2013 has been one of the most violent periods in California law enforcement history since the Gold Rush era. Five officers have been murdered along with two civilians with law enforcement ties as well multiple officers attacked and wounded in the last 90 days.   Questionably, Is the current training and safety standards of law enforcement officers meeting the needs required to engage and defeat a new breed of increasingly violent criminal?

Realistically, there can only be a few in the United States law enforcement community that are not aware of the events associated with the rampage committed by ex-LAPD officer Christopher Dorner. For two weeks, a homicidal psychopath systematically administered his revenge against law enforcement personnel, based upon, his perceived mistreatment and injustice.  Dorner had one of the most dangerous personalities any government entity could ever encounter. He was not suicidal but rather meticulously homicidal.  He did not kill or injure randomly but rather adhered stridently to a well defined plan. He would forgo multiple occasions to attack when the risk to the overall completion of his mission was too high. By laymen assessment, Dorner did not allow emotion to affect his overall goals and implementation of his plan. Arguably, he was well trained physically and mentally and his extreme behavior evident.

Dorner remained focused on the objective to inflict as much possible pain and suffering on his "hit list" of LAPD personnel as well as any law enforcement officers, who tried to stop him.  He chose tactical techniques that afforded him the lowest risk of being captured and the highest success in accomplishing his objectives.  His intelligence and prior training led him away from any direct confrontation with his enemy.  Prior to the "last stand" which resulted in Dorner's death, he used only ambush tactics with no forewarning of attack.  He did not appear to be interested in any single act of violence; he pursued a systematic goal of completing his mission of revenge and atonement.  He was committed to the operational security and patience needed to complete his entire manifesto of justice.

Regardless of the assignment, all law enforcement positions have an inherent risk and potential for violent encounters. For those assigned to hunt for Christopher Dorner, while the ideal of a peaceful resolution was preferred, preparations were for a very tragic and violent finale.  The search teams envisioned a head on battle with Dorner.  Not all law enforcement assignments prepare for daily violent encounters. Even though the majority of California agencies require all their patrol and special operations officers to wear body armor, this is not typically the standard for investigative units. Rarely will a detective wear body armor while performing routine duties.  Is this practice dictated by culture or a belief that investigators only have encounters that are low risk? Sadly, any miss-perception was disproved with the tragic shooting of two Santa Clara detectives while performing a field interview.

With today's criminals likely to be highly trained killers with access to more advanced firepower technology, no law enforcement role should be considered safe from harm's way.  During an after action review of any on duty death or injury, it is paramount not to be critical of the fallen. Yet, the analysis should include all the pertinent facts of the event with attention directed on deficits in training, equipment or trends with the objective of better preparing officers for similar events in the future. While it may not be appropriate to suggest a different outcome would have occurred in Santa Clara if body armor had been worn, it is appropriate to note that recognizing the risk and danger in all law enforcement assignments outside of patrol and special operation assignments is necessary today.
 
Risk assessment is not just the responsibility of policy makers and law enforcement  supervisors, it is the responsibility of every police officer/deputy sheriff regardless of the assignment.  Regrettably,  basic law enforcement policy and culture have not kept up with today's world of violent criminals.  Each officer, therefore, must take added precaution for safety regardless of departments standard protocol. It is important to have risks of every operation evaluated independent of the standard operating procedures. Relying solely on general non specific policy or protocol may actually cloud an accurate assessment of the dangers.  Convinced that he would eventually personally confront Christopher Dorner during the Big Bear manhunt, a San Bernadino Sheriff Deputy donned rifle body armor which he had purchased with his own personal funds.  The reward for his own risk assessment and personal responsibility for safety was his life being saved after being shot in the chest by Dorner

Unfortunately, the SWAT teams cannot be utilized for every criminal encounter.  Because of this, it is important that the risks of every operation be evaluated without allowing culture or department tradition to cloud an accurate assessment of the dangers.  Individual objective risk assessment and responsibility for personal safety is a relatively new paradigm in law enforcement mindset. Unfortunately, the economic environment prevents many agencies from affording the newest and improved safety equipment and training that can be instrumental in  mitigating the increasing dangers faced by law enforcement officers. This leaves officers with one choice.....do it yourself!

Patrol Ready!

No words can or will ever describe the sadness felt by the senseless loss of children. Oregon and Connecticut are stark reminders that several times a day as law enforcement officers prepare to go on patrol, their mindset, training and equipment must be ready to respond to and protect our most precious commodity....human life. Friday morning without a second of hesitation, Connecticut law enforcement officers raced to and entered Sandy Hook Elementary school pursuing the sound of gun fire until they had put a human shield between the children and a crazed murderer. These officers are not Army Rangers, Green Berets, Navy Seals or SWAT, they are the men and women who make up the backbone of all US law enforcement....they are Patrol Officers!

http://www.mydigitalpublication.com/publication/?i=108949&p=34

The Bail-out bag

Few careers allow an effective professional to arrive at their workplace without allocating time to prepare themselves mentally.  Some career professionals need to mentally and physically prepare, making equipment status checks and evaluating the immediate needs of the day crucial to their success.. Physicians, pilots, firefighters and law enforcement officers as well as many other professionals spend a portion of every work day going through surveys of equipment preparation, functionality and assessing any special requirements unique to the day's responsibilities.. Law enforcement officers start each day inspecting their uniform, duty belt, tools, and weapons for function and sign of wear. The patrol vehicle is next undergoing review for operation, wear and damage. Every officer has a unique routine and set of priorities for preparing for their shift. The amount of personal equipment loaded into the vehicle is often a function of an officer's current assignment and personal preferences. Of the many lessons learned from the North Hollywood Bank Robbery, being prepared to sustain long periods of action without logistical support at a crime scene or critical incident is vital. Tactical independence has become a major teaching point in all law enforcement training which requires police officers be mentally and physically prepared.

The term "Bailout" bag has become a popular term for the west coast law enforcement community. It refers to a collection of equipment readily available for use when immediate sustained action is required. It typically is loaded into a patrol vehicle at the start of a shift as part of the vehicle preparation. The bag commonly contains food, water, extra ammunition and a medical kit. Officers can create them individually with the mind set that it be accessible in a split second and it provide them the ability to be self sustaining for a minimum of several hours. In recent years, medical kits have become very popular additions to bailout bags. Though some officers choose to create their own kit, there are several commercial vendors selling pre-packaged kits at various cost. Commercial kits can cost between $25.00 to $100 dollars depending on the contents of the kit.  Many vendors will customize kits to fit specific police department’s needs. Contents often vary depending on the officer's assignment. SWAT or special operation team needs are different then the needs of a patrol officer.   Any first responder is potentially exposed to high risk injuries and the need for emergent medical attention, therefore, should always be required to carry, at minimum, a basic kit

Each member of our SWAT team carries a medical kit attached to their tactical vest. It typically contains a battle tourniquet, pressure bandage and scissors. Each operator is trained in individual care as well as buddy care. The team is supported by a police officer/ medic who carries a fully supplied trauma bag, AED (Automated External Defibrillator) and oxygen. The presence of the Bearcat tactical vehicle allows for immediate rescue and extraction. Unfortunately, patrol and non special operations officers are often not afforded the same immediate medical support as the tactical teams. When creating or purchasing a basic medical kit, assessing potential risk and determining the environment an individual will be operating in is important. The urban area of Los Angeles compared to the remote wilderness of Montana obviously have differences in evacuation complexity and transport time to an acute care hospital.  Many medical items are perishable, expensive and in many cases never used. The size and weight of a kit and, again, the environment of the officer will dictate the content. Expectantly, the Bail-out bag must be a manageable size to be functional.

Recommendations for medical kit content varies. The majority of vendors selling kits attempt to parallel military needs with that of law enforcement. Military statistics indicate 56% of battlefield ballistic injuries are non survivable and 44% of battlefield ballistic injuries are initially survivable. Statistics that clearly do not reflect the environment of U.S. law enforcement.  Of those who initially sustained a survivable wound and later died, 90% of those soldiers died before reaching a medical facility. The majority died from either bleeding to death or a chest wound. Unquestionably, the injury and death rate of the military in battle does not compare to the same statistics in law enforcement. Thousands of soldiers are injured or killed every year on the battlefield while felonious assaults leading to death have never reached such numbers in modern U.S. law enforcement. However, unlike the military, there is no detailed database of the type of injuries or exact causes of death of law enforcement officers. Thus, the mechanism of death associated with initially survivable injuries either on the battlefield or on the streets are arguably compared in light of the amount of military weaponry that has made it to the level of the street criminal. It would seem logical to assume acute bleeding and chest trauma would also be the most likely causes of death of a wounded law enforcement officer.

Consideration of the most probable mechanism of critical injury should guide a officer's decision on what to carry in a medical kit. Function, size and weight are factors. Delayed extraction and transport time are not, typically, considered in an urban environment. The combination use of a battle tourniquet and pressure bandage is the most effective way to prevent the number one cause of death from a survivable injury. Used in combination, almost all extremity bleeding either venous or arterial can be controlled long enough for rescue and transport to a medical facility. The use of clotting agents in civilian law enforcement does not have enough evidence to warrant recommendation. The incidence of survivable chest trauma in law enforcement deaths is not well documented. Typical law enforcement body armor protects against most handguns. Unlike the military battlefield, there is very little explosive shrapnel injuries in civilian law enforcement which is one of the main causes of the "sucking chest" wound along with small caliber ammunition.  Stabbings can also be cause of critical chest trauma but, based on available information, the number of officer deaths by stabbing is very small. These facts make it difficult to suggest the need to carry chest seals in a medical kit. Automatic weapons and rifles cause such extensive chest trauma, there is virtually no piece of first aid equipment available that would be beneficial in this situation.

Allocating time each day to mentally prepare as well as assessing equipment needs and equipment functional status will prepare an officer for almost any encounter.  However, standardizing a basic medical kit to include a battle tourniquet and a pressure bandage as part of a police officer’s equipment needs, such simple items readily available for immediate access, could make the difference of life and death in today’s world of law enforcement.

Why do the cops need a tank?

The tragic death of United States Park Ranger Margaret Anderson on Near Year’s day 2012 highlights one of the worst fears of the law enforcement medical community--a "down" officer with potentially survivable injuries who cannot be reached to receive medical care. After being wounded, Ranger Anderson was able to call for help, but fellow officers could not rescue her for over 90 minutes due to the ongoing gun battle. Back in 1997, the North Hollywood bank robbery brought to the forefront the lack of law enforcement resources available to launch an injured officer rescue in the face of a hostile environment.  By late morning February 28, 1997, numerous civilians and law enforcement officers laid injured and trapped while the fiercest gun battle in United States law enforcement history raged around them for almost 45 minutes. One the most critical decisions made by officers on scene that day was to utilize a bank armored car to rescue the injured caught in the crossfire. Several individuals rescued had sustained life threatening injuries that required emergent medical care to save their lives.  Fifteen years later, some in the general public still question whether life-saving armored vehicles should be afforded to our officers in the field.

 Armored vehicles for law enforcement have been sparsely available through military surplus since the 1960s. Until September 11, 2001, only a handful of armored vehicles specifically designed for the unique needs of law enforcement and rescue operations were in service.  Since 2001, several companies have entered into the law enforcement armored vehicle market. Arguably, the Lenco armored vehicle company has emerged as one the leaders in the industry.  The cost of these vehicles is significant with prices ranging from $200,000-$400,000 dollars. With the increased availability of Homeland Security grants after the terrorist acts of September 11, 2011, hundreds of law enforcement agencies across the United States have been able to purchase law enforcement specific armored vehicles.

The cost to the taxpayers combined with the current difficult economic landscape has led many citizens to question the need and fiscal responsibility associated with the purchase of one these vehicles. It is not difficult to appreciate these concerns when school funding, social services, and public works budgets are continually being reduced to manage increasing budget deficits. Almost every law enforcement agency in the country that has purchased an armored vehicle has encountered some negative publicity through town meetings or print and Internet media.  Fortunately, the need analysis for armored vehicles in law enforcement is overwhelmingly clear. The examples of officer protection provided by armored vehicles as well as serving as a secure platform for any rescue operation can be found in almost every major city in North America.  Countless lives have been saved by the presence of these vehicles in a time of unprecedented violence.

Criticism of such large public expenditures will only continue to grow unless the law enforcement community becomes aggressively proactive in educating the public in regards to the capabilities of these vehicles and the sequence of events associated with acute injuries, rescue time and the loss of life. Unfortunately, a significant percent of the general public build their perceptions and opinions of law enforcement operations from viewing fictional television shows or movies. Educating the public, though not always straight forward and simple, on factual historical data may benefit law enforcement agencies. The use of simulated reenactments of actual situations may make any local educational program more personal, realistic and informative.  The events in Waco, Texas, the North Hollywood bank robbery and Mount Rainier National Park all provide excellent history lessons on the reality of the world we live in.

It will never be known if Ranger Anderson would have been saved if a timely rescue had occurred by her fellow law enforcement officers or if there had been an armored vehicle with a trained tactical medic readily available. What is known is the difference between life and death is often measured in seconds and we need to take advantage of those seconds to preserve the lives of the officers who put their life at stake to serve and protect our communities. 

The arrival of a Lenco Bearcat...a new era of safety

"If tomorrow you were going to be in a fight for your life, how would you train today?"  The protection and safety provided by a Bearcat G4 allows operators to deploy very close to the target, avoid the danger of open ground approaches and improve visual coverage for the snipers. The vehicle also creates significant cover if a firefight erupts and team members need to fall back for protection and regrouping. The distance and time between rally point and an officer rescue should dramatically improve as well. If the rescue team is not close to the injured officer, the Bearcat can deliver the rescue team right to the officer or at least to the entry of the structure containing the "officer down". The trained driver can position the vehicle as to provide maximum protection for the down officer and the rescue team. Within seconds, the injured officer can be loaded into the vehicle and full advanced traumatic life support initiated within the safety of armored walls. Penetrating chest trauma and major vascular injuries, the two most survivable lethal injuries law enforcement officers face, will be treated immediately. The Bearcat will provide the medical platform for large volume fluid resuscitation, chest decompression, vascular injury control and intubation with dual and single lung ventilation. Along with trauma care, advanced cardiac life support capabilities will be present. Treatment of cardiac arrhythmia's and defibrillation of a lethal heart rhythm can occur in seconds and not minutes--the time often separating life and death. With arrival of our new Lenco Bearcat G4, officer safety for our SWAT team has reached a new level. Like all aspects of law enforcement, training with new equipment is paramount. A new leap in safety has arrived for our SWAT team.