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.

 

Is Tactical Emergency Casualty Care enough for first repsonders?....Do we need more?

The core of  Tactical Combat Casualty Care("TCCC") training and later civilian Tactical Emergency Casualty Care ("TECC") training is to provide the front line responder with the knowledge and skill to save their own life or their buddy when death is less then 3 minutes away. TCCC was never designed or intended to replace the need for a highly skilled battle medic.  In the past month, there have been several great discussions among emergency first responder groups on the topic of the civilian TECC and the military TCCC programs respectively. TECC training is a modified version that takes into the account the unique needs of the civilian world injuries while TCCC is focused on the different landscapes of battlefield injuries. Regardless of the modifications and continued improvement to meet the needs of our civilian population, TECC training fundamentally mirrors the foundation of TCCC training which is the recognition and treatment of the top three causes of death after a survivable injury. Uncontrolled bleeding, penetrating injury to the chest, and loss of airway account for ninety percent (90%) of the deaths that occur before reaching an acute care medical facility. TCCC training was developed after the recognition that many soldiers in the field died from survivable injuries because medical care was not started soon enough. Despite the presence of well trained and equipped battle medics, it was realized that the victim was often not reachable by the platoon or team medic in the critical minutes. The injured soldier was either alone or with a buddy. Though a soldier first with the capability of providing superior firepower to the fight, military combat medics are typically equipped and trained to handle a full spectrum of injuries on the battlefield. From a sprained ankle to performing a surgical airway in the middle of a firefight, combat medics rise to almost any challenge except when they cannot reach the wounded soldier or superior firepower is the priority.

The civilian world differs significantly than the military battlefield.  Regardless of the event, school shootings, explosions or natural disasters, in civilian life, large numbers of emergency medical service (EMS) responders are deployed immediately. Evacuations can occur by land , air or sea and arrival time at an acute care medical facility is typically measured in minutes compared to combat where hours to days may elapse. However, the most striking difference is the inability of civilian EMS to work in a hostile environment. The lack of medical personnel in the hot zone makes TECC  training that much more important to the civilian front line responders. Historically, TECC training has resulted in numerous lives saved with examples coming from all regions of the United States. As significant and cutting edge TECC training is, it does not replace or duplicate the education and training of our EMS partners. TECC training provides a time bridge for the critically injured to allow them to be removed from the area of direct fire or danger and be delivered to the EMS personnel for immediate treatment and care throughout the entire evacuation process


 Though bleeding and penetrating chest trauma seem self explanatory, the loss of the airway does not. The airway is defined as the open passages that allow us to take a breath in and expel it out. When the structures of the face, mouth or neck are damaged this can result in the obstruction of these "air" passages that then prevents the injured from breathing.  The education and training of TECC is aimed at extending the critical time the injured has before medical providers can start treatment. Battle tourniquets. pressure bandages, and chest seals make up the tools of TECC training. Education on body positions to maximize the best and easiest breathing patterns rounds out the skill set. No specific skill set of TECC training needs any prior medical knowledge to make a front line responder successful in saving a life. Placing a tourniquet when significant bleeding is occurring, or a chest seal when an obvious chest wound is present requires no special license or government mandated credentialing. Like basic first-aid, TECC training teaches simple skills and these skills  can make the difference between life and death of the injured. There is no confusion that TECC is not a form of paramedic or emergency medical technician training. Its goal rather is to take the professionals who make a career of tactics and operating in hostile environments and give them some life saving skills in the danger zone. TECC emphasizes that tactics, resolution of the mission and individual safety are always first priority.

Given the numerous acts of  war like violence occurring in the civilian environment, does the civilian world also need its version of the combat medic along with TECC?? The civilian version tactical medic is gaining ground throughout the United States. Numerous SWAT teams have embedded paramedics into their tactical teams.  Back in 1982, the San Diego Police and Fire departments joined forces to create the STAR program. Firefighter/paramedics were trained to operate in tactical environment of the San Diego SWAT team and provide immediate advanced medical care in the middle of the hot zone. The California Fire Authority now has several tactical medics deployed on their fire engines. They train independently and are outfitted with ballistic helmets and rifle body armor. The gold standard for the tactical medics has been set by the New York Police Emergency Service unit and the Los Angeles County Sheriff Department Special Enforcement Bureau's Emergency Service Detail (LASD ESD). All members are sworn law enforcement officers who have received additional certified accredited training as paramedics and or emergency medical technicians who are equipped accordingly.. The members of LASD ESD are, traditionally, experienced SWAT operators who apply for and compete for the coveted positions on the ESD team. They are educated in both civilian and military paramedic programs. They mobilize in full ambulance equipped Lenco Bearcats. Like the military medic, they are fully armed SWAT operators with advanced medical training. ESD deploys with every SWAT call out as one of their many other medical responsibilities.

Those in the civilian medical community don't always parallel military medicine success in the general population. Uniform standards of care, credentials, and licenses can be markedly different for these two communities, whereas scope of practice of a paramedic or EMT in the United States is highly regulated. All training is accredited and certified by license exams with input at the county, state and federal levels. Though some individuals may not see the relationship between the needs of an injured soldier and that of a critically injured civilian, TECC training is not enough. The combination of TECC training for front line responders and the embedding of tactical medics is the best model present for our modern world.

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!

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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.