risk reduction in officer rescue: a scenario-based...
TRANSCRIPT
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Risk Reduction in Officer Rescue: A Scenario-Based Observational Analysis of
Medical Care
Matthew D. Sztajnkrycer, MD, PhD
Medical Director, Rochester Police Department
Medical Director, Rochester/Olmsted County Emergency Response Unit
Associate Professor of Emergency Medicine
Mayo Clinic
Rochester MN 55905
P: 507-255-0917
F: 507-255-6592
The views presented in this publication are those of the author, and do not
necessarily reflect those of the Rochester Police Department, Rochester/Olmsted
County Emergency Response Unit, or Mayo Clinic.
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“Then I heard the voice of the Lord saying, “Whom shall I send? And who will go
for us?” And I said, “Here I am. Send me!” Isaiah 6:8
Disclaimer: While I have the privilege to work alongside the men and women of
law enforcement, I am not a sworn officer. As such, I will always defer to my
colleagues regarding sound tactical decision-making. The following article
discusses tactics in terms of medical decision-making. While data-driven, it is
observational, and should not replace sound tactical decision-making and
common sense.
Introduction
At its most basic level, the downed officer rescue reflects the fundamental conflict
between a need to do what is perceived as right for the downed officer versus the
risk such action creates, both to the rescuers and to the downed officer. In its
coldest analytical form, it is a classic risk-benefit analysis. Logic would state that
risks and benefits should be weighed in order to come to a reasonable decision
as to whether or not to effect a rescue.
The reality is that this calculated analysis frequently does not occur. Even when
not under stress, the decision-making process of our brain is frequently illogical,
emphasizing wants over needs [1]. In the setting of a critical incident, mental
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processes are further altered. Adrenaline levels are high, there is a desire (if not
always a need) to help, and time keeps ticking away, increasing the level of
stress and the perceived need to do something. Feeding into the risk benefit
analysis is the fact that law enforcement is by definition a high-risk occupation. In
2007, there were 57 line-of-duty deaths (LODDs) resulting from felonious assault;
55 resulted from gunfire [2]. Officers have already accounted for this risk in
simply accepting their career, and as such are frequently willing to accept a
higher level of risk than would otherwise logically be considered acceptable.
When dealing with injuries under conditions of active threat, such as during a
downed officer rescue, it is important to understand that medical needs are
simply another tactical consideration. This is highlighted in the statement “Good
medicine can be bad tactics, and bad tactics can get everyone killed or cause the
mission to fail”[3]. It is important to understand this concept in order to
successfully do what is best for both the downed officer and the rescuers. The
most appropriate tactical medical care may actually be threat neutralization. As
an example, consider the conflict between medical care and threat neutralization
in an active shooter scenario.
No law enforcement operation is without risk. The goal of any successful tactical
plan is not to completely eliminate risk (which is impossible, and will lead to
inaction), but rather to manage it in such a way that it is reduced to acceptable
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levels. The purpose of this article is to examine the nature of risk specific to
downed officer rescue, and discuss some potential ways to minimize risk.
Phases of Risk in Officer Rescue
Every rescue situation, regardless of the nature of the threat, can be defined in
terms of three phases of risk (Figure 1). The Approach Risk Phase occurs during
the transition from the relative safety of the point of last cover and concealment
(LCC) into the “hot” zone, where a potential active threat exists. The Approach
Risk Phase consists of the distance that must be covered in order to reach the
downed officer. It is during this period of time that the team first exposes itself to
the potential threat.
The Aid Risk Phase consists of the period of time the officers spend in the hot
zone, under threat of effective fire, assessing the downed officer, and performing
preliminary care (Figure 2). This phase is high risk because any suspect is likely
now aware of the rescue attempt, the team is relatively static, and situational
awareness is easily lost while focusing upon the injured officer.
The final Extraction Risk Phase consists of the distance that must be covered to
return the downed officer to a position of relative safety, where further medical
aid and definitive evacuation can be performed.
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Basic Principles: Recovery or Rescue?
Consider the following training scenario: An officer responding to the scene of a
domestic violence call is shot upon exiting his car. 9-1-1 calls from the scene
report an officer down behind his car. The responding tactical team observes the
officer in a seated position behind his car, not moving. The distance from team to
downed officer is approximately 25 meters, all open ground. What should they
do?
Conceptually, a downed officer rescue may be viewed as a barricade situation,
with the open ground between rescuers and downed officer serving as a barrier
to effectively reaching the officer (Figure 3). The most fundamental question the
team must answer is whether this situation represents a downed officer rescue or
a body recovery. A striking example from the Vietnam era demonstrates the risk
of attempting a rescue when the situation is actually a recovery [4]. During a
patrol, a squad member is shot in the head, and lies motionless in the kill zone,
with minimal bleeding from the wound. A squad member responded to his side,
and attempted to apply a field dressing to the lethal head wound. He was shot in
the hand and wrist. A second responder was shot in the forearm, a third in the
shoulder, a fourth in the chest and wrist, a fifth in the back, and a sixth in the
thigh.
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Many times it is difficult to tell whether the situation is a rescue or a recovery.
Due to the nature of the incident, an initial hands-on assessment is often
impossible. As such, the assessment is based upon the presence of absence of
indirect signs of life. These may include spontaneous movement, spontaneous
chest rise, or exhaled breath plume on a cold day. Gunshot wounds to the head
with exposed brain matter may be another indicator, although there are
numerous cases of survival despite these wounds. Tactical medics may be
extremely useful in these circumstances, providing the on-scene commander
with medical intelligence concerning the nature of the injuries, and whether they
are incompatible with life. Thinking outside the box, a frequently under-utilized
medical asset in remotely assessing a downed officer is the sniper. A sniper is
trained to provide real time information in much greater detail than the typical
operator.
If it remains impossible to distinguish between rescue and recovery, the most
appropriate response is often to assume a rescue situation (ie. that a potential
benefit exists) and act accordingly. However, in simply taking a few seconds to
make these quick assessments rather than immediately rushing forward into the
hot zone, rescuers have already made a significant risk assessment modification.
The tunnel vision surrounding the downed officer is removed, and possible
threats and safe areas identified.
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The above-described training scenario was run with approximately 150
participants representing more than 6 agencies, on 3 separate occasions, and in
two different countries. Every group of participating tactical operators approached
the downed officer, despite the fact that the officer showed no signs of life, and
had a simulated head injury with exposed brain (Figure 4). The scenario was
actually designed to force operators to distinguish between rescue and recovery
operations. As in the Vietnam example, teams exposed themselves to risk for no
possible benefit. One of the arguments put forth by the officers for their actions in
this scenario was that they could not tell if the victim was alive or dead without
examining him, and therefore they were required to go forward. This
“requirement” to go forth is beyond the scope of this article. However, other than
one team calling out to the downed officer, no team attempted remote
assessment in a rapid yet organized fashion.
If the situation is determined to be a recovery, no further time pressure exists.
There is no longer a patient with the potential to deteriorate. This is not a foreign
battlefield, where the deceased may find their bodies desecrated, and so must be
rapidly recovered. The situation can hopefully be resolved in a safer manner, and
allow for dignified recovery of the body. Interestingly, once committed to going
forward, teams frequently continued with body recovery rather than simply
determining absence of life and retreating. By locking into a rescue mindset, and
therefore extracting the body, the average time in the hot zone during these
recovery scenarios increased by 26.8 seconds (Figure 5). While these times may
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not appear very long, consider that a semi-automatic AK-47 clone can fire 30
rounds in approximately 5 seconds [5,6].
Approach Risk Phase: Look Before You Leap
Once the decision is made to initiate a rescue, the first critical medical decision to
be made from a tactical standpoint is determining whether the downed officer is
sick or not sick. Sick implies that the officer will die in the next 15-20 minutes
without medical intervention. Not sick means that, while injured and in need of
medical treatment, the officer can survive for at least this long. This decision is
critical from a tactical standpoint, because a sick patient requires immediate
attention, and therefore adds an element of time pressure absent from a non-sick
patient. The sick patient may require a hasty rescue team from responding patrol
officers, while from the medical stand-point the not sick patient can await the
arrival of a specialized tactical team. Time pressure increases stress, which
alters physical abilities and mental processing, and therefore increases
operational risk. By determining not sick, the operational risk to both downed
officer and rescuers is decreased.
Prior to leaving LCC and entering the hot zone, rescuers should take a few
moments to survey the scene one last time. This includes:
• Scanning the area for potential cover, concealment, and for threats
(debris, secondary devices, suspects).
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• Determining the best approach to the casualty.
• Planning the best route of return with the downed officer, given the fact
that several guns will now be off-line and extra weight will be present.
• Remotely reassessing the downed officer to determine self-extrication
capability.
In training scenarios involving an approximately 25-meter distance, the average
time to reach the downed officer during the Approach Risk Phase was 20.9
seconds (range 13 – 31 seconds). Even accounting for a reactionary gap in the
suspect’s response to the rescue, this is still sufficient time to significantly injure
or kill several members of the rescue team. If the officer is awake and able to
move, order the officer to an area of relative cover. This simple action may
actually remove the need for an immediate rescue attempt.
Consider the following case, again from Vietnam [4]. During another patrol, a
squad member is shot in the left elbow, and calls for a medic. The medic
responds, and while evaluating the casualty, is shot in the head and killed. A
second responder responds to both victims, and is shot in the chest and killed.
The wounded soldier then crawls 50 yards out of the kill zone, and is eventually
evacuated to medical care.
If the officer is awake and able to move, order the officer to initiate self-aid as
appropriate, while awaiting rescue. Unfortunately, many people equate being
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shot with being helpless or dead, something frequently reinforced in training.
Nothing could be further from the truth; it is important to remember that this
applies to suspects as well as officers. Once injured, some officers may simply
shut down. Forcefully remind them that they need to fight, that they are not to
give up. If the injury has easy emergency treatment, such as applying pressure to
a wound to decrease bleeding, officers should be ordered to perform these
actions if safe to do so. Depending upon their injury, they may be able to provide
cover for the rescue team. They certainly should be asked to provide intelligence
on the situation, thereby keeping them engaged and actively involved in their
own survival.
Aid Risk Phase: Remote Medical Assessment
Before leaving the LCC, take a few seconds to assess the medical needs of the
downed officer (Figure 6). Remember, you may be the first medical responder in
this rescue. The burden is then placed upon you to know what should and should
not be done, and how to do it [7]. What are the officer’s injuries? What medical
care is needed? More importantly, what medical care can be safely performed?
Is there cover nearby where the officer can be moved to have this care provided,
prior to definitive extraction? How long are you willing to spend in the hot zone?
By answering these questions ahead of time, exposure time in the hot zone will
be minimized, therefore reducing risk. When the decision is made to move, be
decisive and quick. And always try to maintain tactical awareness.
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Aid Risk Phase: Care Under Fire
As a consequence of the events in Mogadishu, Somalia, in 1993, the United
States military reevaluated the way in which it approached medical care in the
combat setting. The result of this re-evaluation was the development of Tactical
Combat Casualty Care (TCCC), arguably the most important tactical medical
development since Vietnam [3, 8, 9, 10]. TCCC recognizes that medicine is
simply another tactical variable in combat. It designates 3 phases of care, based
upon threat potential: Care Under Fire (CUF), Tactical Field Care (TFC) and
Casualty Evacuation Care (CASEVAC).
Care Under Fire (CUF) is the care rendered upon reaching the downed officer
when the potential for active threat still exists. Due to the high threat level,
medical care in the hot zone is extremely limited. The current TCCC guidelines
explicitly establish procedures for hot zone care (Table 1). Most recently, the
prevailing wisdom is to avoid any medical treatment in the hot zone, and to focus
solely on extrication [11]. Minimizing care in the hot zone minimizes exposure
time and therefore risk. In these scenario-based training exercises, the average
time spent in the hot zone assessing the patient and performing CUF was 49.4
seconds (range 9.0 – 131.0 seconds). Recovery assessments took less time
(average 30.0 seconds; range 9.0 – 51.0 seconds) than rescue assessments
(average 62.0; range 55.0 – 131.0 seconds).
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The only medical care provided in the hot zone is control of life-threatening
hemorrhage [8,9,10]. Due to the nature of the hot zone, the need for continued
situational awareness, and the inability to provide sustained pressure on a
bleeding wound in the hot zone and during rapid extraction, this is achieved
through the rapid use of a tourniquet (Figure 2, 7). A general rule of thumb is that
tourniquet placement in the hot zone should take no more than 7 – 10 seconds.
Remember that during this time, the officer applying the tourniquet will lose
situational awareness. In training scenarios, the average time to apply a
tourniquet upon reaching the downed officer was 56.3 seconds (range 37.0 –
121.0 seconds). Again, consider that it takes approximately 5 seconds to fire 30
rounds from an assault rifle [5,6].
This delay in tourniquet application time reflects the perceived need to perform a
cursory assessment of the downed officer, as well as the time required to remove
the tourniquet from a pocket or pouch, open it up for use, and deploy it. Remote
assessment and preplanning will remove delays in assessment and decision-
making. Every officer should be instructed in the rapid use of a tourniquet; the hot
zone is not the place to use any equipment for the first time (Figure 2).
Pre-designation of a rescue aid officer provides multiple advantages. First, that
officer will have personal protective equipment (eg gloves) appropriate for body
substance isolation. While the victim may be a fellow officer, this does not
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preclude the risk of blood-borne diseases. Second, the rescue aid officer will
know that he/she can focus on the downed officer in relative safety, as the other
officers will maintain situational awareness. Most importantly, the rescue aid
officer can expedite medical care and extraction by having a medical preplan,
including having the tourniquet out and readily available for use as appropriate.
Extraction Risk Phase
The extraction phase poses its own unique problems, not the least of which is
being encumbered by a fellow officer who may be unable to assist in movement.
In training scenarios, the average time to extract the team approximately 40
meters was 30.0 seconds (range 15 – 49 seconds), compared with an average
20.9 seconds for approach. In order to minimize risk, an appropriate extraction
route, with suitable points of cover, should be determined prior to leaving the
LCC.
The goal of this phase may not be to remove the officer to a point of definitive
safety. It may be easier to move the officer to a position of relative safety,
provided by the availability of cover. Once in this position of relative safety,
additional care can be rendered, and emphasis placed upon neutralizing the
threat.
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One common failure of the extraction phase is package separation (Figure 8).
This has been noted in a previous article [12]. The extraction package consists of
2 groups of officers, those physically performing the extraction by carrying or
supporting the downed officer (extraction group), and those providing protection
and situational awareness for the extraction group (cover group). Due to a
combination of factors, the extraction group tends to outpace the cover group.
The larger the distance to be covered, the larger the gap becomes, such that
eventually the extraction group is left exposed and with limited defensive and
offensive options.
Another common failure is simply reversing back out to safety. This poses a
problem for several reasons. The first is that there may be safer, alternate routes,
including those that provide better cover. Additionally, teams tend to simply turn
around and face in the direction they are extracting. In so doing, the team faces
weapons and protective equipment (eg ballistic shields) forwards towards relative
safety, while leaving flanks and rear exposed.
Recently, attention has focused upon the extraction risk phase as a priority
phase in rescue [11]. The focus of care under fire is slowly shifting from limited
medical care (stopping life threatening hemorrhage using tourniquets) to rapid
extraction to a position of relative safety. Although research remains limited, this
fundamental change in the concept of care under fire has already resulted in the
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development of several exciting new high-risk extraction tools, including hands-
free tools which permit the use of weapons during the extraction phase.
Immediate Rescue Drills
The rescue of a downed officer is a high threat procedure. The risk exists, during
all phases, that the rescuers come under direct fire, and that one or more
rescuers are injured. This did occur during several of the training drills (Figure 9).
It is important that the team have an immediate action drill should this occur. At a
minimum, this drill should include:
• Suppressing in-coming fire from the threat if feasible.
• Identifying the presence and location of downed rescuers.
• Rapidly identifying who amongst the team will respond to the new downed
officers and who will continue with the primary rescue.
• Immediately extracting the downed rescuer, rather than retreating and re-
approaching.
Due to this potential for rescuer injuries, if team size permits, back-up rescue aid
officers should be identified, not only to respond to any rescuer casualties, but
also to replace the primary rescue aid officer should he/she be injured during the
approach.
Conclusions
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The rescue of a downed officer is a mission critical element in law enforcement.
While these rescues remain high-risk, there are ways to at least favorably modify
the level of risk involved.
The key to any successful operation remains appropriate, realistic, and on-going
training. While training time and budgets become increasingly tenuous, every
officer must understand not simply that they may one day find themselves injured
in the line of duty, but that they may one day find themselves as the first medical
responder in these events. In one study, 32% of officers reported a line of duty
injury serious enough to require transport to an ER. Importantly, 41% of officers
in the same study reported that they had responded to the scene of a seriously
injured officer; 70% of these officers reported that they were on scene prior to the
arrival of definitive medical care [12]. As such, every officer should be familiar
with the basic concepts of TCCC and CUF, and the use of a tourniquet.
Knowledge is power, after all.
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Acknowledgements
I would like to thank all the men and women of law enforcement who took the
time to participate in these training sessions, and who place their lives on the line
every day. This work is dedicated to them and their families.
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References
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Kepp JJ, King K, Pierce J, Wightman J, and Vayer J. Emergency Medicine
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5. Anonymous. Semiautomatic AK47 30 Rounds Extremely Fast Rate of
Fire. http://www.youtube.com/watch?v=fW_HMBLvzuU; last accessed
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6. Anonymous. Fast AK Shoot.
http://www.youtube.com/watch?v=V8OZ4eUvjJY; last accessed 10/14/08.
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10. Committee on Tactical Combat Casualty Care: Military Medicine. In:
Prehospital Trauma Life Support, Military Edition, Revised 5th Ed.
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– 408.
11. Croushorn J and Westmoreland T. Tactical Medical Equipment. The
Tactical Edge 2008; 26 (2): 60,62,64.
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Lessons Learned. Emerg Med Serv 2006; 35; 32,34,36.
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Table 1: Care Under Fire Procedure
1. Keep casualty engaged as a combatant if possible.
2. Return fire as directed or required.
3. Prevent further injuries to responders or casualty.
4. Stop life-threatening external hemorrhage.
5. Defer airway management until the Tactical Field Care stage.
6. Extract the casualty to safety as soon as possible.
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Figure 1: Phases of Risk
Downed officer rescue can be defined in terms of 3 phases of risk. See text for
details.
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Figure 2: Aid Risk Phase
Medical care in the hot zone predominantly involves rapid, safe patient
extraction. Life-saving interventions are limited to tourniquet application for
massive hemorrhage. The hot zone is not the place to learn tourniquet
application. In this image, the officer has unthreaded a pre-threaded tourniquet,
and is now trying to re-thread it.
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Figure 3: Approaching Rescuers Take Fire
The open ground serves as a barrier to safely reaching the downed officer.
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Figure 4: Recovery Scenario
After calling out to the downed officer, the team moves forward (A) and assesses
the downed officer (B), thereby exposing themselves to a potential threat. Note
the simulated brain matter on the facemask of the downed officer.
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Figure 5: Effects of Recovery on Extraction Time
The decision to recover the body (B) or simply extract (A) resulted in a 26.8
second increase in time of the Extraction Risk Phase.
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Figure 6: Aid Risk Phase
Little care can be performed in the hot zone for an eviscerating injury, in this case
caused by an explosive device. By planning prior to movement from LCC, time in
the hot zone is minimized. In this scenario, a secondary device was present.
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Figure 7: Care Under Fire Tourniquet Placement
Continued realistic training is important to develop proficiency under stress
conditions. While two operators are off-line, the remainder of the team provide
cover and situational awareness.
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Figure 8: Package Separation
As time progresses (A through D), note the increasing exposure of the extraction
group to a possible threat.
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Figure 9: Rescuer Down
Rescue operations are not without risk. A responding officer is struck by the
suspect and falls (A). While his partner backs away to safety, officers treating the
original downed officer are unaware of the new casualty.
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