Trauma

Treating Injured Police Officers

As you pull into the coffee shop during a busy night covering your district of an urban city, you place your order with the barista and hear over the police radio, “I’ve been hit, I’ve been hit, send help!”

This plea echoes through your head; you recognize the voice as an officer you went to EMT school with years ago.

You request the location of the officer via the radio and find out you’re only blocks away.

Sirens shrieking, you and your partner pull up to a chaotic scene. Gunshots still ring in the distance.

You see the officer down behind a radio car, with a second officer’s bloody hand draped over his neck. “Tell my family I love them …” are the last sounds you hear on the radio.

Assaults on the Rise

With the unprecedented increase of violent crime in the United States,1 law enforcement responders (in addition to EMS and Fire2) now face high risk for attack.

According to the National Law Enforcement Officers Memorial Fund, a whopping 44 officers were killed in firearm-related incidents in 2017. This was a decrease of 33% from 2016, which saw the highest number of firearm-related deaths recorded since 2011. These officers were killed primarily with handguns and rifles. The 2017 shooting deaths included eight deaths in ambush-style shootings.1,3

Not only are law enforcement officers being shot at, they’re also being assaulted. In 2017, seven officers were beaten to death (vs. only two in 2016).3

In 2016, according to Federal Bureau of Investigation (FBI) data, 57,180 officers were assaulted while performing their duties, 28.9% of them being injured as a result. Suspects used hands, fists, feet, etc. in a majority of these cases (31.4%), followed by firearms (11.9%), knives (10.8%) and other dangerous weapons (23.3%).4

Related Article: Trauma Caused by Law Enforcement Use of Force

Scene Safety & Ops

With the uptick in the number of law enforcement officers shot during a single incident, we should adjust the way we approach scene safety assessments. Remember, where the potential for danger is known or sensed from dispatch information, EMS crews should ensure that law enforcement personnel declare the incident “safe” prior to entering any scene. In general, EMS shouldn’t respond into any scene that’s still active unless appropriate protocols and training for warm zone operation are in place.

All responders should be aware that if a scene becomes unstable, that it’s permissible to retreat until the scene can be declared “safe.” In most situations, casualty care can wait until the scene is secure.

Not all calls for service for injured law enforcement officers will involve violence or an aggressor. Like EMS, law enforcement officers are exposed to many potential occupational hazards, such as motor vehicle crashes, falls, drownings and medical-related problems.

When on scene of a suspected attack or assault resulting in an injured police officer, EMS crews must remember that it’s a crime scene, which means that it will need to be processed by law enforcement technicians. EMS providers should avoid touching, moving and relocating anything they find or must work around unless it’s essential to the treatment of the injured officer.

When removing the clothing of an injured officer, EMS personnel should avoid cutting into any penetrating holes. Anything removed from the injured officer should be handed over to other officers or police supervisors on the scene.

All emergency responders must also be aware that officers may request that a significant amount of information be documented on a crime scene log if you enter. Therefore, responders should use the minimum amount of personnel needed to treat the injured officer. It may be more prudent and expeditious to recruit other officers/responders already on scene for assistance in moving the officer to a less sensitive nearby area.

Upon exiting a scene where an officer has been injured, it’s good practice to advise officers/investigators if you have moved or touched anything as this may be essential when processing the scene.

Assessment & Treatment

There are several key response and care principles that EMS and fire responders should be cognizant of. The first is that injured officers may have already begun self-care/buddy care prior to arrival on scene.

Officers are trained to find cover or concealment from threats and attempt to control any hemorrhage. Officers may have a variety of methods to control bleeding such as tourniquets, hemostatic agents, nonporous dressings to seal penetrating wounds and pressure dressings. Many officers are now routinely carrying these devices while on duty, either on their person or in individual first aid kits (IFAKs) in their patrol/response vehicles.

Once the scene is secure and EMS crews are able to assess the injured officer, they should immediately address any life-threatening hemorrhaging or other concerns and (if time or circumstances permit) complete a primary assessment.

Another officer should be recruited to immediately disarm any injured officer that presents with an altered mental status. It’s also suggested that any injured officer be disarmed, if analgesia or sedation will be administered. Crews should also check for backup or secondary weapons prior to leaving the scene.

Check for any other signs of hemorrhage and control all sources of bleeding. If not already done, use a tourniquet to control external hemorrhage that is anatomically amenable to tourniquet application or for any traumatic amputation. For effective use, apply the tourniquet directly to the skin 2–3 inches above the bleeding site.

For compressible hemorrhage that isn’t responsive to tourniquet application, apply a hemostatic dressing with at least three minutes of direct pressure.

Reassess all tourniquet applications and, when time and the tactical situations permit, check the patient’s distal pulse. If a distal pulse is still present on the limb where a tourniquet has been applied, consider additional tightening of the tourniquet or the use of a second tourniquet—side by side and proximal to the first—to eliminate the distal pulse.

Junctional tourniquets are designed to control bleeding in areas where traditional tourniquets wouldn’t be effective such as the groin, armpit or shoulder. If the bleeding site is appropriate for use of a junctional tourniquet, immediately apply one and assess the site for additional bleeding. The junctional tourniquet is placed at or near the injury site and pumped up (similar to a blood pressure cuff) until the bleeding stops.

Junctional tourniquets can also be used to stabilize a pelvic fracture. If a junctional tourniquet isn’t available or if it is being readied for use, apply hemostatic dressings with direct pressure.

Expose and clearly mark the time of any tourniquet application on each application site.

Rapidly assess the injured officer for signs of shock. If signs of shock are present, initiate a peripheral IV with a large bore catheter (on the opposite side of where a tourniquet may have been applied) and initiate IV fluids.

Reassess after every 500 cc bolus and continue infusions as until a palpable radial pulse, improved mental status, or systolic blood pressure of 80–90 mmHg is present. If resuscitation is required and IV access isn’t obtainable, use the intraosseous (IO) route.

If no signs of shock are present, peripheral IV fluids aren’t needed immediately.

Most fluid resuscitation actions should be completed while in transport. Although crystalloids are typically used in the prehospital setting, whole blood transfusion is ideal.

Once the primary assessment has been completed, reduce any signs of hypothermia and complete a secondary assessment. Begin by removing ballistic vests, gear and uniforms, and use dry blankets or heat-reflective shell blankets to keep the injured officer warm. Place an ECG monitor and complete any additional workups as needed (12-lead, point of care testing of blood glucose, etc.).5

Pain management should be administered as soon as possible. Injured officers may downplay their pain rating for fear of opiate administration or being perceived as weak.

Use compassionate communication to assure the officer that pain management will make them more comfortable in this already stressful situation. Prior to analgesia and sedation, you should support the airway and have airway equipment readily available. Appropriate hemodynamic parameters, including capnography, should be continuously monitored.

Analgesia should be the first goal of pain management and can be achieved with 1–2 mcg/kg IV fentanyl or 0.1–0.3 mg/kg IV ketamine. Ketamine is the preferred agent for hemodynamic stability and can be administered in hypotensive patients with a systolic as low as 70 mmHg. Sedation can be used to augment analgesia, if needed, and can be achieved with doses of IV ketamine 1.0–1.5 mg/kg or IV midazolam 0.005–0.1 mg/kg. Although ketamine may be used in hypotensive patients, use should be considered in an officer with a potential traumatic brain injury.6

Chemical burns have been reported from riot control agents and irritants such as CS gas (2-chlorobenzylidene malononitrile). For any facial burns, especially those that occur in closed spaces may be associated with inhalation injury, aggressively monitor airway status and oxygen saturation and consider early intubation or surgical airway for respiratory distress or oxygen desaturation.

Estimate the total body surface area burned to the nearest 10% using the rule of nines. Cover the burn area with dry, sterile dressings. Begin fluid resuscitation and document the fluid infused, as it will be important for continued critical care.5 Continue to reassess every 5–15 minutes while en route to the hospital.

Unique Protective Gear

Officers routinely wear ballistic armor while on duty; but ballistic armor isn’t bulletproof. These terms are often incorrectly used interchangeably. Ballistic vests are designed to slow down bullets as they attempt to pass through the vest.

The National Institute of Justice breaks down levels of body armor based upon the threats they were designed to protect against. These standards outline exactly what threats each level of body armor will protect against, as well as the strength of the attack it will stop. This means that a ballistic vest at Level 2 for example will not protect against a Level 3a threat.

Ballistic vests come in two different types, hard and soft. The soft armors are designed to protect against most handgun and small arms ammunition, whereas hard armors are designed to stop high caliber and armor piercing rounds.

Patrol officers typically wear Level 2 and 3a vests, which are categorized as soft. Tactical officers such as those in SWAT teams wear Level 3 and 4 vests, or use their patrol vests with ceramic plate inserts.

The ceramic plate inserts can be placed in the front and the back of the vest and are designed to stop rifle rounds traveling at high velocity (approximately 2,700 feet per second). The downfall to the plate inserts is weight, which can weight upwards of 8–12 pounds each, making removal difficult on an injured officer.

Although a ballistic vest is designed to stop a bullet, it may not stop an edged blade weapon. Stab-proof vests designed to stop a knife are available, and there are dual-purpose vests that are designed stop both, but they are often expensive, difficult to locate and hard to obtain. Spike protection can be added to both stab and ballistic vests. They’re typically used by prison officers for protection from ice picks, needles and syringes.

Although you may not know the type of weapon that was used against a law enforcement officer, having an idea of what vest officers are wearing is beneficial to determine the mechanism of injury and predict injury patterns.

The removal of each vest is similar despite different brands trademarking their own type of carrier. Vests are typically secured over the shoulders and around the waist, often using Velcro. Some vests have flaps that wrap around and adjoin together.

If the patient is in a difficult position or can’t be moved, these straps can be cut to assist in vest removal. Don’t attempt to cut into the vest itself; Kevlar is a unique material that won’t give in to your trauma sheers.

Prior to any diagnostic imaging, all vest panels must be removed from the injured officer. Each vest has a front and rear panel to remove, if possible.

All ballistic vests that were removed must be turned over to a representative from the injured officer’s department upon arrival at the hospital.

Note that some officers mark their blood type on the inside of the vest. Check there and note on your patient care report and be sure to relay that information to the hospital.

All officers who are shot or stabbed while wearing body armor should be taken to an ED or trauma center. Even if an officer is wearing body armor, there’s still a risk of injury and they require a full assessment. The vest should accompany the officer because it is critical for ED and trauma center personnel to better understand the officer’s potential injuries.

If the patient is stable, EMS should asses if the bullet or knife blade penetrated or perforated the vest, based on the underlying anatomy.

An officer’s gun belt is most likely made of leather or nylon and can be easily cut if other methods of removing them are unsuccessful. Due to the multiple variety of belts available, each one is removed a different way. Solicit an officer’s assistance removing them prior to cutting.

Communication

Law enforcement is a dangerous profession. It carries the enhanced likelihood of injury and/or illness resulting from performance of duty. Due to the inherent dangers associated with police work, the possibility of an officer suffering a serious or fatal injury is extraordinary.

Other officers on scene may ask for updates, but due to HIPAA laws, crews must be cautious about the information they provide.

Details about the injured officer, including name, medical record number, condition, sex, age, physician name, and other treatment information is protected health information (PHI).

EMS may share patient information with police officials with the consent of the patient or the patient’s legal representative (e.g., the patient’s spouse).

Document the patient’s consent and the information provided in your patient care report. In addition, there are occasions when the law permits or requires you to share patient information with law enforcement.

At the incident scene, the injured officer’s co-worker, supervisor or union representative may request to ride in the ambulance with you to the hospital. This representative will typically make the proper notifications to departmental administration and family, as needed.

One of the most important tenets of a proper notification is the timeliness of the notification to the immediate family. This is especially true in situations regarding serious injury where the family may have an opportunity to go to the hospital prior to the passing of the officer. All pertinent medical information on the officer’s condition should be relayed to the family before any other parties are notified.

If the officer is gravely injured or death is imminent, allow family members to gain access to see the patient, if possible, based on the circumstances. Cooperate as much as possible with law enforcement requests, as this is also a highly stressful situation for them to deal with.

Many departments have officers complete a notification form and release of PHI on a need-to-know basis. Request this document from other officers on scene as it should provide next-of-kin (e.g., spouse, parents, sibling, etc.) notification in death and serious injury.

Every effort should be made to have these notifications made in-person by another officer. EMS should accompany officers in completing this notification, as there will likely be strong emotions, which will vary dramatically.

An officer who’s a close friend of the seriously injured or deceased officer’s family will typically be present as well to provide comfort to the surviving family.

If immediate transportation to a hospital is required or requested by any of the survivors, the officer’s department personnel will usually provide the transportation in a police vehicle, but EMS may be requested to complete this transport if law enforcement resources are actively committed at the scene.

The period immediately following the line-of-duty injury or death of an officer will certainly be traumatic and somewhat confusing for on-duty personnel.

Radio transmissions regarding the injury or death should be avoided at all costs to negate the possibility of the message being intercepted by a civilian scanner or the news media and the subsequent unofficial release of the information through the grapevine.

Also, avoid posting on social media, first responder media applications and similar groups until the proper notifications can be made.

The release of information concerning a line-of-duty injury or death to family, friends and co-workers by on-duty personnel must also be avoided until the surviving family of the affected officer has been properly notified.

Officer line-of-duty injuries and deaths attract a large amount of media. More often than not, media will have camera crews at the hospital upon your arrival. They’re permitted to record you as long as it doesn’t interfere with your treatment or transfer to the hospital.

If the media approaches you for a statement, politely decline and defer all questions to the police department.

Injuries and deaths to law enforcement officers present a large amount of emotion for everyone involved. EMS isn’t immune from this stress, as we’re actively involved in the care for the injured officer. Recognize possible signs of stress and get help if you think you need it. Upon transfer of care at the hospital, take the time you need to recover and relay these needs to your supervisor.

Take advantage of free employer resources. These may include employee assistance programs that provide counseling for workers under stress, go to a gym, consult with a critical incident stress debriefing team, and even seek spiritual counseling (e.g., fire department, EMS or hospital chaplain).

Using available time off in the form of paid vacation or mental health days is another way to escape the pressures of the job and return to work feeling refreshed.

EMS have typically taken a “wait and see” attitude after critical incidents, with an emphasis on rest and relaxation; but having personnel talk about it is often his/her choice. Research has shown that downtime after an incident was associated with significantly fewer symptoms of depression.7

Parting Considerations

Today is a much different environment as compared to yesterday, and we’ll likely continue to see increased violence against first responders. Keeping yourself safe is the most important consideration, but having the necessary knowledge to effectively treat your fellow first responders is key.

There are many nuances about law enforcement that makes treatment challenging. Having an understanding of law enforcement policies for injured officers, the equipment they carry and what to do in these situations will help everyone involved in these stressful instances.

Although this article doesn’t touch upon all circumstances, and every agency may have different procedures for injured officers, we hope it will help to open a proactive dialogue with your local law enforcement agency to discuss how to best handle and plan for these instances.

References

1. Domonske C. (Dec. 30, 2016.) Number of police officers killed by firearms rose in 2016, study finds. NPR. Retrieved Aug. 14, 2017, from www.npr.org/sections/thetwo-way/2016/12/30/507536360/number-of-police-officers-killed-by-firearms-rose-in-2016-study-finds.

2. National Fallen Firefighters Foundation. (n.d.) 16 Firefighter Life Safety Initiatives: 12. Violent incident response. Everyone Goes Home. Retrieved June 2, 2018, from www.everyonegoeshome.com/16-initiatives/12-violent-incident-response.

3. Preliminary 2017 law enforcement officer fatalities report. (2017.) National Law Enforcement Officers Memorial Fund. Retrieved June 2, 2017, from www.nleomf.org/assets/pdfs/reports/fatality-reports/2017/2017-End-of-Year-Officer-Fatalities-Report_FINAL.pdf.

4. Facts and figures: Causes of law enforcement deaths. (March 15, 2018.) National Law Enforcement Officers Memorial Fund. Retrieved May 20, 2018, from www.nleomf.org/facts/officer-fatalities-data/causes.html.

5. 2015 Tactical Emergency Casualty Care (TECC) guidelines. (June 2015.) The Committee for Tactical Emergency Casualty Care. Retrieved Sept. 1, 2017, from www.c-tecc.org/images/content/TECC_Guidelines_-_JUNE_2015_update.pdf.

6. Strayer R. (Feb. 25, 2014.) Ketamine for analgesia in the ED. emDocs. Retrieved May 20, 2018, from www.emdocs.net/ketamine-analgesia-ed.

7. Halpern J, Maunder RG, Schwartz B, et al. Downtime after critical incidents in emergency medical technicians/paramedics. Biomed Res Int. 2014;2014:483140.


A nylon duty belt with a drop leg holster can be cut and removed. The holster is secured to the leg and not around the waist. Photo courtesy Derrick Jacobus

To remove a handgun from a secure holster, an operator typically presses the thumb break forward and releases the trigger guard. Be sure to utilize a law officer’s assistance to remove the handgun. Photos courtesy Derrick Jacobus