By Fabrice Czarnecki and David Q. McArdle
aw enforcement officers (LEOs) face a high risk of on-the-job injury and death. In 2010, the LEO fatal work injury rate was 18.1 per 100,000 full-time equivalent workers, compared to 3.6 across all industries.1 Most of these on-the-job deaths are homicides and transportation-related deaths.2 Nonfatal occupational injuries in 2010 were 10.4 (100 full-time workers) for “police protection,” compared to 3.6 for the entire workforce.3
A number of agencies have developed programs aimed at decreasing the risk of death or disability from injuries suffered by officers in the field. Some of these agencies have presented their programs at IACP conferences over the past several years. The following are brief presentations of some of these programs from several agencies. These are presented here to pass on the ideas that may be of use to departments and to stimulate thought and possible discussion regarding “best practices” programs.
Gainesville, Florida, Police Department Trauma Kit Program
Lieutenant Daniel C. Stout, EMT-P, Gainesville, Florida, Police Department
In March of 2008, the Gainesville, Florida, Police Department implemented a trauma kit program with the goal of providing better training and equipment for officers to render aid to victims of traumatic injuries, in both a “self-aid” situation and for aiding the general public. Since the program was initiated, the trauma kits have been deployed 36 times and have been successful 31 times. The trauma kits have been utilized in situations that included life-threatening injuries and motor vehicle crashes (including two amputations), numerous stabbings, and shooting situations (including four officer-involved shootings). In these cases, local emergency medical services (EMS) and trauma center staff have credited the officer’s efforts and use of the trauma kits for the successful outcome of the injured.
The techniques taught to officers are derived from tactical combat casualty care (TCCC), which is the military counterpart to prehospital trauma life support. From the onset of the training, the officers are taught that these are officer safety tactics and tools that are just as important as defensive tactics, firearms, training, and direct to threat tactics that will save their lives. Having the officers buy in to the concept that this is an officer safety issue is vital to the program being successful and is the most important step in addition to supervisory, command staff, medical direction, and the general public’s support.
The trauma kits consist of an SOF-T Special Operations Forces Tourniquet (self-applied tourniquet); QuickClot Combat Gauze (hemostatic agent); an Oales Modular Bandage; and an Ascherman Chest Seal (sucking chest wound bandage). These items are all contained in a small nylon bag mounted to the cage of the patrol cars for rapid deployment and access. The cost per kit is approximately $92.00 and the training was administered by a department member also certified as a paramedic and TCCC/PTLS instructor at no cost to the department.
After thorough product research and establishment of medical direction based on TCCC techniques and protocols, extensive training was the next vital step to implementing the program. This training included classroom instruction and hands-on lab work and culminated in stress inoculation scenarios involving role play and realistic moulage/injury simulation with active bleeding. Ongoing training and quality control are also core components that continue to advance the program. Having an open, working relationship with local EMS providers and involving them in the training were also integral to the program’s success.
Florida Highway Patrol Troop Surgeon Program
Auxiliary Major Bradley S. Feuer, DO, JD, Chief Surgeon, Florida Highway Patrol
Background/history: The Florida Highway Patrol (FHP) Troop Surgeon program was conceived in 2001 as a plan by which physicians could volunteer to support the health and safety of state troopers. FHP’s first physician was sworn in October 2003 and served the role as an auxiliary trooper, until a formal policy was approved in 2005. By 2006, FHP’s troop surgeon pilot program was launched in Troop L. In 2010, the project was deemed a success, after which FHP began recruiting and vetting other suitable, qualified physicians for program expansion to other troops.
Program description: The FHP Troop Surgeon program has utilized the resources of the agency’s auxiliary program to serve as a framework for operations. Physicians with the ability to donate a generous amount of time; with considerable availability; and with a proven track record of leadership, communication skills, knowledge of and familiarity with local healthcare resources, professionalism, and community service are sought to follow one of two tracks to become an FHP troop surgeon. In both tracks, the physician undergoes extensive background screening, drug testing, polygraph, and psychological testing. In the sworn track, the candidate undergoes further testing required by the Florida Criminal Justice Standards and Training Commission, including basic aptitude and physical agility testing. Nonsworn troop surgeons are assigned as FHP auxiliary level one, and provide a range of medical support to members of the Florida Highway Patrol. Sworn troop surgeons complete the full FHP Auxiliary Academy, a rigorous program of study that includes 320 hours of training in such areas as criminal law, traffic law, search and seizure law, court testimony, accident investigation, human and public relations, firearms training, first aid, and self-defense. Generally, classes are held two evenings per week (four hours each) and one weekend day (eight hours) for 20 weeks. Once appointed, FHP auxiliary level two troopers have the authority to bear arms and the power to arrest while under the supervision of a regularly constituted member of the Florida Highway Patrol. Accordingly, troop surgeons appointed to level two auxiliary may be assigned to the region’s tactical response team.
Goals of the program: Goals include reduction in absenteeism, sick days, and agency exposure to workers compensation claims; enhancement of troopers’ knowledge of medical issues pertinent to duty; enhancement in quality of routine medical care available to troopers; facilitation of the highest quality of care to troopers injured in the line of duty; representation of the patrol on issues pertaining to healthcare; and medical support of tactical operations.
Benefits/Accomplishments:tions, conducted seat belt education in a local elementary school, facilitated vaccinations, advised leadership on complex return to work issues, assisted Bureau of Investigations with medically related issues, provided memorandums to the state attorney’s office on medical aspects of cases involving arrests by troopers, facilitated specialty care to troopers in cases of complex disease, provided leadership to the critical incident stress management team, been the keynote speaker at a county law enforcement officer’s memorial service, and provided medical directorship of the tactical response team.
Costs: Since this is a fully voluntary program, associated costs have been minimal. In essence, the costs to the agency are the same as that invested in any other auxiliary trooper.
Challenge: The challenge of medical malpractice liability was addressed through legislative enactment of statutory sovereign immunity for troop surgeons and allied health personnel operating under their direction.
Tactical Telemedicine: A New Frontier in Emergency Medical Communication
Peter A. Pappas, MD, FACS, Trauma Center, Holmes Regional Medical Center, Melbourne, Florida; Chief Douglas Muldoon, Palm Bay, Florida, Police Department; and Captain John Resh, NREMT-B, Palm Bay, Florida, Police Department
Since 2011, The Palm Bay Police Department and the Trauma Center at Holmes Regional Medical Center in Melbourne, Florida, have partnered to develop a new and exciting means of emergency medical communication for SWAT tactical teams. Known as Tactical Telemedicine or “Tac-Tel,” the concept is to use readily available commercial teleconferencing software and off-the-shelf computer technology to establish a link between officers in the field on high-risk missions and their local trauma centers.
This link can greatly benefit officer safety by providing immediate access to trauma center expertise. Such a system can provide real-time audio and visual information from a trauma center far superior to any radio transmission for information on patient status and injuries. The trauma center in turn receives real-time information on patients in order to better triage multiple casualties, coordinate medical evacuation, and prepare for patient resuscitation on arrival to the center.
During a SWAT training exercise, a secure teleconferencing link was deployed to connect the tactical team directly to the trauma center. With the trauma center available by teleconferencing software as needed, the tactical team practiced a number of scenarios involving serious injuries to both civilians and officers. These included gunshot wound to the torso with shock, head injury with loss of consciousness, and gunshot to an extremity requiring application of a tourniquet to stem bleeding. This exercise successfully demonstrated Tac-Tel’s ease of use and its ability to establish communication between the field and trauma surgical support in real time.
The major cost is accrued in having the servers to run a secure teleconferencing network along with the licensing fees for the software. Beyond that, pre-existing equipment, such as laptops and tablet computers can be used to establish communication. As more hospital systems develop their own medical teleconferencing systems, such costs can be further deferred.
Replicating the program requires a strong partnership between law enforcement agencies and their local trauma centers. The ability to share expertise with information technology and pool resources is crucial to success, as well as establishing guidelines for deployment and use of the technology.
Champaign County, Illinois, Excited Delirium Syndrome Response Protocol
Lieutenant Michael Paulus, Champaign, Illinois, Police Department
The Excited Delirium Syndrome (ExDS) response protocol that has been in place in Champaign County, Illinois, since July 1, 2008, represents a multidisciplinary approach to a multifactorial incident. The biggest concern is the medical emergency that presents itself as a law enforcement problem.
The identified stakeholders are law enforcement and corrections, telecommunications, emergency medical services (EMS), emergency room physicians and nurses, mental health professionals and consumers, coroner, medical examiner, the state’s attorney, and the media. The protocol calls for an awareness of the common signs of a subject in the throes of an ExDS incident and the dispatch of the appropriate resources as soon as possible. This typically includes four to six officers, a supervisor, and an advanced life support ambulance.
First responders are encouraged to contain the subject as much as possible until the arrival of EMS before putting hands on the subject. This is based on the recognition that officers are not trained or equipped to deal with the medical emergency and the longer the struggle with law enforcement before treatment, the worse the situation can become.
A capture plan is developed with the officers and EMS on scene. The subject is controlled; sedated if it fits the EMS criteria; restrained with multiple sets of handcuffs and a leg hobble; secured to a backboard; loaded into an ambulance with at least one officer riding along; and, then, transported to the hospital.
There are two sedation medication options used in Champaign County, midazolam and ketamine. The decision to sedate rests totally with the paramedic, not the law enforcement officers.
The benefit of this multidisciplinary response is that it gets the right resources to the scene as soon as possible. Since law enforcement and corrections are not trained nor equipped to deal with this medical emergency, why would they be expected to take the lead role?
The costs of this protocol were limited to the purchase of leg hobbles that had not been in use prior to its implementation. There was an obvious expenditure of time for meetings and then the follow-up training that took place.
The best way to replicate this protocol is to identify the decision makers in each of the stakeholder categories and then communicate the common behavioral cues, either through videos of incidents around the country, or through local incidents, and how the change in paradigm is needed to address future situations.
Communication focused on getting the subject to the hospital as quickly as possible while enhancing first responder safety will guide the discussions. Once there is agreement on what role each of the stakeholders will play each of them then develops their own policies, procedures, or training plans to share with their larger organizations.
The protocol then goes live, and the learning process begins responding responsibly to these incidents that are at a high risk for sudden unexpected death of the subjects.
Organizations like the Institute for the Prevention of In-Custody Death in Henderson, Nevada, and the American College of Emergency Physicians have information that can assist in developing a protocol based on the resources available.4
Neither EMS nor law enforcement alone can effectively deal with the issue of a subject experiencing the extremely agitated behaviors associated with ExDS. It is through the combined cooperative efforts of both and others that will provide the best possibility of survival to these subjects.
ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
Daniel G. Samo, MD, FACOEM; Medical Director Corporate Health, Northwestern Memorial Hospital, Chicago, Illinois; Assistant Professor, Northwestern University Feinberg School of Medicine; Chair, ACOEM Public Safety Medicine Section; and Chair, Task Group: ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers
At the first IACP Conference in 1893, one of the agendas set forth was “uniform standards to select all police officers according to mental and physical qualifications.” Many agency-specific and state guidelines and standards have been developed to address this agenda. These range from the California POST Medical Screening Manual, which bases guidance on sound correlation to job functions, to others that employ concepts such as “to a reasonable degree of certainty” or based on “moral certainty.” Thus, currently, there is a multitude of standards with variable medical foundations being applied for hiring and retention decisions across the country.
The American College of Occupational and Environmental Medicine (ACOEM) has undertaken addressing this wide disparity in medical standards among agencies with publication of its Guidance for the Medical Evaluation of Law Enforcement Officers in 2010. This guidance has been developed by a task group of the Public Safety Medicine Section of ACOEM made up of occupational medicine physicians with extensive public safety medicine experience in the public, private, corporate, and military sectors along with representatives of police executive organizations, such as IACP and NAWLEE (National Association of Women Law Enforcement Executives), and municipal management, such as ICMA (International City/County Management Association).
Sections published to date address diabetes, vision, hearing, cardiovascular diseases, medication usage, pregnancy, substance abuse, and infectious diseases. Sections under development include seizure disorders, bleeding disorders, sleep disorders, wellness, risk assessment, amputations and prostheses, and pulmonary disorders.
This electronic, subscription-based guidance provides police physicians with information to assist them in making medical qualification recommendations that promote the health and safety of LEOs. As an online document, it is easily and regularly updated.
In addition to the target audience (physicians who provide medical care for LEOs), the Guidance is also a valuable tool for law enforcement executives, officers, municipal managers, attorneys, and insurers.
The Guidance can be accessed online at http://www.acoem.org/leoguidelines.aspx. Subscriptions can be obtained at the same site. As the preamble to the document states, “The purpose of this guidance is to promote the health and safety of LEOs while ensuring their ability to protect civilian life and property.”
The Guidance for the Medical Evaluation of Law Enforcement Officers is another tool that chiefs can and should use to ensure that their staffs have the best information available when making decisions that involve protecting their law enforcement officers and their communities.
Street Survival Casualty Care
David Flory, NREMT-P, Police Chief, City of Hot Springs, Arkansas
The old axiom, “necessity is the mother of invention” has never been more true as law enforcement explores improved training techniques, equipment, and methods to reduce the number of police officers killed and assaulted. The invention that until recently has been overlooked now comes, not in the form of a traditional prevention programs, but rather in the form of recognizing that injuries can and do occur and of providing training and equipment that treats those injuries. Such a training program known as Street Survival Casualty Care is now making its way into the hands of many officers in federal, state, and local agencies with documented success of lives saved and injury mitigation.
Street Survival Casualty Care, known also as Self-Aid/Buddy-Aid (SABA) is an eight-hour program modeled after the military’s TCCC injury care program that has been in place for a number of years in the U.S. armed services. TCCC focuses on the concept of providing medical care at the point of wounding instead of waiting for medical professionals to provide care when often times that care is minutes or hours away. Providing medics, corpsmen, nurses, and even doctors on the battlefield has saved the lives of many military personnel throughout history. Because law enforcement has been successfully mirroring military techniques for years, it comes as no surprise that the placing of paramedics, nurses, and even doctors in close proximity to officers at the point of wounding is now becoming commonplace. One of the most successful casualty care training programs, now responsible for the training of several thousand police officers is being conducted in the state of Texas. The training is provided by approximately 25 tactical paramedics who received a train-the-trainer course in 2009.
This training course focuses first on tactics not necessarily medical intervention techniques. Reinforcing effective return fire during deadly force encounters, learning the effective use of cover and concealment and self-extrication from the potential point of wounding (the “X”) are stressed. Because life-threatening injuries in law enforcement often resemble injuries found on the military battlefield such as gunshot wounds and blunt trauma, the management of major blood loss is emphasized. Simple direct pressure to an extremity wound and wound packing with hemostatic impregnated gauze is taught in practical application exercises. The use of commercially made as well as field-expedient tourniquets is covered in detail as well. Tourniquets, often thought of as taboo in EMS system circles have found their way back to popularity after extensive research, testing, and field use, mainly by U.S. military medics. Tourniquet application is the most effective way to stop severe extremity wound bleeding from penetrating wounds such as gunshots, stabbings, or even amputations. All such injuries can and do occur in U.S. law enforcement environments.
Because airway and breathing abnormalities are often associated with the injuries received by police officers during assaults against them, the casualty care course taught in Texas and other known programs around the country also focuses on simple airway management. Skills ranging from a basic technique of lifting someone’s chin to open their airway to the placement of a large needle in a downed officer’s chest (needle thoracostomy) to treat a tension pneumothorax are taught depending on the level of training desired for the officers by the host agency. Reminding student-officers that blunt trauma from bullets impacting ballistic body armor can still create significant airway difficulties; the curriculum covers management of these injuries as well.
An additional training initiative focusing on officer safety—and one that contains a casualty care component—is named VALOR (Preventing Violence Against Law Enforcement and Ensuring Officer Resilience and Survivability). VALOR (www.valorforblue.org) is a free, multi-faceted, officer safety course developed in 2010 under the leadership and direction of the U.S. Attorney General Eric Holder. VALOR courses have been hosted in over 20 cites in 14 states and are hosted through the U.S. Attorney’s Offices in each state. This author has the honor as serving as a VALOR instructor teaching a shorter version of the aforementioned casualty care (SABA) curriculum. Other exceptionally gifted instructors share with students a variety of officer safety topics all of which have resulted in overwhelmingly positive feedback from officer-students from around the country. New techniques, methods, and training must continue to be explored if the number of police officer injuries and deaths is to be reduced. Programs that are geared toward the prevention of violence should continue. Chiefs should recognize that injuries do occur and must train and equip their officers to deal with those injuries.
Holden, Massachusetts, Police Department Fitness Program
Chief George R. Sherrill, Holden, Massachusetts, Police Department
For the past 30 years the Holden, Massachusetts, Police Department has developed a very progressive wellness program that benefits the police officers and the town as well. The program was developed in the early 1980s shortly after three members of the department retired on full-disability pensions.
During subsequent contract negotiations the union and town recognized the importance of officer health and wellness. The following conditions of employment were agreed upon and ratified by the unions involved:
- Officers are prohibited from using tobacco products on or off duty. Holden became the first department in the nation to ban tobacco products.
- Officer’s physical fitness/strength shall be tested annually and will be a condition of employment. The test consists of a timed 1.5 mile run, sit ups, push-ups, bench press, and height/weight ratio. The test takes into consideration an officer’s age.
- Officers are allowed up to 1.25 hours daily of workout time.
The wellness program has developed to the point where the department now has adopted an internal culture that promotes physical fitness among its employees that has evolved over a generation of officers as they have been hired over the past 30+ years. Since the program’s inception, the department has not had one retirement due to disability and sick time has been reduced by 25 percent. Officers look in shape and are seen running on a daily basis throughout the community as they strive to improve their physical performance.
As a chief of police it is good commonsense for the department to keep investing in the most single important piece of equipment to promote officer safety—the officer’s physical well-being itself. It costs thousands to send an officer to a basic 26 week recruit academy and all too often that is it for an officer’s career. Being proactive by keeping that investment in peek physical shape is a win-win for all the parties involved.
8 Simple Interventions for Chiefs to Ensure the Health and Safety of
1. Demand 100 percent compliance with body armor policy—100 percent compliance with wearing body armor would save at least 8.5 lives annually. See Tom LaTourrette, “The Life-Saving Effectiveness of Body Armor for Police Officers,” Journal of Occupational and Environmental Hygiene 7, no. 10 (October 2010): 557-562.
2. Insist on 100 percent compliance with seat belt use policy—100 percent compliance with wearing seatbelts would save at least 10 lives annually. See Dietrich Jehle von Kuenssberg, David G Wagner, James Mayrose, and Usman Hashmi, “Seat Belt Use by Police: Should They Click It?” Journal of Trauma 58, no. 1 (January 2005):119–20; and FBI LEOKA data http://www.fbi.gov/about-us/cjis/ucr/leoka/leoka-2010.
3. Require 100 percent compliance with reflective traffic vest policy—An average of 12 officers are struck and killed annually by vehicles. See U.S. Department of Justice, Federal Bureau of Investigation, Criminal Justice Information Services (CJIS), Uniform Crime Reports, Law Enforcement Officers Killed and Assaulted [LEOKA] 2010, table 61, http://www.fbi.gov/about-us/cjis/ucr/leoka/leoka-2010/tables/table61-leok-accidentally-circumstance-01-10.xls (accessed October 10, 2012)
4. Do not tolerate excessive driving speeds (even during vehicular pursuits)—Excessive speed was determined to be a cause of at least 30 percent of officers’ deaths in motor vehicle crashes. See Eun Young Noh, Characteristics of Law Enforcement Officers’ Fatalities in Motor Vehicle Crashes (Washington, D.C.: National Highway Traffic Safety Administration, U.S. Department of Transportation, January 2011), http://www-nrd.nhtsa.dot.gov/Pubs/811411.pdf (accessed October 10, 2012).
5. Train all officers in tactical first aid—See IACP Training Keys nos. 667, 668, and 669 on emergency trauma care http://www.theiacp.org/tabid/452/Default.aspx.
6. Implement a wellness program, addressing physical fitness, obesity, smoking cessation, nutrition, and sleep hygiene.
7. Implement a peer support program, employee assistance program and mental health referral policies (addressing stress recognition, alcoholism, PTSD and suicide prevention)
8. Ensure that your medical support providers are familiar with the ACOEM guidelines—See Guidance for the Medical Evaluation of Law Enforcement Officers, http://www.acoem.org/leoguidelines.aspx (accessed October 10, 2012).
Preventing Line of Duty Deaths: A Chief’s Duty, from the IACP National Center for the Prevention of Violence Against the Police, http://www.theiacp.org/portals/0/pdfs/NCPVAP_Brochurefinal.pdf
Please contact the authors of this article for further information about their programs: Fabrice Czarnecki at email@example.com; Daniel C. Stout at firstname.lastname@example.org; Bradley S. Feuer at email@example.com; Peter A. Pappas at firstname.lastname@example.org; Michael Paulus at Michael.email@example.com; Daniel G. Samo at firstname.lastname@example.org; David Flory at email@example.com; and George R. Sherrill at firstname.lastname@example.org. You may also contact the IACP Police Physicians Section at http://www.theiacp.org/About/Governance/Sections/PolicePhysiciansSection/tabid/438/Default.aspx for assistance with program development and information to help you locate a specialist in your area who can assist with skill retention of officers trained in some of these specialized tasks. The IACP Police Physicians Section is a group of physicians of various specialties (emergency medicine, general surgery, internal medicine, occupational medicine, psychiatry, radiology, and so forth) who work with Allied Health Professionals such as physical fitness trainers, nutritionists, and wellness experts to maximize the health and safety of the police who serve their communities. These consultants are experienced in medical issues that law enforcement agencies and officers can face, which include the following:
- Medical support for tactical teams
- Tactical first aid for patrol officers
- Performance under stress
- Occupational medicine (post-offer examinations, return-to-work issues, fitness for duty, medical guidelines, and so on)
- Ergonomics (finding and adjusting the right equipment and the work environment)
- Environmental medicine (e.g., prevention of heat stroke)
- Preventive medicine (smoking cessation, wellness programs, injury prevention, suicide prevention, and so on)
- Prevention of in-custody deaths
- Weapons of mass destruction♦
1U.S. Bureau of Labor Statistics, “Fatal Occupational Injuries in 2010” (chart package, U.S. Department of Labor, 2012), http://www.bls.gov/iif/oshwc/cfoi/cfch0009.pdf (accessed October 10, 2012).
2Hope M. Tiesman, Scott A. Hendricks, Jennifer L. Bell, and Harlan A. Amandus, “Eleven Years of Occupational Mortality in Law Enforcement: The Census of Fatal Occupational Injuries, 1992-2002,” American Journal of Industrial Medicine 53, no. 9 (September 2010;): 940–949.
3Injury Cases—Rates, Numbers, and Percent Relative Standard Errors by Industry, 2010, table SNR05 (Bureau of Labor Statistics, U.S. Department of Labor, October 2011), http://www.bls.gov/iif/oshwc/osh/os/ostb2805.pdf (accessed October 10, 2012).
4For more information on the Institute for the Prevention of In-Custody Death, visit http://www.ipicd.com. For more information on the American College of Emergency Physicians, visit http://www.acep.org.
|Fabrice Czarnecki, MD, MA, MPH, FACOEM; Medical Director, Public Safety Medicine, Northwestern Memorial Physicians Group; Chairman, Police Physicians Section, International Association of Chiefs of Police; Vice-Chair, Public Safety Medicine Section, American College of Occupational and Environmental Medicine (ACOEM); Member, ACOEM Task Group: Guidance for the Medical Evaluation of Law Enforcement Officers, Chicago, Illinois; and David Q. McArdle, MD, FACEP, Medical Advisor, Rocky Mountain Tactical Team Association, Vice-Chair, IACP Police Physicians Section, Medial Officer Health Office, Federal Law Enforcement Officers Training Facility, and Clinical Instructor, Department of Emergency Medicine, Georgia Health Science University, Southeast Georgia Health System, Brunswick, Georgia|
Please cite as:
Fabrice Czarnecki and David Q. McArdle, "A Synopsis of Some Featured Departments Providing Medical Support to Police Field Operations," The Police Chief 79 (December 2012): 70–75.