“I had a lot to be thankful for...” said Marine Corps Gunnery Sergeant Ryan P. Shane, in his 2006 interview with Newsweek. Shane was referring to the fact that despite being shot numerous times, having critical injuries and left-over shrapnel in his body, he was still here, and alive. The original incident arose from a mission in Falujah, where Shane and his unit incurred casualties and had to extricate downed Marines under heavy fire. What Gunnery Sergeant Shane did not necessarily foresee, is the way in which his heroic actions will also shape future thinking about casualty evacuation for cops.
We in law enforcement are also fortunate. Fortunate and grateful for the fact that we are in a unique position to inherit and adapt tools and techniques tried, erred on, and perfected by our military. We have been in this position since the Vietnam War, but not since the development of current combat operations and the war on terror have so many options been implemented with so detailed and fast of feedback.
Despite some opinions to the contrary, this war is still very much ongoing — both overseas and at home — and we’re still learning, and burying our own in military and law enforcement. The field of tactical medicine is no exception. Though not new to law enforcement overall, the acceptance of the fact that we need to be able to help ourselves or our own — as part of regular practice in the field — has been hard to come by until the last few years. While tactical teams have added integrated medical support (including full-fledged doctors) since the 1970’s, the realization of a similar need for patrol level responders has come about 30 years later. Our new mentality in training and tactics have been forced at a cost of officers’ lives.
Self Care, Extraction, Tourniquets, and Drags Straps
These days few will argue that a high threat situation — be it a shooting, barricaded subject, a mass-casualty incident, or a “routine” domestic that gets out of hand — will be first addressed by street cops who respond with limited resources. Everything else will roll, maybe even immediately, but sometimes will still be too late.
For years, Chuck Soltys has told us that for a downed and injured cop the first five minutes are critical. Not only are the tactical considerations and ongoing threats a primary factors, but also the injury itself. The first decision, to return fire or control the scene, will immediately be followed by the assessment of injuries. This is the point in the fight, where a choice to use a tourniquet is made. As Soltys stresses (I’ll pause here to encourage you to see his articles here on PoliceOne), a trained application of a readily accessible tourniquet is critical in controlling the majority of preventable fatalities.
Here, whatever options are practiced and prepared, are used. The most extensive and expensive first aid kit sitting in the trunk might as well still be left on a store shelf, because at this point it is unreachable and useless. Here is also where the decision was made by Shane to drag his wounded and killed marines out of a hot zone.
Cops have traditionally practiced a variety carries. In a rescue team scenario, we have tried everything from a one man fireman’s carry, over the arms seated carry, three-man carry, and so on. We applied the same principles to our traditional first responder training, where no tactical care issues are addressed.
What the Shane’s Marines found — and practiced to perfection — is that dragging a downed casualty is not only faster, it is easier. The research that followed showed that the movement itself uses larger muscle groups, resulting in less fatigue to the rescuer(s), it is faster then setting up a traditional carry, requires less people to be effective, and is easier overall. Additionally, dragging usually allows for the rescuers to look up or straight ahead, keeping eyes on target, gives more chances to have a free hand, and allows for better muzzle control if returning fire is necessary.
This option must be trained by us as well. Local fire departments hold a similar level of expertise, as their rescue methods involve primarily drags as well. In a typical street with unknown threats, or in an open environment of a rural agency, this also allows for smaller exposure and better use of cover. While some tactical equipment manufacturers have integrated drag handles in their tactical vests, many operators have found that those are often not enough. The drag handles, unlike straps, are smaller, and break under weight of a downed officer in full gear. A more viable and more easily achieved alternative may be a drag strap that is carried within regular patrol equipment or a response bag.
The Sling Link company of Texas, for example, specializes in custom drags straps, whether for military, law enforcement, or fire service. But a quickly accessible strap does not have to be purchased. While manufacturers like Sling Link and numerous others have come up with high-quality commercial drag strap systems and kits, one can easily make a similar device for under $30. A climbing grade nylon, strategically set loops, and a carabiner can work just as well.
This training mentality is what Chris Cook, owner and trainer of Medicor Proeliator LLC, refers to as “outside the box” and something to be embraced by our profession and community. Chris knows the need for this thinking well. In 2004 while deployed in support of Operation Iraqi Freedom, he was injured by an vehicle-born IED. After addressing multiple threats and saving his teammate’s lives, he saved his own life by applying a tourniquet to his leg.
Additional consideration should be given to the extraction and the rescue decision itself. The rescuers can avoid becoming additional casualties, by directing the down officer(s) to self aid, cover, and situational awareness. This is especially true when the downed officer is hurt, but is ambulatory or able to move.
Down, But Not Out
In training for the warrior mindset, we realize that even though we are injured and down, we are not out. No one I met makes this point better than Lt. Col. Dave Grossmann and Brian McKenna. Both also endorse the tactics listed below. You may recall a scene from the movie Saving Private Ryan where a character who had been shot in the leg faced sniper fire and stayed down in the middle of an open street. With his teammates unable to get to him, the soldier stood just as much chance getting sniped out in the open as crawling to safety and cover under suppressive fire from his team. He had at least a chance of living and addressing the threat from behind cover, without endangering any of his rescuers. Based on the injuries depicted, he was certainly able to do that, as well as render his own medical aid. Those who saw the film are well aware of the unfortunate outcome.
The realities of our work are certainly far from Hollywood’s interpretation. What is a clear fact, is that in these situations, and others where the possibility of threat still exists, no traditional EMS service will enter to provide any medical aid. Where the scene is not considered safe, let alone the specific nature of the call, EMS will appropriately stage until we give them the green light.
In fact, approximately half of tactical EMS teams still have standing orders not to enter the immediate hot zone or perimeter. While they are much better equipped to do so when called on, or at least get closer to the downed officer faster, the help may still come too late. Considering that an extremity arterial bleed can result in a fatality in as little as three to five minutes, it leaves little doubt that the downed officer and their team are on their own with whatever equipment is on them to provide own medical tactics. And according to Dr. Rick Tovar, a New Berlin, Wisconsin SWAT physicain for the last 15 years and a member of The Emergency Care in Hostile Operations Group, this is how we should perceive the medical interventions.
Medical Training as Tactical Training
Traditionally, cops have a love-hate relationship with job requirements that are medical in nature. Yet, even those who start out saying “I don’t want to be an EMT,” quickly realize that they routinely work in that capacity. So having a basic skill set to help others, why do we limit ourselves from helping our own? With the same realization, the training and understanding of hight threat extraction and rescue techniques, must accompany all tactical medicine taught to law enforcement.
We learn not a medical procedure, but another essential tactic to have at our disposal at a critical time.
Recently we’ve seen a vast amount of information presented as to what these medical tactics actually entail. A lot of statements within the sources of information list specific techniques as options, with general statements on equipment and tactics, introducing various acronyms and memory aids. This often leaves the reader asking exactly what to do, when, and why. We are often asked this information as instructors, because when time comes, you want simple and effective solutions.
Here, we are also indebted to sacrifices made during the battle of Mogadishu by Paul Howe, Scott Galentine, Mike Durant, and the many soldiers and operators involved in that fateful mission. It is following that incident that the military realized their medicine was not adopted for the needs of modern, asymmetric, and non-conventional battlefield. The lengthy research and continuous improvement process that follows to this day is what allows us to say that effective officer aid techniques are adoptable to us as well, and traditional first aid expectations are not sufficient.
The standard in tactical medicine — both military and law enforcement, is tactical combat casualty care. This modality is simply a graduated system that provides medical intervention options, based on a threat level and available resources.
So, if we are in the hot zone, or face a high probability of active threat, we are working in Care Under Fire – Stage 1. Here we are concerned with neutralizing the threat, and addressing one primary injury. If an arterial bleed from an arm or a leg exists, we must address it before any other trauma. We focus on this injury because according to the current statistics it results in highest fatality rate, and coincidentally is the most direct to address. As Mr. Soltys stresses, the tourniquet is the primary method for doing so.
Dr. Tovar notes: “No one in law enforcement should die of extremity wounds. “ An effective tourniquet application also lets the injured operator remain in the fight, and if necessary, remove himself from the threat.”
The following stage of Tactical Field Care allows us to gather additional resources, re-examine the casualty or ourselves, and address the secondary injuries. Once we make sure that the applied tourniquet is still effective, we focus on assuring that the airway is open, and addressing any penetrating chest/torso wounds. The reason — these injuries are secondary to those addressed during Care Under Fire, but still time critical. Here we make use of additional resources. Ideally, it is somewhere at this point that we can be assisted by traditional EMS escorted in, or a tactical team with appropriate medical support.
Realistically, this can last well over 15 minutes in some areas and some situations. It only makes sense then, that we are prepared to provide basic interventions for assuring a positive airway, managing Tension Pneumothorax and recognizing symptoms of shock. The decision for movement or extraction can come at any point in this process. The final stage, in this fluid and dynamic continuum, is Advanced Care or MEDEVAC. It is the point where an officer is turned over to some level of advanced EMS. Pre-planning and interoperability are the key to making this one effective.
Another Note on Tourniquets: Why...
The benefits of having a commercially-designed tourniquet, such as those issued to our troops, like a Combat Action Tourniquet (CAT) or the SOF-T, are obvious, but worth noting. These tools allow for a one-handed self application, take less than 20 seconds to apply, and are proven effective. Weigh this against the time and resource constraints of making something ad-hoc with what you have at a time when you need it, and the benefits become secondary to time lost. It has also been said before, that your agency’s returning veterans as well as new hires have a great deal of practical knowledge, a lot of which is directly applicable to this topic. The threats and actions of well prepared criminals and progress in applied medical tactics dictate and enable us to be better at what we do, and take care of our own.
Bowden, Mark. Blackhawk Down, a story of modern war. Mark M. Bowden. Penguin Books, 2000.
North American Rescue Inc.. Available from http://www.narescue.com. Internet; accessed 25 October 2007.
Wingert, Pat. "Ryan P. Shane: 'I had a lot to be thankful for'" Newsweek. 20 March 2006
The commette on Tactical Combat Casualty Care, Tactical Combat Casualty Care guidelines, 2008
Jadick, Richard. On call in hell, a doctor’s Iraq war story. New American Library/Div Of Penguin , 2007.
Johnson, Ross. Tactical Medical Solutions. Available from http://www.tacmedsolutions.com. Internet; accessed 25 October 2009.
Soltys, Chuck. Tactical Tourniquet Use-Part One, Tactical Tourniquet Use-Part Two. PoliceOne. Available at http://www.policeone.com
Cook, Chris. Medicor Proeliator LLC. Available from http://medicorproeliator.com. Internet accessed 25 October 2009
Steve Rabinovich started his law enforcement career in 1998. He was part of the Emergency Response Team, and later had the privilege of being assigned to the Bike Patrol team, as a boat patrol officer, sensitive crimes investigator, and Mounted Unit officer. He also held dignitary protection assignments, and routinely works large scale special events and crowd control. He is currently assigned to a Crisis Intervention Team. Steve’s military career began with the U.S. Coast Guard, where he was assigned as an NCO to a tactical boarding team as a member and team leader, and continued to an expeditionary force protection and anti-terrorism unit. He then transferred to the U.S. Army as a Combat Medic and later was assigned as a Flight Medic. Steve was awarded numerous citations and commendations, particularly for his involvement in the hurricanes Katrina and Rita recovery efforts. Steve has been a member of Okauchee Fire Department since 2002, where his assignments included Firefighter, EMT/Rescue, and the Dive Team. He holds a Bachelor’s degree from the University of Wisconsin. Steve has taught Tactical EMS to Law Enforcement since 2007, and currently teaches for the Milwaukee Area Technical College. He works full time for the City of Franklin Police Department, and part time for State of Wisconsin. Since 2007, Steve has also volunteered as a Tactical Flight Officer with the Air One Law Enforcement Aviation Coalition. He currently teaches Tactical EMS for Milwaukee Area Technical College and Waukesha County Technical College for Law Enforcement and EMS audiences, in partnership with Medicor Proeliator LLC.