When things go bad
Survival combat medicine every officer must know
By E. John Wipfler, III, MD, FACEP
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The world is always changing, but certain topics remain important to law enforcement officers, particularly the medical facts, devices and techniques they may need to save their own lives, or the life of a partner or other person injured in the line of duty. This article will discuss new concepts and devices officers should place into their combat-medicine closet of tricks and tools.
Imagine you and a partner respond to a robbery-in-progress call, and soon two criminal suspects engage you with pistols. After the gunfight, you experience pain in your left thigh, your partner is down on the ground moaning, one suspect lies motionless and the other suspect limped out the back door. What do you do?
Or how about this: You are arresting a large suspect. After a difficult fight, you handcuff and search him. Your hand is throbbing and bleeding. You notice a bite-mark and deep tooth puncture to the back of your hand, the suspect has a bloody face, and you realize he bit you during the encounter. What do you do?
The remainder of this article reviews several practical combat-medicine principles and discusses the solutions to such life-threatening situations.
Principle 1: The Big Picture
Consider the five major steps of trauma combat casualty care:
1. Provide fire superiority and call for help;
2. Minimize threats and prevent further casualties;
3. Triage out the unsalvageable;
4. Treat life-threatening injuries (using cover and concealment); and
5. Evacuate the victims to more advanced medical care.
These five steps involve a logical approach, which you can remember through a new mnemonic I use: “Call A CAB and Go.” The first two steps deal with making the scene safer, and may be performed simultaneously. “Call” and get help while simultaneously neutralizing the threats. Communicate with dispatch and fellow officers to identify the suspect(s), weapons, direction traveling, etc.
“A” stands for “abolish,” as in abolish threats. Use lethal or less-lethal means to neutralize dangerous suspects and make the scene safer by returning immediate fire and dealing with existing threats (initial suspect, other possible suspects, hidden weapons, blood-borne pathogens, secondary explosive devices, meth-lab chemical threat, etc). This will help prevent unnecessary casualties. For gunshot injuries, delaying medical care 30 seconds while stabilizing the scene will not make any difference in the survival of the injured officer. On the other hand, if a rescuing officer wrongly rushes to aid the victim, odds are the gunman then has another target. Don’t be a hero and immediately rush out to help a downed fellow officer—abolish threats first.
“CAB” is actually an acronym for circulation, airway and breathing, and it’s more appropriate to approach healthy officers shot down in combat this way than the standard ABC (airway, circulation, breathing) approach because the oxygen in their system can sustain them for 2–3 minutes, making bleeding to death the immediate threat. Therefore, you should first ensure circulation and compress killer bleeds by tourniquet or pressure. Besides, oxygen tanks do bad things when struck by bullets, making use of oxygen inside the inner perimeter not worth the weight and risks.
If the scene has multiple victims at this stage, triage—quickly assess and sort—the victims. Complete the abolish step by searching for weapons and disarming appropriately. If an officer is incoherent or confused from shock or lack of oxygen, they may possibly shoot fellow officers, so always cautiously approach the injured officer, talk to them and explain what you’re doing. Remove the weapons threat and then begin assessing the injured while another officer provides appropriate cover. Determine who can likely be saved versus those who will likely die and thus triage out the unsalvageable.
Check carotid (neck) pulses and check for breathing. If you don’t feel a pulse, check the other side of the neck. If it’s absent, make a choice rapidly. Remember, a trauma victim in full cardiopulmonary arrest (no pulse, no spontaneous breathing) has only a 1/1,000 chance of survival, so don’t do CPR inside the inner perimeter while it’s hot if it’s not worth the risk. Most officers will want to make the maximum effort to try to resuscitate a fellow human being, but if they’re dead, consider moving on. Move salvageable victims to hard cover and rapidly stabilize and transport them after considering the risk-to-benefit ratio. If you see obvious signs of severe injury incompatible with life, and no signs of life exist, further medical care will likely prove futile. Move on and use your efforts to help those who might live.
When you have the scene as safe as practical, or moved to a relative point of safety, stabilize the circulation, airway and breathing. Uncontrolled extremity bleeding is the No. 1 cause (80 percent) of preventable trauma deaths in combat environments. Compress killer bleeds by immediately applying a tourniquet or compression battle dressing. Carry and know how to use a military-style combat dressing, such as the Israeli dressing/Israeli combat bandage (ICB) or Blood Stopper to stop bleeding by tourniquet or direct pressure. Expose the gunshot or knife wound site by removing body armor and clothing, allowing more accurate assessment and placement of compressive dressings, Ascherman chest seals and other medical devices. Use Quick-Clot as a last resort after other measures have failed, but do not wait too long to use them if really needed (e.g., you face a deep wound with artery bleeding that you can’t compress). We still need further scientific proof many of these hemostatic agents work.
After stopping major bleeding, stabilize and support the airway and breathing. Make sure the victim’s mouth/trachea (windpipe) is not closing off or blocked by an unconscious officer’s own tongue as they lie on their back. Ensure the injured officer is breathing adequately, and assist as needed. If the officer is shot in the left chest, place them on their side left-side down to allow the good lung to move air better and prevent blood inhalation (vice versa with right-chest gunshot wounds). For penetrating chest trauma, apply a one-way valve dressing, Ascherman Chest Seal (ACS) or needle decompression as indicated.
Then, as soon as possible, go—evacuate the victim(s) to more advanced medical care. Preplanning and immediate action drills prove essential, because if the whole team knows where to go and how to get there, the victim will transport faster.
If penetrating trauma occurs to the head, neck or torso (back, chest, abdomen, pelvis), this is an immediate load-and-go situation because only an operation at a hospital will save lives in most instances. Have an ambulance standing by if possible and practical, but if you have to wait much, the critically injured officer is likely better off placed in the back of a squad car or pickup with tactical EMS medics or officers cross-trained in basic or advanced trauma support, and then rapidly transported to a trauma center or medical facility. If the gunshot wound or trauma is limited to the extremities, expose the site, control bleeding with a tourniquet immediately and, if the patient hasn’t lost a lot of blood, you probably have some time and can consider waiting for an ambulance.
A quick heads-up phone call to the hospital ER will make a huge difference in the preparedness of the medical staff. Gunshot or trauma victims who arrive unannounced are always accompanied by confusion and less organized medical care. Remember: A gunshot victim in shock and bleeding uncontrollably (chest/abdomen/back) will actually do worse if an IV line (intravenous line) is started and IV fluids are given. Why? Simple: It thins out the blood and raises the blood pressure (often unnecessarily—a blood pressure of 80–90mmHg systolic is fine in nearly all circumstances) and, therefore, patients bleed faster due to the higher pressure and uncontrolled, non-clotting hemorrhage.
Make the evacuation plan and route one of the top planning priorities for the team medics. Plainly put, have a plan and know where to go, which roads to take to get there, what type of vehicle you will use and what medical care the medics can provide along the way to the hospital. This will help saves lives.
Principle 2: Priorities of Care
When it comes to triage, whom do you take care of first on scene when faced with multiple injuries in multiple victims? The answer: 1) Take care of the threats, then stabilize your own injuries; 2) take care of your partner and team members; and 3) examine and stabilize, as best practical, the others on scene. Take care of your own first, but rapidly progress to stabilize and care for as many others as possible. Stabilize the most critically injured first. Do the most good for the largest number of people.
Principle 3: Tourniquet First
You are shot in the left upper thigh, you see a whole lot of blood pooling on the ground under your feet and you feel weak. What is your best next step besides prayer? Answer: After dealing with the perpetrator who shot you and ruling out additional threats, rapidly go to treatment.
Should you apply direct pressure, or should you go for the tourniquet? Answer: Apply a tourniquet, and do it fast. Have the means, the skills and the do-not-hesitate mental attitude when it comes to applying a tourniquet. Many of us with gray hair were taught, “don’t use a tourniquet,” but that mentality has changed. Use a tourniquet to stop major bleeding as a first step, not as a last-ditch effort after direct compression has failed. If you try and try to stop a major bleeding vessel and fail, you will eventually grow weak, faint and, unless you have a partner to stop the killer bleed, you could very well die. I’ve seen it happen, unfortunately, to civilians brought to the ER.
How do you apply a tourniquet? The bottom line: Learn how and practice it until you can apply one with one hand (practice left and right) to your arm or leg, as well as to others in need. What makes the best tourniquet? A wide strip of material—nylon, clothing, trauma bandage straps at least 1–2 inches wide—with a small straight stick or rod to twist the material. Twist until the pulse or bleeding stops, and lock the stick or rod in place somehow (in case you faint or need to do something like get the hell out of there fast).
A new CAT tourniquet is nicely designed and seems to be one of the best devices out there—consider getting one for each person on your team. You can use the Israeli and Blood Stopper bandages for tourniquets, as well. Although a rope or shoelace could potentially work, if you use such a narrow piece of ligature, it greatly increases the chances of damaging nerves permanently.
How long can you leave a tourniquet in place? Well, in operating rooms across the United States thousands of times each day, orthopedic surgeons routinely apply tourniquets for several hours without any problems. I’d recommend marking the start of the tourniquet application, and if for some unusual reason you haven’t gotten to the hospital within one hour, loosen it briefly and test for bleeding. Control the bleeding with local pressure only if possible (it is for most major bleeds).
Another change in thinking: If you apply pressure to a moderate wound and the bleeding still oozes around the bandage, old school thought held you should not remove the bandage but instead apply new bandages on top of the old one. This is not correct anymore. If firm pressure can’t stop it, consider a tourniquet. If you want to try a second time to control bleeding with direct pressure, apply pressure to the proximal artery, remove the old bandages and wipe away blood/clots, and visualize the wound. Then apply direct pressure with a new bandage. If the wound has a large hole or missing tissue, consider packing the cavity with a Kerlix-type gauze roll dressing, and reapply firm pressure. For the rare large-vessel laceration or gunshot wound, the tourniquet may prove lifesaving.
Principle 4: Infections Can Kill
Next up: preventing bad infections. As discussed above, the officer with a break in the skin from a human bite wound, or an officer with a cut and a suspect’s blood exposed to that cut, provide a potentially serious threat from infections. What should that officer do?
1) Practice prevention. Use protective gear (goggles, gloves, etc.), avoid body fluids of all types and take steps to decrease exposure to hazardous blood-borne pathogens. Assume everyone you see carries a deadly virus; you rarely can tell from looking at someone if they have HIV, hepatitis, etc.
2) Make the scene safe, control bleeding and seek medical help as soon as possible.
3) Identify the exposure source (e.g., ID the suspect) and later take the proper protocol steps to get a sample of that suspect’s blood to check for infectious agents, including hepatitis, HIV, antibody levels, etc.
4) On the way to the hospital, thoroughly wash out cuts/abrasions with soap and water. Use an antiviral wipe or solution (such as Virex) to clean the skin and any equipment. Remove clothing stained with blood or body fluids as soon as common sense allows (taking into consideration crime-scene investigation matters).
5) Take drastic steps to see a doctor fast. Within 1–2 hours (the sooner the better), loudly and persistently demand to see the emergency physician (or other doctor) now, and have that doctor help evaluate your risks for contracting HIV, hepatitis, wound infections and other infections.
6) If you want to decrease your chance of developing AIDS by 66 percent, talk to the doctor about taking post-exposure prophylaxis medicines as soon as possible, ideally within 1–2 hours. If you take these antiviral, anti-AIDS medicines later than 4–5 hours, they are much less effective. Therefore, it’s an emergency—you must get to the doctor and take these medicines. They cause mild stomach ache and diarrhea, and sometimes other mild symptoms, but the officer (after learning the facts and discussing things with their doctor) may choose to stop the antiviral medicines within the first 1–2 days if the suspect’s or source blood checks out clean of HIV.
7) Hepatitis causes liver disease and failure in many people. All tactical officers should receive the series of hepatitis B vaccinations to decrease their likelihood of contracting hepatitis from blood or other body-fluid exposure. After exposure, have your blood drawn within 24 hours and checked for antibodies to hepatitis. If deficient, you will need several boosters and a shot of immune globulin that will help protect you.
8) Get a tetanus shot at least every 10 years, and get a booster if the wound is dirty or contaminated and the last tetanus shot was given more than five years prior.
9) Human bite wounds have a bad habit of turning into serious skin and tendon infections. A strong antibiotic such as Augmentin, typically prescribed for 3–7 days in significant human or animal bites, helps prevent a bad bacterial infection.
10) Possibly get other immunizations depending upon travel/regional considerations.
11) Follow-up medical care and reevaluation are always a good idea.
Get a good first-aid kit and learn, practice and maintain the skills necessary to provide tactical emergency medical care, including a tourniquet for yourself or your partner in all situations. Remember, Call A CAB and Go. Keep up to date with vaccinations and immunizations, and if an officer is exposed to body fluids, they must be evaluated within 1–2 hours. Wear your ballistic vest at all times when on duty.
Finally, educate all team members in key principles of combat medicine, get a tactical EMS unit together to support your law enforcement agency, know how to prevent injuries and illness, and know what to do when they occur. Because when they eventually do occur, you’ll want your team prepared to save lives.
Dr. Wipfler is a board-certified attending emergency physician who teaches as a clinical associate professor of surgery at the University of Illinois College of Medicine and practices emergency medicine in the Department of Emergency Medicine at OSF Saint Francis Medical Center. He has 14 years experience in the U.S. Army Reserves Medical Corp, directed the largest Life Flight program in Illinois for 5 years and has supported law enforcement agencies for more than 10 years. He started the first tactical EMS program in Illinois certified by the Illinois Department of Public Health and, serving as medical director of STATT TEMS, he has been involved in over 50 SWAT callouts. He is a sworn sheriff’s physician and auxiliary deputy, supporting the Peoria (Ill.) County Sheriffs Department CIERT unit and the Peoria Police Department SRT unit. He serves as team physician and executive council member on the statewide Illinois disaster IMERT team and the Illinois State Police SWMD anti-bioterrorism unit. He serves as co-chair of the ITOA Tactical EMS Committee and coordinates the annual Midwestern ITOA TEMS Conference.