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Fight
The Journal of Emergency Medicine, Vol. 45, No. 5, pp. 710–713, 2013 Copyright Ó 2013 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.01.026
Emergency Forum LAW ENFORCEMENT AND THE LONG GUN: DO WE NEED A NEW FACE IN THE FIGHT? Mark Cannon, MD Anesthesia Services Medical Group, Chula Vista Police Department, University of California, San Diego, San Diego, California Reprint Address: Mark Cannon, MD, Anesthesia Services Medical Group, Chula Vista Police Department, 3626 Ruffin Road, PO Box 82807, San Diego, CA 92138
, Abstract—Background: The threat of rifles in the hands of criminals is now well recognized within law enforcement. Current emergency response systems are not equipped to operate in this combat-like environment. Growing statistics indicate that of the peace officers that were killed in the line of duty in the United States nearly half died by gunfire evidence. Objective: As Emergency Medical Services (‘‘EMS’’) training and standards evolve, the lessons learned from the Tactical Combat Casualty Care doctrine should be incorporated to improve the safety and outcomes of injured law enforcement officers. Statistics show that deaths by gunfire have the highest average percentage of all officer deaths. Although new weapons, armor, and tactics are continually evolving to meet the challenge of officer safety, in the past decade, little has changed in how our EMS system responds to a critically wounded officer. Discussion: Combat data from the US military leads us to believe that to save a wounded officer, emergency care must start immediately, regardless of the ongoing gun battle. Conclusion: It is time for the emergency medical system to evolve to meet the critical needs of today’s law enforcement environment. Ó 2013 Elsevier Inc.
the serious threats regularly faced by peace officers. Indeed, the US Department of Justice, as well as several large municipal police and sheriff agencies, stated publicly that rifles posed no significant threat to their officers (1). Leap forward to the end of the year 2012 and there is probably no one in law enforcement who has to be convinced of the significant threat rifles pose to the lives of law enforcement officers. The Federal Bureau of Investigation noted that in 1990, 1.48% of deaths of law enforcement officers during the past decade involved assault weapons (2). By 2009, this percentage had leaped to 31% (3). It is a common expectation that this percentage will continue to increase. In 2009, 57,268 law enforcement officers were assaulted while on duty and in 2010, the number of deaths by gunfire increased 21% over the previous year (4,5). In 2011, 165 peace officers were killed in the line of duty in the United States and 44% of these officers died by gunfire (6). Statistics show that deaths by gunfire have the highest average percentage of all officer deaths at thirty six percent (5). With a threat that is with little question increasing, law enforcement has recently taken many steps to protect its officers. However, the question we must ask ourselves is: What more actually can be been done to protect these men and women who risk their lives for us every day? On the morning of February 28, 1997, law enforcement in the United States changed forever when two men armed with fully automatic rifles robbed a North Hollywood bank in California (7). At its final conclusion,
, Keywords—rifles; law enforcement; emergency medical response; combat casualty care
INTRODUCTION As recently as the early 1990s, virtually no one in law enforcement considered criminals with rifles to be among
RECEIVED: 1 May 2011; FINAL SUBMISSION RECEIVED: 12 January 2013; ACCEPTED: 24 January 2013 710
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13 people lay injured and two criminals were killed, after over 1800 rounds of ammunition were exchanged (8). This was arguably the first all-out assault on law enforcement by criminals with automatic rifles since the TommyGun Gangster era of the 1920s and 1930s. DISCUSSION During the 1990s, the US military began to recognize just how lethal modern rifles had become and to appreciate the threat they posed to our soldiers. By the time the North Hollywood bank robbery occurred, the military was committed to the development of new weapons, new armor, and new tactics to help decrease the risk these sophisticated weapons create in enemy hands. This paradigm shift included a new mindset as to how to treat and manage wounded soldiers on the battlefield. For the first time, the training of medics and corpsmen was removed from civilian training programs and placed under the direct supervision of the US military medical corps. The philosophy behind this movement was that civilian training programs had no experience in dealing with the kind of injuries associated with modern combat. In 1996, the military developed the Tactical Combat Casualty Care protocol (‘‘TCCC’’) (9). The TCCC was introduced to better treat and increase survival of wounded soldiers between the point of hostile fire and their evacuation to a field hospital. During the creation of this new training regimen, the analysis of casualty data showed that 56% of battlefield wounds were non-correctable and death could not have been prevented. Head and chest trauma overwhelmingly fell into this category. The remaining 44% of combat wounds were found to be correctable, and in such cases the soldiers could survive when lifesaving care is started immediately in the field despite the ongoing fight surrounding them. Of the soldiers who initially had a correctable wound but later died, 90% died before they could reach a medical facility. Of that 90%, 60% died from bleeding to death, 33% died from chest wounds, and 6% from loss of their airway (10). The majority of these deaths occurred because medical care did not start soon enough. Data analysis indicates that the number one factor in preventing the start of immediate care was the presence of hostile fire, with the second limiting factor being medical equipment availability; this was followed by variability in evacuation time. Civilian Tactical Medicine Akin to Military Battlefield Casualties A common relationship between battlefield casualties and a wounded law enforcement officer was not always apparent. However, the civilian world is now recognizing
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what the military already declared—the best type of medicine on the battlefield is incorporated with superior fire power (11). The ability of military medical personal to provide security firepower to the fight is a key factor for soldier survival, although this is still considered mostly a foreign concept in the civilian law enforcement world. Paramedics and Emergency Medical Technicians provide the majority of emergency medical field care in the United States. They are not typically part of any hostile engagement and are not able to render care, or even to approach the victim until all hostile activities have ceased. With death after a survivable wound occurring in as quickly as 180 s, the perception that crucial life-saving training (Self/Buddy Aid) is vital for law enforcement officers is evident (12). Emergency Medical Services (EMS) training is often considered basic relative to that of a military medic, and the EMS medical equipment available on scene is less comprehensive than that of a medic or corpsman. The civilian evacuation method mainly consists of an ambulance or helicopter. Both of these options present their own unique time limitations in the suburban setting, which effect overall survival rates. Prior to the North Hollywood bank robbery, very little, if any, consideration was given to reassessing or modifying the systematic medical response, the training, or the tactics related to a wounded law enforcement officer (13). Despite the same-day deaths of four Alcohol, Tobacco and Firearms agents 4 years earlier in Waco, TX, arguably no universal change in our medical response system had occurred by February 28, 1997 (14). Unquestionably by luck alone, no law enforcement officer or civilian lost their lives that day in North Hollywood, CA. Despite the presence of life-threatening wounds, the ability to reach the victims and initiate treatment on scene as the gunfight ensued was zero. The firefight that occurred that day has been described by some as the closest experience US law enforcement has had to military combat. If this is considered a true and accurate description, it is not difficult to relate the previously noted military casualty statistics to future potential law enforcement activities: 56% killed on scene, 44% wounded with correctable injuries, and 90% of these latter victims dying before reaching a medical facility. A Time for Change In 2008, the question of creating a new system to manage and treat wounded peace officers was briefly and informally discussed with a command staff member of one the largest police departments in the United States (15). Despite the knowledge gained from the North Hollywood shootout and Waco, there did not seem to be a consensus that the emergency response system was inadequate or in
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need of modification. The review of public data on major metropolitan cities indicates the attitude is changing. The cities of Los Angeles, CA, New York, NY, Oakland, CA, Pittsburgh, PA, Memphis, AK, and Saint Petersburg, FL are just a few that are seeing an increase in officer assaults (13,16–21). The overriding philosophy of ‘‘no change needed,’’ compounded by the current significant budgetary constraints, has kept our antiquated emergency response system intact. The prospect of change, though, is gaining interest in both the Emergency Medicine community and in the special operations arms of law enforcement. The development of and increasing attendance at tactical medicine seminars, schools, and the recent formation of the Committee for Tactical Emergency Combat Casualty Care and its advancement of a civilian adaption of TCCC called Tactical Emergency Casualty Care (‘‘TECC’’) indicates the growing concern for the survival of the wounded peace officer (22). Increasingly, physicians are volunteering their time to law enforcement to be on scene when there is a high risk of officer injuries and time is critical. The US Border Patrol has begun cross-training selected agents with paramedic skills (23). They are, perhaps, the first US law enforcement agency to fully embrace the philosophy that the best type of battlefield medicine is in combination with superior firepower. CONCLUSION The time has arrived to make systematic changes in how we respond to wounded officers. Can the emergency medical response system be successfully merged with the operational needs of tactical law enforcement? The 1982 development of the Special Trauma and Rescue Team (‘‘STAR’’) by the San Diego Police SWAT team and Fire Department would indicate that it is not only feasible, but successful (24). Progressive thinking would indicate that the adoption of the TCCC philosophy for law enforcement should be evaluated with the same priority as any new technology, equipment, or training. The infrastructure for creating this change could take many forms. Most likely, the foundation of this change will involve creating a new law enforcement hybrid warrior–medic. This hybrid officer will have the ability to add firepower to the fight and provide life-saving skills immediately. In other words, initiate advanced care as the firefight continues while at the same time maintaining operational tactics and security. This could evolve into a new breed of physician–police officer, advanced medic–police officer, or limited but advanced training for all law enforcement officers in treating acute life-threatening wounds. The utilization of the TECC doctrine may prove training for all law enforcement officers to be the most effective option (25). To date, just in Orange County, CA, an estimated
800 law enforcement officers have received TECC training through a Homeland Security Urban Area Security Initiative grant (26). Regardless of the method chosen to change the current medical response system, education and training will play a vital role in the success of increasing survival. To ensure the ultimate goal, the process will have to be multi-faceted, with a dedication to evidencebased solutions. Absent the rigid command structure of the military, the medical community and law enforcement will need a paradigm shift to embrace mutual respect and acceptance of their mutual expertise to create this law enforcement model. Educating physicians and emergency medical response personnel on the operational needs of law enforcement will be essential to the future success. Like all traditional law enforcement training, it is crucial that the medical community also appreciate the time deterioration of perishable skills, and the importance of creating realistic training scenarios that are consistent with law enforcement operations. The relationship between medicine and law enforcement needs to be codependent, and must not end at conception and implementation. Both professions are continuously dynamic, with change unremittingly occurring. Each needs to rely on the other to be vigilant in protecting the lives of our law enforcement officers. The ultimate goal is to make a very dangerous job safer. In 2010, 41% of the law enforcement officers killed in the line of duty were shot and killed (27). In 2011, the number rose to 47% (28). It is time to make tactical medicine a priority for law enforcement.
REFERENCES 1. Roth JA, Koper CS, Adams W, et al. Impact evaluation of the public safety and recreational firearms use protection Act of 1994. [Urban Institute Website] March 13, 1997. Available at: http://www.urban. org/UploadedPDF/aw_final.pdf. Accessed November 12, 2010. 2. Bea K. CRS report for Congress—Assault weapons: military-style semiautomatic firearms facts and issues (App. B: 65–76). Washington, DC: Congressional Research Service, Library of Congress; May 13, 1992. (Tech. Rev., June 4, 1992). 3. US Department of Justice, Federal Bureau of Investigation. Law enforcement officers feloniously killed, type of weapon 2000–2009; Table 27 [FBI Website] October 2010. Available at: http://www2. fbi.gov/ucr/killed/2009/data/table_27.html. Accessed November 11, 2010. 4. National Law Enforcement Officers Memorial Fund (NLEOMF). Deaths, assaults, and injuries over the past decade (2002–2011). [NLEOMF Web site]. Available at: http://www.nleomf.org/facts/ officer-fatalities-data/daifacts.html. Accessed December 26, 2012. 5. National Law Enforcement Officers Memorial Fund (NLEOMF). Causes of law enforcement deaths over the past decade (2002– 2011). [NLEOMF Website]. Available at: http://www.nleomf.org/ facts/officer-fatalities-data/causes.html. Accessed December 26, 2012. 6. National Law Enforcement Officers Memorial Fund (NLEOMF). Officer deaths by year. [NLEOMF Website]. Available at: http:// www.nleomf.org/facts/officer-fatalities-data/year.html. Accessed December 26, 2012.
Law Enforcement and the Long Gun 7. Parker B. How the North Hollywood shootout changed patrol rifles. Police magazine [serial online]. February 2012. Available at: http:// www.policemag.com/channel/weapons/articles/print/story/2012/ 02/how-the-north-hollywood-shootout-changed-patrol-rifles.aspx. Accessed December 26, 2012. 8. Caprarelli J. Uniform decisions: my life in the LAPD and the North Hollywood shootout. Los Angeles, CA: End of Watch; 2011. 9. Butler FK, Hagmann J, Butler EG. Tactical combat casualty care in special operations. Mil Med 1996;161(Suppl):1–16. 10. Gerold KB, Gibbons M, McKay S. The relevance of tactical combat casualty care guidelines to civilian law enforcement operations. [National Tactical Officers Association (NTOA) Website]. November 1, 2009. Available at: http://ntoa.org/site/images/stories/tccc_ guidelines_ntoa.pdf. Accessed February 2, 2011. 11. Evans B. The time for tactical medics has arrived 2009; Firechief. com [serial online]. January 28, 2011. Available at: http:// firechief.com/ems-training/time-tactical-medics-has-arrived. Accessed February 2, 2011. 12. Champion HR, Bellamy RF, Roberts CP, et al. A profile of combat injury. J Trauma 2003;54:S13–9. 13. Eckstein M, Cowen AR. Scene safety in the face of automatic weapons fire: a new dilemma for EMS. Prehosp Emerg Care 1998;2:117–22. [Informa Healthcare online]. Available at: http:// informahealthcare.com/doi/abs/10.1080/10903129808958854. Accessed November 12, 2010. 14. Reavis DJ. The ashes of Waco: an investigation. New York: Simon and Schuster; 1995. 15. Roberts MR. On the front line. Firechief.com [serial online]. August 1, 2010. Available at: http://firechief.com/ems/paramedic-crosstraining-201008. Accessed November 2, 2010. 16. Aveni TJ. Contagious fire: fact & fiction. [Police Policy Studies Council Website]. December 2006. Available at: http://www.theppsc.org/ Staff_Views/Aveni/Contagious.Fire.htm. Accessed December 5, 2010. 17. Theriault DC, Mangaliman J, Ostrom MA. Oakland uneasy over police shootout death. San Jose Mercury News [Seattle Times website]. March 23, 2009. Available at: http://seattletimes.nwsource. com/html/nationworld/2008906541_oakland23.html. Accessed December 5, 2010. 18. Harper N. Three officers slain responding to call, Pittsburgh police chief says. [CNN Website]. April 4, 2009. Available at:
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