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Risk Reduction in Officer Rescue: A Scenario-Based Observational Analysis of

Medical Care

Matthew D. Sztajnkrycer, MD, PhD

Medical Director, Rochester Police Department

Medical Director, Rochester/Olmsted County Emergency Response Unit

Associate Professor of Emergency Medicine

Mayo Clinic

Rochester MN 55905

P: 507-255-0917

F: 507-255-6592

Sztajnkrycer.matthew@mayo.edu

The views presented in this publication are those of the author, and do not

necessarily reflect those of the Rochester Police Department, Rochester/Olmsted

County Emergency Response Unit, or Mayo Clinic.

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“Then I heard the voice of the Lord saying, “Whom shall I send? And who will go

for us?” And I said, “Here I am. Send me!” Isaiah 6:8

Disclaimer: While I have the privilege to work alongside the men and women of

law enforcement, I am not a sworn officer. As such, I will always defer to my

colleagues regarding sound tactical decision-making. The following article

discusses tactics in terms of medical decision-making. While data-driven, it is

observational, and should not replace sound tactical decision-making and

common sense.

Introduction

At its most basic level, the downed officer rescue reflects the fundamental conflict

between a need to do what is perceived as right for the downed officer versus the

risk such action creates, both to the rescuers and to the downed officer. In its

coldest analytical form, it is a classic risk-benefit analysis. Logic would state that

risks and benefits should be weighed in order to come to a reasonable decision

as to whether or not to effect a rescue.

The reality is that this calculated analysis frequently does not occur. Even when

not under stress, the decision-making process of our brain is frequently illogical,

emphasizing wants over needs [1]. In the setting of a critical incident, mental

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processes are further altered. Adrenaline levels are high, there is a desire (if not

always a need) to help, and time keeps ticking away, increasing the level of

stress and the perceived need to do something. Feeding into the risk benefit

analysis is the fact that law enforcement is by definition a high-risk occupation. In

2007, there were 57 line-of-duty deaths (LODDs) resulting from felonious assault;

55 resulted from gunfire [2]. Officers have already accounted for this risk in

simply accepting their career, and as such are frequently willing to accept a

higher level of risk than would otherwise logically be considered acceptable.

When dealing with injuries under conditions of active threat, such as during a

downed officer rescue, it is important to understand that medical needs are

simply another tactical consideration. This is highlighted in the statement “Good

medicine can be bad tactics, and bad tactics can get everyone killed or cause the

mission to fail”[3]. It is important to understand this concept in order to

successfully do what is best for both the downed officer and the rescuers. The

most appropriate tactical medical care may actually be threat neutralization. As

an example, consider the conflict between medical care and threat neutralization

in an active shooter scenario.

No law enforcement operation is without risk. The goal of any successful tactical

plan is not to completely eliminate risk (which is impossible, and will lead to

inaction), but rather to manage it in such a way that it is reduced to acceptable

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levels. The purpose of this article is to examine the nature of risk specific to

downed officer rescue, and discuss some potential ways to minimize risk.

Phases of Risk in Officer Rescue

Every rescue situation, regardless of the nature of the threat, can be defined in

terms of three phases of risk (Figure 1). The Approach Risk Phase occurs during

the transition from the relative safety of the point of last cover and concealment

(LCC) into the “hot” zone, where a potential active threat exists. The Approach

Risk Phase consists of the distance that must be covered in order to reach the

downed officer. It is during this period of time that the team first exposes itself to

the potential threat.

The Aid Risk Phase consists of the period of time the officers spend in the hot

zone, under threat of effective fire, assessing the downed officer, and performing

preliminary care (Figure 2). This phase is high risk because any suspect is likely

now aware of the rescue attempt, the team is relatively static, and situational

awareness is easily lost while focusing upon the injured officer.

The final Extraction Risk Phase consists of the distance that must be covered to

return the downed officer to a position of relative safety, where further medical

aid and definitive evacuation can be performed.

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Basic Principles: Recovery or Rescue?

Consider the following training scenario: An officer responding to the scene of a

domestic violence call is shot upon exiting his car. 9-1-1 calls from the scene

report an officer down behind his car. The responding tactical team observes the

officer in a seated position behind his car, not moving. The distance from team to

downed officer is approximately 25 meters, all open ground. What should they

do?

Conceptually, a downed officer rescue may be viewed as a barricade situation,

with the open ground between rescuers and downed officer serving as a barrier

to effectively reaching the officer (Figure 3). The most fundamental question the

team must answer is whether this situation represents a downed officer rescue or

a body recovery. A striking example from the Vietnam era demonstrates the risk

of attempting a rescue when the situation is actually a recovery [4]. During a

patrol, a squad member is shot in the head, and lies motionless in the kill zone,

with minimal bleeding from the wound. A squad member responded to his side,

and attempted to apply a field dressing to the lethal head wound. He was shot in

the hand and wrist. A second responder was shot in the forearm, a third in the

shoulder, a fourth in the chest and wrist, a fifth in the back, and a sixth in the

thigh.

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Many times it is difficult to tell whether the situation is a rescue or a recovery.

Due to the nature of the incident, an initial hands-on assessment is often

impossible. As such, the assessment is based upon the presence of absence of

indirect signs of life. These may include spontaneous movement, spontaneous

chest rise, or exhaled breath plume on a cold day. Gunshot wounds to the head

with exposed brain matter may be another indicator, although there are

numerous cases of survival despite these wounds. Tactical medics may be

extremely useful in these circumstances, providing the on-scene commander

with medical intelligence concerning the nature of the injuries, and whether they

are incompatible with life. Thinking outside the box, a frequently under-utilized

medical asset in remotely assessing a downed officer is the sniper. A sniper is

trained to provide real time information in much greater detail than the typical

operator.

If it remains impossible to distinguish between rescue and recovery, the most

appropriate response is often to assume a rescue situation (ie. that a potential

benefit exists) and act accordingly. However, in simply taking a few seconds to

make these quick assessments rather than immediately rushing forward into the

hot zone, rescuers have already made a significant risk assessment modification.

The tunnel vision surrounding the downed officer is removed, and possible

threats and safe areas identified.

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The above-described training scenario was run with approximately 150

participants representing more than 6 agencies, on 3 separate occasions, and in

two different countries. Every group of participating tactical operators approached

the downed officer, despite the fact that the officer showed no signs of life, and

had a simulated head injury with exposed brain (Figure 4). The scenario was

actually designed to force operators to distinguish between rescue and recovery

operations. As in the Vietnam example, teams exposed themselves to risk for no

possible benefit. One of the arguments put forth by the officers for their actions in

this scenario was that they could not tell if the victim was alive or dead without

examining him, and therefore they were required to go forward. This

“requirement” to go forth is beyond the scope of this article. However, other than

one team calling out to the downed officer, no team attempted remote

assessment in a rapid yet organized fashion.

If the situation is determined to be a recovery, no further time pressure exists.

There is no longer a patient with the potential to deteriorate. This is not a foreign

battlefield, where the deceased may find their bodies desecrated, and so must be

rapidly recovered. The situation can hopefully be resolved in a safer manner, and

allow for dignified recovery of the body. Interestingly, once committed to going

forward, teams frequently continued with body recovery rather than simply

determining absence of life and retreating. By locking into a rescue mindset, and

therefore extracting the body, the average time in the hot zone during these

recovery scenarios increased by 26.8 seconds (Figure 5). While these times may

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not appear very long, consider that a semi-automatic AK-47 clone can fire 30

rounds in approximately 5 seconds [5,6].

Approach Risk Phase: Look Before You Leap

Once the decision is made to initiate a rescue, the first critical medical decision to

be made from a tactical standpoint is determining whether the downed officer is

sick or not sick. Sick implies that the officer will die in the next 15-20 minutes

without medical intervention. Not sick means that, while injured and in need of

medical treatment, the officer can survive for at least this long. This decision is

critical from a tactical standpoint, because a sick patient requires immediate

attention, and therefore adds an element of time pressure absent from a non-sick

patient. The sick patient may require a hasty rescue team from responding patrol

officers, while from the medical stand-point the not sick patient can await the

arrival of a specialized tactical team. Time pressure increases stress, which

alters physical abilities and mental processing, and therefore increases

operational risk. By determining not sick, the operational risk to both downed

officer and rescuers is decreased.

Prior to leaving LCC and entering the hot zone, rescuers should take a few

moments to survey the scene one last time. This includes:

• Scanning the area for potential cover, concealment, and for threats

(debris, secondary devices, suspects).

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• Determining the best approach to the casualty.

• Planning the best route of return with the downed officer, given the fact

that several guns will now be off-line and extra weight will be present.

• Remotely reassessing the downed officer to determine self-extrication

capability.

In training scenarios involving an approximately 25-meter distance, the average

time to reach the downed officer during the Approach Risk Phase was 20.9

seconds (range 13 – 31 seconds). Even accounting for a reactionary gap in the

suspect’s response to the rescue, this is still sufficient time to significantly injure

or kill several members of the rescue team. If the officer is awake and able to

move, order the officer to an area of relative cover. This simple action may

actually remove the need for an immediate rescue attempt.

Consider the following case, again from Vietnam [4]. During another patrol, a

squad member is shot in the left elbow, and calls for a medic. The medic

responds, and while evaluating the casualty, is shot in the head and killed. A

second responder responds to both victims, and is shot in the chest and killed.

The wounded soldier then crawls 50 yards out of the kill zone, and is eventually

evacuated to medical care.

If the officer is awake and able to move, order the officer to initiate self-aid as

appropriate, while awaiting rescue. Unfortunately, many people equate being

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shot with being helpless or dead, something frequently reinforced in training.

Nothing could be further from the truth; it is important to remember that this

applies to suspects as well as officers. Once injured, some officers may simply

shut down. Forcefully remind them that they need to fight, that they are not to

give up. If the injury has easy emergency treatment, such as applying pressure to

a wound to decrease bleeding, officers should be ordered to perform these

actions if safe to do so. Depending upon their injury, they may be able to provide

cover for the rescue team. They certainly should be asked to provide intelligence

on the situation, thereby keeping them engaged and actively involved in their

own survival.

Aid Risk Phase: Remote Medical Assessment

Before leaving the LCC, take a few seconds to assess the medical needs of the

downed officer (Figure 6). Remember, you may be the first medical responder in

this rescue. The burden is then placed upon you to know what should and should

not be done, and how to do it [7]. What are the officer’s injuries? What medical

care is needed? More importantly, what medical care can be safely performed?

Is there cover nearby where the officer can be moved to have this care provided,

prior to definitive extraction? How long are you willing to spend in the hot zone?

By answering these questions ahead of time, exposure time in the hot zone will

be minimized, therefore reducing risk. When the decision is made to move, be

decisive and quick. And always try to maintain tactical awareness.

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Aid Risk Phase: Care Under Fire

As a consequence of the events in Mogadishu, Somalia, in 1993, the United

States military reevaluated the way in which it approached medical care in the

combat setting. The result of this re-evaluation was the development of Tactical

Combat Casualty Care (TCCC), arguably the most important tactical medical

development since Vietnam [3, 8, 9, 10]. TCCC recognizes that medicine is

simply another tactical variable in combat. It designates 3 phases of care, based

upon threat potential: Care Under Fire (CUF), Tactical Field Care (TFC) and

Casualty Evacuation Care (CASEVAC).

Care Under Fire (CUF) is the care rendered upon reaching the downed officer

when the potential for active threat still exists. Due to the high threat level,

medical care in the hot zone is extremely limited. The current TCCC guidelines

explicitly establish procedures for hot zone care (Table 1). Most recently, the

prevailing wisdom is to avoid any medical treatment in the hot zone, and to focus

solely on extrication [11]. Minimizing care in the hot zone minimizes exposure

time and therefore risk. In these scenario-based training exercises, the average

time spent in the hot zone assessing the patient and performing CUF was 49.4

seconds (range 9.0 – 131.0 seconds). Recovery assessments took less time

(average 30.0 seconds; range 9.0 – 51.0 seconds) than rescue assessments

(average 62.0; range 55.0 – 131.0 seconds).

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The only medical care provided in the hot zone is control of life-threatening

hemorrhage [8,9,10]. Due to the nature of the hot zone, the need for continued

situational awareness, and the inability to provide sustained pressure on a

bleeding wound in the hot zone and during rapid extraction, this is achieved

through the rapid use of a tourniquet (Figure 2, 7). A general rule of thumb is that

tourniquet placement in the hot zone should take no more than 7 – 10 seconds.

Remember that during this time, the officer applying the tourniquet will lose

situational awareness. In training scenarios, the average time to apply a

tourniquet upon reaching the downed officer was 56.3 seconds (range 37.0 –

121.0 seconds). Again, consider that it takes approximately 5 seconds to fire 30

rounds from an assault rifle [5,6].

This delay in tourniquet application time reflects the perceived need to perform a

cursory assessment of the downed officer, as well as the time required to remove

the tourniquet from a pocket or pouch, open it up for use, and deploy it. Remote

assessment and preplanning will remove delays in assessment and decision-

making. Every officer should be instructed in the rapid use of a tourniquet; the hot

zone is not the place to use any equipment for the first time (Figure 2).

Pre-designation of a rescue aid officer provides multiple advantages. First, that

officer will have personal protective equipment (eg gloves) appropriate for body

substance isolation. While the victim may be a fellow officer, this does not

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preclude the risk of blood-borne diseases. Second, the rescue aid officer will

know that he/she can focus on the downed officer in relative safety, as the other

officers will maintain situational awareness. Most importantly, the rescue aid

officer can expedite medical care and extraction by having a medical preplan,

including having the tourniquet out and readily available for use as appropriate.

Extraction Risk Phase

The extraction phase poses its own unique problems, not the least of which is

being encumbered by a fellow officer who may be unable to assist in movement.

In training scenarios, the average time to extract the team approximately 40

meters was 30.0 seconds (range 15 – 49 seconds), compared with an average

20.9 seconds for approach. In order to minimize risk, an appropriate extraction

route, with suitable points of cover, should be determined prior to leaving the

LCC.

The goal of this phase may not be to remove the officer to a point of definitive

safety. It may be easier to move the officer to a position of relative safety,

provided by the availability of cover. Once in this position of relative safety,

additional care can be rendered, and emphasis placed upon neutralizing the

threat.

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One common failure of the extraction phase is package separation (Figure 8).

This has been noted in a previous article [12]. The extraction package consists of

2 groups of officers, those physically performing the extraction by carrying or

supporting the downed officer (extraction group), and those providing protection

and situational awareness for the extraction group (cover group). Due to a

combination of factors, the extraction group tends to outpace the cover group.

The larger the distance to be covered, the larger the gap becomes, such that

eventually the extraction group is left exposed and with limited defensive and

offensive options.

Another common failure is simply reversing back out to safety. This poses a

problem for several reasons. The first is that there may be safer, alternate routes,

including those that provide better cover. Additionally, teams tend to simply turn

around and face in the direction they are extracting. In so doing, the team faces

weapons and protective equipment (eg ballistic shields) forwards towards relative

safety, while leaving flanks and rear exposed.

Recently, attention has focused upon the extraction risk phase as a priority

phase in rescue [11]. The focus of care under fire is slowly shifting from limited

medical care (stopping life threatening hemorrhage using tourniquets) to rapid

extraction to a position of relative safety. Although research remains limited, this

fundamental change in the concept of care under fire has already resulted in the

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development of several exciting new high-risk extraction tools, including hands-

free tools which permit the use of weapons during the extraction phase.

Immediate Rescue Drills

The rescue of a downed officer is a high threat procedure. The risk exists, during

all phases, that the rescuers come under direct fire, and that one or more

rescuers are injured. This did occur during several of the training drills (Figure 9).

It is important that the team have an immediate action drill should this occur. At a

minimum, this drill should include:

• Suppressing in-coming fire from the threat if feasible.

• Identifying the presence and location of downed rescuers.

• Rapidly identifying who amongst the team will respond to the new downed

officers and who will continue with the primary rescue.

• Immediately extracting the downed rescuer, rather than retreating and re-

approaching.

Due to this potential for rescuer injuries, if team size permits, back-up rescue aid

officers should be identified, not only to respond to any rescuer casualties, but

also to replace the primary rescue aid officer should he/she be injured during the

approach.

Conclusions

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The rescue of a downed officer is a mission critical element in law enforcement.

While these rescues remain high-risk, there are ways to at least favorably modify

the level of risk involved.

The key to any successful operation remains appropriate, realistic, and on-going

training. While training time and budgets become increasingly tenuous, every

officer must understand not simply that they may one day find themselves injured

in the line of duty, but that they may one day find themselves as the first medical

responder in these events. In one study, 32% of officers reported a line of duty

injury serious enough to require transport to an ER. Importantly, 41% of officers

in the same study reported that they had responded to the scene of a seriously

injured officer; 70% of these officers reported that they were on scene prior to the

arrival of definitive medical care [12]. As such, every officer should be familiar

with the basic concepts of TCCC and CUF, and the use of a tourniquet.

Knowledge is power, after all.

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Acknowledgements

I would like to thank all the men and women of law enforcement who took the

time to participate in these training sessions, and who place their lives on the line

every day. This work is dedicated to them and their families.

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References

1. Gardner D. Risk. Virgin Books, Limited. London. 1st Edition. 2008.

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Kepp JJ, King K, Pierce J, Wightman J, and Vayer J. Emergency Medicine

Technician – Tactical Provider Program Student Manual, US Immigration

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5. Anonymous. Semiautomatic AK47 30 Rounds Extremely Fast Rate of

Fire. http://www.youtube.com/watch?v=fW_HMBLvzuU; last accessed

10/14/08.

6. Anonymous. Fast AK Shoot.

http://www.youtube.com/watch?v=V8OZ4eUvjJY; last accessed 10/14/08.

7. Sztajnkrycer MD, Callaway DW, and Baez AA. Police Officer response to

the Injured Officer: A Survey-Based Analysis of Medical Care Decisions.

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Special Operations. Mil Med 1996; 161 (Suppl 1): 3 – 16.

9. Butler FK and Hagman JH. Tactical management of Urban Warfare

Casualties in Special Operations. Mil Med 2000; 165 (Suppl 1): 1 – 48.

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10. Committee on Tactical Combat Casualty Care: Military Medicine. In:

Prehospital Trauma Life Support, Military Edition, Revised 5th Ed.

McSwain NE, Frame S, Salome JP (eds). Mosby. St Louis. 2005. Pp 374

– 408.

11. Croushorn J and Westmoreland T. Tactical Medical Equipment. The

Tactical Edge 2008; 26 (2): 60,62,64.

12. Sztajnkrycer MD, Meoli M, Baez AA, and Etzin JM. Victim rescue Drill:

Lessons Learned. Emerg Med Serv 2006; 35; 32,34,36.

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Table 1: Care Under Fire Procedure

1. Keep casualty engaged as a combatant if possible.

2. Return fire as directed or required.

3. Prevent further injuries to responders or casualty.

4. Stop life-threatening external hemorrhage.

5. Defer airway management until the Tactical Field Care stage.

6. Extract the casualty to safety as soon as possible.

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Figure 1: Phases of Risk

Downed officer rescue can be defined in terms of 3 phases of risk. See text for

details.

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Figure 2: Aid Risk Phase

Medical care in the hot zone predominantly involves rapid, safe patient

extraction. Life-saving interventions are limited to tourniquet application for

massive hemorrhage. The hot zone is not the place to learn tourniquet

application. In this image, the officer has unthreaded a pre-threaded tourniquet,

and is now trying to re-thread it.

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Figure 3: Approaching Rescuers Take Fire

The open ground serves as a barrier to safely reaching the downed officer.

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Figure 4: Recovery Scenario

After calling out to the downed officer, the team moves forward (A) and assesses

the downed officer (B), thereby exposing themselves to a potential threat. Note

the simulated brain matter on the facemask of the downed officer.

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Figure 5: Effects of Recovery on Extraction Time

The decision to recover the body (B) or simply extract (A) resulted in a 26.8

second increase in time of the Extraction Risk Phase.

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Figure 6: Aid Risk Phase

Little care can be performed in the hot zone for an eviscerating injury, in this case

caused by an explosive device. By planning prior to movement from LCC, time in

the hot zone is minimized. In this scenario, a secondary device was present.

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Figure 7: Care Under Fire Tourniquet Placement

Continued realistic training is important to develop proficiency under stress

conditions. While two operators are off-line, the remainder of the team provide

cover and situational awareness.

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Figure 8: Package Separation

As time progresses (A through D), note the increasing exposure of the extraction

group to a possible threat.

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Figure 9: Rescuer Down

Rescue operations are not without risk. A responding officer is struck by the

suspect and falls (A). While his partner backs away to safety, officers treating the

original downed officer are unaware of the new casualty.

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