It was an otherwise quiet morning in Pima County, Ariz., when, at 10:11 a.m. on Jan. 8, 2011, the Pima County Sheriff’s Department received a 9-1-1 call advising of a shooting in progress at a local shopping center. During the next 20 minutes, details of a horrific and historic scene unfolded, despite the lone shooter being taken into custody within five minutes of the original 9-1-1 call.
Before it was all over, that isolated shooter had fired 30 rounds into a crowd gathered for the Congress on Your Corner event with Congresswoman Gabrielle Giffords (D-Ariz.) outside a busy Safeway grocery store on the outskirts of Tucson. Facing the arriving deputies were 19 injured and/or dying people all in close proximity. Luckily, they had trained for such situations. Is your department prepared to receive a 9-1-1 call like this?
The Northwest Fire Rescue District (NWFRD) serves the suburban area of Tucson where the mass shooting occurred. A NWFRD paramedic rescue ambulance and three ground ambulances from Southwest Ambulance were dispatched based on the initial information received by dispatch from the initial 9-1-1 call. Three ALS engines, a ladder company and EMS Captain and Battalion Chief (BC) Lane Spalla also responded on the first-alarm MCI response. Three medical helicopters were also placed on standby based on the scope of the incident.
Although the first EMS/fire units arrived on scene in just five minutes, they were held off in a safe staging area by law enforcement until 10:23 a.m., when the scene was declared safe for entry.
This scene was also different from many other active-shooter mass casualty incidents (MCIs) because the arriving deputies were all trained in MCI and advanced care procedures that enabled them to play a major role in the treatment and survival of the multiple critically wounded patients who were inside the incident hot zone prior to the secured arrival of fire and EMS responders.
In the critical minutes of an incident involving gunfire and the need to secure the scene, where patients had the potential to exsanguinate, the deputies arriving on scene were armed with special emergency care packs that were strategically positioned behind the headrest of each patrol vehicle for easy access and deployment.
During the 47 minutes that deputies were with the injured at the scene, they treated 10 of the 19 injured patients. They controlled bleeding, provided rescue breathing and chest compressions, deployed hemostatic agents, bandaged numerous wounds, and assisted citizens and congressional staffers in the care of the injured.
The first seven patients were triaged, treated and transported from the scene by 10:35 a.m. All were transported by 11:01 a.m.
The early combat and control of hemorrhage before the onset of shock has been proven by the military in the Iraq and Afghanistan war zones to be the key factor in preventing death from severe hemorrhage.
Emergency department (ED) physicians and trauma surgeons from Tucson’s level one trauma center University Medical Center acknowledge that the quick actions of the Pima County Sheriff Department deputies and their specialized training and EMS equipment resulted in decreased hemorrhage, improved vital signs and less need for shock resuscitation for multiple victims.
Initial First Responders
It’s essential that treatment begin immediately and patients be transported expeditiously in accordance to the severity of their injuries. And even in an urban environment, the time it takes for EMS to arrive on scene can mean the difference between life and death for the wounded. Too often the first responder is a law enforcement officer faced with a tactical situation of providing a law enforcement function that must quickly transition into providing first care to civilians or a fellow officer.
The Safeway shooting happened in a geographic location in Pima County that’s readily served by multiple paramedic units from three large fire departments. But it’s conceivable that this same scenario could occur with one or more of the following situational complications:
>> Extended EMS unit response to a rural or remote setting;
>> EMS resources committed on other high-priority calls and delayed in response or arrival;
>> Traffic congestion that delays or prohibits EMS access to a scene;
>> An unsafe scene that doesn’t allow fire and EMS providers to approach immediately.
Any of these complications can significantly affect the well-being of the wounded, because the EMS provider would be markedly delayed in arrival and their ability to provide essential emergency care.
In a 2007 study published in Prehospital and Disaster Medicine, the authors noted, “No widely accepted, specialized medical training exists for police officers confronted with medical emergencies while under conditions of active threat.”1
Given the knowledge’ acquired from historical and modern battle, culminating in the trauma combat casualty care (TCCC) guidelines, we know the following are causes of preventable death on
>> Hemorrhage from extremity wounds;
>> Tension pneumothorax; and
>> Airway compromise.
Each of these conditions can be managed early and effectively using relatively simple techniques and minimal equipment. Unfortunately these techniques and equipment are rarely taught to law enforcement officers.
Even in an urban environment, the time it takes for EMS to arrive on scene can mean the difference between life and death for the wounded. Law enforcement personnel routinely are the first arriving responders to arrive at tactical situations. They are also often the first to arrive at such mass casualty situations as major traffic collisions involving multiple patients.
At tactical incidents, officers are often faced with the challenge of initiating law enforcement functions and almost simultaneously ensuring that needed care is started on critically injured fellow officers and civilians.
Special weapons and tactics (SWAT) teams have long understood how important it is to have paramedics imbedded in their teams, immediately available for any medical need and tactically trained and aware of how to react and respond in a hostile or active shooter environment. Tactical EMS (TEMS) providers can readily address airway, breathing and circulation problems that create an urgency that transcends the response times of most staged civilian medical assistance units.
Although it’s not always practical for law enforcement agencies to employ paramedics to work in the field with officers, much can be done to train police officers to care for themselves, their colleagues and other patients.
Tactical Paramedic Training
In the spring of 2009, the leadership of the Pima County Sheriff’s Department recognizing the need for global training for all staff with “feet on the street.” They took elements of TCCC and results from the research done by Valor Project and created the First Five Minutes, a tactical emergency medical training program that was rolled out to all deputies during annual advanced officer training. This specialized EMS and law enforcement training program was developed with assistance from Richard Carmona, MD, MPH, the 17th U.S. surgeon general and former Pima County Sheriff’s Department SWAT team leader and medical director.
Although the First Five Minutes program isn’t the first medical training course taught to Pima County sheriff’s deputies, it’s different from their normal medical training because the primary goal is to give police officers the training necessary to sustain themselves or others in situations with life-threatening medical emergencies.
Along with the training, a special emergency response equipment kit was developed and issued to all deputies after they completed the training. The law enforcement individual first aid kit (IFAK) was assembled to include essential supplies and devices necessary to combat the three most common causes of preventable traumatic death, namely 1) hemorrhage in accessible and controllable regions; 2) hemorrhage in inaccessible or uncontrollable areas and 3) airway/respiratory management.
Officer safety and tactical considerations are incorporated into every aspect of the First Five Minutes lesson plan. Officers are reminded that they’re police officers first and medical providers second. The program introduction relates the importance of providing immediate medical care to the downed officer. The Fort Hood (Texas) Police Department shooting and the murder of Phoenix Police Department Officer Travis Murphy illustrate this issue.
At numerous points during the class, instructors emphasize that this program isn’t designed to be a first aid class, but rather a survival class for police officers. A law enforcement IFAK is issued to each student at the beginning of the class so become familiar with its contents to ensure rapid retrieval of essential items when necessary.
Although the IFAK is designed primarily for law enforcement professionals to treat fellow officers, deputies are told to use their discretion at emergency scenes. They’re encouraged to use their IFAKs, once the scene is secure, to stabilize civilians when they feel it can be life-saving in advance of EMS arrival. Such was the case at the Safeway/Giffords MCI scene.
Because the assisting officer is often the first person to contact the injured person, the training stresses the idea that the officer’s observations and findings are the most significant issues in long-term care and recovery of the wounded person. Officers are told to report the following to EMS providers:
>> The nature of the injury;
>> Patient’s mental status, including any changes in mental status;
>> Airway control necessary, rates of breathing and circulation;
>> Injuries they saw, who they treated, and how they treated those injuries; and
>> Any unusual findings or concerns.
At the conclusion of the training, the officers’ skills are evaluated through participation in multiple scenarios. Two evaluators are used for each scenario: one evaluates officer safety, use of cover and concealment, tactical movement and other skills related to police work; the second (an EMT or paramedic) evaluates the medical triage and care provided to the patient.
Similar emergency medical training programs address this need. This includes the specialized tactics for operational rescue and medicine program (STORM), developed by the Georgia Health Sciences University in conjunction with the National Tactical Officers Association.
The STORM course provides clearly defined medical strategies, procedures and rescue techniques to enhance the safety of law enforcement personnel and the populations they serve. STORM is tailored to five unique tactical audiences: self aid-buddy care, operator, paramedic, medical director and commander. Each course consists of didactics, hands-on skills stations and tactical scenario-based training.
The Nashville Police Department recently implemented a modern-day “first aid” program, which was taught once a week for five months to their entire roster of 1,400 active-duty officers. The training featured lecture and practical skill sessions training kits, which were issued to each officer as they completed the training program (see “Partners in Crime,” p. 52–55).
Not all law enforcement agencies consider emergency care to be part of a police officer’s job. With the ever-increasing call load and requirements placed on officers, it’s easy to see how agencies can lessen liability and workload by eliminating a job that’s already served by fire departments and EMS agencies.
However, a wounded officer, or an officer responding to a mass casualty incident well in advance of EMS, presents an opportunity for lives to be saved by law enforcement personnel.
Every officer should have the necessary training and equipment to provide on-scene emergency medical self care. They also should be able to assist other officers and civilians injured during a law enforcement operation.
Key aspects of implementing a successful law enforcement emergency care program are simplicity and ease of use in an emergency. Without those two factors, officers are limited in what they can effectively do at a scene.
The training and equipment used by law enforcement personnel prior to EMS gaining access to the scene of the Safeway shooting incident proving it to be worthwhile in a time of crisis, resulting in saved lives. The First Five Minutes program is easy to teach, simple to understand and effective in treating the injured before EMS arrival. JEMS
David Kleinman, NREMT-P, is a detective with the Arizona Department of Public Safety and a tactical paramedic with Pima Regional SWAT. com. He can be reached at firstname.lastname@example.org.
Tammy Kastre, MD, is the medical director for the Pima County Sheriff’s Department SWAT team and a board-certified ED physician.
1. Sztajnkrycer MD, Callaway DW, Benz AA. Police officer response to the injured officer: A survey-based analysis of medical care decisions. Prehosp Disaster Med. 2007;22(4):335–341.
First Five Minutes Training
The concept of training law enforcement officers in initial care and providing them with special medical kits isn’t new. This is a concept that has been used by the U.S. Secret Service for decades, with special kits immediately available to each agent and all agents familiar with the items in the kit. However, the First Five Minutes program is one of the first in which the care provided by officers before EMS arrival has been lauded as having saved several patients. The four-hour First Five Minutes training includes the following elements:
>> Scene safety and orientation components, including familiarity with area fire and EMS agencies and services.
>> The capabilities of local hospitals and the availability of helicopter rescue.
>> Body substance isolation (BSI) and real-world applications.
>> Assessment of circulation, airway and breathing. This includes methods to establish and maintain an open airway, as well as how to provide rescue breathing and continuous compression resuscitation (CCR).
>> How to contact an injured officer.
>> When and how to remove body armor.
They also learn a 90-second assessment of the situation and patient medical conditions with primary focus on hemorrhage control maneuvers and identification of shock. At the end of each assessment, deputies are encouraged to make transport decisions: Do they stay at the scene and wait for EMS, or do they transport the wounded rapidly via police or private vehicles? For hands-on training, the deputies participated in a skills lab that includes the use of the emergency compression bandages, hemostatic combat gauze, chest seals and tourniquets.
The contents of the IFAK are chosen specifically for law enforcement officers who would need to provide care to trauma patients before EMS arrives on scene. The IFAK includes the following items:
>> A zippered bag with interior elastic straps for holding contents in place. The exterior of the bag has multiple attachments points—allowing it to be mounted in the vehicle, on a backpack or even on a duty belt.
>> A pair of trauma shears.
>> Two emergency compression bandages.
>> One package of hemostatic combat gauze.
>> One chest seal.
>> One tourniquet.
The individual first aid kit includes supplies and devices necessary to combat the most common causes of preventable traumatic death.
This article originally appeared in June 2012 JEMS as “Beyond the Tape: Law enforcement officers as initial responders.”