Hemorrhage Control by Law Enforcement Personnel: A Survey of Knowledge Translation From the Military Combat Experience

MILITARY MEDICINE, 180, 6:615, 2015 Hemorrhage Control by Law Enforcement Personnel: A Survey of Knowledge Translation From the Military Combat Experience Sara J. Aberle, MD*; Andrew J. Dennis, DO, FACOS ; John M. Landry, PhD ; Matthew D. Sztajnkrycer, MD, PhD* ABSTRACT Background: Military data demonstrate that exsanguinating hemorrhage is the leading cause of potentially preventable combat death. The purpose of this study was to evaluate attitudes and approaches of civilian law enforcement personnel in the management of acute hemorrhagic trauma. Methods: Anonymous survey administered via an online distribution mechanism. Results: 1,317 U.S. law enforcement personnel began the survey. 370 respondents (30.4%) reported their agencies issued tourniquets, whereas 48.8% indicated their agencies had provided specific training in tourniquet application. Pressure dressings were provided to 43.6% of respondents while hemostatic agents were available to 29.8%. Tourniquets were considered the intervention most likely to save a life, but were also deemed most likely to possibly cause harm or injury if used inappropriately. 43 respondents (0.036%) stated they were aware of circumstances within the past year in which an officer in their agency sustained injuries where a tourniquet could have been used, but was not. Conclusions: Hemorrhage control supplies are being issued to less than half of the responding officers. When used, these interventions were generally thought to be effective. Further study is needed to delineate specific medical interventions, and therefore training and equipment, needed by law enforcement personnel. INTRODUCTION Despite improvements in training, tactics, and equipment, law enforcement remains a dangerous profession. Occupational fatality rates for law enforcement personnel are more than 400% higher than the national average. 1 In 2011, 169 officers died in the line of duty, of which 72 officers were feloniously killed. 2,3 An additional 54,774 were assaulted while on duty, with 26.6% of those assaults resulting in injuries. 2 Among individuals dying from combat-related trauma, exsanguinating hemorrhage is responsible for 35% of prehospital deaths and 33% to 40% of deaths within the first 24 hours from time of injury. 4,5 Military data suggested that nearly 24% of combat deaths were potentially survivable, with exsanguinating hemorrhage the predominant cause of potentially preventable death. 6 Introduction of Tactical Combat Casualty Care (TCCC) at the unit level resulted in dramatic decreases in case fatality rates and preventable combat deaths. 5,7 Knowledge translation refers to the dissemination of data and experience into novel arenas of clinical use, with the objective of improved health and safety. In the absence of law enforcement-specific medical training, U.S. law enforcement agencies have turned to their military counterparts in search of medical training guidelines during conditions of active or unknown threat, which may preclude the entry and assistance of conventional emergency medical services. The use of TCCC-based hemorrhage control guidelines have *Department of Emergency Medicine, Mayo Clinic, Rochester, MN 55905. Department of Trauma and Burn, JHS Cook County Hospital, Chicago, IL 60612. Hillsboro Beach Police Department, 1210 Hillsboro Mile, Hillsboro Beach, FL 33062. doi: 10.7205/MILMED-D-14-00470 been emphasized by national law enforcement agencies and recommended as part of the response to active shooter events. 8 10 One outcome of this knowledge translation is the development of a civilian Committee on Tactical Emergency Casualty Care (TECC). 10 The purpose of this study is to characterize the penetration of current military hemorrhage control guidelines into U.S. law enforcement, including equipment available for use and training of law enforcement officers, in managing acute hemorrhagic trauma. A secondary objective of this study is to begin to define the utilization gap for hemorrhage control among law enforcement personnel, where military hemorrhage control interventions could have been performed but were not. METHODS This study was conducted using the online service SurveyMonkey (Portland, Oregon). The internet link to this survey was distributed through Force Science News (Force Science Research Center, Mankato, Minnesota), a law enforcement-related newsletter. Participation in the survey was entirely voluntary. The survey was administered over a 2-month period from May 1, 2012 to June 30, 2012. The study was reviewed by the Mayo Foundation Institutional Review Board and determined to be exempt. Survey Design An anonymous survey was administered via an online distribution mechanism. In addition to demographic and medical education data, specific information was collected regarding training and use of tourniquets, pressure dressings, and hemostatic agents. Responding law enforcement personnel had the opportunity to describe their opinions and experiences regarding hemorrhage control in comment sections. MILITARY MEDICINE, Vol. 180, June 2015 615

FIGURE 1. Number of respondents per U.S. state. Statistical Analyses Survey responses were initially entered into a Microsoft Excel 2008 database (v12.3.6, Microsoft Corporation, Redmond, Washington, DC). Statistical analysis was performed using JMP statistical analysis software (JMP 9.0.3, SAS Institute, Cary, North Carolina), utilizing Pearson χ 2 tests and basic demographic calculations. According to convention, an α level of 0.05 defined statistical significance. RESULTS Of the 1,363 respondents beginning the survey, 1,317 were U.S. law enforcement personnel, representing all 50 states and the District of Columbia (Fig. 1). Agency type and populations served are described in Table I. TABLE I. Respondent Agency Type and Population Size Served Agency Type Respondents (%) City, Municipal, Population > 250,000 204 (15.0) City, Municipal, Population 100,000 250,000 119 (8.8) City, Municipal, Population 50,000 100,000 164 (12.1) City, Municipal, Population 25,000 50,000 119 (8.8) City, Municipal, Population 10,000 25,000 103 (7.6) City, Municipal, Population < 10,000 111 (8.2) Metropolitan County 127 (9.4) Nonmetropolitan County 118 (8.7) State Agency 139 (10.2) Federal Agency 101 (7.4) Others 52 (3.8) Equipment and Training Table II lists department issue rates for hemorrhage control equipment, as well as the rates at which officers are allowed to purchase intervention equipment on their own for use in the field, whereas Table III lists TCCC and hemorrhage control intervention training rates. Of 1,216 officers who answered the question, 370 (30.4%) reported their agencies issued commercial one-handed tourniquets. 602 respondents (48.8%) indicated their agencies had provided specific training in tourniquet application. Agencies issuing tourniquets were more likely to provide tourniquet-related medical training compared with those not issuing tourniquets (97.3% vs. 30.2%, p < 0.0001). Of officers who reported their agencies did not issue tourniquets, 134 (15.8%) further reported individual officers were not permitted by their agencies to purchase and field a tourniquet. 552 respondents (43.6%) reported being provided with pressure dressings by their agencies, whereas 642 respondents (52.9%) reported receiving training in the use of pressure dressings. Agencies issuing pressure dressings were more TABLE II. Equipment Access to Hemorrhage Control Equipment as Reported by Respondents Agency Issue Rate (%) Ability to Purchase (%) Commercial Tourniquet 396 (30.6) 964 (85.2) Hemostatic Agent 394 (29.2) 953 (81.5) Pressure Dressing 552 (43.6) 955 (88.3) 616 MILITARY MEDICINE, Vol. 180, June 2015

TABLE III. Medical Training Level and Prevalence of Tactical Medical Hemorrhage Control Training Reported by Respondents Respondent Reported Highest Level of Medical Training (%) American Red Cross First Aid/Basic CPR 502 (37.1) Department of Transportation First Responder 229 (16.9) Emergency Medical Technician Basic 228 (16.9) Emergency Medical Technician Intermediate 67 (4.9) Emergency Medical Technician Paramedic 97 (7.2) Tactical Combat Casualty Care/Combat Lifesaver 78 (5.8) Other 152 (11.2) Respondent Tactical Medical Hemorrhage Control Training (%) Tactical Combat Casualty Care/Combat Lifesaver Training 571 (42.1) Agency-Provided Commercial Tourniquet Training 602 (48.8) Agency-Provided Hemostatic Agent Training 408 (32.0) Agency-Provided Pressure Dressing Training 642 (52.9) likely to provide training (82.1% vs. 30.6%, p < 0.0001). 389 respondents (29.8%) reported their agencies issued hemostatic agents, and 408 (32.0%) respondents reported their agencies provided training in the use of hemostatic agents. Agencies issuing hemostatic agents were more likely to provide related training (73.2% vs. 15.5%, p < 0.0001). Experiences and Perceptions Commercial tourniquets were considered the intervention most likely to save a life in the case of life-threatening compressible hemorrhage, selected by 39.5% of the respondents (Fig. 2). Officers who were issued tourniquets, or had received TCCC or Combat Lifesaver training, were significantly more likely to identify this method of hemorrhage control as the most likely lifesaving intervention ( p < 0.0001). The majority of officers thought a basic pressure dressing or direct TABLE IV. Reported Cases of Hemorrhage Control Use and Perceived Efficacy in Managing Bleeding Intervention Officers Cases Perceived Efficacy (%) Commercial Tourniquet 97 123 85.4 Hemostatic Agent 87 125 87.2 Pressure Dressing 214 321 92.5 manual compression were the hemostatic methods most likely to be used during their career (32.0% and 37.3%, respectively; Fig. 2). Direct manual pressure was thought to be the easiest method to employ with minimal training (39.0%; Fig. 2). 97 officers (0.079%) described a total of 123 actual incidents in which a tourniquet was used and reported them to be effective in 85.4% of the cases (Table IV). Being issued a tourniquet (p < 0.0001) or trained in their use (p <0.0001) increased the likelihood of officers reporting knowledge of an actual scenario in which one was employed. Officers who were aware of an incident in which an officer utilized a tourniquet in the field were more likely to trust a tourniquet as a lifesaving measure ( p < 0.0001). 43 respondents (0.036%) respondents stated they were aware of circumstances within the past year in which an officer in their agency sustained injuries where a commercially produced one-handed tourniquet could have been used, but was not. No significant differences in tourniquet issue or training rates were noted for these cases. The majority of responding law enforcement officers (70.6%) identified tourniquets as the most likely hemorrhage control method to possibly cause harm or injury if used inappropriately (Fig. 2). However, there were some groups of respondents who were significantly less likely than their peers to perceive tourniquets as being potentially harmful: those FIGURE 2. Respondent perceptions concerning hemorrhage control interventions. MILITARY MEDICINE, Vol. 180, June 2015 617

who were issued tourniquets by their agency (p < 0.0001), trained in tourniquet use ( p < 0.0001), underwent TCCC training (p < 0.0001), were aware of an actual incident in which a tourniquet was employed ( p = 0.0001), or those who knew of a case where a tourniquet could have been used, but was not (p = 0.037). 214 officers reported 321 actual incidents in which pressure dressings were used in the field. These were felt to be the most successful hemorrhage control intervention, with a 92.5% perceived effectiveness rate (Table IV). Officers who were aware of an incident in which a pressure dressing was used were more likely to consider using a pressure dressing ( p = 0.0065). 92 respondents reported being aware of at least one incident in the past year in which an officer sustained injuries where a pressure dressing could have been used, but was not. There were no significant differences between pressure dressing training rates and missed opportunities. However, those who were not issued pressured dressings by their agency were significantly more likely to report knowledge of a case where a pressure dressing could have been used, but was not (9.12% vs. 5.44%, p = 0.016). 85 officers reported being aware of officers from their agency using hemostatic agents in the field. The hemostatic agent application was considered successful in 87.2% of applications (Table IV). 126 officers stated they were aware of incidents in the past year in which law enforcement personnel sustained injuries where they perceived that hemostatic agents could have been used, but were not. Those who were not trained in hemostatic agent use were significantly more likely to report a missed opportunity (11.52% vs. 7.52%, p = 0.029). Similarly, those not issued hemostatic agents were more likely to think a potential intervention was missed than those who were issued the supplies (11.43% vs. 7.18%, p = 0.023). Those officers trained in hemostatic agent use were more likely to use a technique other than direct manual pressure or a pressure dressing than those who had not received hemostatic agent training ( p = 0.0001). Officers who were issued hemostatic agents or tourniquets, or who had received TCCC training were less likely than their peers to report pressure dressings or direct manual pressure as the most likely interventions they would use in their career ( p < 0.0001, <0.0001, and 0.0013, respectively). Respondents provided a number of comments describing their experiences with hemostatic agents. Mechanisms of injury for which hemostatic agents were used included gunshot wounds, stabbings, complicated lacerations, and motor vehicle accidents. A few respondents specifically identified injuries sustained in noncompressible regions where hemostatic agents were used and considered to be helpful, or were not used but were thought to be potentially helpful. DISCUSSION On average, 53 law enforcement officers are murdered in the line of duty every year. 2 The majority of these events involve penetrating trauma. In addition, more than 50,000 are feloniously assaulted each year. In many of these events, situations are dynamic and rapidly evolving, and medical care is complicated by the presence of ongoing threats. 11 After the 1993 Battle of Mogadishu, Somalia, the U.S. military changed its approach to battlefield trauma care. Using evidence-based data and taking into account operational realities, a novel approach to trauma care was developed. This new approach, designated TCCC, is the current standard of care for prehospital combat trauma care in the U.S. military and many coalition forces. TCCC has proven to be remarkably effective and continues to save lives down range. 5,7,12,13 Units fully invested in TCCC demonstrated improved survival rates; the U.S. Army 75th Ranger Regiment reported no possibly preventable combat deaths after adopting TCCC. 5 Analysis of combat deaths over a 10-year period demonstrated nearly 1,000 deaths that might have been prevented by the widespread adoption of TCCC protocols. 4,14 Of these deaths, approximately 90% were because of hemorrhage. One key finding of these studies was the importance of awareness and support at the command level. In the absence of civilian guidelines for medical care under conditions of active threat, law enforcement agencies have turned to the experiences and successes of the U.S. military TCCC program. 8,9 Among the key differences between TCCC and traditional civilian advanced trauma life support is the prioritization of exsanguinating extremity hemorrhage over airway management, and emphasis on the early use of tourniquets and hemostatic agents. This change in focus was based upon military data, which demonstrated 9% of total deaths and 60% of possibly preventable deaths in combat were because of isolated extremity hemorrhage. 6 As part of this knowledge translation, recently developed civilian TECC guidelines emphasize extremity hemorrhage control as the principal element of medical care to be provided under circumstances of active threat. 10 In contrast to the military medicine environment, the use of tourniquets in the civilian sector remains controversial. The documented lifesaving potential of tourniquets has caused a reconsideration of tourniquet safety, and an increasingly permissive environment for use. Vocal calls for civilian use have appeared in both law enforcement professional journals and media reports. 15,16 Despite this, both the American Red Cross and the American Heart Association state that there is insufficient data for or against recommending their routine use in civilian first aid. 17 Tourniquet use, a foundational skill of TCCC and TECC, was therefore examined closely in this study and was perceptually identified as the most likely lifesaving hemorrhage control method by respondents. Tourniquets may provide a particular advantage to law enforcement officers as compared with other civilian first responders because once placed, tourniquets could permit continued hands-free hemorrhage management and therefore allow officers to better engage any ongoing threat, consistent with key TCCC concepts of 618 MILITARY MEDICINE, Vol. 180, June 2015

providing care under fire. The Israeli experience with tourniquets demonstrated that 69% were applied secondary to such situational constraints, with 34% applied because of care under fire. 13 In contrast to current U.S. military standards, in which almost every U.S. soldier is trained in tourniquet use and issued a commercial tourniquet when deployed, less than half of the responding officers reported receiving agencysponsored tourniquet training and less than one-third of respondents reported being issued tourniquets. Based on the comments from survey respondents, at least some resistance to tourniquet issuance and training appears linked to cost and time required to train personnel and provide the necessary supplies. Some officers also expressed concern for potential harm if those employing the tourniquets were not adequately trained. Previous review of lifesaving interventions and hemorrhage control performed in combat showed tourniquets were applied incorrectly less frequently than airway management, vascular access, and thoracic needle decompression. 12 A more recent study of military prehospital tourniquet placement demonstrated that 83% of tourniquets were inadequately tightened. 18 Pressure dressing application, the most frequently used combat trauma hemorrhage intervention, was also identified as the most commonly used intervention among our survey respondents (371, 37.0%). 12 Pressure dressings were the hemorrhage control supplies most frequently issued to respondents and were thought to be generally safe to employ. Respondents were significantly more likely to report a missed opportunity if they were not issued a pressure dressing, whereas lack of training in this methodology was not significant. The principal limitation for pressure dressing use appears to be lack of access rather than lack of training. Echoing combat experience, hemostatic agent use by law enforcement was the least frequently reported hemorrhage control intervention. 12 Respondents expressed concern for potential adverse effects of these agents. However, when used, they were thought to be effective in the vast majority of occurrences, even more so than tourniquet use. Hemostatic agents were also identified as the hemorrhage control modality most likely to manifest a utilization gap, in which they could have been used, but were not. A lack of training in or issuance of hemostatic agents was significantly linked to reported utilization gaps. Focused education and increased equipment access may be important factors with regard to this hemorrhage control modality. This study identified several interesting patterns in perceptions of hemorrhage control. Experience with, training in, or even secondary knowledge of actual use of various hemorrhage control methods altered perception of the intervention, biasing in favor of the intervention. These results also appear to demonstrate the presence of an affect heuristic toward the intervention, in which a positively viewed intervention is less likely to be associated with perception of potential negative consequences. It remains unclear whether these experientially based perceptions result in any significant consequences in the field. Lastly, a large number of survey respondents identified a need and desire for additional medical training in their comments, specifically as it pertains to the tactical setting. This is supported by other studies, which have shown more than 90% of their respondents were interested in law enforcement-specific medical training. 19,20 The goal of such education should not be limited to having training available but to ensure the skills taught could be executed successfully in the field, and that the skills are maintained over time. Limitations This study has a number of limitations, including those inherent in any survey-based study. Selection bias was introduced simply because of the increased motivation of those respondents receiving the weekly newsletter used to disseminate the survey. Study respondents also reported higher levels of medical training than departmental minimums. The questions queried perceptions in a survey setting, permitting response bias to potentially alter their answers when compared with decisions during actual events. The retrospective nature of some survey questions may have introduced recall bias, in that respondents were asked to remember something from the past in relationship to a potential perceived benefit. It is also important to note that the sample size of 1,317, while large, reflects less than 0.05% of all sworn law enforcement officers in the United States and thus provides only a small window into the law enforcement population. As a consequence, the results of this study reflect the experiences of a very small representation of the total U.S. law enforcement population and should be interpreted as such. TCCC is an evidence-based curriculum focusing on management of the leading causes of possibly preventable combat death. Previous studies have identified differences in military and law enforcement fatality patterns, 21 as well as the incidence of exsanguinating extremity trauma in the civilian sector. 22 Such differences may directly impact the knowledge translation of military TCCC data to the civilian law enforcement setting. Lastly, this study did not directly address certain practical issues, such as availability and oversight of medical direction, lack of national training standards, and subsequent concerns for litigation, after hemorrhage control application. CONCLUSIONS This study suggests that the importance of hemorrhage control has penetrated a large portion of the sample described in this study, either through formal TCCC courses, other agencysponsored training, and trade literature, or through media reports. Hemorrhage control supplies are currently being issued to less than half of the departments represented by the responding officers. When used, TCCC hemorrhage control interventions were generally thought to be effective. There appears to be some correlation between perceived MILITARY MEDICINE, Vol. 180, June 2015 619

missed intervention (utilization gap) opportunities and a lack of supply availability and training. Many respondents expressed a desire for additional training. Further study is needed to identify the leading causes of possibly preventable death in the civilian sector and to further delineate the medical interventions, training, and equipment needed by civilian law enforcement personnel. REFERENCES 1. Evans JA, van Wessem KJ, McDougall D, Lee KA, Lyons T, Balogh ZJ: Epidemiology of traumatic deaths: comprehensive population-based assessment. World J Surg 2010; 34(1): 158 63. 2. U.S. Department of JusticeFederal Bureau of InvestigationCriminal Justice Information Services Division (CJIS): Uniform Crime Reports, Law Enforcement Officers Killed and Assaulted (LEOKA), 2012. Available at http://www.fbi.gov/about-us/cjis/ucr/leoka/2012; accessed March 7, 2014. 3. Anonymous: Causes of Law Enforcement Deaths Over the Past Decade (2003 2012). Facts and Figures. National Law Enforcement Officers Memorial Fund. Available at http://www.nleomf.org/facts/officer-fatalitiesdata/causes.html; accessed March 9, 2014. 4. Eastridge BJ, Mabry RL, Seguin P, et al: Death on the battlefield (2001 2011): implications for the future of combat casualty care. J Trauma Acute Care Surg 2012; 73: S431 7. 5. Kotwal RS, Montgomery HR, Kotwal BM, et al: Eliminating preventable death on the battlefield. Arch Surg 2011; 146: 1350 8. 6. Bellamy RF: The causes of death in conventional land warfare: implications for combat casualty care research. Mil Med 1984; 149: 55 62. 7. Tien HC, Jung V, Rizoli SB, Acharya SV, MacDonald JC: An evaluation of tactical combat casualty care interventions in a combat environment. J Spec Oper Med 2009; 9: 65 8. 8. Butler FK, Carmona R: Tactical combat casualty care: from the battlefields of Afghanistan and Iraq to the streets of America. Tactical Edge 2012; 27: 86 91. 9. Jacobs LM, Wade DS, McSwain NE, et al: The Hartford Consensus: THREAT, a medical disaster preparedness concept. J Am Coll Surg 2013; 217: 947 53. 10. Callaway DW, Smith ER, Cain J, et al: Tactical emergency casualty care (TECC): guidelines for the provision of prehospital trauma care in high threat environments. J Spec Oper Med 2011; 11: 104 22. 11. Schwartz RB, McManus JG, Croushorn J, et al: Tactical medicine competency-based guidelines. Prehosp Emerg Care 2011; 15: 67 82. 12. Lairet JR, Bebarta VS, Burns CJ, et al: Prehospital interventions performed in a combat zone: a prospective multicenter study of 1,003 combat wounded. J Trauma Acute Care Surg 2012; 73(2 Suppl 1): S38 42. 13. Lakstein D, Blumenfeld A, Sokolov T, et al: Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience. J Trauma 2003; 54(5 Suppl): S221 5. 14. Phillips MM: Are U.S. Soldiers Dying From Survivable Wounds. Wall Street Journal, September 19, 2014. Available at http://m.wsj.com/articles/ are-u-s-soldiers-dying-from-survivable-wounds-1411145160?mobile=y; accessed October 25, 2014. 15. Doyle GS, Taillac PP: Tourniquet First! The War on Trauma. Law Officer Supplement, 2014. Available at http://www.lawofficer.com/article/training/ tourniquet-first; accessed October 25, 2014. 16. Lloyd J: Emergency tourniquets, war lessons saved lives in Boston. USA Today, April 17, 2013. Available at http://www.usatoday.com/ story/news/nation/2013/04/17/tourniquets-emergencyboston/2091079/; accessed October 25, 2014. 17. Markenson D, Ferguson JD, Chameides L, et al: Part 13: first aid: 2010 American Heart Association and American Red Cross International Consensus on First Aid Science with treatment recommendations. Circulation 2010; 122(16 Suppl 2): S582 605. 18. King DR, van der Wilden G, Kragh JFJr, Blackbourne LH: Forward assessment of 79 prehospital battlefield tourniquets used in the current war. J Spec Oper Med 2012; 12: 33 8. 19. Kleinman D, Kastre T: Beyond the tape. Law enforcement officers make major impact as initial care providers. JEMS 2012; 37: 38 40, 42 4. 20. Sztajnkrycer MD, Callaway DW, Baez AA: Police officer response to the injured officer: a survey-based analysis of medical care decisions. Prehosp Disaster Med 2007; 22: 335 41. 21. Sztajnkrycer MD: Tactical medical skill requirements for law enforcement officers: a 10-year analysis of line-of-duty deaths. Prehosp Disaster Med 2010; 25: 346 52. 22. Dorlac WC, DeBakey ME, Holcomb JB, et al: Mortality from isolated civilian penetrating extremity injury. J Trauma 2005; 59: 217 22. 620 MILITARY MEDICINE, Vol. 180, June 2015