Discussion

The current study attempted to describe care provided on-scene by law enforcement in the immediate aftermath of OIS, and the time to initiate such care. Given that the injuries in this study involved law enforcement use of force, by definition, officers were on-scene at TOI 100% of the time. Medical care was provided by LEOs to injured individuals in just over one-half of all incidents (50.3%). The number of individuals sustaining obviously fatal wounds during the initial LEO assessment is, however, unclear. Although 97 individuals were not noted to be moving immediately after the OIS, cardiopulmonary resuscitation (CPR) was performed on 17 (Table 4). Some decision making regarding initiation and delivery of medical care may have been based upon the assessment that non-moving individuals were deceased.

Care rendered by LEOs during these incidents increased over the course of the study. Although this may simply reflect annual variability, this may alternately reflect a changing response pattern driven by increasing awareness by police leaders of the importance of rendering care, ^{8,Reference Chang, Williams, Sangii, Britt and Rogers14–Reference Kaufman, Karp and Delgado16} as well as potential changes in public expectations after several high-profile OIS occurring during the study period.

Care was initiated, on average, 156 seconds after TOI (Table 3). Although this delay may appear lengthy, there are several potential operational reasons for this delay, including the presence of a single officer and multiple subjects, weapons located near the subject that prevented approaching, uncontrolled scenes, and the officer being injured during the incident. It took slightly more than six minutes on average for EMS to arrive on-scene to provide definitive care (Table 3). A prior study noted a similar 4.5-minute delay in EMS access to potentially dangerous scenes. ^{Reference Gratton, Garza, Salomone, McElroy and Shearer2} In the current study, LEOs were able to begin rendering care on average three minutes and 34 seconds before EMS arrival. It must be noted that the time to render care and the nature of the care rendered are not necessarily the same. For maximum impact, appropriate care must be rendered at the appropriate time.

Although extremity injuries were noted in only one-quarter of subjects (Figure 1), the most common care provided by law enforcement personnel was extremity hemorrhage control. This may reflect the fact that the minimum medical training requirement for 80.2% of US law enforcement agencies is American Red Cross Basic First Aid/CPR or equivalent, ^{Reference Landry, Aberle, Dennis and Sztajnkrycer17} prioritization of massive hemorrhage control in Tactical Emergency Casualty Care (TECC), ¹⁸ or exposure to civilian Stop the Bleed programs. ^{Reference Schroll, Smith and Martin19–Reference Jacobs, Wade and McSwain21}

The importance of early intervention has been enshrined in concepts like the “golden hour” and the “platinum ten minutes.” ^{Reference Forrester, August, Cai, Kushner and Wren22–Reference Eastridge, Mabry and Seguin25} Despite LEOs rendering aid to injured individuals on average 214.2 seconds prior to EMS arrival, no significant mortality outcome differences were noted between initial LEO or EMS care (Table 6). This most likely reflects the severity of the underlying injuries (Table 5), ^{Reference Schellenberg, Inaba and Cho6} as suggested by the fact that 33.1% of patients were not moving immediately after the OIS, that 10.2% received CPR suggesting traumatic cardiac arrest prior to EMS arrival, and that the overall mortality was 66.3% (Table 4). Numerous studies have suggested an improved survival outcome in patients with penetrating truncal trauma transported to trauma centers via law enforcement vehicle rather than by EMS. ^{Reference Band, Salhi, Holena, Powell, Branas and Carr26–Reference Jacoby, Reeping and Branas29} This has been attributed both to lack of delay in law enforcement transport from point-of-injury and to performance of non-value added procedures by EMS. ^{Reference Seamon, Fisher and Gaughan30,Reference Ruelas, Tschautscher, Lohse and Sztajnkrycer31} The fact that law enforcement rendered care earlier than EMS and yet produced no survival benefit should not be construed as suggesting that law enforcement should not be rendering aid on-scene. Only one patient succumbed to isolated extremity trauma (Table 5), and hemorrhage control was the most common medical intervention provided by LEOs (Table 4). Rather, the current data may suggest that targeted law enforcement interventions coupled with expedited law enforcement transport for selected patients, as opposed to remaining on-scene pending EMS arrival, may be required for optimal outcome. The specific nature of both these life-saving interventions and patient cohort must still be clarified. Until that time, using TECC guidelines is appropriate. ¹⁸

The use of CPR in traumatic cardiac arrest is controversial. There are data to suggest that closed chest compressions in individuals with cardiac arrest secondary to hemorrhagic shock are not helpful and may in fact be harmful. ^{Reference Smith, Rickard and Wise32–Reference Luna, Pavlin, Kirkman, Copass and Rice35} Under such circumstances, law enforcement may be better served focusing on other potentially more value-added interventions as described in TECC guidelines (massive hemorrhage control with tourniquets or hemostatic agents, airway management, and chest seal placement) prior to initiating CPR. ¹⁸ However, during OIS events, the decision to not perform CPR may both be difficult for the officers, who may be used to initiating CPR in out-of-hospital medical cardiac arrest, ^{Reference Hawkins, Shapiro and Sever1,Reference Alonso-Serra, Delbridge, Auble, Mosesso and Davis11,Reference Klassen, Core, Lohse and Sztajnkrycer36} and may also have negative perceptions by the community.