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August 28, 2015

Law enforcement officers as medical first responders can save lives

For many medical and trauma emergencies, law enforcement personnel are the true first responders, arriving on scene before EMS providers. Although the law enforcement skill set is highly specialized to safeguard lives and property, and protect individuals in the communities they serve, many cops have not received extensive training in emergency medical care.

The utilization of law enforcement officers as first responders during medical emergencies has the potential to decrease the time it takes for a patient to receive lifesaving care. Patients who experience a sudden cardiac arrest, an opiate overdose, or significant trauma may benefit greatly from programs that equip and prepare law enforcement for immediate medical intervention.

Sudden cardiac arrest: AED deployment in law enforcement vehicles

The first three links in the American Heart Association’s Chain of Survival are early access to the emergency response system, early CPR, and early defibrillation. Each year, over 350,000 Americans experience an out of hospital cardiac arrest and only 41 percent of those patients receive bystander CPR.[1] Equipping law enforcement vehicles with automated external defibrillators and ensuring that officers are trained in CPR and AED use allows lifesaving interventions to be delivered as quickly as possible.

Training in AED use can be completed in a matter of hours with a high degree of success[2], and many areas in the U.S. have already equipped law enforcement with AEDs. Studies suggest that deployment of AEDs in law enforcement vehicles significantly decreases the time from the initial 911 call to the delivery of the first defibrillation attempt, and increases survival to hospital discharge rates.[3]

Implementing a law enforcement AED program is not without challenges. The effectiveness of equipping law enforcement with AEDs may be directly related to the number of first responding fire department vehicles that also have an AED.

An early study in an urban area of Ohio saw no significant changes in out of hospital cardiac arrest survival after equipping law enforcement with defibrillators, however in the test area all fire department vehicles were also equipped with AEDs.[4] Response times for law enforcement and fire resources were similar in the study area, meaning that an AED usually arrived on scene early regardless of law enforcement response. This suggests that AED programs for law enforcement may have the most impact in areas where response times for EMS are notably longer than for law enforcement.

A study of widespread deployment of AEDs to law enforcement in Miami-Dade County in the late 1990’s revealed the importance of officer support and comprehensive education prior to initiating an AED program. The study found that the average response time for police to a cardiac arrest event was just over six minutes, while response time for all other events was significantly faster at just over four minutes.[5] The study suggests possible factors for the delay as lack of comfort with AED use, and concern over liability.

Another study in a Pittsburgh suburb showed similar results. Although law enforcement consistently arrived on scene before EMS resources, defibrillation was only used in 69 percent of cardiac arrest situations.[6] Factors contributing to the inconsistent AED use included the expected imminent arrival of EMS personnel, failure to bring the AED to the patient, and excessively lengthy patient assessments.

These studies indicate that best practices for AED use by law enforcement include comprehensive education of officers prior to AED deployment. Comfort level of individual personnel with the use of an AED, and commitment to program implementation directly relate to rates of survival for cardiac arrest patients. Officers must be knowledgeable about the impact their AED can have, and be ready to respond to cardiac arrest situations appropriately.

AEDs may be most effective when deployed in areas where law enforcement response times are shorter than those of EMS, however given the effectiveness of early defibrillation on cardiac arrest patients it may be true that deploying more AEDs into a given community is a net plus, regardless of agency response times.

Opiate overdose: Naloxone administration by police

More than 220 law enforcement agencies in at least 24 states currently equip officers with naloxone for emergency administration to opiate overdose patients.[7] Overdose deaths are not isolated to intravenous drug users. The availability of potent opiate-based analgesics makes opiate overdose a concern for patients in virtually all demographics. Death from prescription drug overdose has increased steadily in recent years, and overdoses in heroin users doubled between 2010 and 2012.[8]

Opioid abuse and overdose causes significant respiratory depression. Death from opiate use occurs subsequent to hypoxia, and can occur very rapidly in some cases.[9] The medication naloxone displaces opioids from the receptors in the brain, effectively reversing respiratory depression. Naloxone has been used for decades to reverse opiate induced respiratory depression, can be administered easily via an intranasal atomizer, and has no potential for abuse.[10] The effectiveness of naloxone has prompted the development of community programs that provide naloxone and training in its administration to individuals who use drugs or know someone at risk of overdose.[11]

Given the effectiveness of naloxone, and its successful use by otherwise untrained lay persons, it would seem that equipping law enforcement officers with the medication would provide significant benefit.

One such program, in Quincy, Mass., had great success after supplying officers with intranasal naloxone kits. Officers responded to 191 suspected overdose incidents, and successfully reversed 182 opiate overdoses.[12] That same program identified an unexpected benefit, in that drug users’ perception of law enforcement became more positive once it was understood that lifesaving medication was available.

There are several barriers to successfully supplying law enforcement with naloxone. First, naloxone is a prescription medication and must be administered with some medical oversight. In Michigan and Pennsylvania, law enforcement operates under EMS protocols for naloxone administration and is therefore under the oversight of the EMS agency medical director. The other 22 states, at the time of this writing, that allow law enforcement administration of naloxone have statutes or regulation authorizing its use.[13] Although these precedents are in place for regulation and oversight, organizing and implementing such statutory changes takes time and may hinder other states adoption of naloxone administration by law enforcement.

Legal liability may also be of concern for law enforcement agencies considering naloxone use, however these concerns would be unfounded. There are no records of any lawsuit relating to naloxone use through community programs or law enforcement administration.[14] The use of naloxone for opiate overdose reversal is well established, and the risks of administration are very low. It would seem that concern over liability relating to naloxone use has little merit and would not be reason to delay implementing a law enforcement naloxone program.

The cost of naloxone is relatively low, approximately $60-$80 per two-dose package, but costs may be rising to match the increased demand for the drug. The administration of the drug in its intranasal form is simple and easy.[15]

Law enforcement use of naloxone continues to grow. The prevalence of overdose deaths make the deployment of naloxone to law enforcement justified, as does the time sensitive nature of an opiate overdose emergency. First responding officers carrying naloxone have the ability to provide a life-saving reversal of respiratory depression prior to EMS arrival, allowing the patient to receive more definitive care in a timely manner.

Tourniquets and hemostatic dressings: Police treatment of severe bleeding

In recent years the U.S. has seen an increase in the number of large scale incidents involving penetrating trauma or blast injuries. Active -shooter incidents present an environment that resembles combat, with multiple patients located in a hot-zone environment that may not be safe for EMS personnel. The provision of tourniquets to law enforcement officers can allow for the rapid triage and treatment of individuals, including other officers, at risk of death from severe hemorrhage.

In the early 1990’s the United States military began developing and implementing tactical combat casualty care, or TCCC. A significant component of TCCC is the control of severe bleeding during a traumatic event. Exsanguinating hemorrhage is the leading cause of death from injuries sustained during combat, and the proper application of tourniquets and hemostatic dressings has been shown to increase survivability of penetrating trauma and blast injuries in the military setting.[16]

The benefit of tourniquet use among EMS providers is well recognized, as is the controlled use of hemostatic dressings in the prehospital environment. Military personnel use tourniquets and hemostatic dressings on a daily basis, yet the use of these lifesaving devices in the civilian setting has not yet been widely adopted.

The events of the Boston Marathon bombing highlight the potential benefit of equipping law enforcement with tourniquets. During that incident, it was identified that the rapid application of a tourniquet resulted in multiple individuals surviving who might otherwise have died from exsanguinating hemorrhage.[17]

News reports from recent active-shooter incidents describe patients bleeding heavily, suggesting that tourniquets and hemostatic dressings may have been useful in those cases.[18,19]

Commercially manufactured tourniquets and hemostatic dressings are simple to use, relatively inexpensive, lightweight, and require minimal training to be used effectively. Providing these lifesaving devices to law enforcement allows officers to protect the victims of violent crimes quickly and effectively.

Law enforcement officers are often the first public service providers to arrive at the scene of an emergency. The research in support of AEDs, naloxone, and bleeding control methodssupports the training of officers to provide immediate and life saving care for patients experiencing cardiac arrest, overdose and traumatic injury.

References

  1. Alan S . Go, MD et. al. "AHA Statistical Update." Circulation (2013): n. pag. Web. 11 Aug. 2015.
  2. Kooij, Fabian O., et al. "Training Of Police Officers As First Responders With An Automated External Defibrillator." Resuscitation 63.1 (2004): 33-41.
  3. Hess, Erik P., and Roger D. White. "Optimizing Survival From Out-Of-Hospital Cardiac Arrest." Journal Of Cardiovascular Electrophysiology 21.5 (2010): 590-595.
  4. Sayre, Michael R., et al. "Providing Automated External Defibrillators To Urban Police Officers In Addition To A Fire Department Rapid Defibrillation Program Is Not Effective." Resuscitation 66.2 (2005): 189-196.
  5. Myerburg RJ, Fenster J, Velez M, et al. Impact of community-wide police car deployment of automated external defibrillators on survival from out-of-hospital cardiac arrest. Circulation. 2002; 106: 1058–1064.
  6. Mosesso VN, Davis EA, Auble TE, et al. Use of automated external defibrillators by police officers for treatment of out-of-hospital cardiac arrest. Ann Emerg Med. 1998; 32: 200–207.
  7. Davis, Corey S., et al. "Engaging Law Enforcement In Overdose Reversal Initiatives: Authorization And Liability For Naloxone Administration." American Journal Of Public Health 105.8 (2015): 1530-1537.
  8. Centers for Disease Control and Prevention. 2013 drug overdose mortality data announced [press release]. Atlanta, GA: January 12, 2015.
  9. Mouillon T, Bruhn J, Roepcke H, Hoeft A. “Opioid-induced respiratory depression is associated with increased tidal volume variability”. Eur J Anaesthesiol. 2003; 20(2):127---133
  10. Chamberlain JM, Klein BL. “A comprehensive review of naloxone for the emergency physician”. Am J Emerg Med. 1994;12(6):650---660.
  11. Clark AK, Wilder CM, Winstanley EL. “A systematic review of community opioid overdose prevention and naloxone distribution programs”. J Addict Med. 2014; 8(3):153---163.
  12. "ONDCP And SAMHSA Release Opioid Toolkit, Promote Naloxone." Alcoholism & Drug Abuse Weekly 25.34 (2013): 4-5.
  13. Davis, Corey S., et al. "Engaging Law Enforcement In Overdose Reversal Initiatives: Authorization And Liability For Naloxone Administration." American Journal Of Public Health 105.8 (2015): 1530-1537.
  14. Davis, Corey S., et al. "Engaging Law Enforcement In Overdose Reversal Initiatives: Authorization And Liability For Naloxone Administration." American Journal Of Public Health 105.8 (2015): 1530-1537.
  15. Davis, Corey S., et al. "Engaging Law Enforcement In Overdose Reversal Initiatives: Authorization And Liability For Naloxone Administration." American Journal Of Public Health 105.8 (2015): 1530-1537.
  16. Joseph M. Galante, MD, et. al., “Identification of Barriers to Adaptation of Battlefield Technologies into Civilian Trauma in California”, Military Medicine, (2013) 178, 11:1227
  17. "Tourniquet Use at the Boston Marathon Bombing: Lost in Translation." NCBI. U.S. National Library of Medicine. Web. 8 Aug. 2015.
  18. Keneally, Meghan. "Aurora Shooting Trial: Cop Gets Emotional About Moment He Found Dead 6-Year-Old." ABC News. ABC News Network. Web. 8 Aug. 2015.
  19. "Two Women, Ages 21 & 33, Killed in Louisiana Movie Theater Shooting." Fox4kccom. 23 July 2015. Web. 14 Aug. 2015.

 

About the Author

Shawna Renga, AS, NREMT-P, currently works as an instructor for the United States Coast Guard Medical Support Services School in Petaluma, Calif., providing EMT training for helicopter rescue swimmers and Coast Guard corpsmen. She also works part-time for a private ambulance company, and lives with her husband and two sons in Sausalito.
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