CONTOMS DISPATCH JULY 1995

From the Director:
Keeping the peace and enforcing the law while preserving life is the basic mission of law enforcement. In this context, the application of less lethal technologies in utilizing appropriate force options has become increasingly more important to the law enforcement community. However, public perception and misconceptions about the use of force in general, and less lethal force options in particular, can present obstacles to effective implementation.

Several factors contribute to public's view. Among these is the ability of the media to instantly bring vivid images of any event to millions of viewers around the world. Although the Rodney King Incident and the assault on Reginald Denny are two of the best known examples, similar events occur frequently. Competition to deliver news rapidly necessarily limits the ability of news agencies to verify stories or gather sufficient background information to present the events in context during the early stages. This can result in distorted public perception regarding police use of force and may be a contributing factor in increased interest in force alternatives.

Unrealistic expectations, fueled by television and movies, about the feasibility of shooting to wound or using hands-on techniques without injury have compelled law enforcement agencies to search for less intrusive force alternatives which are unlikely to offend public sensibilities. For example, not long ago, a man taped a large knife to his hand and threatened US Park Police officers on the White House sidewalk. Officers repeatedly ordered the subject to drop the knife, and after realizing that the knife was taped to his hand, ordered him to lay on the ground. When the subject failed to comply, and began moving, a police officer fearing a for the safety of nearby tourists, shot the subject who subsequently died. Within hours, the media was interviewing people who frequent Lafayette Park across from the White House asking whether the shooting constituted excessive use of force. To the best of my knowledge, none of these people were experts, or even well informed on the police use of force. Ludicrous statements like "the officer could have just wounded him in the leg" were heard frequently, leaving the viewer with the impression that the police had done something wrong. You can imagine the commentary would have been much different if the officer failed to subdue the subject, who then attacked a tourist. Such situations present ideal opportunities for newly emerging less lethal technologies if they are sufficiently reliable and can be deployed rapidly enough.

I use the term "less lethal," rather than "less than lethal," and this is quite deliberate. It avoids giving the naive reader or listener the impression that there is no risk associated with these emerging technologies. The term "less than lethal," implies a level of force which unequivocally does not result in death. On the other hand. the term "less lethal" implies a level of force which is less likely to result in mortality, but still has a finite chance of producing death. The latter is a more realistic portrayal of most of the technologies under consideration. For example, the Arwin rifle shoots a blunt projectile at velocities which are unlikely to cause serious permanent injury, but shoot the weapon at the chest of an osteoporotic 75-year-old and death can easily follow.

The EMT-T has an important role to play in advising the team about the medical effects of this new array of weapons now becoming available. Each team should carefully consider the requirement it is trying to meet with a less lethal weapons system and seek TEMS input about the medical risks and benefits associated with it.

A good example of the importance of medical input involves less lethal weapons systems utilizing oleoresin capsicum (OC) or pepper sprays. Many law enforcement agencies in the United States have adopted OC products as an authorized, less lethal weapon in the last live or six years. However, law enforcement practices in the use of these aerosol sprays were recently called into question and the removal of this tool from many department inventories loomed as a possibility.

Angelo D. Robinson died on 11 July 1993. He was a 24-year old male who was arrested by the Concord, North Carolina police for disorderly conduct. In the course of effecting the arrest, police sprayed Robinson with a commercially available OC preparation. He subsequently died in custody and the autopsy report attributed death to asphyxia due to bronchospasm precipitated by pepper spray. The effect rippled through the law enforcement community as many departments considered whether OC was really as safe as the manufacturers had claimed.

The CCRC looked at this issue in an effort to better advise the law enforcement agencies with whom we work. Our investigation suggested that a simple reading of the one line cause of death may overstate the importance of OC as a precipitating factor in this particular case. Absent specific pathological evidence of a contributory role of OC in reported deaths, it is helpful to know the rate of death among all subjects exposed to OC. However, focusing only on known deaths proximate to OC exposure, without regard to the deaths which would occur under otherwise similar circumstances, is insufficient to draw a conclusion. In order to determine if OC presents an unusual risk to arrestees, it is important to determine if the death rate among prisoners who have coincidentally been sprayed with OC is greater than the death rate among prisoners similarly arrested without exposure to OC. Unfortunately, we are not aware of good data sources for either of these rates.

As a rough estimate of the death rate coincidental with the use of OC, we contacted 21 law enforcement agencies currently using OC to determine the number of uses, the number of hospitalizations resulting from the use and the number of deaths. Our preliminary review indicates a total of 4357 uses of OC with no hospitalizations and six deaths (which were attributed to drug overdoses by the medical examiners). This provides a death rate among the population of subjects sprayed with OC of approximately 0.00138 or 14 deaths per 10,000 subjects exposed.

Although this does not seem like an unexpectedly high death rate, there are no good comparison group data readily available for persons arrested under similar circumstances without exposure to OC. Based on information provided by the Bureau of Prisons the overall death rate for prisoners in their custody is approximately 0.00173 or 17 deaths per 10,000 prisoners. While this is not a good control group for the arrestee exposed to OC, there is nothing to suggest that the OC death rate is remarkably greater than that which would be expected in a group of prisoners who have physically resisted arrest. Further research is necessary to identify an appropriate control group.

The National Institute of Justice asked the International Association of Chiefs of Police to collect data on in-custody deaths where OC had been used during the arrest and to determine whether OC was a factor in these deaths. Their report, contained in Science and Technology stated, "Our review concluded that, in these cases, OC was not a factor in any of the deaths and that something else caused the subject to die." More specifically, it was concluded that in 18 of the 22 cases, positional asphyxia was the cause of death, with drugs and/or disease also being contributing factors (Science and Technology. March. 1994. IACP. p.2).

On 7-8 September 1994, at the direction of Mr. Wade Jackson, Chief, FBI Firearms Training Unit. Special Agent Monty Jett convened an OC Conference at the FBI Academy in Quantico, VA. In attendance were highly respected medical examiners from various jurisdictions around the country, chemical agent instructors, emergency physicians and public health scientists. They reviewed in detail 30 in-custody deaths in which OC was used. The following consensus statement was one result of the review:

A review of 30 in-custody deaths in which OC was used revealed no specific evidence that OC caused or contributed significantly to any of these deaths.

1. To date, persons who die in custody after having been sprayed with OC cannot be distinguished from other persons who die suddenly in police custody or in acute care psychiatric facilities without being sprayed.
2. Persons who are at particular risk for sudden death, with or without OC spraying, exhibit some or all of the following features:
   • Male gender
   • Obesity
   • Large size
   • Bizarre behavior due to psychotic delusion/agitated/or stimulant drug induced mental states
   • Have occult heart disease or pulmonary disease
   • Fail to be subdued by OC
   • Are or have been engaged in struggle or are involved in high exertional activity
   • Have been placed in restraints in positions of possible respiratory compromise such as prone position, hog-tied or tightly strapped
   • Die quietly during transport to jail or hospital
3. Recommendations: Persons whose behavior is unusually bizarre or who fail to be subdued by OC, after being brought under control:
   a. Should be kept under close direct supervision for at least one hour.
   b. Shouldn't be placed in positions that compromise respiration such as hog-tied, prone or tightly strapped.
4. 4. Danger signs during transport are:
   • Cessation of conversation
   • Change in breathing pattern
   • Cessation of movement

A recent report from the Portland, ME Police Department (Gauvin, RJ, Oleoresin Capsicum Spray: A Progress Report, Law and Order. Vol. 43. No. 4. April 1995) compared data from 388 use of force incidents prior to the issuance of OC, with 226 similar incidents where OC was used following its adoption as a less lethal tool by the police department. The author reported that, without the use of OC, subjects were injured in 69% of the incidents and Officers were injured in 31 %. In the incidents involving OC, subjects were injured in only 12% of the incidents and officers were also injured only 12% of the time. The pre-OC data showed that 9% of force incidents resulted in subjects filing excessive force complaints. compared to only 3% of OC incidents. These data suggest that OC may be an important and effective adjunct in law enforcement practice, but it should be pointed out that there is a potential selection bias in the study. As noted above, 388 use of force incidents occurring prior to the availability of OC were compared to incidents involving OC after is was issued to Portland police officers. Suppose that officers did not have great confidence in the effectiveness of OC and tended to use it only in those cases where the subject appeared less agitated. This could explain the fewer numbers of injuries associated with the OC cases, and has little to do with the OC Itself, but with the incidents which were selected for OC use. A better comparison would be between the 388 use of force incidents prior to issuance and all use of force incidents following adoption of OC by Portland P.D., not just those involving OC. Despite this shortcoming, the study is one of few which attempts to determine the effectiveness of pepper sprays and suggest significant potential.

All of the investigations and information cited here did not uncover any substantial evidence to indicate that the use of OC in a law enforcement context represents an unreasonable risk at this time. Assurances of absolute safety can never be made. Any policy decision regarding the law enforcement use of OC must carefully weigh the benefits against the risks on the basis of available information. There is currently no compelling evidence to support the withdrawal of OC from field use and it remains a less lethal force option which, although not without risk, has significant value in achieving legitimate law enforcement goals.
 

Medical News
In this section of the CONTOMS DISPATCH we will present an actual request for consultation from an EMT-Tactical medic. Problems beyond the normal prehospital medical operations are common in tactical medical support. It is the intent of the EMT-Tactical program to give the medic the knowledge and skills to address them. The sharing of these difficult situations will assist us all by alerting us to these potential problems. A discussion of possible approaches is a mechanism of developing a national consensus which will assist us in future decision making. Dilemmas encountered in one jurisdiction may be uncommon or never before encountered but are rarely unique. The consultation system is designed for the situation where the medic or his commander would like an additional opinion to form their decision.

Situation:

A SWAT team sent two of its medics to the EMT-T school as part of an effort to establish a medical support system tor its tactical training and operations.

In conducting medical baseline screening utilizing the format available from the EMT-T manual, the medical support team discovered that one team member had recently experienced a myocardial infarction. The MI had presented subtly enough so that the individuals team and supervisor were not aware. The individual was adequately fit. The question was: What to do with this information? The tactical medics were concerned that the individual could have further cardiac problems as a result of the SWAT activities. They were concerned about their responsibility to prevent the individual from harming himself and about the potential threat to the team and its mission if the individual were incapacitated during a mission. Here are the issues the medics identified.

Confidentiality. The information had been voluntarily given to the medics as part of a health screen. The patient had the expectation that this information would only be used for his benefit and not as a discriminator in his job.

Duty to Inform. Since the individual was performing his daily tasks and had been participating in SWAT activities, they were unsure of the risk that a history of previous MI presented to the unit. They were concerned that the individual was at risk, particularly during the stress of tactical operations.

What would you do? Would you take action and ignore the patients confidentiality? Would you do nothing and leave the team with some undefined risks? Before you make your decision, you should know that the individual involved was the SWAT Team Leader.

Analysis: The tactical medics have identified what they believe to be a risk both to the patient and the Team. They have an obligation to address that risk. The threat must be resolved - either by evaluating the situation and finding there is no true threat, by causing actions that result in the threat being eliminated or by notification of appropriate authority that a threat exists. Once the appropriate command authority is fully informed of the threat then the responsibility for action is his and not the medics.

If the individual s physician were able to verify that the medical condition presented no threat to the individual while participating in SWAT operations, then the threat would be eliminated. Problem solved, but not likely.

Informing the appropriate command authority is a clear violation of the patient's confidentiality but would be justified if there was a risk to self or others. This action would remove the problem but jeopardize the new medical support program.

CONTOMS Recommendation
Step 1 Persuade
Direct the individual's attention to the issue. Explain the risk to him and the risk to other team members. Propose the individual have an evaluation for medical fitness for SWAT operations and inform his supervisor of the results.
Step 2 Threaten
Inform the individual that if he will not voluntarily participate in Step 1, you have an obligation to the him and to the team to inform his supervisor that there is a medical problem.
Step 3 Act
Inform the supervisor (in this case, the SWAT Commander's supervisor) that the individual has a medical condition that could be a hazard. You have asked that he address this risk but he has been unwilling to take action. Request that the supervisor have appropriate medical authority evaluate the medical fitness of the individual for SWAT duty. Note that in taking this position. you are not revealing the actual problem and are thereby doing all you can to preserve confidentiality but still address the threat. You are acting with care and in good faith doing what you believe is right for everyone.
Step 4 Document
It is vitally important the tactical medic in this situation maintain an accurate patient record throughout each step, noting what the concerns are. the plan for addressing them and the result. This should begin immediately upon the discovery of the problem in the health survey. If something happens while this process is being discussed, or if the supervisor chooses not to address the issue, then the record is essential to the medic as evidence that the medical program was doing what it should. The final step in the process of resolving the risk is to send a memorandum to the supervisor. giving a copy to the patient. that states the medical concerns. The existence of a paper trail is usually enough to influence even reluctant supervisors to commit themselves in a situation with potential risks.

If the problem has not been resolved after taking each of these steps in succession then you have done your job and you must leave it for the command authority. When we provide care in the tactical environment as medical providers we direct what happens to the patient. When we provide other medical support during tactical operations our job is to advise and not to direct. The Commander is responsible for his decisions and policies.
 

Equipment Notes
We often receive letters and calls from EMT-Tactical graduates who are attempting to obtain information on where to go for surplus items of tactical equipment. With the permission of Mr. Larry Glick, Executive Director of the National Tactical Officers Association we are reprinting part of his article which appeared in the Spring 1994 Issue of The Tactical Edge. The information in the article will assist in accessing the best sources we know of for a wide variety of surplus equipment.

Project North Star is a Department of Defense Project designed to provide non-operational support to local law enforcement agencies in counterdrug activities. DoD has established Regional Logistical Support Offices (RLSO's) in order to facilitate support. Section 1208 of the National Defense Authorization Act of Fiscal Years 1990 and 1991 authorizes the RLSO's to facilitate this transfer to federal and state agencies involved in counter-drug activities. Because local law enforcement agencies are not included in the statutory language of Section 1208 those agencies desiring excess property require a sponsor who can act on their behalf in requesting the excess property.

The DoD Coordinator has requested each State Governor to designate one person within their administration to function as the day-to day coordinator of the states counter-drug effort. This person will also act as sponsor for local agencies which request excess property.

Procedure to Obtain Equipment

A sample letter follows:

Dear Sir,

I am writing regarding the Department of Defense program for assisting law enforcement with non-operational support for drug interdiction and enforcement. (Agency) is located in (city and state). Our (agency) is made up of (x) number of sworn personnel who are responsible for drug enforcement in a (geographically defined area). Our drug interdiction efforts could be greatly enhanced with the addition of (identify equipment desired) because it will ( ). This equipment is currently not within our budget capabilities. We are requesting assistance in obtaining the following (provide an itemized list):

This equipment will be used for the drug interdiction program in (city). We currently depend on (name of agency) for this type of support. While this assistance is greatly appreciated, (reason, i.e., timely access) does not allow for a thorough execution of our drug interdiction program. We feel the approval of this equipment request will greatly enhance our efforts in the drug war. I am requesting the following screeners be approved for the (agency). (list approved points of contact).
Sincerely,
Chief of Police
 

There are four Regional Logistical Support Offices in the United States.

Region I
PO Box 400
Buffalo, NY 14225
716 846 3053
716 846 3067 (FAX)

Region II
Bldg.. 307B
Bay 5, Ft Gillem
Forest Park, GA 30050-5000
404 362 3135
404 362 3276 (FAX)

Region III
PO Box 8051
El Paso. TX 79908-8051
915 568-9088
915 568-3276 (FAX)

Region IV
501 Ocean Blvd. Suite 8100
Long Beach, CA 90822
310 980-4490
310 980-4385 (FAX)
 

Equipment Notes 2
Kevin Arthur, EMT-P, EMT-T is the Team Leader for the York Hospital Tactical Response Unit in York, Pennsylvania. A portion of his article, which will appear in the Spring 1995 issue of the NTOA Journal The Tactical Edge, is reprinted here with permission.

The York Hospital Tactical Response Unit Team found standard methods of airway management unsatisfactory while providing tactical emergency medical care (TEMS) in the hot zone and began a search for an alternative to the Bag Valve Mask (B.V.M.) ventilation technique. The product they have selected is the SafeCare Resuscitator by SIMS/Intertech (fig. 1).

The device is composed of three separate pieces 1) The mask replicates those found on standard B.V.M. without an oxygen port. 2) A filter over the one-way valve decreases the risk of expelled/exhaled matter passing back to the ventilator. 3) A tube and mouthpiece by which to ventilate the patient. It may appear the SafeCare mask is not much different than any other pocket mask/valve assembly, however, our team has found it quite useful in the tactical environment. Once a patient is intubated (digitally, surgically, nasally) the mask end of the valve connects directly to the end of the endotracheal tube (ET) thus allowing hands free ventilation (fig.2). This asset is especially valuable during tactical operations.

It is best to secure the ET with a wrap of tape. The valve can then be secured to the patient's neck (surgical airway) or to the side of the face (oral placement). This permits the tube assembly in a low profile and lessens the likelihood of catching on another object and being dislodged. When placing the valve on to the ET tube, ensure the exhalation port is directed away from the care provider to prevent unexpected expulsions of air or emesis in the wrong direction.

The effectiveness of TEMS in the austere environment is essential. The use of this device allows the EMT-T hands free ventilation during the evacuation of a patient while maintaining a patent airway.

The product is available through:
SIMS/Intertec Resources
300 TriState International, Suite 150
Lincolnshire, IL 60069
 

Graduate News
Texas
Brian Howell would like personnel who are graduates of EMT-Tactical to contact him regarding a support network in North East Texas. Contact him at:
#40 Sunrise Ave.
Longview, Texas 75605

Oklahoma
EMT-T graduate Sam Curotola has relocated to Oklahoma City and would like to be in touch with other graduates in the area. Please contact him at:
7520 Knight Lake Drive # 164
Oklahoma City, OK 73132

Please join the CONTOMS faculty and staff in sending GET WELL WISHES to EMT-T Graduate Charles Hare, who was injured in a training accident earlier this spring. You may write to him at:
4402 Erie
Midland, Texas 79703
 

Medical Director's Course Profile

In response to requests from numerous Emergency Medical Systems, CONTOMS developed a Medical Director's Course. This program draws upon various physicians and law enforcement personnel with expertise in providing medical support for tactical operations. The faculty Is comprised of CONTOMS National Faculty from the USUHS Department of Military & Emergency Medicine and the United States Park Police. The program provides several blocks of instruction which when combined:

1. Provide an understanding of the essential elements of medical support for tactical operations.
   
2. Describe why a traditional approach of separation from the tactical operation until injury occurs has become a sub-standard level of care.
   
3. Describe why the preventive medicine and injury control strategies embraced by the CONTOMS program are absolutely essential to any tactical EMS element.
   
4. Provide Information about the requisite skills needed to develop, plan and execute a medical support program for tactical law enforcement.
   
5. Describe how the CONTOMS program trains basic EMT-T providers to operate in the tactical environment.
   
6. Provide the basis for developing strategies to improve Emergency Medical Systems response to medical support for tactical operations from the scene of the occurrence through the entire system, including the receiving hospital.

Efforts to direct course content have focused on a needs survey done in several urban emergency medical systems as well as intensive discussions with EMS Directors and other physician with solid experience in these important activities. Law enforcement input from the CONTOMS Public Safety Commander's Course and experience of the law enforcement division of the CONTOMS faculty has appropriately focused the lesson objectives for the Medical Director's program.

The Medical director's program is an excellent method for physicians to obtain an awareness of the CONTOMS program and discuss methods for developing or enhancing a tactical medical support program. The course is eight hours in length and is offered at various locations throughout the U. S. Those interested in further information regarding dates and locations should contact the Casualty Care Research Center office.
 

Editor's Note

If your team has developed Standard Operating Procedures or Protocols please consider sending them to CCRC. We are maintaining a file of these and a listing of personnel who have successfully implemented medical support with law enforcement teams. Those personnel who are willing to share their lessons learned with other developing teams around the country are helping those teams implement their programs more efficiently and are making a significant contribution to Tactical Emergency Medicine.

Congratulations to COL Craig H. Llewellyn who has been recognized by the National Tactical Officers Association for his contributions to Tactical Emergency Medicine (TEMS). COL Llewellyn has been selected for his long history in the development of the TEMS concept, his vision in the development and growth of the Casualty Care Research Center, over forty publications and articles in the medical literature and his personal involvement in teaching medical support teams. The National Tactical Officers Association has named this concept award in honor of COL Llewellyn and will recognize in the future, those persons who perpetuate the growth of the speciality and maintain a strong personal commitment to the field of Tactical Emergency Medicine.

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