Your partner has been shot. You have applied a tourniquet and stopped the bleeding, buying them critical time, but you know only a trauma surgeon can truly fix the injury, and the hospital is miles away. It is the goal of tactical medicine to accomplish two things: 1) Provide enough care to keep the patient alive during that time and 2) shorten that time by rapidly handing the patient off to a higher level of care. Typically that is done by efficiently handing a patient off to EMS for care and transport; however, there are circumstances where EMS is not available in time.
Casualty evacuation, more commonly referred to as “casevac” and recently called “nontraditional transport,” is when a wounded party is transported to the hospital through a method other than an ambulance, such as in a squad car. For many years this was a near-forbidden practice for police. Agencies felt an officer transporting a patient could place the department in a position of liability if the patient died.
Then a single act largely changed everything. On July 20, 2012, a gunman opened fire in a Century 16 theater in Aurora, Colorado, shooting 58 people. Responding officers had to decide: Would they continue to wait for EMS to transport them or do what had to be done for the casualties? In the end, dozens of patients were taken to the hospital by a police car, far more than by ambulance, and every single patient who was savable lived. Policies restricting police casevac loosened.
That’s not to say Aurora was the first example of police transporting patients; however, it was the largest and most publicized event. Now agencies may face liability for failure to transport if EMS is not available if such inaction costs a casualty their life. Some agencies have even gone as far as mandating police transport if ambulances are not on scene. While requiring officers to transport may not be the best option, preventing it is substantially worse. Officers should be allowed to assess what the best option is for their patients.
What does the data say?
Agencies’ aversion to casevac stems from a perception of inherited liability. This concern is based on the belief that since officers are less trained and equipped than EMS and unable to provide continued medical interventions en route to the hospital, the transported patient is more likely to die than if they were taken by EMS. However, this is not supported by research.
A study conducted in Philadelphia that compared the mortality of patients transported by police versus those transported by EMS found no difference in patient outcomes based on transport. In fact, that same study discovered patients with more severe trauma had an increased chance of survival when transported by police. [1] This is likely due to the faster transport times law enforcement typically provides.
A second study conducted on the Philadelphia model revealed police transports had a significantly shorter prehospital time, at a median of nine minutes, compared to the EMS median of 21 minutes. This resulted in increased survivability at arrival and at six hours. [2]
A trauma patient’s injury can generally only be treated by a surgeon in an operating room. The faster we facilitate that transfer, the greater the patient’s chance of a good outcome. In the most simplistic form, the goal of prehospital medicine is to keep the patient alive long enough to hand them off to that higher level of care. In most urban settings this transfer usually happens within minutes, and thus that timeline is our goal.
This is not to imply officers should take on the role of transporting every patient they encounter. There are considerations officers must factor in when deciding if a casevac is the best option based on the scenario.
Keep these things in mind
Officers must ensure the patient will survive long enough for the transport. This means we must conduct basic treatments on scene to address the preventable causes of death likely to kill the patient during transport time. The areas on which we need to focus are life-threatening bleeding from the extremities, airway management and sealing any sucking chest wounds that may lead to tension pneumothorax.
One of the primary reasons why officers must address the immediate life-threatening injuries listed above prior to transport is that continued interventions en route will be difficult if not impossible. Treatment in the back of an ambulance by a trained professional is challenging enough, but for an officer in the backseat of a squad car, it’s near impossible. Thus if the patient’s injuries require continuous care, such as airway management, while en route, the patient’s survivability decreases significantly. If the patient requires continued treatment in transport, it may be better to wait for EMS.
One of the most obvious considerations is the proximity of EMS to the scene. If EMS is mere minutes away, stabilizing and waiting for its arrival is most likely the better choice. However, if there is a significant delay in EMS arrival, casevac becomes a more preferred response. This is especially important in rural areas, where there may be a prolonged EMS response time, or in mass-casualty situations, where EMS response to individual casualties may be delayed due to their sheer number.
The time to transport a patient to the hospital is another factor. Officers need to consider the time it will take to transport via squad car compared to the cumulative time of waiting for EMS to arrive and then its additional transport time. A hypothetical example could be that the scene is nine minutes from the trauma center, but EMS is seven minutes from the scene. This would mean the absolute fastest EMS could have the patient in the trauma center is 16 minutes – versus nine by a police vehicle. The officer needs to determine whether this patient can survive the additional time required for EMS.
A consideration seldom discussed is the emotional state of the officer involved in the casevac. This is significant when considering a casevac of a wounded officer. The goal of any transport is to get the casualty to a higher level of care rapidly but safely. If an officer has just been involved in a shooting and has a wounded partner, their stress level is likely extremely elevated. The probability of being involved in an accident during transport is significantly increased. This not only risks further injury to the patient but also delays the higher level of care. Officers must honestly assess their mental state when determining if casevac is the preferred option. Casevac may still be the best transport method; however, it may be better to wait until the next officer arrives and allow them to do the transport, as they are less emotionally involved in the event.
Another factor that cannot be ignored is the lack of trauma activation at the emergency room encountered by most casevacs. EMS has direct communication with the trauma center during transport and can relay information about the patient prior to arrival. This allows the trauma center to have all the needed manpower and equipment ready upon arrival, enabling more rapid treatment. When police conduct a casevac, this relay of information may be reduced. Even if emergency room staff are aware of the coming casualty, information such as patient injuries, vital signs and symptoms are likely not being relayed, as they exceed the transporting officer’s capabilities. This can potentially delay needed surgical treatment. This delay is typically short, so the consideration is minor; however, if casevac and medevac both have comparable transport times, medevac is preferred, in part due to the trauma center activation.
MCIs and hospital coordination
As seen in Aurora and more recently at the Route 91 Harvest Festival in Las Vegas, law enforcement may conduct patient transports during large-scale mass-casualty events – there just won’t be enough EMS immediately available. It is critical that officers take direction from the on-scene EMS command regarding casevac destinations. Even if transporting multiple wounded officers, responding officers or dispatch must establish communication with the emergency department to confirm its ability to receive additional patients. Overcrowding a smaller emergency department with trauma patients it can’t treat while open beds lie waiting at a nearby trauma center is only going to extend the time to appropriate care and cost lives.
Officers trained in the MARCH priority of treatment used by Tactical Combat Casualty Care (TCCC) and Tactical Emergency Casualty Care (TECC) should know there is an appropriate point to consider transport. Following the treatments for massive hemorrhage (M), airway (A) and respiratory complaints (R), they should pause and evaluate: Is EMS on scene? Is casevac needed? Or is it better to wait and continue treatment on scene? Those three questions are the necessary components to ensure patients’ survivability during transport time. Casevac should not be considered until any arterial bleeding is addressed, the patient is able to breathe and any penetrating chest trauma has been sealed, or the patient will likely perish in the transport vehicle.
Law enforcement officers stepping into the role of transporting casualties is a newer concept, and agencies have a variety of policies governing it, from restricting it entirely to only allowing it for wounded LEOs to mandating casevac and everything in between. Agencies are accepting a level of liability regardless of their action; however, in today’s climate, there is more scrutiny on inaction than ever before.
The Philadelphia study noted an increased public perception of police actions when law enforcement transports. While in most scenarios it is probably better to wait for EMS to do a traditional response, there are times when law enforcement casevac is the best transport method. It is the responsibility of officers on scene to evaluate their situation to determine the best action for the outcome of their patient.
ADDITIONAL POLICE1 RESOURCES ON CASUALTY CARE
- What cops need to know about purchasing, applying tourniquets
- 6 tips for effective tourniquet training
- Law enforcement response to EMS incidents using tactical medicine
- How to apply a chest seal
- The evolution of officer-down training
References
1. Winter E, Hynes AM, Shultz K, et al. (2021.) Association of Police Transport With Survival Among Patients With Penetrating Trauma in Philadelphia, Pennsylvania. JAMA Netw Open.
2. Winter E, Byrne JP, Hynes AM, et al. (2022.) Coming in hot: Police transport and prehospital time after firearm injury. J Trauma Acute Care Surg.