You’re dispatched to the 800 block of North 32nd Street in a part of the city that’s been plagued with violence over the past few months. There have been several shootings and assaults on law enforcement. You and your partner are advised that police are on scene with an unconscious 23-year-old male who was struck with a conducted energy device and bleeding. You ask your partner what a conducted energy device is and what you’re supposed to do—is it a Taser or stun gun? Why is he bleeding?

Upon arrival you hear the commotion on scene and see an abundance of law enforcement vehicles and officers, as well as a large crowd of bystanders, many with cellphone cameras facing in their direction. You exchange glances with your partner and exit the rig wondering what happened.



AP Photo/Ted S. Warren

USE OF FORCE CONTINUUM

The use of force by police has been around for centuries. In the 19th century, police officers in New York and Boston used mostly wooden clubs as their weapons. After criminals armed themselves with guns, police departments began issuing firearms to officers. Modern-day law enforcement has since added to the toolbox of force and officers now have many options to control a subject.

In its study, Police Use of Force in America 2001, the International Association of Chiefs of Police (IACP) defined the use of force as “the amount of effort required by police to compel compliance by an unwilling subject,”1 but there’s no single, generally accepted definition. Likewise, throughout the United States, there’s no single policy or law that dictates how law enforcement use of force is to be employed; police must employ a reasonable amount of force given the totality of the circumstances. So how are you supposed to know what guides law enforcement officers in your jurisdiction?

The U.S. Commission on Civil Rights has stated, “in diffusing situations, apprehending alleged criminals, and protecting themselves and others, officers are legally entitled to use appropriate means, including force.”1 Every day, law enforcement officers are faced with split-second decisions on what types of force to use when carrying out their duties and responsibilities. There are occasions where the force applied results in an injury and EMS is summoned to assist. These encounters can be met with a multitude of problems as many levels of force may have been applied to the subject based on the resistance faced by officers. In addition, the patient is under the influence of alcohol or drugs 88.1% of the time when the officer engages force.2,3

The U.S. National Institute of Justice states that law enforcement officers should use only the amount of force necessary to mitigate an incident, make an arrest, or protect themselves or others from harm. The levels, or continuum, of force police use include basic verbal and physical restraint, less-lethal force and lethal force. When faced with a situation, many police departments allow their officers to match or escalate the use of force “necessary” to “reasonably” gain control of the subject.4 In the U.S., only 2% of police and public contacts results in force being threatened or exercised.4 Unfortunately, in those few occasions, many have gained the national spotlight.

Deployment of OC spray is typically in the face, which will cause respiratory distress, irritation of ocular and nasal passages and the feeling of anxiety. AP Photo/Ross D. Franklin

For patients sprayed with OC, rinse the eyes and face with copious amounts of water used with dish soap that’s non-oil-based. AP Photo/Rich Pedroncelli

SIGNIFICANT RECENT EVENTS

Recently throughout the world, law enforcement has gained attention by causing injury and mortality to subjects after applying force. Despite a 4.4% drop in violent crimes between 2012 and 2013, according to the FBI, the tensions between media, the public and law enforcement continue to grow.5 There’s a perception that there’s been an increase of violence against law enforcement—so much so that the U.S. Attorney General has stepped in with safety initiatives for police officers. The court of public opinion has concluded that there’s a “war on cops,” which means misconduct among the public and law enforcement officers will be highlighted and may increase.

Freddie Gray, Eric Garner and Michael Brown have highlighted the media attention drawn by violence between law enforcement and the public. Although these incidents resulted in death, there are many more that don’t and that’s where EMS is often requested to treat the subject. This is important for EMS providers to understand, as calls for service as a result of these encounters may surge.

EMS response to use of force incidents by law enforcement must be done in a professional, ethical and unbiased manner. Your response as an EMS professional may be recorded and placed on any number of media outlets, and includes the potential to go viral on social media. Smartphone cameras continue to increase in popularity and bystanders have grown to be “field reporters.”

Anything recorded may be seen by millions of eyes, so you as an EMS professional must continue to follow the National Association of EMTs’ code of ethics: “To provide services based on human need, with compassion and respect for human dignity, unrestricted by consideration of nationality, race, creed, color, or status; to not judge the merits of the patient’s request for service, nor allow the patient’s socioeconomic status to influence our demeanor or the care that we provide.”6

Scene safety on law enforcement assists is of utmost priority. Just because the police are on scene doesn’t mean that it’s safe. Always “watch your six,” keep situational awareness high and remember that the only controllable factor is you. Scenes can deteriorate quickly without warning, so always have an escape plan just in case.

TYPES OF FORCE & ASSOCIATED INJURIES

The first level of the use of force continuum is merely officer presence and verbalization. You may think that this isn’t an effective tool, but a police officer with command presence has been shown to deter crime or diffuse a situation without physical contact.7 Some states, such as New Jersey, consider displaying the officer’s duty handgun and pointing it at a subject to be in this step of the continuum.

Nonlethal methods of force use different techniques, such as physical force using only the officer’s body, blunt impact with a baton or other similar object, chemical substance such as oleoresin capsicum (OC) spray, deployment of a canine (K-9) and conducted energy devices (CEDs), to gain control of a subject. Not all police departments use or employ these methods, but these are the most commonly used in the U.S. (See Table 1, below.)

Physical force (e.g., empty hand control): The second level of the force continuum, empty hand control, uses bodily force to gain control of a subject. This physical force step can be broken down into two categories: soft and hard control. With soft control, the officer uses grabs, holds and joint locks to restrain an individual. If soft control doesn’t work, the officer can employ a hard control technique of punches and kicks.7 This is the most commonly used physical use of force option, but also results in the highest incidence of injuries to both the subject and the police officer.

In one study of 12 U.S. police departments, physical force resulted in minor injuries to the subject 49.1% of the time, hospitalization 4.1% of the time and no fatalities. Injuries commonly seen at this part of the continuum are similar to those of physical assault.3

Table 1: Prehospital treatment of law enforcement force

Police K-9s use a full mouth bite, which means they use all their teeth and hold on to the subject until commanded to let go. AP Photo/Rich Pedroncelli

Blunt impact (e.g., baton): Blunt impact injuries are commonly associated with the use of a baton or other similar object, such as a flashlight or radio. Baton types vary throughout the world. Some police departments use the expandable baton, which is made of aluminum or metal. Others still use the fixed PR-24 type, which is made of polycarbonate, is about the length of an arm and has a side handle.

Use of a baton results in minor injuries to the subject 32.3% of the time and requires hospitalization 3.2% of the time.3 Officers are taught to strike at the suspect’s attacking limbs and large muscle groups and to avoid areas like the head, neck or spine—unless deadly force is objectively reasonable, when other methods of force such as the handgun may be deployed.

The severity of injuries inflicted as a result of baton use is dependent on the amount of kinetic energy transferred and the tissue to which the energy is transferred. The kinetic energy associated with a moving object is equal to one half the mass of that object multiplied by the velocity of the object squared ( mv2). In general, a somewhat lighter object traveling at high speed will cause more damage than a heavier object traveling at low speed. Note that modern police batons are now being made of more lightweight construction.

OC spray: OC spray is nearly universal for all law enforcement officers. OC comes from the oily extract of the cayenne pepper plant. This tool causes the subject to be temporarily disoriented by a burning and irritation to the sprayed area. Death has been associated with the use of OC spray, but in these instances it was the result of positional asphyxia, pre-existing health conditions or drug-related factors, and not the use of OC spray itself.

Deployment of OC spray is typically in the face, which will cause respiratory distress, irritation of ocular and nasal passages and the feeling of anxiety. Treatment for a subject sprayed with OC is to calm the patient down verbally, ensuring them that the irritation is temporary. Copious amounts of water should be used with non-oil-based dish soap such as Dawn. The use of oil-based products will trap the irritant and cause further discomfort. Oxygen may be applied as OC causes dilation of the capillaries, which may cause some distress, although there are rarely any associated physiological respiratory problems.

K-9: Deployment of a K-9 on a subject can result in a variety of injury patterns depending on the area of the bite, the level of resistance of the subject and the length of the apprehension before the K-9 is withdrawn. Police departments across the U.S. favor large dog breeds, such as the Belgian Malinois and the German Shepherd, each weighing 70–90 lbs. These dogs have the capability of exerting 450–800 psi and use a full mouth bite, which means they use all their teeth and hold on to the subject until commanded to let go. It’s common for officers to allow their dogs to continue to bite suspects as long as they struggle and fight to free themselves. Police dogs aren’t trained to bite any specific area of the body, and the injury locations can vary based on the position and activity of the subject prior to the K-9 deployment.

Dog bite treatment relies on basic first aid such as rinsing the wound with normal saline, bleeding control and dressing the wound. Spinal immobilization may be considered if the K-9 caused the subject to fall or be knocked down. Most bite wounds can be treated in the ED. Essentials of treatment are inspection, debridement, irrigation and closure, if indicated. A complete trauma evaluation is occasionally indicated.

CEDs: CEDs (e.g., Tasers) use propelled wires or direct contact to conduct energy that affects the sensory and/or motor functions of the nervous system. CEDs produce 50,000 volts of electricity. The electricity stuns and temporarily disables people by causing involuntary muscle contractions. Typically it isn’t the CED itself that leads to the need for transport to the hospital, rather the events that have led to the deployment of the CED, such as excited delirium. Treatment must consist of a complete physical examination, including glucose, oxygen, ECG and cervical precautions if the subject fell after being struck.

CEDs use propelled wires or direct contact to conduct energy that affects the sensory and/or motor functions of the nervous system. AP Photo/Toby Talbot

In most cases, EMS personnel won’t perform the removal of the probes. In the event that the probes are still embedded upon arrival, the probes should be considered an impaled object and treated according to the appropriate medical protocol. It’s likely that the wires to the probes will need to be removed in order to transport the patient. This can be done by simply cutting them with a pair of trauma sheers.

In the event that the probes are removed by the police officer, the probes should be treated as a contaminated sharp. The probes can be stored in the Taser cartridge in the absence of a sharps container.

For documentation purposes, determine the amount of cycles of energy the subject was exposed to. If the subject doesn’t comply after the first cycle of energy, the officer may continue to apply cycles of energy until resistance ceases. In the majority of CED incidents it won’t be possible for EMS personnel to determine the extent of injuries that the patient has sustained. Although it’s unlikely that the CED itself will have caused an injury, there’s a high likelihood of an occult injury secondary to the event. Examples of this are fall injuries as a result of incapacitation and pathological fractures secondary to muscle contraction.8

Lethal force (e.g., gun shots): Deadly force is the force a person uses knowing it has a substantial risk of causing death, serious bodily harm or injury. Many people think deadly force by law enforcement can only be inflicted by a handgun, but it may also include strikes by a baton to a critical area such as the head or chest, running into a subject with a vehicle and in some states placing a roadblock on a pursuit.

The basic treatment for any patient who’s been subjected to deadly force is ABCs (airway, breathing and circulation). If the patient is handcuffed and you can’t appropriately treat the patient, ask officers to have the patient handcuffed in front. Remember, any handcuffed patient must have an officer in the ambulance with you during transport. Once you secure an airway carefully, assess for breathing, and then check for bleeding.

When assessing a gunshot wound (GSW), it’s important to understand the differences between types of guns and bullets used when treating patients, as the total damage done depends on the type of ammunition used.

There are different sizes of ammunition used by law enforcement officers. The most commonly used is the 9 mm, .357, .40 and .45 calibers that typically penetrate the body between 11–12″ at short distances (< 25 yards). In comparing ballistics, there’s not a large difference between the types of handgun ammunition in regards to penetration depth, only the size of the entry wound in the body.

Within the last decade, rifles such as the Colt M4 have been placed in patrol cars throughout the country. This gun shoots .223/5.56 caliber ammunition that has nearly 2.5 times the velocity and can penetrate the body up to 16″ from distances of 200–300 yards.9 When checking for bleeding and the presence of GSWs, ensure the patient is fully undressed and count the amount of holes in the body. It isn’t your responsibility to determine entry and exit wounds. If there’s any sucking chest wounds or penetrating trauma to the chest, place a chest seal over that region. The patient should be transported to a trauma center for an evaluation of their injuries.

FINAL THOUGHTS

Although patients subjected to use of force by law enforcement encompasses a small population, with the advent of smartphone cameras, these events are often captured and go viral in days. Law enforcement officers are faced with the pressure of making the right decision amid this publicity, and a small population will continue to challenge those decisions with taunting and violence. This behavior may lead to increased use of force injuries and more contact with these types of calls by EMS, and we need to be ready for these incidents. We must be more alert of our surroundings as there’s no discrimination of violence in the eyes of our patients.

RESOURCES

Blume JH. (1984.) Deadly force in Memphis: Tennessee v. Garner. Cornell Law Faculty Publications . Retrieved Aug 14, 2015, from http://scholarship.law.cornell.edu/facpub/27.

. Retrieved Aug 14, 2015, from http://scholarship.law.cornell.edu/facpub/27. Saunders MJ, McKenna K, Lewis LM, et al.: Mosby’s Paramedic Textbook. Jones & Bartlett Learning: Burlington, Mass., pp. 1045–1046, 2012.

REFERENCES

1. Use of Force. (2004). Community Oriented Policing Services. Retrieved April 5, 2015, from www.cops.usdoj.gov/default.asp?Item=1374.

2. Alpert G, Smith M, Fridell L. (April 28, 2011.) Multi-method evaluation of police use of force outcomes: Cities, counties, and national, 1998-2007 [United States] (ICPSR 25781). National Archive of Criminal Justice Data. Retrieved Aug. 14, 2015, from www.icpsr.umich.edu/icpsrweb/NACJD/studies/25781.

3. Butler C, Hall C. Police/public interaction: Arrests, use of force by police, and resulting injuries to subjects and officers. Law Enforcement Executive Forum. 2008;8(6):141–157.

4. MacDonald JM, Kaminski RJ, Smith MR. The effect of less-lethal weapons on injuries in police use-of-force events. Am J Public Health. 2009;99(12):2268–2274.

5. FBI. (May 14, 2014.) Crime in the U.S. in 2013. Retrieved May 17, 2015, from www.fbi.gov/about-us/cjis/ucr/crime-in-the-u.s/2013/crime-in-the-u.s.-2013.

6. Gillespie C. (June 14, 2013.) Code of ethics for EMS practitioners.NAEMT. Retrieved May 1, 2015, fromwww.naemt.org/about_us/emtoath.aspx.

7. The Use-of-Force Continuum. (Aug. 4, 2009.) National Institute of Justice. Retrieved April 12, 2015 from www.nij.gov/topics/law-enforcement/officer-safety/use-of-force/Pages/continuum.aspx.

8. Whitehead S. After shock: A rational response to Taser strikes. JEMS. 2005;30(5):56–66.

9. Courtney A, Courtney M. (Nov. 30, 2012.) Physical mechanisms of soft tissue injury from penetrating ballistic impact. Air Force Academy. Retrieved Aug. 14, 2015, from www.dtic.mil/dtic/tr/fulltext/u2/a570804.pdf.