The goal of the national Stop the Bleed campaign  is to empower everyday people to provide life-saving bleeding control. While the program is aimed at the general public, it could also be a big benefit to police officers, sheriff’s deputies, state troopers and other public safety personnel. Law enforcement officers (LEOs) are more likely than civilians to encounter serious bleeding, so it makes sense that bleeding control training programs should give them special attention.
However, while Stop the Bleed is a good starting point for LEOs, it does not address the full spectrum of needs in the law enforcement community. The unpredictable nature of scene work creates unique bleeding control challenges. In 2017 an officer was assaulted somewhere in the U.S. every 8 minutes and one was injured every 29 minutes.  During the decade ending in 2018, more than 500 American LEOs died in the line of duty due to firearm injuries.  Because of the changing nature of law enforcement injury and mortality, bleeding control education for LEOs must integrate sound tactical decision making.
In January 2018, the department of trauma at Kaiser Permanente Vacaville Medical Center in Vacaville, California, began offering Bleeding Control for LEOs, a two-hour class that gives first responders the knowledge and skills to control life-threatening bleeding in the law enforcement setting. So far, we have trained more than 600 officers in the San Francisco Bay area.
While this course does not satisfy the standards of advanced tactical medicine certification programs, it does incorporate basic “active threat” principles to help LEOs deal with the common, dynamic situations that can complicate standard bleeding control efforts.
New bleeding control ABCs for law enforcement
The cornerstone of Bleeding Control for LEOs is the recognition that bleeding control instructions meant for the general public must be modified when they are taught to law enforcement officers.
To review, the “ABCs of Bleeding Control” as taught in a traditional Stop the Bleed program are Alert 911. Bleeding. Compress. When we teach these basics to law enforcement professionals, we recommend several modifications:
“Alert” should mean situational awareness. The first step of the standard bleeding control algorithm for civilians is to activate the 911 system. However, professional first responders are 911, so this step is irrelevant for LEOs. Instead, we emphasize the importance of situational awareness as a daily mental exercise.
The fact is that routine scene work tends to lull even the most experienced first responders into complacency. Several years ago, the fire department where I worked as a Firefighter/Paramedic suffered a tragic but preventable incident. It took place on the scene of a simple motor vehicle crash with minor injuries. While rendering care to the victims, on-scene crews became victims of an additional, devastating motor vehicle crash that injured numerous first responders, three of them critically. Root cause analysis performed by a review board showed that several “warning flags” went unnoticed simply because everyone was going about their jobs in rote fashion.
In this case, sadly, professionals who face danger on a regular basis had been injured by complacency. For LEOs, vigilant situational awareness is the key to preventing bleeding emergencies and limiting harm once injury occurs.
At the “Bleeding” step, first identify the emergency. The next step in the standard Stop the Bleed algorithm  is to (first) expose the injured area and (second) identify the different types of life-threatening bleeding. This makes sense for civilians, but we believe it is out of order for law enforcement officers. We teach LEOs to first identify the existence of an emergency and then expose the body part of concern.
This may seem like mere semantics, but we believe it has real repercussions for law enforcement officers. In the field, officers may or may not have the time to expose injuries by removing or cutting away clothing. Instead, their first priority has to be, “Is this life-threatening bleeding?”
If the officer determines that the observed bleeding is life-threatening, he or she should try to control it. If the bleeding is not life-threatening, the officer is free to turn to other priorities.
In the Bleeding Control for LEOs class, we teach participants that people can sustain injuries that are visually shocking but not, in fact, life-threatening. We teach officers to look for five things:
- Blood that SPURTS (the umbrella term for arterial bleeding)
- Blood that SOAKS clothing (except nose bleeds)
- Blood that POOLS around the victim
- Traumatic AMPUTATION of an arm or leg
- Bleeding with signs or symptoms of SHOCK
Looking for signs of shock can be daunting for non-medical personnel. We teach LEOs that it is not rocket science. Three principles are very useful:
- You will likely see significant bleeding. In other words, you will not likely see shock without the other dangerous bleeding symptoms of spurting, soaking and/or pooling.
- The victim will not be acting normally. People in shock will likely be confused, uncooperative, agitated and/or unconscious.
- The victim’s skin will likely be pale. What if the victim has darker skin pigmentation? Gently pull open the victim’s lower lip and observe the appearance of the lip on the inside of their mouth. Regardless of their skin color, all normal people are bright red and vascular on the inner lip and all people in shock will appear very pale at this site.
“Compress” is the same, but expand the focus. After life-threatening bleeding has been identified, pack and press the wound or apply a tourniquet as needed. While this step is the same for both law officers and the general public, our course expands on some key skills that are especially important to LEOs:
First, Bleeding Control for LEOs includes more psychomotor synthesis than the standard Stop the Bleed course. Our students apply a tourniquet to their own arm and their own leg and a partner’s arm and leg, for a total of four applications.
The course also uses a “wound cube” to allow students to practice packing four different wound types — large-caliber ballistic, small-caliber ballistic, stab and slash.
Finally, we teach participants how to treat bleeding in dogs. Police dogs face the same threats as humans, and most LEOs want to know how to recognize and treat life-threatening bleeding in their K-9 partners. We use diagrams to show officers where to place tourniquets, apply chest seals and pack life-threatening wounds on dog anatomy.
Bleeding control under fire
With the creation of the Rescue Task Force (RTF) concept, today’s first responders can get much closer to a casualty than ever before. However, the RTF model has not been adopted in many parts of the U.S. and the world. In addition, not every situation in law enforcement lends itself to an RTF intervention.
In most active threat situations, routine medical care is not initiated until a threat has been neutralized or eliminated. Until then, injured officers or civilians who are pinned down by an active threat (or the potential of it) may be unable to get to safety or be rescued. Obviously, that interferes with them receiving medical care in a timely manner.
In these cases, officers may have to provide medical care to themselves, fellow officers, suspects or members of the public. This situation has occurred on several occasions, including the 1997 North Hollywood bank robbery shootout, the 2011 San Diego homicide/suicide officer-involved shooting, the 2018 Stoneman Douglas High School shooting in Parkland, Florida, and the June 2019 fatal shooting of Sacramento police officer Tara O’Sullivan.
There are two scenarios in which LEOs may be called upon to provide bleeding control:
Active Threat — when there exists an immediate risk to first responders and the public. The focus is always on eliminating the threat, but hemorrhaging wounds should be addressed in this phase depending on rescuer availability and training.
Warm Zone Field Care — which occurs once casualties are no longer immediately threatened. This will often take place after relocating the casualty to some form of hard cover.
During this portion of Bleeding Control for LEOs, we discuss lessons learned in recent military combat and active threat situations. We clearly recognize the imbalance in correlating military combat actions with civilian active threat situations, but we believe there are valuable parallels in these military lessons. Key points for LEOs include:
- Never treat a casualty on the point of injury (aka the “X”). We do not treat a victim where they were injured by hostile fire because the longer you stay in the kill zone, your risk of also becoming a casualty grows rapidly.
- Apply tourniquets “high and tight.” When a casualty is bleeding from an arm or leg, place the tourniquet as high/proximal on the extremity as possible. This provides effective bleeding control and reduces the rescuer’s exposure time in the kill zone.
- Avoid direct pressure/wound packing when an active threat exists. These activities reduce your situational awareness and, again, prolong your exposure in the kill zone. When an active threat exists, the priority is elimination of the threat, but if you are going to provide patient care, you must first remove the casualty to hard cover.
In today’s increasingly violent society, these tactical considerations have a valid place in LEO training. None of these concepts are new to those who have served in our armed forces. However, for LEOs who have no military experience, it is fundamentally important to discuss the principles of caring for victims when an active threat exists.
Here again, situational awareness is a key to effective action. Most people — police officers included — are accustomed to the idea that a rapid paramedic response and high-level trauma care are just minutes away, especially in an urban setting. But for officers who are pinned down by hostile fire, the trauma system may be irrelevant. For this reason, LEOs need to maintain the mental mindset that they may be called on to rescue a civilian, a colleague or even themselves if necessary.
Use the ladder of bleeding control technology
The standard Stop the Bleed course focuses on wound pressure, non-hemostatic and hemostatic gauze or cloth (or t-shirt, etc.), and tourniquet application. This approach is appropriate for civilians who will likely have access to only limited supplies. Most law officers, however, have access to a wider armamentarium of bleeding control tools.
Bleeding Control for LEOs covers the differences between civilian bleeding control kits, wall-mounted bleeding control kits and the typical individual first aid kits (IFAKs) issued to law enforcement officers. Typical tools available to LEOs include:
Hemostatic gauze. Many civilian law enforcement IFAKs contain two sets of hemostatic gauze, mirroring the Tactical Combat Casualty Care (TCCC) guidelines for medical personnel  in a military environment. In addition to discussing the z-fold hemostatic gauze in common use, we introduce hemostatic wound-packing products specifically engineered for penetrating junctional wounds to the groin or shoulder — a highly likely area of injury for LEOs.
Pressure dressings. In California, many police officers are issued some type of pressure dressing, typically an emergency bandage commonly referred to as the “Israeli Bandage”.  This bandage is not complicated to use, but the method of application is very specific. Our class teaches some finer points of using the Israeli Bandage, such as how to apply pressure dressings to the neck or shoulder and how to apply the bandage to yourself.
Tourniquets. The current movement toward widespread tourniquet use is the largest doctrine shift in healthcare in the last several decades. We believe we have an ethical responsibility to educate our students on the many different types of tourniquets available, why “price point” alone is not a valid criterion for tourniquet selection and how to avoid dangerous knock-offs that contribute to poor outcomes.
Chest seals. Non-compressible torso hemorrhage has a mortality rate as high as 55.4% in otherwise survivable injuries.  LEOs are at high risk for torso hemorrhage because ballistic body armor does not always offer 100% protection against this injury. The standard Stop the Bleed course does not cover occlusive chest seals, but they are standard issue in California law enforcement jurisdictions. In accordance with California Commission on Peace Officer Standards and Training (POST), we teach that all open wounds to a casualty’s chest are to be considered life-threatening and should be treated with a non-porous, air-tight dressing (chest seal) as quickly as possible.  We have found that a healthy review of an open, closed and tension pneumothorax is very beneficial for refresher training.
Improvisation. Our course covers the cognitive framework for using the escalating ladder of bleeding control technology. As part of this, we teach officers how to improvise when necessary. While improvised tools are less than ideal, we believe it is important for LEOs to exercise creativity in times of crisis by utilizing material from their immediate environment (T-shirts, towels, etc.) to control life-threatening bleeding.
Tips for teaching bleeding control to LEOs
When designing your own bleeding control course for LEOs, you can ensure maximal engagement by including the following in your program:
Demonstrate the value of the information. Use different examples of bleeding control in both on-duty and off-duty situations. These students are not civilians, so make your training relevant to their unique personal and professional challenges.
Become a tourniquet expert. Learn the history, strengths and weaknesses of the numerous tourniquet types and brands available so you truly understand what good/bad information is being fed to your students. They will have many questions, so be a subject matter expert. One great starting point is to review the recommendations from the Committee on Tactical Combat Casualty Care on bleeding control devices and adjuncts. A wealth of information is available at www.deployedmedicine.com.
Determine whether local police standards cover chest seals. If your state’s peace officer standards require LEOs to understand and use occlusive chest seals, include a review of the most common types available. Body armor has several points of vulnerability and a sucking chest wound is a larger possibility than many LEOs may think.
Challenge yourself to learn more about tactical medicine concepts. A great civilian resource is the Tactical Emergency Casualty Care (TECC) course available from the National Association of Emergency Medical Technicians. This valuable course covers care rendered while under attack or in adverse conditions, care after a threat has been suppressed and care for a casualty that is being evacuated from the incident site.
Reiterate the importance of situational awareness. Emphasize that situational awareness is a daily mental mindset and not necessarily a hard skill. Both small- and large-scale emergencies can be mitigated by recognizing that threats always exist around them. Encourage a healthy balance between a relaxed stance and focused awareness because apathy, denial and complacency can be deadly.
Helping every LEO make it home
Law enforcement is an important and rewarding career, but it is not without inherent risks. The goal of the Bleeding Control for LEOs course is to mitigate those risks to the fullest extent possible.
Our mission is to help make sure every law enforcement officer makes it home to his or her family at the end of their shift. We are proud to look after the everyday heroes who so unselfishly look after each and every one of us.
Evan Edminster, BSN, RN, CEN, TCRN is a retired Firefighter/Paramedic and Military and Civilian Flight Nurse. He is currently the Trauma Education, Injury Prevention and Outreach Programs Coordinator for the Kaiser Permanente Vacaville Medical Center, Department of Trauma, in Vacaville, California.
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7. California Commission on Peace Officer Standards and Training (CA POST). Learning Domain 34: First Aid and CPR. https://post.ca.gov/regular-basic-course-training-specifications