On April 10, 2023, rookie Louisville Metropolitan Police Officer Nickolas Wilt and his training officer Cory C.J. Galloway were the first to respond to the active shooter who killed five people at the Old National Bank.
As they charged toward the bank, the gunman who was reportedly was lying in wait for officers, opened up on them with a rifle. Wilt was hit in the head and fell in front of the entrance to the bank. Galloway was hit, grazed in the hip. He rolled out of the kill zone and behind a concrete planter. For the next few minutes Galloway tried to get a shot at the gunman so that he could help Wilt. The gunman presented himself as a target, Galloway fired, and the incident ended with the gunman down in the bank lobby. As Galloway checked to make sure the gunman was no longer a threat, officers removed the critically wounded Wilt from the scene and transported him to the hospital in a patrol vehicle.
At presstime, Officer Wilt was in a rehabilitation center, reportedly making good progress. It's likely that the rapid transport of Officer Wilt to a trauma center made it possible for him to survive. Which raises the question of should officers use their patrol vehicles for transport of seriously injured officers and civilians.
Casualty evacuation (CASEVAC) is often considered a military versus a law enforcement concept. When hearing CASEVAC, images of extracting wounded casualties from combat is what people who are familiar with the concept envision. This stereotype often immediately discourages law enforcement leadership from discussing casualty evacuation when the topic arises.
In actual definition, the term CASEVAC refers to moving a wounded or injured person off of a battlefield by a non-medically dedicated asset to a medical care facility. Contrast this with the term MEDEVAC, which involves a dedicated and marked medical transport. In modern civilian law enforcement and EMS contexts, the term CASEVAC removes the first context and focuses on the second and third, movement of an injured or wounded person to a higher level of care by means other than a designated medical asset.
Transporting a patient to an emergency room in a dedicated and marked medical vehicle is a “traditional transport” for EMS. Consequently, the term CASEVAC is applied to law enforcement personnel transporting patients via patrol vehicles, either SUVs or sedans, which is commonly referred to as a “non-traditional transport” in EMS circles.
Faster is Better
Law enforcement conducting casualty evacuation on trauma patients is not a new idea; however, it traditionally was met with significant resistance by administrators who believed it was not the role of police and would place the agency at risk for liability.
The 2012 active shooter attack at the Century 16 theater in Aurora, CO, changed that perception. When faced with 57 wounded and injured victims—an actual tactical mass casualty event—officers on the scene had a choice, wait for EMS while patients died or do what they knew needed to be done. Ultimately officers on scene transported more casualties to the hospital by patrol vehicles than were taken by EMS in ambulances. Every savable patient on scene lived, which certainly might not have been the case had officers waited for EMS.
There are scenarios where transport by law enforcement vehicle may be the most rapid way to get a wounded trauma patient to the needed level of care. A research study published by the Journal of the American Medical Association in 2021, “Association of Police Transport With Survival Among Patients With Penetrating Trauma in Philadelphia, Pennsylvania,” revealed that there was statistically no difference in the survivability outcome of patients transported to the hospital by police and those transported by EMS. That same study showed that the more seriously injured patients had an increased chance of survivability when transported by police. A follow-up study published in 2022 by the Journal of Trauma and Acute Care Surgery, “Coming in Hot: Police Transport and Prehospital Time After Firearm Injury,” revealed these survivability rates were due to the faster transport time afforded by law enforcement at a median of nine minutes versus 21 minutes by EMS. These studies prove that the real difference-maker in patient outcome is how rapidly and efficiently the casualty is transferred to a higher level of care. Consequently, in today’s world, agencies may face increased liability and increased public scrutiny for failing to transport when EMS is unavailable.
That does not mean that officers should transport every trauma patient. When available, traditional transport by EMS is always preferable. However, restricting officers’ ability to transport when needed could be detrimental, result in people dying when they could have been saved by more rapid medical intervention, and potentially open the agency to liability for inaction.
The opposite is also true, however. Officers should not immediately rush to a casualty, especially a fellow officer, toss them into a patrol SUV, and speed to the hospital. Officers should be allowed to assess the unique scenarios involved and determine the best course of action.
First Aid First
There is a proper time to determine if CASEVAC is appropriate. If we have not successfully provided the appropriate medical interventions to buy the casualty the critical time needed for transport, then they are likely to perish in our car.
We must, at a minimum, ensure we have controlled any life-threatening external bleeding, opened the patient’s airway, and sealed any sucking chest wounds before initiating transport. Civilian transport times are relatively short on average, and these are the injuries that will kill a trauma patient in that compressed time. These correlate to the first three steps in the Tactical Emergency Casualty Care (TECC) MARCH (massive hemorrhage, airway, respiration, circulation, hypothermia) mnemonic commonly taught to law enforcement so they can remember the most critical emergency medical response necessary for aiding an injured person.
We must work our way through the first three steps in MARCH first. However, after treating respiratory needs, we must pause, and assess whether and when EMS is arriving on the scene or if we need to initiate a non-traditional transport ourselves.
If we fail to address immediate life-threatening injuries, continued treatment while enroute will be near impossible. If the patients’ injuries require ongoing care during the transport, it would not be recommended for officers to conduct CASEVAC. Complex medical treatment by professional EMS in the back of an ambulance is challenging for an officer in a car seat while trying to drive with minimal training, and it is unrealistic at best to think you can do it. Injuries that, for example, require holding an open airway would be best treated by waiting for EMS, since we are unlikely to be able to continue that care enroute, and our casualty’s survivability will substantially decrease.
The most critical factor officers must consider when determining whether to transport an injured person is the proximity to the higher level of care compared to EMS’s arrival. If an ambulance is 10 minutes from the scene, but we are five minutes away from a trauma center by CASEVAC, the choice seems clear. Only a trauma center can provide the treatment to save our casualty. One of the main goals in tactical medicine is to compress the time from injury to medical care as efficiently as feasible. However, if the time for EMS arrival and CASEVAC would be comparable, it is likely the best choice to stabilize and await EMS arrival since they can provide enroute care. There have been instances where in the officer’s haste to grab a wounded officer and speed to the emergency room, they have sped past the ambulance with professional medics staged to receive the patient. In most urbanized metropolitan police forces, the time for EMS is likely only a few minutes. However, for rural law enforcement the time for an ambulance to arrive on scene is likely significantly higher, and waiting for EMS’s arrival could be fatal.
Officers must also recognize that they are likely preventing the trauma response activation at the receiving hospital by conducting a casualty transport themselves. During traditional transport, EMS constantly communicates with the emergency room, relaying critical patient information such as vital signs and ongoing care. This allows the receiving hospital to have the trauma team activated and waiting to receive the patient. Blood is pulled, a trauma room is open, imaging is ready, and the trauma team is at the door so that care begins immediately. In a non-traditional transport, this information is typically not relayed because officers are unable, untrained, and need more resources to get that data. The best scenario is this delays care; the worst scenario is that we catch the emergency room personnel completely unaware that we are coming in.
In a mass casualty scenario, law enforcement will most likely be participating in transporting the wounded. Depending on the scope of the scenario, EMS’s capabilities will quickly be overwhelmed, and they will be unable to get to each patient, render care, and initiate transports with police involvement. Officers conducting CASEVAC operations during a mass casualty event must coordinate with EMS personnel and FIRE/EMS command to determine the appropriate care facilities for patients to avoid overloading any single facility. Officers should take direction from FIRE/EMS Command regarding CASEVAC during these scenarios.
A final consideration often overlooked when deciding if police transport is appropriate is the officer’s emotional state. The officer’s emotions are of even more significant concern during events involving wounded officers. If the transporting officer was just involved in a shooting or witnessed their partner’s wounding, it’s a safe assumption their adrenaline level is significantly heightened. The goal of any transport is to get the patient to a higher level of care safely. Typically, another officer not involved in the event, the initial backup officer perhaps, performs the CASEVAC transport as they will be calmer and think more rationally. Of course, there will always be scenarios where this may be impossible if the backup is an extended distance away.
Non-Traditional transport by law enforcement should not be our immediate response. Certain agencies have mandated that officers transport in all cases if EMS is not on scene.
Mandating CASEVAC is probably swinging the pendulum too far. There are scenarios, such as non-trauma medical calls, where police transport may not be appropriate. However, policies completely restricting officers from transporting are even worse. For trauma casualties, specifically tactical trauma often encountered by officers during high-risk operations, the difference between life and death can be measured in minutes. Officers should know how to and be allowed to make the best decision to increase a casualty’s survivability.
Robert Carlson is a firearms, counter-ambush, and active shooter response instructor for the Memphis Police Department. He is the lead tactical medical instructor for the Mississippi National Guard’s Regional Counterdrug Training Academy, providing no-cost training to law enforcement across the country. Carlson owns Brave Defender Training Group LLC https://www.bravedefendertraining.com and is an IADLEST nationally certified instructor.