The First Five Minutes

    On Jan. 8, 2011 at 10:09 a.m., the Pima County Sheriff’s Department received a 9-1-1 call advising of a shooting in progress at a local shopping center. During the next 20 minutes, details of a horrific scene unfolded despite the lone shooter being taken into custody within five minutes of the original 9-1-1 call.  

    Before it was all over, that isolated shooter had fired 30 rounds into a crowd gathered for Congresswoman Gabrielle Gifford’s Congress on Your Corner event outside a busy Safeway grocery store. Facing the arriving deputies were 19 injured and/or dying people, all in close proximity. Is your department prepared to receive a 9-1-1 call like this? 

    In the 47 minutes that deputies were with the injured at the scene, they treated 10 of the victims. Deputies controlled the bleeding, provided rescue breathing, provided chest compressions, used hemostatic agents, bandaged numerous wounds, and assisted citizens in the care of the injured.

    Emergency Department Physicians and Trauma Surgeons from Tucson’s level one facility, University Medical Center, acknowledge the quick actions of the Pima County Deputies resulted in decreased hemorrhage, improved arrival vital signs, and decreased need for resuscitation such as a transfusion for multiple victims. 

    In a 2007 study published in Prehospital and Disaster Medicine, the respected authors note that “No widely accepted, specialized medical training exists for police officers confronted with medical emergencies while under conditions of active threat.” (Sztajnkrycer, Callaway, Benz 2007)

    Given the knowledge that we have acquired from historical and modern battle, culminating in the Trauma Combat Casualty Care (TCCC) guidelines, we know the causes of preventable death on the battlefield are: 1) hemorrhage from extremity wounds, 2) tension pneumothorax and 3) airway problems.

    Each of these emergencies can be managed readily using relatively simple techniques and minimal equipment. Unfortunately these techniques and equipment are rarely taught to law enforcement officers.

    Even in an urban environment, the time it takes for Emergency Medical Services (EMS) to arrive on scene can mean the difference between life and death for the wounded. Too often the first responder is a law enforcement officer faced with a tactical situation of providing a law enforcement function that must quickly transition into providing first care to civilians or a fellow officer. 

    In Pima County, this event happened in a geographic location readily serviced by multiple paramedic units from three large fire departments, but it is conceivable that this same scenario could occur with one or more complications such as: 1) rural setting with a extended arrival time for EMS; 2) EMS gets lost, has an accident or mechanical breakdown; and 3) scene unsafe and EMS cannot approach.

    Any of these complications would significantly affect the well-being of the wounded, as the EMS provider would be markedly delayed. It is essential that treatment begin immediately and patients be transported expeditiously in accordance to the severity of their injuries.

    Special Weapons and Tactics Teams (SWAT) have long understood how important it is to have paramedics imbedded in their teams, immediately available for any medical need, tactically trained. These Tactical Emergency Medical Service (TEMS) providers can readily address airway, breathing and circulation problems that create an urgency that transcends the response times of most staged civilian medical assistance units. 

    While it is not practical for law enforcement agencies to employ paramedics to work in the field with officers, there is much that can be done to train police officers to care for themselves.

    The Pima County Sheriff’s Department leadership acknowledged the need for global training for all staff with “feet on the street.” Taking elements of TCCC and results from the research done by Valor Project, a Tactical Emergency Medical training program called the “First Five Minutes” was provided to all deputies during annual Advanced Officer Training in the spring of 2009. 

    The program was developed by Officer/Paramedic David Kleinman in consultation with Dr. Richard Carmona, the 17th Surgeon General of the United States, former Pima County Sheriff’s Department SWAT team leader and Medical Director, and Dr. Tammy Kastre, the current Medical Director for the Pima County Sheriff’s Department SWAT Team and Board Certified Emergency Department Physician.

    While certainly not the first medical program taught to agency first responders, the goal of the First Five Minutes program is somewhat different than the normal medical training provided to law enforcement officers. The primary goal is now to give police officers the training necessary to sustain themselves or other officers in life-threatening medical emergencies.

    Along with the training, it was necessary to develop a medical equipment kit that would be issued to all deputies after being trained. The Law Enforcement Individual First Aid Kit (IFAK) was assembled based on the three most common causes of preventable traumatic death. 

    Officer safety and tactical considerations are incorporated into every aspect of the lesson plan. Officers are reminded they are police officers first and medical providers second. The introduction to the class relates the importance of providing immediate medical care to the downed officer.

    The Fort Hood Police Department shooting and the murder of Phoenix Police Officer Travis Murphy are used to illustrate this issue. At numerous points during the class it is emphasized that this program is not a first aid class, rather it is a survival class for police officers.

    The Law Enforcement IFAK is given to students at the beginning of the class and they are encouraged to open it and explore the contents, because the more comfortable they are with the equipment, the faster they will learn how to use it. While the purpose of the IFAK is for treating fellow police officers, deputies are told to use their discretion and utilize the IFAK when they feel it is necessary.

    The four-hour training block includes many aspects of the emergency response. First, scene safety to include familiarity with Fire and EMS agencies and services in the areas to which they are assigned, capabilities of local hospitals, and the availability of helicopter rescue. Next, Body Substance Isolation (BSI) and real world applications. Then, impact of C-A-B assessment for an open airway, breathing and circulation is emphasized from the beginning of the class with a CPR refresher to include Cardio Cerebral Resuscitation (CCR).

    The course also includes instruction in the 90-second assessment of situation and medical condition with focus on hemorrhage control maneuvers and identification of shock. At the end of the assessment, deputies are encouraged to make a transport decision: Do they stay at the scene and wait for EMS or do they transport the wounded? Then, skills lab to include the use of the Emergency Bandage, Combat Gauze, Asherman Chest Seal and a tourniquet (either the CAT or the SOF-T).

    Finally, training is given in transfer of care to EMS workers. Officers are told to report to EMS workers the nature of the injury, mental status, mental status changes, airway control, rates of breathing and circulation, what injuries they saw, what injuries they treated, how they did it and any unusual findings. Since the assisting officer is often the first person to contact the injured person, the training stresses their observations and findings are the most significant issues in long-term care and recovery of the wounded person.

    At the conclusion of the training, the student’s skills are evaluated through scenarios.  Two evaluators are used for each scenario: one evaluates officer safety, use of cover and concealment, tactical movement, and other skills related to police work; the second (usually an EMT or Paramedic) evaluates the medical triage and care provided to the victim. 

    Similar emergency medical training programs, such as the Specialized Tactics for Operational Rescue and Medicine (STORM), developed by the Georgia Health Sciences University in conjunction with the National Tactical Officers Association, address this training need. 

    The STORM courses provide clearly defined medical strategies, procedures and rescue techniques to enhance the safety of law enforcement personnel and the populations they serve. STORM is tailored to five unique tactical audiences: Self Aid-Buddy Care, Operator, Medic, Medical Director and Commander. Each course consists of didactics, hands-on skills stations and tactical scenario-based training. 

    Not all law enforcement agencies consider first aid a part of a police officer’s job. With the ever-increasing call load and requirements placed on officers, it is easy to see how agencies can lessen liability and work load by eliminating a job already serviced by fire departments and EMS. 

    However, a wounded officer or an officer responding well in advance of EMS on a mass causality incident is a completely different situation. Every officer should have the necessary training and equipment to provide on-scene emergency medical care for themselves, any other officer they may contact, or any civilian they are sworn to protect. 

    There are many worthwhile medical programs utilized by law enforcement nationwide.  One of the keys to a successful program is simplicity and ease of use. Without those two factors, officers are limited in what they can effectively do at a scene. The First Five Minutes Program has proven to be simple and effective. 

    In the immediate response to the Safeway shooting, every item supplied with the IFAK was utilized at some point by law enforcement personnel prior to EMS gaining access to the scene. The training and equipment provided proved to be very worthwhile in a time of crisis, resulting in saved lives. 

Dr. Tammy Kastre is currently practicing with Mayo Health Systems in Minnesota and in Tucson, Ariz. as an Emergency Medicine Attending. In 2003, she became the Pima County Sheriff Department physician, the TEMS program for Pima Regional SWAT, and the EMS director for the PCSD Search and Rescue unit staffed with EMT deputies.

David Kleinman has been a law enforcement officer for over 30 years with municipal, county and state agencies. He has been a National Registry Paramedic since 1996. He has also served as Operator/Paramedic for the Arizona Department of Public Safety Tucson SWAT and currently serves as Tactical Paramedic for Pima Regional SWAT. He may be reached at


A sucking chest wound is a time critical/life threatening injury. It must be stabilized rapidly. An occlusive dressing is a fast, effective remedy.

Tourniquets are the most time effective means for controlling extremity hemorrhage in an ongoing incident.

Once life threatening wounds are managed, officer rescue is priority.

Hemostatic agents are an effective means of controlling hemorrhage. Wounds can be packed with hemostatic agent to control bleeding in deeper injuries.

The contents of the IFAK can be purchased for around $100 and are available from numerous vendors.

The Safeway Shooting in Tucson illustrates how emergency medical training for police offices can benefit the community.

Published in Tactical Response, Jul/Aug 2012

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