Police rescue procedures: special preparation for the implementation of tasks. Analysis of selected aspects of training officers of the Police Headquarters.

The first changes in the provision of first aid historians see in the records of the 2nd king's book talking about Elisha, who revived the life of a little boy [1]. In the Polish normative system, the Legislator (modeled on other civil societies) has included a code commitment on the part of citizens to provide assistance to people who are in a life-threatening situation. Article 162 § 1 of the Criminal Code provides: "Whoever in a situation threatening with immediate danger of loss of life or serious damage to health does not provide assistance, being able to provide it without putting himself or another person at risk of loss of life or serious damage to health, is subject to imprisonment for up to 3 years [2], indicating the obligation of all citizens to provide emergency assistance.

The Act on Emergency Medical Services is an expression of concern for the safety of citizens in a state of sudden threat to life and health. Article 1 states: "In order to implement the state's tasks of providing assistance to every person in a state of emergency, a State Emergency Medical System is created, hereinafter referred to as the" system "." [3] The system should be understood in terms of legislation as a set of elements related to mutual relations and performing a superior function. [4] One of the elements of this system is the structure of the Police, as a public institution with a wide scope of responsibility in the field of internal security of the state, involved in rescue operations by the provision of art. 15 of the Act on State Emergency Medical Services: "Units cooperating with the system are statutory services to help people in a state of emergency health, in particular: organizational units of the State Fire Service, fire protection units included in the national fire and rescue system, (...), other units subordinated to or supervised by the minister competent for internal affairs and the Minister of National Defense. "[5]

The new tasks of police officers require a new look at the issue of first aid, training of personnel in specialist rescue procedures prepared and implemented in close relation to the specificity of the duties performed by officers (qualified first aid and emergency medical services) [6], [7]. In order to properly prepare the structures of the Police thanks to the efforts of the Police Commander-in-Chief and the support of the European Social Fund On November 14, 2011, the largest training project in Poland in the field of Qualified First Aid was launched, addressed to Police officers from the departments of prevention, traffic and independent anti-terrorist subunits. After completing 66 hours of training, police officers obtain the title of lifeguard (in accordance with the Act on State Emergency Medical Services) by acquiring the skills to be used, which the lifeguard is obliged to take against a person in an emergency. Unlike persons providing first aid using medical devices and medicinal products made available to the general public, the rescuer, according to the Act, should be trained and equipped in a way enabling the use of specialized equipment. The police officers training program includes the use of rescue equipment of various purposes and specifics. From the oropharyngeal tube, resuscitation mask, self-inflating bag or oxygen therapy kit (oxygen cylinder, mask and reducer) to the semi-automatic defibrillator, orthopedic board, exhaust rails or haemostatic dressings, the lifeguard officer should have sufficient knowledge and skills to assist in a life and health emergency.After the first courses, the need to modify the content of teaching in the field of medical procedures was noted due to the specificity of the work of policemen. As a result of the analysis of selected issues of the training program and the experience gathered, the authors present below the characteristics of changes in rescue procedures and their modifications conditioned by the specificity of the policeman-rescuer service.

Qualified first aid or T.E.M.S. (Tactical Emergency Medical System)?

Qualified First Aid is a set of actions taken against people who are in a state of emergency who have been described in the curriculum. It is based on the available guidelines of Polish and foreign societies and organizations dealing with the methodology of conducting rescue operations, such as the European Resuscitation Council and its national counterpart in the form of the Polish Resuscitation Council, as well as the Polish Society of Emergency Medicine. As a rule, the recommendations of these institutions published in the form of cyclically issued guidelines relate to operation in "civil" conditions, safe for helpers, recommending in most cases the rescuer's withdrawal from all situations where his safety is threatened both by third parties and the surrounding the environment (e.g. hazardous materials). European standards in the first point of the rescue algorithm are: "Make sure you, the victim and any bystanders are safe." [8] ("Make sure you, the patient and any witness of the incident are safe"). In the event of any threat, in particular directed against the person providing assistance, it is advisable to refrain from further action. It is recommended to call the appropriate security services to the place of incident. Their task is to create safe conditions or to evacuate the patient from the place of danger to a location that allows medical emergency operations. It often happens, however, that none of the described options is available, and help from medical staff is only possible in the long term. In these circumstances, there is a need for policemen with the knowledge and skills necessary to obtain the title lifeguard to take action. Their possibilities of operation are limited to a safe zone for them. In view of the above, the most urgent needs are often: immediate evacuation of victims to a safe area and handing them over to medical staff. Unfortunately, the complexity of the scenarios faced by police officers indicates that there are tactical situations in which immediate evacuation is not possible. Then the action in the scope of basic life-saving procedures remains in the hands of officers in the immediate vicinity of the victim. The task of rescue instructors conducting the training of officers is to prepare them for actions ensuring the best chance of survival of victims in conditions of temporary lack of access to medical rescue operations. It is difficult to estimate how long the rescuer stays with the victim in a place cut off from external help. A significant part of the training program should include both the study of evacuation techniques and the training of independent rescue operations in the danger zone (referred to as stay and play strategies as a jargon). In the preparation and implementation of the lifeguard training program, special emphasis should be placed not only on the threat from the surrounding environment, but also often on the significant lack of comfort associated with the work of a policeman. Both working with the patient in a lying position and poor lighting conditions, and in special situations the need to use a gas mask or use a curtain to avoid enemy fire, are a source of stress affecting the quality of rescue operations and their effectiveness. [9] Given this complexity of the working environment, the question arises whether qualified first aid remains a sufficient range of activities to secure police operations. As long as it is sufficient to carry out rescue operations in the conditions of routine implementation of the tasks of patrol couples or prevention units, it should be considered to extend the rescue procedures used in the event of a threat to the life safety and health of police officers intervening as part of special operations or detentions carried out by implementation departments. Following the example of American standards, these procedures are part of the activities of T.E.M.S. (Tactical Emergency Medical Support). To date, the majority of independent police anti-terrorist sub-units are served by a significant number of officers who, irrespective of the basic scope of competence and skills (common to all members of the ward) also have additional education confirmed by a paramedic and equipment enabling them to carry out the activities described above. At present, however, neither the presence of a paramedic in the team is a formal requirement, nor the course of their training introduces a coherent and unified system of competences and skills.

In the daily work of police officers, during interventions or carrying out preventive actions, there are often events requiring officers to take rescue actions. The special nature of these activities lies in the need to implement various, often contradictory, goals, such as: completing formal police obligations, caring for the safety of team members, looking after injured bystanders (e.g. witnesses), as well as providing the minimum necessary protection the life and health of the person in relation to whom police activities are carried out (e.g. arrest). With regard to routine tasks of the Police, the scope of qualified first aid remains a completely sufficient scope of duties to guarantee an optimal level of safety for victims and officers. The correct sequence of actions at the place of an accident under qualified first aid procedures is in these situations: securing the place of the incident, implementation of appropriate medical procedures, eventual organization of evacuation of victims, if necessary, and carrying out official activities in the face of the often hostile environment and limited resources. During the 66-hour training, officers preparing to fulfill the tasks of the Police, as a unit supporting the State Emergency Medical System should, in addition to procedural rules and practical skills, develop the skill of proper interaction with witnesses of the event and bystanders, based on a few simple rules. the key is the behavior of police rescuers, who with their attitude have the ability to influence the participants of the event and the emotions of bystanders. Below is a scheme of good practices for conducting rescue operations, proposed by the authors and implemented by the Rescue Center instructors:

Speak with the body

body language is a very important element in helping. It is an important communication channel and carries a considerable amount of information about the leader and his ability to control a crisis. The rescuer's gestures must be firm, visible and simple. A strong factor influencing the quality of an officer's influence on his surroundings is the use of the symbolism of the uniform and the service badge.

Let everyone hear

a rescuer should do everything to be heard and understood correctly. Messages should be short and simple. The authors 'experience in both rescue operations and officers' training shows that even the best prepared rescue plan will not be effective unless it is clearly presented to all participants.

Prevent

Usually, many events requiring medical assistance occur in publicly accessible places, creating circumstances in which the rescuer, apart from the patient, is obliged to contact a significant number of contingent witnesses. In the above situations, it is necessary to use all available means to prevent panic and undesirable hysterical reactions of individuals.

Be visible

event participants should be able to easily identify and locate the rescuer. In situations where the rescuer is obliged to conduct activities in a larger area, good visibility not only allows victims to get help, support or advice, but also makes it easier for rescuers to communicate with each other. The police officer should encourage cooperation by building team awareness.

Plan

in accordance with the principle of "erroneous planning is error planning", any action to save lives and health must be based on a detailed assessment of opportunities and threats as well as the resources and resources available to the rescuer. The habit of anticipating the consequences of actions should be developed among rescuers at the training stage.

The material mastered during KPP classes should be treated as a set of elementary principles that the rescuer should associate and implement at the scene of the event, adapting his behavior to the development of the situation. Attention should be paid here to the impact of proper preparation of the rescuer during training for conducting rescue operations under the influence of severe stress resulting from the course of the accident. Both among the witnesses of the event and the team undertaking the provision of assistance, the greatest impact of emotions on behavior and the quality of decisions can be seen in the first moments of the rescue operation. When the conditions at the scene have not yet been fully recognized by officers and the remedial actions have not yet been fully implemented, the possibility of planning errors arising from the emotional state of the team conducting the action is the greatest. During this period, reactions expressing: fear, helplessness, anger, aggression, apathy, confusion, anxiety or sadness have a huge impact on the correctness of the decision-making process, and thus the quality of rescue operations. The authors of the article draw attention to the need to shape qualified first aid procedural memory in training participants. [10] Already at the training stage, it is necessary to educate among officers prepared to conduct rescue actions appropriate, reflex behavior that allows to limit the impact of emotions, on the quality of decisions taken in a life-saving situation. During the training, simple rescue procedures should be repeated many times, such as algorithms of conduct in the scope of basic life-saving procedures [11]. This allows rescuers to develop habits in the correct order of diagnostic procedures or control of team safety. This is due to the functional location of cortical and subcortical centers of this type of memory in the structures of the central nervous system responsible for motor motility, i.e. in the cerebellum and basal ganglia [12] The goal of training based on the repetition of rescue procedures is to minimize the likelihood of making wrong decisions under the influence of stress caused by stress environment in which the rescuer operates. The qualified first aid course profiled under the account of police operations not only allows to obtain the qualifications described in the Act on state medical emergency services, but also creates the possibility of shaping correct behaviors related to the implementation of medical procedures both in conditions safe for rescuers and in combat conditions. The authors of the publication entitled: "Principles, policies and parameters for planning medical security ACE-AD 85-8" also pointed to the impact of stress resulting from life-threatening situations in combat conditions, indicating that cases of stress resulting from combat operations may even cause 17% of combat losses, taking Total Battle Casualty (TBC) as the indicator. [13]

The authors of the article pay special attention to the need to introduce, under the qualified first aid program, in the part entitled "classes available to the instructors" [14], a set of simulations of rescue operations conducted in conditions adapted to the specific tasks assigned to a given group of course participants. As part of the training, an officer prepared to obtain the title of lifeguard should be prepared not only to act in stressful conditions, but also to make decisions aimed at saving the lives of victims, as well as in a situation where despite efforts and efforts, the patient's condition may deteriorate or become ineffective activities carried out. During the implementation of the qualified first aid training program, officers should obtain detailed knowledge to understand that the health condition of many victims may, despite the actions taken, deteriorate, leading to irreversible changes and even death, regardless of the correctness of the rescuer. This knowledge allows to limit the phenomenon of rescuer uncertainty as to the effectiveness of assistance provided. In this case, uncertainty is understood by the authors as a cognitive state in which the awareness of one's own position or the ability to predict the consequences of actions taken is disturbed. The complexity of this behavioral phenomenon is determined by many factors, but only some are known and possible to take into account in the decision-making process [15]. The only way to limit its impact on the quality of rescue operations is to educate policemen at the stage of qualified first aid training reflex reactions to changing circumstances at the scene. Another factor determining the behavior of officers in the face of life-threatening situations is the expected and expected effectiveness of their actions. Effectiveness boils down to faith in the possibility of effectively repealing the danger that threatens the life of the victim by implementing appropriate rescue procedures. Assuming that the innate quality of every human being is the general ability to learn [16], it should be assumed that the best way to raise confidence in the effectiveness of one's own actions is simulation training conducted by experienced instructors, during which a lifeguard candidate learns not only the general principles of conduct on at the scene of the incident, but also in conditions similar to real life can convince, as far as possible, of the effectiveness of the rescue techniques used.

In addition to the methodology that takes into account the psychological aspects of training police officers in the field of qualified first aid, the most important element of proper preparation of officers for conducting rescue operations is taking into account the differences in the objectives resulting from the specificity of the service, whose one of the main tasks in addition to protecting human life is "detecting crimes and offenses ( ...) [17]. The discrepancies between rescue procedures used in civil conditions and the algorithms used in police life-saving operations are particularly evident in circumstances where the place of rescue operations also remains a crime scene or poses a direct, real threat to officers and bystanders.These discrepancies relate to both tasks that should be carried out by police officers (i.e. arrests, searches of premises, protection of forensic evidence) and methods of their implementation. For example, in the "survival chain", i.e. the algorithm of rescue operations in the scope of basic resuscitation procedures recommended by the European Resuscitation Council, recognition of the state of life threatened by the injured person should result in the rescuer being notified by medical services using commonly available means of communication, i.e. by phone using numbers : 112 or 999 [18]. Meanwhile, in accordance with police communications procedures, relevant services should be notified by radio, through the duty officer of the appropriate Police organizational unit [19]. These differences result not only from the availability of official means of communication, but also from the specificity of tasks carried out by police officers. In radio messages transmitted from intervention sites, notification of the need to include emergency teams in rescue operations is often only part of the information describing the complex circumstances of the incident. The duties of the duty officer, in addition to notifying the appropriate emergency notification center, include arranging for possible support for officers carrying out intervention by other patrols or Police teams, assessing the measures necessary to secure the place of the incident, as well as coordinating police and forensic activities. The need to include all these elements in the content of messages sent to the police officer makes the use of the conventional communication route described by the guidelines of the European Resuscitation Council ineffective, and the introduction of necessary changes to the qualified first aid training program. Divergences regarding the principles of conducting rescue operations in civil conditions in relation to the specifics of police activities are manifested even in such prosaic issues as equipping officers with the appropriate amount of resources to fulfill different tasks. For example, each officer should be equipped with the right number of disposable latex gloves, which can perform completely different functions while performing their official duties. When providing qualified first aid, they are a means of personal protection for a police officer, while during an inspection of the place of an accident and securing forensic evidence, they mainly affect the quality of secured evidence. The use of the same pair of gloves by the officer to perform both of these activities, which is often the result of an error in the training process or insufficient equipment of police officers, can affect both his level of security and the possibility of using forensic material secured during official activities. Similar differences apply not only to additional activities compared to carrying out rescue operations, but also to treatments in the scope of qualified first aid. For example, officers serving in two-person patrols in many cases will not be able to comply with the recommendations regarding the change of the chest compressor during cardiopulmonary resuscitation, which according to standards should take place every two minutes in order to use the rescuers most effectively and guarantee optimal effectiveness of resuscitation [20] In police operations, tactical involvement of officers at the scene often creates the need for long-term independent resuscitation, which should also be included in the qualified first aid training program at the planning stage.Another of the many differences in the specifics of police rescue operations is the different range of recommendations regarding the use of radical means of securing bleeding in people with post-traumatic life-threatening conditions such as dressings and tourniquets.

In police rescue procedures, as in military operations, an important role is taken by the use of pressure as a means of reducing mortality by up to 9% [21] [22] [23] in a group of victims with severe hemorrhage. Indications for the use of this type of dressing, used on the limb of a injured proximal to the bleeding site, in the specifics of the events with which Police officers have reactions are much more common than in the case of civilian conditions. The circumstances justifying the use of a tourniquet relate in particular to significant arterial bleeding caused by extensive tissue damage in a small amount of time allowing for a different, safer dressing. The effective use of a compression band means that it is often recommended when assisting in bleeding from wounds inflicted by a blade, glass, melee weapon or bleeding from gunshot wounds of peripheral parts of the body.Such action is particularly justified especially in the conditions of combat operations and in situations posing an increased threat to a team of intervening officers. Unfortunately, the effectiveness of this method of stopping bleeding has frequent consequences in the form of critical ischemia of the clover below the place of application of the dressing with the subsequent necessity of its amputation. While the tourniquet is justified by the police actions resulting from its effectiveness and speed of its use, it should not be used routinely in the event of assistance in civil conditions. In order to increase the safety of the use of this dressing by the police officers, it is justified to include in the training program and the instructors to place particular emphasis on the use of compression banding principles. [24]

The contemporary role of the Police and its officers in guaranteeing an efficiently functioning internal security system is subject to significant changes dictated by both changes in social expectations and available technical means of their implementation. One of the additional new tasks of police officers in the field of universal security, which the Legislator imposed on them by the Act on the state medical emergency system is the obligation to provide qualified first aid in the event of a threat to life and health of citizens. This task is in line with both the high level of social expectations towards public officials and the increase in the level of citizens' confidence in the profession of policeman. [25] Considering the above, it should be concluded that preparation for conducting rescue operations in the field of qualified first aid by police officers should not only be a permanent element of their training, but also the basis for a broad and detailed analysis of contemporary tasks of the Police in the field of protecting the health and life of citizens.

1. Stary testament, 2 Księga Królewska, Rozdz. 4 wersety: 34-36
2. art. 162 §1 Ustawy z dnia 6 czerwca 1997 r. Kodeks karny. Dz.U.1997.88.553
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