ORIGINAL ARTICLE
LEITÃO, Ket Jeffson Vasconcelos [1]
LEITÃO, Ket Jeffson Vasconcelos. Technical-legal parameters of basic life support in pre-hospital care in combat. Revista Científica Multidisciplinar Núcleo do Conhecimento. Year. 07, Ed. 02, Vol. 06, pp. 126-147. February 2022. ISSN: 2448-0959, Access Link: https://www.nucleodoconhecimento.com.br/law/support-basic
ABSTRACT
Context: Intentional violent deaths (MVI) have annual quantitative averages of more than 50,000 victims (2009-2018), while the homicide rate of police officers reached the level of 63.5 deaths per group of 100,000 police inhabitants (2018). In the face of this situation, the public health system responsible for pre-hospital emergency care gains relevance as a resource to mitigate such mortality rates, especially for the improvement of pre-hospital care in situations of intentional violence. In this sense, it is necessary to analyze how the problem is treated by health authorities in Brazil and in what legal and technical circumstances the participation of professionals directly linked to the fight against violence, the police. Guide question: are there specific technical guidelines and legal regulations for police officers to act in specialized and immediate pre-hospital care for victims of intentional violence? General objective: to identify the existence of technical and legal parameters for the performance of police officers in pre-hospital care in situations where intentional violence occurs. Methodology: this is a basic and exploratory research with a qualitative approach, whose technical procedure was the bibliographic-documentary investigation about the existence of legislative guidelines, training parameters of specialized first responders and technical literature on pre-hospital care provided by police officers in combat environments. Results: firstly, a legislative gap was proved that leaves pre-hospital care in combat situations unregulated and, secondly, a training gap, considering that, despite the existence of specialized medical literature, this parameter is not adopted as a technical guideline in the training of police officers. Conclusions: it is advocated, as a public policy for the reduction of mortality due to intentional violence, that special norms be created that regulate the performance of police officers in specialized pre-hospital care and that effect the integration of these professionals as special agents of the Emergency And Emergency Network of the Unified Health System (SUS). It is also proposed, as an initial and indispensable condition, a national training program through which all police officers are trained to provide the first basic life support (BLS) that stabilizes victims of intentional violence.
Keywords: Emergencies; Intentional violent deaths; pre-hospital care in combat.
1. INTRODUCTION
Intentional violent deaths (MVI)[2] are a critical reality in Brazil. Every year, more than 50,000 lives are claimed by deliberate violence, according to the Brazilian Public Security Forum (FBSP, 2019a). In 2018, the rate of 27.5 homicides per group of 100,000 inhabitants was reached (FBSP, 2019a).
Specifically in relation to the violence suffered by police officers, it is reported that in 2018, police officers on duty killed during combat totaled 74 individuals[3]. This represented an increase of 5% compared to 2017, when there were 71 cases (FBSP, 2019b, p. 48). This is, in a preliminary analysis, mortality 2.5 times higher than that of Brazilian military[4] personnel on a peacekeeping mission in Haiti during 13 years of operation.
Considering that there were in Brazil, according to the last calculation, a population of 425,000 military police officers (EXAME, 2017) and about 115,000 civilian police officers (FEIPOL, 2019) – which total an absolute police population of 540,000 police officers – these 74 deaths per year represent 14 deaths per group of 100,000 police inhabitants. The rate of people killed in confrontation with the police, for example, is five times lower, reaching the level of 2.99 deaths[5].
If we also counted the police officers killed in off-duty combat, we would have a total of 198 deaths, which would be the 74 police officers killed on duty added to the 124 killed off-duty (FBSP, 2019a; 2019b, p. 49). This would amount to a rate of 36.67 deaths per group of 100,000 police inhabitants. The rate is 47% higher than the country’s average homicide rate in 2018 and an impressive 1,200% higher than the rate of people killed by police interventions in the same year.
If we add the 101 police officers who were suicide victims to the total, the rate would be 63.5 police deaths for a group of 100,000 police inhabitants. This indicator is 2.3 times higher than deaths in the general population and 21 times higher than the rate of people killed in confrontation with the police.
In this alarming scenario, the public health system responsible for pre-hospital emergency care, especially pre-hospital care in combat situations, gains relevance as a potential resource to mitigate mortality from intentional violence.
By pre-hospital care in combat or, by legislative terminology, Pre-Hospital Tactical Police Care (APHTP) it is understood, in a brief introductory synthesis, “emergency care outside the hospital, commonly linked to high-risk operations and armed confrontations (…) police” (CORTEZ et al., 2018, p. 7). These actions as a rule begin through tactical rescue, whose highest priority “is to rescue the wounded” by removing them from the most at-risk areas or “hot zones” to “warm areas, where they should receive the first effective care” (CORTEZ et al., 2018, p. 7 and 10).
It is appropriate, however, to emphasize that the provision of public services, including with regard to pre-hospital care, is regulated by the principle of legality. Individuals are allowed to do what the law does not prohibit; public officials, on the other hand, are only allowed to do what is authorized by law, understood here in its broad sense, which comprises the Constitution of normative administrative acts (RAMOS, 2017, p. 595).
It is observed, however, that that the most important legislation for pre-hospital care in Brazil, Portaria GM No. 2,048 of November 5, 2002, issued by the Ministry of Health, and Resolution No. 1,671 of July 23, 2003, issued by the Federal Council of Medicine (CFM), do not specify procedures for action in specific situations and scenarios in which victims of intentional violence and police officers are found. There are also unstandardized ethical and humanitarian components, such as the action required by police officers in the face of the need to provide aid to their aggressors.
On the other hand, these same governmental and CFM normative instruments require specific training and continuing education of professionals from the area of public security. These are indispensable requirements for pre-hospital care (BRASIL, 2006; CFM, 2003).
Faced with the problem posed, it is questioned: are there specific technical guidelines and legal regulations for the performance of police officers in specialized and immediate pre-hospital care for victims of intentional violence?
As a consequence of the inquiry, we aimed to describe the relevant aspects of technical-legal parameters, criticize the quality of the pre-hospital care segment in Brazilian combat and, from the investigation undertaken, suggest improvements.
2. MATERIALS AND METHODS
This scientific research is basic, as it aims to investigate the existence of legislative guidelines, training parameters of specialized first responders and technical literature on pre-hospital care provided by police officers in combat environments. From this, according to scientific objectives, it can be affirmed that the research is classified as exploratory in nature, thus understood as the purpose of which is “to develop, clarify and modify ideas, with a view to the formulation of more precise problems or verifiable hypotheses” (GIL, 1989, p. 45).
The corpus of academic work consists of research focused on the identification of normative documents, academic papers and similar texts that explain the legal attributions and technical parameters of action for police first responders in combat situations. It can be asserted, then, that the technical procedure adopted is bibliographic-documentary.
Bibliographic research “developed from already elaborated material, such as books and articles” (GIL, 1989, p. 71) is understood as bibliographic. Documentary is the research that “seeks information in documents that have not received any scientific treatment” (QUIRINO et al., 2014, p. 56).
Based on the differentiations proposed by Marconi and Lakatos (2003), one can classify the approach method employed at work as hypothetical-deductive, by seeking the perception of a gap in knowledge, about which hypotheses were formulated.
Taking into account that the study identifies problems and seeks to present possible solutions, it is classified, as the approach of the data studied, as a qualitative research, which is the one in which it seeks to “explain the why things are, expressing what should be done” (GERHARDT; SILVEIRA, 2009, p. 31).
3. RESULTS AND DISCUSSION
3.1 CONTEXTUALIZATION
Health is a social right enshrined in the text of the Federal Constitution. This prerogative must be ensured by “social and economic policies aimed at reducing the risk of disease and other injuries” and by “universal and equal access to actions and services for their promotion, protection and recovery” (BRASIL, 1988).
The current state policies of basic or primary health care are included[6], among others, cases of urgency and emergency[7]. Emergencies are linked to “health conditions that imply a risk of death or intense suffering, thus requiring immediate medical treatment” (CFM, 1995). Such emergency conditions are diagnoses verified by some type of medical declaration[8]. On the other hand, emergencies are “the unforeseen occurrence of health problems with or without potential risk of death, whose carrier needs immediate medical assistance” (CFM, 1995). This article, based on legislation that concerns the subject, will take urgent cases as “resulting from personal accidents or complications in the gestational process[9]” (BRASIL, 1998).
The care of victims of intentional violence in police combat scenarios is theoretically framed as urgent cases, considering that they are unforeseen occurrences resulting from personal accidents.
With regard to generic policies, the process of consolidating public policies of care to the urgent segment can be summarized as this:
A atenção às urgências tornou-se prioridade federal no Brasil em consequência do enorme desgaste vigente nos serviços hospitalares de urgência. No ano 2000, profissionais médicos pertencentes à Rede Brasileira de Cooperação em Emergência (RBCE) denunciaram em um congresso a falta de regulação sobre o tema e, a partir de então, um grupo de trabalho estabeleceu junto ao Ministério da Saúde as bases conceituais que instituíram a Política Nacional de Atenção às Urgências (PNAU). Identificam-se três etapas na implantação da política de urgência no Brasil: até 2003, produção das principais normas que instituem a política; de 2003 a 2008 predomina a implantação do Serviço de Atendimento Móvel de Urgência (Samu); e de 2008 a 2009 predomina a implantação das Unidade de Pronto Atendimento (UPA). A partir de 2011, foi instituída a Rede de Urgência e Emergência (RUE), priorizando-se a integração entre os componentes da atenção às urgências e o investimento menos fragmentado em componentes individuais da política (O’DWYER et al., 2017, p. 2).
The set of guidelines of the National Emergency Care Politic (PNAU) and the Emergency And Emergency Network (RUE) regulate fixed and mobile pre-hospital care (APH). The fixed APH is defined according to Portaria GM No. 2.048/02 in the following terms:
O atendimento pré-hospitalar fixo é aquela assistência prestada num primeiro nível de atenção aos pacientes portadores de quadros agudos, de natureza clínica, traumática ou ainda psiquiátrica, que possa levar a sofrimento, sequelas ou mesmo à morte, provendo um atendimento e/ou transporte adequado a um serviço de saúde hierarquizado, regulado e integrante do Sistema Estadual de Urgência e Emergência. Este atendimento é prestado por um conjunto de unidades básicas de saúde, unidades do Programa Saúde da Família (PSF), Programa de Agentes Comunitários de Saúde (PACS), ambulatórios especializados, serviços de diagnóstico e terapia, unidades não hospitalares de atendimento às urgências e emergências e pelos serviços de atendimento pré-hospitalar móveis (BRASIL, 2006, p. 66).
In this segment of fixed care, the Emergency Care Units (UPA), created after Portaria GM 2028/02, play the role of “health establishment of intermediate complexity between basic health units, Family Health units and the hospital network” (CFM, Resolution no. 2,079, of September 16, 2014, art. 2).
On the other hand, the mobile APH – in charge of the Mobile Emergency Care Service (Samu), rescue units and private sector ambulances, etc. – according to the same standard, is:
O atendimento que procura chegar precocemente à vítima, após ter ocorrido um agravo à sua saúde (de natureza clínica, cirúrgica, traumática, inclusive as psiquiátricas), que possa levar ao sofrimento, sequelas ou mesmo à morte, sendo necessário, portanto, prestar-lhe atendimento e/ou transporte adequado a um serviço de saúde devidamente hierarquizado e integrado ao Sistema Único de Saúde. Podemos chamá-lo de atendimento pré-hospitalar móvel primário quando o pedido de socorro for oriundo de um cidadão ou de atendimento pré-hospitalar móvel secundário quando a solicitação partir de um serviço de saúde, no qual o paciente já tenha recebido o primeiro atendimento necessário à estabilização do quadro de urgência apresentado, mas necessite ser conduzido a outro serviço de maior complexidade para a continuidade do tratamento (BRASIL, 2002, p. 81).
The degrees of complexity of the service provided by the mobile APH can be divided into basic life support (BLS) and advanced life support (ALS). The basic differences between the two modalities are related to the qualified personnel, the equipment employed and the freedom of professionals to apply procedures.
The advanced support is in charge of teams composed of higher education professionals from health (doctors and nurses), crew members of mobile health units with intensive equipment; basic support is practiced by professionals of technical or medium level (nursing assistants and technicians) or middle or higher level professionals not from the health area (such as police and firefighters), all of them crew members of mobile units with equipment for performing noninvasive or conservative procedures (BRASIL, 2006).
From a technical point of view, the BLS is primarily intended “for the maintenance, support or restoration of oxygenation, ventilation and circulation in patients with cardiac arrest, respiratory arrest or both” (MELO; SILVA, 2011, p. 28).
The legislation on BLS provided by police officers and firefighters indicates that they “make conservative intervention in pre-hospital care, under direct or remote medical supervision, using specialized materials and equipment” (CFM, 2003), or, in other words:
Podem realizar suporte básico de vida, com ações não invasivas, sob supervisão médica direta ou à distância, sempre que a vítima esteja em situação que impossibilite o acesso e manuseio pela equipe de saúde, obedecendo aos padrões de capacitação e atuação previstos (BRASIL, 2006, p. 92).
The rescue, the exclusive competence of police officers and firefighters, is the removal of victims from “places or situations that make it impossible for the health team to access” (BRASIL, 2006, p. 92). Tactical rescue, however, is a genre apart within the hypernym “rescue”. Competence is said to be tactical because it occurs in civilian environments subject to combat and the differentiated use of force[10], which excludes firefighters. Thus, in such scenarios, the police, or exceptionally the military of the Armed Forces scheduled for Law and Order Guarantee missions (GLO), are uniquely qualified to act in the rescue and immediate relief of victims of violence, the legal agents themselves wounded in combat and even the neutralized aggressors.
It can be seen, in view of everything, that the APH provided by police officers in combat environments and through tactical rescues are consequences of national public health policies.
3.2 LEGAL BASES
As already stated in a previous section, the attention to emergencies in Brazil was only discussed with necessary depth at the end of the 20th century. Professionals denounced in congress the lack of regulation on the subject. From then on, there was a movement of the Ministry of Health for the creation and implementation of the National Emergency Care Policy, with emphasis on legal regulation and the unification of continuing education strategies (O’DWYER et al., 2017, p. 2).
Until the advent of regulations and the requirement to set up specific education centers for APH, there was a training problem, consistent with:
Grande proliferação de cursos de iniciativa privada de capacitação de recursos humanos para a área, com grande diversidade de programas, conteúdos e cargas horárias, sem a adequada integração à realidade e às diretrizes do Sistema Único de Saúde – SUS (BRASIL, 2006, p. 134)
About two decades after the first generic federal regulations – and all the solid construction of the system, especially with Samu and UPA for generic APH – is that a public institution began to discuss specific standards for the tactical APH sector. The Ministry of Defense, the pioneer par excellence in the practical application of APH techniques in combat environments, organized in 2017 a leading event, as announced:
Os participantes do I Simpósio de Medicina Tática do Ministério da Defesa (MD), realizado entre os dias 26 e 29 de setembro, na Escola Superior de Guerra (ESG), no Rio de Janeiro (RJ), elaboraram as propostas de criação de Portaria Ministerial para normatizar o Atendimento Pré-Hospitalar Tático (APHT) e sugeriram a exigência de um currículo nacional mínimo para a capacitação em APHT (BRASIL, 2017).
The following year, Portaria Normativa No. 16 of April 12, 2018 was issued. In this normative instrument, which, it should be emphasized, has legal effects only for the professional classes of the Armed Forces, the Tactical Pre-Hospital Care Guideline (APHT) of the Ministry of Defense was approved.
According to the standardization, tactical pre-hospital care is intended for:
Emprego operacional, operação real ou de adestramento, ações militares de vigilância de fronteira, ações militares de operações de Garantia da Lei e da Ordem, ações relacionadas às atribuições subsidiárias das Forças Armadas, missões de paz e instrução (BRASIL, 2018).
The military personnel employed specifically in basic tactical-military life support, who do not come from the health area, are classified as level III tactical first responders.
It is up to the personnel of the tactical-military BLS, in the preliminary phase of biosecurity assessment: to analyze the situation; identify threat levels; establish access routes or meeting zone; apply the techniques of immediate actions; establish the numbers of victims and communication with the upper echelon. In the rescue stage, you must choose the withdrawal technique according to the operational environment and carry out emergency transport techniques. Finally, in the care phase itself, it is up to it to contain hemorrhages, assess and unclog the airways and stabilize the lesions (BRASIL, 2018).
In addition to having been previously trained in generic pre-hospital care and in combat, rescue or rescue courses, such Level III professionals must also undergo specific, theoretical and practical training, totaling 40 hours of class. From there, it is only according to these requirements, will be qualified to the tactical PHA, which, according to the standard cited, consists of:
No atendimento à vítima, em um ambiente tático, nas atividades militares, com o emprego de um conjunto de manobras e procedimentos emergenciais, baseados em conhecimentos técnicos de suporte de vida (…) para serem aplicados nas vítimas ou em si mesmos, (…) com o objetivo de salvaguardar a vida humana e prover a estabilização para a evacuação até o suporte médico adequado (BRASIL, 2018).
One can imagine that the problem of lack of legal and technical parameters for tactical police APH could be solved by subjecting police officers to Level III military training. However, as emphasized throughout this work, the ministry of defense standard is not applicable to military police officers who, despite being Auxiliary Forces, are part of state institutions subject to the regulation of the respective federative units. On the other hand, federal, federal and federal police officers are civilian professionals, not subordinate to the Armed Forces and cannot have activities regulated by them.
Thus, legally, the norms that regulate the performance of security professionals in APH require training requirements different from those of the Ministry of Defense, through courses managed with the participation of schools of doctors and nurses, local managers and the SUS, as explained by the CFM:
O treinamento do pessoal envolvido no atendimento pré-hospitalar, em especial ao trauma, deverá ser efetuado em cursos ministrados por instituições ligadas ao SUS, envolvendo as escolas médicas e de enfermagem locais, sob coordenação das Secretarias Estaduais e Municipais de Saúde. Deverá haver um programa mínimo que contemple todo o conhecimento teórico e prático necessário à realização eficaz dos atos praticados (BRASIL, 2003).
In the same sense, Portaria GM n. 2.048/02 determines that it is up to the Centers for Urgency in Education (NEC), “to organize themselves as spaces of interinstitutional knowledge of training, training, qualification and continuing education for emergencies” (BRASIL, 2006, p. 134). This should be done through interaction with public and private managers, with the Unified Health System and with higher education institutions responsible for training and training of personnel in the health area (BRASIL, 2006).
Last but not least, it should be recorded the ethical-legal conflict to which police officers are subjected in the possible need to provide support to people in conflict with the law neutralized during combat actions.
Resolution No. 34 of 17 December 1979, adopted by the United Nations General Assembly to regulate the conduct of law enforcement agencies, states in Article 6 that:
Os funcionários responsáveis pela aplicação da lei devem garantir a proteção da saúde de todas as pessoas sob sua guarda e, em especial, devem adotar medidas imediatas para assegurar-lhes cuidados médicos, sempre que necessário (ONU, 1979).
The rule, when using the terms “under your custody”, would apparently be directed at those applicators who have arrested or have in custody some individual. Considering that a person neutralized by the differentiated use of force would be automatically under the control of the neutralizing police officer, it has been that there is validity of the device for police combat scenarios.
On another normative front, Portaria Interministerial No. 4,226, of December 31, 2010, which establishes guidelines on the use of force by public security agents, determines in item 10(a), that “when the use of force causes injury or death of persons, the public security agent involved shall (…) facilitate the provision of relief or medical assistance to the wounded” (BRASIL, 2010).
From the joint analysis of the norms and based on the principles of human rights, in particular that of the according interpretation of human rights[11], it is necessary that, in the case, the best interpretation would be that in which, overcoming the environmental risks of combat scenarios, and with the aim of reducing human morbidity and mortality rates, police officers should be able to provide the first care of aggressors, guaranteeing them a greater chance of survival.
However, it should be emphasized that there are practical and emotional implications that cannot be concealed or fail to be discussed in the effort to reach a reasonable and feasible consensus. Of course, there is currently no technical regulation to guide safety professionals in the face of the human and ethical challenge posed, either for direct care or through the activation of medical services.
3.3 TECHNICAL BASES IN BRAZIL
The protocol of basic life support of the Ministry of Health for Samu provides for conduct of technical action of professionals in cases of care of victims or potential victims of intentional violence, such as suicide bombers, gunshot wounds, miscellaneous weapons or objects adapted to be weapons (fragments of glass, woods, sharp objects).
It occurs, however, that first responders in this type of pre-hospital care cannot access the victims without full security for care. The orientation, if they are the first to attend the place of care, is to wait for the arrival of police officers so that they evaluate and neutralize any threats, according to the express predictions of the SBV Protocols of Clinical Emergencies (BC28, BC29 and BC32), the Protocols of Traumatic Emergencies (BT8 and BT9) and the Special Protocol PE17 (BRASIL, 2016).
The national theoretical reference also emphatically defends the line of precautions alrelated to the safety of the place of care, making it clear that “the rescuer must initially be concerned with his own safety (…), he must first make sure that the place is safe before approaching the victim” (FREIXO; LEITE, 2013, p. 50).
In the same sense, the foreign doctrine of APH establishes that the absolute safety of the scene is the basic presupposition for the performance: “The first priority for all those involved in a trauma incident is the evaluation of the scene (…) which means ensuring that the scene is safe and carefully considering the exact nature of the situation” (PHTLS, 2019, p. 88).
This correct condition of care is precisely what differentiates the stages of APH provided by Samu from the stages of APH that could be provided by police officers in combat environments. This is the technical-legal gap in the care of victims of intentional violence that the Brazilian health system presents.
As is known, time is a crucial factor in APH, especially in the occurrence of intentional violence, which, due to magnitude, usually involve abundant hemorrhages, direct and cavitation allocated to important organs, chest damage conducive to hemothorax and pneumothorax.
Adams Cowley coined the term “golden hour”, later adapted to “golden period”. This definition consists of a dynamic time interval, less than or more than one hour, depending on the traumatic situation of each patient, in which “if the lesion is not controlled and oxygenation restored (…), the patient’s chances of survival greatly decrease” (PHTLS, 2019, p. 110).
Part of this golden period is not properly used in the occurrences of intentional violence because Samu professionals who arrive early at the scene before the police cannot act until the officers are fired and make the scene safe.
On the other hand, since there is no continued APH training program for police officers, either for general or combat care, even when they arrive early on the scenes before health professionals, the outcome of trauma occurrences usually boils down to the primary mobile APH , which, as seen in section 3.1, relates to a simple telephone activation of the Samu service, without the precedent and due stabilization of victims (which would be secondary mobile APH).
It is precisely within this technical-protocol-legal limbo that pre-hospital care in combat fits as an alternative that can contribute significantly to the use of the golden period and the consequent mitigation of deaths.
3.4 TACTICAL COMBAT CASUALTY AND CARE (TCCC)
The technical-scientific regulation adopted by this study to present the modality of pre-hospital care in combat is the Tactical Emergency Medical Support (TEMS), described in the Prehospital Trauma Life Support, Military Edition.
TEMS is Tactical Emergency Medical Support. The training program consists of a care system that, based on the principles of military medicine and those of conventional emergency medical services, is dedicated to increasing the likelihood of success of police operations (PHTLS, 2020).
In the same way as conventional APH, the APH recommended by the TEMS has as its most fundamental priority the safety of police-first responders. However, the evaluation of the scene, the risks to which police officers can expose themselves and the dynamics of care follow a completely diverse and specialized doctrine, the Tactical Combat Casualty and Care (TCCC).
The technique basically concerns specific conducts, based on the combat situation, according to operation zones and with service phases (PHTLS, 2020).
In the TCCC, the theater of operations is divided into geographical boundaries: safe zone, warm zone and kill zone. These are areas with dynamic classification, which can change depending on the evolution of the tactical scenario. Movement on the combat perimeter can cause warm zones to become hot and vice versa.
Death or hot zones are areas where there are active threats. In these spaces, the service phase of the TCCC is called Care Under Fire. All efforts of police teams will be focused on acting to neutralize users of firearms or carriers of other lethal instruments. The best technique is to overcome the opponent through the use of legal force.
It should be noted that, within the initial combat scenario in the hot zone, the exit of the aggressors from the space in which they were entrusted, the escape or the advance of criminals, the discovery of new aggressors or criminals in other positions are factors that change the geography of that zone and the duration of the Care Under Fire phase, because, as said, the scenario is dynamic and should be continuously reevaluated.
For injured police officers in action at this stage where there are still active threats, the only guidelines are the dragging of victims to safe shelters (warm areas), if possible, and the application of bleeding containers if necessary. If removal is not possible, the orientation is just to roll the injured unconscious face down (to prevent choking) and give remote instructions to the conscious wounded, while the team advances to the priority of this phase, which is to neutralize the threat and try to extinguish the hot zone. The same procedures apply to citizens, victims of combated violence, who can be accessed or contacted before neutralizing the active threat.
The temporary neutralization of the threat or the ceasefire makes the scenario evolve into a warm zone. It should be noted, however, that contained threats may still arise, new aggressors emerge and armed combat can resume. The threats are indirect, potential, and the security of the scene is relative. On the other hand, it is possible that part of the team is in a combat zone, hot zone, and another part of the police is barricaded and relatively safe in a warm area. In any case, for those who are injured who are in warm areas and can be attended to, the service phase will evolve to Tactical Field Care. It is at this stage that pre-hospital care occurs in combat itself.
During the Tactical Field Service, the police-first responders put into practice the mnemonic X-ABCDE[12] of the conventional emergency service. This is the evaluation criterion MARCH (Massive bleeding, Airway, Respirations, Circulation in Head/Hypothermia).
As described in PHTLS (2020): in the Massive Bleeding assessment, the rescuer identifies severe bleeding and uses direct pressure techniques, special bandages for gunshot wounding, tourniquets and anticoagulant medications; in the analysis of the Airway, the police officer seeks the best body positioning for the sick breathing and, if necessary, makes the application of nasogetic cannulas; at the evaluation moment of respiration, the attendant deals with the quality and respiratory movement of the victim, applying thoracic decompressors in the case of identified pneumothorax; in the investigation of Circulation, pulse and the presence of shock in trauma patients are evaluated, and the professional can adopt volume replacement measures and even intraosseous access; at the end of the field care, there is the Head/Hypothermia analysis, in which heat loss is preventable, with the application of thermal blankets, exposure and treatment of important fractures and cervical immobilization.
It is important to emphasize that this type of field care would not have room to occur in Brazil because Samu teams would be fenced for care in warm areas, due to security protocols, and most police officers would be inhibited by direct relief, because they were not provided with technical tools to act, even because there are more complex procedures in question.
The fact is that both police and Samu rescuers expect the victim to be removed outside the hot perimeter or that the perimeter becomes completely safe (a cold zone) for health teams to be able to act.
The present study, as already mentioned throughout the text, advocates that much of the lethality due to intentional violent deaths of the population in general and of the police is linked to this gap and delay in the provision of health services, because this stance limits the golden period, considering that:
Esperar que o doente seja levado para fora pode resultar em perda desnecessária de vida (…). A solução óbvia é que o suporte médico das operações táticas (…) seja executado por socorristas bem treinados e equipados de maneira adequada, capazes de agir no interior do perímetro isolado (PHTLS, 2019, p. 583).
After the completion of the Field Care phase, the TCCC is finalized with the definitive extinction of the threat, starting the Tactical Evacuation Care phase.
In this last phase of evacuation, the rescue is provided to the neutralized aggressors and the already stabilized patients, police or victims of the aggressor, are delivered to conventional medical care services – which have already been previously activated and positioned external perimeters or cold zones. Patients are then directed to referral hospital units for definitive treatment.
4. FINAL CONSIDERATIONS
In response to the research’s guided question, namely, “are there specific technical guidelines and legal regulations for the performance of police officers in specialized and immediate pre-hospital care to victims of intentional violence?”, the following conclusions were reached, the incident research on the legislative basis unequivocally confirmed the regulatory limbo to which the pre-hospital care area is subject ed in situations of intentional violence.
It was shown that the general legislation and technical protocol procedures for mobile pre-hospital care, even those directed to police officers, do not foresee any type of action in the hot and warm areas of combat environments.
Although there is standardization and training of military personnel of the Armed Forces to act in the aforementioned areas, such technical-legal parameters, for reasons of circumscription and constitutional competence, do not apply to the police.
As for technical aspects, the foreign technical doctrine of APH in combat is not formally adopted as a parameter of public training policies certified by NEC or the Higher Health Schools (Medicine and Nursing), not least because there is no specific training course aimed at police forces properly regulated.
In view of everything, it is concluded that the gaps proven by this research are a form of state omission, which results in disrespect for the right to health and, consequently, the right to life of Brazilians. This disrespect is manifested in three distinct groups of people: the general population, who cannot count on trained police officers, equipped and integrated into the urgent and emergency network to help them in situations of intentional violence; to police officers, who are launched in urban warfare operations, without the necessary preparation and integration into the health network to help themselves or peers; and persons in conflict with the law neutralized by the police, who are not the object of humanitarian and technical aid.
In other words, it was found that, with regard to the public care of victims of intentional violence, the constitutional ideal recommended by the public health system is not fulfilling the promises of “social and economic policies aimed at reducing the risk of disease and other injuries” nor the “universal and equal access to actions and services for its promotion, protection and recovery” (BRASIL, 1988).
In view of all this, we defend the urgent need for training of police forces in order to be able to reach victims of violence early and to carry out stabilizing interventions in them, potentiating the possibilities of survival.
It is necessary to scientifically discuss the theme between NEC, Higher Health Schools and police agencies. The SUS needs to develop and offer continuous training, certification and recertification in general APH and APH in combat for all police officers in Brazil. Police institutions and their agents must be effectively integrated into the Emergency And Emergency Network, through specific protocols. It is also necessary to define ethical and legal procedures for the care of neutralized aggressors, with the participation of public prosecutors corresponding to each sphere of action of the police institution.
What would be the cost and time of operation of something of such magnitude? It is difficult to say, but it is absolutely certain that the human, social, psychological and material damage of 50,000 deaths annually from intentional violence is absurdly greater.
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APPENDIX – FOOTNOTE
2. “The category Intentional Violent Deaths (MVI) corresponds to the sum of victims of intentional homicide, latrocinium, bodily injury followed by death and deaths resulting from police interventions on duty and outside” (FBSP, 2019b).
3. It is important to note that statistics do not take into account the deaths of federal police officers and federal highway police officers, whose staff are relatively small, but mortality rates are relatively higher. In the Federal Highway Police, for example, there is an average of 4.25 police officers murdered per year (RODRIGUES, 2019) for a staff of about ten thousand police officers (CARVALHO, 2019). That would represent a rate of 42.5 police officers killed by a hypothetical group of 100,000 federal highway police inhabitants.
4. Over 13 years (2004-2017), Brazil sent 37,500 military personnel to Haiti. There were 26 deaths, but most were victims of an earthquake that occurred in 2010 and not of combat actions (CHARLEAUX, 2017). On average, there were 5.3 deaths per hypothetical group of 100,000 military personnel.
5. Considering 6,220 deaths for a population of 208 million inhabitants (OLIVEIRA, 2018; FBSP, 2019a).
6. “Primary health care or primary care is known as the ‘gateway’ of users in health systems. That is, it is the initial service. Its objective is to guide on the prevention of diseases, solve possible cases of injuries and direct the most serious to higher levels of care in complexity. Primary care works, therefore, as a filter capable of organizing the flow of services in health networks, from the simplest to the most complex” (FIOCRUZ, 2020).
7. The technical differences between urgency and emergency are discussed in depth in an article by GIGLIO-JACQUEMOT, whose reference can be accessed in the list of bibliography of this article. We refer the reader interested in this reading to this reading, because the discussion is not part of the scope of the work.
8. Resolution No. 1,600 of the Federal Council of Medicine, dated March 10, 1995, directly regulates the subject, as it defines the “medical finding” as a characterizer of emergencies. Law No. 9,656 of June 3, 1998, which provides for private health care plans and insurance, indirectly regulates the subject by defining the emergency as situations “declared by an assistant physician” (Art. 35-C, I).
9. The aforementioned Law 9.656, according to Art. 35-C, II, places the factors personal accident or gestational problems as differentiating the urgency in relation to the emergency, with regard to the responsibility of covering health plans.
10. It is the “appropriate selection of the level of use of force in response to a real or potential threat aimed at limiting the use of means that may cause injury or death” (BRASIL, 2010).
11. By this principle, human rights “would be the key core of postmodern rights, all norms (internal and international) present in a given State and that reach, in one way or another, individuals subject to their jurisdiction, must be interpreted in accordance with these rights, that is, in accordance with international standards (conventional or customary) for the protection of human rights in force” (MAZZUOLI, 2016, p. 35).
12. It is also a mnemonic resource adapted from military medicine and brought to the latest versions of the “civil” PHTLS, replacing the former ABCDE.
[1] Specialist in Public Law and Urgency and Emergency, Bachelor of Law, Federal Highway Police and First Responder of Basic Life Support. ORCID: 0000-0002-9160-8657.
Submitted: August, 2021.
Approved: February, 2022.
