Early on the morning of February 20, 2016, New York City police officer Andrew Yurkiw was shot three times in the chest by a suspect wielding a .357 Magnum handgun after a car chase through the rough Bedford-Stuyvesant neighborhood of Brooklyn.
Yurkiw survived but sustained a “grapefruit size” contusion to his chest, according to his father, a retired NYPD officer who ironically was also saved when a gunman fired into his bullet-resistant vest 27 years before.
As fortunate as the Yurkiws were, body armor is not a panacea for all trauma. Its fallibility was tragically displayed during a SWAT team raid on a trailer in the small northwest New Mexico town of Gallup in May 2001. As the team of officers attempted to remove a man high on drugs hiding in a back bedroom who had been firing a weapon randomly, officer Larry Brian Mitchell entered the room amid a fusillade of fire. A single round struck him in the lateral torso between the protective chest panels. Mitchell died. A second officer was saved when a round struck him in his body armor.
Despite this and other similar tragedies, the number of officers saved by body armor far outweighs the number killed while not wearing it. Since 1972, more than 3,000 police officers have been saved by their body armor.1
In these violent and uncertain times, there is also a growing number of EMS personnel who wear body armor.2 This has been advocated by the Department of Homeland Security, especially when dealing with active shooter scenarios.3 According to DHS, “The incorporation of ballistic vests and the concepts of concealment and cover into the EMS and fire professions, when active shooter threats and situations warrant, will better protect first responders.”
While the protective benefits of vests are irrefutable, there are design and anatomic implications that don’t always leave the wearer unscathed, as evidenced by the closed wound sustained by Yurkiw and the penetrating wound of Mitchell. This is why familiarity with body armor’s benefits, limitations, injury potential, assessment and removal is so pertinent to EMS personnel.
Ballistic vests have been a staple of law enforcement since a surge in police shootings in the mid to late 1960s. The benefits of wearing body armor were supported by a 2010 study that found an officer wearing it who sustains a gunshot wound to the torso is 3.4 times more likely to survive than one who doesn’t.4 In New York City alone, 87 police officers have been saved by vests since 1978.5
Surprisingly, some officers prefer not to wear them, and some departments don’t require them. Issues such as comfort, mobility, undercover operation and cost are among the concerns. A 2013 Bureau of Justice Statistics survey of local police departments found 71% required their officers to wear body armor at all times, while 8% required it only in some circumstances.6
One issue agreed upon by many manufacturers and police officials is that not all vests are bulletproof. This is behind attempts to redefine the vernacular from “bulletproof” vests to “ballistic” vests or the preferred identification, “body armor.” Not only are not all body armors bulletproof, some models can’t stop a knife attack. Given the rise of ISIS-inspired attacks using knives and axes, this can be especially relevant to traumatic wound incidence and care.
The National Institute of Law Enforcement and Criminal Justice developed a ballistic-resistant body armor performance standard in 1972. This was updated in 2008 by its successor, the National Institute of Justice. At the core of the revisions was the reclassification of vests to accommodate specific bullet sizes and the contemporary threats, especially from assault rifles, law enforcement faces today (see Figure 1).7
Not all body armor is created equal. The major difference is the bullet-/knife-stopping power of the armor, whether it be Kevlar, ceramic or steel. The majority of level II, III and IIIA protection is provided by various models of high tensile-strength polyethylene (HTSP) fabrics such as Kevlar and Spectra. The amount of protection is determined by the number of layers of fibers. Andrew Yurkiw had a 20-ply vest, or 20 layers of Kevlar, where his father’s was 10-ply.8 Level IV vests will have either steel or high tensile-strength ceramic plates for the anterior and posterior torso.
HTSP alone is not effective in stopping armor-piercing bullets. With this said, the Level II vest is the most commonly worn by police officers because of its stopping potential as well as comfort over long periods of wear.
There is an erroneous assumption that if body armor can stop a bullet, it can stop a knife or penetrating object such as ice pick or syringe. This is not the case. The appropriate garment is determined based on the potential threat the wearer faces. For instance, a prison guard or even a first responder may face a penetrating object more frequently than a firearm.
Body Armor-Wearing Officer Fatalities
According to FBI statistics, 505 police officers were killed between 2005–14. Of those, 466 were killed by firearms, and 313 were wearing body armor.9,10 The location of the wounds, the bullet caliber and the reasons for fatal torso wounds are especially compelling and relative to mitigating fatalities as well as anticipating, evaluating and treating certain injuries.
Of the 313 gunshot fatalities of officers wearing body armor, 89 cases (28%) involved anterior/posterior upper torso wounds.11Figure 2 provides an indication as to where the bullet entered the victim officer’s body despite wearing a vest.12
The majority of fatalities occurred from handguns, but in this era of assault rifles and the need for appropriate protection on the streets, of the 19 incidents where the bullets penetrated the vests, six were the 7.62-caliber found in AK-47s, and three were from a .223 from an AR-15 rifle.13
“As these cases have shown, there is no 100% protection,” noted Jim Pasco, executive director of the Fraternal Order of Police.14
Examination/treatment insight would include an increased index of suspicion for unseen injuries in the chest rather than obvious penetrating injuries. However, meticulous evaluation of the thorax/abdomen must still take place to identify occult penetrating injuries, paying close attention to gaps in body armor and the neck, axillary and abdominal regions.
An increase in lower-extremity and junctional injuries is likely a result of the improvements in body armor. These junctional injuries are injuries to the inguinal, axillary and neck areas that are not amenable to tourniquet use. They can be challenging to treat and often require more time and resources to manage than traumatic amputations.
The perception of invulnerability can be deceiving. Wounds incurred to the wearer of body armor will be predicated on the level of vest versus the caliber and velocity of the bullet and where the bullet strikes. Resultant torso injuries can include blunt force trauma to internal organs that could produce lacerations and rupturing; vertebral disc injuries at the point of contact on the vest; potential for spinal shock; blunt force trauma to musculoskeletal tissue; and perforations of the skin.
Two important considerations when an individual wearing body armor is struck in the torso are knock-back and back-facing.
Knock-back is when the individual is struck in the vest and the transmission of force from the projectile pushes the wearer away from the path of the bullet. Some officers have reported being struck in the torso lifted them off their feet.
Back-facing is the more provocative phenomenon. In this instance, the bullet makes contact with the body armor, and if it is stopped without perforating the vest, the armor will still deform and continue into the torso, resulting in injury. This injury to the torso will resemble a gunshot wound due to superficial deformation.
Following standard protocols of the primary survey to ensure patent airway and the presence or absence of any bleeding, stabilize the patient in a comfortable position. Since the victim will likely be experiencing dyspnea, a seated position may be more comfortable in the absence of a spinal injury.
Gaining access to the wound site is easier than most anticipate. Because most armor designs have four-point Velcro straps, it may be easier and quicker to undo the straps, once you know where they are, than to try to cut through the vest’s material. This is an on-scene judgement call. If the victim is conscious and the injuries do not appear life-threatening, they may request you not cut the vest.
CPT Robert M. Levesque, PA-C, officer-in-charge of the brigade combat team trauma training program at Fort Sam Houston in San Antonio, who trains healthcare specialists (medics) on point-of-injury trauma management, says he teaches his students to access the casualty without cutting the body armor (if possible) so they can utilize that equipment should prolonged field care become a reality. He says body armor is designed with both quick-release and hook-and-pile fastening flaps. Both points of access offer near-instant access to the casualty without destroying the body armor.
“This is of particular importance during combat operations due to potential variability of evacuation timing and the possibility of encountering further enemy contact prior to patient evacuation,” Levesque says. “In that regard, cutting off the body armor compromises its integrity and exposes the casualty to greater risk of injury.”
This same philosophy can be translated into civilian incidents, especially in cases of an active shooter.
After completing the primary and secondary survey and implementing the appropriate care, transport the vest with the victim.
With the presence of small to military-grade weapons on the streets, not only police but emergency responders need to know the appropriate body armor to wear, its capabilities and limitations, and the mechanisms of injury and classification of injuries they may encounter.