What EMTs, paramedics need to know about EMS body armor

Tactical and Disaster Medicine

EMS personnel must be familiar with the types of body armor and its practical on-duty use during patient assessment and care

This article, originally published May 18, 2016, has been updated with current information.

Ballistic protection in the form of vests for EMS providers is becoming increasingly common as part of standard PPE. While law enforcement personnel are accustomed to various types of ballistic vests and their capabilities, many in EMS are not, and this knowledge deficit could lead to a false sense of security. It is important that all EMS personnel issued ballistic protection have a basic understanding of its design and optimal ways in which to use it.

The need for ballistic vests as an all-hazard PPE for EMS personnel reflects their changing role and the constant threat of violent patient encounters.

The National Institute of Justice issued a publication entitled "Ballistic Resistance of Body Armor," which is used worldwide to establish minimum performance requirements and test methods for the ballistic resistance of personal body armor intended to protect against gunfire. When issued ballistic protection, take note of what is known as the "NIJ Threat Level" which should be noted somewhere on the product's labeling.

In general, the type of projectile that the vest is designed to defeat can be surmised by having an understanding of the six basic classification types:

Type I. This armor is designed to protect the wearer against smaller and lower velocity rounds such as .22 LR or .380 ACP. Its main advantage is being lightweight and less cumbersome on the wearer. This comes at a cost, however, in that the level of protection is low. Most agencies opt for a higher level of protection.

Type II-A (9 mm; .40 S&W). This armor protects against jacketed bullets of slightly higher velocity and mass. Many law enforcement professionals consider this level to be the bare minimum required for full-time duty personnel.

Type II (9 mm; .357 Magnum). This armor is heavier and has more bulk but gives more protection for higher velocity rounds up to 1400 feet per second.

Type III-A (High Velocity 9 mm; .44 Magnum). At this level, the wearer begins to be afforded protection from jacketed hollow point rounds. This is considered the highest protection available for most handgun rounds and is about the highest level one can obtain while still maintaining a low profile that might be concealed underneath a uniform shirt. However, its main disadvantage is weight and bulk making it less attractive for hot and humid conditions.

Type III (Rifles). At this level, the user begins gaining protection from high-velocity rifle rounds and is intended to be used by personnel in tactical situations, such as armed barricaded subjects with a rifle. It is not considered standard threat level for everyday usage.

Type IV (Armor Piercing Rifle). While this is considered the highest level of standard protection, it would be uncommon for EMS personnel to be issued Level IV ballistic vests. It is designed to resist "armor piercing" bullets and often uses ceramic plates which can be quite heavy and limit motion.

Standard ballistic vests are designed to trap the kinetic energy of a projectile and spread the energy over a larger surface area thereby preventing it from penetrating vital body cavities. Interestingly enough, it provides little, if any, protection from edged weapons and stabbing instruments.

Additionally, the remaining kinetic energy of the bullet must still be absorbed by the wearer. While the bullet may not have penetrated the vest, one can still suffer a great deal of blunt force trauma behind the vest.

The NIJ measures the backface deformation or backface signature of various vests to determine the depth of distortion that occurs on the rear face of a vest that sits against the user's body. Because of this phenomenon, it is important for any medical provider to look for rib fractures, pneumothorax, solid organ rupture or any other blunt force injury when evaluating a patient shot while wearing body armor.

Also, while body armor may provide some protection from fragments in an explosion — secondary blast injury, it does not protect against primary blast injury from a high order explosion.

No vest is truly bulletproof, and with the growing use of ballistic vests in EMS, providers must be familiar with the various levels of protection and the limitations inherent in this increasingly common form of PPE. It will be essential that EMS personnel familiarize themselves not only with these factors, but with the practical use of this piece of equipment by wearing it and practicing skills with it such as airway management, hemorrhage control, vascular access and lifting and moving patients.

David K. Tan, MD, EMT-T, FAEMS, is associate professor and chief of EMS in the division of emergency medicine at Washington University School of Medicine in St. Louis. He is double board-certified in Emergency Medicine and EMS Medicine by the American Board of Emergency Medicine. Dr. Tan remains very active in EMS at the local, state and national levels as an operational medical director for local police, fire and EMS agencies. He is chairman of the Metropolitan St. Louis Emergency Transport Oversight Commission, vice-chairman of the Missouri State Advisory Council on EMS, and president of the National Association of EMS Physicians. Dr. Tan is a member of the EMS1 Editorial Advisory Board. He also provides medical direction to EMS1.com and the EMS1 Academy.