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Tip: Active shooter response: Are you physically ready?

EMS1.com Tips



Everyday EMS
by Greg Friese

Active shooter response: Are you physically ready?


When news breaks about a mass shooting, I think many of us imagine or visualize at least these three scenarios.

Visualizing responder roles
First, if I were a teacher, how would I have taken action to protect the students in my care? Would I have been able to calmly and quickly escort them to an exit or guide them into a hiding place that offered concealment and cover?

Second, as a parent, how quickly can I get to my children's school? Would I cover the mile between me and my children on foot or with a vehicle? Once at the school, what would I do?

Finally, as a paramedic — and probably like all of you — I feel an urge to do what I am trained to do. Did you visualize applying a tourniquet to stop severe bleeding or inserting an oral airway?

Do you imagine these scenarios? Do you discuss the active shooter scenario in training and with your partners in law enforcement? 

Active shooter response
The response to active shooter incidents is evolving. Law enforcement is training the first arriving officers to move quickly towards the sound ofgunfire rather than establishing a perimeter or waiting for a SWAT team.

Another emerging change is that paramedics are escorted by a second wave of police officers into the warm zone to seek out patients. The paramedic treatment role is straightforward — triage, stop severe bleeding, BLS airway maneuvers, and pocket mask or bag valve mask ventilation.

But before you can do any of that you need to be able to reach the patient.

Paramedic physical readiness
I know of many organizations that are mentally preparing paramedics with training to respond into the warm zone with police officers, but I am not sure if we are physically ready for the task ahead. Have you practiced and are you ready to:

  • Rapidly exit your vehicle with a kit that contains triage tags, tourniquets, wound dressing, oral airways, and pocket masks?
  • Move under the command of police officers at a pace from a fast walk to a sprint for distances up to a quarter mile?
  • Drop to the ground or dive behind cover when ordered by your police officer escort.
  • Kneel at the side of a patient, after sprinting to reach them, on a hard surface for 30-60 seconds to assess circulation, airway, and breathing?
  • Spring back to your feet with your gear and move forward with the officers to reach more patients?
  • Defend yourself from a hand to hand physical attack?
  • Help one or two others drag or team carry a 180 pound patient behind cover and or concealment?

Readiness is multifaceted. There is a mental component of education and visualization. There is a technical component of applying lifesaving skills. The above physical readiness is not just the domain of only tactical medics. Every member of every ambulance crew needs to be physically ready.

Normally, I am strong believer that paramedics are at their best when they saunter into a scene, slowly walking and looking for clues and risks. But an active shooter incident is going to require repetitive bursts of significant physical activity.

What are you doing to make sure you are ready?

Author’s note: I appreciate the review and feedback of a final draft of this article by Chief Skip Kirkwood and Bryan Fass.


About the author

Greg Friese is the Director of Education for CentreLearn Solutions, LLC. He is also an e-learning designer, writer, podcaster, presenter, paramedic, and marathon runner. Read more from him at the EverydayEMSTips.com blog. Ask questions or submit tip ideas to Greg by e-mailing him at greg.friese@ems1.com.
Comments
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Lou Sckunt Lou Sckunt Thursday, January 03, 2013 11:17:24 AM This article goes against everything we are trained to do and not trained to do!
Jacqueline Anne Jacqueline Anne Thursday, January 03, 2013 12:28:27 PM You are def right....This guy is retarded...no off the street medic is going onto an active shooter scene...if ya want to do that ur in the wrong civil servant profession.
Lou Sckunt Lou Sckunt Thursday, January 03, 2013 12:34:34 PM Your kinda cute want to play active shooter in the bedroom!
Marquez First-Response Marquez First-Response Thursday, January 03, 2013 4:54:19 PM Jacqueline and Ben, In all seriousness if you had loved ones that were one of the casualties in a massacre like that and you had some training and protection from law enforcement....you would rather sit back?
Lou Sckunt Lou Sckunt Thursday, January 03, 2013 4:58:12 PM First of all you dont know me or her and have no clue about what training we both have! But the fact remains its not the job of EMS to go into an active shooter incident until the threat has been eliminated! If you want to go in and eliminate said threats then liisten to what Jackie said and go into police work!
Marquez First-Response Marquez First-Response Thursday, January 03, 2013 5:23:11 PM Calm down, there is no hostility meant here. Your point is valid, I am of the mind set that we need to change our ways. I am not talking about being a tactical medic or Rambo, your a trained professonal who can handle a traumatic patient, For us to be sitting outside, while a child is bleeding out just inside the door....we are telling these families that their child's life is an acceptable loss.
Greg Santa Maria Greg Santa Maria Thursday, January 03, 2013 6:25:36 PM Glad to see EMS professionals attacking each other. Maybe sticking to the issue instead of name calling would probably be better. CFFA, I would beg to differ with your opinion. Paramedics are valuable and protectable assets in MCI's and without extensive tactical training, will not be effective in moving into and reacting in hot and warm zones. Using the scenario of a child inside a door bleeding out doesnt change the fact that the shooter is not mitigated and as soon as that door opens, shots get fired and the people most qualified to prolong life are now out of the picture. You have just removed any chance of the childs survival. I have been around a long time and would not be moving into a potential line of fire or educating my students to do so. Since the inclusion of "terrorism response" in our training circa 1994, we have gone out of our way to teach responders about extended scene safety surveys and not becoming victims. I would be disheartened if we saw a trend to forgo safety and began a return to our old rush in regardless mindset. I also believe that law enforcement might have some input into this in regards to bringing untrained personnel into a scene. Im sure they would not venture to do so. All that said, I see a point that Greg Friese is trying to make, but I think we need to take it further and evaluate a need for tactical training for medics, which would include meeting the requirements mentioned in his article as well as integration with law enforcement, etc.
Marquez First-Response Marquez First-Response Thursday, January 03, 2013 6:33:23 PM Greg, your input is appreciated. Lets fix this.
John Dwyer John Dwyer Thursday, January 03, 2013 7:39:56 PM Ben is correct, this does go against everything we are taught about scene saftey. If, however, you take a TCCC course, you learn that lives are saved by simple use of IFAK compinents - tourniquets, quick clot agents, Chest seals, and airways. Look at the statistics for the Tuscon shooting last year to see what a few trained folks can do. Note that in the article, you have dedicated, armed police protection when you enter into the unsecure scene. You are not alone. I cringed when I read about the wounded firefighter in New York that waited an hour and then was driven to safety (and treatment) in his own vehicle while being assisted by a civilian passer by. There is a delicate balance between being to bold and to cautious.
Lou Sckunt Lou Sckunt Thursday, January 03, 2013 7:54:28 PM Sounds like what Greg Marie said is the same as what I said! No one is name calling but lets face it Ive been a Cop, Paramedic, and a Security Contractor over seas protecting diplomates and contractors alike and if you told me to go into a HOT scene with say 2 cops to an active shooter senario I'm not doing it! Those two get ambushed and killed well guess who's next! Think of it this way! I have participated in many active shooter training scenarios as a cop and have learned one think that that contradicts everything you may have said...An active shooter is always ALWAYS dealt with my uniformed patrol! So how many cops are policing a suburban town per se? 4 on a day shift? So when that call comes in the first cop there has to go in and eliminate that threat! No waiting for back up ever! So before EMS ever gets dispatched, chances are the threat has be mitigated! Now like Ive said in the past to other similar threads it would be wiser to brush up on your USAR techniques and symbols showing what rooms have already been searched so things do not get redundant and victim search can move more proficiently! Swat medics are a noble idea but no swat team can mobilize fast enough to deal with an active shooter unless its a huge inner city with say an ESU or SRT teams paid full time on the streets! My.02 take it for what its worth!
Friday, January 04, 2013 1:29:54 PM My thoughts here are for parents and other personnel rushing into an active shooter situation. If you look at major shooting situations such as Columbine H.S. and the Aurora theater, and the most recent school shooting, really bad things happen when parents and loved ones (and even unrequested emergency responders) rush into situations where they have NO business being and are a hinderance to ES operations and to themselves. Instead of trying to figure out if they are in shape to make the dash to the scene (leaving cars locked and blocking ES response[ in all 3incidents]) we should be making sure that all parents are well aware of the emergency procedures followed by their children's schools[Lock Down, Fires, Evacuations and an Active Shooter]. It is a really tough situation but when parents attempt to get to their children - whether it is an active shooter, a fire, earthquake or other 'All Hazard' situation - they create more confusion and divert ES resources from the situation to control them.
Friday, January 04, 2013 1:50:29 PM First-Response Traing Marquez 'An acceptable loss' - NO. We are saying that several lessons have been learned over the years from these horrific incidents include; Restricting the 'Good Samaritans' that want to help but cause even more chaos and confusion with their efforts. Identification of the good guys becomes impossible as these people try to assist but are indistinguishable from a potential shooter who may also be leaning over a victim. The ACTIVE SHOOTER program available through the Emergency Management Institute @ FEMA.gov is a free course that provides insight on the current practices and recommendations by emergency services for an active shooting incident.
Greg Friese Greg Friese Saturday, January 05, 2013 11:46:24 AM Thanks. You have identified a key point "dedicated, armed police protection" which is much different than charging into the hot zone. Stay safe.
Greg Friese Greg Friese Saturday, January 05, 2013 11:47:35 AM Ben, I really like your suggestion that training should also focus on marking searched areas and how to avoid duplicate efforts.
Greg Friese Greg Friese Saturday, January 05, 2013 11:49:43 AM Hi Jacqueline, I am happy to engage in a conversation about the merits of the idea, as many other are, but name calling won't help improve our readiness. Paramedics are training to do the tasks described above. I am questioning/encouraging paramedics to be physically ready to respond if called upon (and escorted) by law enforcement.
Greg Friese Greg Friese Saturday, January 05, 2013 11:51:08 AM I am not sure there is going to be much we can do to keep parents from rushing to the scene. Dedicating enough personnel to barricading will likely compromise other functions. How would you keep parents away or corral them?
Greg Friese Greg Friese Saturday, January 05, 2013 11:53:35 AM Greg Santa Maria Thanks Greg. Without physical readiness and fitness we might be of little use in a rapidly developing situation. Our trained and imagined response needs to be matched with actual physical ability to do what we are called to do.
John P Miller John P Miller Saturday, January 05, 2013 4:03:09 PM yeah Right
John Berry John Berry Saturday, January 05, 2013 4:18:24 PM Active shooter situations can quite often involve large areas. A multi story school, office building, things of that nature. Or one that we encountered this past summer, an active shooter on foot walking city streets. If its in a large building, do you wait for the entire building to be secure? If its out on the street and suspect is moving do you wait until he is down or secured before you move to treat patients?
Daniel Katzenstein Daniel Katzenstein Sunday, January 06, 2013 2:20:00 AM The moment we leave the break room to answer a call we have opted to raise the level of risk that we are exposing ourselves to. When we run hot, we are further increasing that risk, when we treat a patient with a communicable disease we are exposing ourselves to risk. In the above scenarios we manage our exposure to "reasonable" risk with appropriate countermeasures (lights & sirens and PPE). One element not focused on is the risk of the patient we run hot when the patient is imminent danger etc. That is the danger to one patient but what of multiple patients. In active shooter situations as in most dynamic extreme MCI's, burning buildings, sinking ships etc certain pre-planned extensions to our risk mitigation protocols should be put in place. I might add that going in to a WARM area perhaps should be voluntary. Similar to military volunteers for hi-risk missions. On a personal note - In my post-Sandy Hook analysis in addition to the numerous terror attacks that I have responded to in Israel I would opt in to a WARM or questionably safe scene to potentially save lives in an MCI.
John Berry John Berry Sunday, January 06, 2013 7:01:17 AM My favorite thing to tell people new to EMS, the definition of a safe scene in EMS?? There is NO safe scene in EMS.
Marty Caldwell Marty Caldwell Monday, January 07, 2013 10:41:08 AM Greg You are absolutely right. and I am not sure what the answers are other than making parents aware of protocols and policies in place by the schools (Through PTA?) and other facilities with large volumes of people both kids and adults. I would appreciate any comments and thoughts from the ES community. MFC
Greg Friese Greg Friese Monday, January 07, 2013 11:10:12 AM Thanks for joining the conversation. I think the Hot, Warm, Cold descriptions to scenes is useful for analyzing and understanding risk and making decisions about mitigation and acceptance.
Greg Friese Greg Friese Monday, January 07, 2013 11:11:28 AM John, I think you are sharing my opinion that care needs to begin before the scene is "safe" and that care may begin in a warm zone - are area where potential harm does exist but is not within the visual field of the shooter. Thanks.
Marquez First-Response Marquez First-Response Thursday, January 10, 2013 4:57:30 AM We all hope that we never have to encounter such a tragedy as the one that took place in Connecticut but that does not mean we should not be prepared to act immediately in the event it does. This tragedy should have everyone in Emergency Medical Services, law enforcement and other agencies reevaluating protocol. Are we REALLY doing all that we can to get medical attention to the victims in the most expeditious manner possible? We as EMS professionals (Fire and Ambulance) need to step up our game and show the community that we want to make a difference and that we are prepared to assist in a moment’s notice. What most people in our community do not know, is that during or immediately following a shooting, Fire/EMS are not allowed to enter the building until such time as the subject has been detained and the building has been secured, meaning that the building has been checked for other potential assailants and/or any potential life-threatening devices. Nationwide most S.O.G’s have Fire/EMS stage and wait until the building has been completely secured. On average S.W.A.T will not arrive on the scene until after the incident is over. Meanwhile Fire/EMS are staged and ready to go but are not allowed access. As in any emergency situation...time is of the essence and it is often during that "waiting" period that lives are lost. Those that may have survived with immediate care will not make it. Let’s flip this around. If your child or loved one is injured and waiting for medical assistance, is that policy acceptable to you? Are you going to stand by and wait when you know that a few minutes or a few seconds could mean the difference between life and death for your loved one? As professionals we know that having the ability to provide immediate medical attention could be the difference between life and death. I believe Fire/EMS’s answer could lie within a program called the Swift Assisted Victim Extraction (S.A.V.E.) which implements a proactive plan to have Fire/EMS assist in mitigating the aftermath of such a heinous act. When implemented, it will allow our first response teams (medics included) to access the building and to provide immediate medical care to those in need that would otherwise have to wait until the building has been secured. The S.A.V.E. program should not be confused with a S.W.A.T. medic class. It is a program that stands alone and can be taught to every EMT and Paramedic (whether Fire or EMS) and can be implemented by any department or agency. The S.A.V.E. program is a train-the-trainer program which will allow each individual department to teach and implement the program in-house. Everyone’s perspective and input on this post are all valid and important. I found this program and it addresses many if not all of the concerns mentioned. The bottom line we as a profession need to evolve with these violent times.
Mike Ledgerwood Mike Ledgerwood Monday, February 04, 2013 4:36:06 PM Not a fan of this article. As a former cop I am trained in active shooter response. Medics will NOT be brought in until an area is deemed safe. If the area is dangerous we will bring the patient to you. You are no good to anyone if you are hurt or dead. We have tactical medics for a reason. Standard Medic / EMT's will NOT be going in escort or not.
John Berry John Berry Monday, February 04, 2013 4:47:36 PM Mike, define deemed safe. If you have a school shooter, multiple victims in a room, know the shooters location and there are multiple cinder block walls between shooter and said room would that room be safe? ( I am a tactical medic so I know its close to a non issue for me, but for others? )
Mike Ledgerwood Mike Ledgerwood Friday, February 15, 2013 8:36:22 AM Demed safe means we know where the shooter is. We will not allow ANYONE including medics into the scene if the location of the shooter(s) is unknown. Additionally, we will not let them in if there is an additional threat such as explosives. Medics are of no use to anyone if they become victims. In your example john, I probably would not determine it safe for medics to go in. High powered rifle ammunition can travel through cinder blocks. However, If in your situation the shooter was using say a handgun and had made no threats of explosives or other shooters then I might let medics in under escort.
Chris Combs Chris Combs Sunday, May 05, 2013 6:41:23 PM There is a great program called the S.A.V.E. system which came about after the Columbine Shooting. Check out their website survivaloptionservices.com.
Nathan Stanaway Nathan Stanaway Friday, August 09, 2013 4:59:24 PM Great article Greg. I hope folks take it to heart.
Greg Friese Greg Friese Sunday, December 08, 2013 5:23:28 PM Sorry the reply, but thanks.
Chris Strattner Chris Strattner Friday, January 03, 2014 12:06:29 PM So what this article is describing is called the Rescue Task Force. It's already in use in pockets across the country - Arlington, VA started using it some time ago, kind of perfected the tactic and now departments in Ohio, Los Angeles and elsewhere are using it. In New York, all EMS personnel can take Rescue Task Force type training for free at the State Preparedness Training Center (Full disclosure: I am an instructor there.) Basically, the idea is this: we already put ourselves in dicey situations: icy highway crash scenes, fire grounds, violent encounters, so we need to wash the "all scenes must be 100% safe before we can enter" ideas out of our heads, because we don't live that way in the real world anyway. The tactic is simple: first few cops arrive and press on the threat, eliminating it or driving it away. Next few cops grab the first couple medics and follow in the "wake" of the first few cops hunting for serious life threats and doing triage, communicating back the severity and location of patients. We need this. - The first few cops are risking A LOT to press on that threat. To do that effectively, they need to know that medics are steps behind them if they have a bad day. Your presence and this tactic help give them the courage to press hard. - Next, in multiple aggressor events, you are no safer out front or even down the block than you are standing next to people who can defend you, actually, you are probably a lot safer next to good guys with guns. - Patients need this because they bleed to death fast. Yes, Law Enforcement has been training in combat lifesaver/TECC style self and buddy aid more and more, but they can't be cops and medics at the same time - they can't pull their own security while their heads are down putting on a chest seal or applying a tourniquet. And we all know exsanguinating patients can't wait for the structure to be "clear." I had the good or bad fortune of responding to gunman with a hostage at a suburban middle school - it took us hours after the suspect was in custody to get the building cleared. Look back at Columbine - Mr. Sanders waited and waited and waited until he died, even though there were paramedics a few hundred yards away. Look at some other, more recent incidents: Mumbai, Navy Yard, Binghamton, the list goes on. We need a better plan to get advanced care to those patients faster, under 'somewhat safe' circumstances. I know there are some naysayers - I had some serious questions at first, too. Go Google "Rescue Task Force," take a look at the LA times article with the link to the LAFD policy, look at the NY Times article, The Daily Beast article. I'm sure once you understand the tactic and the "why" driving the tactic, it will seem like a good idea.
Harold Hayes Jr. Harold Hayes Jr. Sunday, July 13, 2014 3:19:40 PM Train Train Train, no such thing as Perfect! Over confidence gets people killed! Then Train some more! PGPD/ EST
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