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Home > Topics > active shooter
July 08, 2014

Case study: Fire, EMS response to active shooter

The hard-and-fast rules of scene safety need to be reconsidered in active-shooter incidents where victims need immediate treatment

By Dennis Rubin, EMS1 Contributor

I worked my hardest to become and maintain National Registry Emergency Medical Technician - Basic (NREMT-B) certification right after I was appointed fire chief. I wanted to demonstrate the same skill set demanded of the members; leading by example is a long-time core personal value.

In the mid-1990s, I found myself impatiently watching the mail for my NREMT-B test results. Finally, the white tyvek envelop showed up. The hard work and effort paid off, the gold threaded shoulder patches would soon be added to all of my uniform shirts.

It seems like only yesterday that I was sitting in the front of the Fire-Rescue Training Center classroom at the Westgate Fire Station. The course instructors, Paramedic/Battalion Chief Larry Williams and his training staff, promised all of the students that if we worked hard and studied the textbook they would help everyone to get through the all-important final national registry examination.

After four weeks of class work, he was true to his word. The entire EMT class became NREMT-Bs. I likely didn't thank the chief and his team enough for their efforts. So, I give public thanks to Chief Williams and staff — better late than never.

"Scene is safe"
Chief Williams and his staff insisted that we be able to perform every required NREMT-B skill flawlessly. Each time a student would be put through a skills simulation, that EMT candidate would verbalize, "body substance isolation techniques in place by all responders."

Next, the class members would take a 360-degree look around the staged emergency medical scene. Perhaps the chief added a downed electrical power line or a crazed bystander wielding a knife for the trainee to contend with and successful resolve.

Once the area was cleared of obvious dangers, the student gave the "scene is safe." It was at this point, our practical skills instructor would respond back that he/she copied that body substance isolation equipment was in place and the emergency incident scene was rendered safe to enter.

This two-step process was drilled into everyone who participated in this emergency medical training program.

The real deal
Move the calendar up about 10 years. I knowingly participated in a major operation that broke the emergency "scene is safe" rule.

In fact, the incident called into question the long-standing wisdom about always making sure that the scene is safe before engaging in delivering patient care. As this event unfolded, it didn't seem like I would be engaging our personnel in this high-risk fashion.

It was Friday, March 11, 2005 just before 9 a.m. I was serving as Atlanta's fire chief. I had just completed a meeting at city hall when Paramedic Engine 1 provided an on-scene report of a man down at Martin Luther King Avenue just before Pryor Street.

Soon after, the fire company officer reported that there was a Fulton County Deputy Sheriff who had been shot and advanced life support protocols were being implemented. Being in close proximity to this alarm, I responded to see how I could assist.

We quickly learned that the deputy was fatally shot, but didn't know this officer was part of a much larger active-shooter incident.

On-scene command
The on-scene sheriff deputies were asking for help inside the courthouse for persons who had been shot in one of the courtrooms. I immediately declared a major medical event and asked for a mass causality response with four ALS ambulances.

Next, it was time to set up command on the trunk lid of my chief's car. The initial incident action plan was simple: ensure there were enough emergency medical resources to handle the victims who would soon be removed from the courthouse. We notified local hospitals to request the emergency departments prepare to manage multiple gunshot victims.

To complete the initial IAP, there were other issues that would have to be resolved. In particular, this large incident site would require tracking on-location companies and their assignments to account for everyone at the event.

This incident would also require command to establish a public information officer to keep the mayor's office informed of the fire rescue department's operations and to help with the media as requested. And it would be necessary to stage incoming units in an area that was safe for the evolving law enforcement operation and not blocking ambulance access or egress.

All great plans
Firefighter/paramedics and the necessary ALS equipment were positioned in front of the courthouse and in close proximity to the command post. My plan was that the serious to critically injured would be removed from the building and the pre-hospital care teams would be assigned a patient, an ambulance and on their way to the hospital as quick as possible.

The planned process was simply not happening. No patients were being removed from inside this very large judicial facility.

About then Dr. James Augustine, our medical director and assistant fire chief, arrived. I was quite pleased to have him at the command post asked him to validate the IAP. Dr. Augustine concurred and we intended to move forward with the plan.

A Fulton County deputy sheriff was assigned as liaison with the fire command post. The details that the deputy provided were not very promising.

Spotty information
The belief was that the sergeant who was murdered on the street next to the courthouse was in pursuit of a criminal who had escaped while being transported from the jail to the courtroom for this day's proceedings in a lengthy criminal case.

When asked if the alleged perpetrator was gone from the scene, the answer was a chilling "we are unsure." We asked more size-up seeking questions this officer.

  • Was the shooter operating alone?
  • Were long weapons or automatic weapons involved in the shootings?
  • Was there anyone else shooting inside of the courthouse?
  • Has the shooter(s) inside the courthouse been neutralized?
  • What are the locations of the people shot inside the building?

His answers to all of our questions: "We are unsure." The officer did say that a SWAT unit was being assembled in front of the building.

The potential life loss caused by the delay in reaching and removing the injured was a real possibility. Dr. Augustine strongly suggested that he should travel with SWAT into the hot zone to triage, treat and remove the shooting victims.

Going in
I reluctantly agreed to his heroic request. Dr. Augustine was assigned several firefighter/paramedics who volunteered to go into the hazard zone.

In minutes police made entry; immediately trailing SWAT was Dr. Augustine and two fire fighter/paramedics with a small amount of medical equipment. As each floor of the courthouse was systematically searched and swept for victims, the doctor gave a detail radio situation report to command. An operational line drawing of the building was updated at the same time.

The news from inside the building was not very good. There were two fatalities — a judge and a court reporter. Another deputy was in critical condition from a reported gunshot wound — it turned out the officer was beaten severely, not shot.

The deputy was treated and rapidly transported to a receiving facility where she survived. Another patient suffered severe chest pains. He was provided with pre-hospital advanced cardiac care treatment and transportation.

Finally, there were several other minor injuries. Those simple bruises and cuts occurred in people who were running to avoid being shot.

One major step that was missing, and I take full responsibility, was providing post critical incident stress debriefing of the members on location with emphasis on those who entered the hazard zone.

Questioning long-held wisdom
I had serious second thoughts about sending that team into a highly hostile and volatile dynamic situation. The only protection that my team was afforded was the coverage that SWAT members could provide.

As it turned out, quadruple murderer Brian Nichols had escaped the scene and was a lone gunman. Of course, this was unknown at the time of the entry into the hot zone.

After years of training pre-hospital care providers to ensure that the scene is safe, that wisdom is now being questioned.

The U.S. Fire Administration reports that the average active shooter event end within a few minutes. The Fulton County courthouse shooting in 2005 followed the average.

Generally a shooting victim's injuries are critical to life threading. The active shooter will likely use a high-powered, large-caliber automatic or semi-automatic weapon, causing critical penetrating wounds and hemorrhage. Evidence-based emergency medicine mandates immediate pre-hospital interventions.

The bleeding must be controlled or stopped, if possible. The patient's airway has to be opened and maintained as well. Fluid replacement may be needed quickly to restore perfusion. Finally, rapid transportation to a receiving hospital — preferably a shock-trauma center — will be the required. Once there, surgery is likely.

How to save lives
Armed with this information, it is clear that if there is any chance of saving human lives at an active-shooter event there are three mission-crucial steps that we have to provide.

  • Hemorrhage must be stopped.
  • Rapid removal to the treatment area for immediate pre-hospital care.
  • Expeditious transportation to a trauma-care facility.

If on-scene emergency medical care is withheld until the scene is safe, victim outcomes are clearly compromised. This emerging situation raises many questions, challenges and of course, opportunities.

The questions that must be answered are fairly simple to formulate, but very difficult to answer. Here are 10 of those hard questions.

  • Do we continue to use the mandate of scene safe or don't enter the area?
  • Is there a place for pre-hospital care givers to enter an active-shooter hazard zone?
  • Do we travel with SWAT during the entry and search for victims?
  • If EMS goes in to the hazard zone, what additional training is the need?
  • What personal protective equipment will be needed (bullet-proof vests, ballistics helmets, weapons, etc)?
  • What certifications and authorities (limited police powers) are necessary to perform this service?
  • What are the re-certification cycles for training?
  • What is the replacement cycle for the protective equipment?
  • What type of pay increase is appropriate?
  • Is participation in this type of program voluntary or mandatory?

Like military field medics
A program called Counter Narcotics and Terrorism Operational Medical Support, tactical medic for short, prepares paramedics to travel with SWAT units to provide care for injured public safety members. The framework was similar to a military field medic.  

Perhaps the tactical medic program could become the curriculum for the active shooter hazard zone entry process. Of course, the mission will be expanded to care for public safety officers and civilian victims.

Looking at the devastating active-shooter events in places like West Webster, N.Y. and Newtown, Conn., we need a different approach. If paramedics have been making tactical medic entries for years to protect police officers, we need to seriously consider expanding this program to add the growing numbers of victims of active-shooter violence.

Getting a verbal "scene is safe" before proceeding is still critical on most calls. But changing times and tactics make us rethink the absolute nature of that rule.    

Comments
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Thom Swan Thom Swan Saturday, July 12, 2014 3:30:02 PM I would respectfully suggest that the answers to those questions are best determined during consultation with your jurisdictions law enforcement agencies, including police, sheriff and federal agencies with a presence in your community. Don't be surprised if it becomes difficult to reach agreement. Cross-training medics (or cops) is just as expensive as cross training firefighter / medics. Any time you are asking personnel to perform multiple roles you will need to recognize and establish procedures for prioritizing roles during specific situations. In a dynamic on-going situation it isn't always a simple decision - do I need to response as a cop? A firefighter? A medic? I would suggest that in most jurisdictions, unless the primary LE agency already has a tactical medic program in place, it is safest and least expensive to place responsibility for immediate control of hemorrhage and rapid removal to the treatment area with existing law enforcement agencies. These are well within the scope of BLS First Responder training already provided in many law enforcement training academies and required of most law enforcement officers. In other words, they don't need to be trained from square one, they just need to be trained to address changing mission requirements in a more timely manner. So called "active shooter" events are complex and I believe most LEO/EMS/Fire Service agencies are ill prepared to respond to them. When agency administrators put their heads together I think a reasonable general response plan can, in most cases, be forthcoming without too many interagency pissing contests.
Pete Hannen Pete Hannen Saturday, July 12, 2014 6:24:54 PM These questions need to be addressed before an incident is actually occuring. The one question that doesn't seem to be looked at, is that some of your providers will not be willing to enter the warm/ hot zone. Plans, training and equipment need to be in place to make sure care is delivered quickly.
Jay Friberg Jay Friberg Monday, July 14, 2014 2:22:59 PM Urban Shield has been doing training like this for several years.
Jamie Orsino Jamie Orsino Tuesday, July 15, 2014 5:13:44 AM One of the realities of EMS is that it is fundamentally dynamic and evolving in a public safety arena that is often times static to the point of proud claims of "200 years of tradition unimpeded by progress." The term "safe scene" is a common example of that tradition. The Chief's article provides an excellent example of how the modern world defeats the ancient wisdom. The first arriving medics were under the impression that the "scene was safe" as they began to work on the first victim. As more info developed they realized that there was more going on.Did this new info cause them to abandon the first patient? Of course not. Did they take additional steps to increase their safety? Probably. What level of "safety" is insured at any scene by simply looking around. Any scene at which there is an injury to a human presents the possibility of a reoccurrence of injury to the responders. Workers are injured at construction sites because safety measures have failed and the likelihood of all safety measures being fully reinstituted prior to EMS arrival is slim to none. MVAs occur in the "office space" of EMS in which cars continue to move by the scene just feet from providers. Would we consider a standard in which we wouldn't respond to these two scenarios until they were rendered "safe" by accepted standards? The reality of the current world is that the intent of terrorists, either acting alone and for personal reasons or as part of a global effort, have created yet another challenge for EMS. The community needs to evolve in order to limit the risks. But the idea that we can simply sit on the sidelines during these events is unacceptable to the American people because the result has and will continue to be unnecessary deaths. This topic, expanded beyond the narrow focus of "active shooter incidents" is one of the glaring issues for EMS leadership. We need to develop a national strategy to mitigate the collateral risk to responders from intentional violence.
Daniel Gerard Daniel Gerard Tuesday, July 15, 2014 9:23:16 AM Urban Shield is an exercise, it isn't training.
Jay Friberg Jay Friberg Tuesday, July 15, 2014 9:28:57 AM Daniel Gerard Having been involved with US for many years I disagree. Any exercise is training.
Daniel Gerard Daniel Gerard Tuesday, July 15, 2014 9:35:49 AM Jay Friberg the goal of an exercise is to evaluate the capabilities of the personnel and to stress the system. It is a tool to determine if training is effective, and if plans will work. That is why the performance measures have to be valid and measurable. You cannot participate in Urban Shield or Medical Combat Warrior without being trained. The only thing you learn from failure is failure. If you are trained to operate in an environment, active shooter/SWAT/ERT/HRT, when you have an exercise and you debrief afterwards, you still go back and train to minimize that failure. Exercise is the test to see how well the instructors did when they trained you.
Daniel Gerard Daniel Gerard Tuesday, July 15, 2014 9:50:54 AM Jamie we have real-life situations every day that desperately need to be addressed. Is terrorism a problem? Yes, especially more so with domestic groups/cells than with international organizations. But we fail on a cataclysmic level every day because of the every day responses. When I worked in Newark, we would get dispatched for a 'seizure' or a 'sickness', in a housing project, where the housing authority would typically turn off the elevators after 6 pm...this was always a BLS assignment, so up we go 8 flights of stairs, O2, trauma bag, Reeves stretcher. Into the apartment, down a LONG HALLWAY, and into a back bedroom. No police, and because we only had 4 BLS units and 2 paramedic units to respond to 125,000/year, no back-up ambulance. Door shut and here we are...what is going to happen when something jumps off? Help is not going to get there any time fast...plus I am locked inside the apartment. No one taught us in EMT class how to defend ourselves. No one when we got hired taught us what to do when you are attacked. Fire Department goes on a job, they show up with 4 or 5 guys. Police show up, they show up with the capability to use escalating force to control a situation. The article mentions making the scene safe, sizing things up, etc. You and the author of the article and everyone else knows that never happens and never will. Skip always mentions when a provider gets assaulted. The reality is that many organizations do not provide the training needed to identify potentially hazardous scenes, or when they are developing or about to become explosive. Those organizations that do provide that training, I have not been able to find one that trains their people in self defense. Deescalation? Yes. Physically defending yourself when a situation goes off the beam...no. How many organizations even train their people how to restrain emotionally disturbed patients (EDP)? This is an everyday occurrence, and we abdicate this responsibility day in and day out by saying 'call the police'. The reality of the situation is that (1) many times these situations 'jump-off' just as we arrive on scene, with little or no notice, and poor or scant information being provided to dispatch (2) we restrain people every day without calling the police, the restraint of an EDP is just an escalation on the continuum of what we already do (3) We RARELY provide training for members on how to protect ourselves when confronted with an EDP and how to restrain that EDP (4) We forget that MEDICAL RESTRAINT is different than LAW ENFORCEMENT RESTRAINT. I agree with you wholeheartedly Jamie, we are never going to run from a dangerous situation. BEMS lead the way on that during the Boston Bombing, just as NYC did so many years ago. At the same time we cannot turn our backs on the everyday responses that we fail to provide adequate training, planning, and equipment for. Stay safe my brother - Danny
Paul Perry Paul Perry Thursday, July 17, 2014 10:15:17 AM Maybe it's time to pump up the pay if you want Tactical Medics.
Alan Coleman Alan Coleman Sunday, July 20, 2014 11:54:20 PM We have units that can deploy into Active shooter territory in full ballistic protection, BUT, only in the 'warm zone', warm not safe.. That is the zone that has been cleared by Armed Police, but as the situation is fluid and can rapidly change, 'warm' can become 'hot' very quickly. We are taught to look after ourselves, we do not engage in engaging the hostile, and have a set and rehearsed pattern of working to make it as safe as possible for the Paramedics on scene. Combat medics such as the UK MERT use weapons to protect their patient's and themselves. The scenarios here in UK are very different to those in other countries
C Van Houten C Van Houten Tuesday, August 26, 2014 12:07:39 AM Chief, I agree with all of your talking points and considerations that need to be made regarding this scenario. We must also highlight the need for an "IFF" procedure...Identifying Friend or Foe. Providing care in a "far forward, non permissive, high risk environment" is not for the ill prepared. Emotions and stressors will be running high, and we need to prevent "Blue on Blue" casualties as well. Another consideration is the ability of field personnel to perform in this environment. The willingness of the provider and physical limitations certainly need to be addressed prior to this type of incident. This is certainly a hot button topic, and many agency specific considerations need to be made regarding this type of response.

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