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Home > Topics > Mass Casualty Incidents
February 18, 2014
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Tactical EMS
by Jim Morrissey

Standard EMTs need to be ready for active shooters

While tactical medical teams are helpful, the medics on the scene are often the ones who happened to be on duty

By Jim Morrissey

When it comes to the EMS/medical response to active shooter or mass shooting incidents, it seems the paradigm of EMS staging away from the crisis site and waiting hours before entering the scene is no longer acceptable.

Highly regarded organizations such as the International Association of Fire Fighters and the U.S. Fire Administration both have position papers saying as much. What is less clear is what kind of EMS responder will enter into what is now considered a warm zone once the threat is neutralized?

The regular on-duty engine company medics and standard EMS transport company medics should be there, ready to go in under law enforcement protection. Much like the guys and gals who go into an upside down automobile to render patient care, this is just another part of the job we signed up for.

Some medics, tactical medics especially, seem to think it should only be those who are vetted and attached to a law enforcement team that should go in. I have heard statements such as, "the law enforcement guys I work with trust me and I am not sure they would trust the regular guys," and "Only tactically trained medics should work in that environment."

While it is easy to agree that a tactically trained medic, or a special operations medical team would be ideal for these situation, the reality is it’s just not possible. We need to make sure that the vast majority of the EMS community is prepared to go into these inevitable situations.

The real world

This is an example of the concept, ideal vs. real spectrum. It would make more sense to see most, if not all EMS personnel, at least somewhat trained to work in this environment, rather than a select few who are very well trained to operate in a warm-zone situation. We only need to look at the recent headlines to see who the first-on-the-scene medical assets were: fire and EMS — often times one in the same.

They are the ones who work hand-in-hand with local law enforcement every day on many calls, including motor vehicle accidents and violent injury responses. They are one who will be there every time.

The fact is that there is no tactical presence of any kind for almost all active-shooter events — no SWAT team and no tactical medics either. It has been and always will be the regular patrol officer and other on-duty deputies, followed by a fire department engine company and whatever EMS assets are locally used in that system.

Statically speaking, active-shooter incidents resolve themselves within a few minutes, often before any responder shows up. In the meantime, it is very likely several people have been shot and are bleeding to death. Time is critical and we need to be aggressive, but safe in getting life saving assets into the scene.

Plan your response

Recent war experiences show that extremities hemorrhage is the number-one form of preventable death. Domestic violence induced mass casualty incidents likely have similar injury patterns. While law enforcement contact teams are seeking out and neutralizing the threat, a rescue task force should be mustering and ready to go in.

Law enforcement personnel must also have the knowledge and tools to stop severe bleeding at the point of wounding if the threat is mitigated. Concurrently, a rescue task force made up of law enforcement officers and EMS personnel should be preparing to enter the cleared, but not yet fully secured area where casualties are in most need of immediate life-saving interventions.

EMS should have a light, lean and ready team that is forward leaning and ready to go. Both police and EMS need to embrace the Committee on Tactical Emergency Casualty Care guidelines for point of wounding care.

Ideally, a command post that embraces the concept of unified command is set up just outside the crisis site. This should include law enforcement, fire, EMS and an agency representative who is familiar with the inner workings, layout and procedures of the facility.

EMS into the fray

Prior to EMS entry, law enforcement should give a briefing to EMS about the dos and don’ts, chain of command, emergency egress, room entries and communication. The EMS crew should also be prepared to split up if necessary.

The exact number and ratio of law enforcement and EMS personnel needs to be thought out by each agency and adjusted during training. The nature of the event, available resources and other factors will dictate the exact ratio and numbers as what’s appropriate. A recommended starting place for training is four EMS providers and at least six law enforcement officers to make up the rescue task force.

Active-shooter incidents rarely go from a hot zone to a cold zone quickly. Law enforcement officers know it is their responsibility to get into the crisis site quickly to distract, engage and hopefully eliminate the threat. Many fire and EMS agencies are still waiting for the “all clear” and may be staged for minutes or hours; not willing, able or allowed to get in and start saving lives.

Both EMS and law enforcement need to come together, train together and work together to better respond to these inevitable unfortunate incidents. Our job in EMS is to provide aggressive, safe and effective medical care while the patient is salvageable.

References

Callaway DW, Smith ER, Shapiro G, et. Al. Committee for Tactical Emergency Casualty Care (C-TECC): Evolution and Application of TCCC Guidelines to High Threat Civilian Medicine. J. Special Operations Medicine. Vol 11 (2). Spring/Summer 2011. P. 95-100.

Callaway DW, Smith ER , Cain J, et al. Tactical Emergency Casualty Care (TECC): Guidelines for the Provision of Prehospital Trauma Care in the High Threat Environment. J. Special Operations Medicine. Vol 11 (2). Summer/Fall 2011.

Comments
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Patrick Jackson Patrick Jackson Sunday, February 23, 2014 9:00:55 AM I agree completly. It has always frustrated me to watch these types of events go down and wonder how many lives could have been saved if EMS was right in there with LE.
Jeff Hogan Jeff Hogan Sunday, February 23, 2014 9:26:54 AM So scene safety no longer applies? I'm confused.
Jeff Hogan Jeff Hogan Sunday, February 23, 2014 9:29:31 AM I understand it is each individuals or crews prerogative as to "safe" or "secure", however this is flying in the face of what was pounded into my head.
Mike Hunter Mike Hunter Sunday, February 23, 2014 10:37:06 AM As a 30+ year paramedic I totally disagree. The average EMT has no business inside an active shooter scene. If an EMT or paramedic is training with law enforcement and armed, I have no problem with it, but not the everyday street medic. The issue that needs to be kept in mind is that most of these scenes do not need advanced life support. They need a tourniquet, direct pressure or a hand/dressing over a chest wound. This is all within the realm of an EMR or EMT which the law enforcement agency could train one of their own for this. All those in public service take risks, i.e. firefighters going into a burning building, urban paramedics/EMT's going into a housing project where violence could break out at any minute. But an incident that we know is violent is no place for firefighters or EMS personnel. The law enforcement folks can bring them out to us.
Willie Myers Willie Myers Sunday, February 23, 2014 2:13:50 PM Mr. Morrissey, In reading your article I would say I have some agreement and some disagreement in reference to this topic. I have over 30 yrs experience in EMS, 30 of which as a Paramedic and 24 of those years involving Tactical Medicine. And during that time I have assisted both local and federal SWAT and Special Operation Teams conducting TEMS operations. I have seen the benefits and flaws of having trained and non-trained individuals operating in a tactical setting. When I say non-trained, I’m talking about the weekend TEMS lecture involving a practical application where you dress up and work on scenarios for a couple hours and obtain a certificate of attendance. That’s not tactical medicine and I think you would agree. Recently over the past couple years and further if you wish to go as far back as Columbine. EMS has played a major role in the treatment and transport of patients injured as a result of an active shooter incident. There are motions by the International Association of Firefighter’s, Fire Chiefs, the Public Safety Community as a whole that discuss the application of having tactical medics as well as some that don’t feel it's their responsibility. Years ago, I was involved in a call out in Arizona where a local Police Officer was and shot and killed by a barricaded gunman. There was an Ambulance standing by, but they weren’t trained in TEMS. They staged away from the incident, and though the ambulance operated under a 3rd service agreement with the city, their orders on scene came from the Fire Department, which was to stand fast. The female driver of the ambulance had a police officer stand on the step board of her rig and pulled his weapon to order her to drive into a hot zone to treat the officer. My Sheriff's SWAT Team was called in to assume responsibility of the scene of which that incident happened prior to our arrival. Here was an incident where the local EMS provider was not trained in that area of application or lack of experience and was placed in a position I’m sure she didn’t want to be in. On a Fire or EMS scene of a motor vehicle accident, Firefighters and EMS have training to enter upon an over turned vehicle, stabilizing the vehicle and or patient(s) in those conditions and working together. Multiple assets on scene to assist if needed. Having the proper equipment and knowing how to use it, is the key. As a member of Tactical Unit, operating within a Tactical setting, the Tactical Medic consist of either 1 or possibly 2 or if your agency is lucky enough, they may have a division that's dedicated to Special Operations. In doing so, those medics train with their Law Enforcement Colleagues, learning the policies and procedures of that team, communication, physical requirements of that team. When the SWAT team PT’s (Physical Training), the medic is right their with them. You are correct, the Tactical team members want to know that the medic assigned with them can sustain the physical requirements and carry them if they are injured. Lets be honest, there are some medics that have a hard time getting out of their ambulance and are out of breath by the time they reach the 2nd floor of the apartment complex. Now we want to implement these same individuals in a tactical setting? Not wise. Don’t get me wrong, I agree with you that there should be a level of cooperation between law enforcement agencies and EMS as a whole to see how they could better implement guidelines to work together in the event of a Active Shooter incident or any tactical setting where the medic was in a operational position with the SWAT or ERT team. But not every prehospital provider. If the medic is part of the “STACK” meaning they are entering a hot zone with the team, wearing and carrying tactical gear (i.e.) bulletproof vest? Their medical bag?, there’s a question that should be asked? Are medic(s) armed?, are they trained proficiently with the weapon? And the types of weapon(s) used by the team? And even just as important, if need be, can the medic, under stress take possession of the downed officers weapon to save his/her life and or the officers life? Or did they just become part of the problem? That is the real world; the only difference is depending on the jurisdiction and the cooperation between agencies and the training implemented to sustain these individuals in an operational setting. Though the idea of having a Tactical medic on an operation is a plus and should be considered a win-win situation, if it’s not approached right, it could turn out to back fire on an agency when they depend on the medic and he/she is unable to operate in that environment. Those Fire and EMS agencies that can implement guidelines to work with local and federal law enforcement tactical units should do so and TRAIN, TRAIN, TRAIN. Can’t stress that enough. For the other agencies that can’t afford to send but 1 or 2 medics to training at any given time, see if you can work together to create a training platform for your agency. There a several Tac-Med programs around the country and don’t just complete one course. Thank you, Willie Myers, BS, NREMT-P, PSS, CPS Protective Security Specialist – Paramedic/Shift Leader Department of State - Diplomatic Security Service Office of High Threat Protection / WPS Embassy Protection Detail – RRT /QRF U.S. Embassy - Kabul, Afghanistan
Chris Strattner Chris Strattner Sunday, February 23, 2014 3:50:58 PM OK, so I get it that we are resistant to change, but EMS needs to take a harder look at what we are doing and be willing to open our minds to change and recognize that what we have been doing may not be the best way, and what has “worked” for years may not be working at all. But we can do it. MAST pants, anyone? When I was a young cop our basic plan for, well, pretty much anything dicey was to surround and wait for SWAT. It took a well-publicized job in Littleton Colrado for police to realize what we were doing wasn't the best way and we needed to do better. We realized that rather than wait for SWAT, an aggressive patrol level response to an active shooter was the way to go. In 2003, Illinois State Police did a nice clean study and showed how patrol response to active shooters prevented additional injury and death. So now it’s EMS’s turn. Nobody is suggesting Joe Q. Medic go running into a hail of gunfire, but at an active shooter scene, once that initial group of police puts some pressure on the threat and carves out a pocket of safety, the next group of cops should be grabbing the first few medics and getting them into that relatively safe area to do their thing – little triage, little treatment of critical life threats, little evacuation. This group of police and medics is called a Rescue Task Force. It’s a tactic for line police and line medics, not some kind of special team. So why not just wait down the block like we always have? Two big reasons. -Waiting = death for the victims. We all know how long it takes an arterial bleed, a tension pneumo or a closed airway to turn out the lights for good. Map those timelines against waiting for police to “clear” a structure of any size or waiting for SWAT’s SuperMedics to show up and waiting is just not an option. - And down the block is not always a great place to be. In the initial stages of these kinds of events (or really any violent event) the suspect may be at large and/or the total number of suspects may be unknown. Wearing a uniform might be a poor fashion choice, especially if you are unarmed. Medics are much safer standing in the middle of a group of good guys with guns than they are on the fringe of an incident undefended and just waiting to become a victim of opportunity or misidentification for a badguy. So are we ready to assume the risks involved with this? Sure we are. By vocation and duty we assume some risks all the time. We believe in the priority of life; that innocent patients (who didn’t sign up to be victims) deserve for the responding medics (who did sign up) to assume some risk to save their lives. And with training, equipment and support we know we can mitigate those risks better than the average citizen. Example? Here you go: - We carry altered mental status patients down flights of stairs every day. They might flop and flail and take us all tumbling, but since we have boards & straps and we know how to keep our center of gravity low and lean our shoulders into the wall, we ourselves can mitigate that risk. Not down to zero, but to something more in line with the potential benefit to the patient. And if we didn’t, those patients would suffer and might die. The sicker the patient, the more risk we are willing to assume: maybe the hypoglycemic can wait until an IV Snicker’s bar is available, and we stay put or take extra care in packaging. Maybe the CVA with the unstable airway goes down the stairs with two straps on a scoop because he needs surgery we just can’t do to fix his bleed. We risk a little more when the reward to the patient for immediate treatment is more. - We walk on 55mph highways. That’s dangerous work, but our trucks have lights & stripes and we know how to stay heads up so we help mitigate the risk. We can’t do it all ourselves, so the police work with us, and close some or all of the road to give us a little breathing room. It’s not totally safe, but it’s usually good enough to do our work. And if we didn’t do that work, those patients would suffer and maybe die. Just like above, if the patient is pretty stable, we will spend more time flaring off two lanes so we can carefully immobilize the spine, while the crushed chest that needs to be decompressed gets a sideways police car and slid out of the wreck and onto a board pronto. We risk a little more when the reward to the patient for immediate treatment is more. - Sometimes at those 55mph collision scenes cars are overturned. We can’t really mitigate that risk ourselves at all, so fire/rescue cribs the wreck to make it more stable and in we crawl. The risk is less thanks entirely to our partner agency, but we assume some risk. And if we didn’t, those patients would suffer and maybe die. And the patients from the wreck above are the same here. Stable patient gets a lumberyard’s worth of cribbing. Patient with respirations of 4 gets a couple 2x6’s and three 200 pound firefighters. We risk a little more when the reward to the patient for immediate treatment is more. The Rescue Task Force isn’t really any different than how we deal with the overturned car: we rely on another agency to mitigate but not completely eliminate a threat. The cops carve out a place that is safER than we would be if we were in the wind and on our own that allows us to risk a little bit for patients that seriously need us. If we train a little with the police, communicate between services at the command level and also at the line level, we can all start to implement the Rescue Task Force model, let the police press the threats and help us to save even more lives. Full disclosure, although I am an SME Instructor here http://www.albany.edu/ncsp/training/a2s2_tactics_operations.shtml and a police SWAT Sergeant cross trained as paramedic, my views are my own.
Brendan McStay Brendan McStay Sunday, February 23, 2014 5:30:53 PM Lots of things are pounded into the heads of EMTs, and have been for decades. Many of them are wrong.
Cyndy Peters Cyndy Peters Sunday, February 23, 2014 5:51:55 PM Would love to hear what my First Responder Friends and Family have to say about this article.
Cyndy Peters Cyndy Peters Sunday, February 23, 2014 5:59:58 PM Denise Romano, Michelle Franke, Christina Pearce, Robert McGraw, Chris Robertson, Mark Pollack, David C Adams, Brian Cross, Chris Shay, F Chino Batista,
Mike Branum Mike Branum Sunday, February 23, 2014 7:45:13 PM I have to agree with Mike Hunter. Unless and until we adopt the Israeli EMS model and allow our medics to carry M 16s, they have no business in an area they may encounter an armed hostile. If we can train soldiers to apply tourniquets. We can train cops. I would vote for arming EMS, but that is a lot less likely to ever happen.
Christopher Joe Christopher Joe Sunday, February 23, 2014 7:51:27 PM I agree 100%. EMTs need t prepared for ALL situations. And at the same time while we are concerned with scene safety, patient care is should be the top priority. The more time that we wait for the scene to be rendered completely safe, the less we can be effective in saving a life or limb. I don't know about you, but would you like to explain to the family member of a victim that you could have possibly saved their life had you gotten to them sooner but could not because the scene was not rendered completely safe so you couldn't go in? Further, the training involved would weed out weak EMTs not up to the challenge of the job. We all know weak EMTs who are working in their current job and should not. The more complicated the training, the more you weed out the weak people and retain the strong ones.
Robert McGraw Robert McGraw Monday, February 24, 2014 4:09:33 AM If this is something we see as a profession as necessary, then there needs to be a fundamental shift in training. This cannot be simply as is stated in the article "an update from law enforcement about do's and dont's,.." We not only need additional training but as with extrication, new equipment such as vests and weapons. We cannot just say we will enter these scenes with a 2 hour training class and be expected to be protected, know crime scene issues, law enforcement communication and so much more. We need more that a quick class to do that.
Sean Hemmingway Sean Hemmingway Monday, February 24, 2014 5:35:17 AM Who ever is placing this idea, has no idea how tense these situations can get Saftey is key, let the tactical and equipped personel go into the hot zone, and regular operational personel stay in the cold zone.
Keith M B Niederstadt Keith M B Niederstadt Monday, February 24, 2014 9:54:23 AM I know of a truckload of Combat Medics and Navy Corpsman(Marine Fleet) who could not only do what is needed and are in EMS, they could teach the class.
Michael Binder Michael Binder Monday, February 24, 2014 10:16:27 AM As with Hazmat and Technical Rescue calls, active shooter/tactical calls MUST be treated as a specialized unit call. We absolutely, positively cannot have un-trained, inexperienced, or unarmed personnel running around a scene until it has been either cleared or an evacuation corridor has been established. I whole-heartedly agree that all EMS providers and LEO's need some form of TCCC or TEMS training, but NO ONE needs to be placed in jeopardy without proper training, equipment, and experience. No system is perfect and I completely understand the need for immediate intervention in those situations, but throwing personnel into tactical situations with little to no training is reckless and irresponsible. Would you run into a Hazmat situation with little to no protection or training?

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