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.
