Updated Jan. 5, 2015
In Washington, D.C., the Department of Homeland Security’s Office of Health Affairs, along with several other federal agencies, convened a two-day stakeholder’s meeting related to IED and mass shooting incident response. The session was moderated by Kathryn Brinsfield, M.D., acting assistant secretary of health affairs and chief medical officer for DHS.
The goal of the session was “to assist local, state, and national non-governmental organizations with improving survivability (of first responders and victims) and improving interoperability between law enforcement, emergency medical services (EMS), and fire professionals responding to IED and mass shooting incidents” by providing a venue for information-sharing and collaboration on how multiple agencies from multiple emergency response disciplines can best work together during responses to these types of incidents. The group was composed of chiefs, directors and senior leadership from local law enforcement, fire and EMS agencies, as well as federal law enforcement, national emergency response agencies and the Department of Defense.
William Sugiyama, a conference panelist and president of the International Association of EMS Chiefs, said, “In the management of these types of incidents historically … patient care considerations have often been secondary to tactical decisions when our ultimate goal is patient survival … these types of incidents are dynamic and require information-sharing, interdisciplinary coordination and prioritization of objectives. Maximizing patient survival is a primary objective across all disciplines.”
Special Agent Section Chief Chris Combs of the Federal Bureau of Investigation Strategic Information and Operations Center gave an overview of the active shooter incidents that have occurred across the nation. This was a critical review, as it emphasized the similarities between these events even though they were in very different locations.
A large portion of the conference focused on care for patients and emergency responders related to bleeding control and the use of tourniquets. Evidence was presented about the potential number of lives that could be saved with the widespread deployment and use of tourniquets, both related to mass shooting events and during daily operational responses within our communities. The discussion emphasized the use of tourniquets not only by EMTs and paramedics, but referenced the military’s training and use by all personnel. The session focused on deploying tourniquets as a “best practice” for all first responders, including law enforcement and fire personnel in addition to EMS responders.
During the discussions regarding care for injured victims and emergency responders, the group demonstrated the widespread differences among agencies in regard to the level of equipment and methods currently employed to care for patients. Some agencies reported having tourniquets, quick clot and small first aid kits deployed in each police vehicle, while others with limited resources rely on EMS to provide all emergency care and treatment. Some law enforcement agencies have very aggressive EMS response that will move forward into the “warm zone” to triage and treat patients, while others still operate under the principle that EMS and medical care only occur in the “cold zone.”
A common theme that came out of the discussion is that widespread training of all first responders in the appropriate use of tourniquets, as well as the availability of the equipment, is quickly becoming the best practice for the most positive outcomes. One police chief from a panel discussion showed the “red bag” carried in each police vehicle, which includes tourniquets and other basic first aid equipment. He also emphasized the importance of the kits being readily available and easily located in the time of emergency; he ensures this for all officers in his department by putting the red bag in the same location in all police vehicles: on the headrest of the passenger seat, in clear view and with easy access.
The conference also focused on the coordinated response of multiple agencies and disciplines, with a consistent message that we all must work together as emergency responders to form one unified command and approach to these incidents, and to work together for the best outcomes for everyone involved. A great deal of discussion surrounded the use of the incident command system and how in most cases, we all are using some form of incident command system. However, between law enforcement agencies and EMS/fire, the terms of structure may be slightly different. The theme that emerged is that we must start to practice unified command structures in the smaller events that the agencies handle together daily, in order to best operate as one emergency response system when the larger incidents, such as an active shooter incident, occur. A common message among the participants was that emergency response agencies should include one another as observers or participants in each other’s trainings, so we can further understand how we each would respond to an incident.
As mentioned earlier, one of the topics that engaged the most discussions among the different disciplines is the use of EMS in the warm zone to provide triage and rapid treatment to patients and wounded emergency responders. The overall consensus appeared to be that waiting prolonged periods of time to get medical care to those in need is no longer an option, and that more aggressive alternative approaches need to be implemented in order to achieve the best outcomes in patient survival. The term “rescue task force” was brought up in regard to advancing medically trained providers with law enforcement personnel into the warm zone to allow for rapid triage, provide limited but critical emergency treatment and assist in patient extraction from the warm zone to the cold zone for transport to definitive care. These rescue task forces would be under the protection of law enforcement teams assigned to each task force. In general, the task force would consist of three to four law enforcement personnel paired with two to three medical personnel.
The discussions went further to try and determine what the best practices would be for personal protective equipment for medical providers who are going to be in the warm zone. Agencies across the United States have different approaches to this, ranging from those that send medical providers into the warm zone with no additional personal protective equipment to those that have fitted their staff with personal body armor and ballistic helmets.
It would appear from the discussion that the common middle ground is where the medical task force responder’s equipment would be available in a responding supervisor’s vehicle with multiple sizes or “one size fits most” equipment. This model allows for the most access to equipment without severe budget constraints that would prohibit an entire department from being fitted for ballistic gear. Operationally, however, this model potentially delays the creation of rescue task forces and patient extraction by relegating responding units to wait for the arrival of specialized equipment.
Overall, the meeting proved to be a very positive experience and brought forth many new ideas, concepts and discussions to help everyone involved be better prepared for future events. As Sugiyama stated during his panel discussion, “EMS must also be an equal stakeholder in the preparation for these incidents. This includes planning, preparedness, development of response doctrine and training, as well as the funding to support these activities.”
Often within EMS we have the opportunity to sit and discuss concepts and ideas with other EMS providers or local fire departments, but the foresight of DHS to pull together representatives from all of the emergency responder disciplines in one location from across the nation was truly something to be applauded. It is united efforts such as this that can help lead emergency services to work as one unified response and achieve the best patient and emergency response outcomes.
Ryan P. Greenberg is the chief of EMS operations at Vanguard Health Systems.
