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Rapid Response: Is EMS response different when the active shooter survives?

Despite the shooter’s despicable intent and multiple murders, he becomes another patient to triage, treat and transport


The mass murder is a tragic reminder that some of the most deadly mass murders in the United States have taken place at churches and synagogues.

AP Photo/Gene J. Puskar

What happened: Eleven people were killed Oct. 27 at a Pittsburgh synagogue by a gunman armed with an assault rifle and several handguns. Six others, including four police officers, were injured before Robert Bowers, the shooter, was apprehended.

The 20-minute attack at Tree of Life Congregation killed eight men and three women, ages 54 to 97. The victims included a husband and wife and two brothers. Two victims, including one of the police officers, are still hospitalized in critical condition.

Why it’s significant: The mass murderer is alleged to have made violent threats on social media sites and has been charged with a federal hate crime for “obstructing the free exercise of religious beliefs resulting in death.” It’s also a tragic reminder that some of the most deadly mass murders in the United States have taken place at churches and synagogues.

Top takeaways on active shooter attacks on churches, synagogues and houses of worship

There is still much to learn about the attacker’s motive, the heroic actions of congregants to save lives and the response by Pittsburgh EMS providers and law enforcement. Meanwhile, here are my early takeaways from this incident.

1. The shooter may survive

In many active shooter incidents, the shooter either dies by suicide or is killed exchanging gunfire with law enforcement. The Charleston, Sutherland Springs (Texas) and the Parkland high school shooters left the scene uninjured. Two of the shooters were apprehended uninjured.

Bowers was shot by police and arrested. It’s possible his intent was to die by suicide or through a suicidal confrontation with police. Don’t assume the shooter has a death wish. If the shooter survives, EMS transport is likely.

  • Suicidal intent might continue through assessment, care and transport with a willingness to cause further injury to self and others.
  • Document statements made to EMS providers by the perpetrator. If personnel resources allow, assign one EMS provider to write, in real time, the perpetrator’s responses to assessment questions and treatment actions.
  • EMS assessment and care will be on video. There are sure to be one or more body-camera equipped police officers with the suspect in the patient care compartment. EMS providers’ words and actions will become part of the investigation and scrutinized by investigators and attorneys.

Before arriving at the hospital, EMS leaders should anticipate and prepare EMS personnel for extraordinary media scrutiny. The transporting crew will be found, contacted by phone and email and through social network profiles. They will be confronted on- and off-duty by mainstream journalists and less-than-mainstream opportunists. Prepare all personnel with a succinct and standardized message on how to respond to media inquiries and to whom those inquiries should be directed to.

2. Life safety audits for houses of worship

There will be much discussion and media attention in the weeks ahead about security procedures at the houses of worship in your community. President Trump started the conversation a few hours after the shooting.

“This is a case where, if they had an armed guard inside, they might have been able to stop him immediately,” Trump said. “Maybe there would have been nobody killed, except for him, frankly. So it’s a very, very – a very difficult situation.”

An armed guard, pastor, parishioner or janitor should not be the extent of the conversation about life safety. Look for opportunities to lead and facilitate a discussion on life safety, including:

  • CPR training.
  • AED availability.
  • Severe hemorrhage control.
  • Fire and smoke alarms, along with sprinklers.
  • Marked and accessible exits.
  • Access control, visitor screening and identification requirements.

A life safety audit should include recommendations for equipment, initial and ongoing training, and creation of an enduring partnership between the organization, its members and public safety.

3. Churches, synagogues and other houses of worship are a pre-planned mass gathering

Churches, synagogues and other houses of worship, like schools, large businesses, music festivals or races, are pre-planned and predictable mass gatherings. They deserve and require the same pre-planning with special attention to religious holidays and special events.

Mass gathering planning needs to consider the range of risks, possible injuries and ailments based on the size of the gathering, the organization type, past threats and incidents, and the demographics of the attendees. Patients may range from syncope to myocardial infarction to cardiac arrest to severe hemorrhage.

4. Victims may include police officers

Treating a single injured police officer is stressful for any EMS agency and its providers. Caring for four injured officers is an MCI within an MCI.

At least annually, EMS personnel should receive training on policies and procedures applicable to treating one of our own – a fellow EMS provider, police officer or firefighter. The approach is the same – treat what you find with the tools and training within your scope, whether the patient is a murderous racist or the most kind-hearted cop on the force. But anyone who has treated a public safety colleague will likely tell you, “it’s just different.”

Learn more about active shooter incident response

Here are some other articles from EMS1 and a learning opportunity from the EMS1 Academy on school shooting response, mass casualty incidents and bleeding control.

Greg Friese, MS, NRP, is the Lexipol Editorial Director, leading the efforts of the editorial team on Police1, FireRescue1, Corrections1 and EMS1. Greg served as the EMS1 editor-in-chief for five years. He has a bachelor’s degree from the University of Wisconsin-Madison and a master’s degree from the University of Idaho. He is an educator, author, national registry paramedic since 2005, and a long-distance runner. Greg was a 2010 recipient of the EMS 10 Award for innovation. He is also a three-time Jesse H. Neal award winner, the most prestigious award in specialized journalism, and the 2018 and 2020 Eddie Award winner for best Column/Blog. Connect with Greg on LinkedIn.