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The top tenets of violent threat attack training and practice for EMS responders


All bleeding stops ... eventually. Our job as EMS providers is to safely gain access to victims and render care before a casualty literally bleeds to death.

Photo/AP Photo via John Minchillo

Recent acts of mass violence during active shooter events and other incidents in schools, churches and businesses continue to highlight the need for a multi-pronged strategy for both training and response.

This special EMS1/Lexipol guide outlines lessons identified from past incidents that can direct EMS involvement in pre-planning mass gatherings, improve multi-agency cooperation, and inform incident command and response strategies on the ground: Mass violence: How lessons identified inform training, response

Since its inception, EMS training and practice has evolved with the reality and threats we face each day. During the AIDS crisis in the 1980s, EMS greatly enhanced universal precautions training. Certainly, the COVID-19 pandemic has once again been the impetus for updates in both training and practice. Enhanced universal precautions are now standard in dealing with a known or suspected COVID-19 positive patient. Every EMT class should now include not only standard personal protective equipment, but also teach and practice proper donning/doffing of gowns, N-95 masks, face shields, foot/head covers and decontamination. Our EMS training, procedures and practice change with the evolving threats.

The same modifications, updates and focus on training and practice are also occurring in EMS response to mass violent attacks and active shooter incidents. Most EMS agencies, whether private, municipal or fire based, now have an active shooter incident policy. Horrific, catastrophic and profoundly disturbing events that happened at Columbine; Virginia Tech; the Pulse Night Club in Orlando, Florida; Marjory Stoneman Douglas High School, in Parkland, Florida; and the Las Vegas mass shooting, to name a few, have caused responding agencies to drastically modify their training to prepare for responding to these types of events.

Law enforcement has drastically changed its training and approach to an active shooter incident. Local police understand they can no longer wait for the SWAT team. The current standard and widely accepted approach is for arriving officers to go toward the crisis site/shooter with whatever resources are on hand. They are looking to engage, distract and hopefully neutralize the threat. This is now standard.

So how has EMS addressed this complex threat? First and foremost, highly regarded organizations such as the FBI, The Committee on Tactical Emergency Casualty Care, International Association of Fire Fighters, National Fire Protection Agency, U.S. Fire Administration, and the National Association of Emergency Medical Technicians all support and/or have position papers urging a more deliberate, aggressive and coordinated response to active shooter incidents from EMS providers. They all stress the importance of the following pillars of policy development, training and response:

  • Policies and procedures to be developed, modified as needed and regularly updated
  • Training with law enforcement and other emergency responders on a regular basis, including full scale exercises
  • Ensuring radio interoperability between agencies and disciplines
  • Developing guidelines for safely staging for an active shooter incident, close enough for a rapid response and extrication
  • Using a rescue task force model to integrate and move together with a law enforcement escort inside the crisis site once the threat is neutralized of isolated
  • Using ballistic protection (vest and helmet) for both training and responding to actual events
  • Understanding common active shooter incident response terminology such as cover/concealment, hot/warm/cold zones, safe corridor, casualty collection point, etc.
  • Using a point of wounding approach to initiating life-saving medical interventions at the crisis site for those that have critical injuries
  • Becoming proficient at rapid triage and treatment, including massive hemorrhage and trauma management to include:
    • Rapid trauma assessment
    • Mass casualty triage and patient prioritization
    • Tourniquet application
    • Wound packing for junctional penetrating injuries
    • Open chest wound management
    • Patient positioning and extrication
    • Casualty thermal insulation
    • Using triage tape to rapidly identify the criticality of the patient
    • Casualty collection points and transportation

California paves a path to standardized active shooter response

There has been significant progress in the development of national, state and local emergency medical response strategies and training standards to improve outcomes of active shooter incident victims. In the state of California, the Emergency Medical Services Agency (EMSA); and the California Commission on Peace Officer Standards and Training (POST); the Firefighting Resources of California Organized for Potential Emergencies (FIRESCOPE) program; and various local California EMS agencies, training program providers and EMS employers, have collaborated to develop standards and training guidelines and a standardized statewide approach to the response of first responder personnel to these incidents.

Specifically, every EMT class in California must have training time dedicated to the concepts and practice of active shooter incident response. A minimum of four hours training is required, although eight hours of training is recommended. The course must include the following topics:

  • An overview of the California tactical casualty care initiative and its emergency medical and fire agency personnel response to active law enforcement incidents within state EMS systems
  • Common tactical and rescue terminology and operations
  • Description and demonstration of basic tactical casualty care techniques
  • Casualty movement and evacuation techniques
  • Medical planning and threat assessment considerations
  • Comprehensive, competency-based student demonstration and, when applicable, student skills testing

Treatment at the point of wounding

The paradigm shift in the emergency medical response to an active violent threat incident was not without resistance. Some in the emergency medical business thought it unwise to send responders into harms way, even though that was not what was being proposed, and certainly not the intent.

The partnership with law enforcement was and is a critical link to ensure that no EMS personnel can enter a hot zone, where the threat is still active. Only after the threat is mitigated will a trained group of EMS providers be escorted and protected by law enforcement to enter a warm zone to begin triage and point of wounding care with life-saving medical interventions to ensure that the greatest amount of good can be offered to the greatest amount of victims.

All bleeding stops ... eventually. Our job as EMS providers is to safely gain access to victims and render care before a casualty literally bleeds to death. Thankfully, our EMS training and stressing the importance of multidiscipline exercises has made us better prepared for these catastrophic events.

Read next: Active shooter exercise goals, philosophy and design

Jim Morrissey is the tactical medical program director for the Alameda County EMS Agency and a former FBI SWAT tactical paramedic. He has a Master’s Degree in Homeland Security from the Naval Postgraduate School. He is an internationally recognized expert in the field of the multi-discipline response to active shooter incidents. He can be reached at