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Rapid Response: Active shooter response command decisions are made by first arriving ambulance crews, fire companies and police officers

What are the potential public policy, legislation, social service and healthcare actions fire/EMS providers should advocate to prevent mass shootings?


Twelve people, including the 28-year-old gunman, were killed and Ventura County Sheriff Geoff Dean reported at least 10 to 15 others were injured during the shooting at the Borderline Bar & Grill.


What happened: A single gunman entered a crowded bar in Thousand Oaks, Ca., and began shooting people with a handgun. A Ventura County Sheriff’s deputy, responding from nearby, entered the Borderline Bar & Grill with a California Highway Patrol officer and was shot multiple times. Sgt. Ron Helus died from his injuries a short time later. Twelve people, including the 28-year-old gunman, were killed and Ventura County Sheriff Geoff Dean reported at least 10 to 15 others were injured.

Why it’s significant: The attack at the Borderline is the deadliest mass shooting in the United States since the massacre at the Marjory Stoneman Douglas high school in Parkland, Fla., on Feb. 14, 2018. And it’s only been two weeks since 11 people, mostly older adults, were killed at the Tree of Life synagogue in Pittsburgh.

The Borderline is reported to be a popular country western dance hall and was offering a special promotion on Wednesday night for college students. Several colleges are nearby and it’s likely many of the deceased are young people.

Top takeaways on the Borderline mass shooting

I am unnerved by the frequency, randomness and unpredictability of mass shootings in the United States. Although the total number of people killed in active shooter/hostile events pales in comparison to the deaths from the opioid epidemic, motor vehicle collisions and gun murders where the victim is likely to know their killer, these horrific incidents garner high-interest, fuel the debate about guns and push us to offer more Stop the Bleed training for police, fire, EMS and civilians.

With still much to be learned about the shooter’s motive, the number of people injured and the life-saving response by public safety, here are my initial takeaways:

1. Mass hemorrhage runner before triage

A mass hemorrhage runner(s) is a pre-triage action to rapidly move through victims to identify only the victims with life-threatening bleeding. Mike Clumpner, who has extensively researched active shooter incidents, described the role and importance of a mass hemorrhage runner in a World Trauma Symposium presentation on Oct. 31, 2018.

“Before you even start triage, send initial EMS crews through patients as a ‘mass hemorrhage runner’ to find the patients who might be bleeding out. [Triage doesn’t begin] until the runner confirms there is no one bleeding to death,” he advised.

A mass hemorrhage runner only pauses to apply a tourniquet, give a tourniquet to a patient to self-apply or instruct a bystander to apply a commercial or improvised tourniquet to a patient with severe bleeding.

2. Command decisions are made at the crew and company level

The Borderline shooting began a little after 11 p.m. local time. The reality for many EMS agencies and fire departments is that overnight, the chiefs and middle managers are off-duty. The personnel who arrive first – ambulance crews and fire companies – need to have the ability and training to make command decisions about:

  • Entering the warm zone as a rescue task force.
  • Activating mutual aid partners.
  • Establishing a perimeter and ambulance staging.
  • Transporting patients to the nearest hospital.

3. Teach and equip people to Stop the Bleed

Dr. Peter Antevy, a pediatric emergency physician and EMS medical director, told “60 Minutes” less than a week ago that it’s critical that everyone knows how to stop bleeding, including children and teens, and has access to bleeding control products.

“We have to have the general public understand that they are the first line of defense,” Antevy said. “And every city, every community in this country needs to roll out those bleeding kits, or these active killer kits … and every child has to learn how to do it.”

For patients with survivable gunshot wounds, the risk of death increases with each passing minute. To optimize survival, patients and bystanders need to initiate bleeding control before EMS arrives and patients with gunshot wounds need rapid transport to a hospital. They don’t need scene treatments or sorting in casualty collection points. They need a surgeon.

4. Mass shooting prevention

I believe we have made significant strides in changing the response paradigm to mass killing events. Law enforcement converges on the shooter as quickly as possible. Tragically, that cost Sgt. Ron Helus his life and several Pittsburgh officers were injured in the Tree of Life synagogue, but it’s likely their heroic actions saved lives. We are also likely seeing a reduction in loss of life because of EMTs, paramedics, firefighters and medical first responders focusing on stopping bleeding and rapid transport of the most critically injured.

What’s less clear to me is what is being done, if anything, to prevent mass murder. The lethal mix of mental illness, hate and access to a mass killing weapon – gun, bomb, knife, vehicle – is often cited. But what are the potential public policy, legislation, social service and healthcare actions to actually reduce the number of incidents? Since there isn’t a single solution, as a paramedic, parent and neighbor, what solutions should I advocate?

Learn more about active shooter and mass casualty incidents

Here are some other articles from EMS1 to learn more about mass casualty incidents, bleeding control and active shooter preparedness.

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.