This article was originally posted by MedPage Today. It is reposted here with permission.
By Shannon Firth, Washington Correspondent, MedPage Today
Novel emergency surgical techniques, many born of the military’s experience in Afghanistan and Iraq since 9/11, have revolutionized treatment of domestic gunshot victims. But first responders are still struggling with how to cope with mass shootings in civilian settings, where precious life-saving intervals can elapse before EMS personnel are allowed to reach the wounded.
The unfortunate reality is that many victims in mass shootings die because of delays in treating injuries that aren’t definitively lethal, experts say.
“If you have a lethal injury, then you’ve had a lethal injury, but if you don’t, we want to have a system that will transport you quickly to the appropriate level of care,” said Thomas Scalea, MD, of the Shock Trauma Center at the University of Maryland Medical System. Scalea co-authored a 2016 National Academies report on integrating military and civilian trauma systems to cut preventable deaths after injury to zero.
The notion of preventable shooting deaths garnered support last month from a study examining the number and locations of dead victims’ bullet wounds. The authors, who reviewed full autopsy reports for 213 deaths from 19 events concluded that 16% of those deaths were preventable with quicker treatment.
Co-author Babak Sarani, MD, director of the Center for Trauma and Critical Care at George Washington University, told MedPage Today the way to save that 16 % is “much, much more rapid penetration of the scene by medical personnel,” faster retrieval of victims, and quicker access to trauma centers.
But that is precisely the problem. Police are understandably reluctant to let EMS or fire department personnel into active shooting scenes. Historically, the practice has been for police to confirm that shooters have been neutralized before allowing medical personnel into affected buildings.
In practice, that can mean each room, each closet, each cabinet, each bathroom stall -- anyplace where a shooter might hide -- must be checked and cleared.
‘Stage and Wait’ deaths
Thirty years ago, “if there was a shooter, we were told very clearly to ‘stage,’” Sarani said, meaning to stay “far, far away, maybe upwards of a mile away, and wait for the police to clear the scene.”
Only then, said Sarani, who began his career in medicine as an emergency medical technician, would the paramedics come in, retrieve the people who’d been shot, and take them to the hospital.
"[R]ight now, in many jurisdictions, what happens is the police don’t drag the victim out because they say, ‘We’re the police. We don’t do patient care,’ and the paramedics say, ‘We’re not going to drag the victim out, because there’s some dude who’s shooting.’ So in reality, the victim just stays there and languishes, i.e., Pulse nightclub,” Sarani said, referring to the June 2016 massacre in Orlando that left 49 people dead.
There, EMS personnel were not allowed in until police gave the OK.
Reed Smith, MD, operational medical director for the Arlington County Fire Department in Virginia, who also holds an appointment at GWU and was lead author on the autopsy study with Sarani, said he’d participated in an active-shooter drill years ago when “stage and wait” was the rule.
Nearly an hour and a half passed while the building was cleared by the SWAT team. When his own team entered to check on the victims, Smith said, “I’d be like, ‘No, that person’s dead, because they waited too long,’ and ‘this person’s dead because they waited too long.’”
The GWU group also studied victims in the Pulse shooting, determining that 16 of the 49 who died might have been saved with quicker treatment.
While Sarani is not himself an advocate for any specific protocol, he told MedPage Today that “stage and wait” is essentially a recipe for letting wounded people die. “That I stand behind very resolutely,” he said.
‘Rescue Task Force’ and Pulse Night Club
Otto Drozd, recently retired fire chief for Orange County Fire Rescue in Central Florida, confirmed that firefighters and rescue teams were instructed not to enter the Pulse nightclub scene immediately after the shooting.
While his own roughly 19 units had been trained to enter the “warm zone” of an active shooting event -- an area the shooter has left or one that has been cleared by police -- under the cover of law enforcement in order to quickly treat and extract patients, Drozd said, “the level of training amongst all of the response agencies wasn’t equivalent.” Moreover, he said, “the entirety of the Pulse nightclub was deemed a ‘hot zone.’”
Without a “warm zone” to enter, the protocol his units were trained in, known as Rescue Task Force -- where firefighters and paramedics, with police protection, operate in areas of “limited threat” to treat and extract victims from a scene -- was moot.
Based on After Action Reports, which review critical incidents with an eye towards improvement, it appears that the shooter was “contained” in one section of the building for a period, Drozd said.
Whether other parts of the building could have been “warm zones” and a Rescue Task Force deployed, Drozd isn’t certain.
“We’re making assumptions here, but it would seem reasonable that that could have happened, but that would just be second-guessing [officials] on-scene” who had decided the entire scene was too dangerous, Drozd said.
Communication is almost always a challenge in these events, but the problem was exacerbated by the fact that the sheriff’s office had switched to encrypted radios and the fire department had not, Drozd said.
In addition, having “unified command” among fire and law enforcement -- law enforcement and fire had “proximity” but weren’t unified -- might have resulted in what Drozd would call “a better decision.”
“But we’ll never know the answer.”
Can bystanders make a difference?
Another idea for bringing rapid treatment to victims is “Stop the Bleed,” a national public awareness campaign that trains ordinary citizens to care for victims with severe wounds.
Alex Eastman, MD, has worked as a trauma surgeon and in law enforcement, including as part of a SWAT team, since 2004.
Until last year, Eastman was the chief of trauma at Parkland Health and Hospital System in Dallas. He is currently a lieutenant chief medical officer for the Dallas Police Department and serves as senior medical officer for operations in the U.S. Department of Homeland Security.
Eastman has personal experience in two active shooter events, as a SWAT team responder to both the July 2016 ambush of his own police force in which five officers died, and the June 2015 attack on Dallas police headquarters.
He’s a strong advocate for Stop the Bleed and, prior to that, helped train law enforcement officers in hemorrhage control.
Training the public in hemorrhage control and having the equipment pre-positioned in all the right places, will go a long way to saving lives, he said. The Stop the Bleed program aims to train all 320 million Americans. And while it wasn’t specifically designed as a response to active shooter events, it can certainly help, Eastman said.
He stressed that the Rescue Task Force protocol “looks good on paper, until you actually try to use it,” citing the Oct. 1, 2017, Mandalay Bay mass shooting in Las Vegas, where 58 people died.
“The Las Vegas Metropolitan Police Department and the Clark County and Las Vegas Fire department, those guys have had some of the best most advanced Rescue Task force programs and training in the country. They are truly a model,” Eastman said. And yet “the Rescue Task Force treated no live casualties at the concert.”
“If there’s an active shooter in a big concert venue, nobody’s going to sit around and wait to be triaged. If they can get out, they’re going to get out. If they can’t then we’re going to be left taking care of the people who are critically wounded or already dead,” Eastman said.
But “Stop the Bleed” also has its skeptics — including Smith — because it’s heavily influenced by military experience, where medics can get to the wounded even while under fire.
Also, injuries may differ substantially from civilian shootings: soldiers’ wounds more often affect the extremities than the torso or head, for example, and may come from shrapnel rather than bullets. Most of the potentially preventable deaths in the mass shootings they studied were to the chest and abdomen.
Smith recommended another program for bystanders called “Until Help Arrives” which, in addition to bleeding control, teaches citizens to manage a chest injury or a head injury, how to keep an airway open, and proper body positioning.
“I’m not turning them into doctors,” Smith said, of the civilian trainees, but equipping them with a few basic skills to keep victims alive and out of shock until paramedics arrive.
Las Vegas & warm zone challenges
Greg Cassell, Fire Chief of the Clark County Fire Department in Nevada, which responded to the Mandalay Bay shooting, said that those who criticize the department’s response are ignoring a few key challenges: i.e., “that our event started on a 17.5-acre lot and expanded to 3.5 square miles. This was not a fixed facility like a school, mall, church, etc. No one on Earth had ever planned for that,” he said in an email to MedPage Today.
“We deployed 19 [rescue task forces] on that night on an unimaginable event. Some of those teams came into contact with injured persons. Some did not,” Cassell wrote.
“For some ‘expert’ to say we were ineffective in our approach or deployment of resources during such an event is disheartening.”
Based on his own experience, Cassell said the Rescue Task Force is a “viable option to those departments and communities that support their deployment. I do not come by this determination lightly as I have more than 32 years of experience in emergency response and have helped develop many response plans including the plan we have here in Southern Nevada for hostile events.”
Other first responder models
While Smith and Sarani advocate for approaches aimed at speeding victim extraction, using a “coordinated interdisciplinary approach” by public safety agencies, they acknowledge that the Rescue Task Force isn’t the only response or even the best response.
Everyone interviewed by MedPage Today appeared to agree that each jurisdiction’s leadership needs to evaluate its resources and choose the method that is best for them.
In May 2018, the National Fire Protection Association published new standards known as the NFPA 3000 for guiding community responses to active shooter and/or hostile event situations. (Registration required, but access to the guidelines is free.)
John Montes, an emergency services specialist for the NFPA, told MedPage Today that more paramedics and fire departments are moving towards a system of “warm zone care,” where there is a limited threat.
Other models of “warm zone” care, in addition to Rescue Task Force, include operations with names like “protected island” and “protected corridor” -- all of which call in some way for fire and EMS teams to treat patients while law enforcement keeps watch.
Montes said the standards don’t direct jurisdictions to one option, but instead state that “all first responders shall receive training in threat-based medical care.”
“See what you’re capable of doing and come up with the tactics that work best for you,” he said.
Those jurisdictions that are less risk-averse may choose a protocol in which paramedics accompany and are protected by police. Others may not want their firefighters and paramedics anywhere near the shooter and may encourage police to drag victims out of a building to the paramedics.
Sarani said it doesn’t matter what option is chosen, if it leads to faster treatment of victims: “Pick your strategy and go with it,” he said.
Smith said responders can shift tactics depending on the particulars of a situation. It’s also important to recognize the limits of any approach. “The ugly little secret is ... there’s not a huge amount of people that can be saved,” he said.
But, he added, “if it’s my kid in the school, you better go get him.... If he’s dead and there’s nothing you can do, I’m going to sleep better knowing at least [you] tried.”