Following are three components of having an effective active shooter/mass violence response plan.
Entering and treating patients in a less than secure scene goes against all previously taught practices for fire and EMS responders. Proper planning and policy writing is critical to the effective implementation of an active shooter/mass violence policy. One of the first considerations is that this is not a single agency plan. This will require coordination between law enforcement, fire and EMS. Having representatives from all agencies will allow for a better overall outcome.
The roles of each agency must be clearly outlined. These situations require individuals to make quick and effective decisions based on their expertise. Crossing roles ultimately leads to confusion in situations as dynamic as an active shooter event. Law enforcement focuses on threat neutralization and force protection. What does this mean? The first officers will enter the building looking for the assailant and “clearing” rooms or portions of the building. These officers will move towards the “sound of gunfire or screams.” As they clear areas moving towards the assailant, those areas will then be deemed “warm” allowing for others to enter the building to treat and evacuate patients. The other officers will be involved in “force protection.” These officers have the primary responsibility of protecting the team treating and moving patients found in the “warm zone.” This places an extra layer of protection between the assailant and those treating the wounded. Ideally all officers involved in these operations should have a long gun available.
Fire and EMS then take the responsibility of treating and moving patients. While the organization of these agencies varies from department to department, ultimately this will be a team effort between the two. As the team finds patients they will begin to triage and treat life threats. These are your HABCs — Hemorrhage, Airway, Breathing and Circulation. Minimal and simple treatments are performed to allow the most patients the best chance of survival. With the exception of one procedure, all of the “expected” treatments are of the basic life support level, allowing for more people to treat more patients. These teams are also responsible for the movement of patients back to a Casualty Collection Point (CCP), for further treatment and evacuation to higher care.
As you can see there are a lot of moving pieces to this puzzle. This means they will need a great deal of planning and training to make sure it runs smoothly on game day. A football team doesn’t wait until they are in the Super Bowl to make their plays. It takes a great deal of planning, practicing and revising months and years prior to perfect their plan. The same is true for these situations; it must be thoroughly planned, rehearsed, revised and nailed down.
Primary considerations should include the initial type of assets to be dispatched, radio channels to operate on, which will call initial command, how will teams be made up and what additional protective equipment is to be used. Creation of a committee or working group for this topic will make the continued update and revision of the plan fluid and rapid. Pre-planning for certain “critical infrastructure” is essential. The fire department routinely plans their attack of large buildings. Where are the hydrants, stand pipes, etc. The same makes sense for these events. Planning for where any large group of people congregate would prove beneficial should the event ever take place. While there is much more to consider, this covers enough to help fuel further conversation within your departments.
Training is an essential component of all careers in the fire service, EMS or law enforcement. We routinely practice turning out, starting IVs or firearms manipulation. These our common tasks to our respective fields. So shouldn’t we routinely practice something that requires coordination between all of our skillsets? Logistically this proves quite difficult for many departments based on schedule, manpower or a number of other reasons. With that, the first time these teams work together should not be on the scene of an active shooter. As Lt. Col. Dave Grossman said, “We do not rise to the occasion, we fall to our training.” As one of the world’s leaders in understanding the psychology and physiology of high threat/high stress situations he makes an incredibly valid point. We must give the victims of these incidents the best possible chance of survival by being able to recognize and treat victims based on training. The current best practices for trauma treatment contradict many of the previous teachings.
For instance, the use of a tourniquet first rather than as a last ditch effort, or considering massive bleeding before an airway procedure. This may sound odd to some, however from military operations and data gathered, these are the priorities in ways to prevent life loss in the moments following massive trauma. Tactical Emergency Casualty Care (TECC) is a committee created to address and maintain procedure and currency. They have created the Tactical Emergency Casualty Care guidelines that create a basis for medical treatment in high threat environments. This is a close relative to Tactical Combat Casualty Care that has been adapted by the military, with minor differences such as wording and removal of some medications used.
Training should occur on a regular basis. Whether it is at the agency level or company level. Everyone should routinely perfect his or her performance of skills to be conducted when the call comes. Inter-agency training should occur as often as feasible. There is a need for all involved to build a level of comfort with those they may end up working with. The officers should feel comfortable protecting the providers while they treat and the fire and EMS personnel should feel comfortable with those protecting them so they can provide proper care. They should “know and trust” who has their back.
We have to remember that these types of events introduce a new stressor that fire and EMS have previously made attempts to avoid. Historically, fire and EMS would both stage until the scene has been deemed safe. It is now being practiced not to stage. This alone has caused a great deal of debate and concern within the public safety community. This again is the reason training is so critical. It allows those involved a chance to gain a level of comfort, as well as being able to feel safe performing their duties.
Adding protective equipment such as a helmet or ballistic vest adds a rather new component. Skills must be practiced in these items. It would be the equivalent of practicing fighting fire without wearing your turnout gear. It is a disservice to you and your team to pick up bad habits. Follow the common phrase “train like you fight.”
For more information with regards to training there are many resources available. Seek TECC training and train to a plan that works for your agency.
“Tools of the trade” continues to be a major subject regarding innovation within our field. The evolution of products and tools has been a driver of change within public safety. This is no exception. Responding to and treating victims of an active shooter requires a new set of tools. With the primary objectives of protection, treatment and evacuation the tools had to be simplified and streamlined to meet the need.
Protection from ballistic threats is a must for those entering a “warm” zone. It can provide the wearer with an increased feeling of protection, and allow them to focus on treatment. Protective wear should include at least a protective vest, helmet and protective eyewear. There are variations in helmets and vest. The availability for a “one size fits most” is great, if stocking for a unit rather than a personal asset. If sizing for personal issue, make sure the vests are properly fitted. With helmets, the same considerations should be made. There are now ballistic helmets that have a ratchet style harness allowing for different head sizes to fit correctly. New tools exist for the trade. We should at least be aware of what is available.
Treatment tools should be simple and effective. These tools can get expensive. However, this is no place to scrimp on price. These tools have been proven to work when it counts. There will be grant funding available in the coming years for new and proven equipment. As for a treatment bag, less is more. Having a few tools to treat the major threats rather than an ALS ambulance on your back. Consider a commercial tourniquet since there are multiple options available. Look for one that utilizes a “windlass” or a bar for tightening since these have consistently proven most effective. This is the number one consideration for treatment of hemorrhage.
Next, for basic airway adjuncts, usually the NPA is all that is carried. Treatment for breathing should remain simple as well. Stock a vented occlusive dressing if only a BLS service and consider adding a needle for chest decompression if ALS. Vented seals are again the primary choice of both TECC and TCCC.
Circulation is the next link in the chain. This encompasses the control of less severe bleeding. A pressure dressing, and hemostatic agent should suffice. Multiples of each of the above mentioned should be carried to cover multiple patients or multiple injuries. Utilizing an effective triage system will help aid in the continuation of care for victims. This allows for the next care providers to have an understanding of injuries and severity, as well as treatment.
Many communities have an established triage system and all communities should implement such a system to your plan. Lastly an evacuation device is necessary. There are many options out there but what works best for your department is a personal choice. Look at their availability to be dragged, reused and weight rated. Some training and trial should occur prior to choosing an evacuation platform.
This is a very basic overview of some of the components needed for an effective plan. As your department begins to create and implement a policy, there will be many more considerations to take into account.
Andrew Rowley began his career as a firefighter/EMT at a volunteer fire department. He joined the Army as a medic and is now teaching combat medicine and sustainment at the unit level. He worked in Charlotte, North Carolina for Mecklenburg EMS Agency, as a paramedic. Rowley’s current position is flight paramedic with Wake Forest Baptist Health in Winston-Salem, North Carolina. He is the president of Special Operations Aid and Rescue, LLC.