The Active Shooter Threat:

At Columbine, two perpetrators killed 13 people and injured 20 others. One victim died 90 minutes after the attack ended and another victim died three hours and 30 minutes after the attack ended. Both victims bled out waiting for care. After the perpetrators committed suicide, it took more than three hours and 20 minutes to remove all of the injured people from the building. This was a sentinel event for law enforcement and resulted in sweeping changes in police training and response tactics. However, fire and EMS agencies were much slower to implement any change.

A Need for a Response Change

Many more active shooter events demonstrated a need for public safety agencies to adopt aggressive, integrated response plans. At the 2009 Fort Hood Shooting, it took two hours to transport 30 patients to area trauma centers. At the 2009 American Civic Association shooting in Binghamton, New York, the first patient was not accessed until 60 minutes after the shooting ended, and it took responders three hours to remove four injured people from the building.

At the 2012 Aurora Century 21 Theater shooting, numerous patients received no medical care other than transport to the hospital. Fire and EMS providers at Aurora Century 21 Theater had little interaction with the majority of the people shot. At the 2013 Los Angeles International Airport (LAX) shooting, it took 33 minutes to provide care for the TSA agent who was shot less than 50 feet inside the terminal doors. Some of the injured at the LAX shooting had to create improvised tourniquets and extract themselves because medical responders did not enter the scene. At the 2016 Pulse Nightclub shooting in Orlando, many patients were not treated until three and a half hours after the shooting started.

The Threat of Active Shooter Events Today

More than 18 years after Columbine, the United States continues to experience major active shooter/active assailant events. Former Attorney General Eric Holder stated in 2013 that active shooter events have increased 150 percent and the lethality of the events has tripled. Active shooter perpetrators often study past active shooter events to make their event even deadlier.

It is important to recognize that mass violence attacks are not limited to shooting events. The United States has had mass stabbing events, explosive events, vehicle-as-a-weapon events, and many other types of mass violence attacks. Because of the potential for a non-shooting mass violence attack, all fire and EMS agencies should recognize the active assailant concept. The United States continues to experience a rise in terrorist-related attacks. These attacks often exploit non-ballistic methods of mass violence tactics to obtain high victim counts.

Integration of Fire and EMS

Events such as Columbine, Virginia Tech, Aurora Theater, Los Angeles International Airport, Pulse Nightclub and more continue to show that fire and EMS must integrate quickly to save lives. The six highest casualty active shooter events since 2000 happened despite law enforcement arriving on scene in three minutes or less. A rapid and effective law enforcement response is only a part of a successful public safety response plan.

Research from several active shooter events found that approximately half of the injured have moderate to severe gunshot wounds. Multiple research studies have also found that many active shooter victims die needlessly while waiting for medical care. Many of these victims die from mass hemorrhage. Research conducted has found that integrated police/fire/EMS response significantly reduces the time to provide treatment and extract the injured.

Recommendations for Integrated Fire/EMS Active Shooter Response

In 2008, the Department of Homeland Security stated that rescue teams comprised of additional police officers and medical providers will follow quickly behind contact teams to treat and extract the injured. Following the Department of Homeland Security’s response recommendations, numerous other federal agencies and professional organizations published active shooter best practice papers and model response policies. Each of these papers and policies strongly encourage integrated police, fire and EMS response to active shooter events. The recommendations are from the International Association of Fire Fighters (2013), the International Association of Fire Chiefs (2013), the National Fallen Firefighters (2013), the United States Fire Administration (2013), the International Association of Chiefs of Police (2014), the Hartford Consensus (2014 and 2015), the Federal Bureau of Investigation (2014), the InterAgency Board (2015 and 2016), and the National Fire Protection Association (2016).

Several new initiatives may result in federal response requirements that require integrated police/fire/EMS response at hostile events. The new National Academies of Sciences project, “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury,” focuses on implementing military battlefield best practices in civilian prehospital medical care. This project focuses on integrated medical response at hostile events. This National Academies of Science project may become a 2017 White House initiative. Likewise, the National Fire Protection Agency (NFPA) is currently convening a panel of experts for a new project initiative to create NFPA active shooter response code. This code would establish minimum guidelines for fire department training, equipment, and response to active shooter events. 

In 2016, Federal Bureau of Investigation Special Agent-in-Charge Chris Combs stated, “The FBI has recognized one of the most significant counter-terrorism response issues in the United States is the continued disconnect between police, fire and EMS on hostile event response tactics.” However, many jurisdictions in the United States and especially in North Carolina, recognize the need for integrated police, fire and EMS response to active shooter events. Some agencies in North Carolina have utilized integrated active shooter response tactics for several years.

I reached out to several agency leaders in North Carolina to learn what their agencies have done to prepare for active shooter/active assailant events. Below are their responses.

Question: What has your agency done to prepare for an active shooter event?

“The easy answer would be ‘training’. However, this would be much like saying football is just a game. There is more to an effective active shooter response than the tactics behind the operations. To begin, the entire operation is doomed to fail if the relationships between the responding agencies are dysfunctional. If you don’t know your direct counterparts, how can you expect to make difficult decisions at a high stress, multi-agency response? These relationships must be built beforehand and not at the back of the chief’s vehicle. We have had the luxury of the Democratic National Convention (DNC) to help build these relationships. When you have an event the scale of the DNC, you cannot help but to get to know your counterparts. The issue then becomes maintaining these relationships going into the future. Through continuously nurturing and building agency relationships, you set your agency up to be successful, whether it is an active shooter event or just a football game.”

— Kent Davis, Division Chief,
Charlotte Fire Department

“The Wake EMS system recognizes the importance of integrated response to active assailant events. Over the past several years we have worked to develop and implement a response model that fits our system’s resources. The Wake EMS system utilizes a Rescue Task Force model in which EMS providers integrate with law enforcement officers to access, assess, stabilize and rapidly evacuate victims. Each EMS unit is stocked with a compact response bag equipped with only the supplies required to provide immediate, lifesaving interventions consistent with the threat-based phases detailed in the TECC guidelines to minimize potentially preventable mortality. In the past four years we have executed more than 200 integrated training events specific to active assailant response. Active assailant response, as well as its incident command component, is part of the regular training in our system to ensure best clinical practices and maintain operational readiness for these events.”

— Mike Bachman, Deputy Director of Medical Affairs, Wake County EMS

Orange County formed a multi-disciplinary/multi-jurisdictional active assailant planning taskforce in 2014 which was charged with creating a common response guideline for emergency responders. The taskforce is comprised of representatives from all public safety agencies, communications, emergency management, university/education, and healthcare. Completed in 2015, the guideline has been evaluated through numerous exercises and actual events and continues to be revised. We have conducted a variety of classroom trainings, tabletops, and functional and full-scale exercises. EMS units have developed and are now equipped with shooting and stabbing bags (SAS) that carry an initial cache of necessary medical supplies. We continue to work diligently to improve our response to active assailant incidents with continued emphasis on capability-based training — communication, information sharing, operational coordination and resource management functions.

— W. Kirby Saunders, Emergency Management Coordinator, Orange County Emergency Services