As discussed in the first edition of this series, fire departments and EMS agencies have had to reassess their role in active shooter response after a series of deadly mass shooting events. For so long, fire and EMS agencies have held steadfast to the belief that unless the scene is safe from all threats, fire and EMS personnel will not enter to provide care. Retrospective reviews of Columbine, Aurora, and the Pulse Night Club and other events provide examples of events where a proactive medical response would have saved more lives.
There are several serious flaws to the belief that fire and EMS personnel should stage and wait until the scene is declared completely safe. In emergency services, safe is a very relative word. It is difficult to state that fire and EMS personnel will stage and wait until the scene is safe at an active shooter event; especially when these same personnel operate at motor vehicle accidents on the interstates, enter burning buildings, conduct dive rescues, and mitigate highly dangerous chemical leaks. Each of these situations have much higher proven odds of death than operating at an active shooter event.
The data are very clear; fire and EMS personnel are far more likely to die in a motor vehicle accident responding to a call then getting shot at an active shooter event. The Department of Justice defines an active shooter event as “Three or more people shot in a public place, in the absence of gang or drug activity, or in the commission of a secondary crime (like a bank robbery).” Using this definition, there are only two active shooter events in United States history in which fire or EMS personnel were targeted. The first occurred on December 30, 1974 in Olean New York, when a student went on a shooting rampage at his school and shot six responding firefighters. The second occurred on April 20, 1999 at Columbine, when a paramedic said a bullet went past his head. (Note that many people reference the December 30, 2012 Webster, New York shooting as an active shooter event. This does not meet the Department of Justice definition because of the location of the attack. This is technically classified as an ambush event, not an active shooter event.)
EMS Response Considerations
In many jurisdictions, EMS agencies have accepted a proactive approach to active shooter response and want EMS personnel actively engaged in rescue operations. It is important to understand the role of EMS personnel who respond on an ambulance. The most finite public safety resource in any jurisdiction is the number and availability of transport ambulances. The Hartford Consensus and the position statement from Dr. William Fabbri with the Federal Bureau of Investigation state that treatment focuses on stopping visible, life-threatening hemorrhage; rapidly extracting the injured to waiting ambulances; and rapid transport to the hospital with surgical capabilities.
The most important role of EMS personnel that arrive on ambulances is to rapidly transport the injured. EMS agencies need to understand the potential for a massive number of injured. At the 2009 shooting at Fort Hood, there were 43 people shot, with 31 who survived. At the 2012 Aurora theater shooting, there were 100 injured, with 82 transported by EMS. Seventy of these patients had gunshot wounds. At the 2015 San Bernardino shooting, there were 36 people shot, with 22 transported by EMS. At the 2016 Pulse Night Club shooting, there were 104 people shot, with 49 that either were declared dead on the scene or dead on arrival at the hospital. In many active shooter events, a large number of critically injured patients self-evacuated and were outside waiting the arrival of ambulances.
However, the number of people shot at these events is sometimes just a small number compared to those who were injured at the event. At the 2013 Los Angeles International Airport shooting, there were five gunshot wounds and 400 additional patients transported with evacuation injuries, heat injuries, and other medical emergencies. At the 2017 Hollywood International Airport shooting, there were six gunshot wounds — five fatalities on arrival at the hospital — and 48 additional patients transported by EMS with heat emergencies, and other ancillary emergencies.
The official after-action report of the Aurora theater shooting stated that the single greatest tactical decision made at that event was the decision to transport 27 critically injured patients in police cars. Numerous after-action reports from hostile events repeatedly demonstrate that if patients arrived to the hospital with just a pulse, the patients survived the event (2009 Fort Hooding shooting, 2014 Boston Marathon bombing, and the 2015 San Bernardino shooting).
Many articles on active shooter response discuss the need for casualty collection points. Casualty collection points are created in three ways: (1) the shooter shoots several people in one area, (2) the casualties come together on their own; and, (3) responders create casualty collection points. Responders often create casualty collection points for the purpose of providing triage and care. However, qualitative analysis of more than 32 large-scale active shooter exercises found inherent problems with casualty collection points.
One of the biggest problems is a concept called “tactical evacuation inertia (TACEVAC inertia).” This concept implies that when a rescuer begins to extract a casualty, the casualty has inertia, or forward progress to an ambulance and then to the hospital. When the casualty is placed into a casualty collection point, the casualty’s inertia stops. Scholastic research found that if a victim is brought into a casualty collection point for the single purpose of deciding who goes out first, there is an average of three minutes added onto the extraction time. If the patient is brought into a casualty collection point for the purpose of receiving basic life support care, there is an average of five to eight minutes added onto the extraction time. If the patient is brought into a casualty collection point to receive advanced life support care, there is an average of 10 to 20 minutes added on the extraction time. For patients who suffer a major, survivable ballistic injury, their odds of death increases approximately two percent every minute from the time of injury until they reach a hospital.
Responders need to understand the advantages and disadvantages of casualty collection points. If the providers are overwhelmed with the number of patients, establish a hasty casualty collection point to prioritize care and extraction. If there are adequate providers to extract the injured, do not put the injured in casualty collection points; instead focus on rapid extraction to awaiting ambulances or ad hoc transport vehicles.
Successful rescue task force models show the benefit of utilizing TECC-trained fire personnel to provide the initial treatment and rapid extraction of the injured to awaiting ambulances. If tactical paramedics are available, they are typically best suited to provide oversight at casualty collection points, or provide direction for basic life support providers as they care for the patients.
Fire Department Response
Fire department members are tasked with multiple priorities at an active shooter event. First, if there is a fire, fire department members must address the fire. Ignoring even a small fire can lead to extreme consequences, as the fire or smoke adds another layer of complexity and lethality to the event. Fire department members may also have to address hazardous materials and provide decontamination for victims. At the Aurora theater shooting, the perpetrator deployed two canisters of CS gas into the theater before launching his assault. Multiple people required decontamination from the effects of the gas.
One of the most important priorities of fire department personnel is to create a rescue task force with law enforcement protection, and enter into the scene to treat and extract the injured. All fire department members should receive an eight- or 16-hour course on Tactical Emergency Casualty Care (TECC). This course does not require any previous medical training. This course provides personnel with the skills and knowledge to provide the critical life-saving medical procedures needed inside the “crisis site.” This training is modeled after the 16-hour Tactical Combat Casualty Care training course that is now standard for all military personnel. This course has resulted in dramatically decreasing the number of preventable deaths from ballistic or explosive trauma.
Fire and EMS are now experiencing the same paradigm shift that law enforcement did after Columbine. Fire and EMS personnel understand the clear need to provide rapid care, extraction, and transport of the injured. Dr. Ricky Kue, the medical director for Boston police/fire/EMS departments stated it best when he said, “Fire and EMS must now undergo the same paradigm shift that law enforcement did after Columbine. Instead of asking, ‘Is the scene safe?,’ fire and EMS must now ask, ‘Is the scene safe enough?’” Peter Cox, Watch Commander for the London Fire Brigade described one of the primary reasons the London Fire Brigade has adopted an aggressive response model at hostile events. Peter simply said, “We have far too great a reputational risk to be seen standing around doing nothing.” Both Dr. Kue and Peter Cox aptly sum up the public’s expectations for fire department and EMS personnel at these events.
Dr. Mike Clumpner is the President and Chief Executive Officer at Threat Suppression, Incorporated, a Charlotte-based consulting firm. He has been in the fire service for 25 years and currently serves as a fire captain with the Charlotte Fire Department assigned to Ladder Company 27. He has been a paramedic for 23 years, and spent nine years as a helicopter flight paramedic. He has been a sworn law enforcement officer for seven years, and he is currently assigned as a SWAT operator and tactical paramedic with a large law enforcement agency. He can be reached at mclumpner@ThreatSuppression.com