Training for Active Killer Situations

The Department of Defense has done an amazing job of determining how to best assess, treat, and evacuate combat casualties over the last 15 years of sustained conflict. The days of professional responders staging in the cold zones have come and gone.


It is up to us as professional responders to better serve our communities by preparing for Active Killer events, and other austere situations, that mirror those often only seen on distant battlefields. Note the use of the term “active killer” rather than active shooter; in training and terminology we must be absolute. To use the phrase “active shooter” draws attention to how they’re killing rather than how to treat those in need.

Until recently only dedicated tactical medics have received specialized training to operate in dynamic, high-threat environments. Unless your agency has a dedicated team of these specialized medics on standby, it can call upon in a moment’s notice, these specialized assets will rarely be deployed during the typical active killer situation and even then, will likely be too late to impact much. It will be your EMS crew, engine company or law enforcement officer that will be charged with controlling the chaos of such catastrophes; it is because of this reality that every professional responder must be trained in the principles of tactical medicine.

When looking at the history and success of tactical medicine within the U.S. Military, one cannot help but look at the U.S. Army’s 75th Ranger Regiment. The Ranger Regiment was able to achieve dramatically lower morbidity and mortality rates, while sustaining worse injuries, than the entire DoD; this success can be attributed to the regiment’s requirement that every soldier be trained in the principles of TCCC. If every professional responder is trained in the principles of tactical medicine then we would possess the skills and knowledge to dramatically decrease preventable death within our communities.

Introduction to Tactical
Emergency Casualty Care

Tactical Emergency Casualty Care (TECC) is the civilian trauma model based off the DoD’s Tactical Combat Casualty care principles. This model is broken down into three distinct phases of care: Direct Threat Care (IDC), Indirect Threat Care (ITC), and Evacuation Care (TACEVAC). Each phase provides suggested guidelines and interventions based on the tactical situation. These phases can be drilled upon in almost every type of training conducted for atypical situations (i.e. active killer, tech rescue, etc.) to ensure it becomes muscle memory. This can be done because the TECC guidelines utilize an all hazard approach; despite having a tactical approach, TECC and its principles can be applied to almost any high-risk situation. In TECC, the term tactical does not mean combat or law enforcement, but operational.

When evaluating a casualty within a dynamic, high-threat environment, TECC utilizes a M.A.R.C.H. acronym. This stands for:

Massive Hemorrhage Control

Airway Management

Respirations and Breathing


Hypothermia/Head Injury

The initial phase of care is that of Direct Threat Care and its principles are applied when the situation is the most malevolent. During this phase an active threat to the responders as well as the casualty is still present; the threat may be an assailant, environmental factors or other harmful agents. Much like when treating burns, you must stop the burning process, the same principles apply to Direct Threat Care. You just mitigate the threat to prevent additional injuries and access the casualty. Once the threat has been mitigated and the casualty accessed, this is when the responder would address the “M” in M.A.R.C.H. Massive hemorrhage is the only injury addressed during direct threat care. But what about the rest? It can wait. A complete arterial dissection may result in death in as little as two to four minutes. Also hemorrhage control measures, such as applying a tourniquet or pressure, are quick, simple and effective when performed properly.

As responders begin to move casualties to a more secure location, it is possible to transition to the second phase of care, Indirect Threat Care. This phase assumes that the responder and the casualty are in a relatively “safe” location; meaning they have appropriate security, cover, and/or concealment but it is still possible for a threat to emerge without notice. It is in ITC that responders can get into the “meat and potatoes” of their patient assessment and interventions.

Evacuation Care, the third and final phase of TECC, occurs when the casualty has been stabilized and packaged for evacuation, the responder is continuing to reassess, but more importantly additional personnel and equipment now becomes available. This phase ends when the casualty is transported to definitive care.

Interagency Training for High-Threat Situations

Fire and EMS agencies often conduct joint exercises to prepare for natural disasters, but how often is law enforcement involved? Law enforcement has increased its focus and training to prepare for active killer events, but how often are EMS and fire involved? This becomes a major issue when responding to active killer situations because EMS and fire are not familiar with the tactics, techniques and procedures (TTPs) of law enforcement and vice versa. Some will argue that fire and EMS do not belong in the warm zone and that law enforcement should be trained to a standard to start the triage, treatment, and evacuation process during these Active Killer events. Training law enforcement officers (LEO) to utilize tactical medicine is a good start, but not a definitive solution. We can all agree that LEOs will not likely possess the same skills and competencies of professional medical responders such as fire and EMS. I can testify from my professional experiences that it is much easier to train a medic to be a “shooter” than to train a “shooter” to be a medic. Without having comprehensive medical knowledge, law enforcement is not prepared to address all preventable causes of death seen in tactical environments.

During my career I have had the distinct pleasure of working with Israeli security experts and because of perpetual, indiscriminant acts of violence executed across Israel, they have become very proficient at responding to these catastrophes. In the Israeli model of response, EMS, fire, and law enforcement constantly drill together and are familiar with each other’s TTPs. Luckily nowadays, many authority having jurisdictions are beginning to adopt these principles in the form of Rescue Taskforces (RTFs). In the RTF concept, fire and EMS personnel are trained to a basic operational level to be able to effectively operate with a law enforcement security element. This approach is effective because while the first due LEOs are clearing the scene and mitigating the threat, the RTF has the ability to maintain security of the cleared areas and begin the triage, treatment and evacuation process.

The basic configuration of the RTF consists ideally of three to four law enforcement officers and two to three medical providers — with at least one being a paramedic. This allows for nearly 360 degree security as well as the medical skills, knowledge, and supplies to begin effectively saving lives. Now this is an ideal configuration and as we all know, emergency scenes are never ideal. Therefore, the initial RTF may consist of two LEOs and two medical providers. Moreover, if the agencies have been consistently training together then the LEOs will be capable of assisting until additional medical providers become available.

When evaluating the need for this type of training one must ask several questions: How many lives could be saved if the first arriving officers were trained to provide care? How many lives can be saved if fire and EMS personnel were able to operate within these high-threat situations safely? It is our duty as professional responders to protect and preserve life. With the increased implementation of tactical medical training and the Rescue Taskforce concept we will be better prepared to respond to, mitigate, and recover from these man-made cataclysms.

Tracy Caulder is a U.S. Army combat veteran and Nationally Registered Emergency Medical Technician. Caulder deployed to Afghanistan from June 2013 to February 2014 and served as a squad leader and ground medical evacuation team leader providing care for combat wounded in austere and clinical settings. In 2015 he was called to state active duty by the Army National Guard to provide medical support and humanitarian relief to the victims of severe flooding across South Carolina. Caulder continues to serve in the Army National Guard and works for Berkeley County EMS; he also serves as a Founding Member and Chief Training Officer for Rapha Group, LLC. He possesses an Associate of Applied Sciences in Health Sciences and an Undergraduate Certificate in Military Leadership Studies from American Military University. He is also an ASHI, AHA, AAP, and NAEMT Instructor.

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