By August Vernon
The current and emerging threat of mass violence/active assailant incidents continues to be a concern for fire, emergency medical services (EMS), emergency management, and law enforcement. Agencies, regardless of their size, must find ways to marshal their resources, and local agencies MUST have common tactics, communications, and training. These incidents are not about tactical medics, Special Weapons and Tactics (SWAT), or any other specialized units. Recently released guidelines, discussed below, provide hot, warm, and cold zone models for these types of responses. No model is better than the other; each jurisdiction should select the one that will work best for it.
The rapid, safe, and successful response to a mass-violence incident (active assailant, active shooter, mass stabbing, bombing, and so on) necessitates planning, training, and preparation. The likelihood of a mass-violence incident is low, but public safety officials must be prepared for these situations. Continuing criminal attacks and terrorist threats and incidents have demonstrated the need to prepare for, plan for, and respond to these incidents.
Law enforcement has learned over the years that "SWAT arrives too late" in an active-shooter scenario, fire/EMS understands that waiting for specially trained medics will result in loss of life. The practice of "staging until the scene is secure" will result in the loss of salvageable lives. Using proper law enforcement support, fire/EMS personnel can work in areas that have been cleared but not secured with a high degree of safety. There is a difference between cleared and secured, and fire/EMS agencies need to become familiar with these definitions.
As experience with these events has grown, it is obvious that long-standing fire, EMS, and law enforcement operations are not effective and do not maximize victim survival. Using existing tactics and evolving concepts, the means of improving survival already exists, but it is underutilized. These shortcomings can be addressed with some joint planning and training. Efforts to locate, isolate, and neutralize the active shooter remain paramount, but the point at which medical care is rapidly administered to the wounded is critical to victim survival.
There are four major considerations involved in planning for and responding to these incidents:
- Use the incident command system and unified command.
- Agencies should jointly plan and jointly train together.
- All participating agencies must understand the meaning of terms such as "cleared," "secured," "hot zone," "warm zone," "cold zone," "rescue task force" (RTF), "casualty collection points" (CCP), and so on.)
- Agencies will then need to "war game" these tactics using a series of "joint-agency" tabletop and field exercises.
Between 2000 and 2008, the United States experienced an average of approximately five active-shooter incidents every year. Since 2009, this annual average has tripled. We've seen at least 12 active-shooter situations so far in 2013. These incidents seem to be getting more and more deadly. Over the past four years, America has witnessed an increase of nearly 150 percent in the number of people shot and killed in connection with active-shooter incidents.
This issue and the new suggested tactics/procedures are not new. The "Wanton Violence at Columbine High School, Littleton, Colorado USFA-TR-128/April 1999" report noted: "Hostile, multihazard situations--including acts of wanton violence--challenge the fire/EMS service to respond with nontraditional tactics and to operate under a unified incident command structure with law enforcement." It also identified the following topics as major areas of focus:
- Fire service/EMS' use of protective antiballistic garments.
- Law enforcement escorts during hostile, interior operations.
- Assets dedicated to identify and to render safe potential secondary devices.
- Rapid rescue and medical intervention for tactical teams.
- Enhanced common interoperable communications.
- Pragmatic, unified command procedures for all responding agencies.
These same guidelines from 1999 can and should impact public safety operations in 2013 and beyond. Fire/EMS needs to change its response models in the same way that law enforcement has for these mass-violence type incidents. Law enforcement has gone from "set up perimeter and wait" to "rapidly deploy." Fire/EMS is in "stage-and-wait" mode. It is important to note that the immediate risk in active-shooter incidents is typically over or being mitigated before fire/EMS resources arrive on scene in sufficient numbers to conduct response and effective rescue operations--most active shooter incidents are over in about four to 10 minutes. Also, there is now more discussion of fire and EMS command staff talking about creating specialized teams of SWAT medics and "high hazard response" fire personnel who will enter into active-shooter and active-assailant situations. This is one option, but it may not be the best one. Can you muster these resources within four to 10 minutes? So, just like law enforcement found out SWAT does not work in these events, fire/EMS may also be headed in the same direction.
The majority of fire and EMS agencies have done little to plan or prepare for a mass-violence incident. Nearly 76 percent of fire departments do not have active-shooter policies or training programs in place, according to responses to an International Association of Fire Chiefs (IAFC) survey. Many (maybe most) fire and EMS agencies are looking for guidance on this critical issue.
A victim is seriously injured or killed every 15 seconds after the attack starts. Half of the victims at an active-shooter event will be seriously injured. Sixty-seven percent of victims with a major ballistic injury will be dead in 30 minutes unless they receive basic treatment and are transported to a hospital. Since Columbine, active-shooter response has focused on law enforcement's neutralizing the shooter. This model still fails to get medical attention to victims soon enough. The newly available models of active-shooter response guidelines listed below allow for simultaneous shooter neutralization and victim treatment.
In every community, local, county, and state law enforcement annually conduct active-shooter or rapid-deployment training. Fire/EMS typically is never invited to or is even aware of this training. It is important for fire/EMS responders to be aware of these "active-shooter" tactics. This is free training that is already taking place in your community. You just need to find out how to connect with your law enforcement agencies to observe and participate in this training.
These incidents are well beyond the traditional planning, training, and experience of the majority of law enforcement, firefighter, emergency management, and EMS responders. These fast moving incidents that involve multiple agencies can and will quickly overwhelm most, if not all, response agencies. The most efficient and effective and safest response will require a joint-agency response including fire, EMS, and law enforcement.
Combat data show that the vast majority of victims with blast and penetrating injuries die within 30 minutes of wounding. It takes a minimum of 60 to 90 minutes for law enforcement to secure a scene location, sometimes hours on larger locations. The wounded cannot wait for completely scene-safe operations. Law enforcement has plenty to do on scene--don't add additional work by making them locate, treat, rescue, care for, and transport the wounded.
When it comes to fire/EMS responder safety, it is important to remember that fire/EMS operations are already hazardous. There is risk daily in fire/EMS operations, but this risk is mitigated with training, equipment, personal protective equipment, standard operating procedures/ guidelines, and so on. You accept risk in your daily operations. Studies shows that approximately 100 firefighters and 10 to 20 EMS personnel are killed every year during the line of duty. At least seven first responders, all law enforcement, have been injured responding to active shooter events over the past 35 years; none were killed although some were seriously wounded. In that same time frame, thousands of fire/EMS responders have been killed during "routine" daily operations--none during an active-shooter incident. Some fire/EMS responders have been killed during ambushes and assaults, so it is always important for fire/EMS to be aware of the signs of a violence scene/situation. But these incidents do not meet the definitions of an "active-shooter" incident.
NEW RESPONSE GUIDANCE
Several new guidelines and procedures for fire/EMS pertaining to mass-violence/active assailant type incidents have been released in the past 12 to 24 months. Each of these reports addresses operations in hot, warm, and cold zones. I will address just some of them below. Numerous others are available from the Urban Fire Forum, the International Association of Fire Fighters, and other sources. All these new documents are good news for the first responder community. The trend is clearly shifting toward an understanding that high-threat response must be owned by all stakeholders from patrol to EMS/fire to emergency medicine and emergency management to the trauma operating room.
Following is a brief look at three primary resources:
- Committee for Tactical Emergency Casualty Care (C-TECC). C-TECC was convened to speed the transition of military medical lessons learned from the battlefield to civilian crisis response to reduce preventable causes of death in our first responders and the civilian population. These guidelines are a set of best practice recommendations for casualty management during civilian tactical and rescue operations. C-TECC is modeled after the Committee for Tactical Combat Casualty Care (CoTCCC) and is comprised of a broad range of interagency operational and academic leaders in the practice of high-threat medicine and fire/rescue from across the nation, including members from emergency medicine, EMS, police, fire, and the military special operations community. C-TECC remains an independent civilian entity that maintains a close relationship with CoTCCC for guidance and support.
Taking into account that wounding patterns and mechanisms of injury may be similar in civilian incidents involving ballistic and explosive wounding, TECC recommends treatment modalities based on the situation and available assets. The primary TCCC tenants of placing far forward timely medical care and doing the right thing at the right time are also paramount in the TECC guidelines. As with TCCC, TECC is divided into three phases of care based on the relationship of the provider, the casualty, and the threat. For additional information and guidelines, go to http://c-tecc.org/
Over the past three years, C-TECC has worked with many of the major stakeholders in high-threat prehospital medicine to create a dynamic set of evidence-based and best-practice principles for providing high-threat civilian prehospital trauma care. Working closely with the National TEMS Initiative and Council (NTIC), the Special Operations Medical Association (SOMA), members of the Interagency Board, the Department of Homeland Security, the Federal Emergency Management Agency, and major academic institutions, C-TECC has been able to provide an effective roadmap for the translation of military lessons learned to our civilian response.
- Hartford (CT) Consensus. The ACS has begun to get involved in the critical problem of high-threat prehospital medicine. The initiative consisted of a meeting of eight physicians and one firefighter/paramedic who were either members of or directly representing several of the important groups that need to provide guidance to first responders on this issue. From the public side, there were members of the IAFC, the Federal Bureau of Investigation, and representatives from the Major Cities Police Chiefs and the Military Committee on Tactical Combat Casualty Care. Representatives from a select group of public safety organizations including law enforcement, fire, prehospital care, and trauma care convened in Hartford to develop a consensus regarding strategies for increasing survivability in mass-casualty shootings. The resulting concept document, known as the "Hartford Consensus," includes the acronym THREAT to describe the needed response to active-shooter and intentional mass-casualty events:
--Rapid extrication to safety,
--Assessment by medical providers, and
--Transport to definitive care.
Within the framework of THREAT, there exists the opportunity to improve survival outcomes for the victims of active-shooter and intentional mass-casualty events through mutual collaboration and reinforcing responses.
- U.S. Fire Administration (USFA) "Guidance on Response to Active Shooter and Mass Casualty Incidents." This guide is a fire and EMS resource that can be used to support planning and preparation for active-shooter and mass-casualty incidents. The USFA offers this guide as one source of many available for the public safety community, but it takes into consideration the diverse local service levels available across America. In developing the guide, the USFA consulted with individuals and groups engaged in fire and prehospital EMS, law enforcement, and hospital medical and trauma care. One of the major topics of the report is the creation of RTFs. These personnel are different from tactical EMS personnel, who are committed to their tactical team's assignment and precluded from casualty-care activities. The report describes RTF personnel functions as follows: "Considerations, planning, and interagency training should occur around the concept of properly trained, armored medical personnel who are escorted into areas of mitigated risk, which are clear but not secure areas, to execute triage, medical stabilization at the point of wounding, and provide for evacuation or sheltering-in-place."
One additional resource available at the Fire Engineering Web site is The Firefighters Support Foundation, which has released the free video program Active Shooter Response: The Rapid Treatment Model. This 30-minute video and accompanying 29-slide PowerPoint presentation comprise an introduction to the third generation of active shooter response. Unlike previous approaches, the Rapid Treatment Model specifically integrates fire/EMS with the law enforcement response, and the focus is on getting aid to the wounded within the golden hour, even while law enforcement is still clearing the structure. It allows EMS personnel to work in a safe, secured zone simultaneously with law enforcement clearing, and it does not demand complicated cross-training between the agencies. http://www.fireengineering.com/articles/2013/09/active-shooter-response-the-rapid-treatment-model.html.
Remember, no model is better than the other; each jurisdiction should carefully select the one that will work best for it. It is critically important that law enforcement, fire, emergency management, and EMS train and plan together for these type incidents. The site of a mass-violence/active-shooter incident is not the place to "try out" new ideas (teams, equipment, tactics, and so on). Also, if the security of fire/EMS personnel is ever in question, do not use such tactics in "forward" areas. In none of the current "warm" or "cold" zone models will fire/EMS responders be in the line of fire or in immediate danger. Reach out to all your local agencies to discuss this topic. At a minimum, fire/EMS, observe the free, active-shooter/rapid deployment training already taking place in your community or region on a regular basis--even better, participate! Discussions with all law enforcement, fire, 911, emergency management, EMS and other first response agencies serving the jurisdiction must take place. Establish common expectations and understandings of what each agency will do and what support they will need from each of the other agencies to marshal their resources. The challenge will be to make sure that every first-line law enforcement officer, firefighter, and EMT, and all supervisors understand the concepts and processes discussed. There are now several realistic guidelines and models you can use to develop your own policies, procedures, and training for responding to mass-violence incidents. Start working now with your departments and local law enforcement agencies to establish these relationships and start building the policies, procedures, and training.
AUGUST VERNON has conducted dozens of mass violence and mass shootings courses since 2005. He is the operations officer for the Forsyth County (NC) Office of Emergency Management. He returned to this position in 2005 after a year in Iraq as a security contractor conducting route clearance and long-range convoy security operations for the U.S. Army. He has been employed in emergency management for 13 years and also served as a paid member of the fire service and a fire service instructor. He served in the U.S. Army as a chemical, biological, radiological, and nuclear operations specialist for four years. He has presented more than 250 multiagency presentations at classroom sessions, field training events, conferences, workshops, and seminars over the past 14 years, and instructs in incident management, mass violence/mass shootings, emergency & crisis management, and terrorism planning-response. He is a technical reviewer Emergency Film Group. He has written more than 40 nationally published articles and is the author of the First Responders Critical Incident Field Guide (Red Hat Publishing).