Wed, 4 Sep 2013|
This 30-minute video program and accompanying 29-slide PowerPoint presentation from the Firefighters Support Foundation focuses on getting aid to the wounded within the golden hour, even while law enforcement is still clearing the structure.
[BLANK_AUDIO] As criminal mass casualty incidents, resulting from an actual shooter have increased. It's become very apparent that we are not as prepared in response as we should be. These horrific events can occur anywhere. They happen in our places of worship, our schools, our businesses. Communities large and small, we're all at risk. It is imperative that we look at historical data and be critical both of ourselves and the industries which we serve in. There is an outward call for us to work forward. It's imperative that both Fire EMS employees work together to engineer a system that is not individualistic, but is collaborative. The response solution needs to be manageable, efficient, and, most importantly, to use service personnel as experts in their field. It is our ethical responsibility for fire, police and EMS. To work together, to achieve the ultimate goal, to protect and save lives. Active shooter events are not new in our society. Quite frankly, they've been around for hundreds of years. But, what we're looking at recently, is the proliferation of the rapid mass murders, which is four or more people killed in 20 minutes. Those have been on the steady increase since the 1990s. And 2012 set an all-time record with 16 rapid mass murders occurring in our society. Although active shooters have been around for hundreds of years, the first widely publicised one was in Camden, New Jersey where Howard Unruh had walked down the streets for 13 minutes and killed 12 people, wounding four. A lot of times we look at the Texas bell tower incident as kind of the precipitous. Random mass murder in public. Which, there, Charles Whitman killed 17 and wounded 32. But what we need to look at the stats are important to look at, and to analyze. The wounding patterns and how many people are injured and killed. But what is missing in this is a collaborative effort between police and fire, and how best we can bring those resources to bear, to save lives. Predominantly law enforcement has focused just on the tip of the spear. When we focus on how do we intercede and interrupt the active shooter. However, we neglect the fact that the timeline of these events have been compressed to where the average time in years 2007 through 2012. Is three minutes or less. Aurora, Colorado, tragic incident. Almost 50 people wounded, 12 people killed, occurred in about 90 seconds. What that tells us is, it's imperative that, if we want to have the biggest impact,. On rendering life saving ability, it's to get our partners from the Fire Service into the scene quickly. So the key point is that the paradigm has to change for law enforcement. Instead of looking just solely on getting in there, stopping the shooter, which is important, we need to shift and we need to include as a priority getting Fire EMS into the scene quickly to render life saving efforts. In 2007, we started taking, a serious look at the various criminal mass casualty events and active shooters, dating back to 1949 until present. What we found is over 300 of those events, 93% are over before law enforcement intercedes into the scene. Out of those instants only 31 have been documented that law enforcement has had a positive influence engaging the shooter and stopping the killing pattern. With that in mind we need to look at our overall strategy and work with our fire, ems counterparts and get them into the scene to have the greatest impact in rendering life saving aid to those wounded in the act an act of shooter criminal mass casualty event. [BLANK_AUDIO] I just want you to stay on the line with me cuz I, we need to know what's going on. Okay. Okay? I am on the floor. Okay. And you've got the kids there? [NOISE] I got everything. And I've got all the students on the floor. [NOISE] On the floor, you guys, stay on the floor. Is there any way you can lock the doors? Somebody is going in. [INAUDIBLE] Right outside the library door. Okay? I don't think I'm going out there, okay. [INAUDIBLE] [CROSSTALK] I got three children. Okay, we've got it. Okay. [INAUDIBLE] I got the kids on the floor. I've got all the kids in the library [UNKNOWN]. We have paramedics. We have fire and we have police on route. Really, the precipitous event for law enforcement that changed our response paradigm was the Columbine massacre in 1999. There 13, students were killed and 20 were wounded. When we looked at that incident, prior to the Columbine, the standard law enforcement protocol was to contain, isolate and evacuate around the incident. The tragedy of Columbine was that the killers, in that instant, were able to finish their slaughter in about 17 minutes. So they ended up roaming the halls of Columbine, talking to some of the students, engaged law enforcement and fire with some random gunfire from the library. But, overall, their killing spring was done in 17 minutes. And, Klebold and Harris ended their lives in the library around 45 minutes. What we learned from that is that law enforcement had to make a major shift, and no longer could we just simply wait for SWAT, and to isolate. We had to move in, and try to intercede and mitigate the shooter. We all know that the Columbine massacre changed the paradigm for how law enforcement responds to these types of events. Since Columbine, law enforcement has focused heavily on small unit tactics on how to intercede and interrupt the shooter. Unfortunately the lesson that came out of Columbine was the Dave Sanders story. Over the course of three hours, Dave ultimately bled out. Because we were unable to get fire EMS support to them. So now we believe the paradine needs to change again. And that is getting fire EMS into the scene quickly to render life saving aid. [BLANK_AUDIO] In order to better understand our responding, response in these incidents. We have to take on a healthy dose of statistics. The Wound Data Ammunitions Effectiveness Team did a study from Vietnam to the first Gulf War. In this study, we found the victims that, to which their injuries resulted in death, we can be the greatest effect with those wounds in that percentage of casualty from five minutes. To two hours. Now we have to be cautious when looking at these studies because they are based on military events. The reason why we have to be cautious on these studies is because military people are exposed to a wider range of munitions and ordinances, and are also wearing protective gear. And a very important point from that study, they found that only 10%. Of people died after the initial care was initiated. So therefore it's important that we get care to the victims as soon as possible. The military has gotten very good about saving their casualties. If you look from World War One to the War on Terror, you'll notice that the survivability has greatly increased. And the reason why this is increased is that, cause they've gotten initial care to the patient. Quicker as well as a rapid transport to definitive care. This is where our term the golden hour comes from. The time of on scene incident to the operating room table within one hour. Receiving care for a patient in his golden hour is a systemic problem. The reason why it's, I say it's a systemic problem. Is because this isn't just a law enforcement event. We're gonna include law enforcement, EMFs, fire, 911, receiving hospitals, and many other entities. The reason why we say this is a systemic effort, is if any of your combined agencies don't have the expertise. The clearly defined roles, familiarity, if they're not unified, and most importantly, if we don't have a simplified response, the whole system will be affected. The reason why we have not saved as many lives as we should have is because we don't have a response structure that is multi agency inclusive. Specifically, integrating EMS within the patient's golden hour. Within the last couple year, parent agencies to the Public Safety Organizations to which we work in have come out with statements on how they view we should be moving forward with an active shooter response. The US Fire Service administration in January 2013 came out with a statement. Some of the basic components of this statement to which we need to focus on are: better understand with ICS with every organization involved, we need to develop a casualty collection for easier victim transfer, and most importantly we need to develop a plan. Updated and train annually. In April of 2013, the International Association of Fire Fighters and the International Chief of Police came together and had a statement. The basis of the statement are we need to strengthen our relationship as organization and most importantly, we need to adapt our response. In June of 2013, the International Association of Fire Chiefs came out with a statement. An important point that they made is that we need to be better prepared to work with law enforcement. In June of 2013, the National Center for Disaster Medicine and Public Health came out with a statement. It said, "It is unlikely that any single component of the public safety infrastructure". We'll be able to effectively and comprehensively respond to those threats posed and casualties inflicted during a hostile mass casualty shooting incident. It also goes on to say that we need to have cooperative planning with all of those entities. As of recently the International Association of Chiefs of Police. Came out with a statement. It also sounded similar with the message of. Are we proactively prepared to work together? Regardless of your organization, and if you're working toward these goals. The statements that we just talked about. These statements will be the lens to which your actions, will be viewed after the fact. So what's the current fire/EMS response? Well across the nation we're seeing a spectrum and the spectrum goes from agencies that aren't doing anything, this could be due to funding, technical expertise staffing or just the lack of desire to initiate a program, then you have agencies that have fully technical programs. With trained operators performing tactical emergency medical services. So some of this forms of tactical medicine, first we'll start with TEMS. So TEMS is tactical emergency medical services. TEMS is decided to link up with a operator law enforcement or somebody who has technical expertise in that field. These people are either trained to assist, or trained to go inside a tactical environment with that officer. Another form of tactical medicine you will find TCC. Otherwise know as T triple C, and Tactical Combat Casualty Care. Now TTC is designed for an operator. Specific with that law enforcement or military. And they're taught specific and few, medical techniques to provide self and buddy rescue. The problem with these two EMS based methods of T triple C attempts are cost, training, gear and they're not simple task to perform. And more importantly, depending on the incident. Law enforcement officers may be better utilized somewhere else. Another component of tactical EMS you'll find are rescue teams. In a rescue teams, you'll take law enforcement, the fire or EMS, and you'll link them together in a pod and they will go through the structure, providing emergency medical treatments, and most importantly triaging and extracting the victims out of the structure. The inherent difficulties with the rescue team model are command and control, integration training, and you're putting firefighters in the hazard zone. The command and control issue is obvious because it takes a lot of moving parts and puts them into play. As far as integration. We are taking two entities and if they're not training a lot. If we don't have an identified plan of how to put those groups together it's gonna be a difficult process. And lastly a hazards. We're putting fire fighters in the hazard zone which may be a problem if we're not tactically prepared for it. And these three things are exacerbated because with the rescue team model. Requires a lot of training to be effective. And if you're not using a tactical EMS approach, you're gonna be waiting for an all clear. The problem with the all clear is after law enforcement enter this hot zone it's gonna take well beyond the patient's golden hour until it becomes clear. So in general, what is the hangup with EMS responding to a law enforcement event? The hangup is, are the hazard zones. As police enter a structure, that whole entire structure, maybe even extending thereabouts. Are all going to be considered a hot zone. On Fire EMS we understand that if we're gonna take hazmat zone. You have your hazard zone, your warm zone and your support zone. If you're not trained to do so, you never going into hot zone. And this is the same problem at a shooting scene. Once this threat is, is occurred. It's gonna be a hot zone. As an EMS or, or fire personnel without being a technician, I cannot enter that hot zone. So with the hazard zone modeling, the question becomes, how can we adapt it to make it safe for EMS fire to enter. And the way we came about that, was, is if we take a warm zone. And kinda bubble it or embed it into a hot zone, it makes for safe transport and safe operations for fire and EMS. In the following part of this presentation we will show you how we took a warm zone and securely embedded it into a hot zone. Allowing EMS to perform their duties with law enforcement security. Because predominantly law enforcement has focused on the team tactics of responding to an active shooter, we've neglected the overall strategy of how best to use all of our resources, both from police and from fire. If we look at the nine principles of warfare that the military adopts, one of those principles is economy of force, which simply states are we using our resources to the best of our ability to achieve the overall goal. We've looked to our partners in the military and adopted two principles, both the forward-operating base and the casualty collection point, as a mechanism to utilize our resources efficiently. Because these type of events can draw a huge law enforcement response, the importance of the forward operating base is an area. That we can bring some sort of stability in this chaotic event. Here a first arriving sergeant, and it can be a police officer, can gain that foothold and start directing resources. I.e. the police officers. Where they need to go, what areas need to be swept. What areas need to be locked down. So we can move on to the next step, which is bringing bodies to the casualty collection point. Historically through, looking at real events and through training, we recognize that law enforcement pumps a huge amount of resource into this problem. And what we found through that is, law enforcement can just almost, in some sense, chase their tales and we're not really sure what's been cleared, what's been swept, where we need to focus, our energies at. The forward operating base give us that initial, area of stability where we can best direct our resources, ultimately getting to the next segment which is bringing bodies and casualties to the casualty collection point. But let's not be confused. The forward operating base is not to be looked at as the command post location or a unified command area. In fact, under NIMS, it would be best looked at as a division. So essentially, the casualty collection point is a secured area embedded, or inside, the hot zone where both law enforcement and firemen can work side by side. Law enforcement is working on providing security for that environment, while allowing fire to [INAUDIBLE], provide treatment to the patients. So, the casualty collection point is a proven military tactic used as far back as the 1800s. It allows for simultaneous operation, it provides a bridge both for law enforcement and fire, and provides a secured area where we can render the most effective care to patients. By using these two concepts both the forward operating base and the casualty collection point, we've changed the paradigm in which law enforcement responds to an active shooter event. In the past, law enforcement has charged into these events however neglecting our brothers and sisters in fire. Or we've tried to implement overly complicated integrated models with police and fire working side by side trying to search out and rescue victims. What we found is we need to keep the expertise, both from police and fire, in their respective swim lanes and just give a casualty collection point as essentially a quick connect. Where police and fire can come together and have joint operations. So to detail out the police response and what that looks like. We broke it down into three categories. Response, assessment, and security. Response consists of three main elements. One, law enforcement will respond utilizing rapid response tactics. Two, the law enforcement will mitigate the threat post, and three both the sea\rgeant and fire i.e. the battalion chief will link up and start the unified command. Assessment consist of two elements. Establishing that forward operating base to bring some sort of command and control on the in through, better utilizing and directing resources,. And two, establishing and identifying the casualty collection point, ultimately to bring victims to. Security consist of three main elements. One a security element surrounding the casualty collection zone. Two a corridor lockdown security which provides safe avenues for law enforcement to bring wounded people to casualty collection. And lastly, and probably most importantly, is an external security element providing a safe egress ingress route for both fire and EMS. Once EMS or fire has been embedded into the scene, we have three main goals. And these main goals are the basics of all MCI mitigation. They're triage, treat and transport. Once we're treaging we're going top find out the number of victims and we're going to identify the severity of their injuries after that we're going to treat. And when we treat it's only going to be the minimum life saving techniques to stabilize that person. The big deal we want here is to be able to send that person to the operating room for further medical attention by a physician. And lastly transport. Transport, we're gonna wanna make sure that we coordinate with local hospital so we don't overwhelm those resources. Once we do that we are going to transport the patients to definitive medical care. It's important to not overwhelm just one hospital cuz in that situation patients are gonna go left untreated cuz we've only shifted the incident to somebody else now. It's important to preplan with your local hospitals. Enabling services to best figure out how to mitigate that problem. While using a joint law enforcement and fire EMS response, and utilizing the CDCP, we found many benefits to it. First, are gonna be simultaneous tracks. We're allowing the operation to have two dual priorities enacted at the same time. Second is efficient prioritization. We're able to have a better understanding of who those critical patients are. Central location, we have an area where all of our resources for EMS are taking place. The fort operating base for police, being able to coordinate your interior activities. Simplicity. There is not much to this process, so it requires little training and cost. Manageable. We're able to take our two entities in their tracks, and use a unified command to make it a little bit more efficient. And lastly, it's secure. This incident by having the security not only are we protecting fire EMS we're also protecting the patients from further harm. Let's hit two of those benefits a little bit more with depth. First the simultaneous tracks while law enforcement is doing their job we are able integrate fire and EMS. Fire and EMS are able to work on patients. Triage, treating, and transporting them at the same time that law enforcement are going after the bad guy. As for simplicity, we're allowing responders to act in their comfort zone and do what they do best, which is being experts in their field. And also we're reducing the amount of extensive cross training. A way to think about the CCP is like a quick connect. We're allowing law enforcement to do their job and we are connecting or integrating fire and EMS perform our job connecting away, allowing law enforcement to continue on with their operation. We need to look at the active shooter across the life saving timeline, from the point the person's injured, til we get them to definitive medical care. These components, the law enforcement response establishing the forward operating base and the casualty collection point, providing security to bring fire in and ultimately treating the wounded inside of the CCP, ultimately transporting them to medical definitive care. To not happen sequentially. These components need to overlap and happen simultaneously. And this is an important advantage of this approach allowing for simultaneous operations rather than sequential getting police and fire working together to ultimately save lives. At the onset of the active shooter event law enforcement and fire will be dispatched simultaneously. And law enforcement will be converging the scene with a heavy amount of resources. The fire department will be staging, close to the location, but out of sight. Given the lack of intelligence of the shooter, and just for general safety until we can combine resources. This next event is going to be the law enforcement initial entry. As described, law enforcement has arrived on scene. Our fire counterparts are staged in a safe location but just out of sight of the structure. On the interior, the officers are working in a fashion to isolate and mitigate the shooter. At such time when they reasonably believe that the threat has been mitigated. A forward operating base will be established, which allows for law enforcement to better organize and disseminate the resources on the interior. Ideally inside the fob we'd like to have a sergeant kind of act as the team leader in there, but if a sarge is not available, any police officer can take command and establish the forward operating base. In this next event here, once law enforcement on the interior have determined that the threat has been mitigated or reduced, law enforcement will start to set up the casualty collection point. [INAUDIBLE] and MTI's, we need ten additional ambulance units and three additional fire units. Here's the count right now, eight red. It's also worth mentioning that the casualty collection point does not have to be in the same location as the forward operating base. Although, since law enforcement has grabbed a stronghold in that forward operating base, a lot of times that has a tendency to grow into that casualty collection point. So for sake of this illustration, we will start to call this the casualty collection point. Additionally, the second and third and fourth, fifth waves of officers arriving on scene. Some of those will continue on to the interior to assist, while others will continue down to fire stage in preparation to protect the egress, ingress route for fire EMS. This next event, which we've titled victim transfer happens when there's enough law enforcement personnel on the interior to provide corridor lockdown security. What we mean by that, is officers are responsible to lock down long corridors and allow pathways for additional police officers on the interior to start bringing the wounded to the CCP. Corridor lockdown security... Is an excellent way to maximize the resources of law enforcement on the interior, as to mitigate us just running around and chasing our tails. We come into the facility, mitigate the threat, lock down the corridors and begin the body drags to the CCP. Additionally, corridor lockdown is a very simple, very efficient way to manage your resources on the interior. Literally, one gun barrel can lock down an entire hallway or a vicinity in the interior, allowing for safe travel for the bodies into the CCP. Also to that, if the suspect were to emerge, that person or that officer who's in a stationary shooting platform can deliver effective fire and neutralize that threat. As you see here, we have law enforcement officers. Carrying live victims to the CCP. This may be a concern to some people based off of training or the liability concerns. However, our basic drags and carries were an easy teach to our local law enforcement officers. This is a basic EMS, EMS task. Training a law enforcement officers on basic drags and carries is a lot easier than what we used to do of embedding EMS into law enforcement formations. And, by the way, the drags and carries that we teach law enforcement are the same drags and carries that we will use to move patients. What happens next is the fire introduction of the CCP. As depicted earlier, fires in the fire stage area and law enforcement will begin to set up overwatch cars or overwatch officers in position that being to bolster and protect the egress, ingress route for fire. The emphasis or the purpose of this over watched cars, is to provide long gun support, some refer to it as counter sniper support, onto the structure bolstering a safe corridor for fire, EMS, to come into the scene. It's also important to note that the overwatch protection component is really based on the size, scope and complexity of the overall active shooter incident. This can be as little as one car or one police officer assigned, up to five or six depending on the scope of the incident. As fire responds in the CCP we gonna want that first fire officer to link up with the officer who's in charge of the CCP, the law enforcement officer. We have historically referred to that law enforcement officer as the hall boss and now this person on the fire side will now be in charge of the CCP on the fire side. With the rest of our fire fighters or EMS personnel, we wanted to start making sure that we go through and start identifying our roles such as medical branch and coming down in to triage, treatment, and transport, and ensure those people are identified in the CCP. As we start identifying and triaging the patients, we're gonna wanna make sure that we go ahead and separate out the different classifications. The greens with the greens, the yellows with the yellows, the reds with the reds. At this point in time, we don't need to worry about any black patient, or the deceased. As we're triaging our patients we want to make sure that we are not waiting to identify every classification then transport. We want to start transporting the most critical as our ambulances are available. But as we start trans, as we start triaging our patients, and starting to transport the most critical. We want to make sure that our entrance and egress for that ambulance is clear, which is going to speed up patient transitions. It's important to know that in initial planning we pre-plan with law enforcement. So they understand our needs for ambulance and fire apparatus in terms of the egress. This clear path of travel, often and does get screwed up. So it's important that we work together to understand each others needs, so we can train to prevent this. Because if it does happen, it's gonna slow patient transport down and be all for not. You know, one thing that we adopted from the fire service was benchmark timers. In the fire service a lot of times they'll use a ten minute timer to remind themselves of benchmarks along the way. What we've found is establishing the CCP is a critical time sensitive aspect, so we've adopted a seven minute CCP timer that our 911 center will remind us at the seven minute mark and the 14 minute mark to make sure law enforcement is staying ahead of the game and getting that up and running. The other thing I would express to law enforcement counterparts out there is a willingness to compromise. We have to remember that our counterparts, our brothers and sisters in the fire service, have a long history and are well-trained and well-equipped. And we have to come together, break some of those paradigms, and come at this collectively. One thing that we noticed was cross-agency appreciation. It's easy to build up that wall and kinda be firefighters and cops. however, once we broke down that wall we, we started appreciating each other and, because we had a better understanding of what each agency was responsible for on a daily basis. Daily operations. We notice that even responding from our general domestic disturbance, which fire and police jointly come in on, to the MVA and any other call that they're moving a lot more fluid. And the reason why they're moving fluid is 'cuz we had already laid that groundwork. Of communication and, and, you know, cohesiveness. Tradition. It's easy to be stuck in our ways as far as being a fireman and cops. We have noticed that in order for us to move forward, and our citizens, the people we are paid to protect. Require that. They require us to come together and be unified in our response. And let's not forget our 911 centers. We found through doing this exercise, that really police, fire and communications are all three an integral part of this. It's, we would encourage you to reach out to 911, invite them to your exercises. And understand their needs of how to operate within this chaotic environment.