By Connie Pignataro
Fire department emergency medical services (EMS) have had to evolve to better serve the community. We have added many life-saving treatments and medications to our toolbox, and paramedics are more highly skilled than in any time in our history. Greater demands continue to be placed on us by the public, creating an even more challenging and perilous working environment.
One example of a current challenge is the size of our patients. Obesity is at an all-time high, with nearly 40 percent of adults and 19 percent of children classified as obese.1 Many times, EMS is required to lift, move, and carry these patients, increasing our risk for back, shoulder, and knee injuries. To meet the needs of this population, EMS has responded with special bariatric equipment, stretchers, and transport units to facilitate caring for these patients.
Another area of increased risk for fire EMS is responding to motor vehicle accidents. Vehicle crashes are on the rise; there were nearly 6.3 million in 2015. Fire departments are working under more dangerous conditions on a daily basis because of impaired and distracted drivers.2 Nearly 25,000 people died in crashes attributed to distraction or impairment.3 In 2017, 13 firefighters died after being struck by a vehicle while working an incident.4 The number of injuries and near misses is far greater.
Active Shooter Incidents
Recent tragedies are adding new challenges to fire departments across the country. The mention of Columbine, Fort Hood, Sandy Hook, Pulse Nightclub, Las Vegas, Ft. Lauderdale International Airport, and Parkland brings to mind devastating tragedies that compel the public to ask, “Why?” We in the fire service need to be asking ourselves, “How?” How are we going to respond to an active shooter incident that lands in our jurisdiction?
Active shooter incidents are on the rise. Between 2000 and 2016, there were 220 active shooter incidents in which 661 people were killed and 825 injured.5 From open spaces to places of business, no location, area, or town is immune to an active shooter incident.
In 1999, after the Columbine High School massacre in Colorado, law enforcement (LE) realized that its current policies regarding active shooters no longer served the public. At the time of this tragedy, it was the policy of responding agencies to wait for Special Weapons And Tactics (SWAT). Thirteen people were killed and 24 were injured while waiting for SWAT to arrive and confront the Columbine shooter. It was apparent something more had to be done. LE agencies nationwide developed a new approach and training to respond to active shooters as quickly as possible. Although the new program has not been easy to implement, it has been proven that this new approach saves lives.6
Scene safety has been ingrained in our minds as the number-one priority for fire EMS. Most fire departments have a policy on staging for EMS calls that could pose a threat to personnel such as domestic violence calls, 911 hang-ups, suicide threats or attempts, overdoses, and sometimes even unknown medical calls.
With that in mind, fire EMS is being called on to evolve its handling of active shooter incidents. Just as law enforcement has developed new approaches to save more lives, fire departments are also transitioning to adapt to the changing environment. We can no longer stage for law enforcement to fully secure the scene when responding to an active shooter incident. People are dying when they could otherwise be saved. This became evident during the active shooter event at Columbine when coach Dave Sanders lay bleeding from a gunshot wound. He was shot at 11:26 a.m. Paramedics finally reached him at 3:24 p.m. Unfortunately, he was already dead.7
The military has proven that getting to the injured more quickly dramatically saves lives. They found that from World War I to the War on Terror, survivability of our injured soldiers greatly increased from 30 percent to 98 percent because of quicker initial care and rapid transport to definitive care.8
Fire Service Supports Transition
Fire department leadership is supporting this transition. In a 2014 position statement regarding active shooter events, the International Association of Fire Fighters (IAFF) stated, “Fire and police departments, regardless of size or capacity, must find ways to marshal appropriate and effective responses to these events.” This position was also adopted by the International Association of Fire Chiefs (IAFC).
Elected officials, city managers, and fire chiefs must embrace this international support at the local level. Departments large and small, career, volunteer or combination, have a heavy burden to plan, prepare, and train for these events. This can be an overwhelming task for any agency. Where do we start? We start where we always do—with a plan.
In June 2016, the National Fire Protection Association (NFPA) felt it was time to begin drafting a policy. With active shooter incidents on the rise, it knew it needed to move quickly. In April 2018, NFPA 3000, Standard for an Active Shooter/Hostile Event Response (ASHER), Program was released.
“NFPA 3000 empowers communities to plan, respond, and recover from (active shooter) events in a unified, coordinated manner,” says John Montes, the NFPA’s emergency services specialist. “No one can develop a plan in a vacuum. It takes an entire community working together. All have a role to play.”9
LE, fire, and EMS must agree that an active shooter incident is not just an LE event but a multiresponder, coordinated event.
According to Jeff Gurske, division chief of training with the Hillsboro (OR) Fire Department and co-developer of The Rapid Treatment Model (RTM), “It is our ethical responsibility for law enforcement and fire EMS to work together to protect and save lives. The Rapid Treatment Model allows EMS to safely provide life-saving treatment while law enforcement simultaneously secures the scene.” (8)
This concept of going into the scene before we receive an “all clear” from LE is new to the fire service, but once we understand active shooter events and how they unfold, we will realize that fire EMS participation in these events is low risk and critical to saving lives.
The average active shooter incident lasts 12 minutes; 37 percent last less than five minutes. Ninety-eight percent of the time, the offender is a single shooter; 43 percent of the time, the crime is over before police arrive. In 57 percent of the shootings, an officer arrives while the shooting is still underway, and the shooter often stops when he sees or hears LE.10
Getting access to the critically injured victims as quickly as possible will save more lives. In its paper on active shooter response for fire EMS, the U.S. Fire Administration reports that our number-one focus must be on hemorrhage control, which will improve survival.
The THREAT Acronym
The critical actions that must take place in a coordinated effort by fire EMS and LE follow the acronym THREAT11:
T = Threat Suppression
It is the sole responsibility of LE. It occurs in the hot zone, which is the area of direct threat where the active shooter can engage people. During the initial stages of the incident, the entire building is considered a hot zone. This is similar to a hazmat hot zone where only personnel trained to handle the hazard can enter the zone. LE’s focus is on locating, containing, and eliminating the threat. (10)
H = Hemorrhage Control
There are two schools of thought regarding this component. The RTM teaches that LE will be the largest resource on scene and the first to make contact with the injured in the hot zone. Although some LE personnel engage in threat suppression, others will quickly apply tourniquets to those with extremity injuries and move the most severely injured to a casualty collection point (CCP) designated by LE. The CCP should be located with the quickest and most effective ingress and egress in mind along with enough room to triage and treat the patients. LE will escort fire and EMS to the CCP so that fire EMS can triage and quickly treat the patients and prepare them to be moved to the transport area.12
“[The RTM] allows fire EMS to just come in and perform their operations,” says Gurske. “It requires no additional gear and very minimal training to be effective.” (12)
The Rescue Task Force (RTF) is another school of thought for treating patients. Although this method requires more training, many jurisdictions are using it. The RTF was developed by the Arlington (VA) Fire Department and is recommended by public safety leaders across the country.13 The RTF is a group of EMS members who enter the warm zone, also known as the operational zone, under the protection of armed LE to provide basic, rapid, life-saving medical care to victims as they are encountered. There may be multiple RTFs in an incident. Under this system, the warm zone has been cleared by LE but not secured; risk is minimal because LE has isolated the threat from the part of the building where the RTF will be working.14
All jurisdictions can use the RTF and can adapt the concept to their local resources. The RTF concept allows for LE and fire EMS to focus on what they do best. The ratio of LE officers to fire EMS personnel on the RTF teams and their tactical deployment are based on resources. Before deployment of these mixed asset teams, the agencies must make an initial commitment and engage in education, planning, and training that will enable them to be effective and for all involved to be as safe as possible.
Ballistic Protection. An active shooter incident is dynamic, and the warm zone can quickly become the hot zone, but the chances of this happening are statistically low. To be prepared, EMS members on the RTF must wear ballistic protection (photo 1). NFPA 3000 states that the ballistic vest provided by the jurisdiction shall be rated at least a level III-A. Per the National Institute of Justice (NIJ), this level will provide protection from the largest handguns.15 The vest must also be NIJ certified and on the NIJ compliant products list. The vest must be identified with the jurisdiction’s name or the role of the responder. The NFPA standard also suggests a ballistic helmet, a flashlight, and communication equipment.
Supplies and Equipment. Fire EMS must be prepared with supplies and equipment to triage and treat injuries. Common injuries found at an active shooter incident are extremity hemorrhage, tension pneumothorax, and airway obstruction. Although these life-threatening wounds are treatable with minimal supplies, they must be treated quickly to improve survivability.16
The priority for fire EMS is rapid hemorrhage control and has been placed ahead of airway control since victims can bleed to death faster than they would die from a compromised airway. (16) Two types of hemorrhage control—extremity wounds and neck/torso/groin wounds—will generally present at an active shooter incident. To treat extremity injuries, fire EMS must have multiple tactical tourniquets and pressure dressing supplies in their rescue packs (photo 2). The tourniquet is a quick and easy piece of equipment for stabilizing an extremity hemorrhage if bleeding cannot be controlled with a pressure dressing. To stop the hemorrhage, place the tourniquet above the wound, ensuring that it is visible, and tighten until bleeding stops (photo 3). Do not place the tourniquet over a joint. Write on the tourniquet the time it was applied.
Once thought to be a cause of limb loss because of ischemia, the tourniquet has been proven to be a life saver and can be kept on for up to two hours without causing permanent ischemic injury to the limb. Avoid periodically loosening the tourniquet to try to reduce limb ischemia; doing this could lead to a fatal loss of blood.17 Leave the tourniquet in place until the patient reaches definitive care.
A few different tactical tourniquets are available. A recent study on three of them concluded that their capacity for hemorrhage control is similar. However, the Combat Application Tourniquet® (CAT), used by the military, applied more pressure and was able to be secured faster.18
A hemostatic dressing is used for injuries in areas where tourniquets cannot be used like the neck, torso, and groin. These dressings fall into three categories based on their mechanism of action: factor concentrators, mucoadhesive agents, and procoagulant supplementors.19
Factor concentrators quickly absorb the water content of blood; this concentration results in clot formation. Mucoadhesive agents adhere to the tissues and physically block bleeding. Procoagulant supplementors deliver procoagulant factors to the wound. An example of this category is dry fibrin sealant dressing. (19)
Each has its benefits and drawbacks. Some produce an exothermic reaction that generates enough heat to burn the surrounding tissue. Some are easier to apply; others are not as effective for larger wounds. Some were found to be difficult, if not impossible, to remove at the time of surgery while others were relatively easy to remove. (19) A perfect hemostatic dressing has not yet been developed, and jurisdictions must research the products available to decide which product is best for their needs.
Airway management will be limited to the basics during an active shooter incident. If the patient is conscious and can follow commands, have the patient assume a position of comfort. Do not force a patient to lie down. For those who are unconscious or unable to follow commands, it is recommended you clear the mouth of any foreign material. Perform a quick jaw thrust or chin lift and use nasopharyngeal airways, if appropriate. Place the patient in the recovery position (left lateral recumbent) to keep the airway open.20 A variety of sizes of nasopharyngeal airways should be carried in the rescue pack to manage patients without maxillofacial or neck injuries if needed. For those with injuries to the neck and face, a “sit up and lean forward” posture will help to open the airway if this positioning is possible. (16)
Open or sucking chest wounds need to be treated immediately to lessen the chances of a tension pneumothorax developing. A small study conducted on five Food and Drug Administration-approved chest seals found a wide range of difference in performance. Two were 100 percent successful in keeping intrapleural pressure and oxygenation near normal, preventing a tension pneumothorax from developing. Both are semiocclusive and allowed blood to escape. Two of the others tested were 67 percent successful and 25 percent successful, and one was not effective at all.21 The rescue pack should also contain some chest seals.
If a tension pneumothorax is suspected, needle decompression must be performed with a minimum of a 14-guage needle/catheter, 3.25 inches in length. (20) Keeping a few of these needle/catheters in the rescue packs is a must.
The rescue pack needs to be big enough to hold the medical supplies and yet small enough to not hamper movement. The jurisdiction must also select a pack that is easy to use and well-labeled for when fine motor skills are compromised.
As with any mass-casualty incident, cardiopulmonary resuscitation will likely not be successful, as resources will be too limited to work a trauma code. Victims who are pulseless and apneic with severe injuries will be considered deceased and will not receive treatment. (20)
RE = Rapid Extrication to Safety
After life-saving measures have been performed, the next priority is to remove victims; the plan for doing this will vary at every incident.
Those who can walk without assistance, injured or not, may be directed to evacuate on their own through a cleared area under LE protection. (14) For those who are too injured to evacuate on their own, an RTF may play a role in their evacuation at one level or another.
According to Julie Downey, chief of Davie (FL) Fire Rescue and an NFPA 3000 committee member, “Each agency is a little different. Usually, the RTF will work with LE to move the victims to a CCP; then, an extraction team or litter bearers can be escorted in to move the victims to a treatment area or to awaiting rescue units.”
Downey suggests that in addition to the medical supplies mentioned above, a small, compact patient mover (photo 4) be included with the rescue pack to move patients from one area to another.
A = Assessment by Medical Providers
This takes place from the moment an EMS provider begins to treat the patient and throughout the entire process prior to transport. This step should not delay rapid transport, especially for those most severely wounded.
T = Transporting All Patients to Definitive Care
To do this, a victim may be moved to a few locations prior to transport. Depending on the incident, command may set up an internal and an external CCP. Casualties will need to be grouped into priority levels in each CCP for effective evacuation and transport. (14) Some may choose to use triage ribbons or tags; others may find this to be too cumbersome, depending on the incident. Whatever triage method is chosen, getting the patients into the cold zone and prepared for transport is the highest priority. (13) Transport those most critically injured first because they can tolerate very little delay. The golden hour still applies. Increased delay will mean a higher mortality rate for these patients. (12)
The current fire EMS response ranges from departments doing nothing because of a lack of desire or funding to departments with fully trained personnel to perform tactical EMS. The departments doing nothing must at least begin a dialogue with their local LE to begin to develop a coordinated response strategy. Changing with the times is not a new concept for the fire service. We must adopt new tactics and strategies to better serve our communities when an active shooter event lands in our jurisdiction.
1 Craig M Hales, MD; Margaret Carroll, MSPH; Cheryl D Fryar, MSPH; and Cynthia L Ogden, PhD. Prevalence of Obesity Among Adults and Youth: United States, 2015–2016. Centers for Disease Control and Prevention.
2 National Highway Traffic Safety Administration. Traffic Safety Facts 2015: A Compilation of Motor Vehicle Crash Data from the Fatality Analysis Reporting System and the General Estimates System. Retrieved April 10, 2018.
18 Gibson R, Housler GJ, Rush SC, Aden JK 3rd, Kragh JF Jr, Dubick MA. Preliminary Comparison of New and Established Tactical Tourniquets in a Manikin Hemorrhage Model. Journal of Special Operations Medicine. Spring 2016.
21 Kheirabadi BSI, Terrazas IB, Miranda N, Voelker AN, Arnaud F, Klemcke HG, Butler FK, Dubick MA. Do vented chest seals differ in efficacy? An experimental evaluation using a swine hemopneumothorax model. The Journal of Trauma and Acute Care Surgery. July 2017.