In Fire Engineering‘s November 2013 digital supplement “Major Incident Response,” http://bit.ly/1qO8VlM, I highlighted the task fire departments most commonly perform at emergency scenes-carrying bodies to the colored tarps. The fire service should not perform the function of the incident commander. Actually, the medical group of an incident command system (ICS) should manage fire department personnel and operations as long as there is no need for fire protection or hazardous materials functions. If the incident is a shooting that involves mass casualties, the fire department will be the workhorse that moves patients from various incident scene locations to patient triage and treatment areas.
The fact that the fire department is unmatched in its experience with incident management sometimes leads to conflict. Law enforcement and EMS personnel are commonly operating from single units at scenes that do not require multiple resources. That type of daily operation does not lend itself to acquiring an in-depth understanding and working knowledge of an ICS. In contrast, the fire department uses the ICS every day, primarily because of the multiple apparatus and personnel that need to be managed at an incident. It is easy to argue that even single-engine company responses use and practice ICS, so why can’t single EMS or law enforcement units do the same?
The issue becomes a matter of frequency. More often than not, fire departments will respond to working incidents with multiple units that need an ICS structure to maintain command and control of all the resources and assets on scene. EMS operations rarely need multiple units, and those incidents that do usually involve the fire department, which implements the ICS without prompting, and EMS roll into the established framework. The emergency phase of a law enforcement incident generally ends expeditiously more quickly than a fire emergency. A subject who runs on foot from a stolen car is, for the most part, caught rather quickly. Once the suspect is apprehended, the emergency phase of the incident is terminated. During the chase, officers will receive direction from the officer who initiated the contact with the suspect or from a ranking patrol officer, depending on the department’s policies and procedures.
To summarize, the daily response from EMS and law enforcement personnel is task oriented at the single-unit level, whereas the fire department response is based on a strategic mindset at the company level with a tactical assignment. Most law enforcement and EMS assignments are at the task level. It is not until a major nontypical incident involving multiple resources occurs that law enforcement and EMS will perform at the strategic and tactical levels. These incidents are not frequent in most municipalities. For law enforcement, they may include barricaded subjects, hostage situations, extensive large-area manhunts, incidents involving civil unrest, and special events such as dignitary protection details. This is not to say that law enforcement and EMS agencies cannot or do not implement ICS or implement it well. Major municipalities have agencies that are very skilled in performing the functions of the ICS. These agencies have adopted an attitude that instills the use and promotes the importance of an organized ICS structure.
Recently, officials in Connecticut released telephone and radio recordings from the Sandy Hook school shooting. You can glean some of the ICS shortfalls that occurred from the on-scene law enforcement personnel. Although the command, sector, group, and division positions were identified and assigned, they were not clearly explained using ICS principles. Police unit numbers and individual officer names were used to identify scene functions such as staging and who was in charge. This may seem to be a critical observation of a national tragedy, but it must be identified so that all may learn from what could have gone better. Telephone recordings show multiple dispatchers calling neighboring jurisdictions for ambulance support. Those who received the calls asked the critical question of how many resources were needed. The response was, “Send all that you can.” Dispatchers were fielding calls from personnel who were attempting to self-dispatch to the scene as well as calls from media outlets fishing for information. At one point, a state police dispatcher advised a department he was calling for assistance, “We [state police] have taken over the scene.” Law enforcement personnel were updating dispatchers by cell phone and vice versa. Reports on the Sandy Hook response explained that too many ambulances overwhelmed emergency responders and that no command and control of those resources seemed to be present. If law enforcement personnel had taken over the scene, were they requesting ambulances? Did medical personnel evaluate and triage the wounded to determine transport status and priority?
Fire departments have the ICS experience and proper attitude to assist law enforcement and EMS agencies in becoming more proficient in the use of ICS. The fire service should attempt to make partnerships that foster the exchange of ideas and concepts among other agencies. Relationships that result in arguments and end with fire and EMS personnel being arrested by the police over the issue of opening or closing the roadway need immediate reconciliation. How can agencies work together on a mass-casualty call if they cannot perform with one another on a car accident scene?
RESCUE TASK FORCE
In September 2013, the Metro Chiefs endorsed a position paper during the Urban Fire Forum 1,2 that detailed the use of a Rescue Task Force (RTF) during active-shooter and mass-casualty terrorist incidents. It advocates Tactical Emergency Casualty Care (TECC) guidelines, which were derived from military combat-care procedures. The Hartford Consensus, a group of professionals and experts from the American College of Surgeons and the Federal Bureau of Investigation, met in Hartford, Connecticut, in April 20133 and in September 2013.4 The group examined active-shooter incidents and created procedures to increase victim survival.
At the first meeting, it was recommended that the THREAT (Threat suppression, Hemorrhage control, Rapid Extrication to safety, Assessment by medical providers, and Transport to definitive care and integrated response) protocol be followed. At the September meeting, the Hartford Consensus II announced a call to action. It highlighted the need for public education, law enforcement training in hemorrhage control, and integration of fire/EMS and law enforcement agencies.
Other provisions included the following:
- The task force shall consist of two fire and EMS personnel accompanied by two armed law enforcement officers. It will enter areas that have victims with traumatic injuries but that have no active aggressor threat.
- The objective of the RTF is to reach victims with uncontrolled hemorrhaging wounds quickly to stop the bleeding and increase the survivability profile.
- The incident location will be sectioned into hot, warm, and cold zones. The zones are similar to those used in hazardous materials incidents. Hot zones are areas with an active threat, in which a perpetrator is attempting to wound or kill bystanders. Warm zones are areas in which an
- aggressor has already conducted attacks and there are victims: The “shooter” has come and gone. Cold zones are areas where there is no threat of violence and there are no victims.
- Fire and EMS personnel who form RTFs shall be provided with ballistic protection that includes vests and helmets.
- Multiagency training among fire, EMS, and law enforcement agencies that will form these tasks forces is strongly recommended.
The formation of the RTF appears to be the responsibility of personnel from the fire service who already are engaged in rendering service in the areas of hazardous materials, technical rescue, and fire incident responsibilities. If your fire department does not provide advanced life support transport functions and the EMS response is a separate agency, then the RTF should consist of EMS and law enforcement personnel.
Again, the function of the fire department is to provide personnel and basic life support assistance to EMS and law enforcement. EMS personnel should assess, treat, and triage patients. Most EMT Basics cannot decompress a patient’s chest or use hemostatic agents; however, paramedics can. It does not make sense to train personnel from the fire department to perform these types of interventions when there are personnel on scene who are already trained. EMS personnel will assign treatment, triage, and transportation officers. It makes sense to assign as the triage officer someone who has already been in the facility and possesses firsthand knowledge of the scope and complexity of the incident. Similarly, as a structure fire escalates, command may designate one of the first-due company officers as operations because he is best suited with the knowledge already gained from being on scene to perform that function.
Unfortunately, in areas of the country where the concept of the RTF is valid and has great merit, many of the emergency services agencies cannot create RTFs with the resources available within their jurisdictions. Some law enforcement agencies only have four to six personnel on the road at any given time. These officers may be committed to prisoner transports, active calls such as domestic violence responses, shootings, or foot and vehicle chases that they cannot just break away from. It is not realistic for a department of that size to respond to an active-shooter incident and to provide two personnel to form a RTF.
In addition, some aggressors use the tactic of secondary scenes. In Columbine, Harris and Klebold set a fire bomb to go off in a field so that responders would be on the other side of town when the two began their attack. James Eagan Holmes set more than 30 homemade grenades and 10 gallons of gasoline to explode in his apartment prior to the theater shooting in Colorado. His neighbors reported loud music coming from his apartment and even attempted to knock on his door. It appears that the idea was to have a law enforcement officer or neighbors enter his apartment to investigate the loud music and create a secondary scene that would occupy first responders. Moreover, having neighboring jurisdictions respond may greatly affect response times, negating the team’s core concept of rapid access and initial treatment. Local law enforcement agencies must be equipped with the proper weapons to protect fire and EMS personnel. Using a handgun to protect a group is rarely effective. Officers need long guns such as patrol rifles or rifled shotguns to engage threats from a distance. An officer’s handgun is for self-defense, not group defense in a tactical environment. If local law enforcement cannot provide personnel with these weapons to form an RTF, then other avenues must be pursued.
As active-shooter incidents increase, the public is becoming more aware that they may have to take some action. The Hartford Consensus II suggested public education. I suggest taking that basic education further: Instruct bystanders in how to use hasty tourniquets during general active-shooter awareness training. This skill could prove vital in areas with limited emergency response resources.
If agencies cannot effectively reach the patient, then they must get dynamic to improve victim survivability. Training 911 operators as well as police and fire dispatchers to give TECC instructions over the phone could provide immediate hemorrhage control much more quickly than any RTF could deploy. During the Sandy Hook shooting, a dispatcher was on the phone with a teacher who had a gunshot victim in the room with her for more than 11 minutes. To the dispatcher’s credit, she attempted to give instructions for providing direct pressure to the victim’s wounds, but the caller was too emotional to accept the task.
Agencies that train dispatchers to provide instructions for TECC must train them to aggressively engage the caller. Noncompliance should prompt the dispatcher to ask for someone else in the room to provide the care or receive the instruction. Dispatchers can also provide instructions to control a sucking chest wound. In the military, it was once taught to use the victim’s military identification card. Similar in size to a credit card, the ID was laminated and served to seal a wound and provide identification as to who the victim was. It is an ingenious manner in which to create an occlusive dressing. These simple tactics can be relayed over the phone.
When considering how to execute the rapid extrication of the THREAT principles, consider this: Bystanders of a traumatic event can be vital in assisting emergency responders. Rather than have fire and EMS personnel enter the building in small teams, have the unwounded assist in evacuating the wounded. After law enforcement neutralizes the threat and begins to clear rooms, officers can stop and frisk bystanders who will assist and then direct them to carry the most severely wounded out to care providers. The bystanders are already in the environment and have little choice but to be there. Their emotions will be high and charged. Assigning bystanders to perform a task will focus that emotion in a positive direction. Officers will want to pat down or stop and frisk bystanders who will assist for weapons to ensure they are not aggressors. A single law enforcement officer may escort the bystanders to ensure egress to the proper casualty collection point. Tables can be used as litters or chairs with wheels can be used to extract the most seriously injured first. Law enforcement must be engaged, and training will have to be conducted extensively to accomplish this tactic. Law enforcement may need to identify those in serious need of medical attention over the walking wounded or less injured, which may require additional training. These alternatives are not suggested to replace emergency service agency integration. Fire and EMS personnel must strive to enter the facility as soon as possible. These suggestions are made to provide victims with life-saving interventions quickly with limited resources while providing for safety.
The role of emergency responders in active-shooter incidents is expanding and evolving rapidly. The fire service needs to evaluate how it can be used in these types of events. Small- and medium-size fire departments need not accept roles for which other agencies are better trained and more skilled simply because the departments have knowledge in an aspect of the operation or special knowledge of a tactic or tool. Agencies must evaluate the use of preincident plans and develop response procedures for all target hazard facilities in their response area with the same vigor that was used when preplanning a school shooting. Using a canned response may remove the confusion and indecisiveness of what and how many resources to dispatch as well as prevent an overload of too many resources. Every agency regardless of size or response footprint can prepare for these types of incidents, but they all cannot prepare using the same strategies and tactics.
STEVEN C. HAMILTON, a career lieutenant with the Fort Jackson Fire Department in Columbia, South Carolina, is a 17-year veteran of the fire service and a certified EMT-B, fire instructor II, and fire officer III. He is also a reserve deputy with the Richland County Sheriff’s Department.
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