By DENNIS R. KREBS
It seems that mass-casualty shootings-“active-shooter” situations in law enforcement terms-have been occurring with alarming frequency. Yet, such sad incidents are nothing new. One of the earliest recorded was in 1949 when a lone gunman killed 13 people in Camden, New Jersey. In what became known as the Texas Tower Incident, Charles Whitman climbed the bell tower at the University of Texas at Austin in 1966 and killed 16 people. Since that time, towns and cities like Jonesboro, Arkansas; Littleton, Colorado; Fort Hood, Texas; Newtown, Connecticut; and Washington, D.C. are but a few of the places where the ugliness of mankind has become apparent.
After the Columbine High School shooting in April 1999, the law enforcement community identified the need to adapt its operations to meet the evolving threat of the active shooter. As Federal Bureau of Investigations (FBI) statistics show, the average incident lasts less than 12 minutes; 37 percent last less than five minutes. Thus, law enforcement now recognizes the need to deploy quickly at these situations. Whereas most jurisdictions previously waited for Special Weapons and Tactics (SWAT) teams to handle these incidents, current practice deploys the first-arriving patrol officers in three- or four-person teams (photo 1). Some agencies are even having lone officers enter the business or school to engage the suspects. The strategy in each scenario is to “stop the killing.” Personnel quickly sweep areas and move toward any gunfire, attempting to confine and ultimately suppress the shooter.
|(1) Agencies should develop policies and procedures for mass-casualty shootings. Joint training exercises to prepare for an active shooter incident are critical. (Photos by author.)|
Fire and emergency medical services (EMS) throughout the country typically had personnel and apparatus stage a safe distance from the incident until the scene was secure. Agencies with tactical medical assets would have those responders act in concert with arriving SWAT team personnel.
Recently, a number of consortiums and committees have made recommendations for enhanced coordination and responses to these incidents. The idea of a more aggressive posture by fire and EMS was first proposed more than a decade ago in my book When Violence Erupts: A Survival Guide for Emergency Responders. The current recommendations are impressive; they cover the need for planning, interagency training, using rescue task forces wearing body armor to enter the “warm zone,” and greater use of hemorrhage control.
Position statements and white papers aside, what does the firefighter or emergency medical technician (EMT) responding to these incidents need to know?
PERSONAL AND PERSONNEL ISSUES
Active-shooter incidents and bombings, like that at the Boston Marathon, are outside the normal responses seen by fire and EMS. Since the mid-1980s, firefighters and EMTs have been taught to stage a safe distance away from potentially violent incidents and await word they have been secured by law enforcement.
That paradigm is now changing. Since entry into these scenes is outside the norm, personnel from some delivery systems are asking whether they would be fully covered while operating within the warm zone at one of these confrontations. Management should fully examine such questions prior to an actual incident.
In addition, fire, EMS, and law enforcement must conduct joint training. The site of a disaster is not the place to “try out” new ideas. There is a wealth of knowledge that can be shared among the three services. Fire departments can share their knowledge of forcible entry with police. Police should train firefighters and EMS providers on how to move within their security perimeter. Finally, EMS can provide simple hemorrhage-control techniques to law enforcement. However, just because an individual has the t-shirt and pocket card that says he went through the training does not mean he is the one who should go through the door.
This is not the place for “hot dogs.” The person jumping up and down screaming, “Pick me! Pick me!” is not the person for this assignment. This is also not the place for someone who can’t follow the explicit direction of the police. You need to put your ego aside. These are incidents that are already dangerous; they can go further south in a heartbeat.
But what about the person who begins shaking uncontrollably when the chief assigns him to the four guys with M-4 carbines? His response is, “No way, Chief. I didn’t sign up for this!” Is this insubordination? Does the chief order the person to go in? We can’t have someone inside who is going to freeze or further complicate a tense situation.
Even before the 1992 civil disturbances, the Los Angeles City (CA) Fire Department had body armor assigned to each riding position. This was because of, in large part, the threats posed by gang violence. Most jurisdictions do not supply all of their first responders with armor. With the budgets of most fire and EMS services-career and volunteer-at the breaking point, the purchase of this equipment will be difficult.
One alternative is to have small caches of armor available for response to the mall, school, or business in danger when needed. Remember, though, that most of these incidents are over in less than 12 minutes, and 37 percent are over in less than five minutes. Can you get it there in time to make a difference?
The standard body armor worn by police officers will stop a variety of handgun rounds. However, it is ineffective protection against rifle rounds, which are used in more than 25 percent of active-shooter incidents. This means having armor with ballistic plates. Even though fire and EMS personnel will be operating in the warm zone with police security and away from the shooter, things can go wrong; a warm zone can become hot in an instant. However, some of the officers providing that security may themselves not have ballistic plates in their armor. This is a dilemma that needs further thought. There is no answer for this one.
EQUIPMENT AND OPERATIONS
The unified command has determined that a rescue task force will enter the building where a gunman has shot numerous people. This is not the incident where we load a stretcher down with a cardioscope, oxygen, and a suction unit. We aren’t going to be boarding and collaring patients with penetrating trauma. We’re going to be traveling fast and light: tourniquets, bandaging material (the Emergency Bandage and H Bandage work nicely), and a few nasopharyngeal and oropharyngeal airways are about the extent of the materials we will use. Some departments have designed small backpacks with only the basic materials needed for treating wounded patients.
Once linked with security personnel, you will be guided by their directions. Keep the following in mind: Other than the glass doors at mall entries, there are few windows around malls; hence, the shooter will have little ability to view the team’s approach. The same cannot be said for most schools and many businesses. Large expanses of windows can grace the sides of many of these structures. Open areas encompassing parking lots and playing fields surround most schools (photo 2). Without the use of an armored personnel carrier, the rescue task force could be seen and fired on if the route of entry to the building is not properly coordinated with officers already inside.
|(2) Large open areas around schools and some malls provide little cover or concealment for responding firefighters and emergency medical personnel.
Click to view video
The team will move swiftly, but cautiously, toward the downed victims. Fire and EMS personnel should not touch anything they did not bring with them; this includes patients! Let the police clear them first based on the following three reasons:
- One of the victims may be the shooter himself. In 67 percent of the cases studied by the FBI, the shooter committed suicide.
- Improvised explosive devices (IEDs) were found or used in three percent of the incidents. At a recent shooting incident in Howard County, Maryland, the shooter-found dead-was wearing a small backpack carrying multiple small IEDs.
- The innocent victim you touch may himself be armed, especially if the person is an off-duty law enforcement official who may believe the suspect has returned to continue the fight. Police are taught to survive. You could be severely injured before they realize you are there to help.
TREATMENT AND TRIAGE
Scenario: The rescue task force and its security element come upon five downed people in close proximity to each other; there’s blood everywhere. The police clear the five. What’s next?
Many agencies use the START triage method where respiration, pulse, and mental status (RPM) are used to decide whether a patient needs immediate care, delayed care, or minor care or is deceased. We start triaging the closest victim to us, taking no more than 30 seconds.
The military’s system is slightly different from that of tactical medicine: The focus is on bleeding first. The soldier or tactical medic quickly scans the victims. If someone is bleeding severely, he gets a tourniquet; the medic does not cut open the pant leg or shirt sleeve to expose the wound. Time is not your friend in any of these situations. By the time you get to the victims, they may have already lost a substantial amount of blood. The femoral artery is about the size of your pinky finger; you can lose a lot of blood quickly. Further, an arterial wound may not be spurting blood the way you would imagine. The tourniquet is placed as high as possible on the leg or arm and tightened until bleeding stops. If three of the five victims have blood coming from extremities, they all get tourniquets before any other checks or interventions.
Some may argue the above points, believing you should take the time to examine the extent of the injury. If a tourniquet is needed, place it two inches above the wound. This is not a normal situation where someone has his arm caught in a snow blower. In active-shooter incidents or bombings similar to that at the Boston Marathon, the area may not have been completely secured. Again, the warm zone can turn to a hot zone quickly. I have had bullets zip past my head; that’s not fun, and I don’t want to be there again.
The military teaches to “get the wounded off the ‘X.’ ” This means reducing the potential for further harm-to the victims and the rescuers-by getting the injured out of the immediate area and to a secure casualty-collection point (CCP). Make no mistake; this is battlefield medicine. The unedited images from Boston show horrific injuries similar to many from Afghanistan and Iraq.
In the above scenario, once all five victims have been quickly checked for massive bleeding, then we go back and check the airways. If we were to spend 15 to 30 seconds with each victim doing the standard RPM check, the fifth patient-hemorrhaging severely-may be beyond saving once we do get to him.
The only other intervention that might take place in the warm zone would be the insertion of a nasal or an oral airway in appropriate patients. No IV, no splinting of possible fractures. If the security element suddenly says, “We need to move,” then it’s time to go-no questions asked.
Two of the five victims in this scenario have bleeding controlled by tourniquets. The third is a female with an abdominal wound; the only intervention is a nasal airway. The fourth is a child with a minor gunshot wound from a ricochet. The fifth patient is deceased. There are three rescuers. How will you move all of these patients?
First, the deceased victim stays put; he is part of the crime scene investigation. Did you bring a stretcher? If so, that may account for two victims. Place one head at each end of the stretcher. It may not be pretty, but we aren’t looking for style points. If you elected not to use a stretcher because of its bulk or squeaking wheels, you may be carrying victims a long distance back to the CCP. This does not imply that one is correct and the other is not. Each option has limitations and advantages.
In this situation, one of the officers on security may be able to carry the child while keeping his gun hand free. If there is a teacher or other trusted bystander, we could use them to assist in carrying.
The CCP must be secure; law enforcement should sweep it for IEDs and have little probability of coming under attack. As noted previously, schools and some businesses have lots of windows as well as large open areas surrounding the structure. This may prove difficult for locating the CCP on the exterior of the building. Consider using gyms or cafeterias if they can be swept and secured quickly. At malls, the CCP could be located at the opposite end from where the shooter has been confined.
IF THINGS GO FROM BAD TO WORSE
It has been mentioned a few times that events can quickly change. The warm zone can deteriorate into chaos if gunfire erupts near your position. From the time you leave the command post surrounded by security personnel, rescuers need to be constantly aware of what is nearby that could be used as cover or concealment (cover stops bullets, concealment protects you from being seen). If shooting starts, rescuers need to stay within the protective envelope of the security element but should dive behind some piece of cover. If you are in an open area without some type of cover, hit the ground. Do not attempt to run away! Be guided by the directions given by the security element.
Active-shooter incidents and bombings are chaotic events that can pour vast amounts of information into the command post. Much of the information coming from witnesses and callers to 911 may not be accurate. Where possible, law enforcement will assign an officer to the room in the school or mall where closed-circuit televisions are monitored. The officer can provide real-time intel on the shooter’s location and actions. The fire or EMS service’s operational commander should consider placing one of his own personnel in that same room with law enforcement. While the officer is focusing on the shooter, the firefighter or EMT can provide intel on the location of the victims.
Years ago, a chief officer stated, “The cops have the guns; it’s their problem; they can deal with it.” This type of attitude is no longer realistic, nor is it realistic to believe, “It won’t happen here.” Surely, you must plan, prepare, and train for these incidents just like other emergencies you are called on to handle. Mass shootings and bombings are difficult and leave behind a heavy burden long after the last patient is transported.
Federal Bureau of Investigation. “Addressing the Problem of the Active Shooter.” (May 2013). www.fbi.gov/stats-services/publications/law-enforcement-bulletin/2013/May/active-shooter.
Krebs D. When Violence Erupts, A Survival Guide for Emergency Responders. Sudbury, MA: Jones & Bartlett Publishers. May 2013.
Otero J. Combat Lifesaver. Lecture at the United States Air Force Air Advisor Academy-Joint Base McGuire-Dix-Lakehurst. August 2013.
Stair R and N. Tang. Law Enforcement Responder, Principles of Emergency Medicine, Rescue, and Force Protection. Burlington, MA: Jones & Bartlett Learning, 2013.
Texas State University. United States Active Shooter Events from 2000 to 2010: Training and Equipment Implications. March 2013. http://alerrt.org/files/research/ActiveShooterEvents.pdf.
United States Department of Homeland Security, Federal Emergency Management Agency. Fire/Emergency Medical Services Department Operational Considerations and Guide for Active Shooter and Mass Casualty Incidents. September 2013. www.usfa.fema.gov/downloads/pdf/publications/active_shooter_guide.pdf.
DENNIS R. KREBS is a captain (ret.) for the Baltimore County (MD) Fire Department. He is the author of the Medic Up: Where Criminals, SWAT Teams & Medicine Intersect and the training manual “When Violence Erupts: A Survival Guide for Emergency Responders.” Krebs served as a tactical medic with the Johns Hopkins Division of Special Operations and currently provides training to various military assets.
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