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Emergency Medical Services: Go or No-Go? Entering Active-Shooter Incidents

Fire and emergency services are once again in the midst of change; this time it has nothing to do with the economy or shrinking budgets.

If you look back at the fire service timeline, generally speaking, we added EMS to our mission in the 1970s, hazardous materials in the 1980s, urban search and rescue in 1990s and homeland security in the 2000s. EMS has gone from being operated by funeral homes and small mom-and-pop private companies (who remembers F+B Ambulance Company) to large, corporate companies, hospitals, volunteers, third-service organizations and fire departments.

During these changes, EMS has had to adapt to the hazmat, USAR and homeland-security missions. All of these have been significant changes for EMS and fire agencies, and not all have been readily accepted.

Now, today, we face another significant change in our mission. It’s a Go-or-No-Go decision to enter an active-killer scene to potentially save lives.

For years, the standard question at the start of every EMT and paramedic practical scenario has been, “Is the scene safe?” If not, we wouldn’t enter until law enforcement arrived and rendered it safe. That same practice carried into the field, and scene safety was the first priority to ensure our personnel weren't being placed in harm’s way.

That all changed with Columbine.

At Columbine, members of Littleton Fire Rescue risked their safety, without proper PPE, to save student lives. However, based on operational protocol then—and rightfully so—they didn't enter the school because it wasn't safe to do so and law enforcement hadn't secured the scene. SWAT had to clear the school first to ensure the threat had been neutralized.

Sure, we had begun to incorporate tactical medics into SWAT teams, but those tactical medics were there to render aid to team operators, not injured victims. The question was asked if additional lives could have been saved, and there have been many answers to that. The fact of the matter is that law enforcement changed their procedures so the first arriving officers engage the active killer instead of waiting for SWAT to arrive.

But collectively we didn’t change our policies, as we stood on the premise that the scene needs to be safe. We’ve heard it, maybe even said it: It’s not our emergency. We can’t help the injured if we become injured ourselves. The scene needs to be safe.

Well, 14 years and a number of active-killer incidents later, we need to reassess our position. In the Denver Metro area, we had already begun discussing patient extraction from unsafe scenes before the Aurora Theater shootings, and we were actually scheduled to have a meeting the week this shooting occurred.

In these meetings, which included many of the EMS, fire and law-enforcement agencies in the area, we found that this is a very polarizing issue. Some are all for us entering the hazard zone to extract patients or provide care while others are completely opposed to the idea. These discussions aren't limited to just Denver; they've been occurring all over the United States, and there are just as many opinions out there as we have seen here.

There is, in my opinion, a valid proposal that active-killer incidents should be treated like hazmat incidents by establishing cold, warm and hot zones. Cold is self-explanatory. Warm is an area that has been cleared by law enforcement, but still has potential risk. Hot is the area that hasn't been cleared or is where the killer is known to be located.

As law enforcement moves into the incident, these zones will be established to allow for some level of scene safety where EMS and fire can operate. As law enforcement continues to press into the hot zone, EMS and fire can move into the warm zone to provide triage and extract patients to casualty collection points on the edge of the warm/cold zone. Our risk is mitigated by having additional patrol officers provide force protection for us as we work in the warm zone, while their entry teams continue in the hot zone.

The warm zone will continue to expand as law enforcement clears additional areas, thus allowing us to move deeper into the incident. The overall intent is for us to save as many lives as possible by quickly entering into an environment that we've typically said we wouldn't enter.

The key to a successful outcome on these types of incidents is for EMS, fire and law to address this issue before an incident occurs and then work together at the incident command post as the incident unfolds. I have talked before about the importance of partnerships and teams, and this is one specific area where we all have to be on the same page.

Ultimately, we need to develop a plan that will work for all of us and answer the question of go or no go. We say that we'll risk a lot to save a lot and risk a little to save a little. In the fire service, we readily advance into burning structures to potentially save lives, sometimes not taking into account everything that's going on. Yet, when it comes to active-killer or other potentially unsafe scenes, we hesitate or say we won’t go in until it's safe.

Yes, Gordon Graham is right when he says “predictable is preventable,” and we're in the business of risk. We routinely conduct risk assessments based on available information.

But at what point is it no longer acceptable to say that victims are going to die because we don't feel safe entering the scene? It's both an agency and a personal decision, and the risk may be high. Just don’t wait until the incident is occurring to answer the question.

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