It is hard to believe that next year marks the 20th anniversary of the devastation at Columbine and that the Virginia Tech shootings were 11 years ago. Despite these events and many others, especially in the last decade, many questions remain regarding active-shooter incidents. Debate still surrounds a number of questions:
- Who is responsible for patient care in the active-threat environment?
- How do emergency-medical resources commit to the incident?
- Who is the incident commander and how does communication take place between disciplines?
- How long will it take firefighters, EMTs and paramedics to assemble and deploy?
- What is the appropriate number of medical-care providers needed to render emergency assistance?
- What supplies and PPE work best in the warm zone?
Regardless of the variables, it’s safe to say that as long as these incidents continue to take place, there will be a need to plan and train for a coordinated response.
Active-assailant incidents have the potential to generate multiple injuries in a variety of locations. The number and location of the injured will impact your response, approach and ability to commit to the scene. Responders should plan to treat the injured immediately upon arrival, even if dispatched to a staged location away from the address of origin.
In several cases, patients have presented outside of the hot/warm zone. Fleeing patients may not even know that they are injured until they have escaped to a safer location and taken time to evaluate their condition. As they wander, the injured will search for help; as soon as they see the flashing lights of an emergency vehicle, they will move in that direction.
When a department trains, they should address this reality. In many situations, the first-arriving equipment will immediately need to triage and treat the injured. First-arriving personnel and equipment may be taken out of play as soon as they have communicated that they are on scene; additional resources may be needed sooner rather than later.
This is also a good time to get information (incident intelligence) from the injured about the number of people potentially injured inside the hot/warm zone; this information may help to identify the amount of additional resources that will be required.
As equipment arrives on scene, everything (other than law enforcement) will likely be staged outside the line of sight of on-scene operations, at least far enough to provide responders with geographical protection. Although safer, one should stop short of calling the staging location a cold zone. As we become more acclimated to incidents of terror and complex, coordinated attacks, we understand that the staging location is a resource-rich environment that requires protection. This is why we need to advocate for one staging location.
Law enforcement, fire and EMS must reside in the same area; we can still segregate based on discipline. When all resources exist in the same area, protection is more likely to be immediately available, addressing the vulnerability of an open-area operation.
When fire and EMS arrive on scene, how is the situation status communicated? Is it through dispatch? How long does that take to convey pertinent information? Who is the incident commander?
We know, especially in smaller suburban and rural incidents, that the first-in law-enforcement officer will have pertinent information that must be communicated to assisting personnel and agencies. That officer will not have enough time to monitor more than one radio frequency. So it is likely that most of the incident details will be communicated on that officer’s primary radio frequency. By default, that officer – whether they know it or not – is the incident commander, at least temporarily.
Does your department train with law enforcement? Do you share access to radio frequencies? Can you communicate with each other to determine the incident priorities?
That’s easier said than done; the ability to acknowledge the incident commander’s radio traffic and pass along information about available resources may require direct communication from staged fire and EMS personnel/equipment.
Fire and EMS departments must not over emphasize variables they can control. Your available personnel and response times are what they are; you won’t be able to change your response time without adding personnel and addressing station locations.
That said, are you aware of the preplanning that can be done to mitigate incidents when they occur? Do you know how you plan to use personnel and equipment when they arrive on scene?
A conscientious effort should be made to train the community on bleeding control. It’s been said that the first applied bandage saves the life. Law enforcement should have Stop the Bleed training that allows them to assist with hemorrhage control.
As firefighters and EMS providers arrive on scene, their first priority should be to put on protective equipment and retrieve medical supplies that are needed in this environment. The availability of rescue personnel should be communicated to the incident commander so a joint police-and-fire rescue task force can be assembled. Training should reinforce the protection of unarmed medical providers using a protection element; the rescue element must be held accountable to operate within their protection at all times.
Seems simple. However, training exercises often only emphasize team movement in the warm zone when, in actuality, unarmed providers are likely to be waiting in the staging area. How do rescue providers link up with law enforcement? Link-up concepts require training and repetition.
PPE should be adjustable and easily applied. Those likely to wear it should regularly practice donning and doffing it so they are familiar with the location of adjustments for the best fit. Helmets should have ratcheting suspensions similar to fire helmets; traditional military suspensions take too much time to adjust. An ill-fitting helmet, whether too loose or too tight, will be a distraction that can easily be remedied with the correct suspension.
With the additional stress of an active threat, fine motor skills are likely to be affected. Medical supplies should be easy to locate, access and apply in a high-threat environment. Be aware of the effectiveness of supplies/equipment, equipment readiness and storage practices. The ease of access to medical supplies will directly impact the timeliness with which they can be applied, ultimately impacting their effectiveness.
When it’s possible, items that have been purchased for use in an active-assailant environment should also be made available for day-to-day use to minimize the learning curve; the improved familiarity will be a great help when fine motor skills become affected during an active threat.
The number of medical providers available within the rescue task force depends on the resources in your area as opposed to a dictated standard. Don’t train beyond your local capabilities. Don’t try to be a big-city department when you are lucky to have four people arrive for the initial assignment. This doesn’t mean you can’t do anything; it just means your capability is different and the response needs to be modified for your reality.
Rural and suburban departments account for most American responses. Active-assailant incidents can happen anywhere and are more likely to occur outside of large, metropolitan areas.
Response is more predictable when training is conducted regularly and realistically, within the scope of response probabilities and provider capabilities. Make sure your training involves approach, communication, staging, equipment and movement. Play to your strengths and train your personnel how to think—not what to think. This is a dynamic environment that will require constant revision. As assailants revise their methods, we must revise our readiness.