Mass Casualty -- Active Shooter Incident

[EpiEMS]

Could your EMS system handle an active shooter situation?

I have my doubts about mine. What could your system use to improve mass casualty response? Active shooter response?

I'd like to see:
- Extra trauma kits in the ambulances, with TCCC-type equipment (though I don't think we BLS folks necessarily should be allowed to decompress a tension pneumo in the civilian setting). We don't have enough proper trauma dressings (like Israeli bandages)
- TCCC training for everybody, from PD, FD, EMS, and even Red Cross and CERT folks
- Bullet resistant vests and helmets for EMS (no joke)
- More willingness to have firefighters drive the ambulances

I certainly don't want to be carrying a firearm. But I would be more than ok with following PD right in, as long as we'd be well armored.

Thoughts?

 

[DrParasite]

First off, I don't think any systems can handle an active shooter situation. They just don't have the surge capabilities built in to handle it, in addition to all the routine EMS call volume.

Secondly, these things are crime scenes first. EMS doesn't need Bullet resistant vests and helmets. let PD secure the scene, and secure the shooter(s). hate to say it, but the injured victims are already injured, once PD secures the scene, then EMS can treat the injured. There is no need to have EMS enter unsafe scenes, regardless of if PD is screaming that they have injuries. Until the scene is secure, and until PD has searched the area to ensure no other shooters of threats exist, FD and EMS should be staged in a safe location.

You don't need firefighter to drive ambulances. if needed, get extra EMTs and Paramedics, even if it means tying up 2 ambulances for one patient. let EMS do it's job, so we don't need to rely on other agencies to drive our trucks. After all, when was the last time you hear of an EMT driving a fire truck at a big fire? or an EMT moving a cop car at a major crime scene?

But Alas, that would require EMS to be a profession, and be properly funded with enough surge capacity to handle major incidents on their own, without relying on other agencies to do it's job, which I have been told is just a pipe dream

 

[Handsome Robb]

I'm pretty positive the agency I work for could.

We've proven ourselves efficient at MCI management with similar pt numbers to the Aurora shooting on multiple occasions. They've been different incidents not active shooters but the baseline management is still the same.

As far as surge capacity we back-filled 19 full ALS ambulances into our system in 30-40 minutes during our last major MCI and had 50+ pts transported from the scene in 60 minutes plus had full coverage for the city.

That's without letting the FD drive our units.

 

[NYMedic828]

NYC has had one or too memorable MCI situations... Now we have a good portion of an island with spare vehicles dedicated to the next disaster.

 

[EpiEMS]

Until the scene is secure, and until PD has searched the area to ensure no other shooters of threats exist, FD and EMS should be staged in a safe location.

EMS can get shot at, just like PD can. These sorts of folks target responders – body armor is a must. I'm not a LEO, by any means, but if my knowledge of their methods for handling active shooters in recent days is correct, LEOs move in and eliminate the shooter(s). They are not going to stop to treat patients. If several LEOs are moving up to secure the shooter, even a BLS crew could easily take two LEOs along for security while they move to initiate the most important measures -- hemorrhage control, assuring a patent airway, sealing sucking chest wounds, those sorts of TCCC skills.

You don't need firefighter to drive ambulances.

This is my system, admittedly. And it's been necessary on occasion. Ideal, it is not, but that's how it sometimes has to be.

But Alas, that would require EMS to be a profession, and be properly funded with enough surge capacity to handle major incidents on their own, without relying on other agencies to do it's job, which I have been told is just a pipe dream

I don't disagree.

 

[Handsome Robb]

EMS can get shot at, just like PD can. These sorts of folks target responders – body armor is a must. I'm not a LEO, by any means, but if my knowledge of their methods for handling active shooters in recent days is correct, LEOs move in and eliminate the shooter(s). They are not going to stop to treat patients. If several LEOs are moving up to secure the shooter, even a BLS crew could easily take two LEOs along for security while they move to initiate the most important measures -- hemorrhage control, assuring a patent airway, sealing sucking chest wounds, those sorts of TCCC skills.

We have a TEMS team of paramedics for this exact situation. Let the pros handle initial stabilization and extrication to the other waiting EMS units.

Just my opinion.

 

[DrankTheKoolaid]

Untrained non Tactical EMS have no business in the Hot or Warm zone until the threat is confirmed neutralized. No if's ands or buts.

 

[EpiEMS]

We have a TEMS team of paramedics for this exact situation. Let the pros handle initial stabilization and extrication to the other waiting EMS units.

Just my opinion.

Makes good sense, but what about systems without TEMS? Or without lots of medics? Can't most of the treatable "combat-type" injuries be managed at the BLS level?

 

[Tigger]

First of all, TCCC training or not, as a line EMT I'm not going into an active shooter scene unless there are some very extraordinary circumstances. Body armor and a helmet may not even stop and AR15 round and I fear to provide such equipment to all would only encourage rash behavior during a deadly incident.

I don't think everyone needs TCCC training since most will never use it and it may be difficult to retain. I do like the idea of having a designated tactical EMS team with members on duty (working a regular truck) at all times. I don't think they necessarily have to be armed but the ability to work on the permitted could be helpful. Where I live in Colorado the FD has a TEMS team as a specialty for one engine company.

 

[cruiseforever]

Makes good sense, but what about systems without TEMS? Or without lots of medics? Can't most of the treatable "combat-type" injuries be managed at the BLS level?

Trauma for the most part is BLS. Load and go. Trauma centers are going to make the biggest impact. When you look at the percentage of wounded that died in World War 2 compared to the Korean War is was being strapped to the outside of a helicopter and being tranported to a MASH unit that made the diffrence.

 

[EpiEMS]

I guess my goal is to suggest adopting the LEO approach.
If LEOs wait to enter, more people end up killed.
If EMS waits to enter, more people who might have survived end up dying (60% from extremity hemorrhage, 33% from tension pneumothorax, and 6% from airway obstruction, as per TCCC).

Entering a warm zone, right after PD enters and sweeps through, though, makes sense. We shouldn't be waiting an hour after the incident to enter the place where casualties are.

 

[EpiEMS]

Trauma for the most part is BLS. Load and go. Trauma centers are going to make the biggest impact. When you look at the percentage of wounded that died in World War 2 compared to the Korean War is was being strapped to the outside of a helicopter and being tranported to a MASH unit that made the diffrence.

You can't do BLS until you're at the patient. Trauma centers are great. But if the patient bleeds to death from extremity hemorrhage that would have been easily preventable with direct pressure or a tourniquet, a trauma center isn't going to make a difference.

 

[Meursault]

EMS can get shot at, just like PD can. These sorts of folks target responders – body armor is a must.

No, staging at shootings is a must. If there are enough shooters to occupy police and still pose a threat to EMS units posted a considerable distance away and behind something solid, the incident is of a completely different magnitude.

In most systems, the large cost of body armor would be better spent on making crews safer in their day-to-day work.

There's been some debate about sending EMS into areas secured by law enforcement before the shooter(s) are dealt with. That's a tactical issue, and one I'm not competent to discuss.

 

[DesertMedic66]

Most (if not all) of our fire departments and ambulance companies have MCI training. I think it would run smoothly for a little while (depending on who the IC is).

The real issue for my area is that we are isolated. The next closest place to get ambulances from is 30+ minutes away. So that would leave all of our response area with no coverage and most if not all of their area without coverage.

Also we have 3 hospitals in our response area (with only one of those being a trauma center). The next closest hospital is 30 minutes away (community hospital) with the next trauma center being 1 hour away.

But all of our firefighters are at least EMTs with at least one medic per engine. We also have a MCI U-Haul type truck (able to go code) and a MCI trailer. If communications go down we also have a mobile communication center (it has roughly 5 computers and 5 radios.

Since we are isolated we are used to transporting with up to 5 patients in a type II ambulance (all we have except for one type III).

 

[the_negro_puppy]

Definitely not.

We are stuffed if we get a true MCI in our city.

We are always running at capacity with many units 'ramped' at hospital waiting to offload. Not to mention that our hospital are always running at or over capacity.

Any significant bus/train/plane/shooter scenario, we are all in trouble, including the people who won't be able to get an Ambulance for other 000/911 calls h34r:

 

[Wheel]

The problem I see with EMS entering a scene with an active shooter is that if one is shot, that is one less provider and one more patient. If I as a paramedic enter an unsafe scene and shot in (lets say) the leg, then I'm worthless. Unless you are trained to enter the scene as a tactical medic, you're probably doing more harm than good by doing so, because there's a chance you're going to create a bloody mess for another one of your medic buddies to clean up.

 

[Tigger]

I guess my goal is to suggest adopting the LEO approach.
If LEOs wait to enter, more people end up killed.
If EMS waits to enter, more people who might have survived end up dying (60% from extremity hemorrhage, 33% from tension pneumothorax, and 6% from airway obstruction, as per TCCC).

Entering a warm zone, right after PD enters and sweeps through, though, makes sense. We shouldn't be waiting an hour after the incident to enter the place where casualties are.

The thing that saves lives in the active shooter scenario are the police stopping the actual shooting. For EMS to operate in the warm zone, a police escort is required, and to not have one would be downright dumb. When the local TEMS guys have to do something in the warm zone, they get no fewer than four officers with long guns for an escort, usually more. In the opening stages of an incident the sole focus of law enforcement needs to be to find and disarm (by whatever means necessary) the shooter. To use officers for any other reason is wasteful. If it takes for an hour for the police to determine that there are more shooters, than that is how long it takes, but I want them to be sure of that decision and I am not about to get in their way.

And has TCCC notes, many casualties are the results of extremity hemorrhage which many body armor sets do not protect.

I would not be happy to stage at this sort of incident, it would be crappy to know in the back of your mind that there are people actively dieing very near you. But that doesn't justify EMS entering an active shooter scene.

 

[bahnrokt]

I'm in a rural community between a city and a medium town. We've handled 10pt MVAs and a few bus crashes without our mutual aid system getting taxed. We also run through the same dispatch as the city and roll into the same MCI plan. The medium town next to us has a college, if they had a VT shooting, it would be chaos. Their county wide dispatch staffs 2 radio operators for fire police and ems in the county. I've participated in their MCI drills and its a joke. But it is all a county full of farmers can afford.

 

[Meursault]

EMS World has jumped at the chance to talk about things that are both exciting and in the headlines. http://www.emsworld.com/article/10279321/ems-response-to-active-shooter-incidents

Thoughts on the recommendations/options? The author is a proponent of EMS in the warm zone with an escort and equipping individual providers to do basic trauma care.

To use officers for any other reason is wasteful.

Officers are going to be doing a lot of things other than making contact with the shooter, including crowd and traffic control and securing the larger area.
In the Boston area, at least, there are going to be more than enough LEOs to throw at the problem. Look at scene photos from the Woburn shooting for an example of what I'm talking about.

During the first phase, there will be fewer LEOs on scene and most of them will be trying to assess things and make contact; EMS should be staging at that point, but it will eventually be possible to establish a warm zone. With or without an escort, sending EMS into the warm zone will place them at risk; an escort can't protect against explosives, for one. The author of that column above argues that it's reasonable to expose EMS providers to some risk in these incidents; I agree.

 

[Tigger]

EMS World has jumped at the chance to talk about things that are both exciting and in the headlines. http://www.emsworld.com/article/10279321/ems-response-to-active-shooter-incidents

Thoughts on the recommendations/options? The author is a proponent of EMS in the warm zone with an escort and equipping individual providers to do basic trauma care.


Officers are going to be doing a lot of things other than making contact with the shooter, including crowd and traffic control and securing the larger area.
In the Boston area, at least, there are going to be more than enough LEOs to throw at the problem. Look at scene photos from the Woburn shooting for an example of what I'm talking about.

During the first phase, there will be fewer LEOs on scene and most of them will be trying to assess things and make contact; EMS should be staging at that point, but it will eventually be possible to establish a warm zone. With or without an escort, sending EMS into the warm zone will place them at risk; an escort can't protect against explosives, for one. The author of that column above argues that it's reasonable to expose EMS providers to some risk in these incidents; I agree.

I should have been more clear, in the initial stages of an incident it would be wasteful to have the police escort EMS into the warm zone. Relatively soon afterwards there will be enough LE on scene to spare some officers to assist EMS but even if that takes 10 minutes (and it may take longer depending on the area), an extremity hemorrhage or tension pneumo victim may have already expired. Unless EMS moves in right away we aren't likely to solve the problem unfortunately.