Are your community's law enforcement and EMS agencies prepared to work together effectively in the event of a "rapid mass murder" attempt?

Are your community's paramedics trained to integrate with law enforcement rescue teams and to save lives before the scene can be "totally secured?"  If not, you should be.

This is not a "SWAT medic" question.  The lesson from Columbine is "if you wait for SWAT, people will die."  Law enforcement has evolved a new doctrine for active shooters.....go to the sound of the guns, and neutralize the killers.  And it's not for senior officers and special units - the success of the response to an rapid mass murder event is dependent on the skills, training, and physical condition of every police officer and EMS medic on the street.

EMS medics can be integrated in to LE rescue teams with a relatively high degree of safety, allowing live-saving measures (like tourniquets) to be utilized before it is too late.  But it takes policy, training, communications, and cooperation to make it work.

Here, during a training exercise, City of Raleigh police officers provide security for Wake County EMS system medics conducting rapid assessment, treatment, and casualty collection evolutions.  http://legeros.com/ralwake/photos/2011-07-13-ems-active-shooter/sli...

It CAN be done.  It SHOULD be done.  EMS has to be trained, equipped, and expected to move-communicate-assess-treat while protected by responding LEOs.  It won't happen by accident - it requires planning and communication.

It's time to get started!

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Another reason to focus on situational awareness skills, defensive tactics, and improved PPE for EMS personnel:

http://www.kansascity.com/2012/12/15/3967244/missouri-deputy-killed...

You don't need to be a medic to whack a CAT on someone. Hence the reason every solider at least in our defence force carries two.

You clear a scene, and I'll come and make it better. Not before. Not with the weaponry available to a civilian shooter. The assumption is that basic responding police know what they are doing in providing cover.

I disagree with you on this one Cannulator.  Sometimes a little more than a tourniquet is needed.  

Often the first entry team from law enforcement is a very small number of LEOs, 3 or 4 for the "rolling T formation".  Their job is not to stop and put tourniquets on people.  They are trained to bypass those inured and proceed to the shooter and stop him.  That is where the EMS crew comes in.  They are a supplement to the entry team and its the sole job of the EMS crew to stop the bleeding ect of the injured they encounter letting the officers focus on stopping the shooter.  The "weaponry available to the the civilian shooter" is irrelevant, what matters is how they use what they have.

When a scene is being cleared, with an active shooter, a tourniquet and a trauma dressing at most is about it. Not worried at all about formations of room clearing. We aren't going in.

If that means the police change their techniques to a rolling Q so they do as I suggest then so be it.

The weaponry is relevant not just a shooters technique. A six shooter a shot gun or 30 round semiautomatic rifle all have considerations to avoid. The unpredictability of the nutcase is ample reason to stay out of the way.

If you wish to jump into a scene, you go right ahead. I have 3000 or so in mine who won't.

We value our safety and trust no -one until a scene is cleared.

I guess a different philosophy here, Cannulator.  It takes 1, 2, 7, 8 hours to "clear" a building like a mall or school completely.  Our medics are trained to "go in" with second and subsequent rescue teams.  They know how to work "inside" the police formation, how to drop out and do extractions, how to set up "warm zone" casualty collection points with LEO security.

If we wait for the whole scene to be secure, people will surely die as a result.  For minimal risk, we can perhaps save some lives.  So we train, and we go in.  We will risk a little to save a lot.

 

I realize the difference in practice between 'tactical medic" think and regular 9-1-1 medic think. We have paramedics on our multi-jurisdictional tactical team but those medics are going to be dealing with injuries and the well being of the tactical officers much more often than any injured civilians. At best it takes 30-60 minutes to muster our tactical team. Case in point a active shooter incident we had in a supermarket this past August. The local PD did not make entry until the chance of survival of the shot civilians was beyond consideration. In my service area there are twenty two local municipal police departments, three academic police departments, three railroad police departments, a county sheriff’s office, and state police agency. Meeting with any one of them is difficult let alone over two dozen, combined with the fact that all have different approaches to active shooter incidents. This combined with the thought process of many paramedics and EMTs that a scene must be scrubbed sterile as far as any threats before they engage. The thought that they would risk their life is not in their mental makeup. I doubt many EMS agencies have a thought about what they would do faced with the aftermath of an active shooter. I tend to view EMS (EMS=the average single ambulance on the road) poorly prepared to deal with anything that is beyond the normal day to day menu of items.

Well said Brian.  It is concerning however that the local PD did not make entry during an active shooter situation.  I thought the error of that thinking was thoroughly brought to light after the Columbine incident...  

Im not even really talking about just involving medics with the "tactical" team.  Im talking about one of the first arriving EMS units making entry with the first 3 or so arriving PD units who should be moving toward the sound of gunfire.  If this means providing the medics with vests so they are more comfortable with entering so be it.  The days of waiting until the scene is "secured" are moving quickly into history.  Personally I dont understand the unwillingness to risk our life.  I dont know how many EMS people claim "hero" status but are unwilling to risk a little to save a lot.  I could not sit and wait...  As you said Brian, waiting for that to happen means, "the chance of survival of the shot civilians was beyond consideration".  

If EMS is willing to hand off another area of prehospital medical care to others who are willing/able/educated/trained to perform the function so be it.  I think its a mistake.  We need to recognize needs and adapt as a field to fill those needs.  If we dont, we will go the way of the GOP.  (recent election ring a bell).  Change is inevitable.  Adapt or become extinct.

 

I completely agree with you Nathan. I concur that we should be so cavalier attitude about risking our lives but given the training and experience EMS can do much more then sit around a wait for the bodies to be removed. A couple of year ago my partner and I were clearing a scene and came upon a house with smoke pouring out of it. I had 25 years experience as a firefighter and my partner was a career firefighter who worked EMS part time. We parked our ambulance, made a size up and entered the house and tried to make a much of a search as we could. We didn’t do this based on a whim but taken into consideration our training and experience. We didn’t find anyone and the search by the fire department was negative as well but we were happy we were able to do our best. I also share you feelings about EMS being so willing to pass along jobs to others.

I was a part of Chief Kirkwood’s agency when they started training for “active shooter”. I will admit that although I had some background information on active shooter scenarios, as well as training as a United States Army medic, I was skeptical of the whole concept. My first introduction to the whole concept came in 2006. While attending the National Fire Academy in Emmitsburg, Maryland, one of my instructors, Wayne Zygowicz, was from the Littleton (CO) Fire Department, the location where the Columbine High School shootings occurred. Chief Zygowicz made a presentation to our group about the incident and some lessons learned. As I recall, one of the things talked about was the delay in getting medical help to some of the victims, not through any lack of competence on the part of responders, but that this was something unimaginable.

Not much later, my employer at the time decided to implement an active shooter training program. In providing the background, it was brought out that many of the fatalities of these mass shootings bled to death. Their initial injury was not fatal in and of itself, rather, they simply bled to death. This was because the concept for law enformcement was, as I understood it, to await overwhelming force to gather, and then enter the building. I am not a law enforcement officer, so any of you out there that are LEOs, please correct me if I am wrong.

After the training was complete, I was still skeptical. That all changed May 30, 2010. A call for a shooting at a local Target store brought home some pretty serious realities-

It took almost 20 minutes for the police ‘tactical team’ to arrive.

It took almost 30 minutes for the first ‘tactical team medic’ to arrive.

It took several hours for police to clear the building.

In that incident, fortunately, there were only two victims (a murder-suicide) amongst the dozens who were in the store. However, my partner and I, who had completed the active shooter training, entered the building, with an armed escort of three LEOs who had weapons out and searching for potential targets, to evaluate the two known patients. I say three LEOs because it was almost eight minutes (as I recall) before additional officers arrived on the scene.

Active shooter scenarios are different from the “scene safe; PPE” scenarios of EMT and paramedic class. As our military has learned in Afghanistan and Iraq, people bleeding from gunshot wounds cannot wait. The military has adjusted their practices, i.e. the tourniquet. We have to adjust ours. We cannot expect the initial LEOs to arrive on scene to be focused on patient care- this creates multiple missions that may not work well when carried out by the same person. And waiting to clear a shopping mall, big box discount store, or school is an option that will result in needless deaths.

In rural areas, the first arriving units, in the first few minutes, will make the difference in patient outcomes. Imagine that you are in a county of 800 square miles. You are assigned to an EMS unit based in a town of less than 600. Within three miles of your station there are two schools, each with a student body of at least 500 students. There are a few deputies patrolling the county, as well as a single police officer in your town; six miles north there is another small town with one or two officers on duty, and to the south, six miles away, there is another town with two or three officers on duty. Your nearest additional EMS units are six miles away, or further based upon call volume.

The call comes in for a shooting at one of the schools. Within five minutes there is your unit, two or three volunteer firefighters who are trained to EMT level, and four LEOs on scene. Additional help is on the way but 6-10 minutes away.

What do you do? If your community has had active shooter scenario training and has a plan in place that has been practiced, the first team enters (four officers and four EMS/fire). You take minimal supplies with you (no monitors or medical bags, just a small trauma bag for each member). As additional resources arrive, more teams enter.

But what if your community does not have an active shooter plan in place that has been practiced? In the short term, people stand a good chance of dying.

And don’t talk to me about risk. I enter potentially bad situations every day without benefit of LEO support. Any scene has the potential to take a turn for the worse at any moment. And I know of EMS folks that take terrible risks every day without giving it a second thought- crawling into wrecked vehicles without benefit of suitable protective clothing, driving emergency traffic, and riding unrestrained in the back of a moving ambulance, especially when driving ‘hot’.

Can something happen? Sure. I like the odds of three or four loaded weapons aimed out at potential bad people. It is a calculated risk. But the odds of being able to help someone who will die without that help outweigh the odds of me actually getting hurt by the shooter. I am pretty sure that the LEOs who escort me in will do whatever is within their power to try and prevent harm from coming to me and my partners.

This is no different, really, than staging until LE gets on the scene of a shooting. Even if LEOs are on the scene of a drive-by shooting, for example, and they have declared the scene ‘safe’, there is still the chance of the shooters coming back to finish the job. It’s happened.

The “I’ll stay out until the scene is clear” mentality for the active shooter situation is deadly- for the people waiting for care. A properly prepared plan that has been trained for and properly executed is just as safe, if not safer, for the EMS people, than driving “code 3” in suburban traffic.

I don't think it has anything to with with preparedness to risk your life or hero status. I personally wouldn't run into a fire just because a smokey says the water is on.

I'm CBR trained, so I am prepared to go where others won't.



If your program works, go for it.

However, I don't think what we do is second best, because we put our safety first. Yep people may suffer, but we are no good to anyone injured. Our view may change overtime.

I also wouldn't start a pissing contest between medics in black and medics in blue. We've had our Heroes enter mass shooting scenes - under fire too- and do a stellar job.

Assuming we are little wallflowers who want a sterile scene is garbage. Confirmed area safety is a bit different to running up the backside of a bunch of police moving in a tactical alphabet.

Different communities will handle things different. Whether or not you or I agree with them is irrelevant. What I think is the right idea may not be shared by others. That's OK, too. Me personally? I don't get into urination competitions. Nor am I trying to start anything between medics in black and medics in blue. In the instances I a familiar with, it was a fact that the tac medics were delayed. That was acknowledge in the incident I referenced. At any given time, there were limited numbers of tac medics on duty, and they are not 'stand alone' units. They are assigned to ambulances, and as I recall, the first one that arrived that day had to clear from another call first.

If you have enough tac medics that can respond to these incidents in a timely fashion, great. The fact is, most places don't, nor will they ever be able to afford it. What Chief Kirkwood advocates, has helped to implement, and I, as a member of that system saw, is a viable way to address these situations.

Lots of good discussion. It is also a discussion we had locally a few months ago when planning a multi-agency active shooter table top exercise.

Back in the 1970's, my EMS agency was one of the first in the nation to implement armed tactical medics imbedded with SWAT. Budgets and training requirements were the demise of that program and are still a major hurdle today.

We need to evaluate our options. I am not talking extraordinary acts of heroism. As mentioned earlier, it is a risk benefit analysis. We can't remove all risk so we accept levels of risk. We also take steps to mitigate risk whenever reasonable.

  1. Driving - drive defensively and wear your seatbelt
  2. Infectious Diseases - wear your PPE
  3. Freeway MVA's - wear safety vests and position apparatus to protect the scene
  4. Structure Fires - bunker gear and SCBA's
  5. Transporting Scissors - don't run
  6. etc, etc, etc...

So what risk do we accept in an active shooter situation knowing that the scene will not be "secure" for quite some time and saveable lives will be lost while you wait? I go back to the old adage of treat others as you would expect yourself or your family to be treated.

I believe it to be reasonable for EMS to make entry and remove savable patients if law enforcement has pushed inside the building and an armed escort has been provided.

If you chose to wait until the scene is "secure", you will provide the rest of EMS a lessons learned example similar to what Columbine was for law enforcement. That tragedy has changed the active shooter response plans of virtually every law enforcement agency. I urge everyone to sit down with local law enforcement to discuss your missions, how you carry them out, and what your expectations are of each other. It's great when we all get together and come up with a planned response.

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