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No one in the nation will ever forget April 20, 1999, as the day that two students from Columbine (Colo.) High School opened fire and killed 12 fellow students and one teacher and injured more than two dozen others.
More than 10 years later, it’s still a day that sticks in the mind of E. Reed Smith, MD, FACEP, the operational medical director for the Arlington County (Va.) Fire Department and an assistant professor of emergency medicine for George Washington University. Unfortunately, there have been many days, like Columbine, where active shooters position themselves on campuses or office buildings, with too many lives lost. Despite quick response by law enforcement and EMS in some of these situations, Smith thinks the response could be quicker and more effective.
“We did an active shooter’s drill here in Arlington County, with 20 or 30 students acting as victims,” he says. “We staged, and two or three hours later, we were still staged and waiting. They had the shooters sequestered in the library, and the SWAT team was in negotiations, and we are still not in the building.”
Smith knew something had to change.
A Call for Change
Smith sat down with the Arlington County Fire Department Special Operations Battalion Chief Carl Lindgren, and they discussed developing better ways for EMS to respond more effectively in active shooter situations, while still protecting first responders. What they ultimately developed was the Rescue Task Force, one of the first active shooter response programs in the nation. The Task Force was based on the military’s tactical combat casualty care (TCCC) guidelines and the military doctrine of combat medicine. The Rescue Task Force is so named to comply with National Incident Management System guidelines. “We are putting police and fire, which are two different entities with different resources, together toward a common goal of saving lives,” says Smith. “That’s where the name comes from.”
Initially, basing the program on TCCC seemed to Smith to be the way to go. “TCCC is a phenomenal doctrine that has saved so many lives,” he says. But then, he began to realize that the military basis of the doctrine didn’t quite match up with the civilian situations that fire and rescue departments were encountering. “It’s written for a military environment, with military participants, equipment and resources,” he says. “It’s not written for civilians, and it doesn’t take into account the nuances of the civilian environment. I needed something written for the civilian environment, with civilian equipment and resources.”
Translating the Doctrine
Although TCCC is based on solid battlefield medical procedures, it doesn’t take into account the different scopes of practice between agencies, whether down the block or across the nation. It doesn’t take into account the differing kinds of equipment EMS agencies may deploy. “And it doesn’t take into account that I may be treating 5-year-olds and 65-year-olds,” Smith says. “The bullets are the same; the weapons, the explosives, and a lot of the tactics are the same. But there are significant differences.”
So he and Geoff Shapiro, a colleague at George Washington University, sat down to begin the process of translating and redrafting TCCC into a civilian format that EMS, fire and law enforcement agencies around the nation could use in all high-risk medical scenarios. They coined the term tactical emergency casualty care (TECC) and established a not-for-profit committee of nationwide experts to develop the civilian guidelines.
The goal of Rescue Task Force is aggressive forward deployment of medical assets into a non-secure scene. If someone is standing in a hallway shooting at people, EMS will not be deployed. But, after the police complete a primary sweep, when there is decreased risk with the scene not completely secure, the Rescue Task Force will be deployed.
“It takes four hours to secure an area, and we’re not going to wait that long,” says Smith. “It takes 10 minutes to do a primary sweep to make it safe, but not secure, and then we’re going to go to work. We use tactics and equipment to mitigate the threat.”
Creating a Plan
The first two arriving Arlington Fire paramedics now team up with two police officers. Once the initial police contact teams complete their sweep, the paramedics proceed. Wearing ballistic gear and carrying simple medical supplies, the Rescue Task Force group works rapidly in this “warm zone” to stabilize the wounded and evacuate to care.
“Before Columbine, police officers would show up to the scene of the shooting, surround the building, and secure the perimeter, so the bad guy couldn’t get out. Then they would wait for SWAT to show up. That was the old paradigm,” says Smith. “Now, across the country almost every patrol officer is trained that if there is an active shooter, the first three or four officers that show up immediately go after the bad guy. We wanted to deploy a similar paradigm for fire/EMS. The first few arriving EMS units can team up with police and move into the building to start rendering care without delay.”
Smith admits the selling of the idea initially encountered some pushback.
But he was able to convince others that the idea was sound because the Task Force combination of police and fire working behind the initial contact teams allowed for the mitigation of risk, while saving lives. “You mitigate risk with tactics, good training, and good command,” he says. “It’s training, tactics, and equipment.”
Being on the Rescue Task Force also requires a different mindset. In a high-risk environment, first responders need to do things that are absolutely medically necessary, not things that are nice to do, says Smith. “In standard EMS, we do the things that need to be done, but we also do a lot of things that are nice to do. What we had to do in that high-risk situation in that hallway in a high school was define, ‘What needs to be done?’ Because every second you stay there you’re at risk. We based those medical recommendations on the tactical emergency casualty care guidelines.”
Smith’s idea has been spreading. In this past year, the program has pushed into the regional level, with several agencies in the national capital region adopting the concept. The idea has gone international, as well. The London Fire Brigade met with Smith this past year.
They have taken some of the concepts and guidelines back with them and are now using them to form their own active shooter medical care and evacuation procedures.
Which leads to a point that Smith wants to emphasize: Rescue Task Force is about concepts and guidelines that are flexible and adaptable to different agency and jurisdiction needs. “You can do this,” he says. “You just don’t have to do it the way I’m doing it. This works for my county. Bigger counties and bigger agencies need to figure it out.”
The City of Fairfax Fire Department did just that. “They took the Rescue Task Force idea and made it appropriate for their system,” Smith says. “The point is, the Rescue Task Force doesn’t have to look in my agency the way it looks in your agency, as long as the goals are the same, which is to quickly get medicine at the point of wounding. If you want to send in 20 police officers with one medic, I’m fine with that, as long as we’re getting medicine into that warm zone, which is key.”
Smith says the idea of Rescue Task Force has been well accepted, although he admits getting the idea across has been a challenge at times. He doesn’t seem to mind breaking down the “we’ve always done it this way” mindset, however, equating the process to how people used to think the Earth was flat.
“For a long time, we thought the world was flat,” he says. “When we were presented with evidence that it was otherwise, it took time for people to change their view. Now, everyone knows the world is round. Just because we’ve always been doing something one way doesn’t mean it’s right.”
Smith feels the rescue paradigm in fire and EMS needs to change. He agrees that first responders need to be kept safe, but he also believes the job requires acceptance of risk. “We have to accept risk, but it has to be mitigated risk. It comes down to understanding risk and how you mitigate that risk, not being afraid to change the paradigm.”
Smith is passionate about Rescue Task Force because he has children of his own and because he thinks it’s a simple idea with huge ramifications. “I think this is a way we can make the world better,” he says. “If we train thousands of hours and save just one child, then we’ve done good.”