Major Incidents, Operations, Training

Teamwork Starts Before the Call

Issue 5 and Volume 38.

Recent mass shooting/active-shooter incidents, such as the Aurora, Colo., theater, Sandy Hook Elementary School and Webster, N.Y. first responder shootings, have emphasized the importance that responders in the U.S. become aware of how to respond to these mass violence situations. Regardless of where you work, you and your agency will likely face the challenge of responding to incidents that may include acts of large-scale violence toward civilians, as well as acts of violence toward responders.

These incidents occur in all types of settings—urban, suburban, metro and rural areas. However, they typically occur in smaller to midsize communities. Responses require an immediate “joint” response that includes law enforcement, fire, and EMS working together.  Advanced preplanning for command and control as well as scene safety, staging and scene access is critically important.

Scene Size-up
The first indicators of a situation with possible mass violence situation will be provided during your dispatch and pre-arrival information. Gain as much pre-arrival information as possible, and listen for key verbal indicators and intelligence that may come across as indicators for a large scale incident.

Location, number of victims and injuries, and updates will provide you with the initial indicators of a possible incident of mass violence. It’s also important to conduct a quick “windshield survey,” even when you’ve been informed such a scene is secure. If possible, scan the area using binoculars, spotting scopes or vehicle-mounted cameras before approaching the scene.

Dispatch information isn’t always correct or can be vague due to the information the communications center is receiving. Any type of mass violent incident should raise a red flag for all responders to be more aware of what is occurring prior to and during their response.
The first 20–30 minutes of the incident are often the most critical because first-arriving units will have a drastic effect on the progress of the incident. For EMS and fire agencies, typical procedures require that law enforcement be dispatched to any incident with a potential for violence, but you may find yourself on such a scene due to incomplete dispatch information, a wrong address, victims coming to you or a suddenly developing discovery or incident.

Command & Control
There’s tremendous need for a rapid and coordinated effort among all agencies to ensure a safe and effective response. The incident command system (ICS) and unified command (UC) are two of the best tools for agencies to use when responding to these types of mass violence incidents. After setting up an incident command location, you will need to direct arriving units and designate at least one or more staging areas for where arriving units. This will provide you with better accountability of incoming units, centralized command and give you a running tally of the number of available EMS units.

If you arrive first, you should immediately request other partner agency representatives to join you at your location, communicate with and start building a UC system. This will allow each agency to know exactly where EMS, fire and law enforcement units and personnel are located.

A UC system is important. It is counterproductive and a safety risk to the response to have two or more incident command posts scattered across the incident. To maintain situational awareness, the command staff should monitor radio traffic and other communications. If the incident area is large, such as a college campus, business complex or mall, consider multiple staging areas depending on the number of resources responding to the scene and your “span of control.” Dividing the location into branches or divisions can also make the scene more manageable.

On-scene Operations
The current standard for EMS response to any shooting/mass violence incident is to stage until the scene is secured by law enforcement. The issue with this response guidance during a typical mass shooting or stabbing incident is that securing the scene can take two to five minutes.

During this time, either the injured aren’t receiving medical care or medical support is limited. This requires different approaches for victim approach, care and rescue at each incident and must be coordinated quickly with law enforcement officials. EMS providers and firefighters may only enter the scene if it’s confirmed that all suspects are confined or neutralized—and even then with armed law enforcement escorts. Only a small number of EMS and fire personnel should enter under these circumstances, and additional law enforcement officers should ensure their safe passage.

EMS and fire units should remain in staging areas until the scene is secured by law enforcement if possible. If there are numerous casualties on scene who need immediate extrication and care, police may declare portions of the scene secure enough so that an armed law enforcement escort can bring EMS providers and fire officials to those locations for immediate size-up, victim care and extrication.

Body armor should be obtained for those EMS units responding into the warm “impact” area, if available.  It would be extremely difficult and dangerous to assign an untrained and unequipped EMT or paramedic to enter an active-shooter incident with law enforcement if the agencies haven’t trained on this. EMS may need to use “scoop and run” and “load and go” tactics from the immediate incident scene with law enforcement escorts to a safe area or triage site.

If the incident continues to unfold, staging, command, triage, and treatment areas may have to initially be 1/2–1 mile away from the scene due to the distance a round fired from a weapon can travel. Once the scene is secured, these resources can be deployed closer to the incident site for better command and control.

A mass violence incident will garner a large and immediate media response and an overwhelming and immediate concern from parents, family and friends of patients at the incident scene. The media should be addressed early by a public information officer (PIO) and a joint information center (JIC) as the situation grows. The growing use of social media makes it an important tool to provide information to the public and those in the affected area, so it’s critical to put a PIO forward as soon as possible. .

EMS Scene Considerations
EMS agencies will need to develop standard operating guidelines (SOGs) that include the following, for responses to potentially violent situations.
• Approach the scene cautiously, and position initial arriving vehicles in safe locations.
• Start building the incident management system and rapidly establish a UC post with the other responding agencies and staging areas outside of the hazard area.
• Start building the incident management system as soon as possible. It can be anticipated that law enforcement will assume the lead position in the UC during the tactical phase of the incident until the scene is secured, but this still requires EMS assistance and guidance in the command post (CP).
• Deploy only trained and equipped tactical medical personnel to assist law enforcement with rapid deployment and downed person extractions in the “hot zone” when possible.
• Remain in unsecured areas with law enforcement escorts only as long as necessary to perform your duties or extricate the victims to a casualty collection point (CCP), established in safe areas inside a structure or outside.
• Quickly evacuate the wounded to an area of safety as soon as the tactical situation will allow. Use litters, blankets, SKED stretchers or backboards to quickly remove victims from the danger area. Consider other means than bulky stretchers to remove the victims from the danger area with flexible stretchers, such as the compact MegaMover 5000. Tactical medics may be the only medical staff available to provide medical care in a hazardous environment or the “hot zone” of an incident. EMS may need to implement disaster procedures, such as triaging patients, using triage tags, and setting up CCPs and field treatment areas for minor injuries.
• Render aid in secure locations. Conduct triage outside the hazard area when possible. Triage may occur multiple times before transport of the patients.
• Provide EMS crews with to body armor, if possible, when they are sent into to high-risk areas or situations. All responders on the scene should also wear appropriate, high-visibility identification, such as department or command position vests, for ease of identification and scene security, including helmets and clearly marked jackets. In some volunteer or combination departments, some responders may be responding in plain clothes. They must have proper identification.
• Be alert for of improvised explosives devices (IEDs), incendiary devices or secondary devices in questionable surroundings.
• Finally, it’s important to remember that in hostile incidents like this, it’s essential that EMS, fire, law enforcement personnel have preplanned and practiced operational approaches so they can work together effectively at an actual incident.

Other Ways to Prepare
In conclusion, EMS agencies, fire departments and law enforcement agencies need to discuss tabletop exercises and conduct training on mass shooter and active shooter events. These discussions should be at the national, regional and local level, since these incidents happen in a range community types, from small towns to large cities.

A strong command presence will be required during mass violence/active-shooter incidents and integrating EMS operations with law enforcement in a unified command setting is critical. There may be resistance to this effort. It’s important to remember that training on rapidly removing or casualties from danger areas using other means besides heavy ambulance stretchers. It’s also equally important to remember that every responder should have training on “self-aid/buddy aid” type medical care for the hot zone.