The recent tragedies in Aurora, Colo., Newtown, Conn., and the Navy Yard facility in Washington, D.C., have drawn public attention to the growing number of mass killings in our society. Such events have brought to light the real risk of what law enforcement, fire and EMS responders must be prepared to face, and have spawned initiatives and opened conversations at high levels of government. Yet among all the rhetoric for new regulations, there’s only now dialogue regarding the operational medical response to these events. In fact, although the law enforcement tactical response paradigm changed after the Columbine (Colo.) High School massacre in 1999, fire/rescue and EMS operations overall have been resistant to change from the stage-and-wait operations approach.

 

Law enforcement response

 

Prior to the tragedy at Columbine High School, the standard law enforcement response to active shooters and mass-killing events was focused on the Five Cs: contain, control, call SWAT, communicate with the perpetrator and come up with a tentative plan. Based on the belief that these events were actually hostage barricades in which the perpetrators wanted something specific and didn’t intend to kill, the initial patrol response was to rapidly create a hard perimeter around the incident site, evacuate those who could be easily evacuated and establish communications with the perpetrators while waiting for the special tactical response assets to arrive. By the standards of the time, the law enforcement response at Columbine was tactically correct. However, the resultant negative public opinion and the strong criticism expressed by Governor Bill Owens’ Columbine Review Commission were drivers for law enforcement response paradigm change.1

 

Subsequent law enforcement research proved the rapid emergency deployment model as an effective way to limit “trigger time.” Essentially, without rapid intervention, a single unchallenged shooter could acquire, target and shoot one new victim about every five seconds.2 As a result, the now-accepted standard operational law enforcement response to active shooters is the rapid deployment of the first-arriving patrol officers on the scene. These patrol officers immediately form contact teams and move aggressively to the scene. Using impromptu intelligence from victims and persons evacuating, these rapid deployment teams move toward the sound of shooting to contain or eliminate the shooter.

 

What’s now being found with the rapid deployment model is that these events are ended very quickly by the aggressive response, even if the police response is only a single officer.3 Many perpetrators either surrender or commit suicide at the first sign of police activity.4 In fact, a recent report on active-shooter events showed that, on average, active-shooter incidents last less than 12 minutes, with many as short as 3–4 minutes, and that, given the average 10-minute police response, more than 93% of incidents on school campuses ended prior to the arrival of law enforcement.5,6

 

The paradigm

 

The EMS response paradigm to such events, however, hasn’t evolved to reflect this data. To note, there has yet to be a true sentinel event in the public realm to bring to light the shortcomings of the current EMS approach; thus, the impetus for change may not yet be at critical mass.

 

At the heart of the current EMS response paradigm to active shooters is the concept of staging assets off-scene and waiting for operations to begin once the scene is declared safe by police. This concept of scene safety is one that is ingrained in all EMS personnel from the earliest stages of recruit school and operational training. Rightfully so, this paradigm has grown through attempts to minimize preventable injuries to and death of responding personnel.

 

The rift comes when this paradigm is applied to our new understanding of active shooter scenarios, and the primacy of absolute scene safety for first responders in lieu of mitigated risk acceptance comes at the expense of the injured civilian.

 

Assessing risk

 

The most common argument against EMS operations in active-shooter scenarios is that operating in an unsecured environment is too much risk for the responders to assume and scene safety is paramount above all other considerations. The amount of assumed risk in these active-shooter scenarios is thought to be too high to accept.

 

However, because the greatest immediate threat to first responders in an active-shooter scenario—the shooter—is rapidly incapacitated in almost all incidents prior to EMS response, the true risk to EMS personnel operating in areas that have been declared “clear” but not “secure”—so-called warm zones—is very low.

 

Although the active shooter may engage first responders, even the risk to responding law enforcement is less than what may be expected. In a 2003 study of those responding to active-shooter events over a 33-year period, only four incidents were documented in which first responders were killed or injured.5 More recently, there have been four significant first responder injuries in active-shooter incidents: Sergeant Kimberly Munley was shot during the 2009 Ft. Hood response7 ; Lt. Brian Murphy was shot responding to the 2012 Sikh Temple shooting in Wisconsin,8 and during the initial response to the Navy Yard shooting this past September, both Officer Scott Williams and a second unnamed officer were shot.9 The low number of injured responders is even more significant because these were the law enforcement responders aggressively pursuing and engaging the perpetrator in the direct line of fire, not EMS responders working behind the contact teams in warm zones.

 

Working with law enforcement

 

In systems where either law enforcement or EMS rejects the idea of coordinated medical operations in warm zones, seriously wounded but survivable victims could die while the primary tactical objectives are being addressed. The Aurora theater attack demonstrated the need for forward-deployed EMS medical operations. Although not a criticism of the response, the fact is that there were not enough medical or rescue personnel in the warm zone soon enough after the attack, and police officers had to switch from primary tactical response to rescue/medical response. Half of the victims transported to hospitals that night were in the back of police cars.10 Those injured victims transported by police received no medical care during that transport, and with each police-initiated transport there were fewer law enforcement officers on scene to assist with completing tactical law enforcement objectives.

 

Having no medical personnel in the warm zone means that little immediate or point-of-wounding treatment is being done for the wounded, and that stabilizing and often lifesaving care will be significantly delayed. In light of the available data discussed above and actual risk profile, over-adherence to a culture of absolute safety for responders will likely have a detrimental effect on the wounded survivors. The low risk of danger to the responder is clearly outweighed by the benefit to the patients.

 

The paradigm shift in operations at the London Fire Brigade (LFB) is a perfect example of high-risk medical operations. Highly criticized after the July 2005 attacks on the London Underground subway system, the LFB adopted a more aggressive approach to operating in areas of higher risk that relies on real-time risk/benefit assessment by on-scene commanders.11 Despite official vindication in the coroner’s report, the public outrage over the response paradigm that kept responders from early rescue operations during the bombings forced this change.12 As such, in the years leading up to the 2012 London Olympic Games, LFB researched international best practices and worked with operational partners to develop and implement a new approach to high-threat scenarios.11 The LFB should be applauded for its current approach to indirect threat scenario operations, including aggressive police and fire integration for medical rescue and fire suppression.

 

New standard of care

 

Another argument frequently heard against paradigm shift in the EMS response to active shooters is that warm zone care is outside the standard EMS protocols and, therefore, instituting such a paradigm would require a new standard of care and extensive training. Although care provided to the wounded in areas of mitigated threat requires a different approach than traditional EMS, this doesn’t represent a significant and expensive training mandate. Instead, because it does not require certification or proprietary medical courses, the implementation of the high-threat medical guidelines into medical operations can easily be developed on a local level or agency level.

 

The guidelines of Tactical Emergency Casualty Care (TECC), developed by a consensus group of civilian operational medical experts, represent simple, evidenced-based and best practice guidelines for care provided by any caregiver at or near the point of wounding during high-risk operations.13 In lieu of the standard EMS approach, TECC offers threat-based care guidelines that use the relationship between the provider and the threat to define the minimum of what is medically needed for life-saving.

 

Developmentally, TECC is the civilian-appropriate, civilian-guided evolution of the successful military Tactical Combat Casualty Care (TCCC) guidelines. Although TCCC has already been taught to civilians through a variety of training programs, it is at its most basic a military doctrine of care. Significant issues can arise when this military guidance is implemented carte blanche into civilian prehospital operations. Instead, written by civilians for civilian use, TECC accounts for aspects of the civilian setting and scope that do not exist in the military, including, among other things, common operating language across disciplines, scope of practice, liability, special populations such as geriatrics and pediatrics, and baseline health of the population. It is not dogma, and allows for differences among different levels of providers, different scope of practice and different operational systems. The TECC guidelines are essentially a set of bricks with which agencies can build an operational response that is unique and individually tailored to their operations, scope and protocols.

 

An additional argument against EMS response paradigm shift comes down to history. Despite good evidence and a healthy dose of common sense supporting it, resistant administrators often say, “Well, that’s not our incident and is just not the way we operate.”

 

Rescue and EMS operations are based largely on apprenticeship-like training in which we emulate what we have been told and shown by our superiors. This can lead to propagation of operations and procedures that are grounded in anecdotal experience rather than evidence.

 

As a whole, human beings are uncomfortable with change. This natural resistance makes change slow and cumbersome, and it requires time, patience and a lot of discussion. Change is never easy, especially when it addresses one of the earliest and most culturally entrenched ideas in operational response.

 

So, how should paradigm shift be addressed? The answer is to move forward with solid training, tactics and equipment to develop an operational paradigm that allows for medical operations in the setting of mitigated risk. The foundation for the paradigm must include:

 

• Well-developed and frequent training on high-risk operations, the inherent risks and the mitigation strategies

 

• Sound tactics that are developed and vetted by experts to allow for operations that reasonably mitigate the risk

 

• Dependable, user-friendly equipment that both assists in completing the task at hand and provides protection to give personnel confidence in their acceptance of risk

 

Solid training, tactics and equipment will decrease the uphill climb that comes with changing operational inertia and, in the end, will help to ease the assimilation of new paradigm.

 

Conclusion

 

When closely examining the arguments against paradigm shift, the need for change comes in light of the evidence available on the true risk and operational restraints. A new EMS response paradigm for active shooters must be implemented.

 

During active-shooter response, the first-arriving EMS responders, not special operations or tactical medical teams, must accept the responsibility for life rescue and medical operations and must work with first-responding law enforcement assets to rapidly deploy into warm zones to initiate treatment and rescue injured victims.

 

These operations must be coordinated with law enforcement patrol officers providing security for these personnel during operations. EMS must have appropriate medical supplies and equipment, and should be trained in some basic law enforcement tactics. And, these EMS responders must base their treatments on the medical principles of civilian TECC to meet the situational standard for application of medicine in civilian high-threat scenarios.

 
 
References

 

1. Columbine Review Commission. (May 2001) The report of governor Bill Owens’ Columbine Review Commission. State of Colorado. Retrieved on Dec. 19, 2013, from http://www.state.co.us/columbine/Columbine_20Report_WEB.pdf.

 

2. Rielage R. (Dec. 1,2009) In the line of fire. Fire Chief . Retrieved on Dec. 19, 2013, from http://firechief.com/incident-command/line-fire.

 

3. Force Science Institute. (May 14, 2008) Ohio trainer makes the case for single-officer entry against active killers. PoliceOne. Retrieved on Dec. 19, 2013, from http://www.policeone.com/police-products/training/articles/1695125-Ohio-trainer-makesthe – case -for-single – officer- entry-against-active-killers/.

 

4. Blair J, Martaindale M. (March 2013) United States active shooter events from 2000 to 2010: training and equipment implications. Advanced Law Enforcement Rapid Response Training. Retrieved on Dec. 19, 2013, from http://alerrt.org/files/research/ActiveShooterEvents.pdf.  5. Illinois State Police Academy. (April 2003) Rapid deployment as a response to an active shooter incident. Retrieved on Dec. 19, 2013, from http://www.scribd.com/doc/16693309/Rapid-Deployment-as-a-Response-toan-Active-Shooter-Incident.

 

6. Drysdale D, Modzeleski W, Simons A. (April 2010) Campus attacks: targeted violence affecting institutions of higher education. U.S. Secret Service. Retrieved on Dec. 19, 2013, from http://www.secretservice.gov/ntac/CampusAttacks041610.pdf.

 

7. Jankowski P. (Aug. 17, 2013) Kim Munley on Hasan: ‘We began to blindly exchange fire.’ Killean Daily Herald. Retrieved Dec. 19, 2013, from http://kdhnews.com/military/hasan_trial/kim-munley-on-hasan-we-began-toblindly-exchange-fire/article_c8bb168e-0682-11e3-a6b1-001a4bcf6878.html.

 

8. Fussman C. (Dec.27, 2012) Lieutenant Brian Murphy: What I’ve learned. Esquire. Retrieved Dec. 19, 2013, from http://www.esquire.com/features/whative-learned/meaning-of-life-2013/brianmurphy-sikh-temple-shooting-0113.

 

9. WJLA. (Sep. 24, 2013) Second police officer was shot at Navy Yard during attack, Lanier says. Retrieved Dec. 19, 2013, from http://www.wjla.com/articles/2013/09/navy-yard-shooting-chief-lanier-talks-about-mass-shooting-94429.html.

 

10. City of Aurora. (n.d.) Century theater shooting: Aurora fire department preliminary incident analysis. Retrieved Dec. 19, 2013, from https://www.auroragov.org/cs/groups/public/documents/document/015169.pdf.

 

11. Personal communication with London Fire Brigade, 2008.

 

12. Hallett C. (May 6, 2011) Coroner’s inquests into the London bombings of 7 July 2005. Retrieved Dec. 19, 2013, from http://webarchive.nationalarchives.gov.uk/20120216072438/http://7julyinquests.independent.gov.uk/docs/orders/rule43-report.pdf.

 

13. Callaway D, Smith E, Shapiro G, et al. The Committee for Tactical Emergency Casualty Care (C-TECC): Evolution and application of the TCCC guidelines to civilian high threat medicine. Journal of Special Operations Medicine. 2011; 11(2):95-100.