Administration and Leadership, Mass Casualty Incidents, Operations, Patient Care, Terrorism & Active Shooter

Delivering Critical Care in Ciudad Juárez and on the U.S.-Mexico Border

Issue 4 and Volume 39.

The U.S.-Mexico border is 1,900 miles of some of the most unforgiving and dangerous terrain in North America. Temperatures can reach well into triple digits during the day and then drop below freezing at night. The deserts, mountains, rivers and thick brush have claimed thousands of lives of migrants attempting to cross into the United States, and abuse at the hands of guides and smugglers adds even more danger.

Compounding the violent nature of the border, however, is a drug war that’s claimed the lives of some 60,000 people in Mexico since 2006. Amid this danger and chaos are the first responders who provide emergency medical care on both sides of the border and who must face these added challenges.


American first responders have had to be more cognizant of the complexities and psychological trauma associated with active shooter and mass casualty incidents ever since the Columbine shootings. But imagine a single city where tragedies like Columbine, Virginia Tech, Sandy Hook, Fort Hood, Boston Marathon, and the Aurora, Colo., movie theater shooting occur on a regular basis and are responded to by the same emergency personnel.

The Texas-Mexico border along the Rio Grande River, and specifically Ciudad Juárez, Mexico, has received international attention because of drug war violence and migrant deaths. Few cities in the world have experienced the remarkable violence seen in this area, when a brutal war between the Sinaloa and Juárez drug trafficking organizations began in 2006. Since then, more than 11,000 have been left dead.

According to the FBI’s 2012 Uniformed Crime Report, Chicago, Detroit and New Orleans had the nation’s highest murder rates with 506, 386 and 193, respectively. Juárez experienced 787 murders in 2012, and the number of murders peaked in 2010 with 3,622, giving Juárez the dubious honor of being called “the murder capital of the world.”

Violence in Juárez exploded exponentially in 2008, two years after Mexican President Felipe Calderón declared a nationwide war against drug trafficking organizations, when the Sinaloa Cartel attempted a violent takeover of the “Juárez Plaza”—the drug trafficking route into El Paso, Texas. This led to Calderón augmenting a corrupt and besieged municipal police department with some 7,000 soldiers the following year.

The unrelenting drug war violence in Juárez put the city’s EMS on a footing few metropolitan areas in the world experience. As the two drug organizations fight for lucrative passage of their drugs into the U.S., mass shootings, mutilations, dismemberments and even threats to providers became the norm.

Such was the case in the relatively quiet neighborhood of Villa de Salvarcar. During a Jan. 30, 2010, celebration at a house on a tree-lined street, gunmen, many in their teens, burst into the house, systematically shooting anyone in their field of vision. When it was over, 15 teenagers were dead. On arrival, paramedics had to untangle bodies piled near the doorway, where partygoers had attempted to flee, before being able to treat those inside. It was later learned the gunmen had entered the wrong house to exact their murderous plot against a rival drug gang.


The hazardous environment EMS personnel experience in Juárez was redefined on a hot July night in 2010, when members of La Linea, a street gang used as enforcers for the Juárez Cartel, detonated a vehicle-borne improvised explosive device on a busy downtown street.

Just before the explosion, an ambulance was dispatched to respond to a call of a police officer shot on a nearby street. The crew found a man in a federal police uniform bound and bleeding in a vehicle, but he wasn’t a real police officer. An old Pontiac he was in was rigged with 22 pounds of Tovex, a water gel explosive commonly used as a replacement for dynamite in mining activities. When the smoke from the explosion cleared and the debris finally came to rest, a doctor, paramedic and two police officers lay dead on the street. Three other paramedics were wounded.

A car bomb attack results in the death of a doctor, a paramedic and two police officers, with three other paramedics wounded.

A car bomb attack in Ciudad Juárez on July 15, 2010, results in the death of a doctor, a paramedic and two police officers, with three other paramedics wounded. AP Photo

Since 2008, the Cruz Roja Mexicana (Mexican Red Cross) in Ciudad Juárez instructs EMS personnel to wait until police secure the scene of an attack before treating the wounded. In the wake of the 2010 car bombing, crews were instructed to be even more vigilant in looking for shooters and explosive devices.

“They have to think with their heads and not their hearts,” Gilberto Contreras, the president of the Cruz Roja Mexicana in Juárez, told media outlets at the time of the bombing.

Despite the city’s declining murder rate, EMS providers continue to experience violent calls. A frightening uncertainty of what can happen lingers with every call, when violence can erupt at any moment.

En route to a local hospital on a seemingly routine transport call in June 2011, a Juárez ambulance crew monitored two male patients in the back of the rig, both suffering from renal failure. The crew was abruptly stopped on a major boulevard when a vehicle crashed into them head-on. Before they knew it, the driver was summarily shot in the head, followed by the two renal failure patients and the paramedic. A woman accompanying the patients was severely wounded. Officials initially suspected the driver may have been the target, but like so many investigations in Ciudad Juárez, no final determination was made.


Providing EMS services in Ciudad Juárez is daunting. With a population of some 1.2 million people, crews are pushed to the limit of their physical and emotional abilities.

The Cruz Roja Mexicana in Ciudad Juárez is the city’s primary ambulance service. According to Administrative Coordinator Mario Carmona, there are only three stations equipped with a total of 24 ambulances. Filling the typical eight-hour shifts are 35 paid and about 30 volunteer “technicians” who receive no less than one year of training on par with an EMT-Basic in the U.S.

With the small staff called out to an average of 1,500 calls per month in parts of the city even police fear to go, anxiety runs high.

This is in stark contrast to the city’s cross-border neighbor El Paso, Texas, whose population of slightly more than 827,000 is served by 27 full-time mobile ICU ambulances and four peak-time transport ambulances. The violent crime rate in El Paso is so negligible that it ranks among the safest cities in the U.S.

Ciudad Juárez officials like Carmona are reluctant to provide statistical data such as training routines, shifts and pay scales, for fear the narcos, as the cartel members are called, can use the information to extort money from the individual or agency. Carmona doesn’t take chances with the safety of his crews, especially in a city that’s seen nearly 200 police officers murdered in the past six years.

“We haven’t had any incidents of extortion, but we are concerned about the safety of our employees,” Carmona said. He added that incidents like the 2010 car bombing have become increasingly rare and that “people have always been respectful of the institution.” But he knows the specter exists for anything to happen.

Paramedics carry an injured woman

Paramedics carry an injured woman outside a bar where gunmen opened fire in downtown Ciudad Juárez on Sept. 17, 2010. AP Photo/Guillermo Arias


In a 2010 short film produced by Ioan Grillo, author of El Narco; Inside Mexico’s Criminal Insurgency , veteran paramedic Carlos Buenrostro recalled how a police escort was necessary on each shooting call because of the threat that gunmen would attack the ambulance to finish their job if the patient happened to survive.

In July 2009, there were two separate incidents where individuals were killed in the ED waiting room. In October 2010, gunmen killed three wounded men who had been taken to a city ED. One patient was even pulled from an ambulance and murdered in the street.

“[Members of drug trafficking organizations] have threatened us on our radio frequency, telling us not to go to a certain crime scene,” Buenrostro said in the film. “They warn us we’ll get shot at, so they tell us not to go.”

Buenrostro, like his colleagues, chooses to ignore the threats and still responds to the scene regardless of the call or possible danger. Fortunately, these direct assaults against EMS and patients have significantly abated in the past two years as security strategies have improved and the murder rate has decreased. But acts of senseless brutality still occur throughout the city.

The crime scene after gunmen opened fire on an ambulance

The crime scene after gunmen opened fire on an ambulance, killing the driver, two patients and a relative of one of the patients in Ciudad Juárez on Dec. 7, 2011. AP Photo/Raymundo Ruiz

Most recently, in September 2013, 10 people, including a 7-year-old girl, her mother and three teenage boys, were killed in Loma Blanca, an eastside suburb of Juárez, after two gunmen burst into a house where families were celebrating a youth baseball championship. The gunmen sprayed the occupants with AK-47 fire.

The emotional strain of constant exposure to this level of violence isn’t being ignored by administrators like Camrona.

“If our people have a problem, we offer counseling,” he said, but wouldn’t say how frequently it’s utilized in this notoriously machismo culture.


Since the violence began in Juárez, there’s been concern and debate over whether it’s spilled into El Paso. However, there’ve only been two recorded incidents of violence in El Paso linked to Juárez.

In February 2012, a 48-year-old grandmother was on a downtown El Paso street shopping with her grandson when she heard a pop and felt pain in her leg. When she looked down she saw a bleeding wound and was rushed to an area hospital. Police suspect the.223 caliber assault rifle round that hit her had come from a gun battle between Juárez police and carjackers on their side of the border.

The other incident occurred in 2010 when a round from a shot fired in Juárez crashed through a window on the University of Texas-El Paso campus, which is only blocks away from the border. No injuries were reported in that incident, but the two episodes prove innocent victims could be hurt on both sides of the border.

Margaret Althoff-Olivas, director of public affairs for University Medical Center-El Paso (UMCEP), the only Level 1 trauma hospital in the region, said 90% of patients treated in the ED are victims of trauma. This number comes into more startling view when it’s revealed there’ve been more than 200 arriving patients classified as “victims related to violence in Mexico.” Of these, 75% are American. Because it’s a public hospital, UMCEP can’t legally turn away patients. At one point, the outstanding accounts receivables from these cases reached nearly $5 million, and officials sought federal aid to be reimbursed.

The hospital hasn’t experienced any violence or direct threats. Security concerns were raised in 2008 when a high-profile patient was transported across the border into El Paso. According to Althoff-Olivas, a Chihuahua state police official was shot in an assassination attempt. Fearing reprisal from the hit men, the hospital was placed on lockdown and surrounded by heavily armed police.

“That was the only time we had to put the hospital on lockdown,” said Althoff-Olivas.


According to Roger Maier, spokesman for the U.S. Customs and Border Patrol (CBP) El Paso sector, patients presenting at the border don’t have to be American citizens to receive treatment in the U.S, but Mexican ambulances don’t transport across the border. However, a patient transfer can be coordinated in advance to have a U.S. ambulance waiting. If CBP doesn’t know in advance, El Paso-based EMS is immediately contacted on arrival.

“While waiting for the (American) ambulance to arrive, CBP officers process patients/passengers to assess admissibility,” Maier said. He said in many cases people are U.S. citizens or foreign nationals with appropriate entry status. If the patient doesn’t have admissibility documents or admissibility can’t be immediately determined, CBP will generally provide temporary parole so appropriate medical attention can be obtained. CBP will also provide escort/guard of the admitted patient until admissibility is established and/or the person departs the U.S.

During this process, the Mexican ambulance is inspected in the same manner as any arriving vehicle, even though the ambulance isn’t making entry and the crew is simply transferring a patient from one vehicle to another.


Regardless of political beliefs or national policies, the U.S.-Mexico border region remains a fluid stream of humanity. Law enforcement, border protection and EMS agencies have adapted to the inherent risks they take every day to keep both Mexican and American citizens alive and safe. 


Sidebar: Border Patrol Medics

For those who enter the U.S. illegally, whether they be migrants or drug couriers, the risk of injury escalates dramatically due to immigration control policies. Border security has been beefed up in the metropolitan area; therefore, these groups tend to cross in areas where they perceive to be minimal security measures in place, such as natural barriers like the Rio Grande, thick brush areas, desolate deserts and seemingly impassable mountains. Injuries from the heat/cold of the desert, rapid river currents and a plethora of other injuries have created a need for a unique team of border patrol medics.

The Border Patrol Search, Trauma, and Rescue (BORSTAR) was created in 1998 as part of the Border Safety Initiative developed in response to the high number of migrants injured or killed while attempting to cross the border. Headquartered in El Paso, BORSTAR was created to be a quick medical reaction force made of specially trained border patrol agents required to have two years in the field before going through a rigorous five-week training program that includes EMT-Basic certification, as well as search-and-rescue training. Many BORSTSAR agents also pick up paramedic, rescue diver, water rescue and rescue boat training.

A recent high-drama BORSTAR rescue occurred at 5 a.m. on Dec. 6, 2013. BORSTAR agents were dispatched to the riverbanks of the Rio Grande where they spotted a naked man in severe distress. A team of five BORSTAR agents entered the water in swift water rescue gear and proceeded to swim to the rock to rescue the man. Once they reached him, they noticed he was in the early stages of hypothermia and other medical conditions wouldn’t allow him to walk on his own. A personal flotation device was utilized to get him back to the riverbank.

To migrants and smugglers, the border patrol agents are often seen as an enemy, but when in need, BORSTAR teams have become a welcome presence in the so-called “death zones”—areas along the border that appear to have easy access into the U.S. in the absence of the border fence. With 651 miles of fence along the 1,900 mile U.S.-Mexico border, the inhospitable nature of the non-fenced regions is thought to be enough of a deterrent. In 2012, an estimated 477 migrants were found dead along the U.S.-Mexico border. In Texas—the state with the longest border with Mexico—271 were found dead; more than all of the other border states combined.

BORSTAR is sometimes dispatched after a migrant uses one of the rescue beacons the CBP has placed in the “dead zones.” These beacons essentially act as a desert 9-1-1 system. The solar-powered beacons stand prominently in the desert and are push-button activated to summon help.

Bill Brooks, a CBP spokesman, told USA Today in March 2013 that there was a 25% increase in rescues of people struggling to make the cross-border journey in 2012. “CBP works hard to avoid loss of life among those who attempt to enter the U.S. illegally,” Brooks said.

BORSTAR agents receive EMT-B certification as well as search-and-rescue training.

BORSTAR agents receive EMT-B certification as well as search-and-rescue training.


BORSTAR agents receive EMT-B certification as well as search-and-rescue training. Photos courtesy U.S. Customs and Border Protection

The job of protecting the southern border doesn’t come without its risks, and sometimes the BORSTAR agents respond to injuries sustained by their own. Three agents have been killed in shootouts along the border since 2009: two in Arizona and one in California. Other injuries sustained by agents range from musculoskeletal to soft tissue, head and face, and even cardiac events. One area of particular concern is rock assaults from individuals either crossing the border or while in Mexico. In 2011, there were 339 rock-throwing incidents, dropping to 185 in 2012. The rock-throwing tactic is typically used to either taunt or attempt to distract agents and has resulted in serious head, face and ocular injuries. It has also forced the CBP to add metal grates and deflectors to the windshields and side windows of some of their vehicles.