Major Incidents, Training

Preparing EMS Agencies and Civilians to Respond to Active Shooter Events

Issue 40 and Volume 41.

Recent events leave no doubt as to the importance of active shooter incident preparedness for first responders and their communities; but what are the essential elements of comprehensive preparedness?

The American College of Surgeons (ACS) gathered world-renowned subject matter experts from law enforcement, Fire/EMS/ rescue and medicine for the purpose of producing guidelines to increase the survivability of mass casualties in active shooter incidents in April 2013 in Hartford, Conn.1

The resulting guidelines, commonly referred to as the Hartford Consensus, recommended a “seamless, integrated response” from all incident stakeholders including: “Immediate responders,” or those present at the time of the incident; “professional first responders,” such as Fire/EMS/law enforcement; and “trauma professionals,” such as emergency physicians, trauma surgeons, nurses and other in-hospital providers.2

The Hartford Consensus group also created the THREAT acronym that describes the action items, in chronological order, that must be addressed to increase the likelihood of survivability during an active shooter incident:

  • Threat suppression;
  • Hemorrhage control;
  • Rapid Extrication to safety;
  • Assessment by medical providers; and
  • Transport to definitive care.

Other Hartford Consensus suggestions included the integration of hemorrhage control with law enforcement response; approaching casualty care as a team effort conducted by law enforcement, Fire/rescue and EMS responders, and a response to active shooter incidents that requires a continuum of care across all public safety personnel.3


Fourteen years of conflict in Afghanistan and Iraq have completely transformed battlefield trauma care in the U.S. military.4 The Committee on Tactical Combat Casualty Care (CoTCCC), in partnership with the National Association of EMTs (NAEMT), provides an excellent evidence-based source of medical information for EMS providers with its Tactical Combat Casualty Care (TCCC) course.

Although developed by the military, the curriculum serves as the source for which other courses, such as Tactical Emergency Casualty Care (TECC), rely on heavily.

Until recently, the CoTCCC outlined a single, 16-hour course encompassing BLS and ALS interventions for individuals providing medical care in a hostile setting. Since May 2015, however, the TCCC course is now offered in two versions: an all-combatant (TCCC-AC) eight-hour course and a 16-hour medical provider (TCCC-MP) course.

Like other NAEMT programs, successful completion of either option results in certification and Continuing Education Coordinating Board for Emergency Medical Services approved continuing education units.

The two distinct curriculums were developed to address requests to the CoTCCC by military medical leaders to facilitate standardized training for non-medical combatants. Both the 75th Ranger Regiment as well as the Canadian Armed Forces attributed the large reduction in preventable deaths in Afghanistan and Iraq in significant part to training all members, including non-medical combatants, in TCCC.5,6

The TCCC-AC curriculum lays the foundation of care for the most likely causes of preventable battlefield deaths, specifically: maintaining tactical awareness during casualty treatment, external hemorrhage control through the use of extremity tourniquets and hemostatic dressing, and basic airway management maneuvers including allowing a conscious casualty to assume whatever body position allows them to breathe most easily, such as the “sit-up and lean-forward” position.

Non-medical combatants also learn about hypothermia prevention, assessing for shock, managing suspected eye injuries with a protective shield, and the use of oral antibiotics and non-narcotic analgesics.

The TCCC-MP curriculum targets those serving as combat medics, corpsmen or pararescuemen, and includes tactically appropriate fluid resuscitation with an emphasis on the use of blood products as soon as is logistically feasible, tranexamic acid, “triple-option” battlefield analgesia dependent upon casualty pain and shock status, needle decompression of suspected tension pneumothorax, and invasive procedures such as surgical cricothyroidotomy.


EMS agencies train to respond to active shooter scenarios

Fairfax County Fire Department TCCC curriculum includes learning how to use hemostatic dressing to control hemorrhage.

Regardless of how quickly a public safety agency can respond, there will always be a critical time period before arrival of trained professional assistance. We see this in out-of-hospital cardiac arrest (OHCA), where increased public access to AEDs and improved bystander response has been successful at raising OHCA survival rates.7

Just as an OHCA patient’s fate may rely upon the first shock or chest compression, the words of Col. Nicholas Senn come to mind when thinking of victims wounded during active shooter incidents: “The fate of the wounded rests with those who apply the first dressing.”8

Efforts are underway—the U.S. Department of Homeland Security’s Stop the Bleed campaign is one example—to better enable the general public to recognize and manage life-threatening bleeding, whether caused by natural or manmade events.9

There are also training courses, such as Bleeding Control for the Injured (B-Con), developed by Peter Pons, MD, and the late Norman McSwain, MD. This 2.5–3-hour NAEMT-sponsored course teaches and empowers participants to perform basic lifesaving interventions and concepts seen in the TCCC-AC curriculum, including the use of extremity tourniquets, the application of direct pressure, wound packing, hemostatic dressings and basic airway management.10

In addition to facilitating public education, caches of hemorrhage control supplies such as the Combat Application Tourniquet (CAT) or the Special Operations Forces Tactical Tourniquet (SOFT-T) should be made readily available in community-identified high-risk venues, in a similar fashion to the availability of public access AEDs.

By utilizing the information and resources from the Stop the Bleed initiative as well as the B-Con course, public safety agencies can facilitate a self-aid/buddy-aid mindset for the general public, making them ready and able to care for themselves in the event of an active shooter or other terrorist event.

Medical preparation is one component of a survival mindset. Being at the wrong place at the wrong time first requires surviving the event. The Department of Homeland Security’s “Run. Hide. Fight: Surviving an Active Shooter Event” provides guidance on responding to an active shooter in the vicinity.11

Should an individual find themselves in the vicinity of an active shooter, they should create distance between themselves and the threat. If running isn’t an option, locate a hiding spot out of sight of the threat, ideally in a barricade-capable area. When the other options have failed and when confronted by the assailant, fighting may be the only way to survive the event.

In response to the events of San Bernardino, Calif., and Paris, Aaron Jannetti of Endeavor Defense and Fitness has developed a curriculum addressing the last resort of Run. Hide. Fight. His classes have been featured on the Blaze and CBS Evening News, and include candid discussions of what’s required and realistic for the average person to survive similar events.12 The three-hour course provides students with opportunities for hands-on practice and testing the skills in reality-based scenarios.


Fairfax County, Va., has experienced two significant active shooter events that have precipitated internal review of operational guidelines and interagency training by department leadership. The first incident occurred in the morning hours of Jan. 25, 1993, when a gunman opened fire on commuters arriving outside of the Central Intelligence Agency headquarters on Chain Bridge Road

The attack resulted in the deaths of two agency employees and the wounding of three others.13 In May 2006, the first line-of-duty shooting deaths for Fairfax County Police Department occurred when an armed man attacked officers outside the Sully District Police Station. The shooter killed Fairfax County Police Detective Vicky Armel and Master Police Officer Michael Garbarino.14

After-action reviews determined improvements were needed in casualty access times and treatment as well as public safety interagency communication and response.

In a collaborative effort to address the identified hazards of past incidents, Fairfax County Fire Chief Richard Bowers and Police Chief Edwin Roessler authorized the formation of the Joint Active Shooter Working Group. This group was tasked to author personnel response guidelines to active shooter events and other hostile incidents.

The working group’s first meeting highlighted the need to approach both routine and catastrophic events in a coordinated manner, the specifics of which were formalized in the Joint Event Action Guide.

This document provided the framework for interdepartmental response and training to include common terminology and situational policies and procedures. This new framework also outlined the Rescue Task Force (RTF) concept.

After the development of the guide, the working group was then tasked to create and implement an interdepartmental training plan. Conducted over seven weeks, RTF principles were practiced by 2,500 police and fire department personnel.

The initial training of the RTF concept facilitated the requisite integrated operational mindset and actions for Fire and law enforcement functioning within the “warm zone.” During the joint training activity, personnel gained a better understanding of each agency’s capabilities and mission, how the new RTF model fit within those roles, and facilitated additional topics of discussion among personnel.

In the Fairfax RTF model, responding medics aren’t expected to function as “tactical paramedics,” but rather as a medical asset brought to the side of a casualty. RTF members provide potentially lifesaving patient care interventions while operating within a security escort.

To facilitate casualty movement, fire department personnel are teamed to form an Extraction Task Force (ETF). Personnel functioning within the extraction teams again combine with law enforcement personnel to safely and rapidly move patients from casualty collection points to the cold zone, where additional treatment and transport are provided by awaiting medical personnel.

All fire department personnel operating with law enforcement officers understand the fluid nature of active shooter events and the potential of instantaneous zone changes from warm to hot.

Situational awareness and teamwork is paramount. The ultimate test of success for this model of response will be determined during repeated real-world application.

Through these tragic events, the Fairfax County Police and Fire Departments have strengthened their interagency response capabilities through review of operational policies and joint training. As a result, they’ve improved efficiency and teamwork across their agencies to include active shooter training in both fire and police recruit academy classes.


There are many components to preparation and response with many questions still to be answered:

  • What’s an appropriate level of medical training and integration with law enforcement?
  • Should EMS providers serve as tactical medics or single-role assets inserted with a security element?
  • Should they be armed? If not, should they receive a basic course on likely encountered weapon systems on how to make them safe should the need arise?
  • What’s an acceptable response time from point of injury to arrival of a medic?
  • Should officers provide initial bleeding control in the form of extremity tourniquets?
  • If the ideal response is “as fast as possible,” is a 3- to 5-minute integration and response with law enforcement realistic?

These are the types of questions to ask when developing a tailored, all-incident stakeholders approach to active shooter events. Fortunately, there are many examples to study to determine what are the right questions and answers for each jurisdiction to consider when addressing the preparation of active shooter events in their communities. JEMS

Acknowledgment: Special thanks to Frank Butler, MD; Peter Pons, MD; Fairfax County (Va.) Fire and Rescue Training Academy’s EMS Training Division Instructor cadre; Fire Chief Richard Bowers; and Fairfax County Police Department SWAT Officers Second Lieutenant Brian Ruck and Master Police Officer Anthony Depoto.

For questions regarding Fairfax County active shooter response please email [email protected].


1. Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events, Jacobs LM, Eastman A, et al. Improving survival from active shooter events: The Hartford Consensus. Bull Am Coll Surg. 2015;100(1 Suppl):32–34.

2. Hartford Consensus III focuses on empowering the public to serve as first responders. Bull Am Coll Surg. 2015;100(6):52.

3. Pons PT, Jerome J, McMullen J, et al. The Hartford Consensus on active shooters: Implementing the continuum of prehospital trauma response. J Emerg Med. 2015;49(6):878–885.

4. Butler FK Jr, Blackbourne LH. Battlefield trauma care then and now: A decade of Tactical Combat Casualty Care. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S395–S402.

5. Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating preventable death on the battlefield. Arch Surg. 2011;146(12):1350–1358.

6. Savage E, Forestier C, Withers N, et al. Tactical combat casualty care in the Canadian forces: Lessons learned from the Afghan War. Can J Surg. 2011;54(6):S118–S123.

7. Hallstrom AP, Ornato JP, Weisfeldt M, et al. Public-access defibrillation and survival after out-of-hospital cardiac arrest. N Engl J Med. 2004;351(7):637–646.

8. Schwartz RB, Swienton RE, McManus JG: Tactical emergency medicine. Lippincott Williams & Wilkins: Philadelphia, 2007.

9. National Association of EMTs. (2016.) Stop the Bleed campaign. Retrieved Feb. 29, 2016, from

10.National Association of EMTs. (2016.) Bleeding control for the injured. Retrieved Feb. 29, 2016, from

11. Department of Homeland Security. (Nov. 30, 2015). Active shooter preparedness. Retrieved Feb. 29, 2016, from

12. Jannetti A. (n.d.) Active shooter training. Endeavor Defense and Fitness. Retrieved Feb. 29, 2016, from

13. Davis P, Glod M. (Nov. 14, 2002.) CIA shooter Kasi, harbinger of terror, set to die tonight. The Washington Post. Retrieved Feb. 29, 2016, from

14. Pennybacker G. (May 4, 2011.) Garbarino family remembers slain Fairfax county police officer. WJLA. Retrieved Feb. 29, 2016, from