It’s taken years to get crews into a standardized mindset to practice incident command (IC) and mass casualty incident (MCI) management in a non-chaotic and coordinated manner.
Progressive systems now routinely set up MCI operations at incidents that tax their available resources, request pre-arranged MCI waves/levels of units or task forces, and refrain from scooping up the first patients that come to them.
Instead, they perform systematic triage, begin tagging patients according to their severity, set up patient collection points (PCPs) with color-coded tarps staffed by red, yellow and green priority treatment coordinators, establish and staff a transportation group, stage ambulances and assign patients to units and hospitals by highest criticality first, and begin the systematic flow of patients from the scene in an even distribution to hospitals.
Daylight view of direct route to transportation loading area.
But terrorist and active shooter attacks have changed things and place our crews and patients in harm’s way, so we modify our plans and mode of operations in certain circumstances.
1. July 20, 2012: A mass shooting at the Aurora, Colo., Century 16 movie theater involved an assailant who set off tear gas grenades and shot into the audience with multiple firearms. Twelve people were killed and 70 others were injured. The assailant used an AR-15 rifle, a 12-gauge shotgun and two .40-caliber handguns. The shooter was arrested in his car parked outside the cinema minutes after the shooting.1 His apartment was booby trapped with a tripwire at the front door that would have set off an array of explosives and flammable liquids if EMS, fire or police officers entered. Police found more than 30 homemade grenades and 10 gallons of gasoline inside the apartment.1
2. Dec. 2, 2015: A radicalized husband and wife team killed four people and wounded 22 others in a terrorist attack at the Inland Regional Center in San Bernardino, Calif., using two .223-caliber semiautomatic weapons and two 9 mm semiautomatic handguns. The shooters were killed by police after a car chase and exchange of gunfire not far from the original shooting scene.
Officers fired 380 rounds during the fierce gun battle with the couple, and the suspects shot 76 rifle rounds at officers, injuring two officers. Police found over 1,400 rounds for the assault rifles and over 200 rounds for the two handguns inside the black SUV. At the couple’s home, police found 3,000 rounds of ammunition, 12 pipe bomb devices and hundreds of tools that could be used to make improvised explosive devices.2
3. June 12, 2016: The mass shooting occurred inside the Pulse Nightclub in Orlando, Fla. Forty-nine people were killed and an additional 53 people were injured. The gunman used a Sig Sauer MCX assault rifle designed to fire dozens of rounds in seconds. When police breached one of the club’s bathroom walls, the shooter came out shooting after a three-hour standoff and was killed by Orlando police.3
These sample Orlando dispatch notes exhibit what callers presented to the dispatchers and what incident commanders were confronted with:4
>> “Shots fired; multiple people down” [Pulse Nightclub] (Time stamp: 2:02 a.m.)
>> “[Caller reports] second gunman”
>> “[Shooter] went upstairs-six people hiding”
>> “[Caller] thinks gunman has a bomb”
>> “[Hiding] in a handicap stall of a bathroom”
>> “[Shooter] is saying he is a terrorist and has several bombs strapped to him in a downstairs female restroom.
>> “Nine people evacuated through the air conditioner window of a dressing room” (Time stamp: 4:21 a.m.)
>> “Patrons using their hands to stop the bleeding of shooting victims”
>> “Hearing gunshots closer, multiple people screaming”
>> “My caller is no longer responding, just an open line with moaning”
>> “Bad guy down” (Time stamp: 5:17 a.m.)
Two engines are parked back to back so any bullets fired toward rescuers or patient treatment areas will be slowed/stopped when they enter the water tanks.
With crews working in areas where high-caliber weapons are involved, here are a few important facts about weapons and projectiles we’re seeing at active shooter events:
- An AR-15 round (.223-caliber) and rifled shotgun slug can travel and hit a target at 300-900 yards.5–6 That’s the length of 3–9 football fields.
- A .223 caliber round can defeat regular body armor, ballistic helmets and many ballistic shields. Therefore, experts recommend great care be exercised during incidents.7 This includes positioning of patient collection and treatment areas, as well as patient loading/transportation areas.
- A .223 projectile will readily perforate and breach mild steel such as is found on fire apparatus or ambulances. However, very little of the .223’s mass is retained after it penetrates the steel, so significant wound potential is severely diminished after it penetrates the steel.7
- When concrete, brick or macadam are struck at an angle at close range, .223 rounds tend to fragment or break up. Therefore, if it a .223 round strikes a hard object, it will most likely break up and become less lethal.7
- A round from a high powered weapon like an AR-15 can only penetrate about three feet into a water source!8–11 In the TV show Mythbusters, the hosts molded a ballistics gel target with the same consistency as human flesh. They then suspended it in the deep end of a pool and used multiple weapons, firing from a 30-degree angle. The 9-mm handgun bullets and 12-gauge shotgun shells came to a halt after penetrating a few feet into the pool. The rounds shot from an automatic rifle, which shoot at a lightning-quick 2,800 feet (853 meters) per second-disintegrated within just three feet after entering the water. The bullets decelerated in the water so quickly, in fact, they burst, leaving the ballistics gel target intact.11–12 (Video available through references 8 and 12, below.)
Special 10-foot test tanks used by the Lehigh County (Pa.) forensics lab and other law enforcement labs further validate the fact that water dramatically slows and stops bullets of all sizes. Therefore, emergency responders need to know that water tanks on fire engines can be a helpful protective barrier during an active shooter event.
FoxFury Nomad 360 lights set up in < 20
seconds to light up patient collection and treatment areas.
Need for a Safety Perimeter
In light of active shooter incidents in the past year that involved secondary devices, the potential for secondary devices, multiple shooters, return attacks or nearby gunfights, EMS and fire personnel need to be strategic in the location of patient collection points, triage tarps and transportation and loading zones.
In addition, triage has to be modified when involved with active shooter incidents. Although the military uses survivable/non-survivable classifications, civilian triage personnel should consider the use of move or stay criteria classifications.
Critically injured patients who self-extricate or are rapidly extricated by emergency personnel should be directed or moved toward a red tarp where providers can determine if they should be rapidly placed in an ambulance or other vehicle and moved to a medical facility or placed on the tarp for care on scene.
Crews must be taught that not every patient needs to leave the scene immediately and that doing so could jeopardize the survivability of the most critically injured. Patients who can move on their own after being shot or injured in a terrorist attack should be quickly directed to a safe zone and color-coded collection and treatment areas.
.223 caliber round
Most importantly, police officials, law enforcement personnel and training academy staff need to be familiarized with these essential EMS/fire operational procedures so they work cohesively with us at major incidents. That’s a piece of the MCI and active shooter/scene management puzzle that has been lacking and causing confusion and patient care delays at some incidents.
Illuminate Critical Scene Areas
You can’t treat what you can’t see, so scene lighting that can be initiated rapidly is essential, particularly at fast-moving and chaotic nighttime scenes.
The entry path to your patient collection, treatment and transportation/ambulance loading areas need to be lit up to ensure proper assessment.
Fast-Tracking Critical Patients
Just as hospital have EMS crews bypass the ED to go straight to a trauma bay or operating room, we too have to be set up to do the same at incidents involving a high volume of patients. Early into an active shooter or other hostile MCI, crews should establish a reasonably protected patient collection, triage, treatment and transportation areas.
The photo below illustrates the rapid fast-tracking—not stopping at the red tarp—of a critical patient to an ambulance.
Police Transportation of Patients
There have been several recent incidents when police decided to transport patients in lieu of waiting for ambulances to arrive, or because they considered the scene too potentially dangerous for EMS and fire personnel.
In Aurora, police, confronted with multiple dying victims, an initial shortage of ambulances, and the awareness that at least one gunman was caught trying to flee the movie theater in a vehicle, got approval through their incident commander to begin transporting patients to area hospitals and trauma centers in police vehicles.
In Orlando, police held back responders for their own safety and began using police vehicles to start transporting patients a mile away to Orlando Regional Medical Center, the area’s only trauma center, because the gunman was still inside firing his weapon. Orlando police rapidly moved critically injured patients in the back of police pickup trucks that proved to be valuable at that incident. While it would be preferred to transport all critical patients in ambulances, improvisation in this instance probably saved multiple lives by getting them to surgical intervention rapidly.
A critical patient is fast-tracked to an awaiting ambulance for rapid transport.
I wasn’t at either incident, but my opinion is that these officers did what they felt was in the best interest of the patients and was an effort to protect responders until they were sure the scene was under control and safe.
However, rapid removal of patients in police vehicles, while helpful when EMS resources aren’t at full strength during the initial moments of an incident, can be detrimental to patients and have an impact on their morbidity and mortality if the law enforcement personnel don’t participate in a structured EMS patient distribution process.
An EMS transportation group supervisor must be put into place early into a dynamic and active threat situation to poll hospitals, preferably through an established communication system, and be in charge of distributing those patients to the appropriate medical facilities in a coordinated and systematic manner so that the patients end up at the proper hospitals and no hospital gets overloaded.
Such was the case in the Philadelphia Amtrak derailment on May 12, 2015—a crash that killed eight people and injured more than 60 others. Police clogged access routes, hindering ambulance entry/access to the scene. They also began to rapidly move patients to just a few hospitals of their choice in the back of police vans with little or no care en route.
Of the 43 critical or seriously injured multi-systems trauma patients transported, only three were transported to trauma centers by ambulance, according the National Transportation Safety Board (NTSB).13
Most of the critical trauma patients were transported by the police to the nearby Temple University Trauma Center, causing multiple other fully staffed Philadelphia trauma centers to not receive evenly distributed critical patients.
With just 24 of the 186 passengers taken to hospitals after the Amtrak crash by ambulance, Philadelphia is now working to correct this uncoordinated practice. The NTSB recommended the city develop a plan to systematically work “scoop-and-run” into its emergency response plan, including a method for better spreading patients among hospitals.14
Because police and fire radio communications are largely separate in Philadelphia, the NTSB also recommended that the city’s emergency responders should communicate better during mass-casualty events and integrate the police department into its EMS transportation plans.
The city is now working to update its emergency response plan and will require those transporting victims to hospitals to check in with a transportation coordinator first.14
Threats on the community and our personnel dictate that we all work to modify our MCI response and on-scene action plans to work more closely than ever with dispatch and law enforcement to bring order to chaos, protect our unarmed personnel at the scene and evenly distribute patients in a fast, coordinated manner to the appropriate care facilities. jems
1. CNN Library. (May 22, 2016.) Colorado theater shooting fast facts. CNN. Retrieved July 1, 2016, from www.cnn.com/2013/07/19/us/colorado-theater-shooting-fast-facts/.
2. Jones A, Frosch D. (Dec. 3, 2015.) Rifles used in San Bernardino shooting illegal under state law. The Wall Street Journal. Retrieved July 1, 2016, from www.wsj.com/articles/rifles-used-in-san-bernardino-shooting-illegal-under-state-law-1449201057.
3. Ingraham C. (June 12, 2016.) Assault rifles are becoming mass shooters’ weapon of choice. The Washington Post. Retrieved July 1, 2016, from www.washingtonpost.com/news/wonk/wp/2016/06/12/the-gun-used-in-the-orlando-shooting-is-becoming-mass-shooters-weapon-of-choice/.
4. Schneider M/Associated Press. (June 29, 2016.) Police-dispatcher logs released on Orlando shooting. Arkansas Online. Retrieved June 30, 2016, from http://m.arkansasonline.com/news/2016/jun/29/police-dispatcher-logs-released-on-orla/.
5. Jeff3230. (March 14, 2010.) 900 Yard AR-15 Long Range Shooting. YouTube. Retrieved June 29, 2016, from www.youtube.com/watch?v=1KuOmVqKoEk&feature=youtu.be.
6. Hawks C. (2003.) Rifle ballistics table. Chuck Hawks. Retrieved July 1, 2016, from www.chuckhawks.com/rifle_ballistics_table.htm.
7. Taubert RK. (n.d.) About .223 penetration. Olympic Arms. Retrieved June 29, 2016, from www.olyarms.com/index.php?option=com_content&task=view&id=14.
8. KWC. (July 13, 2005.) Annotated Mythbusters. Retrieved June 29, 2016, from www.kwc.org/mythbusters/2005/07/mythbusters_bulletproof_water.html.
9. Discovery. (n.d.) Bulletproof Water. Retrieved June 29, 2016, from www.discovery.com/tv-shows/mythbusters/mythbusters-database/water-bulletproof/.
10. TimberrockRanch. (Sept. 10, 2015.) What happens when bullets are fired into water? YouTube. Retrieved June 29, 2016, from www.youtube.com/watch?v=Dihs9JcVt3E.
11. SmarterEveryDay. (July 22, 2014.) AK-47 underwater at 27,450 frames per second (part 2)—Smarter Every Day 97. YouTube. Retrieved June 29, 2016, from www.youtube.com/watch?v=cp5gdUHFGIQ.
12. Criminiolgytube. (Dec. 6, 2012.) Mythbusters shooting 50 caliber sniper into water SD. YouTube. Retrieved June 29, 2016, from www.youtube.com/watch?v=tR856ingowI.
13. Wood S. (May 13, 2016.) After Amtrak chaos, new limits coming on police ‘scoop and run.’ Philly.com. Retrieved June 29, 2016, from http://articles.philly.com/2016-05-13/news/73042710_1_ntsb-police-cars-train-188.
14. Whelen A. (May 19, 2016.) Philly’s use of cops to ferry derailment victims did no harm, NTSB finds. Philly.com. Retrieved June 29, 2016, from http://articles.philly.com/2016-05-19/news/73180425_1_ntsb-amtrak-crash-emergency-responders.
Incident Command MCI Report
What follows is what I believe could be a future report by EMS/fire incident commanders at future high-threat incidents. Is this visionary or futuristic? No—it’s necessary in today’s terrorist response environment.
1. Active shooter incident, shots being fired; police extricating victims.
Backboards lined up at ground level along the engines to deflect ricocheted bullets.
2. Police have multiple cars and pick-up trucks lined up and getting loaded with victims who are shot and critical. I want four ambulances: one at the end of each block leading away from the structure, in a reasonably protected area, to intercept transporting police vehicles and to screen, re-triaged and distribute the injured to the appropriate hospitals.
3. Hospitals have been notified of the incident and made aware patients may be self-transporting to them or coming by police and civilian vehicles. They are awaiting further updates.
4. No one is to leave without a rapid EMS evaluation. Deploy your MCI supplies, vests and active shooter/blast kits. Be prepared to triage and provide initial care for priority 2 and 3 patients who flee in your direction. A central, protected treatment and transportation zone will be established and its location reported to you soon.
5. Engine 6 and Engine 12: On arrival I want you to set up a defensive position to shield EMS triage, patient collection, treatment, transportation and loading areas, one block West of the scene at 10 Avenue and Oxford.
6. I want one engine facing north and one facing south, with a four-foot entryway created between the rear of the vehicles so your water tanks can dissipate stray bullets.
7. I want ladders and backboards lined up at ground level on the east side of the engines to attempt to deflect ricocheted bullets.
8. The transportation group is to set up a rapid transport zone for critically shot victims who can’t be delayed on the tarps, and color-coded re-triage and treatment areas for those who can be held for care.
9. I’m requesting armed officers be assigned to each patient contact/treatment and patient loading location for your protection and the protection of your victims.
10. I want a secured area away from the living for any deceased victims brought to you or who die while under your care. Shield the area from public and press view.