Mass Casualty Incidents, Terrorism & Active Shooter

EMS Crews Share their Experience of the San Bernardino Terrorist Attack

Issue 8 and Volume 41.

With three months of careful planning completed for a multi-agency mass casualty incident (MCI) drill, Dec. 8 was quickly approaching. It was to be the first joint drill conducted between San Bernardino City Fire Department (SBCFD), San Manuel Fire Department (SMFD), and CAL FIRE Highland. The scenario: a vehicle crashing into a bus with approximately 30 victims. The objective: fine-tuning incident command support roles and use of simple triage and rapid treatment (START), and orienting staff to new MCI supplies.

Six days before the big drill, EMS Coordinator Carly Crews and fire engineer Scott Leidner were finalizing preparation of new MCI kits and individual packs in the EMS office at SBCFD. Engineer/tactical paramedic Ryan Starling, along with members of the SWAT team, were training on the north end of town on their response procedures at active shooter events.

Two battalion chiefs and the deputy fire chief were attending an antiterrorism class in a neighboring city, and the fire chief was in a meeting at city hall dealing with the transition of SBCFD to the San Bernardino County Fire Department.

In a city of approximately 215,000 residents, and a call volume of an average of 30,000 calls per year, the call volume was lower than normal that morning. Fire and police dispatchers located on the same floor in the San Bernardino Communications Center were answering calls as they routinely do, in an arrangement that has greatly assisted the interoperability of communication for major events in the past.

At 10:58 a.m., calls reporting shots being fired at a public building began bombarding the police dispatchers. A minute later on the other side of the room, fire dispatcher Kathy McRaven received a water flow alarm. With her outstanding listening skills, she realized the addresses of the calls and the alarm were the same: the Inland Regional Center (IRC)-a two-story, state-run facility for individuals with developmental disabilities where community events are held.

EMS crews respond to San Bernardino terrorist attack
The crews learned a unified command needs to be set up and followed immediately between fire/EMS and law enforcement at the scene.

McRaven, operating without a second fire dispatcher at the time, was forced to switch from her first call to a second call. The second came from a woman hiding in a bathroom, frantically attempting to assist another woman who’d been shot. Similar calls of this nature continued.

Because the attack lasted less than five minutes, victims and witnesses could only provide the dispatchers minimal information, which varied. However, all those in the dispatch center almost immediately realized this was an active shooter incident, and McRaven began dispatching units. The first paramedic engine, ME231, was sent at 11:03 a.m. along with an ALS ambulance from American Medical Response (AMR).

“I was doing everything at that moment,” McRaven said. “I was answering calls, hand-ling all radio traffic, and within moments, had dispatched every fire department medical vehicle available, plus two battalion chiefs. We wiped out everything we had to cover the city,” said McRaven. “In addition, we called AMR to send 15 ambulances to the scene. Then we had to worry about covering the remainder of the city for any other calls that came in that were not related to the shooting.”

Initial Incident Command Report

Battalion Chief Grant Hubbell, the first command officer on scene, established incident command as well as tactical command. He assigned other incident command responsibilities to responding and staged fire personnel, who were instructed to stage north and south of the incident and wait for clearance to enter the scene. Predetermining these roles en route was a key factor in the success of the response.

The Medical Communications (Med Com) officer, firefighter/paramedic Cody Underwood, on the job for only four months, declared an MCI through the County Communication Center (Comm Center) after reports confirmed approximately 20 victims. He then requested bed availability through the county’s Reddinet system.

“Engineer Chris Bowen decided to listen to the police traffic,” said Underwood. “This was huge because it provided further details to us about the severity of the incident.”

Both Underwood and firefighter/paramedic John Marini then made calls to the base station and trauma center to inform them of the incident.

Starling and his team received notice of the incident immediately. They traded their blanks for live ammo and traveled what was normally a 22-minute route in just nine minutes.

EMS crews respond to San Bernardino terrorist attack
Shooting victims aren’t uncommon in the San Bernardino area, so SBCFD responders knew how to respond and care for each patient.

On arrival, the SWAT team and Starling entered the southeast entrance of the building to find smoke lingering from discharged weapons in and around the conference room where the first shots had been reported.

Victims pleaded for help, fire alarms were sounding and there was a rush of water from the sprinkler system that created a chaotic and loud environment.

“The water was flowing out the entrance door and had a red tinge of color to it. It was obvious it was blood from the victims,” Starling said.

Starling branched off from his tactical medic duties and began triaging patients within the conference room, utilizing START. He marked victims with medical tape to best identify those who needed immediate and rapid extrication to the casualty collection point and the treatment area.

This identification system made it easier to direct the officers to victims they should extract first; the officers would then drag, carry or use chairs to extract the victims to waiting vehicles that could transfer them to the EMS treatment area.

Crews recalls, “When the first [alarm] taps came through the station, it seemed like a normal call for San Bernardino. Dispatch requested ME231 to ‘stage for multiple gunshot victims.’ It was the second taps that requested the whole city that made me realize this was bigger than we could have imagined. I realized if I didn’t make it onto an engine, I wouldn’t be going.”

Shooting victims aren’t uncommon for SBCFD first responders, so, whether it was one patient or multiple, they knew what to do.

“Being able to monitor the police radio traffic was huge,” Marini recalls. “I kept thinking, ‘This is going to be a big event, this is going to be make the news, this has to be done right.'”

The triage and treatment area was set up utilizing salvage covers and paramedic gear from the engines and AMR. Ironically, all of the updated medical gear and new, color-coded triage/treatment tarps remained in the EMS coordinator’s office ready to be delivered to each engine that afternoon and the following morning.

“While we were staging, I kept thinking that I had spent 16 years on the SWAT team as a tactical medic, and now it was the real deal. I was praying for Ryan [Starling] since I knew he was all alone as the sole medic,” Captain Craig Mashburn said.

After the triage, treatment and transportation areas were established, “There was an awkward 4-5 minute period while we waited anxiously for the first patient,” Marini said.

Captain Ron Good was designated as the triage unit leader. He, Captain Greg Soria, Engineer John Miller, and firefighter/paramedic Cody Strickland were approached by Starling to assist with triage within
the building.

“When I said, ‘Let’s go in,’ my team didn’t hesitate and did a great job, even in an unsecured environment,” Soria recalls.

The crew worked to re-triage patients directly around and within the IRC. Black triage tags were placed on deceased patients and they were left in place. Red-, yellow- and green-tagged patients were placed in various probation and police vehicles and moved from the casualty collection point to the triage and treatment area.

Rapid Care & Patient Distribution

Patients moved to the triage and treatment area were found to have massive gunshot wounds that needed immediate attention.
(See Table 1, below.) Although MCI kits and bags with a large volume of important supplies were yet to be deployed, it was fortunate that the paramedics carried wound clot and pressure dressings, occlusive chest seals, and tourniquets in their kits.

EMS crews respond to San Bernardino terrorist attack

AMR sent multiple supervisors to the scene and they connected with Captain Kevin Whitaker, the transport unit leader, to assist with transportation of patients.

Whitaker made several key decisions regarding patient destinations as he worked alongside MedCom and the treatment group. One decision was to utilize San Bernardino County Fire Department Air Rescue 6 to transport one immediate and one delayed patient to a trauma center out of the county. The time from liftoff to touchdown was 11 minutes, the same time it would have taken to drive these patients to a local facility. This decision helped avoid overloading local hospitals that had already received critical patients.

Seventeen critical patients were transported within 17 minutes of their arrival to the triage and treatment area. All 21 patients transported by EMS survived the incident.

More Commotion

Just when fire and EMS crews believed the scene was stabilized, and shortly after the initial removal of patients from the center, crews were instructed by police personnel to evacuate the building and triage/treatment areas and reestablish them at SBCFD Station 231 because tactical teams had located a suspicious package in the conference room of the primary assault building. Fortunately, the package turned out to be unrelated to the incident.

Because the roadway was blocked directly in front of the IRC from numerous police vehicles, providers had to carry their gear a long way from the engine to the new triage/treatment areas. They reported an uneasiness proceeding down the road to the treatment area, not knowing if the building was cleared, what the package was, or if the assailants were still on location and going to engage the officers in a gun battle.

A decision was made to transport walking wounded (i.e., START triage green classification) away from the emotionally-charged treatment area. Two separate locations were designated for them to be taken for triage, assessment and transport. After each patient was cleared, probation department staff assisted EMS/fire crews in loading these minor injury patients on school buses to transport them for basic care, debriefing and reunification with family members.

Approximately four hours after the initial incident, commotion began again. Reports of a car pursuit and a shootout were spreading among personnel on scene. It was discovered that police were in pursuit of a vehicle believed to contain the shooting suspects. The SWAT team, three SDCFD engines and three AMR ambulances responded.

Rapidly boxed in by multiple police vehicles, both assailants were killed. Crews worked alongside the SWAT team to provide safety and care to the civilians and officers, as well as to an officer who received minor injuries during the shootout.

Lessons Learned

This high-risk/low-frequency active shooter incident demonstrates the value of preplanning, training and experience in managing MCIs. Whitaker said, “If anyone involved in patient care had ended up at the hospital, we would have felt that we screwed up. Since our engines retained their full complement of personnel after the incident and were able to go back into service when we were done, we did well.”

However, after sifting through stacks of reports and documentation, along with the accounts of personnel on scene, we’ve identified the following lessons learned:

  • Unified command needs to be set up and followed immediately between fire/EMS and law enforcement at the scene;
  • Interoperability of communication is critical so that all agencies know what is transpiring and when it is transpiring;
  • Patient funnels and containment zones need to be established rapidly and triage/treatment put into operation immediately to control or avoid patients being transported by civilian, law enforcement or personal vehicles;
  • Assignments such as triage, treatment and transportation need to be made prior to crews arriving on scene;
  • Set up triage/treatment area as close as possible to the casualty collection point for easy access in and out;
  • Salvage covers and color-coded tarps aid in delineating priority treatment and transport areas and help reduce confusion at the scene;
  • Triage/treatment area perimeter control by law enforcement needs to occur for the early into the incident;
  • The safety officer needs to be tasked with assessing the location and safety of the triage, treatment and transportation areas as well as ensuring there are an adequate number of armed officers positioned around these zones throughout the incident in the event of a secondary assault occurring as has happened at other incidents;
  • Apparatus should be positioned as safety barriers to protect personnel working in the triage/treatment and transportation areas at active shooter and other high-threat incidents;
  • Treatment area leaders should be designated, identified by scene vests and tasked with managing and remaining in the immediate, delayed and minor treatment areas/tarps throughout the incident. They’re tasked with performing secondary triage and ensuring the proper management of patients in their priority zone; and
  • Triage, treatment and transport managers must all be tasked with time management of patient assessment, care, movement and transportation at the scene to ensure effective treatment, maximum efficiency and minimal delays at the scene.
EMS crews respond to San Bernardino terrorist attack

The Aftermath

Forty-two victims (not including the two terrorists) were triaged, treated and transported as a result of both the primary and secondary incidents. (See Table 2, above.)

Critical incident debriefings were conducted and open to all on-duty personnel the evening of the incident as well as on the following Monday.

SBCFD and AMR received tremendous support and appreciation from the victims, families, survivors and community after the incident. President Barack Obama traveled to the city twice after the incident; on his first visit he made a point to thank all of the emergency responders. During the second visit, Hubbell was front and center during the president’s reflection of the incident, a moment that was justly deserved to recognize Hubbell’s outstanding job.

In April, both on-duty dispatchers received the California Public-Safety Radio Association’s Team Award for 2015 Dispatcher of the Year. That same day, Starling received both a Lifesaving and a Star of Merit medal alongside police personnel who performed acts of personal bravery in the line of duty.

On July 1, the SBCFD transitioned to San Bernardino County Fire District due to an annexation. As a final farewell and celebration of a legacy of 137 years, the department held a recognition dinner to acknowledge the selfless acts of all responders who acted during the attacks.

This article is intended to recognize everyone who responded to the IRC terrorist attack and recognize them for their bravery and selflessness. Our goal in presenting this account of our incident in JEMS is to also share our experiences and lessons learned to assist other departments in preparation and program development. And, above all, it is our intention to remember those who lost their lives that awful day.