I’ve been asked by several colleagues to address the evolving issue of active shooter situations. It seems that every time we check social media or turn on the news, there’s another multi-casualty shooting. No place is safe; concerts, hotels, malls, banks, schools, the middle of the interstate, anywhere you can think of.
It used to be that we did not enter the scene until law enforcement cleared the threat, and either apprehended or eliminated the suspect. But as we’ve discussed before, our EMS industry is in a constant state of flux – and so, too, are our clinical roles as first responder providers.
At some point during your EMS career, you will respond to a shooting. It is inevitable. And while we are prepared to handle such an emergency, an active shooter situation is far different than a self-inflicted GSW, hunting accident or a drive-by shooting.
In my career, I have had one active shooter situation – and it was a mess. A man with a semi-automatic rifle chose a popular tourist spot at a hotel on one of the jam-packed beaches to open fire. He selected his victims in a closed parking garage. Where things went wrong was that everyone called 911 at once, and dispatch ran each of the shooting victims as separate incidents.
We went in as single units to care for each patient, and for the first few minutes on scene, no one made the connection. Units were entering from all sides of the incident. Law enforcement could not locate the shooter, and no command structure was in place until far into the situation. We entered the hot zone thinking it was a single incident, when in truth we had multiple victims, all from the same perpetrator. We had to back out and reenter several times. It was a miracle that no responders were injured or killed.
There were no casualties that day. We were lucky. But as we’ve seen with the active shooter situations of late – the Orlando PULSE nightclub shooting being a prime example – these types of calls are volatile and complex, and most of the time result in multi-casualties. And the “not in my backyard” theory isn’t working; no matter how safe you think your district is, an active shooter scenario can present itself at any time. Think of the mass shooting at Columbine H.S., and the one at Sandy Hook Elementary; those two incidents alone shaped the way we view active shooter scenarios.
A 2014 U.S. Department of Justice study determined that an active shooter incident could happen in any size or type of community. What that means is we need to prepare for just such an event. Definitive care for a shooting victim revolves around rapid extrication from the scene, aggressive bleeding control and surgical intervention. It is imperative that our agencies have standard operating procedures and policies in place before an incident happens; we need a coordinated effort for planning, response and treatment.
In 2013, a group chaired by the American College of Surgeons, in conjunction with the FBI in Hartford, CT took charge of developing a protocol guideline for active shooter situations. The group, the Joint Committee to Create a National Policy to Enhance Survivability From Mass Casualty Shooting Events, published a document with very specific recommendations for not only EMS and LEO responders, but for first-arriving civilian bystanders as well. The paper, called ‘The Hartford Consensus,” focused on real-world tactics to minimize casualties in active shooter situations. And their solutions are evidenced-based and backed by years of clinical data.
It may sound familiar, but there’s a twist: those civilian bystanders are now considered ‘immediate responders.’ The committee is calling on the public to use their hands and whatever else is in reach to control hemorrhage. EMS is considered the ‘professional responders’ with, of course, the appropriate equipment and knowledge to manage patient care. The third tier to this is the “trauma professional’ who can render definitive care in the surgical suite.
It used to be that we as EMS providers staged well away from the active shooter scene, waited for SWAT and tactical units to arrive, gear up and discuss a battle plan. Once the decision to make contact with the shooter was made, and subsequently make entry, the chances of victim survival decreased with every minute that passed.
And while SWAT and tactical units are still very much needed, data from recent active shooter tragedies has shown that law enforcement making rapid entry into the scene and engaging/eliminating the shooter threat is getting EMS in quicker to treat and transport, and get that victim to surgical intervention rapidly. LEOs entering immediately have a better chance of bringing the incident to a rapid close.
The Hartford Consensus came up with an acronym for EMS to remember and act upon: THREAT.
T – Threat suppression (LEOs)
H– Hemorrhage control
Rapid Extrication to safety
Assessment by medical providers
T – Transport to definitive care
The focus is also on empowering the public to do more than just “see something, say something,” and jump in to help with whatever means they have. Because of this initiative, the National Association of Emergency Medical Technicians holds classes for civilians to do just that, “The Bleeding Controlled for the Injured” or B-Con. Some of that educational content includes:
- Ways to ensure their own personal safety
- How to interact appropriately with law enforcement/EMS/fire rescue and higher- level medical personnel
- Use of hands for direct pressure on uncontrollable hemorrhage
- Use of safe and effective hemostatic dressings
- Proper use of tourniquets
- Types of improvised tourniquets as a last-ditch effort
And as mass shootings evolve and become more frequent, the Hartford Consensus has undergone three volumes, the last being in July, 2015. With the events of late, it is safe to say we will see volume four very soon.
In September of this year, the White House and the Department of Homeland Security teamed up for the “Stop the Bleed” campaign, further empowering the civilian bystanders to step in and act in active shooter situations. The points are very short and easy to grasp. “Stop the Bleed” reminds the public that no matter how fast EMS and law enforcement respond, bystanders at an incident will always be able to render care first. This is crucial considering that uncontrollable hemorrhage is fatal if left unchecked for over five minutes.
They also stress that being aware of their surroundings and moving them and the patient to safety is paramount. Then, they need to act quickly to perform these five steps:
- Call 911
- Compress (the wound)
- Compress again
- Second tourniquet
Disclaimer: The content in this article is the opinion of the writer and does not necessarily reflect the policies or opinions of US Patriot Tactical.
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